Dr. Ritchie: There is a term I will throw in here that I think will help the discussion. Moral injury. It’s related, but not the same as PTSD, which is a diagnosis in the DSM-IV and DSM-5, while "moral injury" is not. Moral injury refers to the feelings of guilt and shame that might be related to killing others or having your friends killed: being tainted by being at war.
So when I look at PTSD, it isn’t as a risk factor for suicide itself. As we talked about, more than half of the suicides now happen in those who have not deployed. PTSD does factor in, in the sense that it can contribute to the breakup of relationships, the feeling that you don’t fit in, and those are risk factors for suicide. So, I am not saying PTSD is unrelated, but if you look at the number of completed suicides, only 10% had a PTSD diagnosis. More could have had PTSD, and it just wasn’t in their records. But, back to the question about existential angst, I think it’s around having seen vast amounts of death and destruction.
Question: Is that your point of view, or does the military recognize this?
Dr. Ritchie: There is increasing recognition, but there are no systematic studies that have been done on it yet. And, the issue about asking people if they’ve killed is difficult, because in many of these cases there is a gray area. If someone is shooting at you, there is no question that you can defend yourself, but people worry whether they have committed a war crime, so it’s difficult to study this scientifically without getting into questions about ethics and legal quandaries.
Question: So language is very important. PTSD used to be called "shell shock." When did it broaden out to become PTSD and become used to address anything that traumatizes a person, not just soldiers?
Dr. Ritchie: Here’s a brief answer. We have called PTSD many things: shell shock, battle fatigue, combat neurosis, and combat stress injury. There have been many names. The term PTSD began in 1980, after the Vietnam War. And a lot of the concepts were based on soldiers and service members from that war. It also encompasses other trauma, the largest amount of literature being on sexual assault victims and disaster victims.
The diagnosis was upgraded in the DSM-5, meaning that there were more symptoms added to the classic symptoms, which were hypervigilance – being jumpy and nervous, the flashbacks and memories, and the numbness, and being detached. Now, the symptoms include sleep difficulties, depression, irritability, cognitive difficulties, and somatic reactions. So, it’s a wider diagnosis now, and it will be interesting to see how that affects the prevalence of the disorder.
Question: People have been traumatized since the beginning of humanity, and have needed to cope with it. That’s where the existentialism comes in. Does PTSD offer an opportunity to find meaning in life that wasn’t seen before?
Dr. Ritchie: Certainly, people talk about posttraumatic growth. People used to join the army because it "made a man out of you." I think there are certainly good things that come out of military service on all kinds of levels. Seeing trauma and being around trauma don’t mean you are scarred for life. You can grow as a result of the experience.
Question: Barbara Rothbaum, Ph.D., a leading expert in exposure therapy, says that the trauma will always be sad, but that it doesn’t mean you can’t feel joy again. People forget that you can come out the other side – that PTSD isn’t permanently debilitating.
Dr. Ritchie: PTSD has a range of severity. Dr. Robert Ursano at the Center for the Study of Traumatic Stress in Bethesda, likened it to being the common cold of psychiatry. A lot of people are exposed, have symptoms; most become better quickly, but in some it becomes chronic bronchitis or pneumonia. So, it’s important to recognize there is both a range in the severity of the trauma and people’s reaction to it.
It’s also important to remember that people who are going to combat now are well trained, well armed, and in combat gear, and they are expecting traumatic things. That’s different than if you’ve been the victim of sexual assault, and you’re surprised and feel vulnerable and helpless. So, I think the vast majority of those who experience the psychological effects of war go on to grow from the experience.
–Interview by Whitney McKnight
*CORRECTION, 4/30/2014: An earlier version of this article misidentified Col. (Ret.) Elspeth Cameron Ritchie.