Intended for healthcare professionals

Clinical Review Lesson of the week

Post-traumatic stress disorder following military combat or peace keeping

BMJ 2002; 324 doi: (Published 09 February 2002) Cite this as: BMJ 2002;324:340
  1. Roger Gabriel, civilian consultant physiciana,
  2. Leigh A Neal, consultant psychiatristb
  1. a Gulf Veterans' Medical Assessment Programme, St Thomas's Hospital, London SE1 7EH
  2. b Head of Defence PTSD Services, Duchess of Kent Military Hospital Catterick, Catterick Garrison, North Yorkshire DL9 4DF
  1. Correspondence to: R Gabriel
  • Accepted 3 December 2001

Psychological or somatic dysfunction after military conflict may hide post-traumatic stress disorder

Trauma related to military service is not only physical. Since the American civil war it has been recognised that a proportion of veterans have symptoms but few physical signs.1 Conflicts and peacekeeping tours potentially carry long term psychiatric consequences. There is a strong concordance between symptoms after conflict regardless of the conflict.1 Histories of physical symptoms would be similar if taken from veterans of any of the 20th century conflicts. In the Gulf Veterans' Medical Assessment Programme we continue to recognise new cases of post-traumatic stress disorder.2 We present four histories of people who served in the Gulf during the conflict. All patients were provisionally diagnosed by RG and the diagnoses confirmed by consultant psychiatrists.

Usually the diagnosis is not difficult, and its initial recognition is within the ability of all medical practitioners. According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),3 initiation of post-traumatic stress disorder comprises experiencing, witnessing, or being confronted with a catastrophic stressor event that involves actual or threatened death or serious injury or a threat to the physical integrity of self or others. The response involves intense fear, helplessness, or horror (box).

Criteria for diagnosis of post-traumatic stress disorder

Re-experiencing the trauma by recurrent, intrusive, distressing recollections of the stressor

Persistent efforts at avoidance of the memories and numbing of general responsiveness by adjustments in behavioural and cognitive patterns with emotional blunting

Persistent symptoms of hyperarousal: sleep impairment, irritability, reduced concentration, hypervigilance, and exaggerated startle response

Case reports

Case 1

During active service in Northern Ireland the patient was involved in a helicopter crash. The patient was strapped in but the blood and brains of his “best mate” spattered him. Four months of psychological help was deemed successful. Later, in the Gulf war, observation of …

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