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All the combatant nations of the first world war struggled to deal with the problem of large-scale casualties that could not be ascribed to simple physical injury. After a brief flirtation with medical explanations ('shell-shock') these were soon realized to be psychological in nature, but not until the end of the war was there much consensus on whether these represented a psychological response to the stressors of industrial warfare, or alternatively a failure of motivation or even masculinity. Simultaneously combat motivation was seen within a moral framework that emphasized duty, patriotism, leadership and character. It was these latter virtues, or lack of them, that gradually came to explain combat breakdown, and not the psychological theories, even if modern narratives tend to overlook this. If a person had sufficient character, leadership and training, breakdown was unlikely even under the harshest conditions. By the end of the second world war, new thinking and research, mainly from the American forces, now downplayed the importance of ideological and personal factors, and instead concluded that the most powerful motivation for combat (as opposed to enlistment) came from the role of the small group—'men fight for their buddies'. Breakdown was still seen as the reserve side of combat motivation, most likely when the small group disintegrated, although ultimately even the most robust could succumb after prolonged combat exposure. However, provided that the individual was previously of normal personality, this would be short lived. Long-term illness was still almost entirely attributed to vulnerabilities acquired by inheritance or during childhood. Combat breakdown could also be made chronic by the influence of secondary gain, and so medical labels for combat breakdown were avoided, treatment was by reassurance and return to duty, and compensation was discouraged where possible. It was not until the aftermath of the Vietnam war that views on combat motivation and breakdown began to diverge. As a result of the efforts of American psychiatrists opposed to the Vietnam war a new medical label, post-traumatic stress disorder (PTSD), was introduced in 1980. It was now believed that not just transient, but also chronic, mental disorders could be caused by combat, even in those previously of robust disposition, and that the necessity for a diagnosis and compensation overcame concerns about illness reinforcement and secondary gain. Social explanations for breakdown based on group psychology largely disappeared, to be replaced by a framework based almost entirely on individual responses to trauma, although the role of predisposition quickly needed to be rediscovered. In contrast, the military continue to insist on the importance of small group psychology in explaining motivation to fight, and are distrustful of either ideological or individual explanatory models.

The symptoms that make up the construct of neuras thenia, including fatigue and exhaustion, are dimension ally distributed in the community. The decision to create a category called neurasthenia is an arbitrary one, influenced by issues of severity and morbidity. The prevalence and nature of the resulting concept are also substantially influenced by the decision on how to classify the close relationships among excessive fatigue, depression and anxiety. Superimposed upon this classi fication is a second, parallel structure of illness beliefs. The original construct of neurasthenia as a physical disease that resulted from overwork, was of consider able utility to both doctors and patients. This early concept of neurasthenia can be recognized in the modem revival of interest in chronic fatigue syndrome (CFS) in Western cultures. The current highly charged atmosphere surrounding these diagnoses reflects the issues of legitimacy and non-legitimacy in illness, usually expressed in competing physical and psychologi cal explanations of ill health.

The UK scientific community is rightly concerned about the impact of leaving the EU on UK science. These concerns are particularly pertinent for mental health research, which is chronically underfunded in comparison to research on physical health conditions. The EU is one of the largest funders of mental health research in the world, with the UK clearly benefitting from this because of its strong track record. Any loss of funding, leadership or influence would weaken this. Likewise if we are unable to attract the best or most promising researchers from the rest of Europe, the loser will not just be research into mental health across Europe, but patients themselves. Those working on the Brexit negotiations must develop clear and coherent plans to safeguard scientific research in UK and ensure that the momentum gained in mental health policy in recent years is not lost.

In contemporary culture, soldiers held as prisoners-of-war (POWs) or as hostages are considered at significant risk of mental illness, in particular post-traumatic stress disorder (PTSD). This assumption contrasts with the psychiatric orthodoxy of the First World War when it was concluded in both Britain and Germany that POWs were protected against 'war neurosis'. Although 'barbed wire disease' was identified during time of captivity, post-release effects were not recognized. The repatriation of 'protected' POWs in 1943 prompted a reassessment of the psychological impact of imprisonment when servicemen of previous good character began to behave aberrantly. Rehabilitation programmes were designed to enable soldiers to re-adapt to service or civilian roles. Difficulties of adjustment were cast in social and cognitive terms, and corrective measures were occupational and educational. Psychiatric disorders found in POWs were explained in terms of a pre-conflict predisposition to, or a history of, mental illness. However, retrospective studies of veteran POWs have found a high prevalence of PTSD. A change in attitudes is explored in relation to the advance of medical terminology into the territory of emotions and the attribution of pathological processes to self-recovering mental states. The reclassification of the effects of imprisonment implies that diagnoses in military psychiatry are culturally determined and can be understood only if they are placed in a context that includes changing beliefs about mental illness, the formal development of the psychiatric profession and the immediate needs of the armed forces.