Combat Loss and PTSD – Part 2: The Link Between Combat and PTSD

This is a paper about how infantrymen in the United States Marine Corps handle combat deaths. It was researched and written by Stephen Smith, Th.M., in partial fulfillment for a seminary course on Death and Dying. While Steve has never experienced the dark side of man, his twin brother – me – has. Together, we offer this paper in eight parts. Footnotes follow at the end of each section. Part 1 dealt with the physical and psychological casualties of the wars in Iraq and Afghanistan, ending with the question of whether there is a causal link between combat and PTSD. This is Part 2.

Part 1: Post 9-11 Casualties

Part 2: The Link Between Combat and PTSD

Part 3: Learning to Kill

Part 4: Preparing for Death

Part 5: When the Metal Hits the Meat

Part 6: Memorials and Unit Healing

Part 7: When the War Continues – PTSD

Part 8: Conclusion and Bibliography

Part 2: The Link Between Combat and PTSD

Causal Link between Combat and PTSD

Charles Hodge, M.D., Col. (Ret) believes there is a link.[1] In his book, Once a Warrior Always a Warrior: Navigating the Transition from Combat to Home, Dr. Hodge notes that PTSD symptoms are normal responses to life-threatening situations, such as combat: “Every ‘symptom’ of PTSD stems from things your body normally does in response to severe danger or stress. PTSD symptoms can be manifestations of normal stress reactions to threatening situations, as well as a disorder that requires treatment. That’s the paradox of it.”[2]

The nature of combat, argues Dr. Hodge, lends itself to potentially traumatic experiences (PTEs). Though the link between PTEs and PTSD is by no means 1-to-1, it seems much higher than the 14% incidence rate currently cited by the VA.[3] And this is important, because how warriors perceive themselves is crucial to their healing process. An infantryman who has been diagnosed with PTSD can believe one of two things. He can either believe that he has an abnormal mental disorder; or he can believe that he has a physical response which is normal as a result of experiencing combat and the traumatic death of friends.[4]

Make no mistake: while support personnel can—and sometimes do—experience trauma in a war zone, there is a higher likelihood that infantrymen will encounter combat death or

KARABILAH, Iraq- (June 17, 2005)  Marines open fire on a sniper in Karabilah after recieving fire. Offcial USMC photo.

KARABILAH, Iraq- (June 17, 2005) Marines open fire on a sniper in Karabilah after recieving fire. Official USMC photo.

other traumatic events. [5]  This is because combat infantry Marines encounter more PTEs than do support personnel who live “inside the wire.” According to the Marine Corps website, “Infantry is the central component of Marine ground forces. Infantrymen are trained to locate, close with and destroy the enemy by fire and maneuver, or repel the enemy’s assault by fire and close combat. Riflemen serve as the primary scouts, assault troops and close combat forces within each infantry unit.”[6] This job description almost guarantees that infantry Marines deployed in a war zone will encounter a traumatic event.

PTEs during the Initial Invasion of Iraq

For example, in the initial invasion of Iraq in 2003, a high percentage of infantry Marines encountered PTEs.  Dr. Hodge surveyed Marines in Regimental Combat Teams (the infantry units doing the fighting) to see how many of them had encountered potentially traumatic events. 95% of these infantry Marines reported being attacked or ambushed; 97% reported being shot at or receiving small arms fire; 87% reported shooting at or directing fire at the enemy; 65% reported being responsible for the death of an enemy combatant; 28% reported being responsible for the death of a noncombatant; 94% reported seeing dead bodies or remains; 57% reported handling or recovering human remains; 75% reported seeing dead or seriously injured Americans; 87% reported knowing someone who was seriously injured or killed; 10% reported being shot, hit, or having a close call; 26% reported having a buddy shot or hit nearby; and 9% reported being involved in hand-to-hand combat.[7] From these statistics, at least, it appears that the majority of infantry Marines who participated in the initial invasion of Iraq encountered potentially traumatic events.

Infantry Marines, Casualties, and PTEs

While these figures were only true for the initial invasion of Iraq, the overall numbers of casualties among Marines since 9/11 suggests that a large percentage of infantry Marines have continued to encounter death in combat. The Washington Post maintains a website called “Faces of the Fallen” which catalogues all of the deaths of service personnel in Iraq and Afghanistan since 9/11. While Marines have made up only about 10-12% of total American forces, they have incurred a disproportionate 24.7% of the total killed in combat (1,374 out of 5,557).[8] If a similar proportion is maintained among those wounded in combat (12,350 out of 50,000), then the Marines have suffered almost 14,000 combat casualties.[9]  While not all of the wounded represent life-threatening or even serious wounds, the figure is still staggering when one considers that approximately 300,000 Marines deployed, of which only about 15% (45,000) are classified as infantry. With these statistics, it takes little imagination to realize that most infantry Marines have probably encountered potentially traumatic events, including the death of a friend or unit-member in combat.

Given the figures of Marine combat killed and wounded in Iraq and Afghanistan, how do infantry Marines handle combat death? To understand this question, we need to look first at Marine infantry training, the tempo of combat operations, and anecdotal evidence from Marines who encountered traumatic death in Iraq and Afghanistan.

(Next Post: Part 3 – Learning to Kill)


[1] “Everyone who has ever deployed to a war zone is changed by his or her experiences; it would be abnormal not to be. Some reactions may seriously interfere with your life, but that doesn’t mean there’s something wrong with you as a person.” – Charles W. Hoge M.D.. Once a Warrior–Always a Warrior: Navigating the Transition from Combat to Home–Including Combat Stress, PTSD, and mTBI (Kindle Locations 356-357). Kindle Edition.

[2] Charles W. Hoge M.D.. Once a Warrior–Always a Warrior: Navigating the Transition from Combat to Home–Including Combat Stress, PTSD, and mTBI (Kindle Locations 372-374). Kindle Edition.

[3] A fascinating exception seems to be with the elite U.S. Navy SEALs who enjoy an extremely low incidence of PTSD despite their aggressive combat schedule. Psychologists are studying SEALs to see how their rigorous selection process, intense training, incredible esprit de corps, and wide acceptance and approval amongst society at large may contribute to such resilience to PTSD. Another prominent factor may be the nature of SEAL combat operations which generally involve a high level of specific training, planning, and pin-pointed execution where the SEALs always remain in control. And as will be seen later in this paper, being in control in a combat situation markedly reduces the risk of developing PTSD. Cf. Brian Mokenhaupt, A State of Military Mind From http://www.psmag.com/health/a-state-military-mind-42839/ June 12, 2012. Accessed 11/15/12.

[4] Charles W. Hoge M.D.. Once a Warrior–Always a Warrior: Navigating the Transition from Combat to Home–Including Combat Stress, PTSD, and mTBI (Kindle Location 346). Kindle Edition.

[5] “We need to appreciate that the experiences of infantry warriors operating in hostile territory 24/7 are different than warriors who mostly work inside a protective perimeter. Personnel working inside the wire (pejoratively dubbed in the current wars ‘Fobbits,’ from ‘FOB’ or ‘Forward Operating Base’) often don’t live with the same level of day-to-day threat from direct combat as line infantry personnel. Yet, it’s also important to appreciate that these warriors in support roles can experience substantial stress from indirect fire and other deployment stressors. They may also be at higher risk than line infantry warriors when they do go on support missions outside the wire (as most do), because of a lower level of experience dealing with unexpected combat scenarios, such as ambushes. Combat teams often have higher cohesion and combat readiness than support teams, and are therefore better equipped to handle unexpected enemy engagement. This can actually translate into lower rates of PTSD for some line units, despite much higher levels of combat, compared with some support units.” – Charles W. Hoge M.D.. Once a Warrior–Always a Warrior: Navigating the Transition from Combat to Home–Including Combat Stress, PTSD, and mTBI (Kindle Locations 434-438). Kindle Edition.

[7] Charles W. Hoge M.D.. Once a Warrior–Always a Warrior: Navigating the Transition from Combat to Home–Including Combat Stress, PTSD, and mTBI (Kindle Location 459). Kindle Edition.

[9] As of 2008, the proportions were similar between the percent of Marines killed in combat compared to total deaths, and the number of wounded Marines. Rod Powers, “The Cost of War,” http://usmilitary.about.com/od/terrorism/a/iraqdeath1000.htm, Accessed 11/15/12.

About Nate

A 2003 graduate of the Virginia Military Institute and former Marine infantry officer, Nate is the Chief Operating Officer of Hire Heroes USA, a nonprofit organization that helps veterans get jobs. He holds a Master's in Public Administration from the University of Georgia. Nate lives with his wife and dog in Alpharetta, Georgia.
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5 Responses to Combat Loss and PTSD – Part 2: The Link Between Combat and PTSD

  1. Pingback: Combat Loss and PTSD – Part 3: Learning to Kill | The Soldier's Load

  2. Pingback: Combat Loss and PTSD – Part 4: Preparing for Death | The Soldier's Load

  3. Pingback: Combat Loss and PTSD – Part 5: When the Metal Meets the Meat | The Soldier's Load

  4. Pingback: Combat Loss and PTSD – Part 6: Memorials and Healing | The Soldier's Load

  5. Pingback: Combat Loss and PTSD – Part 7: When the War Continues – PTSD | The Soldier's Load

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