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After
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After
the war is over …
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After the war is over …
PTSD symptoms in World War II veterans
Abstract
Little is known about the psychological effects of war service on Australian World War II veterans. Eighty-eight survivors of one of the war's most intense actions responded to a survey asking for their recollections of the battle, and for a description of its affect upon them. Many said that they had yet to recover from the experience. Large numbers indicated continuing ill effects. These included nightmares, sleeplessness, negative imagery, "flashbacks", problems with concentration, weeping, generalized anxiety, and distress caused by situations recalling the battle. Many commented that they had never talked to anyone about their war experiences, or the effects of these experiences. Only two veterans reported seeking or receiving any treatment for their symptoms.
After the war is over …
PTSD symptoms in World War II veterans
World War II combat exposure has been shown to affect long-term mental and physical health. For example Elder, Shanahan and Clipp (1997) reported combat exposure predicted physical decline and death in the 15 years after the war. In addition, a longitudinal study of Harvard University alumni found 56% of World War II veterans who experienced heavy combat were chronically ill or dead by age 65 (Lee, Vaillant, Torrey & Elder, 1995).
Research with World War II (Lee, Vaillant, Torrey & Elder, 1995) and Vietnam (Pitman, Altman & Macklin, 1989) veterans also suggests combat veterans are at risk of Post Traumatic Stress Disorder (PTSD), and degree of combat exposure influences the severity of PTSD. According to DSM-IV (APA, 1994), PTSD has three clusters of symptoms: arousal, re-experiencing and avoidance. Arousal symptoms include irritability or outbursts of anger, difficulty concentrating, and sleep disturbance. Re-experiencing symptoms include flashbacks, intrusive thoughts, nightmares, and emotional distress or physiological arousal when reminded of the trauma. Avoidance symptoms include avoiding thinking of the event or reminders of the event, low interest in activities, detachment or distance from others, and emotional numbing.
Combat veterans typically report symptoms in all these areas. In addition, the effects of combat-related PTSD appear to be long lasting. For example, Hamilton and Workman (1998) describe their persistence in a veteran 75 years after World War I.
Moreover, World War II veterans seem reluctant to seek treatment. A study of Dutch veterans conducted 47 years after the war found that 59% of those still suffering PTSD had not seen any health care professional in the last three years (Bramsen & van der Ploeg, 1999).
The health of veterans exposed to heavy combat is clearly an issue, and the mental health of Vietnam veterans has been a topic of academic interest and humanitarian concern for many years (e.g., Creamer, Jackson & Ball, 1996; Kulka et al., 1990). In contrast, there has been little follow-up of World War II combat veterans, particularly in Australia. The aim of this study is therefore to describe the mental health of a sample of these veterans. As other evidence suggests they may be reluctant to seek help for symptoms of mental ill health or PTSD, this research sought information from the veteran community rather than a treatment-seeking sample.
The Isurava battle took place on the Kokoda Track in Papua in August 1942. Isurava lies high in the jungle several days walk and climb from Port Moresby. The terrain is steep. The weather is extremely hot during the day, and wet and cold at night. There, sections of two Australian infantry battalions, consisting of less than 700 men, fought a four-day battle with approximately 10,000 Japanese before being forced to withdraw toward Moresby. The battle was strategically significant to Australia's defence. However, the fighting was intense, and its cost in human terms was enormous. Five hundred and forty six men of one battalion started up the Track. Five weeks later 87 came out. One hundred and sixteen had been killed, and many of their bodies have never been found. The rest were wounded or cut off trying to make their way out of the jungle.
In 2000 a group of seven veterans from the two battalions travelled with a support team to PNG to attempt to identify the battle site. The veterans' Battalion Associations supported the survey. Part sponsorship was provided by a national magazine, which asked for a report on the trip. Using lists provided by the battalion associations, battalion members were written to individually. The cover letter explained the information provided might be used in a report to the magazine, and also in academic research.
Veterans were asked to either write as much or as little as they wanted, or ring the researcher. In addition to questions relating to battle experiences, the veterans were asked open-ended questions such as “When did the action end for you, and how?”; “Tell me about what happened when you came out. How long did it take you to recover (if you have)”; and “How did what happened in the Kokoda Track and Isurava areas affect you later?”
Responses were received from 116 veterans aged from 75 to 91 years. Eighty eight had participated in the battles along the Kokoda Track. Most responses were written. Answers varied from a few lines to 76 single-spaced typewritten pages. Some sent additional material. Some potential respondents rang the researcher and asked if they could speak on the telephone. Some both wrote and rang. Some asked if they could tape record their memories and send them to the researcher. Others asked if the researcher would visit them and tape record an interview. In all cases the researcher agreed to the requests. The results that follow are a qualitative report of the veterans' descriptions of their mental health.
Several consistent mental health effects emerged. Veterans most frequently reported problems with concentration, sleep disturbance, nightmares, flashbacks, intrusive thoughts, and emotional distress. Many reported actively avoiding reminders of the event.
Several veterans reported chronic problems of concentration. For example, “ I was discharged in September 1945 and returned to my job, but could not settle down and left the job in October 1946, returning to my old trade... That job did not last long either…”. Another veteran said “As for my time, after being discharged, I was hopeless. Couldn't settle down, although had a wonderful wife, two lovely kids…”
Ongoing sleep disturbances and nightmares were also common. For example, “I guess none of us have fully got over the time we were away. I suffer from nerves and anxiety; sleepless nights and most nights lay awake and think about the whole rotten episode in my life”. Another veteran said “I took my memories of ghastly experiences on a refresher course every time I saw war pictures on television, and never slept well”.
Ongoing nightmares were also reported. One man commented “I still suffer nightmares out of this. I went away fit and came back not very fit…”. Another stated “You never really get it our of your mind. In my case, I still have dreams…I often wonder how I went through that horrific maelstrom and came out alive”. A third reported the outcome of seeking compensation for these recurring nightmares “I tried to convince the Repat. Dept that I should be given a little pension to balance out these nightmares and illnesses, but after quite a lot of medical exams by Repat. doctors, I was virtually called a bludger, so I told them to get stuffed! Repat. did accept me for one thing though – tinea – for Christ sake!”.
Some veterans reported still suffering from flashbacks and distress caused by situations that recall the battle. For example, one recalled “Working in the garden when wet, I sometimes get back the stench of blood and death”. For another “Not a day goes by it all comes back again… The sick, wounded in hospital who could not walk…. I can still hear their screams as the Japs killed them…I came home broken in mind, body, and spirit and it all still comes back again…”. And a third “I've never got over it… just worked really hard to try to get around it. One day I saw a green fly … I couldn't stop shaking. I had to go inside and sit down. The last time I'd seen a green fly was going in and out of the ears of dead Japanese”. One veteran noted “I was quite unable to sleep in a closed room for many years – had to have the door open”; and another said “The humidity caused me to have a constant headache and fingers and toes, and under my armpits would stick together. This effect is still with me today, cannot use an electric blanket or a sleeping bag without getting claustrophobia”.
Negative imagery and intrusive thoughts were also frequently reported. One respondent recalled “There is one thing …I cannot get out of my mind. S., 17½ yrs old, and I laid on the ground, when a mountain gun shell fell on S.'s side. When I looked up, he had half his foot hanging off and holes in his back. How I got him down to the track, I do not know, when I got my senses back, the doctor was cutting off part of his foot, with an army knife”.
Another veteran wrote “I have never really been free in my mind of my experiences of war endured during my time in New Guinea. You ask how long it took to recover. Well, not yet as I still have my retracing steps of how, why”. For yet another: “How did one survive all the trauma, death? I am afraid it is an on-going question – something one cannot explain to people who were not there”. Others commented “I try to cast the gory details from my mind but that's hard when you can still see your dead mates laying there”; “It will always be in my thoughts”; “Really, it's always on my mind day in and day out to see always those young Australians lying under all those white crosses… My mind always goes back to the big battle we fought… That's constantly in my memory”; “I have never really been free in my mind of my experiences of war endured during my time in New Guinea… I was wounded behind the Japanese lines… That night is my constant companion”.
Other responses also highlighted the continuing effects of the battle. An officer worried “I for one have never fully recovered. I started out with eight men and I came out with three. Was I a bad leader or were the odds too great?…”. An infantryman said “At the start I weighed 10 stones. When we came out of the valley, it was 6½ stones... It seemed like a nightmare that never ended... my nerves are bad…as the years passed by these conditions worsened. The war years have left its mark on us...”. Another reported “I had a bright future planned ... My doctor advised me to retire when I was 60 years of age. He was very concerned re my mental state. Gone was the future I had fought for…”. Another said “I have not recovered from the memories of Kokoda and Isurava and was unable to work because of a bout of war neurosis in 1948 for six months”. Others responded in a similar vein. For example “The effects… will live with me forever. It's always with me. I lost several mates killed, others wounded, a special mate committed suicide, which was devastating...”. Another commented “You ask how long it took to recover. Well, not yet as I still have my retracing steps of how, why”.
Some veterans attempted to explain these outcomes. For example, one noted “I am quite sure that everyone who has endured almost total physical and emotional exhaustion, almost total starvation and a considerable all embracing fear for extended periods as we did in those dreadful mountains, and then do it all again a few weeks later at Gona, never fully recovers to be his former self, regardless of subsequent treatment and conditions. I believe his emotional capacity is in some ways restricted, and that probably he is, in some ways, a little crazy”.
Yet, despite the severity of their symptoms, the veterans often commented that they never talked about their war experiences, or sought help. One said “I could never speak about my experience to anybody and do not like to think about it. It was so depressing”. Another noted “It was very bad, very bad… I wrote down what I could. I couldn't remember everything. And I've never told anyone about it you see. This is the first time I've ever mentioned what I went through…”. A third explained “It has taken a long time to be able to talk about things that happened, even now, I see those lads at Kokoda every night, some were only 17 years old”.
Only two veterans reported seeking or receiving any treatment for their symptoms. One explanation is that stories of the Repatriation Department's failure to acknowledge some men's symptoms as legitimate outcomes of war service (as in the example of the veteran seeking a pension for recurring nightmares) may have dissuaded others from seeking help.
Another explanation perhaps comes from the tape made by one veteran. After describing his experiences, he notes, “Many many years have rolled on since those wartime days. There's an old saying of mine. Try to forget. Try to forget those five and a half years service we gave in wartime to our country. Try to forget it. Don't stretch the wounds. Don't stretch the scars. Let the wounds heal. Let the wounds heal.”
Despite the latter veteran's hope that war experiences could be forgotten, it is clear that for many veterans the memories linger. Thoughts of battle experiences interrupt their waking hours, and make sleep difficult. In addition, veterans' descriptions of the effects of their war service are congruent with the three clusters of Post Traumatic Stress Disorder symptoms: arousal, re-experiencing and avoidance.
Yet most veterans in this study see these symptoms as a natural outcome of war service. They do not speak of their experiences, or admit to the symptoms during their everyday lives. Nor have they sought any form of treatment. One reason may be that treatment which requires conscious recollection and description of their experiences may seem worse than the current spontaneous recollections. Veterans' desires not to talk about their experiences may extend to the therapeutic context.
Another possibility is that the veterans of this era place a high value on independence and self-reliance. A study of Dutch World War II veterans found the desire to solve problems independently was a common reason for not seeking professional help for PTSD symptoms (Bramsen & van der Ploeg, 1999). Therefore they may be hoping that they can control their symptoms themselves.
A third option is that they may accept the psychological consequences of war in the same way they accepted the reality of war, and its physical consequences. They carry the mental scars in the same way as they would carry physical scars.
This study did not have the rigour normally expected of scientific research. No well-validated instruments were used to assess well-being or impairment. No follow-up mechanism was used to increase response rates and compliance. There was no standardized response format – veterans answered whatever questions they wanted to answer, and told their story in their own words. They were also encouraged to use whatever response form suited them – written, taped, or in a face-to-face interview with the researcher.
However, the responses show that the psychological well-being of many veterans is affected by a battle which took place 60 years ago. Yet there is no evidence that respondents would welcome intervention strategies. Perhaps the best that can be hoped for is that those dealing with this generation will better understand the reasons for some of their behaviour and emotions.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th. Ed.). Washington DC: APA.
Bramsen, I., & van der Ploeg, H.M. (1999). Use of medical and mental health care by World War II survivors in The Netherlands. Journal of Traumatic Stress, 12, 243-261.
Creamer, M., Jackson, A., & Ball, R. (1996). A profile of help-seeking Australian veterans. Journal of Traumatic Stress, 9, 569-575.
Elder, G.H., Shanahan, M.J., Clipp, E.C. (1995). Linking combat and physical health: The legacy of World War II in men's lives. American Journal of Psychiatry, 154, 330-336.
Hamilton, J.D., & Workman, R.H. (1998). Persistence of combat-related posttraumatic stress symptoms for 75 years. Journal of Traumatic Stress, 11, 763-768.
Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough, R.L., Jordon, B.K., Marmer, C.R., & Weiss, D.S. (1990). Trauma and the Vietnam war generation. New York: Brunner/Mazel.
Lee, K.A., Vaillant, G.E., Torrey, W.C., & Elder, G.H. (1995). A 50-year prospective study of the psychological sequelae of World War II combat. American Journal of Psychiatry, 152(4), 516-522.
Pitman, R., Altman, B., & Macklin, M. (1989). Prevalence of posttraumatic stress disorder in wounded Vietnam veterans. American Journal of Psychiatry, 146, 667-669.
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