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During the American Civil War, it was referred to as “soldier’s heart”; in World War I, it became known as “shell shock”; and in World War II, it was called “battle fatigue” or “combat fatigue.”
Today, these conditions are recognised as Post-Traumatic Stress Disorder (PTSD)—a syndrome characterised by psychological symptoms such as intrusive re-experiencing of traumatic events, nightmares, hypervigilance, exaggerated startle responses, and heightened anxiety. Following a severe traumatic event, some of these symptoms may be considered a normal short-term reaction; however, persistence over weeks or months reflects the development of a clinical disorder.
Although the formal term PTSD is relatively recent, the condition itself has been described for centuries. The concept gained prominence during WWI, when soldiers exposed to relentless shelling and the horrors of trench warfare returned home profoundly psychologically affected. At the time, the physiological distress of soldiers was attributed to concussions caused by exploding shells, believed to disrupt the brain and cause *“shell shock.”*¹ Shell shock was characterised by “the dazed, disoriented state many soldiers experienced during combat or shortly thereafter.” However, even those not directly exposed to blasts exhibited similar symptoms.
This led to the false assumption that affected soldiers were displaying cowardice or weakness. Treatment was minimal—often limited to a few days of rest—followed by the firm expectation that soldiers return to combat. Because approximately 65% of shell-shocked soldiers ultimately resumed front-line duty, such treatment was deemed a “success,” despite leaving many men with lasting psychological wounds.²
The conflicts in Iraq and Afghanistan have led to a sharp increase in the number of Veterans experiencing traumatic brain injury (TBI). According to the U.S. Department of Defense (DoD) and the Defense and Veterans Brain Injury Center (DVBIC), approximately 22% of all combat casualties from these conflicts involve brain injuries. Moreover, 60–80% of soldiers who sustain other blast-related injuries are also found to have concurrent TBIs.
The majority of these injuries are classified as mild TBIs (mTBI), with the DVBIC estimating that around 90% of all TBIs fall into this category.
The prevalence of Post-Traumatic Stress Disorder (PTSD) among Veterans varies by service era:
Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF): About 11–20% of Veterans experience PTSD in a given year.
Gulf War (Desert Storm): About 12% of Veterans experience PTSD annually.³
Among OEF/OIF Veterans presenting with PTSD, 34% had sustained a level 1 mTBI and 47% a level 2 mTBI.⁴ Blast-related exposures appear distinct from other causes of mTBI, producing different symptom profiles and recovery trajectories. Notably, Veterans often experience post-concussive symptoms for 18–24 months post-injury, far longer than typically observed in civilian populations.
The economic burden is significant. For the approximately 1.6 million U.S. troops deployed since 2001, the costs associated with PTSD and major depression are estimated at $4.0–$6.2 billion over two years. Applying TBI cost-per-case estimates to the 2,726 diagnosed cases identified as of June 2007, the first-year costs alone were projected at $591–$910 million.⁵
The broader consequences also include increased suicide risk. Compared with Australian men, the age-adjusted suicide rate was 48% lower for serving and reserve men, but 18% higher for ex-serving men. Among ex-serving women, the suicide rate was also higher than that of the general Australian female population.⁶ Between 2001–2017, 419 suicides were recorded among serving, reserve, and ex-serving Australian Defence Force (ADF) personnel who had served since 2001.⁷
Over/self-medication is not the answer.
Diagnosis
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.
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