Combat exposure and co-occurring mental health problems in UK Armed Forces personnel.

BACKGROUND: Mental disorders and alcohol misuse are often comorbid, and this comorbidity is more common in those who develop mental disorders following exposure to traumatic events. AIMS: To investigate the relationship between combat exposure and operational role (support versus combat) with mental disorders and associated comorbidity in a UK military cohort. METHODS: 4896 participants from a UK military cohort reported their operational role and frequency of exposure to combat events during deployment. Outcome measures included self-reported post-traumatic stress disorder, common mental disorder and alcohol misuse. RESULTS: Personnel reporting higher levels of combat exposure were more likely to meet criteria for two or more co-occurring mental disorders (odds ratio [OR] 3.90, 95% confidence interval [CI] 2.73-5.58). While having a combat role increased the risk of developing co-occurring disorders compared to having a support role (OR 1.67, 95% CI 1.26-2.23), this effect diminished following adjustment for variables including combat exposure (OR 0.89, 95% CI 0.62-1.27). CONCLUSIONS: Combat exposure may play a greater role in the development of comorbid mental disorders than operational role, i.e. job title. Clinicians treating military personnel should be alert to the increased risk of comorbid mental disorders and alcohol misuse among those with a history of combat exposure.

Delivering treatment to morally injured UK military personnel and Veterans: The clinician experience.

This study explored the experiences of clinicians in providing treatment in cases of military-related moral injury (MI). Qualitative interviews were carried out with 15 clinicians. Clinicians found patients experienced particular maladaptive appraisals following MI, which were considered different from the responses experienced after threat-based trauma. To address MI-related distress, clinicians utilized a range of treatment approaches. Several difficulties in providing care to patients following MI were described, including the impact of providing treatment on the clinicians own mental health. This study provides detailed insight into the approaches currently used to identify and treat UK Veterans with MI-related psychological problems. These findings highlight the need to evaluate the effectiveness of the treatments currently provided for MI-related psychological problems and suggest developing best practice guidance may improve clinician confidence in delivering care to those adversely impacted by MI.

Moral injury in a context of trauma.

Moral injury, characterised by guilt, shame and self-condemnation, is conceptualised either as an adjunct to post-traumatic stress disorder or as a new syndrome. Studies of symptoms and potentially morally injurious events have produced a possible definition and informed the design of rating scales. The current challenge remains the design of effective interventions. Because moral injury relates to ethical behaviour, the meaning attached to events and perceptions of the self, moral philosophy and spirituality could contribute to the design of treatments.

Extremism and common mental illness: cross-sectional community survey of White British and Pakistani men and women living in England.

BACKGROUND: Mental illnesses may explain vulnerability to develop extremist beliefs that can lead to violent protest and terrorism. Yet there is little evidence. AIMS: To investigate the relationship between mental illnesses and extremist beliefs. METHOD: Population survey of 618 White British and Pakistani people in England. Extremism was assessed by an established measure of sympathies for violent protest and terrorism (SVPT). Respondents with any positive scores (showing sympathies) were compared with those with all negative scores. We calculated associations between extremist sympathies and ICD-10 diagnoses of depression and dysthymia, and symptoms of anxiety, personality difficulties, autism and post-traumatic stress. Also considered were demographics, life events, social assets, political engagement and criminal convictions. RESULTS: SVPT were more common in those with major depression with dysthymia (risk ratio 4.07, 95% CI 1.37-12.05, P = 0.01), symptoms of anxiety (risk ratio 1.09, 95% CI 1.03-1.15, P = 0.002) or post-traumatic stress (risk ratio 1.03, 95% CI 1.01-1.05, P = 0.003). At greater risk of SVPT were: young adults (<21 versus ≥21: risk ratio 3.05, 95% CI 1.31-7.06, P = 0.01), White British people (versus Pakistani people: risk ratio 2.24, 95% CI 1.25-4.02, P = 0.007) and those with criminal convictions (risk ratio 2.23, 95% CI 1.01-4.95, P = 0.048). No associations were found with life events, social assets and political engagement. CONCLUSION: Depression, dysthymia and symptoms of anxiety and post-traumatic stress are associated with extremist sympathies.

Assessing risks of violent extremism in depressive disorders: Developing and validating a new measure of Sympathies for Violent Protest and Terrorism.

OBJECTIVE: Clinicians are tasked with assessing the relationship between violence and mental illness. Yet, there is now a legal expectation in some countries that public services, including health professionals, assess risk of violent extremism - with few available measures. We previously developed a new measure of Sympathies for Radicalisation, using items that measure Sympathies for Violent Protest and Terrorism. In this paper, we present the detailed psychometric properties of a reduced item measure of Sympathies for Violent Protest and Terrorism. We use data from two studies to test replication and then validity against outcomes of self-reported violence and convictions in the entire sample and in those with depressive symptoms. METHODS: Data from two cross-sectional neighbourhood surveys, consisting of Pakistani and Bangladeshi adults (survey 1, n = 608) and White British and Pakistani adults (survey 2, n = 618), were used to undertake confirmatory factor analysis of Sympathies for Radicalisation and produce a short measure of Sympathies for Violent Protest and Terrorism. Survey 2 data were used to test the Sympathies for Violent Protest and Terrorism's convergent validity to classify presence/absence of violence and convictions in the whole sample and for subgroups by depressive disorder. RESULTS: The seven-item measure's structure was a consistent measure of extremist attitudes across the two surveys. A threshold score of zero to classify violence was optimal (specificity = 89.7%; area under the curve = 0.75), but sensitivity to a risk of violence was poor (34.5%). The short version Sympathies for Radicalisation was a better classifier of violence in respondents with depression, dysthymia or both (area under the curve = 0.78) than respondents with neither (area under the curve = 0.69; ß = 0.62, 95% confidence interval = [-0.67, 1.92]; standard error = 0.66). CONCLUSION: The seven-item measure of Sympathies for Violent Protest and Terrorism is an accessible and valid measure for clinical assessments and helpfully identifies low risk of violence. It enables clinicians to conduct detailed assessments of people endorsing one or more of the items, although further research is needed.

Patients behind the front lines: the exchange of mentally-ill patients in the 1948 Arab-Israeli War.

The British Mandate in Palestine ended abruptly in 1948. The British departure engendered a complex situation which affected all areas of life, and the country's health system was no exception. Gradual transition of the infrastructure was almost impossible owing to the ineffectiveness of the committee appointed by the United Nations. The situation was further complicated by the outbreak of the Arab-Israeli War. We relate for the first time the story of 75 Jewish patients who were left in a former British mental hospital in Bethlehem - deep behind the front lines. Despite the hostilities, there were complex negotiations about relocating those patients. This episode sheds light on the Jewish and Arab relationship as it pertained to mental institutions during and immediately after the British Mandate.

The symptomatology of psychological trauma in the aftermath of war (1945-1980): UK army veterans, civilians and emergency responders.

BACKGROUND: UK veterans suffering from a psychological or psychiatric illness as a consequence of service in the Second World War were entitled to a war pension. Their case files, which include regular medical assessments, are a valuable resource to investigate the nature, distribution and duration of symptoms. METHODS: A standardised form was used to collect data from pension records of a random sample of 500 UK army veterans from the first presentation in the 1940s until 1980. Data were also gathered from 50 civilians and 54 emergency responders with a pension for post-traumatic illness following air-raids. RESULTS: The 10 most common symptoms reported by veterans were anxiety, depression, sleep problems, headache, irritability/anger, tremor/shaking, difficulty completing tasks, poor concentration, repeated fears and avoidance of social contact. Nine of the 10 were widely distributed across the veteran population when symptoms were ranked by the number of subjects who reported them. Nine symptoms persisted significantly longer in the veteran sample than in emergency responders. These included seven of the most common symptoms, together with two others: muscle pain and restlessness. The persistence of these symptoms in the veteran group suggests a post-traumatic illness linked to lengthy overseas service in combat units. CONCLUSIONS: The nature and duration of symptoms exhibited by veterans may be associated with their experience of heightened risks. Exposure to severe or prolonged trauma seems to be associated with chronic multi-symptom illness, symptoms of post-traumatic stress and somatic expressions of pain that may delay or complicate the recovery process.

The return of the traumatized army veteran: a qualitative study of UK ex-servicemen in the aftermath of war, 1945 to 2000.

The challenge of transition from service to civilian life is explored through the experiences of a sample of 225 UK army veterans between 1945 and 2000. All subjects had a war pension for a psychological disorder, and most had served overseas in combat roles. Statements about issues of adjustment and health were analyzed by the constant comparison method. Although 20 themes were identified, three ('anxiety, nerves and depression', 'enduring illness attributed to combat exposure', and 'illness interferes with the ability to find or keep employment') accounted for 46% of the total and were reported by between 53% and 86% of subjects. Consistency was observed in the ranking of themes over time. In content, they replicate those reported by veterans of recent conflicts, suggesting that the core issues of transition have an enduring quality. Most statements (66%) date from the 1940s, a time when the application process for a pension required the veteran to provide an explanation for his illness. A rise in the number of statements during the 1980s and 1990s reflected wider cultural acceptance of post-traumatic illness and veteran population entering retirement with time to reflect on defining experiences.

Combat Experiences and their Relationship to Post-Traumatic Stress Disorder Symptom Clusters in UK Military Personnel Deployed to Afghanistan.

The association of post-traumatic stress disorder (PTSD) symptom clusters with combat and other operational experiences among United Kingdom Armed Forces (UK AF) personnel who deployed to Afghanistan in 2009 were examined. Previous studies suggest that the risk of developing PTSD rises as combat exposure levels increase. To date, no UK research has investigated how specific classes of combat and operational experiences relate to PTSD symptom clusters. The current study was a secondary analysis of data derived from a two-arm cluster, randomized-controlled trial of a postdeployment operational stress-reduction intervention in deployed UK AF personnel. 2510 UK AF personnel provided combat exposure data and completed the PTSD checklist (civilian version) immediately post-deployment while 1635 of the original cohort completed further followed-up measures four to six months later. A 14-item combat experience scale was explored using principle component analysis, which yielded three main categories of experience: (1) violent combat, (2) proximity to wounding or death and (3) encountering explosive devices. The association of combat experience classes to PTSD 5-factor "dysphoric arousal" model (re-experiencing, avoidance, numbing, dysphoric-arousal and anxious-arousal symptoms) was assessed. Greater exposure to violent combat was predictive of re-experiencing and numbing symptoms, while proximity to wounding or death experiences were predictive of re-experiencing and anxious-arousal symptoms. Explosive device exposure was predictive of anxious-arousal symptoms. The present study suggests that categories of combat experience differentially impact on PTSD symptom clusters and may have relevance for clinicians treating military personnel following deployment.

The reception of broadcast terrorism: recruitment and radicalisation.

The declaration of a caliphate by Islamic State in June 2014 witnessed the recruitment of increasing numbers of foreign terrorist fighters drawn from a diverse range of nations across the globe. This paper seeks to explore the appeal of extreme groups and how recruiters persuade young people to risk either their lives or lengthy terms of imprisonment. The processes of radicalization and recruitment are differentiated and compared with conventional means of encouraging individuals to enlist in state-sanctioned armed forces. The reasons why people join terrorist organizations are influenced by their education, formative experiences, and social or familial connections, whilst these variables, in turn, have an impact on the roles that they then undertake. Whether personality traits explain an over-representation of engineers and doctors amongst leaders of particular extremist groups remains a moot question. The increasing use of the internet and social media as instruments to propagate extremist philosophies may, in part, be responsible for the recent rise in sole actors. The need to involve respected and influential Muslim leaders and organizations is crucial in providing a counter-balance to the message of righteous adventure and belonging promoted by Islamic State.

Adapting to Stress: Understanding the Neurobiology of Resilience.

There is significant variation in the way individuals react and respond to extreme stress and adversity. While some individuals develop psychiatric conditions such as posttraumatic stress disorder or major depressive disorder, others recover from stressful experiences without displaying significant symptoms of psychological ill-health, demonstrating stress-resilience. To understand why some individuals exhibit characteristics of a resilient profile, the interplay between neurochemical, genetic, and epigenetic processes over time needs to be explained. In this review, we examine the hormones, neuropeptides, neurotransmitters, and neural circuits associated with resilience and vulnerability to stress-related disorders. We debate how this increasing body of knowledge could also be useful in the creation of a stress-resilient profile. Additionally, identification of the underlying neurobiological components related to resilience may offer a contribution to improved approaches toward the prevention and treatment of stress-related disorders.

Pathways to sympathies for violent protest and terrorism.

BACKGROUND: Radicalisation is proposed to explain why some individuals begin to support and take part in violent extremism. However, there is little empirical population research to inform prevention, and insufficient attention to the role of psychiatric vulnerabilities. AIMS: To test the impact of depressive symptoms, adverse life events and political engagement on sympathies for violent protest and terrorism (SVPT). METHOD: A cross-sectional survey of a representative sample of Pakistani and Bangladeshi men and women from two English cities. Weighted, multivariable, logistic regression yielded population estimates of association (odds ratio (OR) and 95% confidence intervals) against a binary outcome of SVPT derived from a three-group solution following cluster analysis. RESULTS: Depressive symptoms were associated with a higher risk of SVPT (OR = 2.59, 95% CI 1.59-4.23, P<0.001), but mediated little of the overall effects of life events and political engagement, which were associated with a lower risk of SVPT (death of a close friend: OR = 0.24, 95% CI 0.07-0.74; donating money to a charity: OR = 0.52, 95% CI 0.3-0.9). CONCLUSIONS: Independent of SVPT associations with depressive symptoms, some expressions of social connectedness (measured as life events and political engagement) are associated with a lower risk of SVPT.

Battle for the mind: World War 1 and the birth of military psychiatry.

The 100th anniversary of the outbreak of World War 1 could be viewed as a tempting opportunity to acknowledge the origins of military psychiatry and the start of a journey from psychological ignorance to enlightenment. However, the psychiatric legacy of the war is ambiguous. During World War 1, a new disorder (shellshock) and a new treatment (forward psychiatry) were introduced, but the former should not be thought of as the first recognition of what is now called post-traumatic stress disorder and the latter did not offer the solution to the management of psychiatric casualties, as was subsequently claimed. For this Series paper, we researched contemporary publications, classified military reports, and casualty returns to reassess the conventional narrative about the effect of shellshock on psychiatric practice. We conclude that the expression of distress by soldiers was culturally mediated and that patients with postcombat syndromes presented with symptom clusters and causal interpretations that engaged the attention of doctors but also resonated with popular health concerns. Likewise, claims for the efficacy of forward psychiatry were inflated. The vigorous debates that arose in response to controversy about the nature of psychiatric disorders and the discussions about how these disorders should be managed remain relevant to the trauma experienced by military personnel who have served in Iraq and Afghanistan. The psychiatric history of World War 1 should be thought of as an opportunity for commemoration and in terms of its contemporary relevance-not as an opportunity for self-congratulation.

Invited commentary on . . . Word use in first-person accounts of schizophrenia.

The use of pronouns and causal attributions in personal accounts has been analysed to distinguish between schizophrenia and mood disorders. The implications for both cognitive processing and the underlying pathology of symptoms are explored. Context is identified as a key variable in the analysis and interpretation of text.

Shell shock at Queen Square: Lewis Yealland 100 years on.

This article reviews the treatment of functional neurological symptoms during World War I by Lewis Yealland at the National Hospital for the Paralysed and Epileptic in London. Yealland was among the first doctors in Britain to incorporate electricity in the systematic treatment of shell shock. Our analysis is based on the original case records of his treatment of 196 soldiers with functional motor and sensory symptoms, functional seizures and somatoform disorders. Yealland's treatment approach integrated peripheral and central electrical stimulation with a variety of other--psychological and physical--interventions. A combination of electrical stimulation of affected muscles with suggestion of imminent improvement was the hallmark of his approach. Although his reported success rates were high, Yealland conducted no formal follow-up. Many of the principles of his treatment, including the emphasis on suggestion, demonstration of preserved function and the communication of a physiological illness model, are encountered in current therapeutic approaches to functional motor and sensory symptoms. Yealland has been attacked for his use of electrical stimulation and harsh disciplinary procedures in popular and scientific literature during and after World War I. This criticism reflects changing views on patient autonomy and the social role of doctors and directly impacts on current debates on ethical justification of suggestive therapies. We argue that knowledge of the historical approaches to diagnosis and management of functional neurological syndromes can inform both aetiological models and treatment concepts for these challenging conditions.

Neuro psychiatry 1943: the role of documentary film in the dissemination of medical knowledge and promotion of the U.K. psychiatric profession.

In 1943, Basil Wright produced a documentary film about the treatment of servicemen and civilians with psychological disorders at Mill Hill Emergency Medical Service Hospital. Funded by the Ministry of Information, Neuro Psychiatry was shot to convince influential clinicians and policy makers in North America that the British had developed expertise in the management of psychiatric casualties. By emphasizing novel and apparently effective interventions and excluding severe or intractable cases from the film, Wright encouraged an optimistic sense of achievement. Filmed at a time when victory was considered an eventual outcome, the picture presented a health service to which all had access without charge. Children and unemployed women, two groups excluded under the 1911 National Insurance Act, had been required to pay for healthcare in the prewar period and were shown receiving free treatment from the Emergency Medical Service. However, the therapeutic optimism presented in the film proved premature. Most U.K. battle casualties arose in the latter half of the conflict and follow-up studies failed to confirm the positive outcome statistics reported in the film. Aubrey Lewis, clinical director of the hospital, criticized research projects conducted at Mill Hill for a lack of rigor. The cinematographic skills of Wright and director Michael Hankinson, together with their reformist agenda, created a clinical presentation that emphasized achievements without acknowledging the limitations not only of the therapies offered by doctors but also the resources available to a nation at war.

'An atmosphere of cure': Frederick Mott, shell shock and the Maudsley.

Although recognized as a medical scientist, the work of Frederick Mott as a physician, educator and clinical policymaker has been overshadowed. As a late entrant to the asylum system, Mott questioned established practices of treating mentally-ill patients and campaigned for reform. During World War I, entrusted with the management of the Maudsley neurological section, he sought to raise clinical standards and experimented with a range of therapies designed to treat the most severe or intractable forms of shell shock. While Mott believed that psychiatric disorder was underwritten by inherited characteristics, he did not dismiss the impact of the environment. The diversity of his interests has led to an understatement of his contribution as a physician, not only to the design and founding of the Maudsley Hospital but also to the therapeutic regime practised there during the interwar period.

Mental health, ethnicity and the UK armed forces: Historical lessons for research and policy.

BACKGROUND: UK armed forces have recruited from other races and ethnicities at times of crisis. To meet diversity targets, they have also recruited indigenous groups of non-White British heritage. Considered at greater risk of mental health problems generally, these populations are likely to suffer more in combat and in transition to civilian life. Yet, there is little data on how they fare. METHODS: A scoping review was conducted of peer-reviewed studies of psychological illnesses suffered by racial and ethnic minority soldiers from World War One to the present, together with research at the National Archives, Wellcome Trust Archives and the Imperial War Museum for unpublished studies. RESULTS: British commanders and psychiatrists argued that 'martial races' were protected against post-traumatic illnesses because of an innate resilience related to a rural heritage. Consequently, low morale and breakdown were interpreted as malingering to avoid combat. Indian troops received lower levels of psychiatric care than provided for British soldiers delivered with limited cultural understanding. Inferior terms and conditions were offered to Indian soldiers with lesser opportunities for promotion. These practices, established in both World Wars, continued for Gurkha and Commonwealth soldiers recruited to meet manpower and diversity targets. Disproportionate complaints of discrimination may explain why ethnic minority status is a risk factor for mental illness. CONCLUSION: Management patterns laid down during the Imperial era continue to influence current practice for ethnic minority service personnel. Yet, armed forces can play a positive role in fostering diversity and integration to provide protective factors against mental illness.