FM 22-51
LEADERS' MANUAL FOR COMBAT STRESS CONTROL

CHAPTER 6
POST-TRAUMATIC STRESS DISORDER

6-1. Introduction

a. Over the years, there were sporadic reports of veterans from WWI, WWII, and the
Korean conflict who suffered from persistent war neurosis or exhibited disturbed
conduct. It was not until the late 1970s that PTSD was recognized as a classifiable
psychiatric syndrome. A major driving force was the large number of Vietnam veterans
who were suffering from what was at first labeled post-Vietnam syndrome (a pattern of
symptoms). This syndrome involved varying combinations of anxiety and hyperarousal,
depression and guilt, impulsive or violent behavior, social alienation or isolation, and
often substance abuse. The common theme was the intrusive, painful memories of
Vietnam and the ways the sufferer used to try to avoid or escape them. The post-Vietnam
syndrome was also identified in noncombat military personnel. Similar symptoms and
behavior were recognized in combat medics, hospital personnel and female nurses from
Vietnam (and prior wars), and in ex-prisoners of war and concentration camp survivors.

b. Also in the mid-1970s, a similar syndrome was being recognized in some traumatic
civilian situations, such as victims of natural or human-caused disasters, rape and other
violent crimes, and terrorist acts or hostage-taking episodes. The same symptoms were
found in many cases of burnout in civilian police, fire, and emergency medical personnel.

c. The American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, 1979, established the criteria for making a diagnosis of PTSD.
These were updated in Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised (DSM III-R), Washington, DC: American Psychiatric Association,
1987. See Table 6-1 for specifics.

d. The DSM III-R classification recognizes that PTSD can be --

• Acute (beginning within 6 months of the traumatic event, but not lasting longer
  than 6 months).
• Chronic (beginning within 6 months and lasting longer).
• Delayed (beginning or recurring after 6 months and perhaps even many years
  later).

Delayed PTSD can usually be related to other stressors going on in the person's life at the
time, especially those which remind him of the combat stressors, such as a threat of loss
of life, self-esteem, or love relationships.

e. It should be obvious when comparing the criteria in Table 6-1 with the descriptions of
battle fatigue in Chapter 5 that if a war or operations other than war continues for more
than a month, some of the battle fatigue cases could meet the criteria for a diagnosis of
PTSD. However, by US Army convention, the label PTSD will not be used while the
soldier is in the theater of operations as battle fatigue more clearly implies the positive
expectation of recovery and return to duty without persistent problems. The diagnosis of
PTSD will be reserved for symptoms which persist or arise after the cessation of
hostilities or after returning to the US.

Table 6-1. Diagnostic Criteria for 309.89 Post-Traumatic Stress Disorder

Editor's Note: Coprighted material has been omitted becuase it is not essential to understanding of this publication.

 

6-2. Psychologically Traumatic Events

a. Explanation of Psychological Trauma. Psychological trauma, by definition, involves a
crisis situation which makes the person feel he is changed for the worse. The implication
is that the victim has suffered psychological injury and bears the psychological scars. To
qualify under DSM III-R, the traumatic event must be something which is outside the
range of usual human experience; it is an event which anyone would find horribly
distressing. It is true that for professions like police, fire fighters, emergency medicine
personnel, and the combat soldier many events come to be accepted as routine and even
positive that other people would find unusual and traumatic. There remain, always, those
terrible events (because of chance or mistake) that one hopes (and deep down believes)
will never happen to oneself or one's close friends.

b. Causes Contributing to Post-Traumatic Stress Disorder. Traumatic events tend to be
discrete events which provoke especially vivid memories of terror, horror, helplessness,
failure, disgust, or "wrongness." Even in prolonged stress situations like being a PW or
hostage or serving a medical or mortuary tour in Vietnam, subsequent PTSD will call out
specific bad events. The events often (but not always) involve especially vivid sensory
stimuli which are distinctly recorded in memory -- visual images, smells, sounds, or
feelings. The sense of "wrongness" may be from a personal violation or error, or from a
sudden realization of the arbitrary unfairness in life as it affects others. So, for fire
fighters, the death of children in fires is especially distressing. Combat soldiers who have
killed enemies at long range in open battle with pride may be haunted years later by the
memory of a soldier they killed in ambush. They are haunted because they searched the
body for documents and instead found letters and photographs of loved ones similar to
their own. Mortuary affairs personnel, too, tend to suffer when they inadvertently learn
too much about the lives of the people whose bodies they must handle.

c. Situations Likely to Provoke Post-Traumatic Stress Disorder. The following is a listing
of some of the situations in combat (and civilian equivalents):

• Loss of friends, buddies, and loved ones --
  • Under especially horrible circumstances.
  • With associated guilt because of an actual or perceived mistake or an error
    (omission or commission).
  • By having exchanged places so that a friend went and died instead of
    oneself.
• Injury or death to innocents (especially women and children).
• Seeing grossly mutilated bodies or wounds.
• Atrocities (done, condoned, or just observed).
• Lack of respect; lack of ceremony and "closure" for deceased friends.
• Lack of apparent meaning or purpose to the sacrifice, as might result from
  careless accidents or military errors.
• Inadequate quality of the homecoming reception which fails to validate the
  sacrifices and inhibits talking out the bad memories with family, friends, or fellow
  veterans.

d. Symptoms of Post-Traumatic Stress Disorder.

(1) As the DSM III-R criteria (Table 6-1) reveal, PTSD is driven by intrusive
memories of the traumatic event. These may come while awake or in dreams. The
memories may come when a person is intoxicated. Occasionally these memories
can be so vivid and multisensory that the person feels briefly he is reliving the
experience (called a flashback). These thoughts are often triggered by sensory
stimuli like those of the original -- events, such as objects, helicopter sounds, or
smells. They become more intrusive for a while after the initial reminder. Because
the memories are painful, the person with PTSD tries to avoid things that bring
them on and may be quite successful.

(2) The memories themselves do not constitute PTSD. The issue is whether (and
how) they interfere with general well-being, happiness, and occupational or social
functioning. For example, an infantry battalion colonel who had been a company
commander in Vietnam described how he could still not see a piece of trash on
the ground without suddenly becoming alert and being inclined to stay well away
from it. Along with this would be painful, vivid memories of the horrible wounds
which his young soldiers had suffered from booby-trapped trash. The colonel,
however, does not see himself as scarred by those memories. Rather, he reassures
himself that it was a hard lesson he has not forgotten and that if his unit should
find itself in a similar war, he will see that his men do not have to learn this lesson
in such a hard way again. He has reframed the painful memories in his mind so
that they resulted in positive growth rather than an unhealed scar.

(3) The colonel (mentioned above) did say that for several years after returning
from Vietnam, he had experienced other symptoms which approached those of
PTSD. He felt isolated and alienated from other people, especially from civilians
and other Army coworkers who had not been in Vietnam. He felt they could not
understand what it was like and did not want to hear about it. He felt considerable
anger towards them and held his temper chiefly by keeping to himself. He also
tended to shut out his wife and children that way for a while.

(4) In more extreme cases, the isolation takes the form of an inability to feel
affection or form close relationships. In losing close friends in combat, the soldier
learned not to get too close again to the new replacements. The pattern has
continued involuntarily. Negative feelings towards women and children (such as
mistrust combined, perhaps, with guilt) may also have been acquired by the types
of interactions encountered in the combat zone. The veterans with PTSD may go
emotionally numb, continuing to function without any feeling when something
happy or sad occurs.

(5) The angry and hostile feelings may stay tightly suppressed, as in the infantry
colonel's experience described above, or they may erupt in angry outbursts or
even in rage and violence. The ex-combat soldier who was once authorized to use
lethal force in combat missions (and perhaps went beyond that to exercising force
in the form of misconduct stress behaviors) has the memory of that power to
provide temptation or self-justification for using violence again. This is especially
likely when inhibition is impaired by alcohol or other intoxicant drugs. See
Chapter 4 for details on misconduct stress behaviors.

(6) Substance abuse, especially alcohol, is common with PTSD. It provides an
escape from or dulling of the memories. It is often used to try to get to sleep
without the bad dreams and to reduce the anxiety and tension.

(7) Post-traumatic stress disorder characteristically involves symptoms of anxiety
and hyperarousal -- exaggerated startle responses or excessive alertness and
vigilance for potential threats. These may be the threats of the past combat
situation (such as the colonel's alertness about the trash or automatically noting
potential ambush sites), or it may lead to excessive suspicion and caution in daily
life (such as sleeping with a loaded pistol under the pillow or never sitting with
one's back to a crowded room).

(8) Depressive symptoms, with poor sleep, loss of appetite and other pleasures,
poor concentration, and guilt feelings are also characteristic of true PTSD. The
sufferer is preoccupied with what he did or did not do to survive when others
died. He may blame himself for mistakes that were real or quite beyond his
control. He may have guilty thoughts, such as "If only I had not been so slow" or
"If only I had been six feet closer, I would have seen that sniper before he shot my
friend." The risk of suicide in PTSD is related to this depression and should not
go unrecognized. It may also lead to reckless, potentially self-destructive behavior
without conscious suicidal intent.

e. Early (Preventive) Treatment of Psychological Trauma.

(1) An analogy has been made between psychic trauma and physical trauma, such
as lacerated muscles and broken bones. People sometimes try to reassure the
traumatized victim with the saying, "Time heals all wounds." This reflects the
common observation that feelings of grief, loss, and guilt do normally tend to fade
with time. But the analogy with physical wounds suggests the fallacy in such
reassurance.

(2) Time heals broken bones, but only if they have been carefully realigned and
stabilized to permit correct healing to begin. Time heals lacerated muscles, but
only if they do not become badly infected by bacteria and dead tissue trapped in
the wound. One of the most important lessons of combat wound surgery is not to
attempt immediate primary closure (stitching the muscle and skin together again)
as would be done in civilian hospital surgery. Instead, it is better to leave the
wound open, keep it clean, and let it heal from the inside out for a few days. It can
then be closed under sterile hospital conditions to decrease the size of the scar.

(3) With especially traumatic physical injuries, such as high-velocity bullet
wounds, the surgical treatment is even more stringent. The surgeon provides
immediate intervention to stop the bleeding. He then debrides dead tissue and
surgically repairs the wound. In many cases the surgeon may delay primary
closure and insert a drain which allows the wound to heal from the inside out.

(4) This analogy between physical traumatic injury and psychic traumatic stress
appears accurate regarding immediate treatment. It is best not to attempt
immediate primary closure of psychic trauma by forcing the feelings out of mind
and pressing on with other tasks that keep the disturbing feelings from surfacing.
Instead, it is better to open up the psychic wound and let it drain. It may even be
necessary to "insert a drainage tube" (to permit proper healing) -- that is until the
sufferer actually feels and expresses the suppressed, painful emotions and allows
them to come out. This should be done as soon as the soldier who is suffering can
pull back from the mission safely and regain (through brief rest and physical
replenishment) the strength and clarity of mind needed to participate in his
therapy.

(5) Another analogy perhaps more familiar to the nonmedical leader is the
preventive maintenance of complex equipment. A good officer or NCO would not
accept bringing an MlA1 tank (or an M16 rifle) back from fighting in a sandy
desert or muddy/salt marsh without performing maintenance. This maintenance
includes cleaning, re-oiling, and preparing the MlA1 tank for its next mission.
The good leader knows that even though the dirt has not already jammed the
weapon, the salt particles or sand grains will greatly increase corrosion and wear.
The result could be unreliable performance, increased maintenance costs, later
catastrophic failure, or maybe just a decreased useful life. Especially traumatic
memories can have the same corrosive effect on the individual. They can impair
the soldier's future performance. They can result in much unnecessary pain and
suffering, both to the soldier and his family.

f. Small Group After-Action Debriefing.

(1) Every small unit leader should routinely conduct after-action debriefings
following any difficult situation. This is especially important if mistakes or
misunderstandings occurred or losses were suffered. After-action debriefing for
stress control may be integrated into the routine after-action review if the time
available does not permit the separation of the two.

(2) The after-action review should be practiced in training and continued in
conflict or war. The after-action review should be conducted as soon as it is safe
for the leader to bring his team together. The purpose of the after-action review is
to talk about the details of the recent action and agree on lessons learned. The first
step is to agree on what actually happened. It may be necessary to share
everyone's observations to get a clear picture. The after-action review focuses on
how well the battle/crew drill or TSOP worked. What went well and needs no
change? What could use further improvement? What did not work at all and needs
a new approach? When properly conducted, the after-action review increases
understanding, trust, and cohesion within the team. It builds confidence that future
events be handled even better.

(3) The after-action debriefing process shares the after-action review's concerns
with details of what happened. It goes further by actively encouraging the team
members to share and talk out their emotional responses to the event. After-action
debriefings should also be routine during training, operations other than war, and
war following any difficult or unpleasant event. Doing after-action debriefing
routinely will make them second nature following any especially traumatic event.
The objective of after-action debriefings following traumatic incidents is to
promote "healing" by opening up, "cleaning and draining" any unpleasant or
painful memories. Table 6-2 lists the key steps of the after-action debriefing
process and Appendix A provides additional information.

(4) Leaders and buddies have the responsibility of continuing to talk through
especially traumatic events. This should be done in a supportive way to
individuals who show signs of distress in the after-action debriefings through
personal conversations. Unit ministry teams may be helpful in the debriefings and
in individual pastoral counseling to help the soldier redirect the painful memories
toward positive spiritual growth. Individual referral to mental health/ combat
stress control personnel is indicated for severe distress.

Table 6-2. Key Steps in an After-Action Debriefing

g. Following Up the After-Action Debriefing.

(1) People who live through extremely traumatic experiences should not expect to
forget them. It is entirely normal to remember such events with sadness,
resentment, guilt, or whatever emotions the event deserved. It may be appropriate
to atone for mistakes made. It is also normal to dream about the event, even many
years later. The "normal" pattern is for these painful feelings to become less
intense and less frequent as they are balanced by later, positive events.

(2) Combat stress control/mental health personnel should always be notified
whenever serious psychological trauma has occurred in a unit. They can assist
command in assuring that the after-action debriefing process is done correctly.
When indicated, the unit should arrange for combat stress control/mental health
personnel to conduct a critical event debriefing. Critical event debriefings are
similar to after-action debriefings but differ in the following ways:

• The critical event debriefing is led by a trained debriefer who is not a
  member of the unit being debriefed; the after-action debriefing is led by
  the small unit's own leader.
• The critical event debriefer explicitly defers issues of operational lessons
  learned in order to focus on the stress aspects and stress responses; the
  after-action debriefer does seek to capture relevant operational lessons
  learned in positive terms.

(3) Prior to redeployment home, units should schedule time for everyone to
verbally review the high and low points, talk through any unresolved issues, and
conduct memorial ceremonies, if appropriate. Chaplains and combat stress
control/mental health personnel should also take an important supportive role in
these activities.

h. Cautions for Preventive Intervention After Traumatic Stress.

(1) The analogy between PTSD preventive interventions and traumatic wound
surgery suggests a cautionary warning. If the surgery is not done skillfully, it can
cause more harm than good, leaving dead tissue and bacteria in the wound. It may
cut away tissue that did not need to be sacrificed, or realign the broken bones
incorrectly. The same is potentially true for poorly executed after-action
debriefings or critical event debriefings.

---

CAUTION
A poorly executed stress debriefing can cause harm. It can --

• Leave important and painful issues unexplored, waiting to
  fester into future PTSD which will be harder to treat.
• Compound rather than relieve the feelings of guilt, anger, and
  alienation.
• Glamorize and encourage chronic PTSD disability.

---

(2) The problem for early prevention efforts is to forewarn of possible posttraumatic
stress symptoms without glamorizing them or advertising them as a
reimbursable longterm disability. To do the latter invites malingering. It also
subtly encourages those who do have real but not disabling post-traumatic
symptoms to magnify them. This will be especially likely if they have other
psychological issues or grievances which the symptoms also address, such as
feeling unappreciated for the sacrifices suffered or guilt at having left their
buddies.

(3) As with the treatment of acute battle fatigue, it is essential that all persons
involved in preventive or treatment interventions for PTSD express positive
expectation of normal recovery. At the same time, they must indicate that
continuing or recurring symptoms can and should be treated, still with positive
expectation of rapid improvement. They should advise that post-traumatic stress
symptoms may recur in the future at times of new stress. Successful treatment
after future episodes should deal with the ongoing, new stressors as much as with
the past trauma.

6-3. Identification and Treatment of Post-Traumatic Stress Disorder After the War

a. Because PTSD can recur months or years later (usually at times of added stress),
coworkers and supervisors, chaplains, and health care providers should all be alert to the
often subtle signs of PTSD long after combat. They should provide normalizing support
and encourage (or refer the soldier for) mental health treatment.

b. Remember, one of the common symptoms of PTSD is social alienation, withdrawal,
and attempts to avoid reminders of the memories. Sufferers of post-traumatic stress
symptoms are, therefore, not likely to volunteer their combat history or to admit easily to
the "weakness" of not being able to control their painful memories. In fact, many soldiers
with PTSD from prior combat (or accident or disaster) present as cases of substance
abuse, family violence, or other misconduct. They will not receive the mental health help
they deserve unless the causal stress relationship is explicitly asked about and recognized.

c. Another hidden cost of inadequately treated post-traumatic stress will be the potentially
large number of combat-experienced veterans (especially in the elite units) who either ask
for transfer out of the combat unit, do not reenlist, or submit resignations. They will often
say "My spouse wants me to leave the Army, and was especially worried that I almost got
killed in that last deployment." Only with careful exploration will it become clear that the
spouse is not upset with the Army or its risks but because the soldier came home
changed. He keeps to himself, will not say what is wrong, gets mad at the children, drinks
too much, and wakes up at night shouting and crying. The spouse thinks that if the soldier
can only get away from the Army, he will get back to the way he was before.
Unfortunately, if simply allowed to resign, whatever guilt, shame, or other traumatic
memory is haunting him will probably continue unresolved.

6-4. Combat Stress Control (Mental Health) Personnel Responsibilities

a. Combat stress control personnel have critical roles in assisting command in the
prevention and early recognition of PTSD and in treatment of the individuals to avoid
long-term suffering or disability following traumatic combat experiences. Treatment is
often best when conducted in groups. The Department of Veterans Affairs (veterans'
counseling centers) also may provide valuable consultation and treatment expertise.
Whenever the Department of Veterans Affairs is involved, however, special care should
be taken to avoid the negative expectation of long-term treatment and chronic disability
reimbursement.

b. Post-traumatic stress disorder also occurs following natural and accidental disasters,
terrorist attacks, rape or criminal assault, and hostage situations. Mental health/combat
stress control teams have consistently demonstrated their value in rapid deployment of
medical response teams for such contingencies. Their involvement following such
incidents, as well as following combat, should be requested by the chain of command
according to standing operating procedure.

 

Go to Chapter 7 - Stress Issues in Army Operations

FM 22-51
LEADERS' MANUAL FOR COMBAT STRESS CONTROL
Table of Contents
Preface
Chapter 1 - Overview of Combat Stress Control
Chapter 2 - Stress and Combat Performance
Chapter 3 - Postive Combat Stress Behaviors
Chapter 4 - Combat Misconduct Stress Behaviors
Chapter 5 - Battle Fatigue
Chapter 6 - Post-Traumatic Stress Disorder
Chapter 7 - Stress Issues in Army Operations
Chapter 8 - Stress and Stressors Associated with Offensive/Defensive Operations
Chapter 9 - Combat Stress Control in Operations other than War
Chapter 10 - War and the Integrated (Nuclear, Biological and Chemical) Battlefield
Chapter 11 - Prevention of Battle Fatigue Casualties and Misconduct Stress Behaviors

Appendices
Appendix A - Leader Actions to Offset Battle Fatigue Risk Factors
Appendix B - Organization and Functions of Army Medical Department Combat Stress Control Units
Appendix C - United States Army Bands
Appendix D -The Unit Ministry Team's Role in Combat Stress Control and Battle Fatigue Ministry
Appendix E - Example Lesson Plan
Glossary - Abreviations and Acronyms
References - Sources Used