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Combat Exposure Through a Trauma Informed Lens

Through research and thorough investigation by psychologists, neuroscientists and doctors, combat trauma has been studied through a scientific and biological lens many times over. We have learned how the after effects of combat have far reaching consequences in the daily lives of those who have lived through such trauma- but what about the trauma itself caused by direct experience in war? As many people my age have lived through what we know colloquially as The Longest War, this is a topic that has piqued my interest since I first started studying psychology. Our involvement in conflict in Afghanistan and regions of the Middle East post 9/11 has wrought deep scars on the psyche of our nation as a whole- but exposure to war has caused what seems like endless problems for those who faced combat on individual levels. Combat in its many forms has left a lasting impression not just on veterans, but their families, colleagues, and society in general. Psychologists have been able to understand more about PTSD when studying the after effects of combat exposure, but we are now learning what happens in the moment when soldiers are engaging in combat. This includes how these actions play a role in the hyperarousal of the ventral vagal system of the brain and the regions in close proximity long after the fight is over.

By defining combat and understanding the mechanisms of what keep humans alive in the heat of war, we can also understand how those mechanisms cause long term hyperarousal in the form of PTSD. We can learn how this manifests in physiological and mental ways, leaving those who have experienced combat traumatized and fighting for their lives even as they reintegrate back into civilian life. In understanding how combat exposure creates a domino effect in the way these people interact with the world around them in various, sometimes negative ways, we can understand the root of what causes this trauma in the first place, and why so many have a hard time escaping the grip of hyperarousal at the hands of their PTSD.

Combat Exposure Defined by Numbers

Combat has long been believed to be the height of what society considers the most harrowing, yet courageous situations that any American soldier could be put in. However, we know now that the exposure to combat is just the beginning of a series of events that can lead to a litany of physiological and mental health issues. For the purpose of this report, combat will be described (specifically Americans in the Middle East), according to Britannica’s definition: “Active fighting especially in a war. To try to stop (something) from happening or getting worse. To fight against (someone) : to engage in combat against (an enemy).” (Britannica, 2022)

While combat could be uniquely defined by an individual’s lived experience, through this research combat will be looked at through a lens of traumatic events, and how they affect the overall well being of human mental processes. When analyzing the effects of trauma, it is important to understand some of the statistics when looking at the subject of combat. According to Pew Research, “About three-in-ten veterans (29%) had combat experience at some point in their military career. The share is markedly higher among veterans who served after 9/11. Roughly half of post-9/11 veterans (49%) have had combat experience, compared with 24% of veterans who served only before 9/11. About half of all veterans (51%) say someone they knew and served with was seriously injured while performing their military duties. This includes 35% who say they knew someone who was injured in combat and 16% who say the injury was not combat-related. Four-in-ten veterans say someone they knew and served with was killed while performing their duties (30% say this was combat-related, 10% say it was not). About six-in-ten combat veterans know someone who was killed while performing their duties. Veterans who have had combat experience are much more likely than those without it to know someone who was killed or injured. Roughly three-quarters of combat veterans (74%) say they know someone who was seriously injured while in the military, compared with 41% of veterans without combat experience.” (Parker et al, 2019)

While the statistics are important, the basic activity of combat situations should not be overlooked, as these are the heart of how scientists have come to define combat stress and PTSD. Gunfights, engaging in warfare on unfamiliar territory, bombings, human rights issues, harmful cultural practices during warfare from enemies, IED’s, chemical exposure and death on the sides of both colleagues and enemies help substantiate what we have come to know as combat exposure in modern society.

Brief History of Americans in Combat

But this is nothing new- throughout history and the wars our country has been involved in, we know that combat has caused long term deficits in our ability to handle certain social situations and stressors. We first started scrutinizing combat stress when the Civil War left American citizens “battle fatigued.” These men and women were left with brutal scars, mental and physical, from the exposure to the terrors of warfare on U.S. soil. In World War I, soldiers came home from Europe with what was colloquially called “shell shock”. During and after World War II, this shell shock never seemed to leave the minds of doctors, physicians and those left to tend to the wounds that could not always be seen. Imagery of the horrors of battle, lost limbs and physical injuries were just a fraction of what was still largely undefined, but were carried home from war by those who experienced it.

By the time we became involved in the Vietnam War, our country had collectively become familiar with what the repercussions were for those exposed to combat. The draft was protested by many, and the enforcement of military service only added to the traumas of what soldiers would experience in Vietnam. For these men, coming home and having little to no recourse only exaggerated their still undiagnosed PTSD. By the time doctors, researchers and psychologists had come to define Post Traumatic Stress Disorder due to combat exposure, this was something Americans had been dealing with for centuries. Finally, during America’s heightened involvement in conflict in the Middle East, we came to understand that combat exposure created another battle for those who would come to know its negative effects. Often, this battle took place at home and slowly led the way to improved treatment options for those who find themselves grappling with its effects.

Symptoms Associated with Combat Exposure

Combat itself comes with a list that one could argue has become the foundation of how we’ve come to understand the symptomology of PTSD related disorders. Sleeplessness, hypervigilance, anxiety, dissociation, anger, paranoia, fear of large crowds, are just some of the many ways that combat is related to disorders following the experience. While the aforementioned symptoms are not an exhaustive list of what one might experience after combat, they form the basis of what researchers, doctors and psychologists believe to be the culprit of long term PTSD.

It is worth mentioning that there is a difference between combat stress and PTSD. While PTSD envelops what some soldiers experience long after their time in combat is finished, combat stress is the short term after effect of stressors related to combat exposure. According to Military One Source, “Combat stress usually happens for brief periods and is considered a natural reaction to the traumatic events that service members experience. Symptoms often disappear after a service member is home for a few months or even weeks.” (Military One Source, 2022)

These symptoms highlight what is going on within the human body at the time of the traumatic event, continuing long after the initial event has taken place. We know through psychobiological processes that it is the job of the Central Nervous system to send communications from the brain throughout the body when humans need to respond to environmental threats and stressors. The issue that is presented after exposure to combat begins with the initial threat. However, as mentioned previously, these signals continue to fire. For those with PTSD, the threat is not over despite returning to a homeostatic state of relative safety following combat.

When faced with threats in our environment, our sympathetic nervous system begins the process of alerting the body that decisions need to be made to ensure our survival. The body is flooded with cortisol and adrenaline, our heart rate increases, our digestive system goes offline to allow for optimal functioning of our fight or flight. The prefrontal cortex, responsible for making informed decisions that may take some considerable time, is overridden by the brain’s ability to make split second decisions to secure our safety. This is an excellent system of making sure that we remain safe and avoid harm if possible. The efficiency of making timed decisions has become a marker for our evolution, and has kept our species enduring since our conception. However, this system becomes hijacked when it’s exposed to long instances of duress, and this is an all too common problem for soldiers in combat.

Interestingly, it has been found that those who experienced prolonged stress and suffer from PTSD, especially in combat, have larger amygdala’s than those who do not experience prolonged stress. The role of the amygdala within the limbic system is to recognize threats. Typically in regular situations, this is controlled by the prefrontal cortex and it’s duty is to activate our fight or flight when it perceives danger. However, because of the increased size, it may also have an increase in function for those who suffer from PTSD as a result of their combat exposure. This difference in size is believed to lead to the dysregulation of perceived threat, ultimately making the prefrontal cortex unable to perform its function as the mediator for appropriate survival behaviors. Thus, threats seem boundless to those with prolonged exposure to these stressors in and out of combat situations. (Piper et al, 2020)

Treatments

While there are many ways in which combat adversely affects those who have lived through it, there are also many treatment options available from those who relive what they have seen over and over. Some of these treatments have very high success rates, like Cognitive Behavior Therapy, considered the gold standard for treating PTSD. CBT allows the patient to change harmful patterns of thinking, leading to new and improved ways of behaving, in turn improving their coping abilities and overall mental health. Other modalities of treatment include Eye Movement Desensitization and Reprocessing (EMDR), which uses eye movement to initiate a “desensitization” of traumatic memories for patients. This bilateral stimulation in conjunction with the recollection of the triggering memory helps to cut down the hyperarousal caused by the reaction to the memory. This is still being studied, as many treatments are best used on an individual basis. Meaning, these therapies should be explored on a case-by-case level, as one treatment may not be right for everyone suffering from trauma related to combat exposure.

Other treatments are being studied for future use, like psychedelic-pharmacological remedies. Many veterans, exhausted by the ineffectiveness of the typical treatments found in their VA hospitals have turned to these alternative methods as a way of journeying inward to alleviate the symptoms left by their wartime experiences. An interesting path that many veterans have chosen to take is that of psychedelic treatments through the use of psilocybin, ayahuasca or ketamine. While these treatments require further study, and must go through legal processes that allow the studies to occur here in the United States, many individuals suffering from post-combat PTSD have seen great progress in treating their symptomatology in places like the UK, South America and treatment centers that are approved for K-Therapy (ketamine therapy) in the U.S.

Case Examples

In a 2018 case study published by the National Library of medicine, researchers measured the after effects that combat exposure had on sleep, and how this related to risky behaviors, aggression and substance abuse. The study measured results from 2, 420 soldiers post deployment in Afghanistan who had been exposed to combat while deployed. The results found that sleep disturbances caused by combat exposure, such as nightmares, hypervigilance and general anxiety caused by the stress of combat was directly related to the symptoms of long term PTSD, as well as risky behaviors. Here, we can see the clear correlation between combat exposure and its long term effects on the overall well being of veterans. (Osgood et al, 2019) The reports of this study, along with many others in the field, have helped researchers develop stronger questions when looking at the symptoms related to combat exposure. The importance of its findings cannot be understated, as this study and many like it have highlighted the urgency in the need for treatments for those exposed to combat stress.

Another study looked at the trajectories of overall health for those who have been exposed to combat. It examined the results from 11, 950 participants who had been deployed between 2001 and 2005. Using a scale of high-stable, delayed-declining, worsening, improving-worsening, and low-stable health outcomes, they discovered that those who had been exposed to combat had worse health outcomes than those who were not exposed to combat. The final analysis of health outcomes was completed in 2016- this study spanned more than a decade, and researchers came to the conclusion that combat exposure had a direct result on the overall health of those who served in the military. (Porter et al, 2019)

From personal experience, I have witnessed the progression of PTSD symptomology post combat and the toll it can take on an individual’s mental, emotional and physical health. A male Specialist, age 20, was an Army Ranger with 3rd Battalion, 75th Ranger Regiment stationed in Ft. Benning, GA with multiple deployments under his belt to Afghanistan and regions in the Middle East. During his time as a Special Operations Ranger, he experienced multiple situations in which he faced high levels of threat in combat. Most notable was an instance in which he received injuries from a male suicide bomber disguised as a female while on mission with his company. After losing multiple battalion members who were his close friends, he grappled with traumatic memories of the incident, as well as multiple TBI’s from this and other combat missions. His symptoms have led to a long, painful battle on the homefront as his TBI’s have brought him on a journey to seek answers for the physiological symptoms he now presents. Diagnosed with Conversion Disorder and PTSD, he suffers from chronic depression and anxiety, nightmares and sleeplessness, chronic pain, hypervigilance, migraines, temporary paralysis, intrusive thoughts, and suicidal ideation. Treatment has included Cognitive Behavior Therapy and medication, although with fluctuations in mood and medical needs, treatment has proven to be incredibly difficult to pursue.

Concluding Thoughts

As a student of psychology and someone with personal ties to those who have been affected by combat exposure, this topic remains at the heart of many questions I have regarding the biopsychology of trauma. For many, combat becomes the center of a universe that revolves around appointments in and out of the VA Hospital, looking for treatments and answers to their mental and physiological ailments. It is the reason for their suffering, but also their resolve in the face of challenge. For many, despite its negative effects, combat has contributed to the resilience of many members in the US military, along with their families and support systems. Surviving seemingly the worst possible scenario, many remain steadfast in their goals to live with the symptoms that come from their experiences.

Combat has revealed so much to us about the way traumatic experiences manifest in the body and how the brain responds to certain stimuli. Its purpose in research continues to drive discussions and theories of what humans are capable of, what treatments work on individual levels, and what we can do to improve the lives of those who suffer from PTSD and other issues caused by trauma. We continuously progress towards treatment modalities that are person centered, and rely on previous combat research to develop new perspectives in the areas of care that soldiers and veterans receive. These men and women are on the forefront of this journey, as they have gone to great lengths protecting the people they care deeply for. It is important to highlight their contributions and challenges after facing these ultimate tests of survival. In understanding these challenges we can help others move out of survival mode and help them focus more on thriving in their post military careers and experiences.

Sources

Mitchell, T. (2021, October 1). 1. deployment, combat and their consequences.Pew Research Center’s Social & Demographic Trends Project. Retrieved November 6, 2022, from https://www.pewresearch.org/social-trends/2019/09/10/deployment-combat-and-their-consequences/

Encyclopædia Britannica, inc. (n.d.). Encyclopædia Britannica. Retrieved November 6, 2022, from https://www.britannica.com/dictionary/combat

Rfletcher. (2022, November 14). Combat stress, PTSD symptoms & recovery • military onesource. Military OneSource. Retrieved November 18, 2022, from https://www.militaryonesource.mil/military-basics/wounded-ill-injured-and-caregivers/understanding-and-dealing-with-combat-stress-and-ptsd/

Osgood, J. M., Finan, P. H., Hinman, S. J., So, C. J., & Quartana, P. J. (2019, March 1). Combat exposure, post-traumatic stress symptoms, and health-related behaviors: The role of sleep continuity and duration. Sleep. Retrieved November 18, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424082/

Porter, B., Bonanno, G. A., Bliese, P. D., Phillips, C. J., & Proctor, S. P. (2019). Combat and trajectories of physical health functioning in U.S. service members. American Journal of Preventive Medicine, 57(5), 637–644. https://doi.org/10.1016/j.amepre.2019.06.015

Malloryk. (2020, June 26). WWII post traumatic stress: The National WWII Museum: New Orleans. The National WWII Museum | New Orleans. Retrieved November 27, 2022, from https://www.nationalww2museum.org/war/articles/wwii-post-traumatic-stress

American Psychological Association. (n.d.). Treatments for PTSD. American Psychological Association. Retrieved November 28, 2022, from https://www.apa.org/ptsd-guideline/treatments

Pieper, J., Chang, D. G., Mahasin, S. Z., Swan, A. R., Quinto, A. A., Nichols, S. L., Diwakar, M., Huang, C., Swan, J., Lee, R. R., Baker, D. G., & Huang, M. (2020). Brain amygdala volume increases in veterans and active-duty military personnel with combat-related posttraumatic stress disorder and mild traumatic brain injury. The Journal of head trauma rehabilitation. Retrieved November 28, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6814512/