By Aparna S
May 3, 2026: War has long been defined by alliances, victories, and shifting borders. Yet beyond redrawn maps lies another battlefield—silent, invisible, and enduring: the human mind. War devastates lives in ways no statistic can fully capture. Families are torn apart, homes destroyed, and identities uprooted as people are forced into sudden migration. Careers collapse, economies falter, and entire ways of life are disrupted. In these quiet, cumulative losses, post-traumatic stress disorder (PTSD) takes root, binding grief, uncertainty, and dislocation into a wound that can last a lifetime.
The psychological cost of war has shaped individuals, families, and societies across centuries. This is why wartime mental health has emerged not merely as an academic discipline, but as a necessary response to the profound toll war takes on the public psyche. At the heart of this evolution lies one of the most significant concepts in modern mental health: PTSD.
Long before trauma or “stressors” were formally defined, soldiers were already experiencing their effects. Ancient texts describe warriors returning from battle with nightmares, emotional withdrawal, and persistent fear. In The Iliad, Achilles exhibits rage and grief that resonate with modern understandings of trauma. For centuries, such reactions were misinterpreted as moral weakness, cowardice, or spiritual failure, largely because no structured framework existed to explain what we now recognise as trauma-related disorders.
“The Soldier’s Heart”
The first systematic observations of war-related psychological distress emerged during the American Civil War. Soldiers reported palpitations, breathlessness, fatigue, and anxiety—a cluster of symptoms without a clear medical explanation. This condition came to be known as “Soldier’s Heart” or “Da Costa’s Syndrome.”
Although not yet fully understood, this marked an important turning point: combat-related psychological symptoms were acknowledged as legitimate medical concerns, even if their origins were not clearly identified.
World War I and “Shell Shock”
World War I ushered in industrialised warfare, transforming both the nature of combat and its psychological consequences. Soldiers exposed to relentless artillery bombardment exhibited tremors, paralysis, mutism, and severe anxiety. The term “shell shock” was coined to describe these symptoms.
Initially attributed to physical brain injury from exploding shells, it soon became evident that even soldiers far from blasts could develop similar conditions. This realisation was pivotal—it established that trauma could be psychological, not just physical.
Treatment approaches, however, were inconsistent and often harsh. While some soldiers received compassionate care, others were accused of cowardice or malingering and subjected to punishment. Despite these shortcomings, World War I firmly established the need for a psychological understanding of war trauma.
World War II and Evolving Insight
By World War II, psychiatry had advanced significantly. The term “combat fatigue” replaced “shell shock,” reflecting a growing recognition of cumulative stress rather than isolated injury. This later evolved into “combat stress reaction,” a precursor to the modern diagnosis of PTSD.
Early intervention strategies became central. The “PIE principles”—Proximity, Immediacy, and Expectancy—emphasised treating soldiers close to the front lines, as soon as symptoms appeared, with the expectation of recovery. This framework was later expanded to “BICEPS,” adding Brevity, Immediacy, Centralisation, Expectancy, Proximity, and Simplicity. These principles aimed to enable a safe and effective return to duty while minimising long-term psychological harm.
This period also saw the introduction of psychological screening and selection processes for soldiers. Research into resilience, stress, and group dynamics accelerated, laying the foundation for modern military psychology.
The Vietnam War and the Emergence of PTSD
The Vietnam War marked a turning point in wartime psychiatry. Many veterans returned to a divided and often unsupportive society. They reported persistent nightmares, flashbacks, emotional numbness, hypervigilance, and difficulty reintegrating into civilian life.
Crucially, these symptoms did not always appear immediately; they could emerge months or even years after combat. Veterans and clinicians began advocating for recognition of this delayed and enduring condition.
In 1980, PTSD was formally recognised in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). This milestone acknowledged that exposure to traumatic events—whether in war, disaster, or personal violence—could result in a distinct and diagnosable mental health condition.
PTSD Beyond the Barracks
PTSD has four core symptom clusters: Intrusion: Flashbacks, nightmares, and distressing memories, Avoidance: Efforts to evade reminders of trauma, Negative changes in mood and cognition: Guilt, detachment, persistent negative beliefs, and Hyperarousal: Irritability, heightened startle response, and sleep disturbances
Advances in neuroscience have identified changes in key brain regions, including the amygdala, hippocampus, and prefrontal cortex, demonstrating how trauma reshapes neural circuits involved in fear, memory, and emotional regulation.
Although rooted in wartime experiences, PTSD is now recognised across a wide range of contexts, including natural disasters and interpersonal violence. War, however, remains one of its most intense and extensively studied triggers.
Contemporary Wartime Psychiatry: Prevention and Care
Today, combat mental health is a sophisticated field integrating biological, psychological, and social approaches. Key developments include early intervention strategies to reduce chronic PTSD, pharmacological treatments, trauma-focused psychotherapies, and resilience training before deployment.
There is also growing recognition of the mental health needs of civilians in war zones, refugees, and humanitarian workers, expanding the scope of wartime psychiatry beyond soldiers alone.
Look, Listen, Link: Psychological First Aid
Psychological First Aid (PFA) is a humane, supportive, and practical approach to helping individuals in acute distress following crises or traumatic events. It prioritises safety, calmness, connection, and access to support over formal clinical intervention.
The three core principles of PFA are: Look: Assess safety and identify immediate physical or psychological needs. Listen: Offer calm, empathetic, and nonjudgmental attention and Link: Connect individuals to information, social support, and professional help
PFA is not a substitute for therapy but serves as an immediate response to stabilise individuals and reduce initial distress. It can be administered by anyone present and focuses on addressing urgent needs in context.
From Stigma to Support
Perhaps the most profound transformation in the history of wartime mental health is cultural. Where psychological distress was once dismissed or punished, it is now increasingly recognised as a natural human response to extreme stress.
This shift extends beyond the military, challenging societies to rethink concepts of strength, vulnerability, and healing. It underscores the need for systems that support mental health long after the visible wounds of war have healed.
The story of PTSD is ultimately one of recognition—of giving language and legitimacy to suffering that was once hidden or denied. As science continues to advance, the goal is not only to treat trauma but to prevent it, foster resilience, and ensure that those who endure the horrors of war are not left to fight their battles alone.
(Dr Aparna S is a consultant psychiatrist and an Assistant Professor at the Believers Church Medical College Hospital, Tiruvalla, Kerala. Views expressed are her own and not of an organisation or company.)
