Can soldiers get PTSD from boot camp


Accidents, physical attacks, attacks, acts of violence and the use of firearms can leave deep marks in the soul of our soldiers. So that no long-term effects occur, it is necessary to prevent these burdens in a professional manner or to deal with these burdens.


The current version of the International Statistical Classification of Diseases of the World Health Organization (ICD-10) characterizes trauma as "a stressful event or a situation of exceptional magnitude that would cause profound despair in almost anyone". Traumatic events are exceptional not only because they are rare, but because they overwhelm people's normal adaptation strategies. Unlike ordinary misfortune, traumatic events generally pose a threat to life or physical integrity. They bring the victim to an immediate encounter with violence and death. As a result of traumatic events, people are exposed to extreme helplessness and fear and react in the usual way in the event of a disaster. After an extreme event, almost everyone experiences a stress reaction, the acute stress reaction. (Fig. 1) The probability or the risk of developing an acute stress disorder or a post-traumatic stress disorder differs from person to person. Protection and risk factors as well as the type, severity and duration of the traumatic experience influence the likelihood of occurrence, as they can lower the threshold for developing such disorders. In research, a distinction is made between three groups of people:

  • A third are "self-healers". You get over a psycho trauma after a few weeks.
  • A third are "changers". They can cope with psychotrauma if they are well looked after and if family and friends also support them.
  • Finally, a third represents the "risk group" who can develop PTSD and may need professional help.

Acute stress disorder

The ICD-10 defines acute stress disorder as "a transient disorder that develops in a person who is not mentally disturbed in response to exceptional physical or psychological distress," and which generally occurs within two or three days, often within hours , subsides. Individual vulnerability and the coping mechanisms available (coping strategies) play a role in terms of occurrence and severity. The symptoms typically show a mixed and changing picture, beginning with some kind of "numbness", with a certain narrowing of consciousness and limited attention, an inability to process stimuli and disorientation. This state can be followed by a further withdrawal from the environmental situation (up to dissociative stupor) or a restless state and overactivity (like escape reaction or fugue). Partial or total amnesia related to the episode may occur. Vegetative signs of panic anxiety, such as tachycardia, sweating, and flushing, are most common.

Post-traumatic stress disorder

According to ICD-10, PTSD arises “as a delayed or protracted reaction to a stressful event or a situation of shorter or longer duration with an extraordinary threat or catastrophe-like extent, which would cause deep despair in almost everyone.” Predisposing factors such as certain, e.g. compulsive ones or a history of asthenic, personality traits or neurotic disorders can lower the threshold for the development of this syndrome and make its course more difficult. The latter factors are neither necessary nor sufficient to explain the occurrence of the disorder. Typical characteristics are the repeated experience of the trauma in intrusive memories (reverberation memories, flashbacks), dreams or nightmares that occur against the background of a persistent feeling of numbness and emotional dullness.

There is also indifference to other people, indifference to the environment, joylessness, and avoidance of activities and situations that could evoke memories of the trauma. Usually there is a state of vegetative overexcitation with increased vigilance, excessive nervousness and insomnia. Anxiety and depression are often associated with the symptoms and signs mentioned. Thoughts of suicide are not uncommon. The onset follows the trauma with a latency that can last a few weeks to months. The course is changeable. In the majority of cases, however, a cure can be expected. In a few cases the disorder takes a chronic course over many years and then turns into a persistent personality disorder.

Adjustment disorders, affective or other anxiety disorders are to be distinguished from PTSD in the differential diagnosis. If the symptom pattern in response to the severe stress factor meets the criteria for another mental disorder (e.g. brief psychotic disorder, conversion disorder, depression), these diagnoses should also be given instead of or in addition to PTSD.

Obsessive-compulsive disorder has recurring intrusive thoughts that are perceived as inappropriate and unrelated to a traumatic event. Flashback episodes in PTSD must be distinguished from the illusions, hallucinations, and other perceptual disorders that occur in schizophrenia, other psychotic disorders, mood disorders, delirium, and substance-induced disorders. Simulation should be excluded when financial compensation or forensic decisions are involved. The number of soldiers suffering from PTSD has increased since the Bundeswehr began deploying abroad. This is partly due to an increase in deployment intensity. The increase is also due to the increased willingness within the armed forces to be treated as a victim. In the period from 1996 to 2009 inclusive, a total of 1,512 Bundeswehr soldiers were examined or treated for a PTSD that occurred in connection with the foreign missions KFOR, SFOR (since 2007 EUFOR) and ISAF (since 2003). The following table shows the PTSD figures broken down by year and area of ​​application: (Tab. 1) The table shows that the number of PTSD sufferers at ISAF has increased since 2007 - as expected.


Research results from the last few years indicate clear connections between pre-traumatic and post-traumatic outcomes. (Fig. 2) Psychagogical and informal measures before a potentially traumatizing event are consistently more relevant than just following up on corresponding missions. Contrary to the widespread focus on the situation after a potentially traumatizing mission, the focus should therefore continue to be placed on the implementation of concepts that identify measures for the broadest possible and comprehensive prevention of psychological stress reactions.

The cognitive and emotional preparation for traumatogenic missions of our soldiers is therefore an essential protective factor. Knowing about possible reactions after special stresses and exchanging ideas with colleagues about borderline situations before a special incident makes it much easier to process what has happened . The basis of trust that has to develop in order to deal with a special event has its basis in the time before the event and can develop even in phases with little stress. The following subject areas should continue to be dealt with in the corresponding courses:

  • Psychotraumatologically oriented psychoeducation
  • Methods of coping with stress
  • Methods of increasing stress resistance
  • Sensitization for one's own internal psychological processes

Communication in the team At the executive level, the following topics should also be deepened:

  • Sensitivity to deployment-related disorders and their prevention options in the Bundeswehr
  • Opportunities to provide psychosocial support and social recognition
  • Knowledge of special hazardous situations, e.g. no deployment in the "front line" for deployment participants who experienced a significant loss or separation in the weeks prior to deployment
  • Knowledge of the particular relevance of a high level of cooperation and the structured nature of operations
  • Opportunities for comradely sensitivity and support for emotional processes

Comprehensive training is therefore stress-relieving. If problems typical of the profession are solved professionally, the likelihood of making mistakes decreases. This means that a significant load factor has already been eliminated. Everything through training quality of the upcoming decisions. The training also serves to increase individual psychological resilience. This is achieved by imparting elementary knowledge regarding the correct handling of stress and the application of stress management techniques. This in turn should enable both help for self-help and support for stressed comrades. The superiors at all levels or the comrades should be sensitized and empowered to quickly recognize the need for action and initiate appropriate measures.

In order to avoid psychological stress disorders in soldiers and to ensure a long-term high level of motivation, pastors, psychologists, psychotherapists and psychiatrists support the military leadership on site in advance in the planning of operations and service organization through forward-looking and solution-oriented management advice. The leadership behavior of superiors and group cohesion have a significant influence on our soldiers' ability to cope with stress. Improved resistance (resilience) reduces the likelihood of post-traumatic stress. In general, the following strategies can be useful for coping with stressful events: (Box 1) A person with high resilience has a higher ability to cope with the consequences of stressful living conditions, to develop coping skills and to integrate them into their own life. The soldier profession, however, is associated with incalculable risks. In addition, the personal stress tolerance varies from person to person. Strengthening stress resilience in the sense of preventing psychological stress disorders therefore has its limits. In this context, it is also important that the soldiers are convinced that their assignment makes sense. The sense of coherence, i.e. the ability to mentally classify what has happened, to understand it and to be able to give it a meaning, has a favorable influence on coping with extreme stress without psychological disturbance.

An additional positive aspect of consistent information and broad education would be a departure from the "macho image" and thus an adaptation of the previous understanding of roles, which makes it easier for those affected to actively process what they have experienced. As a result, they could talk to comrades about their problems without fear of stigma. After all, the behavior of people close to you is a factor influencing the development of psychological problems such as PTSD that should not be underestimated. Positive behaviors such as understanding and consideration, e.g. in the form of social support, act as a protective factor, the opposite as a risk factor. It therefore makes sense that, in the course of the preliminary measures, the soldiers receive instructions on how to behave towards comrades who have experienced a stressful event. This reduces the likelihood of unfavorable behaviors and has a positive influence on the processing of stresses experienced by the affected soldier.

The possibilities of the training do not only exist in the optimization of the psychological abilities or the resilience of the deployment participants. In addition to the best possible mastery of important professional processes, the improvement of mental agility and physical fitness are of similar importance. In this context, the handling of errors should also be considered. An adequate error culture appears to be essential. In summary, it can be stated that the following support measures can promote effective management of mission-related extreme stress: (Box 2)

Support measures

Psychological support after the stressful event is of essential importance for successfully coping with the experience. It should be noted that a highly stressful event can shake not only those directly affected, but also eyewitnesses, additional helpers or other indirectly involved as well as relatives and other caregivers, so that they also require appropriate care. PTSD symptoms will develop during the recovery process decrease, but can come back with further stress. But the negative effects can be reduced to a minimum if the person concerned learns and is encouraged to take care of their own recovery.

The normalization process after a particular stress consists in interpreting this dramatic phase of life and classifying it in the individual life biography. Trust and positive experience of human closeness as well as the opportunity to openly talk about your own feelings support the self-healing powers, which often lead to the restoration of mental equilibrium very quickly. The approach of the Bundeswehr in terms of coping with stress during operations can be differentiated into the respective levels of the relevant 3-level 3-phase model. The first level encompasses methods of self-help and companionship help. Those affected are relieved, for example, by holding discussions with their superiors and comrades or by being removed from the action at short notice. If these efforts are inadequate and the symptoms of stress do not noticeably subside in the affected person, the members of the so-called psychosocial network (troop doctors, troop psychologists, military chaplains, social workers) become active on level 2. (Image 3) These then initiate medical, psychological, social, administrative and pastoral support and help according to their possibilities.

It can be stated that the rejection of so-called debriefings in the area of ​​prevention of work-related stress disorders does not appear to be justified any more than the euphoric assessments in the early 1990s. In connection with the investigations that found positive effects, the statements by the emergency services that the follow-up talks helped them personally and were an important experience for them allow the cautious conclusion that it makes sense to carry out interventions after an extreme event. However, the question of which specific intervention, by whom, for which person, at what point in time makes sense needs to be further investigated. The previous procedure has proven its worth due to the widespread use and standardization.

Recognizing and avoiding PTSD is a constant management task of the soldier's superior. This makes use of the support of troop doctors, troop psychologists, military chaplains and / or social workers. If, after a particularly stressful individual incident, the measures of psychological self-help and comrade help are not sufficient to bring about a stabilization of those affected, crisis intervention teams (KIT), led by doctors or psychologists, can organize structured discussions and individual measures for psychotrauma-related Follow-up work can be carried out. KIT is supported by specially trained peers (psychological first aiders). If necessary, a 3-day so-called recreation measure under professional guidance can be used to stabilize the mission.

After returning from the mission, the troop doctors pay particular attention to signs of incipient or manifest PTSD during the mandatory return examinations. If there is a corresponding suspicion, further diagnostics or necessary intervention measures are initiated.

Finally, soldiers who are particularly stressed and have no signs of a specific mental illness requiring therapy can take part in a preventive cure, which usually lasts three weeks, as part of a recovery concept in the pre-therapeutic room, which supports them in their regeneration. It is not carried out due to an existing health problem, but rather serves to prevent possible long-term consequences of the assignment abroad. The aim of the measures is psychophysical recovery and strengthening of resources.In addition to group psychotherapeutic sessions with the modules psychoeducation, exposure and cognitive restructuring, the underlying concept includes training in psychological and social skills. In addition, individual counseling to develop a positive life and coping perspective, motivational training, relaxation therapy, daily physical activity to reduce physiological stress reactions in group contact as well as rest and recovery phases are on the program.

A free anonymous telephone hotline for PTSD sufferers and their family members or other caregivers (0800-5887957) and online advice ( round off the Bundeswehr's range of assistance. The third level comprises measures by psychiatrists and medical psychotherapists, which are only used if the efforts of the first two levels were insufficient or ineffective, i.e. if there are clinical abnormalities. If the affected soldier has successfully coped with what they have experienced, it is the responsibility of the superiors, if necessary, to facilitate and support the reintegration into daily service.

Finally, it is emphasized that the processes mentioned are only of an ideal type and serve as a kind of stopping action. The actual implementation of the support process is always dependent on the currently existing framework conditions and the individual requirements of the specific case. Thus, the order and type of implementation of all support measures varies and is flexible.


It is important for those affected to hope that a cure is possible and that the symptoms can be brought under control. It is true that it will not be possible to regain the mental state as it was before a trauma; there will be a scar. It is important to be sensitive and creative with what you have experienced and to integrate particularly stressful events into your own view of the world. Trust and positive experience of human closeness, the opportunity to openly talk about your own feelings, support the self-healing powers. In the broadest sense, the function and task of the treatment can be described as a dosed and balanced handling of a stressful memory in order to bring about a healing and beneficial integration.

At the medical level, a careful and sensitive examination is recommended in suspected cases of PTSD, which should specifically inquire about possible trauma, without provoking symptoms through untargeted "drilling". Other members or employees of the psychosocial network, such as military chaplains, troop psychologists and social workers, can provide valuable help.

If the first suspicions are confirmed, further treatment takes place, if possible after the "threshold anxiety" has been reduced by the responsible military doctor, in a specialist medical examination center or department for psychiatry at a Bundeswehr hospital. The therapy is carried out by medical and psychological psychotherapists on an outpatient or (partially) inpatient basis, using civically established and evaluated trauma therapeutic procedures (such as Eye Movement Desensitization and Reprocessing (EMDR) and corresponding medication).

The trauma therapy follows a three-stage model that includes stabilization, trauma processing in the narrower sense, as well as trauma integration and reorientation. The duration of therapy is around 2 to 6 weeks, which, depending on the course of the therapy, can be shortened, extended or supplemented by one or more further inpatient therapy sequences. Outpatient follow-up care is offered or arranged. In individual cases it can prove to be beneficial to ensure a careful tapering off by extending the outpatient session intervals and still maintain a good and sustainable therapeutic relationship over a longer period of time.

An important aspect here is how to deal with setbacks. It is very important to support realistic expectations with regard to further development. This is particularly the case with trauma with permanent physical damage, with losses (e.g. through death) as well as with greatly changed (restricted) life perspectives. The effectiveness of the therapy is indicated in various studies with success rates between 70 and 90%. The goal of treatment for psychological trauma is to

  • to deal with what has happened and to end avoidance behavior,
  • To develop distancing skills,
  • To learn stabilization techniques,
  • to transform destructively processed experiences into constructive experiences,
  • to integrate the painful and agonizing experience into a new, appropriate perspective (e.g. "past", "I am safe", "I did what I could"),
  • to discharge stressful emotions (such as fear),
  • delete psycho-vegetative and motor reactions,
  • to enable a confrontation with the trauma and
  • to develop new options for action.

The specific goals a patient sets for themselves must be worked out individually. Finally, the psychosocial integration of psychologically traumatized soldiers often requires, in addition to the actual psychiatric-psychotherapeutic treatment, the comprehensive inclusion of the social environment (relatives, other caregivers, comrades, superiors), measures for professional reintegration and the clarification of questions about victim compensation and the consequences of accidents at work .


Based on the Mental Health Research Concept of June 23, 2008, the Mental Health Department was established on May 1, 2009 in the existing infrastructure of the Institute for Medical Occupational and Environmental Protection of the Bundeswehr in Berlin. It was a first, quickly implementable organizational measure to set up a research and competence area in the sense of initial qualification, whereby the immediate proximity of the institute to the Bundeswehr Hospital Berlin - both offices are located in the same property - an essential criterion for the establishment there was.

In the meantime it has been shown that a direct and immediate interlocking of "theory and practice" and an even faster transfer of knowledge and experience into practice is necessary. It is therefore intended to abandon the current separation between "Practice" (Bundeswehr Hospital Berlin Department VI B Psychiatry) and "Research" (Department of Mental Health at the Institute for Medical Occupational and Environmental Protection of the Bundeswehr) and both parts in the Bundeswehr Hospital Berlin lead to trauma Center. With this change, the explanations of the coalition agreement are also taken into account. The structural further development will take place depending on future needs.

The first major project is the coordination and support of an epidemiological study on the "prevalence and incidence of traumatic events, PTSD and other mental disorders in soldiers with and without deployment abroad" under the scientific direction of Professor Dr. U. Wittchen, Technische Universität Dresden. This study allows a reliable assessment of the magnitude of mission-related mental illnesses and their facets to be expected in the relatively short term. In addition, basic data for any necessary adjustments to the previous intervention and therapy regimes are made available through the identification of relevant influencing factors on the disease patterns mentioned.


Soldiers with mental stress disorders are often faced with two problems. On the one hand, they have to cope with the symptoms of their illness; on the other hand, they suffer from the fact that mental disorders are still afflicted with a stigma in society and in the armed forces. Stigmatization and discrimination not only have a negative impact on the self-esteem and self-worth of those affected. Both of these have a generally unfavorable effect on the social structure of relationships, the quantity and quality of relationships with other people decrease. Likewise, the professional situation (in the workplace and also with regard to the career) and the subjective quality of life deteriorate. Stigmatization and discrimination also lead to the fact that many of those affected seek help too late or not at all out of shame and a lack of self-esteem and withdraw. Because soldiers with mental disorders live with the fear of being additionally stigmatized by psychiatric-psychotherapeutic treatment. This in turn significantly increases the threshold for claiming professional treatment. The result is a deterioration in the condition of those affected and an increase in symptoms - a vicious circle for soldiers with mental illnesses.

The fact that mentally ill people often internalize this stigmatization and discrimination or take it over themselves and thereby intensify their suffering is also referred to as the "second illness" in the professional world. Demoralization and depression increase, self-esteem decreases. In addition, adherence to therapy is negatively influenced by psychotherapeutic treatment. Even after recovery, these impairments - due to stigma and discrimination, among other things - can continue. These burdens also affect the relatives of those affected. They range from social and emotional to economic effects. (Pic 5).

From the perspective of the Bundeswehr medical service, important strategies for reducing the stigma of mental disorders are, in addition to the further development and improvement of psychiatric care for our soldiers, the following three approaches:

  • Education about causes, treatment options and the course of mental illnesses,
  • Information and education about and protest against stigmatizing and discriminatory behavior and
  • personal encounters between those affected and those who are not sick.

What is essential in all of these strategies is the joint approach of those affected, their relatives and other caregivers as well as superiors, members of the psychosocial network and psychiatric experts.

Summary and Outlook

The Bundeswehr takes psychological stress and its possible consequences just as seriously as visible injuries or wounds. She recognized the importance of mental stress disorders including PTSD in good time and acted quickly and appropriately. Since the 1990s, the care measures in the field of psychotraumatology and mental stress disorders have been continuously expanded and improved. The Bundeswehr - and especially the Bundeswehr medical service, but also the psychological service, the social service and the Protestant and Catholic military chaplaincy - is well positioned in terms of prevention, diagnosis, therapy and rehabilitation of psychological stress disorders including PTSD in soldiers. (Box 3)

Professional help supplements self and comrade help as well as the welfare measures of superiors. In the interest of maintaining, restoring and promoting mental health, the Bundeswehr now takes comprehensive care of its relatives. The existing concepts for the management of mental health disorders including psychotraumas have proven to be viable and conclusive. (Box 4) They also coincide with the latest scientific research and international guidelines on the effectiveness of interdisciplinary and organized cooperation in psychosocial support. The aim of all measures is to improve and maintain the mental health of the soldiers and thus to sustainably support the operational readiness, ability and perseverance of the troops. The Bundeswehr's concepts will continue to be evaluated continuously and will continue to be further developed as required in the future. The mental health department (or the planned trauma center) in Berlin plays an important role as a central element. The regional psychosocial networks in Germany and the psychosocial network in action, the PTSD hotline and the online counseling services will be further expanded and improved in the future.

Date: 10.01.2010

Source: Military medicine and military pharmacy 2010/1