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What do we actually expect from our Soldiers on Overseas Missions?

Only since the publication of an empirical study by Hans Ulrich Wittchen’s working group1 has it been possible to assess more accurately the health risks faced by soldiers in the German armed forces (Bundeswehr) in the context of their military service and particularly during overseas missions. According to this study, around two percent of Bundeswehr soldiers return from overseas deployment in Afghanistan with a post-traumatic stress disorder (PTSD). Only one in every two soldiers who is affected subsequently seeks professional help, despite reports that soldiers on average experience twenty trauma-relevant events during their deployment. Yet PTSD rates in the Bundeswehr are better than in other similar armies, e. g. among British and American soldiers. This appears to be due to better selection criteria for overseas deployments, better mission preparation, a shorter deployment duration of four to five months instead of up to two years, and less direct exposure to violence2. The fact that the occurrence of post-traumatic stress disorders (PTSD), for example, rises linearly with the number of traumatic stress events (and possibly the number of overseas deployments) has been little mentioned so far in discussions concerning this research, but it will gain importance as the Bundeswehr is increasingly deployed overseas.

Yet this is only half the story. As has been shown particularly in more recent studies on gene-environment interaction3, first of all, in the future, it will be possible to identify and perhaps preventively observe high-risk groups via neurobiological and psychological risk factors. Secondly, the risk of developing another mental disorder in later life – such as a depressive disorder – is greatly increased. Considerable latency periods have been found here, with the result that risk assessments should be based on timeframes in excess of five years.

In addition, subsyndromal symptoms are reported by many soldiers. These are defined as symptoms which fail to meet the full diagnostic criteria for a disorder, but include, for example, sleep disturbance, anxiety symptoms that are more likely to be experienced as somatic symptoms, and the feeling of returning home a changed person after such a deployment. Thus questions about one’s own existence and identity are touched upon.

And now another dimension comes into play, whose health consequences cannot yet be assessed, i. e. the use of drones in military situations, not only for reconnaissance but in targeted armed missions which explicitly aim to kill an enemy who is “invisible” in certain respects, for whom the soldier concerned also remains “invisible”. Although no empirical studies on this topic currently exist, a number of surveys have been published, which are evidently based on qualitative case study reports and theoretical considerations. For example, Sparrow4 and Pepper5assume that the interface systems used must play an important role as a stress factor. Systems that deliver abstract and mediated images of the battlefield result in less exposure to stress, whereas real depictions may be significantly associated with hyperarousal. They also discuss the quite considerable risk of developing a psychological disorder after witnessing or being involved in visible traumatic events, and having to intervene in or passively watch such events. The “collateral damage” that is frequently reported – where in addition to the intentional killing of targeted persons or groups, non-combatants are also harmed – is likely to be particularly relevant here, especially since there is agreement in the literature that in wars of all kinds, these types of casualties among the civilian population far exceed the numbers of soldier casualties. With the beginning of a “virtual war”, therefore, the associated guilt and shame issues take on a completely new form, while we know little about the coping mechanisms used by the persons involved. The armies in which this is already common practice remain shrouded in silence.

But how does a Bundeswehr soldier face up to the fact that he has killed not only one or more “enemies” but also a critical number of innocent persons via a “virtual maneuver”, as has often happened in past combat deployments? How does he subsequently behave in the unfamiliar cultural context of the overseas deployment in which this terrible event has taken place? How does this change his attitude toward the local population? How does it change his inner concept of what it means to be a soldier, and a person in other social roles? These are questions which have not yet been answered in any way and about which we can currently only speculate.

In a broader context, there is a relevant analogy between these systems and computerized “war games” or “violent games”, whose desensitizing impact, resulting in a lowering of the naturalistic threshold for violence and aggression, is widely discussed. In this regard, however, Ritchie and others6 point out that only a comparatively small number of psychologically damaged war veterans subsequently become involved in violent crimes in civilian life. In contrast, a number of forensic authors estimate that the likelihood of a victim turning perpetrator is as high as 15%7.

Thus the health risks for soldiers involved in the use of “combat drones” cannot be accurately assessed.

Dresden; Wittchen, H. U., Schönfeld, S., Kirschbaum, C., Thurau, C., Trautmann, S., Steudte, S., Klotsch, J., Höfler, M., Hauffa, R. & Zimmermann, P., “Traumatic experiences and posttraumatic stress disorder in soldiers following deployment abroad: how big is he hidden problem”, Deutsches Ärzteblatt, Int. 109, 559-568, 2012.

Trautmann, S., Schönfeld, S., Höfler, M., Heinrich, A., Hauffa, R., Zimmermann, P. & Wittchen, H. J., ”Posttraumatic stress disorder after deployment of German soldiers: does the risk increase with deployment duration”, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 56, 930-940, 2013.

For example: Grabe, H. J., Schwahn, C., Mahler, J., Schulz, A., Spitzer, C., Fenske, K., Appel, K., Barnow, S., Nauck, M., Schomerus, G., Biffar, R., Rosskopf, D., John, U., Völzke, H. & Freyberger, H.J., „Moderation of adult depression by the serotonin transporter promoter variant (5-HTTLPR) child abuse and adult traumatic events in a general population sample“, Am J Med Genet B Neuropsychiatr Genet 159B, 298-309, 2012.

Sparrow, R., “Building a better warbot: ethical issues in the design of unmanned systems for military applications”, Sci Eng Ethics 15, 169-187, 2009.

Pepper, T., “Drones – ethical considerations and medical implications”, J R Nav Med Serv 98, 37-40, 2012.

Ritchie, E. C., Benedek, D., Malone, R. & Carr-Malone, R., “Psychiatry and the military: an update”, Psychiatr Clin North Am 29, 695-707, 2006.

Dudeck, M., Drenkhahn, K., Spitzer, C., Barnow, S., Kopp, D., Kuwert, P., Freyberger, H. J. & Dünkel, F., “Traumatization and mental distress in long-term prisoners in Europe”, Punishment & Society 31: 13(4), 403-423, 2011.



Harald J. Freyberger is director of the Greifswald University Clinic and Polyclinic for Psychiatry and Psychotherapy. Born in 1957, he studied human medicine in Hamburg and Zurich. 1987 doctorate in Hamburg, 1996 habilitation in Lübeck. 1985-1995 research fellow and senior physician at the Lübeck Medical University Clinic for Psychiatry. 1996-1997 head of department at the Bonn University Clinic and Polyclinic for Psychiatry and Psychotherapy. Since December 1997 university professor for psychiatry, psychosomatic medicine and psychotherapy. His working and research fields are the classification, diagnosis and epidemiology of mental disorders, risk factor research including in the field of dissociative and post-traumatic stress disorders, psychiatric and psychotherapeutic intervention research, and care and therapy research.