Psychological Trauma in Soldiers

a Challenge for the German Armed Forces (Bundeswehr)

Editorial to accompany the articles “Traumatic Experiences and Posttraumatic Stress Disorder in Soldiers Following Deployment Abroad: How Big Is the Hidden Problem?” by Wittchen and Schönfeld et al. and “Deployment-Related Stress Disorder in German Soldiers: Utilization of Psychiatric and Psychotherapeutic Treatment“ by Kowalski et al. in this issue of Deutsches Ärzteblatt International

According to the ICD-10, psychological trauma is defined as exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone. So-called post-traumatic disorders—for example, acute stress disorder, post-traumatic stress disorder (PTSD), and affective disorders—have in recent years become the focus of discussion in the psychiatric-psychotherapeutic context but also in the overall social context.

Traumatization—a long-neglected problem

Publications about the sexual and physical abuse of children and adolescents and the debate around the protection of victims after acts of violence have drawn attention to the fact that psychological trauma is a common phenomenon in our society that has thus far received too little attention. The experience of psychological trauma can prompt substantial mental suffering and psychosocial impairments. A look at the data does, however, not confirm an increase in the number of cases of trauma and post-traumatic disorders in Germany (1); rather, the findings point towards a long-neglected problem. Extensive debate within society—for example, in the media (including Deutsches Ärzteblatt [2]) and at the federal government’s so-called round table discussions—is now followed by a period of concrete changes. These include

• preventive measures,
• regulations for compensation, and
• improved support and therapy services for those affected.

One positive example are the new trauma outpatient clinics for victims of acts of violence in accordance with the law on compensation for victims, such as have been established in the form of model projects in collaboration with the responsible state authorities in North Rhine–Westphalia, Rhineland-Palatinate, Bavaria, and, since early 2012, Berlin at the Charité university medical center (Charité-Universitätsmedizin Berlin).

In the context of this overall positive development within our society, the German armed forces (Bundeswehr) are increasingly facing up to questions relating to the appropriate treatment of soldiers traumatized while deployed. Further to trauma therapeutic treatment approaches, primary and secondary prevention pose particular challenges associated with military deployment owing to the special constellation. Training and treatment processes cannot be planned in any other setting to the same extent that they can be planned for military deployment.

Deployment-related psychological trauma in soldiers

After earlier studies reported by non-German authors, Hans-Ulrich Wittchen and Sabine Schönfeld et al. (3) and Jens Kowalski et al. (4) in this issue of Deutsches Ärzteblatt International report for the first time Bundeswehr data on deployment-related psychological stress. According to (3), after a mean deployment period of 4 months, 291 in 10 000 soldiers have PTSD. The risk of developing PTSD is highest for deployments to Kunduz (Afghanistan) and explicit combat missions. The resulting prevalence of 2.9% of post-traumatic stress disorders is still notably lower than in other armies deployed to the same areas (5, 6).

It would seem that educational programs, shorter periods of deployment compared with other armies, and therefore a probably lower cumulative dose of traumatic events have a positive effect on those affected. In this context it is important to note that the study reported by Wittchen and Schönfeld et al. reported merely on PSTD—no other data are included, for example relating to anxiety disorders and affective and substance-related disorders, which might add to a more complex overall picture.

Furthermore, the study indicates that the proportion of undetected or untreated cases of PTSD is high, at 45%. Even the comparatively low incidence of PTSD in soldiers should not distract from the fact that qualified, disorder-specific treatment facilities are lacking, in spite of the fact that the numbers of overseas deployments are rising. According to Kowalski et al., the wide public discussion and psychoeducational measures in the armed forces in the time period from January 2010 through June 2011 did not result in increased utilization of psychosocial support services provided by the Bundeswehr. Instead, the data show merely a slight rise in first contacts in relation to deployment to the Balkans and in female soldiers. The data do not allow any conclusions about possible effects of cumulative traumatic experiences and other independent variables.

Utilization of therapeutic services

In order to derive practical treatment pointers from the studies it seems appropriate in future study designs to collect data on the disorders and utilization of therapeutic services separately. Especially in the military setting, consulting a physician and the associated communication with the employer with regard to fitness for deployment and ability to perform is often difficult for those affected, in spite of educational measures. Fears of impaired career opportunities and ignorance about treatment options may constitute barriers to service utilization.

The interplay of personal wellbeing, mental health, and professional deployability is a challenge for occupational health physicians in civilian companies too, especially if verbalizing psychological stress is associated with stigmatization or shame. In addition to the oft-discussed symptoms, which include hyperarousal, intrusions, and avoidance behaviors, psychological trauma often has a negative influence on personal relationships and sexuality (7). Studies have shown that even after experiences of violence that is non-sexual that many people are affected by sexual dysfunction after military deployments to war zones, and that this is independent of the development of PTSD (8).

The fact that the Bundeswehr as an employer with a substantial risk for severe psychological trauma is actively involved in evaluating the data on post-traumatic disorders in a scientific manner is to be welcomed. It seems of particular importance in this setting that future follow-up studies, which are urgently needed, use designs that take into account the specific context of soldiers’ professional environment and thus help to set out targeted therapeutic options and guidelines for how to proceed. Those who are at particular risk by virtue of their professional exposures have a right to optimal care and treatment.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Corresponding author
Prof. Dr. med. Andreas Heinz
Klinik für Psychiatrie und Psychotherapie,
Charité-Universitätsmedizin Berlin
Campus Charité Mitte
Charitéplatz 1, 10117 Berlin

Cite this as:
Schulte-Herbrüggen O, Heinz A:
Psychological trauma in soldiers—a challenge for the German armed forces (Bundeswehr). Dtsch Arztebl Int 2012; 109(35–36): 557–8. DOI: 10.3238/arztebl.2012.0557

References

1. Bieneck S, Stadler L, Pfeiffer C: Erster Forschungsbericht zur Repräsentativbefragung Sexueller Missbrauch 2011. KFN. (last accessed on 10 July 2012)

2. Häuser W, Schmutzer G, Brähler E, Glaesmer H: Maltreatment in childhood and adolescence—results from a survey of a representative sample of the German populaton. Dtsch Arztebl Int 2011; 108(17): 287–94.

3. Wittchen HU, Schönfeld S, Kirschbaum C, et al.: Traumatic experiences and posttraumatic stress disorder in soldiers following deployment abroad: how big is the hidden problem? Dtsch Arztebl Int 2012; 109(35–36): 559–68.

4. Kowalski JT, Hauffa R, Jacobs H, Höllmer H, Gerber WD, Zimmermann P: Deployment-related stress disorder in german soldiers: Utilization of psychiatric and psychotherapeutic treatment. Dtsch Arztebl Int 2012; 109(35–36): 569–75.

5. Fear NT, Jones M, Murphy D, Hull L, Iversen AC, Coker B, et al.: What are the cosequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet 2010; 375: 1783–97.

6. Hoge CW, Auchterlonie JL, Milliken CS: Mental health problems, use of the mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006; 295: 1023–32.

7. Schulte-Herbrüggen O, Ahlers CJ, Kronsbein JM, Rüter A, Bahri S, Vater A, et al.: Impaired sexual function in patients with borderline personality disorder is determined by history of sexual abuse. J Sex Med 2009; 6: 3356–63.

8. Arbanas G: Does post-traumatic stress disorder carry a higher risk of sexual dysfunctions? J Sex Med. 2010; 7: 1816–21.