Dr Ruwan M Jayatunge M.D.

Combat soldiers who were exposed to distressing battle events can go in to dissociative reactions. Dissociation can be interpreted as a protective or defensive reaction in extreme stress. Repression of war experience may be a temporary reaction. Among the dissociative features psychogenic seizures, psychogenic tremors, aphonias and fugue states are frequent. Some of these reactions evident soon after the traumatic battle events and some manifest as delayed reactions. The combat stresses led soldiers go in to an unprecedented numbers suffering from dissociative disorders.The Nature of Dissociative Disorders in Combat

The dissociative disorders are usually associated with trauma in the recent or distant past, or with an intense internal conflict that forces the mind to separate incompatible or unacceptable knowledge, information, or feelings. Dissociative disorders appear to be ways of avoiding psychological stress while denying personal responsibility for doing so. In this context combat related stress can generate a numerous traumatic experiences and this overwhelming stress can lead to dissociation. In addition combat experience in many occasions can cause unresolved mental conflicts among the soldiers.
Somatoform dissociation

Somatoform dissociation is a lack of the normal integration of sensorimotor components of experience such as hearing, seeing, feeling, speaking, moving, etc. It is a major consequence of psychological trauma. Trauma-related structural dissociation, including somatoform symptoms model was developed by British army psychiatrist/psychologist Charles Samuel Myers. He had investigated soldiers suffering from vivid, painful sensorimotor memories of the trauma, i.e., hypermnesia, partial or complete amnesia of the trauma, detachment, and numbing. Myers and other WWI psychiatrists also noted various dissociative symptoms more directly manifested in the body, such as lack of awareness or control of movements and sensations.Private D witnessed the death of four soldiers following an incoming mortar. Although Private D was physically unharmed he was frightened and felt powerless. He went in to heightened stress reaction and later evacuated. Even after several years Private D could not remember how he was evacuated from his bunker and he has memory lapses about the incident which occurred in the battle field.

Dissociative Amnesia

Dissociative amnesiais classified by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, as one of the dissociative disorders, which are mental disorders in which the normally well-integrated functions of memory, identity, perception, or consciousness are separated (dissociated). Patients with dissociative amnesia usually report a gap or series of gaps in their recollection of their life history. The gaps are usually related to episodes or abuse or equally severe trauma. In dissociative amnesia, the continuity of the soldierƒÆ’‚¢ƒ¢-¡‚¬ƒ¢-¾‚¢s memory is disrupted. They have recurrent episodes in which they forget important personal information or events, usually connected with trauma or severe stress.

Fugue States in the Battle Field

Fugue states can be resulted from dissociative disorders as well as depressive disorders. Dissociative fugue states are not uncommon in combat situations.

Corporal A has served 17 years in the operational areas. On one occasion he went in to dissociative fugue and walked in to the enemy linens. When he was found by a friendly group of soldiers Corporal A had thrown his weapon and was wondering about in hostile territory. He did not have any idea of what he was doing near the enemy lines. Later this soldier was diagnosed with dissociative disorder.

Psychogenic Seizures

Psychogenic seizures are caused by subconscious mental activity, not abnormal electrical activity in the brain. Psychogenic seizures are not classified as epilepsy and it can arise from various psychological factors, may be prompted by stress, and may occur in response to suggestion. It has also been found that such disorders may be self-induced. They may be used to get attention, to be excused from work or merely to escape an intolerable combat situation.Corporal C was exposed to traumatic combat situations. A number of times he witnessed killings and faced enemy artillery attacks. Several times his platoon was surrounded by the enemy and every occasion he felt desolated. Corporal C was lucky enough to survive without any physical injuries. In 2004 he manifested convulsions and investigated at the National hospital. His post ictal EEG report and brain scan did not confirm any pathological condition. The eye witnessed account revealed that Corporal C is experiencing psychogenic epilepsy. He was diagnosed with Dissociative Disorder.
Psychogenic Aphonia

Psychogenic voice disorders are distinguished from other vocal dysfunction by the fact that, though the symptoms or secondary characteristics are physical or ‘organic’, the origins of the problem are psychological rather than physical. It is not always easy to distinguish from listening and quick observation alone whether the cause of the problem is psychological or organic. It is usually important to have a full medical and laryngeal investigation to rule out physical causes first (such as viral infection, allergy, neurological disease, cancer). Examples of psychogenic causes of vocal problems are chronic anxiety states, stress, depression, intrapersonal and interpersonal problems (often dating back to unresolved emotional and psychological issues from childhood), and trauma.
Lance Corporal S was investigated for tremors and weakness of the right hand which had no apparent medical basis. After neuro-physiological investigations it was revealed that Lance Corporal S was suffering from psychogenic tremors. Combat stress may have a link with his psychogenic tremors. Several years ago he had undergone a numerous combat related stress events. At one incident (1991) they were trapped inside the Elephant Pass camp for nearly one month. He was distressed and uncertain about the rescue. Finally they were freed by the friendly forces. The psychogenic tremors in the right hand indicate unconscious avoidance of the battle field.

Psychogenic attacks differ from epileptic seizures in those out-of-phase movements of the upper and lower extremities, pelvic thrusting, and side-to-side head movements are evident. However, psychogenic seizures vary from one occurrence to another and are not readily stereotyped. Indicators like pupillary dilation, depressed corneal reflexes, the presence of Babinski responses, autonomic cardio-respiratory changes, tongue biting and urinary/fecal incontinence are more probable with epilepsy and are not usually manifested in psychogenic seizures.

Bombardier T experienced horrendous combat events during 1997-1998. On one occasion he and his team went on an ambush. Unexpectedly the enemy attacked them and Bombardier T witnessed the death of his friends. The enemy shot them and chopped their heads with swards. He was hiding in the woods and observed the terrible events. He was the only member who survived that day. In 1993 he complained of the numbness of the right hand and difficulty in speech. Bombardier T was seen by the Consultant ENT surgeon and found no ENT pathology. He regained his voice after hypnotherapy.

Psychogenic Tremors

Tremor is defined as a rhythmic, involuntary, oscillating movement of a body part occurring in isolation. Psychogenic tremor may involve any part of the body, but it most commonly affects the extremities. Usually, tremor onset is sudden and begins with an unusual combination of postural, action, and resting tremors. Psychogenic tremor decreases with distraction and is associated with multiple other psychosomatic complaints.

Delayed Dissociative Reactions

Combat stress has a residual effect on some veterans. The delayed retrieval of traumatic events have been written about for nearly 100 years in clinical literature military veterans who survived combat. Some of the dissociative reactions can manifest 5-10 years after the original trauma or may be after a long period. According to Dr. Michael Robertson of the Mayo Wesley Clink, aging veterans of WW2 have manifested combat stress reactions after 50 years. Therefore treatment of combat stress cannot be limited to the battle era.