Select Committee on Defence Appendices to the Minutes of Evidence


Further Memorandum from the Soldiers, Sailors, Airmen and Families Association—(SSAFA Forces Help) (11 December 2000)

  In my letter of 6 December I promised that I would submit some notes on Post Traumatic Stress Disorder (PTSD) to the Committee to help in the Personnel Inquiry. I believe the Services manage the PTSD problem adequately.



  Post Traumatic Stress Disorder (PTSD) is a relatively recent name for a condition which has existed for a long time. Older terms for the same condition include Soldier's Heart, Shell Shock, and Battle Fatigue; and it is worth noting that the condition used to be thought to be of biological origin. During the Second World War it was accepted that psychological factors played a role. It was not until 1980, however, that PTSD was first properly described, when the psychological effects of the Vietnam War on some American Servicemen was recognised. The Falklands War was the first conflict in which British Servicemen were diagnosed with PTSD.

  Civilians can also suffer. The railway accident at Clapham, the ferry sinking at Zeebrugge, the fire at King's Cross and other traumatic incidents have all resulted in psychological injury to a number of civilians who have subsequently been diagnosed with PTSD.

  Nowadays, stress and stress-related conditions appear to be relatively commonplace and the public have become more aware of them because of litigation and media interest.


  PTSD is a specifically defined and diagnosed condition which involves the development of certain potentially disabling symptoms following a psychologically distressing event that is beyond the range of normal human experience. It is a psychological injury. Symptoms may occur at the time of the traumatic event or they may occur many years—sometimes decades—later.

  Not all people who experience the same traumatic event end up with PTSD. Imagine a grenade exploding in a confined area. Some people will be killed; some people will be seriously injured; some will be lightly injured and some will not be injured at all. In the same way, one can imagine the effects of a traumatic event using the same analogy; some will be seriously psychologically damaged but others will not be affected at all. Thus some of the Servicemen who witnessed atrocities in Kosovo will be psychologically injured and may have PTSD whereas others, whilst having found it a distressing experience, will be able to cope and will not develop PTSD.


  Only someone who is medically qualified can diagnose PTSD. The current standard for diagnosis is contained in the American Psychiatric Association publication Diagnostic and Statistical Manual of Mental Disorders, fourth edition, (1994). It is referred to as DSM4.


  People with PTSD may also have other conditions including depression, alcoholism, anxiety or panic attacks or schizophrenia, and someone with PTSD may (quite correctly) be diagnosed as having one of these conditions but without also being diagnosed as having PTSD. Treatment of the diagnosed condition is unlikely to help the undiagnosed condition and so recognition that other conditions may also be present (co-morbidity) is important for successful treatment.


  Clinical Guidelines exist for the management of Serving personnel exposed to traumatic events. These have been written by the medical staff at the Defence Medical Services Psychological Injuries Unit at the Duchess of Kent Military Hospital (DKMH) in Catterick Garrison.

  The Guidelines include strategies for the prevention and detection of PTSD and other stress-related conditions. Education and training of all Servicemen is recommended and the guidelines are reviewed every two years. Critical Incident Stress Debriefing is a tool that has been used but there is currently some debate as to its usefulness, following a number of case reports and uncontrolled studies which suggested that it may be harmful. It is currently under review.

  Servicemen who are injured on training or operations are treated initially by the first line medical support services. If their injury is pscyhological this treatment will be carried out by a Community Psychiatric Nurse (CPN). Most of those treated by CPNs are able to return to training or operations within a relatively short time. Those who need further treatment are referred to the Psychological Injuries Unit at DKMH. A decision will be made there as to whether further treatment followed by return to duties is possible, or whether medical discharge is the better option.

  Servicemen who are medically discharged with a stress-related condition will receive a Service pension, the type of which depends on whether the condition is attributable to Service, in which case they may also be entitled to a War Disability Pension. These bring financial and other benefits which may not be available to those who are discharged for other reasons. Current protocol allows the details of Servicemen medically discharged in this way—if they give their consent—to be passed on to the Ex-Services Mental Welfare Society (Combat Stress), the ex-Service organisation which specialises in helping former Service men and women of all ranks suffering from psychiatric disabilities.


  Ex-Servicemen who were not diagnosed with a stress-related condition during their Service and who find themselves suffering after their Service and needing help will normally turn first to their General Practitioner (GP). Fortunately, most GPs are now aware of PTSD and will either be able to make the correct diagnosis themselves, or refer them to a consultant psychiatrist who will investigate and diagnose. Treatment will depend on what is available locally; resources vary according to the area in which a person lives.

  Ex-Service clients who are receiving a War Pension for a stress-related condition, or whose history makes it likely that they would be entitled to one, can be referred to the Ex-Services Mental Welfare Society (if this has not already been done). The Society is not a substitute for the National Health Service and the support it offers complements that which the NHS is able to provide. It does, however, have a network of regional welfare officers who can visit clients at home or in hospital, and who will assist with the presentation of claims and appeals for War Pensions. The Society also has a number of short-stay treatment and respite homes. To be eligible for admission to these homes, the ex-Service person must be receiving a War Pension or be in the process of making an application. In urgent cases, admission may be authorised whether or not an application for a War Pension has been made.


  SSAFA Forces Help exists to relieve the need, suffering and distress of anyone who has ever served in the Armed Forces (as well as his family and dependants). Clients who approach SSAFA Forces Help are visited in their own homes by a SSAFA Forces Help trained volunteer caseworker, who will use his skills to help that person and to relieve his need. In the case of mentally ill or psychologically injured clients, the caseworker would encourage the client to go to his GP (if he has not already done so) and he may also seek advice from the Ex-Services Mental Welfare Society. If the Society is unable to help for whatever reason, referral will be made to other agencies. These include Ty Gwyn, a private hospital in North Wales. A lot depends on what the NHS is able to offer and how the client's GP feels. Mentally ill clients can be their own worst enemies and they are not always easy to help.

  During the past year SSAFA Forces Help has established a number of support groups for ex-Servicemen with stress-related conditions. We act as facilitator and seek to bring in help from the Ex-Services Mental Welfare Society, the War Pensions Agency, local Community Psychiatric Nurses, and others who may be able to help. It is our experience that ex-Servicemen benefit greatly from the company and support of other ex-Servicemen and that these support groups are extremely valuable.

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