American Veterans and the Evolutions of Mental Health: A Historical Review of Diagnoses and Depiction

Stephanie K. Erwin Abstract This article reviews the interwoven history surrounding mental health diagnoses and military veteran depictions of the twentieth and twenty-first centuries. Including a detailed historical review focusing on three major time periods: WWI-Korean War (1915-1950s); Vietnam War (1960s-1980s); and the Gulf/Middle East conflicts (1981-Present). By noting prevailing connections throughout these time periods, including the continuity of stigma and the depictions of veterans as well as the evolution of changing interpretations in what images and depictions of veterans mean including their associated social and political usages. Finally, a number of implications, both positive and negative surrounding the interconnected nature of veterans and mental health (namely PTSD), are offered, with recommendations for future inquiry and policy.


Introduction
The invisible wounds of war are fundamentally and continually associated with the United States' (US) perceptions of its war veterans. The image of the traumatized war hero returning home with physical, mental, psychological, and emotional wounds is one oft seen in the public sphere, whether as a patriotic recognition or political gamesmanship. Wounded warriors, particularly those with wounds not visible to the eye, have become synonymous with the whole of American military veterans returning from the battlefields. This is certainly not a recent development: "in…military conflicts of the twentieth century, behavioral/psychiatric symptomatology continued to be noted in military personnel with combat experience" (Shively & Perl 2012: 236). As early as World War I (WWI), images and stories were prevalent of American veterans whose experience in war and conflict had left an indelible imprint on who they were, how they functioned, and inevitably how they interacted with the world and society.
These images and depictions of wounded veterans become an inherent component of the social representations of the time. They are used by social forces, political means, and special interests. While the inherently interconnected relationship between war veterans and mental health have been continuous across the twentieth century and thereafter, the interpretations of such portrayals and their associated messages have evolved in accordance with the particular social and political forces of the times. These evolutions and diversity of representation are particularly evident in the time periods surrounding the world wars, the Vietnam War, and the recent conflicts in the Gulf and Middle East. These three component time periods starkly reflect the interwoven relationship between veterans and mental health over the course of the twentieth century and into the twenty-first century, as well as the variety of interpretations of this relationship and their subsequent portrayals in American society. Throughout the course of this evolution, mental health diagnoses have been intrinsically tied to the depiction and perception of veterans amongst the American populace. This includes not only how veterans are represented, but also what social forces, policies, and political movements surround them. Are they weak malingerers, heroes, victims, villains, or the continued to dwell on past conflicts were simply nostalgic for the glory of war; Civil War troops suffered from war neurosis, and more recently, soldier's heart (Shell Shock 2016). Prior to WWI, invisible wounds of the mental or psychological variety were generally attributed to such nostalgia, an idle malingering, or worse, an affliction similar to female hysteria: distilled to an inherent personal weakness of the individual rather than a reflection upon war itself (Lembcke 2016: 80;McDonald, Brandt, & Bluhm 2018;Maseda & Dulin 2012: 4;Alexander 2010;Scragg 2016: 175) Inevitably, formal military and medical responses were simply akin to "suck it up and be a man," and societal reactions were generally those of avoidance, ignorance, or scorn: a depressing and oft disregarded consequence of war. Those whose wounds could not be managed or failed to recover, were retired to convalescence reflective of their station and subsequently lost to the collective memory.

1915-1950s
"War has historically been a crucible that catalyzes advances in medical care" (Hoge et al. 2016: 334). In 1915, at the height of WWI, unseen numbers of wounded, both physical and other, were being reported in hospitals across battlefronts. Military medical professionals were faced with sending obviously symptomatic men back to the front, since they possessed no identifiable or treatable injury. It was in direct response to this dilemma which saw the first medical acknowledgement that such wounds were more than just displays of cowardice or weakness. With the permission of Army medical leadership, Capt. Charles Myers, MD, studied three soldiers with physical symptoms and no visible malady. He later identified their diagnosis as shell shock in A Contribution to the Study of Shell Shock, stating that "comment on these cases seems superfluous. They appear to constitute a definite class among others arising from the effects of shell-shock. The close relation of these cases to those of 'hysteria' appears fairly certain" (Myers 1915: 320). The shell shock diagnosis, or as the trenches called it, the 100-yard stare, would eventually become the allencompassing diagnosis for any non-physical ailment amongst military servicemembers and veterans throughout the first world war (Loughran 2012: 104;Stagner 2014: 256).
However, this diagnosis was fraught with complications. Since it encompassed any and all physical, mental, emotional, and psychological symptoms without visible physical injury, it included injuries not necessarily derived from the blast of nearby ordnance shells. "During the war, shell shock was understood in many different ways: as a psychological reaction to war, as a type of concussion, or as a physiological response to prolonged fear" (Loughran 2012: 257). Though debated, estimates list shell shock cases as somewhere between 15,000 to 76,000 (Stagner 2014: 257). Subsequently, the military would mark all those who derived the diagnosis from proven ordnance detonation as pension-eligible, and all those not as service-connected but not pensionable injuries (Alexander 2010). This approach and understanding of the broad diagnosis of shell shock would continue into World War II (WWII). Over the course of WWII and the Korean War, the understanding of those shell shock cases not directly resulting from artillery blasts grew to encompass all those ailments associated with a general war weariness or combat/battle fatigue, subsequently leading to a greater acknowledgement of the previously non-pensionable cases.
As veterans of the wars of the first half of the twentieth century returned to American soil, they were hailed as conquering heroes who defeated the great enemies of mankind and defended the American ideals of liberty and freedom. Given the demographics of American veterans, nearly every member of American society was directly connected in some fashion to a veteran of the time and had personally felt the hardships of a nation at war (US Department of Veterans Affairs, 2018). As such, veterans of the time were welcomed home to great fanfare. Yet not all the images of returning heroes were joyful images of victory and heroism. For perhaps the first time, the realities of war were portrayed to the American populace with images of physically, emotionally, mentally, and psychologically wounded warriors returning home. "…Post war, shell shock created a new understanding that circumstances could cause mental breakdowns, which had nothing to do with moral fiber, and that mental illness was something that could be transient and wasn't necessarily genetic or degenerate" (Shell Shock, 2016). While there remained negative connotations both within the military and in civilian society, for the first-time, veterans returning with invisible wounds at least had a diagnosis.
Shell shock put a name to what had previously been a stark but unspoken reality. Veterans were able to seek treatment and pensions if their diagnosis demonstrated a direct connection to ordnance detonation. What would come to be known as the Bonus Expeditionary Force, a group of WWI veterans and families, lobbied the federal government for war compensation. Congress would eventually pass the World War Adjusted Compensation Act (US Congress, 1926). Public portrayals of mental health associated with the trauma of war grew into the public sphere. This trend would endure with WWII, when returning veterans would continue to promote a greater acknowledgement of those invisible wounds. Seeking solace while recuperating in military and veteran hospitals, these veterans sought outlets to express the inerasable traumas of war, "...drunk with fatigue, deaf even to the hoots of disappointed shells that dropped behind" (Owen 1920: 461).

1960s-1980s
By the 1960s, medical and military professionals were recognizing that a number of attributes exhibited in shell shock, were prevalent in civilian medical cases surrounding trauma of some facet (Shively & Perl 2012;Summerfield 2001). Soon after, the Vietnam War saw unprecedented numbers of servicemembers and returning veterans displaying symptoms associated with shell shock. In an effort to address those cases not ordnance-related, military medical professionals coined the term post-Vietnam Syndrome (Lembcke 2016: 78) or Vietnam Syndrome (Shively & Perl 2012: 236).
While this diagnosis enabled the encompassing of broader cases and a more concrete acknowledgement of the mental and psychological damage inflicted by military conflicts, it failed to reflect the similarities displayed in civilian cases or to provide a connection across time and armed conflicts. As greater numbers of Vietnam veterans sought treatment upon return, their frustration with the lack of civilian medical professional acknowledgement and understanding of their diagnosis grew. Vietnam veterans lobbied strongly in support of official representation and were central to the formalized medical establishment of Post-Traumatic Stress Disorder (PTSD) as a medical diagnosis in the 1980 Diagnostic and Statistical Manual of Mental Disorders (DSM) third edition (APA 1980). This diagnosis reflected the broad spectrum of symptoms and causes for PTSD, but was not strictly limited to military service and associated injuries. In the later part of the 1980s, the National Vietnam Veterans Readjustment Study estimated nearly 30.9 percent of Vietnam War veterans suffered from PTSD (Fisher 2014: 1).
Recognition of PTSD as a treatable, legitimate medical condition, served two purposes for veterans in the 1960s and 1970s. It would enable the greater reach of medical care and it served to change the harsh image perceived of veterans in light of their association with the Vietnam War. The Vietnam War was perhaps the most unpopular war in American history and veterans returning home were its visible and tangible image to the American populace. It mattered little that these veterans were conscripted draftees in a war they may not have even supported. Their very relation to a uniform served as a target for a population frustrated with government and political actors (Summerfield 2001: 95). Subsequently, this perception in society of a battle-hardened warrior returned, was exacerbated by unprecedented numbers of veterans with mental health issues. The predominant image of the war would become a hyper-violent anti-social veteran (Maseda & Dulin 2012: 9). The formalization of PTSD as a diagnosis would aim in reorienting this portrayal to one where Vietnam veterans were unfortunate victims of political machinations-heroic individuals forced to serve their country and become victims themselves (Botti 2008: 12;Maseda & Dulin 2012: 12). Vietnam veterans would become survivors rather than warriors or perpetrators even in the supposed defeat of the war itself. This reimagining has continued ever since with the focus in American dialectic being that of the drafted soldiers lost in conflict and "only images of veterans healing at the wall remain" (Maseda & Dulin 2012: 19). The American populace hearkens to Vietnam veterans and their experiences following the war more so than the war itself, and the stereotype of a mentally scarred and psychologically wounded veteran lingers in the public consciousness (Botti 2008;Satel & Mcnally 2018). Vietnam veterans no longer coincide with the political narrative surrounding the Vietnam War.

1981-Present
In the waning of the twentieth century, and the turn of the twenty-first, PTSD has become a well-documented, studied, and treated diagnosis in both civilian and military spheres. Additionally, in 2012, a Congressional resolution designated June 27 th at National PTSD Awareness Day (Purtle 2014: 505). The narrative established in the Vietnam era surrounding veterans and mental health now pervades popular American discourse. PTSD as a medical diagnosis has continued to evolve, and now reflects a more nuanced understanding of the malady, which has grown to include associated injuries such as Traumatic Brain Injury (TBI). Military veterans remain at the forefront of mental health and PTSD awareness; approximate numbers show between five and twenty percent of veterans suffer from PTSD (Fisher 2014: 1). Efforts continue amongst veteran organizations, military leadership, and governmental entities to enhance support capacities of a growing number of veterans suffering from the invisible wounds of war.
An oft thrown around number is 22-the notional number of veterans who commit suicide every day, generally as a result of some form of untreated mental health issue like PTSD or TBI. This dialogue has become the forefront in American perception of returning veterans. "The discourse of trauma has displaced almost all else from the coming-home news coverage of the current generation of veterans returning to the United States from operations in the Middle East" (Lembcke 2016: 78). The legacies of Vietnam imagery and memorialization have dictated mental health as the highlight of veterans' issues, distorting the perception of the American public as to the numbers associated with it. The dominant image is one of a "broken hero" (Phillips 2015). While such portrayals certainly highlight the need for support for mental health and PTSD, it has also served to alter public perception of veterans as emotionally unstable citizens on the verge of breakdown who may selfmedicate with drugs or alcohol (Phillips 2015.

Continuity and Change
Throughout the course of the twentieth century and the evolution of what is now called PTSD, there have been two continuous aspects: the stigma surrounding mental health in the military and veteran community, and the continually linked representations of these maladies as illustrations of veterans as a whole. In contrast, these portrayals are oft used as fodder for the social and political forces reflective of the time. The relatively similar depictions may be used in a number of facets to provide an interpretation aimed at furthering whatever aim is sought.

Continuity of stigma and depiction
For the former (continuity), the stigma associated with mental and psychological illness is likely as old as war itself. As aforementioned, prior to WWI and even during the Great War, victims of such injuries were generally met with disdain and disbelief. "There are two main criteria used to evaluate acts of heroism: risk to self and benefit to others. The solider who risks physical peril for benefit of country is an archetypal hero in most contemporary societies" (Purtle 2016: 13). Men who went to war and came home were heroes, the masculine ideal, who fought to defend their nation and liberty, returned victorious and proud to rejoin society. Those who did not fit into this archetype, were seen as weak malingerers who failed to do their duty as men of war-cowards who hid in their bunks while their comrades fought for them; sentimental, nostalgic fools who failed to move on and insisted upon dwelling on the past. With the advancement in acknowledgement of 1915's shell shock diagnosis, the stigma associated with such illnesses may have waned. However, 100 years later, the stigma of seeking mental health treatment still discourages veterans from seeking help. Little progress has been made despite the continued evolution in medical understanding. Not only do veterans stigmatize such injuries amongst themselves, society still retains that those contrary to the masculine standard are inherently weak. Even a strong desire to provide care and support for those wounded warriors afflicted with PTSD cannot overcome an inherent stigmatization of those seeking treatment.
That is, many individuals who emphasized a need to reduce PTSD-related stigma in the military also conveyed other messages which could lead to stigmatization of servicemembers and veterans expressing symptoms of or seeking treatment for PTSD. For example, some labeled them as individuals with an invalid diagnosis or as malingerers, assertions that may be stigmatizing and serve as barriers to PTSD treatment in military contexts (Fisher 2014: 6).
Here, the lack of social evolution has hindered progress. Despite the advancements socially and medically in the recognition of mental health and PTSD amongst veterans, there remains an inherent stigma associated with such perceived personal weakness, an antithetical counter to the very archetype of the strong, masculine, war hero. For American veterans, mental health and PTSD remains a socially stigmatized condition.
As with the continuity of stigma, so too have the depictions of veterans in relation to mental health and PTSD remained a continuous entity across the twentieth century. In this, the very nature of their depictions has been relatively streamlined. In each of the aforementioned time periods, returning veterans were marked by a constant depiction in mainstream society of the returning warrior traumatized by the horrors of war and suffering from some invisible wounds, unseen to the human eye, which can only be understood by those who have also seen such trauma (Maseda & Dulin 2012;Phillips 2015). Yet even at its height in the Vietnam War, diagnosed cases of PTSD were only 30.9 percent (Fisher 2014: 1), and are even less in the present conflict. However, this prevalence of the topic in veteran discourse, would imply far greater numbers, and generally paints the diagnosis as a broad and widespread condition of nearly all returning veterans: war is inherently traumatic and as such all veterans are traumatized. The depictions and images of PTSD and veterans have been a continuous thread since WWI and grow ever more present in the national conscious.

Changing interpretations
These portrayals often have dire consequences by coloring American perceptions. In the early twentieth century, such portrayals lent to the stigma of personal weakness: Vietnam veterans were subject to the political agendas of the time, and modern veterans have suffered from higher rates of unemployment, substance abuse, and suicide (Maseda & Dulin 2012: 25). Though these statistics have continued to improve over recent years (US Department of Labor, 2018). The reality herein lies in the "sticky-thicket of political history and cultural imagery and medical science" (Lembcke 2016: 79). The depictions of wounded military veterans suffering from psychological trauma from war, spur public emotions surrounding national identity and patriotism (Lembcke 2016: 84). These constructs are cannon fodder for changing social and political forces and agendas. National identity and patriotism were key components to the war efforts in the first and second world wars. Acknowledgement and discussion on the horrors and traumas of war was rarely a topic in popular portrayals, but if it was, it was reflective of the issue as one of weak character. Rather, more nuanced depictions of the conflicts' legacy would come later in more artistic expressions such as Owen's (1920) Dulce et Decorum Est. andMcCullin's (2011) Shaped by War.
The Vietnam War was particularly subject to the political and social forces of the 1960s and 1970s. Vietnam veterans were subject to constant political machinations by both supporters and detractors of the war as the veritable face of the conflict. Eventually, the veterans themselves would work towards distancing themselves from the conflict and taking ownership of their representations (Lembcke 2016: 83;Maseda & Dulin 2012: 8). Later imagery and film portrayals would focus on the veterans themselves as victims of the horrors and trauma of war. The national desire to simply forget the war and its complexities have served to focus instead on the victimized veterans (Maseda & Dulin 2012: 19). Legacies of the Vietnam War era have made modern debates on the conflicts in the Middle East dangerous topics for politicians, public officials, and society. Critics must be careful to not mistake political critique for disparagement of American troops and veterans. The establishment of the all-volunteer force has further complicated such examinations. No longer are most Americans directly connected to military service. Unlike in previous conflicts where upwards of eleven percent of the population served, and draftees were garnered across the US, contemporary volunteers number less than one percent, and hail from communities with histories of military recruitment and service (The War Comes Home 2014). Additionally, patriotism has become synonymous with military and veteran support. Sports leagues have military recognition events, companies promote veteran friendly efforts, yet "mostly, veterans said they felt invisible, anonymous, and ignored by the public" (Satel & McNally 2018). Supporting wounded warriors, particularly those with PTSD, has become a veritable cornerstone of popular American culture. The changing interpretations of relatively continuous depictions of veterans with mental health and PTSD issues, reflects their usage in social and political forces not necessarily reflective of veterans themselves.
The varying nature of interpretations of veteran representations are stark when seen through the light of their inherent similarities. However, these at times similar portrayals and veteran depictions are used to support the unique narratives of their time: to demonstrate the enemies' evils as well as the heroism (and at times weakness) of American veterans in the first and second world wars; the frustrations and anguish of Vietnam veterans victimized by political intrigues; and the patriotism and psychological trauma of more than a decade at war in the Middle East and a failing mental health support system and US Department of Veterans Affairs (VA).

Implications, Recommendations, and Conclusion
Throughout the course of the American veteran mental health medical evolution, the diagnoses have been intrinsically tied to the depiction and perception of veterans amongst the American populace. This includes not only how veterans are represented, but also what social forces, policies, and political movements surround them. Are they the weak malingerers, the heroes, the victims, the villains, or the unfortunate?

Implications
The interconnected nature of veterans and mental health has a number of implications for the present and future. To its benefit, the high value placed upon research surrounding PTSD has continued the evolution of veterans' mental health and PTSD, incorporating greater nuance and understanding to the diagnoses and treatments, as well as other mental health injuries such as TBI (Hoge et al. 2016). It has encouraged a popular and significant level of support amongst the American populace for services in aid of veterans with mental health injuries and other invisible wounds, as evidenced by the continually increasing numbers of veteran service organizations (US Department of Veterans Affairs 2017). However, the prevalence of representations of veterans with PTSD, risk not only overrepresentation as we have seen in the general assumption amongst Americans that most veterans possess the malady, but also in oversimplification, that PTSD is a common and easily treated illness not limited to warfare. Such generalization risks misunderstanding the context that war and conflict has upon PTSD and its sufferers. "As it turns out, the more we know about shell shock, the more problematic PTSD and TBI become as touchstones for generalizing about war and trauma" (Lembcke 2016: 79). The trauma of war is unavoidable; it is war after all. However, that does not inherently make each experience the same, nor do veterans of war experience PTSD the same, nor make veteran PTSD the same as any other form of traumatic experience. For PTSD in general, the definition and criteria for such diagnosis has continued to evolve, both in concert and separately from the veteran community. With each emerging edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) growing awareness and knowledge has continued to evolve, within an iterative process, the definitions, criteria, and aspects of the diagnosis of PTSD. Within the fifth edition of the DSM (APA 2013), a number of changes reflect the growing knowledge surrounding PTSD.
Changes to the diagnostic criteria from the DSM-IV to DSM-5 include: the relocation of PTSD from the anxiety disorders category to a new diagnostic category named 'Trauma and Stressor-related Disorders', the elimination of the subjective component to the definition of trauma, the explication and tightening of the definitions of trauma and exposure to it, the increase and rearrangement of the symptoms criteria, and changes in additional criteria and specifiers (Pai et al. 2017: 1). Each of these changes incorporates the growing streams of research surrounding PTSD both within the veteran context and disparate from veterans and warfare. As such, diagnosis and treatment must reflect the multifaceted nature of PTSD and other mental health injuries particularly when associated with veterans. Overrepresentation and oversimplification are particularly dangerous, as fewer American serve, and the all-volunteer force draws from fewer communities (The War Comes Home 2014).
Additionally, whilst not all, veterans may face higher rates of suicide and unemployment. These raise concerns over the quality of support services available to veterans regardless of how "supportive" the American populace appears. The aforementioned stigmas of mental health and overrepresentations may deter servicemembers and veterans from seeking help. At the same time, veteran services are at an all-time high. The sheer numbers of veteran service organizations are staggering (US Department of Veterans Affairs 2017); yet either veterans are not seeking treatment, or if they are, it is insufficient to meet the needs of the veteran experience. Nevertheless, the image of a veteran suffering from PTSD remains a dominant narrative and poignant image used by any number of social and political forces.

Recommendations
In light of the entwined relationship of veterans and PTSD, there requires a more multifaceted and reflective representation of veterans as a demographic. Future portrayals and representations of veterans should highlight the realities of those suffering from mental health not as a sole depiction of veterans, but as one of many experiences of war. Continuing that growing representation should highlight and incorporate a more diverse reality of American veterans, recognizing race, ethnicity, and gender, etc., in both PTSD and other depictions of the veteran experience. The archetypal young, white, male as the American hero of the twentieth century no longer accurately depicts the realities of veteran demographics.
The narrative legacies of the Vietnam veterans have brought to the forefront the invisible wounds of war. However, there remains a continued need for research and support development surrounding mental health and PTSD. Further inquiry must include community building within the veteran community itself and the greater civil society, ensuring the depictions and representations of veterans are accurate portrayals. While support for veterans and mental health has swelled, veterans maintain a sense of isolation only exacerbated by such invisible wounds.

Conclusion
It is certainly no great surprise that one of the most enduring images of the American twentieth century, is the veteran suffering from some invisible wound of war. They may be on the battlefield or returned to the homeland, it may take the form of shell shock, post-Vietnam Syndrome, PTSD, or some other unseen psychological or mental trauma, but this image permeates the American consciousness. It is a lasting and continuous reflection on the past and a visible narrative of the present. Its image, though, is used in a variety of capacities and for a multitude of agendas. The implications for veterans themselves are often subject to the social and political forces of their time.
The interpretation of such images ebbs and flows with time and differing conflicts, while the fundamental components and the associated stigmas remain: a veteran struggling with the invisible wounds of war. Bibliography