​It has been called 'soldier's heart' during the American Civil war; WW1, it was called 'shell shock' and in WW2, 'battle fatigue' or 'combat fatigue'.

Post Traumatic Stress Disorder (PTSD) describes a collection of psychological symptoms such as frequent re-experiencing of the event, nightmares, being excessively vigilant or jumpy and feeling anxious. After a severe traumatic event some of these symptoms may be 'normal' for a while but should be accepted as such after weeks or months.

The actual term PTSD, may not have been around for hundreds of years, but certainly the condition associated with the term has. The general concept of PTSD most probably became part of the vernacular during WWI. The repercussions of constant shelling and most specifically living underground for hours on end with bombs going off constantly during that time above your head, would be enough to unsettle the mind of many if not most. Combined with the horrors lived and seen, most survivors would have come back to their families at the least mentally wounded.

In WWI, the physiological distress of soldiers was attributed to concussions caused by the impact of shells; this impact was believed to disrupt the brain and cause “shell shock”.1. Shell shock was characterized by “the dazed, disoriented state many soldiers experienced during combat or shortly thereafter”. However, even soldiers who were not directly exposed to exploding shells were experiencing similar symptoms. Thus, it was assumed that soldiers who experienced these symptoms were cowardly and weak. Treatment was brief, consisting only of a few days of comfort, with the “firm expectation that the soldier return to duty”. Because 65% of shell-shocked soldiers ultimately returned to the front lines, treatment was considered a success.2.

The conflicts in Iraq and Afghanistan have resulted in increased numbers of Veterans who have experienced TBI. The DoD and the Defense and Veteran's Brain Injury Center estimate that 22% of all combat casualties from these conflicts are brain injuries. 60% to 80% of soldiers who have other blast injuries may also have traumatic brain injuries.

About 90% of TBIs are mild, according to the Defense and Veterans Brain Injury Center.

The number of Veterans with PTSD varies by service era:

Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF); About 11-20 out of every 100 Veterans (11-20%) who served in OIF or OEF have PTSD in a given year.
Gulf War (Desert Storm); About 12 out of every 100 Gulf War Veterans (12%) have PTSD in a given year.3.

Specifically, OEF/OIF veterans presenting with PTSD, 34% had received a level 1 mTBI, 47% received a level 2 mTBI.4.

Exposure to blasts is unlike other causes of mTBI and may produce different symptoms and natural history. For example, Veterans seem to experience the post-concussive symptoms described above for longer than the civilian population; some studies show most will still have residual symptoms 18-24 months after the injury.​

For the approximately 1.6 million troops who have deployed since 2001, PTSD-related and major depression–related costs could range from $4.0 to $6.2 billion over two years. Applying the costs per case for TBI to the total number of diagnosed TBI cases identified as of June 2007 (2,726), the total estimated costs incurred within the first year after diagnosis could range from $591 million to $910 million.5.



​The diagnosis of TBI, associated post-concussive symptoms and other comorbidities such as PTSD, presents unique challenges for diagnosticians. No screening instruments available can reliably make the diagnosis; the 'gold standard' remains an interview by a skilled clinician. The current military, Veterans' and non-military screening tools are intended to initiate the evaluation process, not to definitively make a diagnosis.

Relevant Links



​1. Bentley, S. (2005). Short history of PTSD: From Thermopylae to Hue soldiers have always had a disturbing reaction to war.

2. Scott, W. J. (1990). PTSD in the DSM-III: A case in the politics of diagnosis and disease. Social Problems, 37(3), 294-310. Retrieved from​

3. Department of Veterans Affairs website;

4. Schneiderman, Braver and Kang. 2008 Am J Epidemiol 167:1446-1452.

​5. T. Tanielian, L.H. Jaycox (2008) Invisible Wounds of War Psychological and Cognitive Injuries Their Consequences and Services to Assist Recovery. For RAND (Center for Military Health Policy Research).