Post Combat Depression (PCD)

By Dr Ruwan M Jayatunge M.D

(February 13,Toronto, Sri Lanka Guardian) The concept of Post Combat Depression (PCD) is not new. There are many historical records to provide that combatants manifested depressive symptoms after the war. The feeling of guilt and despair plays a major role in post combat depression. For instance, the King Dutugamunu went in to a depressive type of reaction soon after the Wijithapura battle. The king’s emotional worries were later healed by a monk. Similarly, Napoleon Bonaparte developed depression while he was in exile in the island of St Helena.

Post combat depression is evident among some combatants who were exposed to traumatic battle events. Apart from common depressive signs, PCD is usually characterized with unresolved mental conflicts, survival guilt, negative interpretation of combat events and pessimistic outlook on the post combat environment.

The component of depression was evident to Dr. Mendez Da Costa who introduced the term Irritable heart during the US Civil War and Lt Col (Dr) Fredric Mott who coined the term Shell Shock during the World War one. Sometimes depression is obvious among the servicemen who were exposed to traumatic combat events. In addition to depressive symptoms, they can have anxiety related features.

In common, terms depression is a medical condition leading to persistent feelings of worthlessness, hopelessness, guilt, agitation and indecisiveness. Depression can occur following negative life event, physical illness such as thyroid imbalance or diabetes mellitus. Post combat depression (PCD) usually takes place mostly as a result of traumatic combat experience with negative cognitive interpretations.

A depressed soldier experiences deep unshakable sadness and diminished interest in most of the personal as well as military activates. Depression can dramatically impair a soldier’s ability to function in field situations. A soldier who develops severe depression may appear so confused frightened and unbalanced.

Depression is a mood disorder in which pathological moods and related vegetative and psychomotor disturbance dominate the clinical picture. The term Post combat depression has been used for the first time in the publication “PTSD Sri Lankan Experience” and described as a group of symptoms such as anhedonia (feeling of sadness and loss of ability to experience pleasure) low energy, decreased libido, reduced life interests, somatic pain, alienation, numbing, self blame and survival guilt that is experienced by combat solders after exposing to traumatic battle events. Depression causes a disturbance in a soldier’s feelings and emotions. They may experience such extreme emotional pain that they consider or attempt suicide.

Learned Helplessness in the Battle Field could be described via Psychologist Seligman’s research work. Seligman (1975) was studying the effects of learned helplessness, which is associated with depression. He studied the series of escape mechanism of doges when exposed to electric shock. In this study, many doges did not attempt to escape although there were escape paths. Instead they suffered eclectic shocks and remained helplessly. Seligman stated that learned helplessness is a factor in depression. The learned helplessness model proposes that the depressive posture is learned from past situations. Soldiers in the battlefield act in certain way as the Seligman doges when exposed to traumatic events. Sometimes they do not take any positive measures to change their situation. Also they hardly take measures to detach from depressive components.

Beck (1979, 1983) hypothesized that depression prone individuals possess negative self schemata which he describes as “cognitive triad”. Combatants with PCD often have negative view of themselves may be as a result of the acts that they have committed in the battle field or may be due to low recognition of post military service by the society. They see their environment as overwhelming filled with obstacles and failure. Also they have the pessimistic outlook of the future.

Many soldiers become emotionally shattered witnessing the death of their buddies. Sometimes they hold responsibility for the deaths of their friends. These solders always question their conscience. Often they say to themselves it’s unfair for me to live since I could not save their lives or they have gone because of my error, I don’t deserve to live etc. These are the common self blame patterns that can be seen among the soldiers with PCD. They carry the memories of their dead comrades for decades.

Many depressed soldiers use natural defenses against self-attacking shame by striking out at others, attacking others by being critical, sarcastic or abusive. Alcohol and substance abuse can be a prevailing feature of PCD. Depressive behavior clearly has a powerful interpersonal impact. The affected servicemen have deteriorated interpersonal relationships in the battle field. On certain occasions, combatant’s family members too feel this distance and coldness.

Depression represents a masochistic life style. Soldiers with post combat depression suffer from lack of assertion and outwardly directed aggressiveness. Aggression turned inward mechanism is a universal explanation for depressed behavior. Freud’s concept of aggression turned inward model or depressed affect is derived from retroflexion of aggressive impulses directed against an ambivalently loved internalized object was actually formulated by his student Carl Abraham.

As the psychoanalyst Carl Menninger elaborates suicide is a murder in 180 degrees. Soldiers are taught to be aggressive. Killing is a part of military training. Therefore aggressive tendency and will to kill the enemy is an accepted component in the military culture. Sometimes this outward directed aggression turns 180 degrees and PCD soldiers shoot themselves. Frequently soldiers with post combat depression go in to various types of self harm including risk taking behavior. In the height of depression they can take their own lives. Very often these soldiers use their weapons to commit suicide.

Undiagnosed and untreated depression can lead to many complications in the battlefield. In the height of the depression, combatants with PCD can go in to fugue states. When they are under fugue states they become numbed and can be disoriented. This is a story of a soldier who went in to fugue state a result of overwhelming depression during the Eelam War. This combatant was found by a group of soldiers when he was wandering and heading towards the enemy lines. When questioned he had no idea how he came out if his bunker. In addition, there was no trace of his weapon. Probably he must have dropped it in the jungle. When he was referred for a psychiatric assessment, he denied any kind of substance abuse. There was no history of dissociative disorder. But he was depressed following the deaths of his platoon members. His depression was undiagnosed and untreated until he went in the depressive fugue.

Physical injuries, Disabilities and PCD go hand in hand. A large number of soldiers who sustain physical injuries and become disabled can go in to post combat depression. This category describes depression that occurs in response to a major life stressor or crisis. Stressful events such as physical injury and disability often appear to be triggered by the temperamental instability that precedes clinical episodes.

PCD can be treated with medication and psychotherapy. Antidepressants are effective in PCD. Psychotherapy is an effective treatment for PCD. Cognitive Behavior Therapy or CBT focuses on identification of distorted perceptions that patients may have of the combat and themselves changing these perceptions and discovering new patterns of action and behavior. PET or Rational Emotive Therapy helps to change the irrational and illogical thoughts such as survival guilt held by the combatants. RET is an approach that focuses on altering client’s patterns of irrational thinking to reduce maladaptive emotions and behavior.

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