Anne Llewellyn discusses the intricacies of underwriting policies for clients affected by the various illnesses that come under the heading ‘post war syndromes'
The physical wounds sustained by troops involved in front line action are tragically obvious. What is not so obvious are the psychological wounds, and even whether post war syndromes can be described as psychological disorders at all has caused a great deal of controversy.
However, they must be dealt with if disclosed on an insurance application form.
Although it is highly likely that the psychological trauma of war has affected soldiers since war began, it was not until the American Civil War that the phrase "soldier's heart" was used, and this is probably the first time such a syndrome was recognised. After World War I "shell shock" was used to describe the behaviour of some of the returning soldiers. Following World War II we had battle fatigue, Post Traumatic Stress Disorder after the Vietnam War, then Gulf War Syndrome. The fact that conflicts often have their own distinctive post war symptoms has caused a great deal of medical debate as to whether the origin is purely psychological or whether there is also a physical cause.
World War I - Shell Shock
The term shell shock was coined by Charles Myers in 1917 when it was thought to be the direct result of the physical injuries of enduring things like being buried alive, air movements during heavy bombardment, exhaustion, or even the pressure of carrying heavy back packs on the chest and heart. However, it was soon realised that the horrors experienced on the battlefront were causing psychological trauma.
While the syndrome may have been recognised, doctors were at a loss as to how to treat their patients. The aim of medical officers was to get soldiers back to the front as quickly as possible. Rest and hypnosis, electric shock treatment and ‘talking cures' were used with varying measures of success, but in all cases the sufferer was rather unhelpfully encouraged to "face his illness in a manly way". It was widely believed that the most effective cure was to treat the soldiers as close to the battlefront as possible, allowing a quick return to the front.
By the end of WWI the army had dealt with 80,000 cases of identified shell shock. An unidentified but substantial number remained undiagnosed and were often classified as malingerers, or punished for being cowards. Some of these who just could not cope with the pressure ran away, and of the 306 soldiers shot for desertion it is likely a high proportion of these were suffering from shell shock. (They were given a posthumous pardon in 2006 in recognition of this fact).
Most officers and some soldiers were returned to Netley or Craiglockhart War Hospitals. Here they were treated with little sympathy, and the belief of both the sufferers and those caring for them was that they had become less of a man and less of a soldier because of their psychological injuries.
World War II - Battle Fatigue
In 1922 the government published a Report of the War Office Committee of Enquiry into ‘Shell-Shock'. The recommendations were still very much geared towards returning the soldier to useful military service as soon as possible, and there was still an overriding perception that it was somehow the moral fibre of the soldier that was lacking. The report stated that "No soldier should be allowed to think that loss of nervous or mental control provides an honourable avenue of escape from the battlefield".
However, during World War II military medicine experienced a paradigm shift as they came to realise that all men, no matter how courageous, were vulnerable to the development of psychological symptoms as a result of war zone stress.
Just as in World War I, the common belief was that rapid rehabilitation was preferable to a diagnosis of an abnormal mental condition. Most armies recognised that food, rest and a few calm days restored to victim to a state where he could return to his unit, and provided facilities such as Casualty Clearing Stations in Normandy which were set up to give battle fatigued soldiers 24 hours to rest, after which time they would either be sent back to battle, or more reluctantly posted to a job away from combat.
Studies have been carried out up until the present day on post World War II servicemen who are still suffering the effects of their war experiences, showing that traumatic experience of war persists well into later life.
The Vietnam War - Post Traumatic Stress Disorder
Initially called post-Vietnam syndrome, Post Traumatic Stress Disorder (PTSD) was the name given to those suffering not only the acute reaction to the battlefront but also the longer term stress reaction. The symptoms of fatigue, palpitations, diarrhoea, forgetfulness, nightmares, disturbed sleep, loss of concentration, headaches, confusion and dizziness were similar to the complex of symptoms experienced during the two world wars as well as the Korean War, and it was also realised there were longer term consequences in common.
By medicalising the symptoms and giving the syndrome a name, the stigmatisation of post war trauma was largely removed. In addition, the term was no longer confined to war veterans, but was also used to describe the problems experienced by civilians exposed to non-war related traumatic incidents.
Persian Gulf War - Gulf War Syndrome
Mortality rates and morbidity rates were far lower in the Gulf War than in previous conflicts. However, on returning home members of the British, Canadian and US Forces began to report similar chronic illnesses.
Muscle and joint pains, fatigue, chest pain, shortness of breath, diarrhoea, sleep disturbance, depression and irritability were the most commonly reported symptoms. Although these are similar to those found in previous post war syndromes, they were reported with greater frequency, and there were more non-specific physical symptoms reported. This led to a huge number of studies being carried out to determine whether there was a syndrome specific to the Gulf War and if so, the causes.
Professor Simon Wessely is the director of the King's College Centre for Military Health Research, and civilian consultant adviser in psychiatry to the British Army. He has conducted extensive research to explain the Gulf War veterans' health problems. Prof Wessely was the principal investigator of a study published in the Lancet in 1999 entitled ‘Is there a Gulf War Syndrome?'. Three military cohorts were surveyed; men who had served in the Gulf, men who had served in Bosnia, and men in active service but not deployed; all in all about 12,500 personnel. They were asked 50 questions regarding their symptoms. The pattern of answers from the non-active service and Bosnia cohorts were very similar and indeed veterans of the Bosnia conflict did not report any significantly different post-war syndrome. Interestingly the findings of the Gulf cohort also had the same pattern of answers but the scoring was consistently higher. The underlying similarity in symptom reporting did not support the existence of a unique Gulf War syndrome, or physiological illness such as would have been caused by chemical warfare, but clearly there was something causing a higher frequency of ill health.
Khalida Ismail, who contributed to the above study, later revisited the topic and published an article in 2001 entitled ‘A review of the evidence for a ‘Gulf War Syndrome'. The conclusion was drawn that Gulf war related ill health was the product of the complex interaction of a number of factors.
In 2005, the UK government accepted the phrase Gulf War Syndrome for the purpose of awarding war pensions. The debate as to whether the symptoms fulfilled the medical criteria to be labelled a ‘syndrome' became an academic one.
Iraq and Afghanistan
Speculation on whether there will be post Iraq or Afghanistan syndromes began early in the campaigns, which is not surprising given the history of post war syndromes, and particularly the intense media and public scrutiny following the Gulf War. In 2006 an article was published in the Lancet entitled ‘Is there an Iraq war syndrome?' which compared the health of 3,642 male regular UK armed forces deployed to Iraq in 2003 to 4,295 of their colleagues who were not deployed. The conclusion was that "increases in common symptoms in the 2003 war group were slight and no pattern suggestive of a new syndrome was present". They did find that overall, symptoms have increased in frequency in the control group, possibly due to better reporting, and that improved health surveillance and research may have reduced the health concerns and feeling of neglect felt by the Gulf War veterans.
Underwriting Considerations
With such a wide variety of symptoms and very little medical explanation as to cause, post war syndromes can be difficult to evaluate. There is some scientific evidence that there could be a link with cancer and Gulf war syndrome but this is controversial. Each case must therefore be underwritten on its own merits but is most likely to be assessed as post traumatic stress disorder. Ratings will depend on the extent of impairment of social and occupational function, type of treatment and response to treatment, and whether there has been any drug or alcohol abuse. Life and critical illness (CI) cover is likely to be accepted at standard rates or with a small loading in cases where response to treatment is good and there is little or no occupational and social dysfunction. However, the majority of disability covers will be declined due to the unpredictable nature of the condition and because it tends to be longstanding.
Anne Llewellyn is underwriting development manager at PruProtect
