Psychiatrists studying the feelings of guilt or shame associated with close combat say the wars in Iraq and Afghanistan are influencing changes in the "bible" of psychiatry in the USA.
The section of the American Psychiatric Association's manual for diagnosing mental illnesses that outlines the diagnosis of post-traumatic stress disorder — an illness afflicting 15 percent to 20 percent of returning combat veterans — is being expanded to include symptoms of persistent and reoccurring guilt or shame.
"We've seen … thousands of young men and women coming ho me terribly impaired emotionally by the war, and it certainly has gotten us thinking about what the consequences are (of combat)," says David Spiegel, a member of the association's working group that is rewriting the PTSD section.
The Department of Veterans Affairs has treated more than 200,000 veterans of Iraq and Afghanistan for PTSD.
The triggers for PTSD have traditionally been linked to witnessing or experiencing violence or life-threatening events. Sufferers include victims of rape, domestic abuse and traffic accidents, as well as combat.
The illness can lead to recurring nightmares, feelings of isolation and withdrawal and numbness to the world.
Those revising the psychiatric manual say it is clear that PTSD is also characterized by distorted feelings of self-blame. In the chaos of war, this can include reactions to the unintentional killing of innocent people, Spiegel says.
The revisions provide examples of symptoms that result from moral hazards: "I am bad," "I've lost my soul forever," and "the world is completely dangerous."
USA Today reported in November that a preliminary study of more than 200 Marines involved in intense fighting in southern Afghanistan found the leading cause of PTSD was moral conflicts faced in combat, more virulent than fears of death.
Matthew Friedman, executive director of the VA's National Center for PTSD, who worked on the revisions, says the war influenced the changes, but rape and other traumatic events that cause the illness also played a role.
Psychologist and neuroscientist Rachel Yehuda, a professor at the Mount Sinai School of Medicine in New York who does extensive research with combat veterans, says the new criteria for PTSD can reduce stigma about seeking care.
"What sometimes happens is that people miss the diagnosis because (patients) don't have one or two symptoms that are not listed," Yehuda says. "The more symptoms that we can list that really capture the post-traumatic state — the one that really causes a lot of difficulty in readjustment — the better off we are."