Terrible as such experiences are, however, roughly 80 percent of people exposed to them eventually recover, according to a 2008 study in the Journal of Behavioral Medicine. If one considers the extreme hardship and violence of our prehistory, it makes sense that humans are able to sustain enormous psychic damage and continue functioning; otherwise our species would have died out long ago. “It is possible that our common generalized anxiety disorders are the evolutionary legacy of a world in which mild recurring fear was adaptive,” writes anthropologist and neuroscientist Melvin Konner, in a collection called Understanding Trauma. “Stress is the essence of evolution by natural selection and close to the essence of life itself.”
A 2007 analysis from the Institute of Medicine and the National Research Council found that statistically, people who fail to overcome trauma tend to be people who are already burdened by psychological issues—either because they inherited them or because they suffered trauma or abuse as children. According to a 2003 study on high-risk twins and combat-related PTSD, if you fought in Vietnam and your twin brother did not—but suffers from psychiatric disorders—you are more likely to get PTSD after your deployment. If you experienced the death of a loved one, or even weren’t held enough as a child, you are up to seven times more likely to develop the kinds of anxiety disorders that can contribute to PTSD, according to a 1989 study in the British Journal of Psychiatry. And according to statistics published in the Journal of Consulting and Clinical Psychology in 2000, if you have an educational deficit, if you are female, if you have a low IQ, or if you were abused as a child, you are at an elevated risk of developing PTSD. These factors are nearly as predictive of PTSD as the severity of the trauma itself.
Suicide by combat veterans is often seen as an extreme expression of PTSD, but currently there is no statistical relationship between suicide and combat, according to a study published in April in the Journal of the American Medical Association Psychiatry. Combat veterans are no more likely to kill themselves than veterans who were never under fire. The much-discussed estimated figure of twenty-two vets a day committing suicide is deceptive: it was only in 2008, for the first time in decades, that the U.S. Army veteran suicide rate, though enormously tragic, surpassed the civilian rate in America. And even so, the majority of veterans who kill themselves are over the age of fifty. Generally speaking, the more time that passes after a trauma, the less likely a suicide is to have anything to do with it, according to many studies. Among younger vets, deployment to Iraq or Afghanistan lowers the incidence of suicide because soldiers with obvious mental-health issues are less likely to be deployed with their units, according to an analysis published in Annals of Epidemiology in 2015. The most accurate predictor of post-deployment suicide, as it turns out, isn’t combat or repeated deployments or losing a buddy but suicide attempts before deployment. The single most effective action the U.S. military could take to reduce veteran suicide would be to screen for preexisting mental disorders.
It seems intuitively obvious that combat is connected to psychological trauma, but the relationship is a complicated one. Many soldiers go through horrific experiences but fare better than others who experienced danger only briefly, or not at all. Unmanned-drone pilots, for instance—who watch their missiles kill human beings by remote camera—have been calculated as having the same PTSD rates as pilots who fly actual combat missions in war zones, according to a 2013 analysis published in the Medical Surveillance Monthly Report. And even among regular infantry, danger and psychological breakdown during combat are not necessarily connected. During the 1973 Yom Kippur War, when Israel was invaded simultaneously by Egypt and Syria, rear-base troops in the Israeli military had psychological breakdowns at three times the rate of elite frontline troops, relative to their casualties. And during the air campaign of the first Gulf War, more than 80 percent of psychiatric casualties in the U.S. Army’s VII Corps came from support units that took almost no incoming fire, according to a 1992 study on army stress casualties.
Conversely, American airborne and other highly trained units in World War II had some of the lowest rates of psychiatric casualties of the entire military, relative to their number of wounded. A sense of helplessness is deeply traumatic to people, but high levels of training seem to counteract that so effectively that elite soldiers are psychologically insulated from even extreme risk. Part of the reason, it has been found, is that elite soldiers have higher-than-average levels of an amino acid called neuropeptide-Y, which acts as a chemical buffer against hormones that are secreted by the endocrine system during times of high stress. In one 1968 study, published in the Archive of General Psychiatry, Special Forces soldiers in Vietnam had levels of the stress hormone cortisol go down before an anticipated attack, while less experienced combatants saw their levels go up.
Shell Shock
All this is new science, however. For most of the nation’s history, psychological effects of combat trauma have been variously attributed to neuroses, shell shock, or simple cowardice. When men have failed to obey orders due to trauma they have been beaten, imprisoned, “treated” with electroshock therapy, or simply shot as a warning to others. (For British troops, cowardice was a capital crime until 1930.) It was not until after the Vietnam War that the American Psychiatric Association listed combat trauma as an official diagnosis. Tens of thousands of vets were struggling with “Post-Vietnam Syndrome”—nightmares, insomnia, addiction, paranoia—and their struggle could no longer be written off to weakness or personal failings. Obviously, these problems could also affect war reporters, cops, firefighters, or anyone else subjected to trauma. In 1980, the APA finally included post-traumatic stress disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.
Thirty-five years after acknowledging the problem in its current form, the American military now has the highest PTSD rate in its history—and probably in the world. Horrific experiences are unfortunately universal, but long-term impairment from them is not, and despite billions of dollars spent on treatment, half of our Iraq and Afghanistan veterans have applied for permanent disability. Of those veterans treated, roughly a third have been diagnosed with PTSD. Since only about 10 percent of our armed forces actually see combat, the majority of vets claiming to suffer from PTSD seem to have been affected by something other than direct exposure to danger.
This is not a new phenomenon: decade after decade and war after war, American combat deaths have dropped steadily while trauma and disability claims have continued to rise. They are in an almost inverse relationship with each other. Soldiers in Vietnam suffered roughly one-quarter the casualty rate of troops in World War II, for example, but filed for disability at a rate that was nearly 50 percent higher, according to a 2013 report in the Journal of Anxiety Disorders. It’s tempting to attribute this disparity to the toxic reception they had at home, but that doesn’t seem to be the case. Today’s vets claim three times the number of disabilities that Vietnam vets did despite a generally warm reception back home and a casualty rate that, thank God, is roughly one-third what it was in Vietnam. Today most disability claims are for hearing loss, tinnitus, and PTSD—the latter two of which can be exaggerated or faked. Even the first Gulf War—which lasted only a hundred hours—produced nearly twice the disability rates of World War II. Clearly, there is a feedback loop of disability claims, compensation, and more disability claims that cannot go on forever.
Part of the problem is bureaucratic: in an effort to speed up access to benefits, in 2010 the Veterans Administration declared that soldiers no longer have to cite a specific incident—a firefight, a roadside bomb—in order to be eligible for disability compensation. He or she simply has to report being impaired in daily life. As a result, PTSD claims have reportedly risen 60 percent to 150,000 a year. Clearly this has produced a system that is vulnerable to abuse and bureaucratic error. A recent investigation by the VA’s Office of Inspector General found that the higher a veteran’s PTSD disability rating, the more treatment he or sh
e tends to seek until achieving a rating of 100 percent, at which point treatment visits drop by 82 percent and many vets quit completely. In theory, the most traumatized people should be seeking more help, not less. It’s hard to avoid the conclusion that some vets are getting treatment simply to raise their disability rating.
In addition to being an enormous waste of taxpayer money, such fraud, intentional or not, does real harm to the vets who truly need help. One Veterans Administration counselor I spoke with described having to physically protect someone in a PTSD support group because some other vets wanted to beat him up for faking his trauma. This counselor, who asked to remain anonymous, said that many combat veterans actively avoid the VA because they worry about losing their temper around patients who are milking the system. “It’s the real deals—the guys who have seen the most—that this tends to bother,” this counselor told me.
The majority of traumatized vets are not faking their symptoms, however. They return from wars that are safer than those their fathers and grandfathers fought, and yet far greater numbers of them wind up alienated and depressed. This is true even for people who didn’t experience combat. In other words, the problem doesn’t seem to be trauma on the battlefield so much as reentry into society. Anthropological research from around the world shows that recovery from war is heavily influenced by the society one returns to, and there are societies that make that process relatively easy. Ethnographic studies on hunter-gatherer societies rarely turn up evidence of chronic PTSD among their warriors, for example, and oral histories of Native American warfare consistently fail to mention psychological trauma. Anthropologists and oral historians weren’t expressly looking for PTSD, but the high frequency of warfare in these groups makes the scarcity of any mention of it revealing. Even the Israeli military—with mandatory national service and two generations of intermittent warfare—has by some measures a PTSD rate as low as 1 percent.
If we weed out the malingerers on the one hand and the deeply traumatized on the other, we are still left with enormous numbers of veterans who had utterly ordinary wartime experiences and yet feel dangerously alienated back home. Clinically speaking, such alienation is not the same thing as PTSD, but both seem to result from military service abroad, so it’s understandable that vets and even clinicians are prone to conflating them. Either way, it makes one wonder exactly what it is about modern society that is so mortally dispiriting to come home to.
Soldier’s Creed
Any discussion of PTSD and its associated sense of alienation in society must address the fact that many soldiers find themselves missing the war after it’s over. That troubling fact can be found in written accounts from war after war, country after country, century after century. Awkward as it is to say, part of the trauma of war seems to be giving it up. There are ancient human behaviors in war—loyalty, inter-reliance, cooperation—that typify good soldiering and can’t be easily found in modern society. This can produce a kind of nostalgia for the hard times that even civilians are susceptible to: after World War II, many Londoners claimed to miss the communal underground living that characterized life during the Blitz (despite the fact that more than 40,000 civilians lost their lives). And the war that is missed doesn’t even have to be a shooting war: “I am a survivor of the AIDS epidemic,” a man wrote on the comment board of an online talk I gave about war. “Now that AIDS is no longer a death sentence, I must admit that I miss those days of extreme brotherhood . . . which led to deep emotions and understandings that are above anything I have felt since the plague years.”
What all these people seem to miss isn’t danger or loss, per se, but the closeness and cooperation that danger and loss often engender. Humans evolved to survive in extremely harsh environments, and our capacity for cooperation and sharing clearly helped us do that. Structurally, a band of hunter-gatherers and a platoon in combat are almost exactly the same: in each case, the group numbers between thirty and fifty individuals, they sleep in a common area, they conduct patrols, they are completely reliant on one another for support, comfort, and defense, and they share a group identity that most would risk their lives for. Personal interest is subsumed into group interest because personal survival is not possible without group survival. From an evolutionary perspective, it’s not at all surprising that many soldiers respond to combat in positive ways and miss it when it’s gone.
There are obvious psychological stresses on a person in a group, but there may be even greater stresses on a person in isolation. Most higher primates, including humans, are intensely social, and there are few examples of individuals surviving outside of a group. A modern soldier returning from combat goes from the kind of close-knit situation that humans evolved for into a society where most people work outside the home, children are educated by strangers, families are isolated from wider communities, personal gain almost completely eclipses collective good, and people sleep alone or with a partner. Even if he or she is in a family, that is not the same as belonging to a large, self-sufficient group that shares and experiences almost everything collectively. Whatever the technological advances of modern society—and they’re nearly miraculous—the individual lifestyles that those technologies spawn may be deeply brutalizing to the human spirit.
“You’ll have to be prepared to say that we are not a good society—that we are an antihuman society,” anthropologist Sharon Abramowitz warned when I tried this theory out on her. Abramowitz was in Ivory Coast during the start of the civil war there in 2002 and experienced firsthand the extremely close bonds created by hardship and danger. “We are not good to each other. Our tribalism is about an extremely narrow group of people: our children, our spouse, maybe our parents. Our society is alienating, technical, cold, and mystifying. Our fundamental desire as human beings is to be close to others, and our society does not allow for that.”
This is an old problem, and today’s vets are not the first Americans to balk at coming home. A source of continual embarrassment along the American frontier—from the late 1600s until the end of the Indian Wars, in the 1890s—was a phenomenon known as “the White Indians.” The term referred to white settlers who were kidnapped by Indians—or simply ran off to them—and became so enamored of that life that they refused to leave. According to many writers of the time, including Benjamin Franklin, the reverse never happened: Indians never ran off to join white society. And if a peace treaty required that a tribe give up their adopted members, these members would often have to be put under guard and returned home by force. Inevitably, many would escape to rejoin their Indian families. “Thousands of Europeans are Indians, and we have no examples of even one of those aborigines having from choice become European,” wrote a French-born writer in America named Michel-Guillaume-Saint-Jean de Crèvecoeur in an essay published in 1782.
One could say that combat vets are the White Indians of today, and that they miss the war because it was, finally, an experience of human closeness that they can’t easily find back home. Not the closeness of family, which is rare enough, but the closeness of community and tribe. The kind of closeness that gets endlessly venerated in Hollywood movies but only actually shows up in contemporary society when something goes wrong—when tornados obliterate towns or planes are flown into skyscrapers. Those events briefly give us a reason to act communally, and most of us do. “There is something to be said for using risk to forge social bonds,” Abramowitz pointed out. “Having something to fight for, and fight through, is a good and important thing.”
Certainly the society we have created is hard on us by virtually every metric that we use to measure human happiness. This problem may disproportionately affect people, like soldiers, who are making a radical transition back home.
It is incredibly hard to measure and quantify the human experience, but some studies have found that many people in certain modern societies self-report high levels of happiness. And yet numerous cross-cultural studies show that as affluence and urbanization rise in a given society, so do rates of depression,
suicide, and schizophrenia (along with health issues such as obesity and diabetes). People in wealthy countries suffer unipolar depression at more than double the rate that they do in poor countries, according to a study by the World Health Organization, and people in countries with large income disparities—like the United States—run a much higher risk of developing mood disorders at some point in their lives. A 2006 cross-cultural study of women focusing on depression and modernization compared depression rates in rural and urban Nigeria and rural and urban North America, and found that women in rural areas of both countries were far less likely to get depressed than urban women. And urban American women—the most affluent demographic of the study—were the most likely to succumb to depression.
In America, the more assimilated a person is into contemporary society, the more likely he or she is to develop depression in his or her lifetime. According to a 2004 study in The Journal of Nervous and Mental Disease, Mexicans born in the United States are highly assimilated into American culture and have much higher rates of depression than Mexicans born in Mexico. By contrast, Amish communities have an exceedingly low rate of reported depression because, in part, it is theorized, they have completely resisted modernization. They won’t even drive cars. “The economic and marketing forces of modern society have engineered an environment promoting decisions that maximize consumption at the long-term cost of well-being,” one survey of these studies, from the Journal of Affective Disorders in 2012, concluded. “In effect, humans have dragged a body with a long hominid history into an overfed, malnourished, sedentary, sunlight-deficient, sleep-deprived, competitive, inequitable and socially-isolating environment with dire consequences.”
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