Combat Stress vs. Post Traumatic Stress Disorder

By Cmdr. Carrie Kennedy, Ph.D., ABPP, neuropsychologist/aerospace experimental psychologist, Marine Corps Embassy Security Group

1st Medical Battalion, Combat Stress Team, Helmand Province, 2010. Left to right: Hospitalman Ryan Baker, Hospital Corpsman 3rd Class Casey Brown, Hospitalman Andrew Brown, Lt. Cmdr. Carrie Kennedy, Lt. Cmdr. George Cowan and Lt. Cmdr. Robert Lippy. (Photo courtesy of Cmdr. Carrie Kennedy)
First Medical Battalion, Combat Stress Team, Helmand Province, 2010. Left to right: Hospitalman Ryan Baker, Hospital Corpsman 3rd Class Casey Brown, Hospitalman Andrew Brown, Lt. Cmdr. Carrie Kennedy, Lt. Cmdr. George Cowan and Lt. Cmdr. Robert Lippy. (Photo courtesy of Cmdr. Carrie Kennedy)

It seems like the terms combat stress and PTSD are everywhere these days; it’s hard to go a few days without seeing a news story about veterans and these issues.  But what are these concepts?  Do they mean the same thing? And perhaps most important what can be done?

Combat stress and PTSD are VERY different things. Unfortunately, sometimes they look quite similar which makes them somewhat complicated.

By definition, combat stress is an expected and predictable reaction to combat experiences. After being in a combat zone where people are under constant physiological stress (for example, poor diet, extreme temperatures, little opportunity for good personal hygiene, etc.) and psychological stress (for example, concerns about the presence of improvised explosive devices or snipers or the death of fellow service members), it is expected that most people will experience a number of responses.

These responses often show up as hyperstartle (that exaggerated response when something surprises you – often a loud noise), hypervigilance (being always on guard or super-alert), bad dreams/nightmares, irritability, sleep problems, etc.  While these sound negative, some of these reactions are actually considered adaptive, notably hyperstartle and hypervigilance, as well as other benefits of combat stress, including increased physical strength, better endurance and enhanced feelings of competency (not all combat stress is bad).

PTSD, on the other hand, refers to a psychiatric disorder which impairs functioning. It is considered very serious whereas combat stress is considered standard.

To receive a diagnosis of PTSD, a number of specific symptoms have to be present following a traumatic event in which death, serious injury or sexual violation occurred or was a real possibility. These include re-experiencing symptoms (such as recurrent dreams, flashbacks or intrusive images), avoidance symptoms (such as avoiding conversations about the event or people associated with the event, memory loss, etc.) as well as other problems such as sleep disturbance, irritability/anger problems, concentration difficulties, hypervigilance or hyperstartle.

Hospital Corpsmand 3rd Class Casey Brown provides follow-up blast concussion assessment followed by a few minutes of combat stress education to a Marine injured in an IED blast. A few minutes of strategic education can help to prevent the development of problems following combat events. (Photo courtesy of Cmdr. Carrie Kennedy)
Hospital Corpsman 3rd Class Andrew Brown provides follow-up blast concussion assessment followed by a few minutes of combat stress education to a Marine injured in an IED blast. A few minutes of strategic education can help to prevent the development of problems following combat events. (Photo courtesy of Cmdr. Carrie Kennedy)

You’ll notice some overlap between combat stress responses and PTSD symptoms, but that doesn’t mean they are addressed in the same way.Keep in mind that combat stress isn’t considered a medical problem or something that needs treatment. For many war veterans, combat stress simply wears off after being back in the states for a few weeks to months. However, if service members don’t do certain things, combat stress can persist or morph into something else (like PTSD, depression, an alcohol problem, etc.).  Letting people know what responses are expected and giving some brief education about them can help to prevent problems.

Because of destigmatization programs and policies, service members are becoming more likely to question whether or not their combat stress reactions should worry them. Military mental health providers and psychiatric technicians can provide one or two sessions of psychoeducation discussing what combat stress is and what the usual reactions are, assist in processing difficult experiences, and teach how to proactively address combat stress (for example, maintaining contact with other veterans, having a plan for anniversaries of friends’ deaths, keeping alcohol use low, etc.). For those with normal reactions, this is often all it takes to make a smooth transition from the combat zone.

However, the real key to effective management of combat stress and long term adjustment is something that veterans have known through the ages – namely – veterans have to be in regular contact with other veterans. Talking over difficult experiences with members of the same unit is the best way to process combat experiences, stay grounded, get rid of lingering doubts and concerns and prevent the development of abnormal problems. This is done somewhat constantly while in the combat zone and should continue upon return from the warzone. Other good people to talk to are veterans of the same war even though they may have served in a different unit or branch of service as well as veterans of any other war.  While warfare changes somewhat over time, the basic stressors are enduring. American Legions, Veterans of Foreign Wars (VFWs) and other veteran-centric groups are significant assets in effectively dealing with combat stress.

What about PTSD? While treatment for PTSD will involve some of the same concepts as those necessary to effectively manage combat stress, the primary interventions need to be done with a mental health provider. The good news is that there is very effective treatment available – therapies such as Cognitive Processing Therapy and Exposure Therapy are provided by just about every mental health department in military/VA hospitals and clinics. These treatments help with not only symptom resolution but also lifelong strategies for the effective management of disturbing wartime experiences, decreasing the likelihood of symptom recurrence.

In short, combat stress is a reaction which through some basic self-implemented strategies, in addition to the passage of time, wears off. Terrible experiences and memories will always be troubling to think about – the goal is never to make these kinds of experiences easy. However, through observation of anniversaries, life-long interactions with members of the unit and involvement with other veterans, veterans typically move into different phases of their lives without difficulty.

PTSD is a higher hurdle, but not one which is impossible to get over. New, empirically validated treatments effectively address PTSD, even for veterans of prior wars and it is highly recommended that veterans experiencing PTSD go get the help they deserve.