Summary Therelationship between combat andpsychiatric breakdownhas

combat andpsychiatric breakdownhas beenwellrecognised fordecades.The change to smaller, professional armed forceshas reduced the riskof large-scale acute psychiatric casualties, and should have led to a correspondingdecrease in long-termillhealth, butthis expected reduction seemsnotto havehappened. Likewise, attempts atpreventing psychiatric injury, by screeningbefore deploymentordebriefingafter, have been disappointing.Three reasons for this are proposed: a rethinking ofthe relationship betweentrauma and long-termoutcome, catalysed by the attempts of US society to cometotermswiththeVietnamconflict; a broadening ofthe scope of psychiatric injury as itmoved to the civilian sector; and the increasedprominence of unexplained syndromes and contested diagnoses such as Gulf War syndrome. Traditionalpsychiatric injuryispredictable, proportionate and can, in theory, be managed.Thesenewer forms of injuryare in contrastunanticipated, paradoxical, ill understood andhard tomanage. Traditional approaches to risk management byreducingexposurehave not been successful, andmayincrease risk aversion andreduce resilience.However, the experiences of civilians inwartime or themilitary show that people are not intrinsicallyrisk-averse, provided theycan see purpose in acceptingrisk.