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					WAR PSYCHIATRY




                 i
             The Coat of Arms
                   1818
      Medical Department of the Army


      A 1976 etching by Vassil Ekimov of an
       original color print that appeared in
     The Military Surgeon, Vol XLI, No 2, 1917




ii
The first line of medical defense in wartime is the combat
medic. Although in ancient times medics carried the caduceus
into battle to signify the neutral, humanitarian nature of
their tasks, they have never been immune to the perils of
war. They have made the highest sacrifices to save the lives
of others, and their dedication to the wounded soldier is
the foundation of military medical care.




                                                               iii
     Textbook of Military Medicine


                              Published by

                      Office of The Surgeon General
                        United States of America



                             Editor in Chief
         Brigadier General Russ Zajtchuk, MC, U.S. Army
                       Director, Borden Institute
                              Commander
           U.S. Army Medical Research and Materiel Command
                          Professor of Surgery
                  F. Edward Hébert School of Medicine
           Uniformed Services University of the Health Sciences

                Officer in Charge and Managing Editor
           Colonel Ronald F. Bellamy, MC, U.S. Army
                            Borden Institute
                Associate Professor of Military Medicine,
                     Associate Professor of Surgery,
                  F. Edward Hébert School of Medicine
           Uniformed Services University of the Health Sciences




iv
The TMM Series

Part   I. Warfare, Weaponry, and the Casualty

         Medical Consequences of Nuclear Warfare
          (1989)
         Conventional Warfare: Ballistic, Blast, and Burn
          Injuries (1991)
         Military Psychiatry: Preparing in Peace for War
          (1994)
         War Psychiatry (1995)
         Medical Aspects of Chemical and Biological
          Warfare
         Military Medical Ethics

Part II. Principles of Medical Command and Support
         Medicine and War
         Medicine in Low-Intensity Conflict

Part III. Disease and the Environment
         Occupational Health: The Soldier and the
          Industrial Base (1993)
         Military Dermatology (1994)
         Mobilization and Deployment
         Environmental Hazards and Military Operations

Part IV. Surgical Combat Casualty Care
         Anesthesia and Perioperative Care of the
          Combat Casualty (1995)
         Combat Injuries to the Head, Face, and Neck
         Combat Injuries to the Trunk
         Combat Injuries to the Extremities and Spine
         Rehabilitation of the Injured Soldier




                                                            v
Soo Suk Kim                                         War                                                 1966

Soo Suk Kim, a 22-year-old art student, painted War in 1966 as a gift to his brother-in-law, Captain Franklin
D. Jones, who was serving as a division psychiatrist in Vietnam. Soo Kim had experienced war first-hand
as a 6-year-old refugee during the North Korean occupation of Seoul, hiding from a communist edict calling
for the execution of his prominent family. The painting depicts his childhood recollection of the horrors and
chaos of war.




vi
WAR PSYCHIATRY


                    Specialty Editors

      FRANKLIN D. JONES, M.D., F.A.P.A.
        LINETTE R. SPARACINO, M.A.
         VICTORIA L. WILCOX, Ph.D.
        JOSEPH M. ROTHBERG, Ph.D.
           JAMES W. STOKES, M.D.




              Office of The Surgeon General
                   United States Army
                  Falls Church, Virginia
United States Army Medical Department Center and School
                Fort Sam Houston, Texas
         Walter Reed Army Institute of Research
                   Washington, D.C.
   Uniformed Services University of the Health Sciences
                  Bethesda, Maryland

                          1995




                                                          vii
       Lorraine B. Davis
       Senior Editor




       This volume was prepared for military medical educational use. The focus of the information
       is to foster discussion that may form the basis of doctrine and policy. The volume does not
       constitute official policy of the United States Department of Defense.
       Dosage Selection:
       The authors and publisher have made every effort to ensure the accuracy of dosages cited herein.
       However, it is the responsibility of every practitioner to consult appropriate information sources
       to ascertain correct dosages for each clinical situation, especially for new or unfamiliar drugs and
       procedures. The authors, editors, publisher, and the Department of Defense cannot be held
       responsible for any errors found in this book.
       Use of Trade or Brand Names:
       Use of trade or brand names in this publication is for illustrative purposes only and does not
       imply endorsement by the Department of Defense.
       Neutral Language:
       Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively
       to men


       CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS.
       ALL RIGHTS RESERVED.

       NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR
       TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL
       (INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND
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       COPYRIGHT OWNER


       Published by the Office of The Surgeon General at TMM Publications
       Borden Institute
       Walter Reed Army Medical Center
       Washington, DC 20307-5001


       Library of Congress Cataloging–in–Publication Data

       War psychiatry / specialty editors, Franklin D. Jones . . . [et al.].
                 p. cm. — (Textbook of military medicine. Part I, Warfare,
          weaponry, and the casualty)
              Includes bibliographical references and index.
              1. War Neurosis. 2. Military psychiatry—United States.
          I. Jones, Franklin D., 1935- . II. Series.
              [DNLM: 1. Combat Disorders. 2. War. 3. Military Psychiatry.      WH
          390 T355 pt 1 1989 v.4]
          RC971.T48 1989
          [RC550]
          616.9'8023 s—dc20
          [616.85'212]
          DNLM/DLC
          for Library of Congress                                   95-18334
                                                                         CIP
       PRINTED IN THE UNITED STATES OF AMERICA
       04, 03, 02, 01, 00, 99, 98, 97, 96,       54321



viii
Contents

   Foreword by The Surgeon General                               xi
   Frontispiece Plates                                            x
   Preface                                                     xiii
   Patient Flow in a Theater of Operations                      xv

    1.   Psychiatric Lessons of War                              1

    2.   Traditional Warfare Combat Stress Casualties           35

    3.   Disorders of Frustration and Loneliness                63

    4.   Neuropsychiatric Casualties of Nuclear, Biological,
         and Chemical Warfare                                   85

    5.   Psychiatric Principles of Future Warfare              113

    6.   A Psychological Model of Combat Stress                133

    7.   U.S. Army Combat Psychiatry                           149

    8.   U.S. Air Force Combat Psychiatry                      177

    9.   U.S. Naval Combat Psychiatry                          211

   10.   Combat Stress Control in Joint Operations             243

   11.   Debriefing Following Combat                           271

   12.   Postcombat Reentry                                    291

   13.   Behavioral Consequences of Traumatic Brain Injury     319

   14.   Disabling and Disfiguring Injuries                    353

   15.   Conversion Disorders                                  383

   16.   Chronic Post-Traumatic Stress Disorder                409

   17.   The Prisoner of War                                   431

   18.   Follow-Up Studies of Veterans                         457

   19.   Summation                                             473

   Acknowledgements                                            487
   Acronyms                                                    489
   Index                                                       493



                                                                      ix
Foreword
             This volume of the Textbook of Military Medicine addresses the delivery
         of mental health services during wartime. The foreseeable future of the
         U.S. military includes the potential for involvement in a variety of con-
         flicts, ranging from peace-keeping missions to massive deployments of
         personnel and materiel and possible nuclear, biological, and chemical
         threats as was seen in the Persian Gulf War. The medical role in wartime
         is critical to success of the mission. For the mental health disciplines, this
         role encompasses identification and elimination of unfit personnel, im-
         provement of marginal personnel to standards of acceptability, preven-
         tion of psychiatric casualties, and their treatment when prevention fails.
         All of these efforts must be guided by past experience and sound prin-
         ciples of human behavior.
             The identification and elimination of unfit personnel must be prudently
         managed. During World War II, medical personnel mistakenly believed
         that soldiers who had exhibited any prior symptoms of anxiety would be
         prone to breakdown. However, review of casualty breakdown in World
         War II revealed that breakdown was largely related to unit and battle
         conditions rather than predisposition.
             Prevention of psychiatric casualties must address the factors known to
         be important in soldier efficiency and breakdown. These can be grouped
         into biological, interpersonal, and intrapsychic factors. Of these, interper-
         sonal factors may be the most critical. Soldiers living and working
         together in conditions of shared danger and hardship will foster unit
         cohesion, which is known to reduce the risk of psychiatric breakdown.
         Thus, producing cohesive combat forces has become a mainstay of psychi-
         atric prevention.
             The soldier brings with him many, sometimes conflicting, intrapsychic
         beliefs and attitudes, including a strong sense of invulnerability. These
         contribute to his psychological defense against the rigors of the battlefield.
         It is the loss of such defenses that produces breakdown on an individual
         basis. The treatment of the combat psychiatric casualty near the front with
         replenishment of physiological deficits and expectation of return to one’s
         unit shores up these failing defenses.
             I strongly recommend that all commanders and medical officers read
         this book and heed its central theme: the stresses of combat are significant,
         but with appropriate and timely prophylaxis and treatment, the majority
         of these soldiers can be returned to their units as functional members of
         their group.

                                             Lieutenant General Alcide M. LaNoue
                                                             The Surgeon General
                                                                       U.S. Army



July 1995
Washington, D.C.




                                                                                          xi
Frontispiece Plates

Frontispiece   War                                                                vi
                  Soo Suk Kim, 1966
Chapter    1   Fighting at Guadalcanal                                             2
                  Richard W. Baldwin, 1943
           2   Going In, Peleliu                                                  36
                  Tom Lea, 1944
           3   Bunker on Nuo Ba Dhn Mountain                                      64
                  Edward J. Bowen, 1969
           4   Match Sellers, Class of ‘17                                        86
                  Kerr Eby, 1918
           5   The Attack                                                        114
                  Mario H. Acevedo, 1991
           6   Soldiers Resting on Omaha Beach, Normandy                         134
                  Manuel Bromberg, 1945
           7   American Doctor II—Field Force Doctor Examines Vietnamese Child   150
                  Samuel E. Alexander, 1968
           8   Aerial Gunner, England                                            178
                  Peter Hurd, 1944
           9   Crew’s Quarters Aboard U.S. Submarine, Pacific                    212
                  Paul Sample, 1943
          10   Patients Being Loaded on C-54, England                            244
                  Hans H. Helweg, 1944
          11   Killed in Action                                                  272
                  Burdell Moody, 1968
          12   Troops Boarding Homebound Ship                                    292
                  Leslie Anderson, 1947
          13   Purple Heart                                                      320
                  John O. Wehrle, 1966
          14   Requiem Mass                                                      354
                  Barse Miller, 1944
          15   Tent Hospital                                                     384
                  Aaron Bohrod, 1943
          16   Long Binh                                                         410
                  David N. Fairrington, 1968
          17   Prisoner Interrogation                                            432
                  Artist Unknown, circa 1943
          18   The Dental Front                                                  458
                  Marion Greenwood, 1945
          19   The Sentinel                                                      474
               Michael Pala, 1968




x
Preface
        The stresses of the military environment are diverse and significant—the
     potential for deployment and combat, long and arduous training missions, and
     separations from families. A companion volume, Military Psychiatry: Preparing
     in Peace for War, addresses these issues in a peacetime military. As stressful as
     garrison life can be, it pales when compared to the stresses of combat. These
     stresses are greatest during actual combat, but begin with notification of a
     deployment, and often continue after the fighting is over as the participants deal
     with the aftermath of the battlefield, which may include post-traumatic stress
     disorder, especially if they have been prisoners of war or experienced mutilat-
     ing injuries. This volume discusses the evolution of the concept of combat stress
     reaction, the delivery of mental health care on the various battlefields our
     soldiers are likely to experience, and the psychological consequences of having
     endured the intensity and lethality of modern combat.
        The concept of the stress casualty has changed considerably from times past
     when the symptoms of stress breakdown were thought to be evidence of
     cowardice and thus were punished rather than treated. As our understanding
     of the dynamics of the stress casualty and the battlefield environment have
     increased, we have discovered that the most important lesson learned from
     previous wars is the need for timely and appropriate handling of stress casual-
     ties. Psychiatric casualties should be seen as close to the battlefield as possible
     (proximity) and as quickly as possible (immediacy), and should be provided with
     rest and nutrition. They should be told that their symptoms are normal in combat
     and that they will recover (expectancy). These are the principles of proximity,
     immediacy, and expectancy, known by the PIE acronym. Psychiatric casualties
     treated under these principles are more likely to recover than those for whom
     treatment is delayed or occurs far from the battlefield. These principles can also
     be utilized in debriefing groups exposed to unusual stress whether in combat or
     in disasters (critical incident debriefing). This early intervention often prevents
     later development of chronic post-traumatic stress disorders.
        While the principles of combat psychiatry are relatively universal, their
     application may vary in the different military services, depending on the
     mission. Thus, service-specific scenarios and issues are presented in separate
     chapters on combat psychiatry in the U.S. Army, the U.S. Air Force, and the U.S.
     Navy. An important area addressed in this volume is the need for uniform
     psychiatric procedures in joint operations, which will likely be more common in
     the future.
        The prevention and treatment of combat stress reaction is not simply the
     domain of the mental health provider. Commanders must also play an active
     role by maintaining contact with soldiers when they are temporary casualties
     and welcoming them back to the unit after they have rested and recovered. This
     increases the likelihood of continued long-term functioning and enhances unit
     cohesion. It is also the honorable thing to do for those individuals who have
     temporarily been overcome by the horrors of battle, but are now ready to rejoin
     their unit to continue the fight.


                                                    Brigadier General Russ Zajtchuk
                                                          Medical Corps, U.S. Army
July 1995
Washington, D.C.


                                                                                           xiii
      The current medical system to support the U.S. Army at war is a
      continuum from the forward line of troops through the continen-
      tal United States; it serves as a primary source of trained replace-
      ments during the early stages of a major conflict. The system is
      designed to optimize the return to duty of the maximum number
      of trained combat soldiers at the lowest possible level. Far-
      forward stabilization helps to maintain the physiology of injured
      soldiers who are unlikely to return to duty and allows for their
      rapid evacuation from the battlefield without needless sacrifice
      of life or function.




xiv
                            Medical Force 2000 (MF2K)
                  PATIENT FLOW IN A THEATER OF OPERATIONS


                                               Cbt
                                              Medic
                        1st E
                                                           RTD
                                   UNIT
                                  SUPPORT      BAS
                                  AREA



                                                            RTD

                              BRIGADE         Med Co
                             SUPPORT
                             AREA
                                                                    x
                   2nd E
                                                                        RTD
             CZ
                                                                  Med Co

                         DIVISION
                        SUPPORT
                        AREA
                                        FST                             xx




                                                                              RTD
              3rd E
                                               CSH                 ASMC/ASMB




                    CORPS                     MASF
                   SUPPORT
                   AREA
                                                                              xxx

                              RTD



                             FH                                                 RTD

    4th E                                         GH                ASMC/ASMB
 COMMZ



                                               ASF
             COMMUNICATION
             ZONE




   CONUS




ASF:         Aeromedical Staging Facility, USAF        E:      Echelon
ASMB:        Area Support Medical Battalion            FH:     Field Hospital
ASMC:        Area Support Medical Company              FST:    Forward Surgical Team
BAS:         Battalion Aid Station                     GH:     General Hospital
Cbt Medic:   Combat Medic                              MASF:   Mobile Aeromedical Staging Facility,
CSH:         Combat Support Hospital                             USAF
COMMZ:       Communication Zone                        Med Co: Medical Company
CZ:          Combat Zone                               RTD:    Return to Duty



                                                                                                      xv
                                                                                                              Psychiatric Lessons of War




Chapter 1
PSYCHIATRIC LESSONS OF WAR


FRANKLIN D. JONES, M.D., F.A.P.A.*



                                        INTRODUCTION
                                          Case Study: A Combat Crisis in a Marine
                                          Withstanding the Stress of Combat

                                        PRE-20TH CENTURY CONCEPTIONS OF PSYCHIATRIC CASUALTIES

                                        20TH CENTURY COMBAT PSYCHIATRY
                                           Development of Principles
                                           Application of Principles
                                           Rediscovery and Extensive Application of Principles
                                           Discovery of Mediating Principles
                                           Validation and Limitations of Principles

                                        SUMMARY AND CONCLUSION




* Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
  President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and
  Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                           1
War Psychiatry




Richard W. Baldwin                               Fighting at Guadalcanal                            1943

This painting by Richard W. Baldwin, who was a sergeant in the U.S. Army Air Forces, depicts World War
II jungle fighting in the South Pacific at Guadalcanal, which was characterized by environmental depriva-
tion, disease, and isolation. The psychiatric lessons of World War I had to be relearned and expanded
during World War II to include physical stressors.



Art: Courtesy of US Center of Military History, Washington, DC.




2
                                                                                            Psychiatric Lessons of War




                                               INTRODUCTION

   War, with its lesser elaborations such as competi-         Erikson3 gave a classic example of the interaction
tive sports, has been an enduring aspect of human          of the biological, interpersonal, and intrapsychic
existence. Survival for the prehuman individual            factors in the breakdown and later elaborations of
and the species was largely dependent on the evo-          symptoms in a World War II combat veteran.
lution of physical attributes until fairly late in human
development. The ability of prehumans and humans           Case Study: A Combat Crisis in a Marine.
to organize into groups resulted in the supplanting
of biological evolution with social evolution. Social          The patient, a young teacher in his thirties, primarily
evolution was so powerful an agency that while mod-        suffered from severe headaches. History at a veterans’
ern humans are less well developed physically than         clinic revealed that he was with a group of medical corps-
their human and prehuman ancestors, they are never-        men who lay in pitch darkness on a South Pacific beach-
theless more capable of survival. Social evolution         head, pinned down by enemy fire, with little supporting fire
has necessarily been accompanied by psychological          from U.S. Navy ships. The group experienced mounting
evolution such that the two cannot be separated. In        anger and fear; however, the patient seemed unaffected
modern wars, beyond a minimal level of physical            by the group anxiety. The patient did not drink, smoke, or
                                                           even swear, and had chosen to be a medical corpsman
fitness and technical learning of how to fight, the
                                                           because he could not bring himself to carry a gun.
soldier’s most important training is in social-psy-
                                                               During the night, he had only isolated memories of a
chological reaction patterns, particularly the han-        dreamlike quality: the corpsmen were ordered to unload
dling of fear and aggression and the bonding with a        ammunition; the medical officer became angry, swearing
group for accomplishing the military mission.              abusively; someone thrust a submachine gun into the
   While wars differ along many dimensions rang-           corpsman’s hands. By morning he was a patient sedated
ing from ideology to technology, the human ele-            in the improvised hospital, with severe intestinal fever. At
ment remains the same. After millions of years of          nightfall, the enemy attacked by air. The patient was
evolutionary molding, the human organism is rea-           immobilized and unable to care for the sick and wounded.
sonably well equipped physically to fight the soli-        He felt fear, and next day he was evacuated. At the rear
                                                           area hospital he was initially calmer, but became upset
tary or group combat that our Stone-Age ancestors
                                                           and crawled under his sheets when the first meal was
endured. This physical development alone, how-             served. The metallic clanging of the mess kits sounded
ever, would never have allowed humans to achieve           like salvos of incoming shots. He was plagued by severe
dominion over the natural world. This dominion             headaches and when not suffering from them remained
resulted from the development of implements of             apprehensive, jumpy, easily startled. Although the fever
combat and a social structure that facilitated coop-       which could have justified the initial headache was cured,
eration in battle. Part of this social structure in-       his other symptoms persisted and he was evacuated
cluded the ability of protomen to band together on         home as a “war neurosis.”
hunting expeditions as well as their ability to dis-           Erikson found that the patient’s family had been in
                                                           economic and moral decline. At age 14, the patient had
cover and then propagate the knowledge of how to
                                                           left home after his mother, in a drunken rage, threatened
make and use weapons. It is a striking observation
                                                           him with a gun. He had secured the secret help of his
that men through all periods of recorded history           principal, a fatherly man who protected and guided him,
have fought ultimately as small groups consisting          asking in exchange that he never drink, swear, indulge
of from 2 to 20 or 30 persons.1                            himself sexually, or touch a gun.
   The same cultural evolution of groups that maxi-            Erikson was able to separate out the biosociopsycho-
mized warrior skills in the past, however, has             logical vulnerabilities that produced the breakdown. In
increasingly prepared homo sapiens for peace               the biological area were exhaustion and sleeplessness
rather than war. Individual psychology, reflecting         coupled with subliminal infection and fever. In the socio-
family and cultural influences, often hinders rather       logical area were the lowering of group morale and growth
                                                           of group panic, immobilization under enemy fire, the
than facilitates successful adaptation to combat.
                                                           inducement to give up in the hospital bed, and finally
This can be seen, for example, in religious prohibi-       immediate evacuation creating a conflict between the
tions against violence, which when internalized            desire to escape and the call to duty to care for his mates.
by any of a variety of processes, may even over-           In the psychological area were the loss of support for an
come near-instinctive behaviors for self-pres-             idealized father substitute when the medical officer swore,
ervation.2(p512)                                           and conflict over his identity as a noncombatant when a



                                                                                                                     3
War Psychiatry


submachine gun was pressed on him, for “the gun had                  the 20th century, most soldiers who broke down in
become the symbol of his family’s downfall and repre-                combat were considered to be cowards or weak-
sented all … which he had chosen not to do.”3(p44) The               lings, an attitude that persists to this day in some
subsequent headaches represented “the unconscious                    settings. The result of this attitude was usually
wish to continue to suffer in order to overcompensate
                                                                     unfortunate for the soldier and the unit. The term
psychologically for the weakness of having let others
down; for many of these escapists were more loyal than               “decimate,” for example, originally referred to the
they knew. Our conscientious man, too, felt ‘shot through            policy of killing every tenth soldier in a unit that
the head’ by excruciating pain whenever he seemed                    had shown lack of fighting will in combat. When
definitely better.”3(p44)                                            breakdown was recognized as medically legitimate
    Comment: This case illustrates not only the tripartite           before the 20th century, it was considered to be of
elements of combat breakdown but also the sequelae of                organic causation, and terms such as “nostalgia”
improper treatment (evacuation) of such breakdown, in                and “exhausted heart” were sometimes used. The
this case a chronic traumatic neurosis, which would cur-             recognition of biological/interpersonal/intrapsy-
rently be called post-traumatic stress disorder (PTSD). This
                                                                     chic factors and their successful manipulation to
chapter will, through historical analysis, show the impor-
                                                                     prevent breakdown in combat or disasters and to
tance of these elements in understanding combat break-
down and the importance of appropriate interventions.                facilitate recovery is the special province of military
                                                                     psychiatry.4
Withstanding the Stress of Combat                                       Exhibit 1-1 illustrates a number of stressors found
                                                                     to be important in combat breakdown, also called
   The three groups of factors—biological (inherent                  combat stress reaction (CSR). This listing obviously
propensities and physical attributes), interpersonal                 is not all-inclusive, because the human mind is
(cultural, social), and intrapsychic (individual psy-                infinitely adaptive in the service of physical and
chological)—can affect positively or negatively the                  psychological survival. In addition, some stressors
soldier’s ability to withstand the stresses of combat.               may overlap, they may interact to exacerbate each
Such stresses are multidimensional: injury; disease;                 other, and specific factors will be of greater or lesser
physical and psychological fatigue; and fears of                     significance in a given individual and in a particu-
death, maiming, showing cowardice, and releasing                     lar situation. The history of psychiatry in warfare is
aggressive and destructive tendencies. Recogni-                      a study of the recognition of stressors that lead to
tion of these factors was slow to develop. Prior to                  psychiatric breakdown and the development of pre-



    EXHIBIT 1-1
    COMBAT STRESS FACTORS




        Exhibit 1-1 is not shown because the copyright permission granted to the Borden Institute, TMM,
     does not allow the Borden Institute to grant permission to other users and/or does not include usage
     in electronic media. The current user must apply to the publisher named in the figure legend for
     permission to use this illustration in any type of publication media.




    Adapted with permission from Jones FD, Crocq L, Adelaja O, et al. Psychiatric casualties in modern warfare: Evolution of
    treatment. In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the Art. Vol. 6. New York: Plenum; 1985: 461.



4
                                                                                                      Psychiatric Lessons of War




      Table 1-1 is not shown because the copyright permission granted to the Borden Institute, TMM, does
   not allow the Borden Institute to grant permission to other users and/or does not include usage in
   electronic media. The current user must apply to the publisher named in the figure legend for
   permission to use this illustration in any type of publication media.




PTSD: post-traumatic stress disorder
Adapted with permission from Jones FD, Crocq L, Adelaja O, et al. Psychiatric casualties in modern warfare: Evolution of treatment.
In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the Art. Vol. 6. New York: Plenum; 1985: 462, with subse-
quent updates.


                                                                                                                                 5
War Psychiatry


ventive and treatment measures to alleviate their          mental health professionals to avoid mistakes made
effects. It is most appropriate and logical to discuss     earlier and to devise new ways to deal with modern
stressors and treatment chronologically as they            stress. Lessons both learned and not learned but
have been discovered in the contexts of various            available are outlined in Table 1-1. One example of
wars.                                                      a lesson not learned in the Russo-Japanese War is
   The historical approach has practical value. An         that providing a medical label for stress symptoms
understanding of how military medicine dealt with          results in the development of such symptoms by
combat stress breakdown in the past can enable             other soldiers as an honorable way out of combat.5

                  PRE-20TH CENTURY CONCEPTIONS OF PSYCHIATRIC CASUALTIES


   While combat stress breakdown and some of its           physicians assessed the importance of conditions
causative factors were described in the epic ac-           ranging from cultural (rural vs urban conscripts),
counts of early cultural mythology, not until the late     and social (boredom vs rigorous activity and orga-
17th century were some of them given a particularly        nized vs disorganized camp conditions), to envi-
medical cognizance in the form of the diagnosis, nos-      ronmental (clement vs inclement weather), and
talgia. Initially called “the Swiss disease” because of    battle (victorious armies suffering few cases of
its prevalence among young Swiss uprooted from             nostalgia vs those experiencing reverses having
their villages and placed in mercenary armies, it          many cases). Exhibit 1-2 discusses factors currently
was soon recognized as a more universal ailment.           thought to promote or prevent nostalgic casualties.
By the mid-18th century it was firmly established             Baron Larrey, Napoleon’s Chief Surgeon, pre-
in the medical terminology with excellent clinical         scribed a course of treatment that, while ostensibly
descriptions, as was discussed by Leopold                  biologically oriented, reveals a keen awareness of
Auenbrugger in his Inventum Novum of 1761:                 social factors and is surprisingly close to modern
                                                           handling of combat psychiatric casualties, both pre-
    When young men who are still growing are forced        ventively and curatively:
    to enter military service and thus lose all hope of
    returning safe and sound to their beloved home-          [T]o prevent this sort of cerebral affection in sol-
    land, they become sad, taciturn, listless, solitary,     diers who have lately joined their corps, it is neces-
    musing, full of sighs and moans. Finally, they cease     sary not to suffer those individuals who are predis-
    to pay attention and become indifferent to every-        posed to it more repose than is necessary to recruit
    thing which the maintenance of life requires of          their strength, exhausted during the day; to vary
    them.                                                    their occupations, and to turn their labours and
    This disease is called nostalgia. Neither medica-        recreations to their own advantage, as well as to
    ments, nor arguments, nor promises nor threats of        that of society. Thus, after the accustomed military
    punishment are able to produce any improvement.          exercises, it is desirable that they should be sub-
    While all thought is directed toward ungratified         jected to regular hours, gymnastic amusements,
    desires, the body wastes away, with a dull sound         and some mode of useful instruction. It is in this
    (sonitus obscuras) on one side of the chest. [Some       manner, especially, that mutual instruction, estab-
    cases of nostalgia were undoubtedly linked with          lished among the troops of the line, is beneficial to
    tuberculosis and other chest diseases. Such dis-         the soldier and the state. Warlike music, during
    eases were noted in the author’s descriptions of         their repasts, or at their hours of recreation, will
    autopsy reports.—Au.]                                    contribute much to elevate the spirits of the soldier,
    Some years ago this disease was rather common            and to keep away those gloomy reflections which
    but now occurs very rarely since the wise arrange-       have been traced above.6(p348)
    ment was instituted of limiting the period of mili-
    tary service to a definite number of years. As a
    result the young men retain the hope of leaving           One could hardly ask for a better prescription to
    military service after this period has elapsed, and    ensure physical bodily integrity and thus to pro-
    of being able to return to their homes and enjoy       duce a conviction of health, to give a sense of mas-
    their civic rights.6(pp344–345)                        tery of weapons and, as Larrey points out, espe-
                                                           cially to effect an integration into the unit through
   French physicians of the Napoleonic Era recog-          “mutual instruction, established among the troops
nized numerous factors important in producing or           of the line.”6(p348) This regimen prevents evacuation
preventing nostalgia; many of the same factors in-         home (the treatment approach of earlier physicians)
fluence combat breakdown in the modern era. These          and minimizes any secondary gain from illness.


6
                                                                                                     Psychiatric Lessons of War



  EXHIBIT 1-2
  FACTORS AND CHARACTERISTICS OF NOSTALGIC CASES




         Exhibit 1-2 is not shown because the copyright permission granted to the Borden Institute, TMM,
      does not allow the Borden Institute to grant permission to other users and/or does not include usage
      in electronic media. The current user must apply to the publisher named in the figure legend for
      permission to use this illustration in any type of publication media.




  Adapted with permission from Jones FD. Psychiatric lessons of low-intensity wars. Ann Med Milit Fenn [Finland]. 1985;60:131.




   In parallel with their European colleagues, Ameri-             Union soldiers, mainly among teenage conscripts.8
can physicians considered nostalgia to be a disor-                Apparently lacking any knowledge of Larrey’s pub-
der associated with the military. No significant                  lished insights, Civil War physicians urged screen-
data are available concerning psychiatric casualties              ing as the primary method of preventing nostalgia.
prior to the American Civil War, except that prob-                Surgeon General William A. Hammond in 1862
lems of alcoholism and desertion were not uncom-                  recommended that the minimum age of recruits be
mon. Physicians during those times dealt almost                   fixed at 20 years to screen out those prone to this
entirely with surgical and infectious cases, leaving              condition; despite this effort, the rate did not change
morale and discipline problems for commanders to                  appreciably.8 It was recognized, however, that group
handle.7(p4)                                                      cohesion was important in preventing nostalgia
   The Civil War, however, saw the first appearance               and that the battle experience could forge these
of recognized nostalgic casualties in significant                 cohesive bonds.9 Writing in a textbook of psychia-
numbers. Approximately three cases of nostalgia                   try 20 years after the Civil War, Hammond10 recom-
per 1,000 troops per year were reported among                     mended an army activity program similar to that of


                                                                                                                                 7
War Psychiatry


Larrey. He wrote: “The best means of preventing           the irritable and exhausted heart of DaCosta.8 This
nostalgia is to provide occupation both for the mind      latter condition was not recognized as a psychiatric
and the body … soldiers placed in hospitals near          entity and may well have included rheumatic and
their homes are always more liable to nostalgia than      other heart disease. However, most cases diagnosed
those who are inmates of hospitals situated in the        as exhausted heart were probably functional, second-
midst of or in the vicinity of the army to which they     ary to anxiety. They may have resembled the
belong.”10(p34) Hammond referred to Bauden’s ac-          neurocirculatory asthenia of World War I.7(p3)
count of the Crimean War in which similar prin-              In addition to innovations in treatment of surgi-
ciples were applied. He further stated that “in some      cal wounds and application of similar procedures
cases it may be necessary for the military surgeon to     pioneered by Florence Nightingale in the Crimean
send the nostalgic soldier to his home in order to        War a decade earlier, the major medical accom-
save his life. This, however, should be done with all     plishment during the Civil War was the establish-
possible precautions to prevent his comrades be-          ment of the specialty of neurology by such pioneers
coming acquainted with the fact.”10(p35)                  as S. Weir Mitchell, W.W. Keen, G.R. Morehouse,
   From 1861 to 1865 the Union Army officially            and William A. Hammond.8 The development of
recognized 2,600 cases of “insanity” and 5,200 cases      neurology laid the foundations for differentiating
of “nostalgia” requiring hospitalization at the Gov-      combat disorders with organic causes from those
ernment Hospital of the Insane (now St. Elizabeths)       with psychological causes.
in Washington, D.C.7 Probably still in the realm of          Following the Civil War, alcoholism, venereal
psychiatric casualties, in this same conflict there       diseases, and disciplinary infractions continued to
were 200,000 Union deserters and 160,000 cases of         be present in soldiers fighting the Indian Wars, the
“constipation,” the latter reminiscent of the             Spanish-American War, and the Philippine Insurrec-
“precombat syndrome.”11                                   tion, but these psychiatric problems in U.S. forces
   Other psychiatric entities of the Civil War included   were not so labeled until World War I. Recognition of
malingering, which usually took the form of exagger-      these and other aberrant behaviors as psychiatric prob-
ated trivial conditions or neurological symptoms, and     lems first occurred during the Russo-Japanese War.12

                                 20TH CENTURY COMBAT PSYCHIATRY


   In the decade immediately preceding the out-           casualties.2(p311) Jones, Belenky, and Marlowe13(pp1-2)
break of World War I, Russian physicians during           have discussed the impact of labeling in producing
the Russo-Japanese War (1904–1906) reportedly first       adverse outcomes in such casualties:
utilized psychiatric specialists in the treatment of
combat stress casualties both at the front and upon         The interaction between label and belief and be-
return to home territory.12 This war also provided          havior was particularly striking in the consequences
the first good description of war neurosis. Empha-          of the use of the term shell shock in World War I ….
sis was placed on treatment of “insane” soldiers (an        As a metaphor for the new shape of battle that
unfortunate term suggesting incurability), and no           characterized that war, it was particularly appro-
                                                            priate. In no previous conflict had men, pinned
distinction was made between psychotic and neu-
                                                            into place by the stasis of trench warfare, been
rotic soldiers. Although some psychiatric casual-           subjected to artillery exchanges of such regularity,
ties were returned to combat, evacuation home,              intensity and magnitude. The tactics of the day
usually accompanied by psychiatric personnel, was           ensured that artillery shells and other explosive
the standard treatment. As this evacuation policy           devices would be the primary cause of death,
became known among the troops, the number of                wounding, and stress. In a professional world in
psychiatric patients increased 6- to 10-fold at some        which most psychiatry was articulated to a neuro-
collecting points.12 Nevertheless, such psychiatric         logical base, shell shock was initially seen as a
casualties were not recognized as a significant source      species of actual shock to the central nervous sys-
                                                            tem—a “commotional” syndrome that was the re-
of personnel lost in battle until World War I.
                                                            sult of the effects of a blast pressure wave that was
                                                            coupled to the body of the victim. Although the
Development of Principles                                   German, Oppenheim, had hypothesized a “mo-
                                                            lecular derangement” of brain cells as the pathologic
  “Shell shock” was the popular label given to              agency,14 a number of observations discredited this
most World War I (1914–1918) neuropsychiatric               theory. Soldiers nowhere near an explosion devel-


8
                                                                                       Psychiatric Lessons of War


  oped “shell shock.” German prisoners of war ex-        hospitals to support them, was the first rational
  posed to shelling or bombing did not develop “shell    system of echelon psychiatry in U.S. military forces.
  shock” while their allied captors did. Soldiers        American Expeditionary Forces (AEF) physicians
  exposed, or thinking themselves exposed, to toxic      fine-tuned this design based on their own
  gases developed “shell shock.” Finally, Farrar,15
                                                         experiences.16(p313) When fully conceptualized by
  after observing scores of Canadian soldiers with
  severe head injuries from shrapnel and gunshot         Artiss,17 three principles—proximity, immediacy,
  wounds, noted that symptoms of psychosis or trau-      and expectancy—became the cornerstones of com-
  matic neurosis practically never occurred. He con-     bat psychiatric casualty treatment. They referred to
  cluded “ … trench neuroses occur usually in un-        treating the combat psychiatric casualty in a safe
  wounded soldiers.”15(p16)                              place as close to the battle scene as possible (proxim-
                                                         ity), as soon as possible (immediacy), with simple
   In spite of the fact that British and French psy-     treatment such as rest, food, and perhaps a warm
chiatrists rapidly came to understand that the great     shower (simplicity), and most importantly an ex-
majority of “shell-shocked” soldiers were the vic-       plicit statement that he is not ill and will soon be
tims of transient stress-induced psychological dis-      rejoining his comrades (expectancy). Proximity and
orders, the label and the beliefs and behaviors asso-    immediacy are important because the soldier’s time
ciated with it continued to exercise a major influence   away from his unit weakens his bonds with it and
on the battlefield. While the clinicians dispensed       allows time for consolidation of his rationalization
with “shell-shock,” the troops did not. It became        of his symptoms. The patient’s rationalization may
part of the self-diagnostic and self-labeling nomen-     take many forms but basically consists of a single
clature of the soldier.13(pp1-2)                         line of logic: “If I am not sick, then I am a coward
   British and French forces during World War I          who has abandoned his buddies. I cannot accept
discovered the importance of proximity or forward        being a coward, therefore I am sick.” The psychia-
treatment. The British had been evacuating               trist offers an alternative hypothesis: “You are
neuropsychiatric casualties back to England and          neither sick nor a coward. You are just tired and
finding them most refractory to treatment. By 1917,      will recover when rested.”
when Salmon (Figure 1-1) made his famous report
on “shell shock” among British and French soldiers,
one seventh of all discharges for disability from the
British Army had been due to mental conditions; of
200,000 soldiers on the pension list of England, one
fifth suffered from war neurosis.2 However, within
a few months of the onset of hostilities, British and
French physicians had noted that patients with war
neuroses improved more rapidly when treated in
permanent hospitals near the front than at the base,
better in casualty clearing stations than even at the
advanced base hospitals, and better still when en-
couragement, rest, persuasion, and suggestion could
be given in a combat organization itself. The impor-
tance of immediate treatment quickly became obvi-
ous when vicissitudes of combat prevented early
treatment of war neuroses even in forward settings.
Those who were left to their own devices due to a
large influx of casualties were found more refrac-
tory to treatment and more likely to need further
rearward evacuation.2(p508)
   As an emissary of the U.S. Army Surgeon Gen-          Fig. 1-1. Thomas Salmon inaugurated the principles of
eral, Thomas Salmon in 1917 observed and synthe-         forward treatment of combat psychiatry casualties and
                                                         was the Neuropsychiatry Consultant to the American
sized the British and French experience into a com-
                                                         Expeditionary Forces in World War I. He subsequently
prehensive program for the prevention and                held many distinguished positions, including Presidency
treatment of shell shock cases, which were renamed       of the American Psychiatric Association, and is remem-
“war neuroses.” Salmon’s program, which involved         bered for championing the mental health movement
placing psychiatrists in the divisions with forward      started by Clifford Beers.


                                                                                                               9
War Psychiatry


   Expectancy is the central principle from which        in situations of ambiguity when such escape behav-
the others derive. A soldier who is treated near         ior can become an “evacuation syndrome,” as de-
his unit in space (proximity) and shortly after leav-    scribed by Belenky and Jones:
ing it (immediacy) can expect to return to it. Dis-
tance in space or time decreases this expectancy.          An evacuation syndrome develops in combat or in
Similarly, the principle of simplicity derives from        field training exercises when through accident or
the concept of expectancy. The application of              ignorance an evacuation route, usually through
involved treatments such as narcosynthesis or              medical channels, opens to the rear for soldiers
electroshock treatment may only strengthen the             displaying a certain constellation of symptoms and
                                                           signs…. In the First World War, lethal gases were
soldier’s rationalization that he is ill physically or
                                                           used in combat. In one battle, an incident occurred
mentally. The occasional use of these more elabo-          in which soldiers from a certain division came to
rate procedures in refractory cases actually rein-         their medical aid stations in large numbers com-
forces the preeminent role of expectation; they con-       plaining of being gassed. This division had taken
vey the message: “Yes, you had a mild ailment;             heavy casualties, but now was involved in a desul-
however, we have applied a powerful cure, and you          tory holding action, with no particular aim or ob-
are well.”                                                 ject. The soldiers in the division had been expect-
   The role of expectancy can be seen in the labeling      ing to be relieved following the previous heavy
of these psychiatric casualties. Soldiers in World         fighting and when they had not been, morale had
                                                           declined precipitously. During the current action,
War I who were called “shell-shocked” indeed acted
                                                           there was some gas shelling, but not of sufficient
as though they had sustained a shock to the central        intensity to produce any serious casualties. Never-
nervous system. As recounted by Bailey, Williams,          theless, soldiers usually in groups of comrades
and Komora, “There were descriptions of cases              were coming to their battalion aid stations com-
with staring eyes, violent tremors, a look of terror,      plaining of cardiorespiratory symptoms. The medi-
and blue, cold extremities. Some were deaf and             cal personnel seeing these men evacuated them to
some were dumb; others were blind or para-                 the rear. An initial trickle of soldiers turned into a
lyzed.”18(p2) When it was realized that concussion         flood, and very soon this inappropriate evacuation
was not the etiologic agent, the term “war neurosis”       of men—for symptoms only—turned into a signifi-
                                                           cant source of manpower loss. Once the line com-
was used. This was hardly an improvement be-
                                                           manders became aware of the magnitude of the on-
cause even the lay public was aware that Freud had         going loss they intervened and sought consultation
used William Cullen’s 1777 nonspecific term, “neu-         from the division psychiatrist. The psychiatrist
rosis,” to describe chronic and sometimes severe           reorganized the system of evacuation by treating
mental illnesses. The soldier could readily grasp          the soldiers coming to the aid station with a com-
this medical diagnosis as proof of illness. This           plaint of gas exposure and cardiorespiratory symp-
problem was remedied when medical personnel                toms as psychiatric casualties. He gave them a brief
were instructed to tag such casualties as “N.Y.D.          rest, a warm drink, and a change of clothes, and
(nervous)” for “not yet diagnosed (nervous).” The          rapidly returned them to their unit. The flow of
                                                           men with cardiorespiratory complaints slowed and
term “N.Y.D. (nervous)” gave soldiers nothing defi-
                                                           finally stopped. Overall the incident lasted over a
nite to cling to and no suggestion had been made to        week before it was finally terminated. 20(pp140–141)
help them in formulating their disorder into some-         [Similarly, during the Vietnam conflict, Jones re-
thing that was generally recognized as incapacitat-        ported an “epidemic” of sleepwalking, which is
ing and requiring hospital treatment, thus honor-          described in Chapter 2, Traditional Warfare Com-
ably releasing them from combat duty. This left            bat Stress Casualties.—Au.]
them open to the suggestion that they were only
tired and a little nervous and with a short rest            Following World War I, the principles of forward
would be fit for duty. Eventually, many of these         treatment were gradually lost to the U.S. military.
cases began to be referred to simply as “exhaus-         The psychoanalytic notion that the origin of psychi-
tion,” then, with the rediscovery of the principles      atric disorders could be traced to childhood trauma
during World War II, as “combat exhaustion.” Fi-         prevailed. A natural consequence of this theory
nally, during World War II, the term “combat fa-         was that evidence of such trauma could be detected,
tigue” came to be preferred in that it conveyed more     and such potential casualties screened out. The
exactly the expectation desired.19(p993)                 Spanish Civil War revealed an interesting admix-
   Another finding of World War I was the “conta-        ture of this faith in screening along with a pragmatic
giousness” of medical disorders that allow honor-        application of forward treatment of combat stress
able escape from combat. This occurs particularly        casualties.


10
                                                                                       Psychiatric Lessons of War


Application of Principles                                  Late in the war (July 1938), Mira organized the
                                                        various psychiatric services that had developed
   The Spanish Civil War (1936–1939) was a struggle     during the war into a coordinated program of 5
between a monarchist-military faction supported         centers with 32 psychiatrists.21(p73) Not all of the rear
with money, equipment, and volunteers by Ger-           area military psychiatric casualties were evacuated
many and Italy and a republican-socialist faction       to the central psychiatric clinic (in the civilian zone)
supported by France, the United States, and the         but some were sent toward the forward emergency
Soviet Union. Much of the combat psychiatry             psychiatric center of the corresponding battle sec-
learned in this war was not available until after       tor. In Mira’s words, “They were surprised that
World War II because those who learned the proper       instead of going backward they were moved ahead
handling of psychiatric casualties were on the los-     when they complained of mental disorder! The
ing side and were scattered. Mira, the psychiatrist     purpose was to avoid the encouragement of malin-
who set up the mental health program for the Span-      gering or the exaggeration of nervous symptoms as
ish Republican Army, gave the Thomas W. Salmon          a means of escape from the hardships of military
Memorial Lecture in 1942 and later expanded it into     life.”21(p74) Psychiatric casualties in the front lines
a book. His work was not published until late in        were “not to be put to bed but treated boldly by
World War II, by which time U.S. forces had re-         suggestive measures and directly transferred …
learned the lessons of World War I. Mira made two       where much gymnastic and kinetic exercise was the
main contributions to the literature of combat psy-     basis of their readjustment.”21(p75) The average per-
chiatry: (1) the revalidation of forward treatment      centage of recovery of psychiatric casualties from
for psychiatric casualties, and (2) the value of psy-   the front centers was reported to be 93.6%, and the
chiatric screening. The latter point will be ad-        total percentage of men temporarily discharged
dressed first.                                          because of war neurosis was not greater than
   Mira21 described a written psychiatric question-     1.5%.21(p73) Subsequent experience with similar pro-
naire to be filled out by potential recruits for the    cedures suggests that the high recovery and low
Spanish Republican Army. The 17 questions, when         discharge rates were primarily attributable to for-
skillfully interpreted, allowed the physician to as-    ward evacuations. The Israelis in the 1982 Lebanon
sess motivation, intelligence, and, it was believed,    War also successfully utilized “forward evacua-
the probability that men were “likely to suffer from    tion” and a stringent physical fitness program for
war neurosis.” After demographic questions, the         psychiatric casualties.22
following were then asked: “Do you ever faint?”            Unfortunately, the forward treatment methods
“Do you suffer from dizziness?” “How often do           used in the Spanish Civil War were unknown by
you have sexual relations?” “How often would you        U.S. physicians at the inception of World War II and
like to have a 7-day leave if it were possible? Where   had to be painfully relearned. Furthermore, Ameri-
and how would you spend the time?”21(p68)               can recruiters shared Mira’s view of the efficacy of
   According to Mira,                                   psychiatric screening, resulting in the rejection of
                                                        hundreds of thousands of potentially effective sol-
  Broadly speaking, the cases of mental and neurotic    diers during World War II. World War II studies
  disorders occurring subsequently in the group of      suggest that beyond minimal screening to eliminate
  approximately twenty thousand troops selected in      severe mental disorders such as schizophrenia or
  this way were three times less frequent than among
                                                        brain deficits, mass screening is inefficient.23
  those not given any such examination. This sug-
  gests that considerable value would be derived
  from the adoption of this or similar methods of       Rediscovery and Extensive Application of
  selection and group testing at the recruiting         Principles
  centers.21(p69)
                                                            The United States became involved in World War
   Although Mira attributed the very low rate of        II in 1941, 2 years after its outbreak in Europe. At
psychiatric casualties to screening, it seems more      the outset, American medical personnel were un-
likely, based on U.S. experience in World War II and    prepared to carry out the program of forward psy-
Vietnam, that the policy of forward treatment, in-      chiatry that had been devised by World War I psy-
cluding “forward evacuation,” was far more critical     chiatrists. No psychiatrists were assigned to combat
than screening in accounting for the low figures.       divisions and no provisions for special psychiatric
The forward treatment program reported by Mira          treatment units at the field army level or communi-
seems to have worked well.                              cations zone had been made.24 American planners


                                                                                                              11
War Psychiatry


under the guidance of Harry Stack Sullivan had
believed that potential psychiatric casualties could
be screened out prior to induction.7(p21)
   To minimize these casualties, physicians at the
outset of hostilities did not select draft registrants
who had any significant history of psychiatric dis-
turbance, especially those with anxiety symptoms.
Furthermore, soldiers showing symptoms after in-
duction were expeditiously discharged. In effect,
production of psychiatric symptoms as an honor-
able way of avoiding induction produced a massive
loss of manpower reminiscent of an evacuation
syndrome.
   Although about 1,600,000 registrants were clas-
sified as unfit for induction during World War II
because of mental disease or educational deficiency
(a disqualification rate about 7.6 times as high as in
World War I), separation rates for psychiatric disor-
ders in World War II were 2.4 times as high as in
World War I.24 Not only was screening ineffective in
preventing breakdown, but also the liberal separation
policy for those presenting with neurotic symptoms        Fig. 1-2. Frederick Hanson, an American who volun-
threatened the war effort. For instance, in September     teered for duty with the Canadian military before entry
                                                          of the United States into World War II, was later assigned
1943 more soldiers were being eliminated from the
                                                          to the U.S. Army as a consultant to General Omar Bradley’s
U.S. Army than accessed; most of those separated          forces. He rediscovered the principles of forward treat-
were for psychoneurosis (35.6/1,000/y).24(p740)           ment in the North Africa campaign.
   Studies attempting to find predisposition to psy-
chiatric breakdown in combat have revealed more
similarities between psychiatric casualties and their     consisted of resting the soldier and indicating
fellow soldiers than differences. For example, in a       to him that he would soon rejoin his unit.26(p9) On
comparison of the combat records of 100 men who           April 26, 1943, in response to the recommendations
suffered psychiatric breakdowns requiring evacua-         of his surgeon, Colonel Long, and psychiatrists,
tion to a U.S. Army hospital in the United States and     Captain Hanson and Major Tureen, General Omar
an equivalent group of 100 surgical casualties, Pratt25   Bradley issued a directive that established a hold-
found no significant difference in numbers of awards      ing period of 7 days for psychiatric patients and
for bravery. Glass remarked, “Out of these experi-        further prescribed the term “exhaustion” as the
ences came an awareness that social and situational       initial diagnosis for all combat psychiatric
determinants of behavior were more important than         cases.26(pp9–10) The word exhaustion was chosen be-
the assets and liabilities of individuals involved in     cause it conveyed the least implication of mental
coping with wartime stress and strain;…”19(p1024) The     disturbance and came closest to describing how the
reliance on screening to prevent psychiatric casual-      patients really felt. The World War I principles had
ties was recognized as a failure when large numbers       been rediscovered!26(p10)
of these casualties occurred during fighting in North
Africa. Because no provision for treatment had            Discovery of Mediating Principles
been made, they were shipped to distant centers
from which they never returned to combat.                    In addition to rediscovering the principles of
   World War I-style forward treatment was re-            treatment applied so effectively in World War I, and
learned during two battles of the Tunisian Cam-           the ineffectiveness of large-scale screening, World
paign in March and April 1943.26 Captain Fred             War II psychiatrists learned about the epidemiol-
Hanson (Figure 1-2), a U.S. Army psychiatrist from        ogy of combat stress casualties (direct relationship
Canada who may have been familiar with the Salmon         to intensity of combat, modified by physical and
Lectures, avoided evacuation and returned more            morale factors) and the importance of unit cohesion
than 70% of 494 neuropsychiatric patients to com-         both in preventing breakdown and in enhancing
bat after 48 hours of treatment, which basically          combat effectiveness. During the war, prospective


12
                                                                                            Psychiatric Lessons of War




       Figure 1-3 is not shown because the copyright permission granted to the Borden Institute, TMM,
    does not allow the Borden Institute to grant permission to other users and/or does not include usage
    in electronic media. The current user must apply to the publisher named in the figure legend for
    permission to use this illustration in any type of publication media.




Fig. 1-3. Relation between rates for neuropsychiatric and wounded admissions in World War II. These figures illustrate
the dependent relationship of combat stress casualties to combat intensity, as measured by rates of wounded in action.
The absence of such a relationship in the Southwest Pacific Theater may represent a phenomenon of sporadic combat
or may represent a data collection problem. Reprinted with permission from Beebe GW, De Bakey ME. Battle Casualties:
Incidence, Mortality, and Logistic Considerations. Springfield, Ill: Charles C Thomas; 1952: 28.


                                                                                                                   13
War Psychiatry


     Anxiety        A. Soldier in First Battle               B. Experienced Veteran                                               C. Overstressed Veteran

                                                                                                                        (1)
      High                       (2)
                                                                                                                                                       (2)
                                                                                                                                                                   (3)




      Mid

                  (1)                                  (1)
                                                 (3)
                                                                                            (3)
                                                                      (2)

      Low

                         Battle Action                           Battle Action                                                             Battle Action

Fig. 1-4. Anxiety, fear, and arousal at different stages in combat tour. A soldier new to battle is more likely to break
down than an experienced soldier; however, a soldier exposed to combat for a long period of time is also likely to be
a stress casualty. Reprinted from US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington
DC: DA; 1994. Field Manual 22-51: 2-10.


studies conducted by Stouffer and colleagues27 con-                devised a graph showing the relationship of psychi-
clusively showed that units with good morale and                   atric morbidity to experiences in battle and non-
leadership had fewer combat stress casualties than                 battle settings (Figure 1-5). Thus, the theory of
those without these attributes when variables such                 ultimate vulnerability was promulgated and usu-
as combat intensity were comparable.                               ally expressed as “everyone has his breaking point.”
   The dependent relationship of combat stress ca-                 Hanson and Ranson32 found that while a soldier
sualties to combat intensity, as measured by rates of
wounded in action, can be seen in Figure 1-3 taken
from Beebe and De Bakey.28(p28) The absence of such
a relationship in the Southwest Pacific Theater was
explained by Beebe and De Bakey as a collection                                                                                                              x
problem; however, this may be a phenomenon of
sporadic combat. In such warfare, neuropsychiatric
                                                                            Relative Risk




casualties take the form of venereal disease, alcohol
and drug abuse, and disciplinary problems. This
                                                                                                                                                         x
phenomenon, which has been detailed by Jones29
for subsequent wars, will be discussed later.
   Another finding during World War II was the
chronology of breakdown in combat. It had long                                                                  x                               x
been recognized that inexperienced troops were                                                                                     x                             x
                                                                                                x
more likely to become stress casualties. Green troops
                                                                                                        Predeployment




                                                                                                                                                                 Postcombat
                                                                                                                                                        Combat
                                                                                             Garrison




                                                                                                                              Deployment


                                                                                                                                           Precombat




have usually accounted for over three fourths of
stress casualties; however, with increasing expo-
sure to combat after 1 or 2 combat months, an
increasing rate of casualty generation also occurs.
Figure 1-4 addresses battle stress relative to combat
experience. Sobel30 described the anxious, depressed
                                                                   Fig. 1-5. Relationship of psychiatric morbidity to experi-
soldier who broke down after having lived through
                                                                   ences in battle and nonbattle settings. This figure illus-
months of seeing friends killed, as “the old sergeant              trates the risk of psychiatric breakdown in troops rang-
syndrome.” Today, it would probably be called                      ing from garrison settings through combat and
chronic post-traumatic stress disorder. Swank and                  postcombat situations. As is apparent, troops are at great-
Marchand31 discussed the relationship of combat                    est risk during combat; however, increased risk of break-
exposure and combat effectiveness. The author has                  down precedes and follows combat.


14
                                                                                           Psychiatric Lessons of War


who broke down after his unit experienced 4 to 51⁄2      group firing activities, among members of crew-
months of combat exposure could be returned to           served weapons teams such as machine guns, the
full combat duty in 70% to 89% of cases, those           percentage was much higher.
exposed over 1 year returned in only 32% to 36% of          This element of group cohesion has already been
cases.                                                   alluded to in terms of morale and leadership.
   Beebe and Appel33 analyzed the World War II           Marshall again probably made the point best in
combat attrition of a cohort of 1,000 soldiers from      reviewing his experiences in World War I, World
the European Theater of Operations (ETO). They           War II, Korea, and various Arab-Israeli wars:
found that the breaking point of the average rifle-
man in the Mediterranean Theater of Operations
                                                           When fire sweeps the field, be it in Sinai, Pork Chop
(MTO) was 88 days of company combat, that is,              Hill or along the Normandy coast, nothing keeps a man
days in which the company sustained at least one           from running except a sense of honor, of bound
casualty. A company combat day averaged 7.8                obligation to people right around him, of fear of failure
calendar days in the MTO and 3.6 calendar days             in their sight which might eternally disgrace him.37(p304)
in the ETO. They found that due to varying causes
of attrition in both theaters, including death, wound-      Cohesion is so important in both prevention and
ing, and transfers, by company combat day 50, nine       treatment of psychiatric casualties that Matthew D.
of 10 “original” soldiers had departed. In their         Parrish, an eminent psychiatrist who served in com-
projections, Beebe and Appel found that if only          bat aircrews during World War II and as U.S. Army
psychiatric casualties occurred, there would be          Neuropsychiatry Consultant in Vietnam, has sug-
a 90% depletion by company combat day 210;               gested it as another principle of forward treatment.38
however, due to other causes of attrition (transfer,     Parrish observed that combat fatigue patients who
death, wounding, illness), the unit would be virtu-      had regular visits from their units in which they
ally depleted by company combat day 80 or 90,            were welcomed to return, were far more likely to do
approximately the breaking point of the median           so. He suggested that this preventive and curative
man.33(p92)                                              principle be termed “membership.”
   Noy34 reviewed the work of Beebe and Appel and           In the words of Parrish,
found that soldiers who departed as psychiatric
casualties had actually stayed longer in combat            [T]he principles of proximity, immediacy, simplicity,
                                                           expectancy … seem to imply that the medics are
duties than medical and disciplinary cases and that
                                                           trying to get the individual so strong within his
their breakdowns were more related to exposure to          own separate self that he will be an effective sol-
battle trauma than were medical and disciplinary           dier. Thus we would have a newly pre-combat
cases.                                                     person with a strong character and therefore could
   From studies of cumulative stress such as these         be predicted to perform well. There is no … men-
as well as observations of the efficacy of a “point        tion of the principle [of] … the maintenance of his
system” (so many points of credit toward rotation          bonded membership in his particular crew, squad
from combat per unit of time in combat or so many          or team (at least no larger than company). This
combat missions of aircrews) used during World             bonding maintained, he never faces combat alone.
                                                           In Vietnam, when possible, the entire such primary
War II, the value of periodic rest from combat and of
                                                           group would visit the casualty, keep him alive to
rotation came to be understood.19(p1002)                   the life of the group and show him the other mem-
   The final and perhaps most important lesson of          bers’ need for him. Often an “ambassador” would
World War II was the importance of group cohesion          visit and leave a sign on the casualty’s bed an-
not only in preventing breakdown,19 but also in            nouncing that he was a proud member of his unit.
producing effectiveness in combat. This latter point       (This sort of thing was effective for some medical
is demonstrated by Marshall’s35 account of soldiers        and surgical casualties too, who could easily have
parachuted into Normandy. The imprecision of               developed the evacuation syndrome.)
this operation resulted in some units being com-           What did we call this 5th principle? All I can think
                                                           of is membership. Of course, like everything else in
posed of soldiers who were strangers to each other
                                                           psychiatry, it is ultimately a command responsibil-
and others with varying numbers who had trained            ity—yet its effectiveness is in the hands of team
together. Uniformly, those units of strangers were         leaders and the troops themselves….38
completely ineffective. In Men Against Fire,
Marshall36 had also observed that only a small per-         In summary, World War II taught combat psy-
centage (about 15%) of soldiers actually fired their     chiatrists that psychiatric casualties are an inevi-
rifles at the enemy during World War II but that in      table consequence of life-threatening hostilities, that


                                                                                                                        15
War Psychiatry


they cannot be efficiently screened out ahead of               generally functioning well.39 Since only 5 years had
time, that their numbers depend on individual,                 elapsed, the lessons of World War II were still well
unit, and combat environmental factors, and that               known and the principles learned during that war
appropriate interventions can return the majority              were applied appropriately. Combat stress casual-
to combat duty.                                                ties were treated forward, usually by battalion sur-
                                                               geons and sometimes by an experienced aidman or
Validation and Limitations of Principles                       even the soldiers’ “buddies,” and returned to duty.
                                                               Psychiatric casualties accounted for only about 5%
   Just as in the initial battles of World War II,             of medical out-of-country evacuations, and some of
provisions had not been made for psychiatric casu-             these (treated in Japan) were returned to the combat
alties in the early months of the Korean conflict              zone.39 To prevent psychiatric casualties, a rotation
(1950–1953). As a result they were evacuated from              system was in effect (9 months in combat or 13
the combat zone. Due largely to the efforts of                 months in support units).39 In addition, attempts
Colonel Albert J. Glass (Figure 1-6), a veteran of             were made to rest individuals (“R and R” or rest and
World War II, who was assigned as Theater                      recreation) and, if tactically possible, whole units.
Neuropsychiatry Consultant, the U.S. combat psy-               Marshall40 warned of the dangers to unit cohesion
chiatric treatment program was soon in effect and              of rotating individuals, but this lesson was not to be
                                                               learned until the Vietnam conflict.
                                                                  These procedures appear to have been quite ef-
                                                               fective with two possible exceptions. One was the
                                                               development of frostbite as an evacuation syndrome.
                                                               This condition, which was the first psychiatric
                                                               condition described in the British literature dur-
                                                               ing World War I,41 was almost completely prevent-
                                                               able, yet accounted for significant numbers of
                                                               “ineffectives.”
                                                                  The other problem was an unrecognized portent
                                                               of the psychiatric problems of rear-area support
                                                               troops. As the war progressed, U.S. support troops
                                                               increased in number until they greatly outnum-
                                                               bered combat troops. These support troops were
                                                               seldom in life-endangering situations. Their psy-
                                                               chological stresses were related more to separation
                                                               from home and friends, social and sometimes physi-
                                                               cal deprivations, and boredom. Paradoxically, sup-
                                                               port troops who may have avoided the stress of
                                                               combat, according to a combat veteran and military
                                                               historian, were deprived of the enhancement of
                                                               self-esteem provided by such exposure.42 To an
                                                               extent the situation resembled that of the nostalgic
                                                               soldiers of prior centuries. In these circumstances
Fig. 1-6. Albert Julius Glass taught and popularized the
principles of forward treatment throughout his life. He        the soldier sought relief in alcohol abuse (and, in
was a division psychiatrist in World War II, where his         coastal areas, in drug abuse)43 and sexual stimula-
experiences shaped his views of appropriate care of stress     tion. These often resulted in disciplinary infrac-
casualties. In the Korean conflict, as Theater Neuro-          tions. Except for attempts to prevent venereal dis-
psychiatry Consultant, he instituted policies that maxi-       eases, these problems were scarcely noticed at the
mized the effectiveness of treatment of psychiatric casu-      time, a lesson not learned.
alties. Subsequently, he applied these principles to the          The Korean conflict revealed that the appropri-
garrison military as Psychiatry and Neurology Consult-         ate use of the principles of combat psychiatry could
ant to the U.S. Army Surgeon General, resulting in clo-
                                                               result in the return to battle of up to 90% of combat
sure of five of the six U.S. Army prisons. After his retire-
ment from the military, he edited Neuropsychiatry in           psychiatric casualties; however, there was a failure
World War II, the two-volume official history of               to recognize the types of casualties that can occur
neuropsychiatry in the Zone of the Interior (Vol 1) and        among rear-echelon soldiers.11 These “garrison ca-
the Overseas Theaters (Vol 2).                                 sualties” later became the predominant psychiatric


16
                                                                                                    Psychiatric Lessons of War


TABLE 1-2
SELECTED CAUSES OF ADMISSION TO HOSPITAL AND QUARTERS AMONG ACTIVE DUTY
U.S. ARMY PERSONNEL IN VIETNAM, 1965–1970

                                                                        Rate Expressed as Number of Admissions
                                                                              (per 1,000 Average Strength)

Cause                                                       1965           1966      1967        1968        1969        1970


Wounded in Action                                            61.6          74.8       84.1       120.4        87.6         52.9
Neuropsychiatric Conditions                                  11.7          12.3       10.5        13.3        15.8         25.1
Viral Hepatitis                                                5.7          4.0        7.0         8.6         6.4          7.2
Venereal Disease (includes CRO*)                            277.4         281.5      240.5       195.8       199.5       222.9
Venereal Disease (excludes CRO* )                              3.6          3.8        2.6         2.2         1.0          1.4

* CRO: Carded for record only, ie, not hospitalized
Adapted from Neel S. Vietnam Studies: Medical Support of the US Army in Vietnam, 1965–1970. Washington, DC: US Department of the
Army; 1973: 36.



casualties of the Vietnam conflict.11 Vietnam and                    in-action rate by more than half in 1970 compared
the Arab-Israeli wars revealed limitations to the                    with the high in 1968, the neuropsychiatric casualty
traditional principles of combat psychiatry.                         rate in 1970 was almost double the 1968 rate. In
   America’s longest conflict, Vietnam (1961–1975),                  other words, wounded-in-action and neuropsy-
can best be viewed from a psychiatric perspective as                 chiatric casualty rates showed an inverse relation-
encompassing three phases: (1) an advisory period                    ship that was unique to the Vietnam conflict until
with few combatants and almost no psychiatric                        the 1982 Lebanon War.
casualties; (2) a build-up period with large numbers                    This was contrary to prior experience and expec-
of combatants but few psychiatric casualties; and                    tations. For example, Datel,45 in reviewing neuro-
(3) a withdrawal period in which relatively large                    psychiatric rates since 1915, showed that in the U.S.
numbers of psychiatric casualties took forms other                   Army the rates had previously peaked coinciden-
than traditional combat fatigue symptomatology.                      tally with combat intensity (1918, 1943, and 1951)
   During the initial phases of the build-up in Viet-                but in the Vietnam conflict they peaked after the
nam, the psychiatric program was fully in place,                     war was over (1973), as seen in Figure 1-7.
with abundant mental health resources and psy-                          In one study of combat psychiatric casualties in
chiatrists fairly conversant with the principles of                  Vietnam46 during the first 6 months of 1966, less
combat psychiatry. Combat stress casualties, how-                    than 5% of cases were labeled “combat exhaustion.”
ever, failed to materialize. Throughout the entire                   Most cases presented with behavioral or somatic
conflict, even with a liberal definition of combat                   complaints.
fatigue, less than 5% (and nearer to 2%) of casualties                  This initially (1965–1967) low incidence of
were placed in this category.11                                      neuropsychiatric cases in Vietnam was posited by
   The Vietnam conflict produced a number of para-                   Jones47 to reflect the low incidence of combat fatigue
doxes in terms of the traditional understanding of                   in Vietnam compared to other wars. This low inci-
psychiatric casualties. Most spectacular was the                     dence of combat fatigue was in turn attributed to
low rate of identified psychiatric casualties gener-                 the 12-month rotation policy, the absence of heavy
ally and, in particular, the relative absence of the                 and prolonged artillery barrages, and the use of
transient anxiety states currently termed combat                     seasoned and motivated troops. Because the rate of
fatigue or combat reaction. Table 1-2, taken from                    psychiatric cases did not increase with increased
statistics compiled by Neel,44 reveals that the Viet-                utilization of drafted troops in 1966 as compared to
nam conflict was unusual in that the psychiatric                     1965, the latter consideration seems less important.
casualty rate did not vary directly with the wounded-                Other explanations of the low incidence of psychi-
in-action rate. Despite the decline of the wounded-                  atric cases included thorough training of troops,


                                                                                                                             17
War Psychiatry


                                     50
                                     50
                                                                                                                                      x


                                     45



                                     40
                                     40

                                                                                                                                          x
                                     35                                                                                           x
 Hospital Diagnosis/1,000 Men/Year




                                     30
                                     30
                                                      x

                                     25
                                     25
                                                                                                                                                                     x


                                     20
                                     20                       x                                                                                                          x
                                                                                      x                                                                                      x
                                                                           x                                                                                     x                     xx                                                        x
                                                  x                    x                                                                             x
                                                                               x x
                                                                                                                                                x        x
                                                          x       x                       x                                x                                                     x x        x       x                                           xx
                                     15
                                     15       x                       x                       x                                                                                                 x                                        x
                                          x                                                                x x       x x                                     x
                                                                                                  x
                                                                                                                 x
                                                                                                      xx                                                                                                x       x
                                     10
                                     10                                                                                                                                                                     x                        x
                                                                                                                                                                                                                    x       x
                                                                                                                                                                                                                        x       xx


                                     5
                                     5



                                     0
                                     0
                                          1915



                                                              1920



                                                                               1925



                                                                                              1930



                                                                                                             1935



                                                                                                                           1940



                                                                                                                                              1945



                                                                                                                                                                 1950



                                                                                                                                                                                   1955




                                                                                                                                                                                                                        1965



                                                                                                                                                                                                                                         1970



                                                                                                                                                                                                                                                     1975
                                                                                                                                                                                                    1960




Fig. 1-7. Incidence of neuropsychiatric disorders, U.S. Army worldwide, active duty, 1915–1975. The incidence of
neuropsychiatric disorders peaks during and immediately after major wars. Reprinted from Datel WE. A Summary of
Source Data in Military Psychiatric Epidemiology. Alexandria, Va: Defense Technical Information Center (ADA 021265);
1976.


troops’ confidence in their weapons and means of                                                                                              tion of future noneffectiveness; however, no orga-
mobility, helicopter evacuation of wounded, early                                                                                             nized screening program beyond basic combat and
treatment of psychiatric casualties in an atmosphere                                                                                          advanced individual training was in effect.
of strong expectation of rapid return to duty, and a                                                                                             In an interesting sociological and psychodynamic
type of combat that consisted largely of brief skir-                                                                                          analysis of 1,200 U.S. Marine Corps and U.S. Navy
mishes followed by rests in a secure base camp.                                                                                               personnel serving in the Vietnam combat zone,
Fatigue and anxiety did not have a chance to build                                                                                            Renner49 suggested that the true picture was not one
up.11                                                                                                                                         of diminished psychiatric casualties but rather of
   Huffman48 suggested that a factor in the low                                                                                               hidden casualties manifested in various character
incidence of psychiatric cases was the effectiveness                                                                                          and behavior disorders. These character and be-
of stateside psychiatric screening of troops being                                                                                            havior disorders were “hidden” in the sense that
sent to Vietnam. This possibly affected in a spo-                                                                                             they did not present with classical fatigue or
radic way the initial deployment of troops because                                                                                            anxiety symptoms but rather with substance abuse
some company level commanders did attempt to                                                                                                  and disciplinary infractions. Renner developed
eliminate “oddballs” from their units in anticipa-                                                                                            evidence supporting an explanation of character


18
                                                                                        Psychiatric Lessons of War


and behavior disorders based on a general alien-
ation of the soldier from the goals of the military
unit. He contrasted support units with combat
units, noting that the former faced less external
danger, allowing greater expression of the basic
alienation that he regarded as present among virtu-
                                                            Figure 1-8 is not shown because the copyright per-
ally all U.S. troops in Vietnam. He attributed this
                                                         mission granted to the Borden Institute, TMM, does
alienation to the lack of group cohesiveness largely     not allow the Borden Institute to grant permission to
resulting from the policy of rotating individuals        other users and/or does not include usage in elec-
and disillusionment with the war after 12 months.        tronic media. The current user must apply to the pub-
The result was that the prime motivative behaviors       lisher named in the figure legend for permission to
became personal survival, revenge for the deaths of      use this illustration in any type of publication media.
friends, and enjoyment of unleashing aggression.
These in turn produced not only disordered behav-
ior reflected in increased character and behavior
disorder rates but also feelings of guilt and depres-
sion. Alienation from the unit and the U.S. Army
led to the formation of regressive alternative groups
based on race, alcohol or drug consumption, delin-
quent and hedonistic behavior, and countercultural
life styles.
   A second paradox in the Vietnam conflict was the
development of greatly increased rates of psychosis
in U.S. Army troops11 (Figure 1-8). Datel45 showed      Fig. 1-8. Annual psychosis rates, U.S. Army Vietnam, per
that this was a worldwide phenomenon of all active      1,000 strength, 1966–1972. In all kinds of military set-
duty personnel, but especially of U.S. Army troops      tings, combat and noncombat, the rate of psychosis in
                                                        troops averaged about 2 per 1,000 per year until the war
(see Figure 1-7). Like the total neuropsychiatric
                                                        in Vietnam. The paradox, that is the doubling of the
incidence rate previously mentioned, the psychosis      normal psychosis rate of military troops in Vietnam in
rate also peaked after active combat. Previous ex-      1969 and 1970, was thought by the author to be due to the
perience had shown only minor increases in the          influence of illegal drugs in confusing the diagnosis. This
psychosis rate during wartime. In both combat and       rate declined when drug abuse treatment facilities be-
noncombat situations the psychosis rate had re-         came available in 1971. Adapted with permission from
mained stable at approximately two or three per         Jones FD, Johnson AW. Medical and psychiatric treat-
1,000 troops per year.7                                 ment policy and practice in Vietnam. J Soc Issues.
   Hayes50 suggested two hypotheses to explain the      1975;31(4):63.
increase in psychoses. One was the increased pre-
cipitation of schizophrenia and other psychotic re-
actions in predisposed persons by their use of          to about 3% when the screening became publicized.
psychoactive drugs. The other was the tendency of       Soldiers frequently took potent hallucinogens as
recently trained psychiatrists to classify borderline   well as marijuana and heroin. Jones and Johnson11
syndromes as latent schizophrenia, while more ex-       showed that out-of-country evacuations were es-
perienced psychiatrists would have chosen a differ-     sentially reserved for psychotics until the begin-
ent nosological category (presumably character and      ning of 1971 (Figure 1-9) but with the advent of
behavior disorders).                                    emphasis on drug abuse identification and rehabili-
   Jones and Johnson11 suggested that the doubling      tation, often by detoxification and evacuation to
of the psychosis rate in the U.S. Army Vietnam          stateside rehabilitation programs, an alternative
(USARV) troops in 1969 was due not to drug pre-         diagnosis was available. Finding a new diagnostic
cipitation of schizophrenia or styles of diagnosis      category for soldiers who just did not belong in a
per se but rather due to the influence of drugs in      combat zone, namely, drug dependence, the evacu-
confusing the diagnosis. Holloway51 showed that         ating psychiatrists stopped using the schizophrenia
large scale abuse of drugs other than marijuana and     label. This is reflected in the decline in psychosis
alcohol began about 1968. Approximately 5% of           back to approximately two per 1,000 troops per
departing soldiers were excreting detectable heroin     year.11 Also, fluctuation began to increase due to
products in the summer of 1971; however, this fell      the smaller samples.


                                                                                                                19
War Psychiatry




          Figure 1-9 is not shown because the copyright permission granted to the Borden Institute, TMM,
       does not allow the Borden Institute to grant permission to other users and/or does not include usage
       in electronic media. The current user must apply to the publisher named in the figure legend for
       permission to use this illustration in any type of publication media.




Fig. 1-9. Quarterly psychosis and out-of-country psychiatric evacuation rates, U.S. Army Vietnam, per 1,000 strength,
1966–1972. This figure illustrates that out-of-country evacuations were predominantly reserved for psychotics until
the beginning of 1971. With the advent of emphasis on drug abuse identification and rehabilitation, often by
detoxification and evacuation to stateside drug programs, an alternative diagnosis was available. The result was a
decline of the psychosis rate to its expected level of about 2 per 1,000 troops per year, but an exponential increase in
out-of-country evacuations, primarily drug-abusing patients, to a level exceeding 100 per 1,000 troops per year.
Adapted with permission from Jones FD, Johnson AW. Medical and psychiatric treatment policy and practice in
Vietnam. J Soc Issues. 1975;31(4):62.


   In other overseas areas the U.S. Army policy                  Vietnam revealed the limits of World War II-type
of not evacuating persons with character and                  psychiatric treatment policy in a low-intensity, pro-
behavior problems, including drug dependence,                 longed, unpopular conflict. Such conflicts, if they
still held; therefore, the psychiatrist seeing a pa-          cannot be avoided, must be approached with pri-
tient who did not belong overseas might label                 mary prevention as the focus. Career soldiers with
him with a psychosis, especially if the patient de-           strong unit cohesion will not endanger themselves,
scribed perceptual distortions and unusual experi-            their fellows, or their careers by abusing alcohol or
ences. Such a psychiatrist might be applying                  drugs. When casualties do occur, the Larrey treat-
a broad categorization of schizophrenia as                    ment for nostalgia, mentioned earlier, can be used
Hayes suggests. Because U.S. Air Force and U.S.               as a model.6
Navy psychiatrists have generally had more lati-                 Since World War II (as, indeed, long before World
tude in being permitted to evacuate patients with             War II), the Middle East has experienced essentially
character and behavior problems than have U.S.                continual conflict of every conceivable nature. Ex-
Army psychiatrists, one would expect their rates              hibit 1-3 illustrates the variety of these conflicts,
of psychosis to be lower, and, in fact, they were.            ranging from state-sponsored terrorism, in which
This may explain the discrepancy between Datel’s              countries fight indirectly and often by proxy,
worldwide psychosis rate with diagnoses by                    through low-intensity and guerrilla warfare to high-
U.S. Navy, U.S. Air Force, and U.S. Army psy-                 intensity and even chemical warfare. The signifi-
chiatrists and Jones and Johnson’s Vietnam psy-               cance of terrorist activities should not be mini-
chosis rate with diagnoses by U.S. Army psychia-              mized. In 1983, a single terrorist suicide attack
trists only.                                                  killed 241 U.S. Marines on a peace-keeping mission


20
                                                                                                  Psychiatric Lessons of War



   EXHIBIT 1-3
   POST-WORLD WAR II MIDDLE-EAST CONFLICTS


   1948: Israel fought the Arab League in a civil war which became Israel’s war of independence
   1956: Egypt fought the tripartite powers (France, Great Britain, and Israel) when they attempted to prevent
         Egypt from asserting sovereignty over the Suez Canal; ie, repulsion of former colonial powers
   1962: Egypt fought against the Royalists in the Yemen Civil War, somewhat similar to the U.S. involvement
         in Vietnam, a guerrilla war
   1967: Israel launched a preemptive surprise attack on Egypt and her allies, a conventional medium-intensity
         war but of brief duration
   1968–1970: Arab-Israeli War of Attrition, a war with a static front and primarily indirect fire, thus having
        some similarity to World War I
   1973: Egypt launched a surprise attack on the Israelis in what became an example of high-intensity, high-
         technology, continuous combat
   1982: Israel bombed a nuclear reactor in Iraq, thus even a “nuclear” war (but radioactive material had not
         yet been acquired by Iraq)
   1982: Israel attacked Palestine Liberation Organization forces in Lebanon, a state within a state. This was a
         war fought in an area of high-density civilian population, with besieged cities reminiscent of the latter
         phases of World War II
   1982–1987: Iraq-Iran War, primarily a conventional war but with the use of chemical agents
   1989–1990: Intifada in Israeli-occupied Palestinian territories. Urban guerrilla war carried out largely by
        adolescents repressed by Israeli army
   1991: Persian Gulf War; U.S.-led coalition war against Iraq was primarily an uncontested aerial attack for 5
         weeks followed by a 4-day ground assault using conventional weapons
   1991: Iraqi war between the established government and Shiite and Kurdish minorities

   Adapted from Jones FD. Lessons of the Middle Eastern Wars. Originally presented at Grand Rounds, Psychiatry Department,
   Walter Reed Army Medical Center; March 15, 1984 with subsequent updates; Washington, DC.




in Beirut, producing nearly as many deaths as the               duty were not counted; only those disabled longer
Spanish-American War.52,53                                      than 4 days and sent to rear hospitals were counted.
   The periodic wars between Israel and its Arab                In addition, soldiers who were psychiatrically dis-
neighbors have served as a human factors labora-                abled but also had light wounds were not counted
tory as well as a testing ground for technological              as psychiatric casualties but as wounded in action.
developments in weapons systems (see Exhibit 1-3).              Finally, psychiatric casualties occurring after 26
In 1967, Egyptian ground troops, surprised by Is-               October 1973 (2 days after the cease-fire) were not
rael with its air superiority, had a feeling of help-           counted.
lessness that resulted in large numbers of psychiat-               The Egyptians also reported high psychiatric ca-
ric casualties. Having been surprised by Israel in              sualties, but most occurred later when the tide of
the 1967 Six Day War, the Arabs had learned the                 battle began to favor Israel. El Sudany El Rayes55
effectiveness of surprise so well that Israel was               reported that in some units “the surgical and psy-
almost defeated before it could organize its de-                chiatric casualties were equal.” The Egyptians
fenses against the sudden 1973 Arab attack. From                treated psychiatric casualties according to then-
the perspective of psychiatric breakdown, the 1973              Soviet doctrine, which called for forward treatment
Yom Kippur War is most instructive. For the first               similar to that advocated by the U.S. Army. They
time Israel suffered significant combat stress casu-            were unable to apply this doctrine, however, be-
alties, initially reported as 10% of total casualties,          cause there was no safe forward area. As a result,
but later estimated to be from 30% to 50%.54 The                casualties were sent to distant facilities where they
10% rate was artificially low because casualties                became chronically disabled. The author saw some
treated at forward medical facilities and returned to           of these patients on a consultant visit to Maadhi


                                                                                                                             21
War Psychiatry


Military Hospital, Cairo in 1984. Their symptoms             After the Lebanon War, large numbers of de-
were of severe PTSD.                                      layed or chronic post-traumatic stress disorders
   Unexpectedly, the rate of the 1973 Israeli combat      appeared, perhaps similar to the experience after
stress casualties was highest among support per-          Vietnam. Both were wars in which many civilian
sonnel who, although sometimes exposed to hostile         bystanders became casualties. Belenky57 has re-
fire, were probably responding primarily to the           ported that after the initial casualties related to the
trauma of seeing their dead and mutilated com-            active combat in June 1982 (25%, with most occur-
rades. Israeli support troops additionally felt com-      ring during the 2 weeks of active combat), there was
paratively helpless during this threat to national        a continuing influx of psychiatric patients among
survival. According to a former Deputy Surgeon            the participants. Ultimately the majority of cases
General of the Israeli Defence Forces,56 many sup-        developed subsequent to combat.
port personnel took up weapons and fought along-             The Arab-Israeli conflicts have continued to vali-
side combat troops. These Israeli combat support          date the significance of factors preventing or pro-
soldiers have traditionally been considered to have       moting breakdown in combat, and they have vali-
less aptitude for the military; those with higher         dated the efficacy of forward treatment.58 These
intelligence and leadership ability are allocated to      conflicts have also revealed the weaknesses of this
combat units.                                             treatment approach in high-intensity, high-tech-
   Factors contributing to psychiatric casualties in      nology, mobile, and sustained combat in which
all units in the 1973 war were surprise, fear of          there may be no relatively safe forward area at
national destruction, lack of expectation or prepa-       which rest and recuperation can occur. Treatment
ration for psychiatric casualties, and the hasty con-     is further jeopardized by inadequate capability to
stitution of reserve units by personnel who had not       return the casualty to his unit because of the high
trained together (impaired cohesion).22                   mobility and wide dispersion of combat units in
   However, the primary generator of initial stress       actions. These conflicts have not yielded treatment
casualties may be the unparalleled intensity of sus-      approaches that can prevent chronic and delayed
tained combat with numerous mutilated victims.            post-traumatic stress disorders.
This is suggested by results in the June 1982                As in so many prolonged wars, the 1980 Soviet
Lebanon War, which again saw a relatively high            military assistance to the unpopular leaders of its
(23%) stress casualty rate.57 Because the factors of      client state, Afghanistan (1980–1989), led not to a
combat other than intensity (surprise, lack of cohe-      quick return to ante-bellum stability but rather to a
sion, and national vulnerability) were absent, in-        prolonged conflict with no foreseeable resolution.
tensity alone may be a predominant factor in pro-         The Soviet lack of military success against deter-
ducing combat stress casualties. It must be noted         mined guerrilla forces, despite sophisticated weap-
that the majority of acute combat stress casualties       onry including chemical agents,59 has been likened
occurred during 2 weeks early in June when fight-         to the U.S. experience in Vietnam. In fact, Soviet
ing was intense though not as intense as that during      combat casualties have been reported at about
the first week of the 1973 war. The role of expect-       70,000, of which approximately 13,000 were killed.60
ancy may have contributed to the relatively high             Afghan partisans viewed the presence of over
rates of psychiatric casualties in Lebanon, where         110,000 Soviet soldiers as just another invasion by
frequent visits of field psychologists to units may       their ancient Russian enemies, thus their morale in
have produced an expectancy that psychiatric casu-        protecting their homeland remained high. Soviet
alties would occur. This may have led to                  soldiers, fighting on foreign soil against elusive
overdiagnosis of soldiers with normal battle reac-        enemies remarkably similar to the friends whom
tion symptoms as casualties and may have con-             they came to help, reportedly experienced prob-
veyed the impression that becoming a psychiatric          lems with alcoholism, drug abuse, and disciplinary
casualty was acceptable.57                                infractions.61 Similarly, returning soldiers have
   As in the 1973 Yom Kippur War, during the 1982         suffered from PTSD.62
Lebanon War, some psychiatric casualties were                An adverse morale factor for combatants on both
evacuated to civilian treatment facilities far rear-      sides of a conflict consists of observing the displace-
wards, bypassing the forward treatment teams. Very        ment of friendly or enemy civilians, usually women,
few of these soldiers returned to combat. In con-         children, and the elderly, from their homes. This
trast, about half of the stress casualties were treated   was seen in the dislocation of large numbers of
in forward facilities, and almost all of these soldiers   Vietnamese civilians by the strategic hamlet policy
returned to their combat units.22                         to neutralize the guerrilla support bases. Similarly,


22
                                                                                      Psychiatric Lessons of War


the Afghan War resulted in the generation of hun-        flict involved high-technology weaponry in the
dreds of thousands of refugees, most of whom fled        midst of harsh environmental conditions and primi-
to Pakistan.63 Thus, Afghanistan is an object lesson     tive hand-to-hand combat. Apparently intending
in the problems met by industrialized nations in         only a limited police action to publicize their terri-
fighting low-intensity, unpopular foreign wars           torial claims, Argentine forces occupied the major
against indigenous guerrilla forces. Except with         part of the Falkland Islands. While this action
strictest government censorship (not available in a      quelled political unrest at home, it was so popular
democratic country), refugee flight engenders anti-      that public opinion did not allow the Argentine
war sentiments, lack of public support for the war,      forces to withdraw expeditiously. The result was a
and ultimately poor soldier morale.                      short, bitterly fought land, sea, and air war with
   In the midst of the turmoil that characterized the    Britain.
Iranian revolution in 1980, forces from neighboring         Most of the British soldiers had ample opportu-
Iraq seized control of disputed border territories,      nity to prepare and acclimate in the leisurely 2-
thereby initiating a conflict that raged about 8 years   week transatlantic cruise from England. British
(1980–1988). An unusual mixture of high- and low-        troops were also able to practice amphibious as-
technology fighting, the Iraq-Iran War resembled         sault landings on St. George’s Island, which was
World War I in the use of chemical agents and the        still under British control.70 Airplane pilots, how-
relatively static front. Casualty patterns initially     ever, often flew directly to the combat zone. Benzo-
were similar to those in World War I. Early reports      diazepine hypnotics were successfully used to regu-
of Iranian psychiatric casualties indicated that many    late sleep and prevent fatigue in pilots.67
of them suffered from “explosion blow,” which               Major casualties on both sides occurred from
resembled the “shell shock” of World War I. Ini-         naval fighting. Of the over 1,700 Argentine forces
tially attributed to concussion, these cases were        killed and wounded, 368 seamen (of the 1,000
later viewed by Iranian psychiatrists as having          aboard) were killed when a British nuclear subma-
psychogenic causes and requiring treatment simi-         rine sank an Argentine cruiser.68 Most of the ap-
lar to that given combat fatigue cases of more recent    proximately 1,000 British casualties (250 dead, 750
wars.64 An additional similarity of this war to          wounded69) occurred during the destruction of five
World War I was the report of the Iraqi use of           ships by air-launched bombs and missiles.71
chemical agents.65 This may have been particularly          Psychiatric casualties among combatants on both
terrifying to Islamic soldiers who believed that for     sides were surprisingly low. This may have been
death in battle in a holy war to lead them to the        due to the fact that becoming a psychiatric casualty
Islamic paradise, the combat must involve the shed-      did not result in evacuation. In British forces psy-
ding of blood. Anecdotal reports indicate that           chiatric casualties were reported as less than 2% of
this morale problem was alleviated by Islamic holy       total casualties; however, 20% of the land forces
men who informed the soldiers that the chemicals         casualties were from immersion foot.67 The latter
altered the blood to render it useless in a way          probably resulted more from the terrain and weather
analogous to its being shed. Post-traumatic stress       than from psychogenic causes. Collazo72 reported
disorders occurred primarily among displaced             that psychiatric casualties were also quite low in
civilians.66                                             Argentine forces, representing about 4% to 5% of
   Although low-intensity, guerrilla-type conflicts      total combat casualties (wounded in action [WIA]
have recently occurred or are occurring in numer-        and killed in action [KIA]). These figures are prob-
ous parts of the world (Ulster, Cambodia, Angola,        ably equivalent to the British figures if the British
Sri Lanka, Nicaragua, El Salvador, Peru, Colombia,       figures were to exclude medical casualties (immer-
West Irian, and the Philippines, to name a few),         sion foot, infections, etc.) and include WIA and KIA
there are no data to suggest that psychiatric casual-    only. In one Argentine unit exposed to heavy naval
ties have been a significant variable even though        and air bombardment for 45 days, however, psychi-
many of these conflicts might be characterized as        atric casualties represented 14% of total casual-
psychological warfare. Some psychiatric lessons          ties.72 One surprise among Argentine psychiatric
and casualty figures are presented below from the        casualties was that the age of officers afflicted was
Falkland Islands War in 1982, the U.S. invasion of       higher than that of enlisted men. This may simply
Grenada in 1983, the U.S. invasion of Panama in          reflect the greater likelihood of enlisted to be
1989, and the Persian Gulf War in 1991.                  wounded compared with officers. Significant num-
   The Falkland Islands War lasted only 73 days, 45      bers of post-traumatic stress disorder cases were
of which involved significant combat.67–69 This con-     reported among British forces after the war.73


                                                                                                             23
War Psychiatry


   The Falkland Islands War reveals again that while     ploded. Their memories centered on feelings of
psychiatric casualties are rare in elite forces (Brit-   helplessness and fear of dying before rescuers could
ish), they do occur. Furthermore, the absence of an      reach them. Survivor guilt was high among Beirut
evacuation route for psychiatric casualties (Argen-      casualties but almost absent among Grenada casu-
tine forces) contributes to low rates of such casual-    alties. Both groups had post-traumatic stress symp-
ties. When becoming a psychiatric casualty does          toms (nightmares, intrusive thoughts, anxiety), but
not offer an evacuation from combat, there is little     Grenada casualties had high morale and a strong
reinforcement for becoming a casualty. In future         desire to return to the combat unit. In contrast, the
wars, the possible use of drugs to regulate sleep and    Beirut casualties wanted to go home. These differ-
improve performance in combatants who have been          ences in symptoms are attributable to the different
rapidly deployed across multiple time zones is sug-      forms of combat. In Beirut, the U.S. Marines had no
gested by the British use of temazepam (Restoril)        clear enemies or mission, and some viewed them-
and triazolam (Halcion) for some of their airplane       selves as vulnerable targets, whereas U.S. forces in
pilots.                                                  Grenada had a clear mission with a known enemy
   In late October 1983, American forces invaded         and had numerical and logistical superiority.
the small Caribbean island country of Grenada,              Belenky75 interviewed a dozen men wounded in
whose leadership had been assassinated by a Com-         Grenada who had been evacuated to Walter Reed
munist splinter group. Operation Urgent Fury was         Army Medical Center in Washington, D.C. The
undertaken to insure the safety of about 1,000 Ameri-    main lessons reported from Belenky’s observations
cans, including 700 medical students, and to restore     included the need to emphasize self/buddy aid,
order as requested by Grenada’s neighboring is-          communication, and water discipline. He also noted
land countries.74 Most of the 19 Americans killed in     that clear evacuation channels for the wounded
Grenada died from accidents, although U.S. forces        were necessary.
did meet stiff resistance from 600 well-armed and           In December 1989, U.S. combined forces invaded
professionally trained Cuban soldiers.74 Because         Panama in Operation Just Cause to oust the military
elite forces (Rangers, SEALS [SEa Air Land com-          dictator Manuel Noriega and his loyal soldiers. The
mandos], and airborne units) made the assault, few       experience was similar to that of Grenada. One
psychiatric casualties were expected, and few oc-        difference was the presence of women in military
curred (three so designated in 3,000 invading troops     police units who engaged in combat. With few
with 19 KIA and 73 WIA).52                               exceptions they acquitted themselves well.
   Dehydration and heat exhaustion casualties ac-           Stokes,77 in his capacity as the Combat Stress
counted for most of the preventable casualties.          Action Officer for the U.S. Army Medical Depart-
Fullerton74 debriefed most of the commanders after       ment Center and School, reviewed mental health
combat had ended. He reported that one battalion         issues in Operation Just Cause. He reports that no
suffered 29 heat casualties in a single day but an-      unit mental health personnel or formal stress hold-
other battalion suffered only two heat casualties on     ing capability was deployed to Panama in conjunc-
the same day, while both engaged in virtually iden-      tion with the operation due to the priority given to
tical tasks. The commander of the latter battalion       combatants and weaponry. During the combat
had emphasized water discipline.                         phase of the operation, which lasted only a few
   Some of the wounded soldiers suffered delayed         days, some soldiers evidencing symptoms of com-
post-traumatic stress disorders.74,75 Mateczun and       bat stress reaction were given nonstressful duties in
Holmes-Johnson52 had an interesting opportunity          their units without being evacuated. Stokes reports
to compare the psychological adjustment of U.S.          only one case in which medical personnel (U.S. Air
Marines wounded in the Grenada invasion with             Force nurses at Howard Air Force Base in Panama)
those wounded in the Beirut massacre when casual-        successfully held and returned to duty a “classic”
ties from both incidents arrived almost simulta-         battle fatigue casualty. This occurred on the third
neously at Bethesda Naval Hospital in Maryland.          or fourth night of Operation Just Cause (after the
About 25 U.S. Marines, more from Beirut than             surgical mass casualty was over).77
Grenada, were treated in a psychiatric consulta-            Many soldiers with potentially “return to duty”
tion-liaison model with “group therapy” as the           medical conditions, including Rangers and Air-
primary intervention. The group therapy was mod-         borne, were evacuated to military hospitals in San
eled after Marshall’s76 group debriefing technique;      Antonio, Texas through the mobile aeromedical
however, the Beirut casualties had less to recount       staging facility (MASF) at Howard Air Force Base
because they were sleeping when the bomb ex-             over the first several days. These cases included


24
                                                                                      Psychiatric Lessons of War


minor orthopedic injuries (most parachute-assault       cases of post-traumatic stress disorder, especially
related), heat exhaustion, and other conditions such    from small units which had had especially horrible
as headache in a soldier whose helmet had been          experiences such as the death of a pregnant woman
struck by a bullet (but not penetrated) while he was    at a roadblock. Stokes also noted that a military
shielding his dead buddy who had been killed by a       police company at Fort Drum requested and re-
sniper. These evacuations were because Howard           ceived stress debriefing from the division social
Air Force Base had only surgical teams, very limited    work officer about 1 month after homecoming.77
x-ray and laboratory capability, no holding person-        The Department of Military Psychiatry of the
nel, and many surgical casualties.77                    Walter Reed Army Institute of Research, as part of
   Many of these elite soldiers were mortified that     their ongoing research relating unit cohesion and
they had been evacuated to San Antonio for what to      combat readiness, sent debriefing teams to the 7th
them were “dishonorable” or “shameful” injuries.        Infantry Division (Light), the 5th Infantry Division
One broke down crying on being told that his ankle      (Mountain), and the 82d Airborne Division, all units
was only sprained. One officer was going to refuse      that had been part of Operation Just Cause. The
the Purple Heart he was to receive on television, on    teams found numerous examples of unresolved
grounds that he didn’t deserve it (although the         combat memories which could become post-trau-
combat assault in which he had injured himself was      matic stress disorder months after returning from
from 250 feet altitude, on a moonless night, under      Panama.77
fire, with full combat load, onto a concrete runway).      Anecdotal evidence suggests that a Ranger
He was finally persuaded by the chief ward nurse to     battalion’s attrition rate from the U.S. Army was
take it without making a scene. Some soldiers left      high after return from Panama. Attrition was also
behind the decorations they had been given when         high in the months following Urgent Fury (Grenada),
they were evacuated further to home base. Infor-        according to a physician assistant who jumped in
mal follow-up has indicated that some of these elite    with one of the Ranger battalions. The physician
soldiers suffered post-traumatic stress symptoms        assistant told Stokes that he had talked with many
and sought treatment covertly at a Department of        of his Ranger comrades during their preretirement
Veterans Affairs center or left the service.77          medical outprocessing. A common explanation for
   Two soldiers were sent to a nearby U.S. military     retiring was, “My wife wants me to; she worried
hospital several days after they had presented with     about me in Grenada.” Only with careful question-
stress-type symptoms. The hospital was not staffed,     ing would it become clear that the wife had ac-
configured, or geographically located to function as    cepted the danger in Grenada, but was worried that
a combat stress recovery unit or restoration center.    her husband had come home changed, with symp-
These two soldiers were evaluated in the busy ad-       toms of PTSD. She felt that if he left the military, he
missions area and admitted on the psychiatric ward.     would get back to being the man she had married.
After several more days, both were administra-          Finally, some of the Rangers shared with the physi-
tively/medically evacuated to the continental           cian assistant their traumatic memories, often in-
United States via Brooke Army Medical Center in         volving survivor guilt.
Texas with psychiatric labels. Stokes interviewed           Stokes reported a number of lessons learned in
both at Brooke Army Medical Center, and consid-         Panama,77 which have subsequently been incorpo-
ered both evacuations to have been inappropriate,       rated into U.S. Army doctrine.78,79 Very short, victo-
although one became inevitable once the soldier         rious campaigns such as Operation Urgent Fury in
was admitted to the psychiatric ward and reacted        Grenada and Operation Just Cause in Panama are
by behaving like the adolescent psychiatric patient     just long enough for soldiers (especially the highly-
she was expected to be.                                 trained elite units) to experience the “Stage of
   After soldiers returned to their home bases, there   Alarm”80 and suboptimal combat performance.31
were several instances in which units consulted         The combat is not long enough to achieve the “Stage
with mental health professionals to deal with lin-      of Resistance”80 and the enhanced combat skills of
gering issues pertaining to experiences in Panama.      the experienced veteran. The soldiers, including
For instance, Fort Bragg and the XVIII Corps called     the leaders, often return with their confidence in
in an outside consultant in post-Vietnam PTSD to        themselves and their comrades shaken, but are hesi-
give training, because of symptoms among a unit         tant to share such thoughts with anyone (even their
that had performed mortuary duties for Panama-          peers) for fear of being thought weaklings. This
nian civilian casualties. The division and U.S. Army    observation supports the need for routine after-
Medical Department mental health staff treated          action debriefing within the units themselves.


                                                                                                             25
War Psychiatry


    Stokes77 suggested that even a very austere hold-       Most division mental health sections found it
ing capability could enable keeping stress casual-       advisable to send one of the mental health officers
ties and highly motivated minor disease/nonbattle        (social worker, psychologist, or psychiatrist) for-
injury (DNBI) cases in theater for return to duty.       ward to augment the behavioral science specialist
Many of the elite soldiers with minor injuries in        (91G NCO) which doctrine said should be with
Operation Just Cause would have volunteered to           every brigade. In the Persian Gulf War, the bri-
sleep on the ground, in an airfield hanger or keep       gades were the principal fighting element. The
watch in a foxhole, M16 in hand, with their ankle        division’s main support medical companies were
wrapped and ibuprofen (or nothing) for the pain.         often left far to the rear.
If, after 1 to 2 days, they were not able to return to      Ideally the function of these officer/NCO com-
their units’ headquarters for limited duty and re-       bat stress control teams was like that of the original
quired further x-rays or treatment, they could have      World War I division psychiatrists: to educate, tri-
been evacuated without shame. This would de-             age, and prevent the evacuation of any stress cases
crease post-traumatic stress disorder, guilt over        who could be managed in their own organizations.
failure, and attrition of good soldiers from the U.S.    The ability to hold for treatment at that forward
Army.                                                    echelon is minimal, which is why expert triage
    Doctrine79 now states that division mental health    to prevent overevacuation is so crucial. Like the
sections (and the new combat stress control units)       World War I psychiatrists, the mental health
should be deployed in brief contingency operations       personnel’s place in the Persian Gulf War during
such as Operation Just Cause. Even if they don’t         combat was at the main triage point (now the medi-
arrive until after combat is over (due to limited        cal company in the brigade support area, and some-
space on aircraft), they can debrief units in theater,   times forward at the ambulance exchange points).83,84
soon after action, at the scene of the action. This is   These teams also provided preventive debriefings
far more effective than waiting until after the units    and consultation to command following traumatic
come home and return from family leave with prob-        incidents.
lems already locked in. The mental health person-           Stokes77 provided several examples of the appro-
nel also gain the knowledge, experience, and cred-       priate treatment of combat stress casualties during
ibility with the units that will enable them to be       the Persian Gulf War. For instance, the Tiger Bri-
much more helpful to soldiers who are experienc-         gade was attached to a U.S. Marine Division for the
ing difficulty over the following months.                frontal assault on Iraqi defenses around Kuwait
    Stokes77 also reviewed deployment of mental          City. Four stress casualties were evacuated to the
health resources during the Persian Gulf War which       U.S. Marine’s Surgical Support Company, which
involved the largest deployment of U.S. forces in        had been augmented by the U.S. Navy with a Com-
the 20 years since the withdrawal of U.S. forces from    bat Stress Center. Three of the four soldiers were
Vietnam. The Persian Gulf War rivaled the Vietnam        returned to duty to their units shortly after the brief
conflict in total forces in a combat zone at a given     campaign was over. The remaining case, who had
time. It was reported that during the Persian Gulf       more severe psychopathology, was evacuated.
War the 540,000-member U.S. forces had 148 killed           The U.S. Navy’s creative improvisation in sup-
in action and 467 wounded.81 Of these, 35 were           port of the U.S. Marines is another example. In mid-
killed and 78 wounded in fratricidal incidents. Iraq’s   January, the U.S. Navy psychiatrist aboard the USNS
military is estimated to have lost between 30,000        Comfort began a move in concert with the Specialty
and 100,000 killed and 100,000 to 300,000 wounded.       Advisor for Psychiatry and the Medical Officer of
There were an estimated 60,000 to 70,000 Iraqi pris-     the U.S. Marine Corps to move neuropsychiatric
oners of war by war’s end.82                             resources forward of the hospital ships and fleet
    During the peacetime interim between the Viet-       hospitals.85 Four combat stress centers, each with a
nam conflict and the Persian Gulf War, division          psychiatrist and a psychologist (or two psycholo-
mental health sections had been preoccupied with         gists, under the supervision of the nearby combat
clinic mental health and U.S. Army Medical Depart-       stress center which had a psychiatrist), were estab-
ment PROFIS (Professional Officer Filler System)         lished at each of the four surgical support compa-
duties. Thus they lacked field experience and cohe-      nies. These were assisted by a mix of psychiatri-
sion with their divisions. Fortunately, the pro-         cally-trained or on-the-job-trained corpsmen and
longed mobilization phase (Operation Desert Shield)      nurses. The combat stress centers had a 40-cot
of the Persian Gulf War allowed most to correct this     holding capability. Fortunately, the battle did not
before combat started.                                   require weeks of fighting in chemically-contami-


26
                                                                                        Psychiatric Lessons of War


nated trenches, which could have generated mass           it continued that mission while splitting off three
stress casualties to fill those cots.                     teams. One team established a combat stress con-
   The regimental surgeon of one U.S. Army ar-            trol restoration/reconditioning center collocated
mored cavalry regiment requested and received a           with a hospital at King Khalid Military City. The
combat stress control team from the corps, which          other two teams reinforced the 528th and 531st
consisted of two psychiatrists, a social worker, and      psychiatric detachments which were supporting
an enlisted technician.86 The team accompanied the        the two corps. The stress control teams were inte-
medical troop into Iraq, went forward to interact         grated into the medical task forces which deployed
with the line troops, and conducted debriefings           forward behind the ground offensive. Along with
following traumatic incidents. They also advised          surgical and preventive medicine teams, some of
the command regarding pre- and post-homecom-              them reached the Euphrates River. Hospital psy-
ing activities.                                           chiatry was not neglected by the forward deploy-
   Three medical (psychiatric) detachments (OM            ment of these teams. The neuropsychiatry sections
teams) were activated and deployed to the Persian         of two evacuation hospitals combined to form a
Gulf War. The one active component detachment,            stress recovery unit which followed the principles
the 528th, became XVIII Corps’ combat stress con-         of combat psychiatry. Between 16 February 1991
trol asset. It did not reach Saudi Arabia until late      and 9 March 1991, it admitted 22 cases and returned
October, but immediately set up a brief restoration       21 to duty after an average stay of 4 days.87
program collocated with a combat support hospital            Stokes77 observed that total stress casualties in
and sent mobile teams to provide consultation/            the Persian Gulf War from 16 January 1991 (the start
education at the battalion aid stations and dispen-       date of the air war against Iraq) through early March
saries. This produced a marked decrease in the            1991 would include all those held in division clear-
evacuation of “psychiatric” cases, and also of cases      ing stations for over 24 hours, in the OM team
with stress-related somatic complaints who were           facilities collocated with hospitals, and in the hospi-
being evacuated with other tentative diagnoses.           tals themselves. These have not been tabulated and
Most of the cases held for treatment and returned to      may never be fully counted. However, it requires
duty by this detachment were from the corps-level         only 94 cases from all the services held for treatment
combat support/combat service support units. This         in the theater between 16 January 1991 and mid-
may have been in part because the division person-        March 1991 to constitute the “standard” one to five
nel were geographically more distant, and had their       ratio for the 467 wounded in action. The distinction
own division mental health sections to prevent un-        between “combat stress” and “noncombat stress”
necessary evacuation or referral. The combat sup-         casualties becomes unclear when the Scud missile
port/combat service support personnel in corps            threat was greater in the rear than near the front,
were also often reservists who had been called up         and driving a truck long distances on the Tapline
unexpectedly, with unresolved homefront prob-             Road was at least as likely to result in death as
lems.                                                     driving a tank against Iraqi armor and infantry.77
   The combat support/combat service support                 Nostalgic casualties were few because the host
personnel were also working the hardest during the        country (Saudi Arabia), in keeping with Muslim
buildup phase of the Persian Gulf War. Some               tradition, did not allow importation of alcoholic
worked extremely long hours under difficult and           beverages or prostitution. Accidents reportedly
dangerous environmental conditions. When the              were one third the rate of other U.S. forces due to
528th psychiatric detachment deployed forward in          absence of alcohol. However, casualties secondary
late December and divided into teams to provide           to substance abuse did occur when soldiers at-
backup support to each division in 18th Corps (in         tempted to make homemade alcohol and died from
accordance with evolving doctrine79) the evacua-          methanol ingestion. Clear grain alcohol was avail-
tion of “psychiatric casualties” began to rise again.77   able at stores along the Tapline Road, disguised as
   Two Reserve OM teams were activated and de-            bottles of drinking water, for those who knew how
ployed in December 1990. The 531st from Balti-            to ask and were willing to pay.77 Only a few drug-
more, Maryland became the combat stress control           related incidents occurred, including that of a U.S.
asset for 7th Corps, and divided into teams to pro-       Air Force pharmacist who used and distributed
vide backup support for each division. The 467th          drugs illegally.
from Madison, Wisconsin was initially assigned to            Some of the lessons learned from the Persian
provide echelon above corps support at Riyadh,            Gulf War appear to have been of a negative nature.
Saudi Arabia. As the ground campaign approached,          On the evening of 21 February 1991, a Scud missile


                                                                                                               27
War Psychiatry


holding a ton of explosives struck the 14th              were needed. It was also recommended that each
Quartermaster’s barracks at Dhahran, Saudi Arabia,       divisional brigade, separate brigade, and armored
killing or mortally wounding 13 members of the 69-       cavalry regiment should have a predesignated (if
member unit, including the first woman soldier           not organic) officer/NCO combat stress control
killed in Persian Gulf combat. The missile wounded       team.77
37 others. The doctrinal requirement to send the            The Persian Gulf deployment left 17,000 children
combat stress control teams forward to support the       of single parents or two-soldier couples tempo-
combat arms had left the corps area with little          rarily without any parents during the war. How
combat stress control support for such a large area.     significant this will be in the subsequent develop-
Consequently, when the Scud missile caused mass          ment of these children is unknown.89 Schneider and
casualties in Dhahran, there was no mobile combat        Martin discuss these issues in greater detail.90
stress control team available to provide immediate          The United States has continued involvement in
command consultation and debriefing. A critical          mercy and peacekeeping roles in Somalia (Opera-
incident debriefing did not occur. There was also        tion Restore Hope), Macedonia (to contain the civil
ambivalence by unit officers and troops’ suspicion       war in Bosnia), and Haiti. These relatively small
of military mental health officers. Even worse, days     and brief operations may be the main role of the
later the survivors were shipped far from the front      military in the future as the responsibilities of the
to a European-based hospital for evaluation and          U.S. military are expanded to add peacekeeping
eventual evacuation to the United States.88 One          and humanitarian missions to those of fighting wars
official U.S. Army Medical Department lesson             and deterring aggression.91 However, these opera-
learned from the Persian Gulf War was to support         tions will not necessarily be without combat stress
the fielding of the new TO&E (Table of Organiza-         casualties. At least one Ranger who was in the
tion and Equipment) combat stress control units          battle of the Olympic Hotel in Mogadishu, Somalia
and their doctrine. At one of the lessons-learned        (October 1994) was dropped from the Rangers (al-
conferences, the senior U.S. Army Medical Depart-        though not from the U.S. Army) as a result of mis-
ment leaders in the Persian Gulf War declared com-       conduct that was clearly related to undiagnosed
bat stress control “one of the success stories” of the   post-traumatic stress disorder.77 The cause of his
operation, but added that there were not enough          survivor guilt was identified (and quickly dispelled)
combat stress control units to be everywhere they        during a group debriefing one year later.

                                     SUMMARY AND CONCLUSION


   This history of warfare reveals certain recurring     Cohesion is fostered by good leadership and by
themes concerning soldiers who persevere in com-         having soldiers train, live, and experience stress
bat versus those who break down in combat. Both          together. Further preventive measures include ad-
groups are often quite similar as individuals (and       equate rest, sleep, and nutrition so that chronic or
may even be the same individuals); however, their        acute fatigue does not develop. Rest from battle
social situations are markedly different. The social     should ideally occur through small group rotation
situations consist of a matrix of factors that deter-    so that group support is continuous. Commanders
mine whether the soldier excels or breaks down.          should be open and honest with their subordinates
   Thus, in adapting to combat, as in all survival-      to build trust and vertical cohesion, and to enhance
relevant activities, humans respond holistically.        the soldier’s understanding of the importance of
Their physical, intrapsychic, and social states form     his contribution to the unit mission and the nation-
this matrix of factors, which influences their re-       al interest. The soldier must believe that his
sponses to environmental danger. In combat, deep         entire society supports him in his privations and
urgings for individual survival often conflict with      sacrifices.
socially conditioned expectations, requirements, and        Factors that foster psychiatric breakdown are the
desires for “soldierly conduct,” which have been         negatives of the preventive factors: poor leader-
embodied in ideals such as patriotism, discipline,       ship, cohesion and training; inadequate social sup-
loyalty to comrades, and identification with the         port; and the buildup of fatigue. Factors that em-
leader.                                                  phasize perceptions of individual or collective
   To prevent combat breakdown, the presence of          vulnerability increase the probability of psychiatric
mission-oriented small group cohesion is essential.      breakdown. This accounts for the strong relation-


28
                                                                                             Psychiatric Lessons of War


ship between intensity of combat (as measured by             soldier’s experience rather than give an imputation
wounded and killed in action) and numbers of                 of mental illness. In garrison or rear-echelon set-
stress casualties. It also accounts for the observa-         tings, prevention is even more important because
tion that the death of a comrade was the most                the disorders that occur (alcohol and drug abuse,
common precipitant of breakdown during World                 character disorders, and sexual problems) are even
War II. A feeling of helplessness in controlling             more difficult to treat than combat stress disorders.
one’s fate also exacerbates stress and weakens resis-        In rear-echelon settings, attention should be paid to
tance. This is seen in the increased stress casualties       discipline, morale-enhancing activities, and recog-
that occur in circumstances of indirect fire such as         nition of the critical role played by support troops.
artillery or bombing barrages, or gas attacks com-           Communication between support troops and those
pared with the direct fire situation (even though the        they support should be encouraged. Temporary
wounded and killed rate may be the same or higher            assignment to combat units should be available.
than under indirect fire).                                   Infractions should be dealt with through forward
    After a soldier has become a psychiatric casualty,       rather than rearward evacuation to minimize sec-
it is important to restore as many positive factors as       ondary gain from misbehavior.
possible: rest, sleep, and nutrition. Bonds to the              Prevention of combat stress casualties is prima-
unit are kept intact with expectation of return to the       rily a command responsibility but the medical per-
unit, hence the importance of treating as far for-           son, through consultation with command and avoid-
ward and as quickly as possible. Treatment must be           ance of medical “evacuation syndromes,” plays a
kept simple to emphasize the normality of the                critical role in this endeavor.


                                                  REFERENCES


   1. Marlowe DH. Personal Communication, 1985.

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                                                                                                                    29
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 13.   Jones FD, Belenky GL, Marlowe DH. Shell shock and battle fatigue: The importance of a name. Presented at the
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 32.   Hanson FR, Ranson SW. Statistical studies. Supplement on Combat Psychiatry. Bull US Army Med Dept.
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30
                                                                                              Psychiatric Lessons of War


33.   Beebe GW, Appel JW. Psychological breakdown in relation to stress and other factors. In: Variation in
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34.   Noy S. Battle intensity and length of stay on the battlefield as determinants of the type of evacuation. Milit Med.
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35.   Marshall SLA. Night Drop: The American Airborne Invasion of Normandy. Boston, Mass: Little, Brown; 1962: 15–21.

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38.   Parrish MD. Written Communication, 1991.

39.   Glass AJ. Psychiatry in the Korean Campaign (Installment 1). US Armed Forces Med J. 1953;4:1387–1401.

40.   Marshall SLA. Pork Chop Hill. New York: William Morrow; 1958: xii, xv.

41.   Fearnsides EG, Culpin M. Frost-Bite. Br Med J. January 1915;1:84.

42.   Kirkland F. Personal Communication, 1991.

43.   Glass AJ. Personal Communication, 1982.

44.   Neel S. Vietnam Studies: Medical Support of the US Army in Vietnam, 1965–1970. Washington, DC: Department of
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45.   Datel WE. A Summary of Source Data in Military Psychiatric Epidemiology. Defense Technical Information Center,
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46.   Bowman J. Recent Experiences of Combat Psychiatry in Vietnam. Washington, DC: Division of Neuropsychiatry,
      Walter Reed Army Institute of Research; 1967. Typescript.

47.   Jones FD. Experiences of division psychiatrist in Vietnam. Milit Med. 1967;132(12):1003–1008.

48.   Huffman RE. Which soldiers break down: A survey of 610 psychiatric patients in Vietnam. Bull Menninger Clin.
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49.   Renner JA. The changing patterns of psychiatric problems in Vietnam. Compr Psychiatry. 1973;14(2):169–180.

50.   Hayes FW. Military aeromedical evacuation and psychiatric patients during the Vietnam war. Am J Psychiatry.
      1969;126:658–666.

51.   Holloway HC. Epidemiology of heroin dependency among soldiers in Vietnam. Milit Med. 1974;139:l08–113.

52.   Mateczun J, Holmes-Johnson E. The psychiatric care of the combat-injured and clinical differences between
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      Operational Experiences. Fort Sam Houston, Tex: US Army Health Services Command; 1985: 180–206.

53.   Department of Defense. Selected Manpower Statistics, 1992. DoD, Washington Headquarters Service. Washing-
      ton, DC: GPO; 1993. GPO Stock No. 1993-720-091/80107.

54.   Noy S. Personal Communication, 1983

55.   El Sudany El Rayes M. Combat psychiatry in Arab-Israeli wars. Presented at Grand Rounds, Psychiatry
      Department, Walter Reed Army Medical Center; October 21, 1982; Washington, DC.



                                                                                                                      31
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 56.   Harris P. Personal Communication, 1986.

 57.   Belenky GL. Varieties of reaction and adaptation to combat experience. Bull Menninger Clin. 1987;51(1):64–79.

 58.   Soloman Z, Benbenishty R. The role of proximity, immediacy and expectancy in frontline treatment of combat
       stress reaction among Israelis in the Lebanon War. Am J Psychiatry. 1986;143(5):613–617.

 59.   Haggerty JJ. Afghanistan—the great game. Milit Rev. 1980;60(8):37–44.

 60.   Krivosheyev GF. Losses to the Armed Forces of the USSR in Battles, Combat Operations, and Military Conflicts:
       Statistical Investigations. Moscow: Military Press; 1993: 402–404.

 61.   Klose K. Ex-Soviet’s escape into a childhood dream. Washington Post. 16 November 1985: A-3.

 62.   Moore M. A post-Afghan syndrome? Washington Post. 1 October 1989: D-1, D-5.

 63.   O’Ballance E. Soviet tactics in Afghanistan. Milit Rev. 1980;60(8):45–52.

 64.   Mohair M, Mottaghi Y. Psychiatric war casualties in Iran: Presentations. Presented at American Psychiatric
       Association Annual Meeting; May 1985; Dallas, Tex.

 65.   Kadivar H, Adams SC. Treatment of chemical and biological warfare injuries: Insights derived from the 1984
       Iraqi attack on Majnoon Island. Milit Med. 1991;156(4):171–177.

 66.   Mohajer M, Dekjam M, Moheb-Ali A. Psychosocial condition of war refugees of Iran after 4 years. Presented at
       American Psychiatric Association Annual Meeting; May 1986; Washington, DC.

 67.   Fisher M. Lessons of the Falklands: Prepare for surprises. US Medicine. 1983;19(5):3,16.

 68.   Pincus W. British got crucial data in Falklands, diary says. Washington Post. 23 December 1984: A1, A20.

 69.   Harmon JW, Llewellyn C. Lessons of the Falklands. Med Bull US Army Europe. 1984;41(2):11–13.

 70.   O’Connell MR. Psychiatrist with the task force. In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State
       of the Art. Vol 6. New York: Plenum Press; 1985: 511–513.

 71.   Russell G. Falkland Islands: Explosions and breakthroughs. Time. June 7, 1982: 30–36.

 72.   Collazo C. Psychiatric casualties in Malvinas War: A provisional report. In: Pichot P, Berner P, Wolf R, Thau K,
       eds. Psychiatry: The State of the Art. Vol 6. New York: Plenum Press; 1985: 499–503.

 73.   Abraham P. Post-traumatic stress disorder. J R Coll Gen Pract. 1987;37(300):321–322. Letter.

 74.   Fullerton T. A soldier’s view of combat medicine in Grenada. Presented at Psychiatric Grand Rounds, Walter
       Reed Army Medical Center; November 1984; Washington, DC.

 75.   Belenky GL. Talking with US casualties from Grenada. Presented at Chief’s Roundtable, Neuropsychiatry
       Department, Walter Reed Army Institute of Research; December 1983; Washington, DC.

 76.   Marshall SLA. Bringing Up the Rear: A Memoir. San Rafael, Calif: Presidio Press; 1979: xiv.

 77.   Stokes J. Written Communication, 24 February 1994.

 78.   US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA; 29 September 1994.
       Field Manual 22-51.

 79.   US Department of the Army. Combat Stress Control in a Theater of Operations. Washington, DC: DA; 29 September
       1994. Field Manual 8-51.


32
                                                                                            Psychiatric Lessons of War


80.   Selye H. The General Adaptation Syndrome and the diseases of adaptation. J Clin Endocrinol [now J Clin
      Endocrinol Metab]. 1946;6(2):117–230.

81.   Miscellanea Medica. JAMA. 1991;266(15):2053.

82.   Gunby P. Another war...and more lessons for medicine to ponder in aftermath. JAMA. 1991;266(5):619–621.

83.   Campbell SJ, Engel CC. Combat psychiatry the “First Team” way: First Cavalry Division mental health
      operations during the Persian Gulf War. In: Belenky G, Martin J, Sparacino L, eds. A Shield in the Storm: Mental
      Health Operations During the Gulf War. Westport, Conn: Greenwood Press. In preparation.

84.   Campbell SJ, Carter BS. Forward location of the combat stress control team contributing to the primary
      prevention of combat stress and battle fatigue in Operation Desert Shield/Storm. Paper presented at the 7th
      Military Medicine Conference, Uniformed Services University of the Health Sciences, Bethesda, Md. April 1992.

85.   Mateczun J. Personal Communication, 1995.

86.   Martin JA. Personal Communication, 1995.

87.   Johnson LB, Cline DW, Marcum JM, Intress JL, Effectiveness of a stress recovery unit during the Persian Gulf
      War. Hosp Community Psychiatry. 1992;43(8):829–833.

88.   Cody P. Military fails to follow own psychiatric guidelines in handling survivors of Dhahran Scud attack.
      Psychiatric News. 16 August 1991: 2, 5.

89.   Persian Gulf vets, families expected to need mental health care at some future time. Psychiatric News. 16 August
      1991: 2, 13.

90.   Schneider RJ, Martin JA. Military families and combat readiness. In: Jones FD, Sparacino LR, Wilcox VL,
      Rothberg JM, eds. Military Psychiatry: Preparing in Peace for War. Part 1. In: Textbook of Military Medicine.
      Washington, DC: Office of The Surgeon General, US Department of the Army and Borden Institute; 1994: 19–30.

91.   Graham B. Responsibilities of U.S. military expanded. The Washington Post. 9 March 1995. A36.




                                                                                                                   33
                                                                                        Traditional Warfare Combat Stress Casualties




Chapter 2
TRADITIONAL WARFARE COMBAT
STRESS CASUALTIES

FRANKLIN D. JONES, M.D., F.A.P.A.*



                                      INTRODUCTION

                                      DEFINITION AND MANIFESTATIONS

                                      ETIOPATHOGENESIS
                                        Psychiatric Casualties and Combat Intensity
                                        Prediction of Psychiatric Casualties

                                      TREATMENT
                                        Normal Reactions to Combat
                                        Pathological Reactions to Combat
                                        Atypical Reactions to Combat

                                      CONCLUSION




*Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
 President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and
 Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                         35
War Psychiatry




Tom Lea                                              Going In, Peleliu                                   1944

Tom Lea was an artist correspondent for Life Magazine during World War II. He participated in the landing
of U.S. Marine forces at Peleliu, hitting the beach 15 minutes after the troops. This painting was done from
memory as he spent the first 36 hours after landing just trying to stay alive. The painting powerfully depicts
the psychological mindset of a veteran going into combat yet again. The set of the jaw and the look of
determination, against the background of ongoing death and destruction, was familiar to combat artists
during World War II as they accompanied the fighting troops into “traditional warfare.”



Art: Courtesy of US Center of Military History, Washington, DC.




36
                                                                      Traditional Warfare Combat Stress Casualties




                                             INTRODUCTION


   The diagnosis and treatment of combat stress          not unusual for sheer numbers of surgical casual-
casualties range from the easily accomplished to the     ties to overwhelm the forward treatment capabili-
highly difficult. Diagnosis may be apparent when         ties and result in evacuation rearward of stress
a fatigued, anxious, otherwise intact soldier says,      casualties. High-intensity warfare, in addition to
“Doc, I can’t take it anymore.” Diagnosis may be         making forward treatment difficult because of the
more difficult when the casualty is mute and unre-       absence of a safe treatment area, will likely over-
sponsive, or aggressive. Making the diagnosis is         whelm the forward treatment facility with very
complicated not only by the heterogeneity of symp-       large numbers of surgical and psychiatric casual-
toms in the unwounded but also by potential wound-       ties.1 Low-intensity warfare can also produce psy-
ing agents that can present with or mimic psychiat-      chiatric casualties and misconduct stress casualties
ric symptoms. In addition to bullets, fragments,         (drug abuse, disciplinary infractions, venereal dis-
and burns, such wounding agents include biologi-         eases) that may be difficult to treat—as was seen in
cal and chemical agents, and radiation, both nuclear     Vietnam.
and microwave.                                              The types of casualties and their treatment de-
   Treatment involving rest, nutrition, and expect-      pend on the type of war. It is, therefore, appropriate
ancy, while generally easy in concept, may be diffi-     to discuss them in this context after first defining
cult in application. During World War II, it was         stress and psychiatric casualties.

                                 DEFINITION AND MANIFESTATIONS


   Historically, since late World War I, a combat        ment of which will be best for the mission, the unit,
psychiatric casualty has been defined as any mili-       and the individual soldier. This textbook will dis-
tarily ineffective soldier (or organization) in whom     tinguish the psychiatric, stress, and misconduct
the predominant factors producing ineffectiveness        categories except when making historical references
were of psychological (as opposed to physical)           and citations where “psychiatric” is historically
or neuropsychiatric origin. Although partly fulfill-     accurate.
ing this definition, disorders involving structural         Manifestations of combat stress overlap at both
damage or major physiological disturbances of            ends of the psychobiological spectrum, and one role
brain tissue were normally excluded from this cat-       of the psychiatrist is to separate out particularly the
egory. Nonconflicted malingering was also ex-            neurological cases that require a different, sometimes
cluded.                                                  surgical form of treatment. Sometimes it is important
   Current U.S. Army doctrine 2 distinguishes psy-       also to separate out the conscious malingerers, but
chiatric from stress casualties. Psychiatric casual-     this is not always the case because the treatment
ties are those with standard Diagnostic and Statisti-    involving rest, expectancy, and strengthening the
cal Manual (DSM-IV)3 diagnoses which are not             desire, however attenuated, of the soldier to return
simply the temporary consequence of the intense          to his unit is generally the same in cases of combat
psychological and/or physiological stress of com-        fatigue and malingering. In the latter instance,
bat or other highly stressful missions. These latter     however, a more coercive stance (threat of court-
are labeled “stress casualties,” “battle fatigue,” or    martial) may be required if early rest, expectation of
“contingency fatigue.” The U.S. Army classifica-         recovery, and talking therapy do not produce will-
tion also defines the “misconduct stress behaviors”      ingness (however reluctant) to return to duty.
as violations of regulation or law which require            It is important to remember that most psychiatric
disciplinary action even though they are largely         casualties are soldiers who, because of the influence
attributable to stressful conditions. It is recognized   of negative psychological, social, and physiological
that psychiatric disorders, battle fatigue, and mis-     factors, unconsciously seek a medical exit
conduct stress behaviors can coexist in the same         from combat. Most cases, therefore, will mimic
soldier, with some grey areas where any of these         features of other medical disorders that would be
labels can be used, based on the command’s judg-         “legitimate” forms of escape from combat, thus



                                                                                                               37
War Psychiatry


becoming “evacuation syndromes.”4 Improperly              a legitimate escape from combat, leading to a policy
treated through evacuation, the symptoms                  by medical personnel of using a cryptic label,
may persist or worsen, developing characteristics         “N.Y.D. (nervous)” which stood for “not yet diag-
of traumatic neurosis (chronic post-traumatic stress      nosed (nervous),” as described in Chapter 1, Psy-
disorder).                                                chiatric Lessons of War.
   The symptoms displayed are those considered               Similarly, in the early phases of U.S. involvement
more acceptable by fellow soldiers, commanders,           in World War II, medical personnel used the term
and medical personnel. The symptoms often                 “psychoneurosis.” Soldiers abbreviated this unfa-
have a neurological or psychophysiological flavor,        miliar term to “psycho,” and the casualties
which in the past led to their classification as neuro-   frequently displayed bizarre and regressive symp-
ses (anxiety and somatoform disorders). The ab-           toms similar to those often seen in psychotic
sence of “neurotic” personality patterns and              patients.7 With the rediscovery of the principles
the transience of the syndrome when properly              of treatment by Hanson in North Africa, 8 and
treated indicate a more appropriate categorization        the use of the term “exhaustion,” the bizarre symp-
as a transient or situational stress or adjustment        toms receded to be replaced by symptoms of fa-
disorder.                                                 tigue.
   Based on World War II experience, Weinstein               Glass7 explained the efficacy of the term “exhaus-
and Drayer5 distinguished the anxiety states of com-      tion” compared with the diagnosis of psychoneu-
bat from those of civilian life by the following char-    rosis. Psychoneurosis implied unresolved intra-
acteristics of combat anxiety: (a) the extraordinary      psychic conflict with unconsciously derived
precipitating factors in the perils and hardships of      symptoms. The linkage between the symptoms and
the combat environment, (b) symptom plasticity, (c)       the conditions of combat was lost, and such casual-
the importance of hostility and guilt, which is more      ties would not be accepted by the soldier’s combat
immediately apparent than in most neuroses in             reference group as a normal result of battle. In-
civilians, and (d) the fact that they are in large part   stead, such soldiers were considered weaker, pre-
group phenomena. The soldier is a member of a             disposed persons who had not been properly
closely knit, interdependent group, and group ef-         screened out at induction. Exhaustion was selected
fectiveness and attitudes as well as ability to iden-     because it best described the appearance of most
tify with the group modify significantly the soldier’s    psychiatric casualties and of most combat partici-
capacity to withstand the traumas to which he is          pants of the time. Exhaustion was readily accepted
subjected. Failure in group membership may result         by the casualty and his combat reference group.
in symptom formation.                                     They could appreciate that anyone could become
   From this discussion it is obvious that the symp-      exhausted by the stress and strain of continual com-
tom complex may be quite heterogeneous and fluid.         bat. The psychiatric casualty became a rational
During the early years of World War I, when it was        consequence of battle conditions. The new termi-
believed that many soldiers were suffering from           nology communicated that the casualty was af-
concussion caused by exploding shells or bombs, a         flicted with a temporary, situationally-induced dis-
diagnosis of “shell shock” was given and the symp-        order that only required rest for restoration of
toms mimicked those of persons who had suffered           function.
from a blow to the central nervous system. In the            Despite the variability of symptoms in combat
words of Bailey, Williams, and Komora: “There             breakdown, some groups of symptoms have pre-
were descriptions of cases with staring eyes, violent     dominated in various wars. Bar-On and colleagues,
tremors, a look of terror, and blue, cold extremities.    as cited in Belenky,9 have reviewed the predomi-
Some were deaf and some were dumb; others were            nant symptoms described in U.S. and Israeli casual-
blind or paralyzed.”6(p2)                                 ties in World War I, World War II, Vietnam, and the
   Later, after the use of poison gas had become          Arab-Israeli wars of 1973 and 1982. These symp-
widespread, many soldiers presented with respira-         toms were grouped by Jones10 in Table 2-1. These
tory symptoms, particularly “choking” and hyper-          listings are not actuarial and should be viewed as
ventilation, and they were often labeled “gas hyste-      showing tendencies only. When the anxiety and
ria.” As the psychological nature of the syndromes        fear categories are collapsed, these symptoms are
became known and the term “war neurosis” came             found to predominate in all U.S. wars except the
into vogue, soldiers would present themselves as          Vietnam conflict. Even in the Vietnam conflict, an
suffering from neurosis and latch onto this label as      examination of psychiatric syndromes among sol-



38
                                                                                Traditional Warfare Combat Stress Casualties


TABLE 2-1
SYMPTOM CLUSTERS IN VARIOUS WARS




           Table 2-1 is not shown because the copyright permission granted to the Borden Institute, TMM, does
        not allow the Borden Institute to grant permission to other users and/or does not include usage in
        electronic media. The current user must apply to the publisher named in the figure legend for
        permission to use this illustration in any type of publication media.




Adapted with permission from Jones FD. Psychiatric lessons of low-intensity wars. Ann Med Milit Fenn [Finland]. 1985;60:129.



diers seen at a rear-echelon care facility staffed by a              Support troops, although exposed to little physical
mobile psychiatric detachment (KO Team) early in                     danger or hardship, nevertheless were stressed by
the war before drug abuse and disillusion became                     separation from family, boredom, and job frustra-
widespread reveals a large number of anxiety-type                    tion. These men were frequently seen because of
                                                                     excessive drinking, psychosomatic complaints, and
symptoms. This is evident in Exhibit 2-1. In
                                                                     behavioral problems. Such individuals from sup-
nonwounded soldiers, Bowman11 found a predomi-                       port units were contrasted with advisors to combat
nance of dissociative, anxiety, and conversion symp-                 units in which there was constant physical danger
toms, and in wounded soldiers anxiety dreams and                     and far less comfortable environmental surround-
neurological symptoms.                                               ings. These stresses resulted in casualties referred
   Similarly, Jones12 found that anxiety and fear                    to as combat fatigue, although this entity tended
symptoms predominated in combat soldiers in Viet-                    frequently to be disguised in the form of antisocial
nam. In contrast, combat-support soldiers were                       behavior or vague physical symptoms.4(p50)
more likely to present with what Jones referred to as
“disorders of loneliness,” which may be the modern                  Thus, it appears that some manifestations of psy-
analog of the “nostalgia” of previous centuries.                 chiatric difficulty are related to frequency and in-
Copen described the psychiatric stresses of military             tensity of exposure to combat. The relationship of
advisory soldiers in Vietnam in 1962 before large-               breakdown and its psychiatric manifestations to
scale U.S. involvement:                                          combat conditions will now be examined.



                                                                                                                               39
War Psychiatry




     EXHIBIT 2-1
     STRESS SYMPTOMS IN WOUNDED AND NONWOUNDED SOLDIERS AT THE 93RD EVACU-
     ATION HOSPITAL, VIETNAM, JANUARY–JUNE 1966 (Not listed in order of prevalence)


     A.   Stress Symptoms Seen in Wounded Soldiers
          The disabling symptoms of wounded soldiers usually developed after hospitalization, or if present
          when hospitalized, the symptoms persisted or became more severe, requiring neuropsychiatric
          consultation.
           1.   Persistent anxiety dreams.
           2.   Pain in wounded extremity following complete healing.
           3.   Sensory defects in which the patient claimed hypesthesia and weakness of an extremity but the
                neurological examination was negative.
     B.   Stress Symptoms Seen in Nonwounded Soldiers
           1.   Somnambulism.
           2.   Anxiety dreams with talking or shouting.
           3.   Syncope and vertigo.
           4.   Narcolepsy-like complaints.
           5.   Seizures—not proved to be grand mal or petit mal.
           6.   Musculoskeletal-type complaints, such as low back pain, where the orthopedic examination is
                negative.
           7.   Amnesia, especially following exposure to explosions (mortar, artillery, or mines) but having no
                concussion.
           8.   Blurred vision—when the ophthalmologist can find no visual defects.
           9.   Stuttering, expecially following exposure to loud noises or automatic weapons fire.
          10.   Aphonias or other speech disturbances, such as whispering.
          11.   Persistent nausea or abdominal pain in which no gastrointestinal disease could be demonstrated
                by the internal medicine service.
          12.   Headaches, atypical but severe, persistent, and disabling, most often diagnosed as “tension
                headache.”
          13.   Loss of hearing—in which ear, nose, and throat examination could find no hearing loss.

     Adapted with permission from Bowman J. Recent experiences in combat psychiatry in Vietnam. Presented at the Social and
     Preventive Psychiatry Conference. 1967; Walter Reed Army Medical Center. Washington, DC.




                                                  ETIOPATHOGENESIS


   The etiopathogenesis (origin and process of dis-                  tion stirring deep and strong affective currents vs.
ability) of the stress casualties of mid- to high-                   the conscious expectations, desires, and require-
intensity combat was well known by the French and                    ments of “soldierly-ideals” imbedded in an emo-
British during World War I and became the basis for                  tional matrix of discipline, patriotism, and the like)
                                                                     was so dynamic and stimulating that it served as a
Salmon’s “forward treatment.” Strecker describes
                                                                     beacon light to every psychiatrist in France, no
Salmon’s etiological concept as follows:                             matter how dark the outlook. 13(p386)

     His visualization of the concept of the emotional
     conflict underlying war conversion hysteria (the               Appel and Beebe put it more starkly in describ-
     moving demands of the instinct of self-preserva-             ing psychiatric casualties of World War II:


40
                                                                           Traditional Warfare Combat Stress Casualties


  [T]he danger of being killed or maimed imposes a            Obviously, during some periods of engagement
  strain so great that it causes men to break down …       with the enemy, BI & W rates for the engagement
  Each man (up there) knew that at any moment he           may be quite high but may or may not reflect signifi-
  may be killed, a fact kept constantly before his         cant changes in the overall rate. For example, dur-
  mind by the sight of dead and mutilated buddies
                                                           ing the first 6 months of the Korean conflict, casual-
  around him. Each moment of combat imposes a
  strain so great that men will break down in direct       ties were higher than in any other American war by
  relation to the intensity and duration of their expo-    a factor of two due to the surprise North Korean
  sure. Thus psychiatric casualties are as inevitable      invasion, the retreat to Pusan, the amphibious U.S.
  as gunshot and shrapnel wounds in warfare. 14(p185)      counterattack at Inchon, and the surprise Chinese
                                                           attack from Manchuria. Because of the large num-
Psychiatric Casualties and Combat Intensity                bers of U.S. casualties and relatively small numbers
                                                           of U.S. troops in Korea, the annual rate approaches
  Glass has described the relationship of intensity        that of a high-intensity conflict.19
and breakdown as following a bell-shaped or                   Similarly, during much of the Vietnam conflict,
Gaussian curve:                                            battle intensity as measured by BI & W rates was
                                                           low; however, during the several months of the Tet
  Very obviously, if you raise the destructive power       offensive of 1968, casualties were relatively high,
  of the weapon so that the individual cannot cope
  with it, then non-effectiveness is enhanced. If you
  have a weapon that is of minor destructive power         TABLE 2-2
  such as bows and arrows, or rifles, more people can
  cope with it. This is why men tell you in combat         BATTLE INJURY AND WOUNDING RATES/
  they don’t mind small arms fire; what they detest is     1,000 TROOPS/YEAR DURING VARIOUS
  artillery fire or mortar or other high explosives. So    U.S. WARS
  if you diminish the destructiveness, your curve
  looks different; if you raise it, then you have more
                                                           War                       Year      Nonbattle Battle Injuries
  non-effective people.15(p4)
                                                                                                Injuries  and Wounds

   Marlowe16 has discussed the concept that combat
                                                           U.S. Civil War         1861–1865         —                 97
stress casualties occur as a function of various “battle
ecologies” in which the most important variable is         World War I            1917–1918         —               238
the lethality of the environment. The stress casual-       World War II
ties more directly related to combat have been shown        Pacific               1942–1945        122                39
in numerous studies to occur in a direct ratio to
                                                            Europe                1942–1945        101              108
combat intensity as measured by killed-in-action
(KIA) or wounded-in-action (WIA) casualties.17 This         Mediterranean         1942–1945        131                80
ratio usually is about one stress casualty per three       Korea                  1950             242              460
or four WIA casualties; however, other factors re-                                1951             151              170
lated to morale, training, physical fatigue, prior                                1952             102                57
exposure, and combat success can markedly change
this ratio. It, therefore, becomes appropriate to          Vietnam                1965               67               62
group stress casualties according to combat inten-                                1966               76               75
sity. Combat intensity has generally been mea-                                    1967               69               84
sured by numbers of WIA and KIA per combat day                                    1968               70             120
(any day in which one or more soldiers per com-                                   1969               63               87
pany was killed or wounded). Because some inju-
ries are combat-related but not caused by wound-
                                                           Data sources: [US Civil War, World War I, and World War II]
ing, statisticians often combine the rate of battle        Beebe GW, De Bakey ME. Battle Casualties: Incidence, Mortality,
injury and wounding (BI & W), usually given per            and Logistic Considerations. Springfield, Ill: Charles C Thomas; 1952:
1,000 troops per year. Based on BI & W rates, World        21. [Korea] Office of the Surgeon General. Korea: A summary of
War II and most of the Korean conflict may be              medical experience July 1950–December 1952. In: Health of the
                                                           Army, January, February, and March 1953. Washington, DC: US
considered mid-intensity combat, and much of the           Department of the Army; 1953. [Vietnam] Neel S. Vietnam Studies:
Vietnam conflict may be considered low-intensity           Medical Support of the U.S. Army in Vietnam, 1965–1970. Washing-
combat,18 as seen in Table 2-2.                            ton, DC: US Department of the Army; 1973: 33, 36.




                                                                                                                              41
War Psychiatry


resulting in an annual BI & W rate for 1968 of            produced similar casualties, and the roughly
120, above the World War II (1942–1945) European          2-week period of intense warfare during the
rate of 108. Despite some intense battles, U.S. Civil     1982 Lebanon War also produced these casualties.
War (1861–1865) casualties among Union troops             Except for that 2-week period, which produced
were only 97/1,000/y, 15(p6) making it a low- to          most of the “traditional” (anxiety and fear) stress
mid-intensity conflict, while the American Expedi-        casualties, engagements in Lebanon were more of a
tionary Forces’ World War I (1917–1918) rate of           low-intensity, insurgency nature with snipers and
238 would place it in the mid- to high-intensity          booby traps accounting for many casualties.9 In
range. 17(p6)                                             this situation the development of symptom overlap
    Another factor in intensity is total number of        between Vietnam, overall a classic low-intensity
casualties per unit of time. The suddenness and           conflict, and the 1982 Lebanon War (ie, social es-
intensity of the 1973 Yom Kippur War resulted in          trangement) is seen. In a review of follow-up stud-
the compression of the amount of casualties nor-          ies, Belenky23 has detected another similarity be-
mally occurring in the first 20 days of combat in         tween Israeli casualties from the 1982 Lebanon War
World War II battles into the first 24 to 72 hours of     and U.S. casualties from the Vietnam conflict,
combat.1                                                  namely, the development of delayed stress casual-
    To take into account this factor of large numbers     ties, which are reported as high in both groups of
of casualties in a brief period of time, combat inten-    veterans.
sity has also been measured by the numbers of                These low-intensity warfare casualties, who
“pulses” of fighting in a given time period. During       present with problems that suggest a depressive
most of the battles of World War II and the Korean        core and depressive symptoms, were the primary
conflict, the number of battle pulses per day of          presentation of nostalgia in preceding centuries.24
combat did not exceed 4 or 5, whereas during the          Unchecked, these casualties can significantly de-
1973 Yom Kippur War there were 10 to 12 battle            grade the combat efficiency of a unit as was seen in
pulses per day for the first week.1                       the latter phases of the Vietnam conflict.4
    Battle pulses of high-intensity combat are accom-        The “short-timer’s syndrome,” the development
panied not only by high rates of killing and wound-       of superstitious dread that one’s chances of being
ing but also by high rates of stress casualties. In the   killed are increased followed by phobic anxiety and
1973 Yom Kippur War, some units, for example,             attempts to avoid all risks even when called for by
had as many stress casualties as surgical casualties      the military mission, was described as a frequent
among both the Israeli and Egyptian forces.20,21 There    occurrence in most combat and many combat-sup-
is much overlap not only in combat environments           port soldiers in Vietnam in the final weeks before
but also in symptom complexes.                            rotation home.25 This syndrome had been described
    In general, however, when one compares the            in other situations in which exposure to combat is
symptoms predominating in various wars during             limited by length of time (9 mo of combat in the
the past century, a clustering can be seen based to a     Korean conflict) or number of missions (a fixed
degree on the intensity of combat. For example, in        number of bombing runs by aircrews during World
addition to venereal diseases and “voluntary casu-        War II). Its appearance in Vietnam was, therefore,
alties”—those caused by failure to take antimalarial      not surprising; however, its widespread occurrence,
pills, engaging in substance abuse, presenting dis-       affecting even those in minimal danger, may have
cipline problems (including refusal to fight and          reflected disaffection and a sense of hopelessness in
assassination of superiors)—are the primary char-         fighting the war.
acteristics of low-intensity, unpopular wars: explo-         Stress casualties of low-intensity combat differ
sive aggressive behavior, social estrangement, and        substantially from those of mid- to high-intensity
constricted affect. Depressive affect reported by         combat, which present primarily with anxiety and
Bar-On and colleagues22 as occurring in World War         conversion and dissociative symptoms. In contrast,
I, the 1973 Yom Kippur War, and the 1982 Lebanon          low-intensity combat casualties tend to present with
War psychiatric casualties may also fit into this low-    “nostalgic” symptoms such as alcohol and drug
intensity war symptom complex depending on how            abuse, venereal diseases, and character and behav-
it is defined.                                            ior problems of indiscipline. Nostalgic casualties,
    During World War I, stress casualties presented       for the purposes of this chapter, will be defined as
with hysterical syndromes, psychomotor distur-            the psychiatric symptom clusters that predominated
bances, and fear, as well as depressed affect. The        in the behavior leading to ineffectiveness in Viet-
high-intensity combat of the 1973 Yom Kippur War          nam (see Table 2-1). Venereal diseases may be


42
                                                                      Traditional Warfare Combat Stress Casualties


included because, like failure to take malarial pro-      clinician under usual battle conditions, and, even if
phylaxis or to protect oneself from frostbite, psy-       they were known, it would be difficult to assign
chological ineffectiveness is often manifested by         them a particular weight for prediction purposes.
their appearance.                                         Their importance lies in preventive programs. Judg-
                                                          ing from historical review and recent experience of
Prediction of Psychiatric Casualties                      Israeli medical personnel in the 1982 Lebanon War
                                                          (23% stress casualties despite attempts to prevent
   From this discussion one may conclude that there       the influence of predisposing factors), the factor of
is a certain degree of predictability of numbers and      combat intensity seems to outweigh most of the
types of stress casualties when one knows the inten-      other factors in generating combat stress casualties.
sity of warfare (WIA rate) and composition of the         In future wars, therefore, the battle ecology can be
soldier population (combat vs combat-support              expected to produce high or low stress casualty
troops). In a general way this is true. In a mid- to      rates. A “Yom Kippur” (sustained, high-intensity)
high-intensity battle, soldiers will present with com-    war may result in large numbers of combat stress
bat stress disorders, but in low-intensity or nonbattle   cases, while a “Vietnam” (low-intensity, garrison)
conditions, “garrison neuropsychiatric” casualties        war may produce “nostalgic” disorders. Military
will predominate. As combat intensity increases           psychiatry must have the flexibility to respond to
the number of combat stress casualties also increases.    either circumstance and to the possibility of nuclear,
There are not yet enough data to predict with con-        biological, and chemical (NBC) warfare. The latest
fidence the incidence of garrison stress casualties,      U.S. Army neuropsychiatry doctrine2,27–29 addresses
but the subject is treated extensively in Chapter 3,      the distribution of mental health resources to re-
Disorders of Frustration and Loneliness.                  spond to all scenarios.
   This generalization is, however, an oversimplifi-         Both traditional combat stress casualties (“com-
cation that does not take into account the numerous       bat fatigue,” “battle shock,” or “combat reaction”)
factors that protect a soldier from or predispose him     and low-intensity combat casualties (“nostalgic”)
to breakdown. The protective factors include unit         will occur in most protracted conflicts. The tradi-
cohesion, good leadership, experience with and            tional casualties will occur proximate to the battles
confidence in one’s weapons, absence of fatigue,          and the nostalgic will occur among rear-area troops
and prior exposure to combat. Predisposing factors        or when combat troops rotate back to rear areas.
would be the negatives of these. The progress and         The principles of combat psychiatry were devel-
type of battle also influence the rate of stress casu-    oped during World War I and refined during World
alties. Advancing victorious and retreating de-           War II and the Korean conflict, but not until the
feated armies usually have few stress casualties. In      Vietnam conflict were nostalgic casualties recog-
static warfare, with much indirect fire from heavy        nized as a serious cause of ineffectiveness in U.S.
artillery barrages or aerial attack, stress casualties    forces. It seems appropriate to address first the
are increased.15                                          traditional combat stress casualties that predomi-
   A recently identified factor found to be signifi-      nate in mid- to high-intensity conflicts. Low-inten-
cant in producing Israeli stress casualties in the        sity combat stress casualties will be addressed in
1973 Yom Kippur War is the presence of concurrent         Chapter 3, Disorders of Frustration and Loneliness;
nonspecific stress.26 The stress usually is a product     NBC combat stress casualties in Chapter 4, Neuro-
of situations in the soldier’s nonmilitary life; for      psychiatric Casualties of Nuclear, Biological, and
example, pregnancy of spouse, birth of offspring,         Chemical Warfare; and high-intensity combat stress
an ill relative, or financial adversity.                  casualties in Chapter 5, Psychiatric Principles of
   Many of these factors would be unknown to the          Future Warfare, of this textbook.


                                                 TREATMENT

   The principles of forward treatment were devel-        ciples were not applied. This usually occurred
oped and refined during the mid-intensity battles         when the conflict took on the characteristics of
of World War I, World War II, and the Korean              high-intensity battles, overwhelming forward medi-
conflict. For the casualties of such conflicts they       cal resources and forcing evacuation of casualties,
worked reasonably well. Treatment failures, when          or the characteristics of low-intensity battles, mak-
they occurred, were generally because the prin-           ing evacuation more feasible. With future battle


                                                                                                               43
War Psychiatry


circumstances uncertain, all medical personnel and          these labels can be useful, there are two compelling
unit leaders should become familiar with the tradi-         reasons to avoid making judgments early in treat-
tional principles of combat psychiatry and be pre-          ment about the presumed etiology and prognosis of
pared to adapt them to a variety of evolving situa-         individual cases of battle fatigue. First, the initial
tions, ranging from low-intensity insurgency actions        appearance and symptoms of soldiers may reveal
to high-intensity NBC actions.                              little about the cause or the course of their condi-
   The treatment of combat stress casualties de-            tion. Second, in time of battle and during the initial
pends on a variety of circumstances impossible              interviews, it may not be possible to obtain com-
to foresee until actual engagement with the                 plete and accurate information about the casualty’s
enemy. These circumstances include the type of              personal history. Therefore, all battle fatigue casu-
battle, the length and location of the war, the type        alties should receive immediate treatment guided
of soldier, the manifestations of ineffectiveness, the      by the expectation of rapid and full recovery, as far
type of treating person, and other unforeseen               forward as possible without jeopardizing the mis-
conditions.                                                 sion. As the soldier improves or arrives at a new
   The treatment setting depends on the type of             echelon of care, the label should be modified ac-
war, the type of evacuation (if any), and the avail-        cordingly.
ability of resources. Possible treatment settings               Casualties are labeled as light or heavy battle
range from the active battle scene to a medical             fatigue casualties to designate their initial treat-
center in the United States, as shown in Table 2-3.         ment. Battle fatigue cases designated as “light”
   Treatment of battle fatigue cases begins with            continue on duty or rest in the unit. Treatment can
their identification. Battle fatigue casualties should      be provided through buddy aid, unit medics, or
never be referred to as psychiatric casualties. The         leader actions, or can be self-administered. Most
term battle fatigue is more appropriate because it          soldiers exposed to combat will experience light
suggests a normal response to the extreme mental            battle fatigue at some time. Light battle fatigue
and emotional demands of combat.                            includes the normal, common signs of battle fa-
   Treatment of identified combat stress casualties         tigue, as shown in Exhibit 2-2. It also includes the
begins with casualty sorting, as shown in Figure 2-         warning or more serious symptoms, as shown in
1. Battle fatigue cases may be labeled to indicate          Exhibit 2-3, if the symptoms respond quickly to
where they are being treated, with labels such as           treatment. Even soldiers with relatively serious
light, heavy, duty, rest, hold, and refer. These labels     symptoms can often continue on duty and do not
do not indicate the presumed cause of the symp-             necessarily need immediate medical attention. If
toms or the likely response to treatment; they merely       the symptoms continue despite rest, the soldiers
designate where the soldier is being treated. While         should be sent to their unit surgeon or physician


TABLE 2-3
PSYCHIATRIC ECHELON CARE

Site                                       Level                                                Holding Time

Battle                                     1. Self/buddy                                              4h
                                           2. Small unit leader                                       4h
                                           3. Medical aidman                                          4h
Forward area                               4. Battalion aid station                                   8h
                                           5. Brigade clearing station                                3d
Rear area                                  6. Division clearing station                               4d
                                           7. Special treatment hospital                            1–2 wk
                                           8. Evacuation hospital                                   1–2 wk
Communication zone                         9. Hospital outside combat zone                         wk–mo
Continental United States                 10.   Medical center in United States                   Indefinite



44
                                                                                 Traditional Warfare Combat Stress Casualties



                                                           Battle Fatigued Soldier




                                                           Sorted by Leader, Medic



                                        Light                                                  Heavy

                                                                          Fails to
                                                                         Improve
                                                                                              Sorted by
                     Continue on Duty           Rest in Unit                             Physician, Physician
                                                                                      Assistant, or Mental Health
                                                                                                 Officer



                               Treated and Released                                   Battle Fatigue Casualty




                            Duty                    Rest                             Hold                    Refer




                                                Reevaluate                      Reevaluate                Reevaluate




                                                                                Reclassify MOS                Evacuate
                                   Return to Duty

                                   Evaluate

             MOS: Military Occupational Specialty

Fig. 2-1. Diagram of sorting choices and labels for battle fatigue cases according to severity of symptoms and unit
situation. Reprinted from US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA;
September 1994. Field Manual 22-51: 5-7.


assistant at routine sick call and treated as a heavy            continual medical attention and are sent to their
battle fatigue casualty.                                         unit’s nonmedical combat service support elements
   In contrast to light battle fatigue, heavy battle             for brief rest and light duties. Hold cases are heavy
fatigue requires immediate medical attention. In                 battle fatigue casualties who are held for treatment
addition to failure to respond to initial treatment,             at the triage medic’s own medical facility if the
the “heavy” label can indicate that the soldier’s                tactical situation and the symptoms permit. Refer
symptoms disrupt the mission of the unit, or that                cases are those who must be treated at a medical
the casualty has a medical condition such as heat                facility that is more secure or better-equipped than
stroke that may require emergency treatment.                     the triage medic’s own facility due to the tactical
   The triage medic sorts soldiers experiencing                  situation or the casualties’ symptoms. Refer cases
heavy battle fatigue based on where they can be                  are relabeled as hold cases when they reach a medi-
treated, as indicated by the labels duty, rest, hold,            cal facility where they can be treated.
and refer. Duty cases are heavy battle fatigue                      The decision to label an individual soldier as a
casualties who are treated immediately by a physi-               case of duty, rest, hold, or refer battle fatigue is not
cian, physician assistant, or mental health officer              a simple one. Rather, it must be guided by a combi-
and returned to duty. Rest cases do not require                  nation of factors, including the soldier’s character-


                                                                                                                          45
War Psychiatry



     EXHIBIT 2-2
     NORMAL, COMMON SIGNS OF BATTLE FATIGUE


     Physical Signs*                                              Mental and Emotional Signs *
        Tension: aches, pains; tremble, fidget, fumble               Anxiety: keyed up, worrying, expecting the
         things.                                                      worst.
        Jumpiness: startle at sudden sounds or move-                 Irritability: swearing, complaining, easily
         ment.                                                         bothered.
        Cold sweat; dry mouth; pale skin; eyes hard to               Difficulty paying attention, remembering details.
         focus.                                                      Difficulty thinking, speaking, communicating.
        Pounding heart; may feel dizzy or light-headed.              Trouble sleeping; awakened by bad dreams.
        Feel out of breath; may breathe too much until               Grief: tearful, crying for dead or wounded
         fingers and toes start to tingle, cramp, and go              buddies.
         numb.
                                                                     Feeling badly about mistakes or what had to be
        Upset stomach; may throw up.                                  done.
        Diarrhea or constipation; frequent urination.                Anger: feeling let down by leaders and others in
        Emptying bowels and bladder at instant of                     unit.
         danger.                                                     Beginning to lose confidence in self and unit.
        Fatigue: feel tired, drained; takes an effort to
         move.
        Distant, haunted (“1000 yard”) stare.
     * Many soldiers have these signs, yet still fight well and do all their essential duties.
     Source: US Department of the Army. Battle fatigue: Normal, common signs; What to do for self & buddy. US Army Training
     and Audiovisual Support Center, GTA 21-3-4, June 1986. GPO Stock No. 1991–303-121/49293.




istics, the stressors involved, the soldier’s response            is strengthened when the casualty’s small unit com-
to treatment, the tactical situation, and the resources           rades can visit him and indicate that they need him
available. Furthermore, once the decision is made,                and will welcome him back. Treatment is kept
it may need to be modified to reflect changing                    simple to foster this expectancy by giving the mes-
conditions. Successful treatment of combat stress                 sage that nothing is seriously amiss. Glass30 has
casualties prevents unnecessary evacuation and                    characterized Salmon’s approach as a three-tiered
shifts battle fatigue casualties from refer to hold,              (division psychiatrist, front-line specialized hospi-
from hold to rest, and from rest to duty. The lowest              tal, rear-area specialized hospital) related echelon
level of treatment likely to be effective should be               treatment system that takes into account individual
administered, since holding or evacuating casual-                 and battlefield hindrances to recovery and maxi-
ties may delay or prevent recovery.                               mizes the return of the casualty to combat. A
   Since World War I, the appropriate use of the                  further aspect of this echelon approach to treatment
principles of forward treatment has resulted in the               calls for soldiers evacuated rearward to be screened
return of 40% to 90% (optimal conditions) of combat               at a central collecting point from which they may
stress casualties to combat duty within days.7 For-               still be returned to duty if further rearward move-
ward treatment consists of immediate, brief, simple               ment is inappropriate (centrality).
interventions (immediacy, brevity, simplicity) such                   In practice this approach requires four essential
as rest and nutrition in a safe place as near the battle          elements: (1) a safe place near the battle area (ref-
lines as possible (proximity), with an explicit state-            uge), (2) a treating person (therapist), (3) time for
ment to the soldier that he will soon be rejoining his            restoration of physiological needs (rest), and (4) a
comrades (expectancy). These measures create in                   method for returning to one’s unit (return). Each
the soldier a sense that he is only temporarily dis-              element is critical to the process; and each is poten-
abled by fatigue and further create the expectancy                tially jeopardized by modern, high-intensity war-
that he will quickly return to duty. This expectancy              fare.


46
                                                                           Traditional Warfare Combat Stress Casualties



   EXHIBIT 2-3
   MORE SERIOUS SIGNS OF BATTLE FATIGUE


   Warning signs that deserve special action, but do NOT necessarily mean a “casualty” who must be evacuated.
   Even the normal, common signs become “more serious” if:
     They still disrupt the mission after you take action.
     They don’t improve somewhat after good rest.
     The soldier is acting very differently from the way he or she usually does.
   More Serious Physical Signs
     Can’t keep still; constantly moving around.
     Flinching or ducking at most sudden sounds and movement.
     Shaking (of arms or whole body); cowering in terror.
     Part of body won’t work right, with no physical reason:
        Can’t use hand, or arm, or legs.
        Can’t see (or hear, or feel), partially or at all.
     Freezing under fire, or prolonged, total immobility.
     Physical exhaustion; slowed down, just stands or sits.
     Vacant stare, “spaced out”; staggers, sways when stands.
   More Serious Mental and Emotional Signs
     Rapid talking; constantly making suggestions.
     Arguing, starting fights; deliberately reckless action.
     Inattention to self-care, hygiene; indifference to danger.
     Memory loss:
        For orders; for military skills; for a bad event;
        For time, place, what’s going on; or for everything.
     Severe stuttering, mumbling, can’t speak at all.
     Afraid to fall asleep for fear of terror dreams, danger; unable to stay asleep even in a safe area.
     Seeing or hearing things that aren’t really there.
     Rapid emotional shifts; crying spells; wishing was dead.
     Social withdrawal; silent or sulking; prolonged sadness.
     Apathetic; no interest in food or anything else.
     “Hysterical” outburst, frantic or strange behavior.
     Panic running under fire.

   Source: US Department of the Army. Battle fatigue: ‘More serious’ signs; Leader actions. US Army Training and
   Audiovisual Support Center, GTA 21-3-5, October 1983.




   Both for historical reasons and because psychiat-           (hypochondriasis/following prior combat), (4)
ric interventions are most successful in handling              chronic anxiety-depressive syndromes (old sergeant
the typical stress casualties of mid-intensity, con-           syndrome), and (5) atypical syndromes (occurring
ventional conflicts, they will be addressed first.             at all levels of exposure).
Such casualties may be grouped roughly in order of                Although these symptom constellations may ap-
increasing exposure to combat as follows: (1) nor-             pear at any level of combat intensity, they have been
mal battle reactions (not counted as a casualty), (2)          most apparent in World War I and World War II,
acute anxiety syndromes, (3) precombat syndromes               now considered to be mid-intensity conflicts, based


                                                                                                                    47
War Psychiatry


on frequency of battle pulses in a 24-hour period
and levels of casualties sustained.
   The bulk of combat stress casualties typically
occur in the first week of exposure to combat (80%)
and present with severe anxiety or with physical
symptoms that reflect fear and anxiety. 31 Such
symptoms may consist of one or more of the follow-
ing: rapid heart rate (DaCosta’s “soldier’s heart” of
the U.S. Civil War), profuse sweating, muscle ten-
sion, shaking and cramps, nausea, vomiting, diar-
rhea, and involuntary defecation and urination. At
times the casualty may present with minimal anxi-
ety but with complaints that render him unable to
function such as loss of the use of muscles (paralysis
or aphonia) or disturbances of sensory organs (blind-
ness, deafness, anesthesia, or pain). As with the
anxiety symptoms, the unstated but implicit mean-
ing is clear: the soldier has a recognizable medical
condition that, he believes, prevents him from fur-
ther engagement in combat and is thus an honor-
able escape from battle.
   Although malingering might be suspected in
some cases, most soldiers present with uncon-
sciously derived symptoms similar to those found
                                                         Fig. 2-2. William C. Menninger, from a family of famous
in the neurotic conditions of civilian life. During
                                                         psychiatrists, was Neuropsychiatry Consultant to the
World War I and thereafter, able clinicians have         Army Surgeon General during most of World War II.
found that interpreting this temporary defection as      Among many accomplishments, he arranged for appro-
malingering only forces the soldier to strengthen,       priate treatment of psychiatric casualties and established
usually unconsciously, the symptoms to disprove          a psychiatric nomenclature that formed the basis for the
such an allegation, making restoration to duty less      first Diagnostic and Statistical Manual of the American
likely.                                                  Psychiatric Association.

Normal Reactions to Combat
                                                         psychological (mutism) responses to combat that
   Transient fear reactions are universal and should     led to psychiatric intervention.
not be considered pathological. In fact, such re-
sponses came to be called the normal battle reac-        Case Study 1: The Tunnel Rat
tion. During World War II a number of surveys
were made of physical symptoms experienced by                Corporal A, a 20-year-old single man who had come to
infantry soldiers in combat. According to several        Vietnam by troopship in late February 1966 was brought
                                                         to the 25th Infantry Division Base Hospital in late March
studies reviewed by Menninger,32 (Figure 2-2) and
                                                         1966 by his platoon sergeant and lieutenant in a mute and
summarized by the author, of infantry soldiers in        unresponsive, but tense and alert condition. On a “search
combat for any length of time, approximately 50%         and destroy” mission he had volunteered as a “tunnel rat”
would experience a pounding heart, 45% a sinking         to enter part of the extensive Viet Cong underground
stomach, 30% cold sweat, 25% nausea, 25% shaki-          tunnels near Cu Chi, where the 25th had its base camp.
ness and tremulousness, 25% stiff muscles, 20%           Jumping into an 8-foot hole, he found himself facing a Viet
vomiting, 20% general weakness, 10% involuntary          Cong (VC) soldier , who was lying in a side tunnel. The VC
bowel movement, and 6% involuntary urination.            aimed a pistol at CPL A’s head and pulled the trigger. The
Menninger refers to this group of symptoms as the        pistol misfired, and CPL A’s platoon sergeant shot the VC
                                                         in the head with several blasts from his M16 rifle, splatter-
normal battle reaction. The author will detail a
                                                         ing CPL A with blood and brain tissue. Examination at the
number of cases from his experience as a division        base hospital revealed no wound, other than a small facial
psychiatrist in Vietnam to illustrate various kinds      scratch from a bone fragment, despite CPL A’s gory
of stress reactions to combat. The following case        appearance. The 25th Division psychiatrist (the author)
illustrates physiological (involuntary urination) and    was called to see a “catatonic” patient.


48
                                                                            Traditional Warfare Combat Stress Casualties


    The psychiatrist saw CPL A alone in a shielded area of    ness. Reexamination in better light revealed a small tear
the hospital tent (the “Mental Hygiene tent” had not yet      in his field jacket, which had been covered by his MP belt.
been erected), and a repeat physical exam was per-            Removing the jacket and undershirt revealed a small
formed. During the examination the physician soothingly       puncture wound of the left lower back. A diagnosis of
pointed out that CPL A was safe and that he had normally      hemorrhagic shock was made, and the Division Psychia-
functioning body parts and the ability to cooperate in the    trist accompanied the patient to the division surgical unit
examination. He was then told that his “vocal cords,”         where the patient received blood transfusions. Subse-
which had been temporarily “stunned,” were back to            quently he was evacuated to a field hospital where ab-
normal and that he could say anything he wished. After a      dominal surgery revealed massive hemorrhage from a
brief hesitation CPL A broke into a long, pressured explo-    ruptured spleen.
sion of profanity, ending with, “Damn, I peed my pants.”          Comment: This patient had typical symptoms found in
He was told that his reactions were completely normal and     acute anxiety or fear reactions in combat: apprehensive-
that after resting that night in his own bed, he would wake   ness, sweating and peripheral vasoconstriction (produc-
up fully able to return to his usual duties tomorrow.         ing the “cold sweat”), tachycardia, and increased muscle
    Comment: The psychiatrist did not see CPL A again;        tension. The weak pulse, presumably due to impending
however, informal follow-up with the corporal’s platoon       hypovolemic shock with decreased pulse pressure, should
leader a few months later revealed that he became cheer-      have been a clue to the internal hemorrhaging. Had this
ful the following day when told that he would get a Purple    patient been uninjured, reassurance and return to his unit
Heart medal for the wound to his face. CPL A did not          would be the treatment procedure.
volunteer for “tunnel rat” duty again.
                                                                 Ranson has described a spectrum of symptom-
   The labeling of such normal reactions to battle as         atology in combat ranging from “the normal battle
abnormal can create psychiatric casualties who may            reaction” to “the pathologic battle reaction.” He
become “evacuation syndrome” patients. Such sol-              observes that:
diers are best handled by enlightened commanders
and senior noncommissioned officers (NCOs) who                   [T]he normal battle reaction is made up of a vari-
can reassure them that their responses are normal                able set of symptoms that arise from (1) moderate
                                                                 to extreme physical fatigue; and (2) extreme, re-
for the situation. Should such soldiers come to
                                                                 peated, and continued battle fear, with (a) marked
medical attention, a brief but thorough physical                 psychosomatic symptoms resulting from this fear
exam (to rule out brain injury, internal hemorrhage,             and (b) certain psychologic symptoms resulting
or spinal cord injury) followed by reassurance usu-              therefrom.33(p3)
ally suffices. The following case illustrates the need
for a physical exam.                                             Ranson describes normal psychosomatic response
                                                              patterns to combat stress to include muscular ten-
Case Study 2: The Mortar Attack Victim                        sion, “freezing” or temporary immobility, shaking
                                                              and tremors, excessive perspiration, anorexia or
   During the course of an all-night mortar attack on the     nausea, occasionally vomiting, abdominal distress,
25th Infantry Division base camp by Viet Cong guerrillas,     mild diarrhea and urinary frequency including in-
the author, as division psychiatrist, was assisting the       continence of feces or urine, tachycardia and palpi-
headquarters surgeon in treating casualties presenting        tation, hyperventilation to the point of giddiness
with minor injuries (most caused by small pieces of frag-     and syncope, weakness and lassitude, and aches
mentation devices or bruises and abrasions sustained
                                                              and pains. He also described special psychologic
when soldiers were hastily seeking shelter). A military
                                                              considerations in the normal battle reaction includ-
policeman (MP) brought his youthful fellow MP for treat-
ment of complaints of apprehensiveness. The two of them       ing combat sensitization with anticipatory anxiety,
were driving across the compound when a mortar landed         sensitization to combat noises, insomnia, dimin-
just behind their jeep, momentarily “stunning” the patient,   ished drive and initiative, irritability and increas-
who had been sitting in the back seat. The patient had        ing fear, including fear of showing fear.33
been “jarred” by the concussion but was unaware of any           This normal reaction may be mislabeled as ab-
injury.                                                       normal. This may have occurred in Israeli forces in
   Examination revealed a pale (even in the subdued light     the 1982 Lebanon War. Despite relatively low-
used to avoid targeting the dispensary tent), apprehen-
                                                              intensity combat, 23% of Israel’s total casualties
sive young man who was sweating profusely. His muscles
                                                              were labeled as psychiatric. Israel, following the
were tense, and his skin was cool and clammy (“cold
sweat”). He had no complaints of pain and no apparent         1973 Yom Kippur War, had devised a system of
injury; however, his pulse was rapid and weak (low pulse      early identification of psychiatric casualties with an
pressure). He was allowed to rest, but his condition          increased expectancy that such casualties would
deteriorated with development of marked apprehensive-         occur.10 Furthermore, by labeling such casualties


                                                                                                                      49
War Psychiatry


“combat reaction,” Israeli mental health personnel       nial remains the predominant, underlying mecha-
created an expectancy that combat alone would            nism in such patients with manifestations such as
create such casualties. Early in World War II Ameri-     phantom limb, amnesia, confabulation, reduplica-
can medical personnel, by eliminating soldiers who       tion, and other often bizarre responses. These are
exhibited symptoms of anxiety, had created a simi-       discussed in Chapter 14, Disabling and Disfiguring
lar expectancy that was further compounded by the        Injuries.
evacuation of such soldiers out of combat. Manage-          In summary, it has been shown that the normal
ment, therefore, requires informing the soldier that     psychological reactions to combat when inappro-
his symptoms, while calling for rest, are not a rea-     priately labeled and evacuated lead to actual dis-
son for evacuation.                                      ability. Such inappropriate evacuation of the lightly
   Inappropriate evacuation of the lightly wounded       wounded likewise often results in psychiatric de-
not only creates an evacuation syndrome but often        compensation.
results in a psychiatric casualty. Lightly-wounded
Israeli soldiers in the 1973 Yom Kippur War were         Pathological Reactions to Combat
found to respond similarly to psychiatric casualties
when evacuated from battle,21 that is, they devel-          Ranson33 argues that these normal responses to
oped complaints that prevented them from return-         battle shade into pathological responses usually as
ing to combat. These complaints were both physical       prolonged or exaggerated normal responses. Ex-
(eg, pain, weakness) and psychological (eg, anxiety,     amples include the immobilized soldier who re-
fear, depression). As seen in Bowman’s11 listing of      mains so for several hours or when the immobility
psychiatric casualties in Vietnam (see Exhibit 2-1), a   poses a danger to himself or his comrades; auto-
significant number were wounded soldiers. Wound-         nomic overactivity symptoms that persist long after
ing always elicits psychological responses, though       the danger; noise sensitization that generalizes to
not always negative. During World War II, soldiers       innocuous noises; lassitude that becomes persistent
spoke with elation of receiving “the golden wound,”      apathy and depression; and fear that develops into
one that would honorably excuse the soldier from         panic. Such symptoms in response to the threat of
battle but not produce permanent disability.             death are normal and virtually universal. A variety
Bowman’s patients, for instance, developed symp-         of personal and interpersonal interactions can re-
toms as the time drew near for them to return to         sult in the transformation of the normal battle reac-
combat. Such symptoms were usually physical              tion into a pathological battle reaction. Also, if the
complaints—pain in healed wounds, weakness, and          soldier lacks the adaptive capacity to handle the
even frank conversion reactions.                         anxiety, it may be expressed through mental de-
   In treating the lightly wounded, it is important to   fense mechanisms as conversion or dissociative re-
treat forward and attempt to avoid rearward evacu-       actions.
ation. If evacuation has occurred, “forward evacu-
ation” nearer the battle area with application of the    Acute Anxiety Syndromes
principles of combat psychiatry was found effective
by the Israelis in the 1982 Lebanon War.9 The more          As suggested earlier, the symptoms in such cases
seriously wounded who have recovered to the point        are the same as those occurring in the normal battle
of return to combat must be managed with the same        reaction—basically exaggerated physiological re-
expectancy approach utilized with recognized             sponses of autonomic overactivity combined with
psychiatric casualties.                                  mental states of fear or apprehension.
   By contrast, severely disabled soldiers—those            Conversion reactions generally involve interfer-
with amputations, severe thoracic or abdominal           ence with voluntary muscle (paralysis, convulsions,
wounds, widespread burns, blindness, and brain or        muteness, ataxia, movement disorders) or sensory
spinal cord injuries—generally cannot be returned        (anesthesia, blindness, deafness, pain) function.
to combat; thus early psychiatric treatment is often     Psychogenic loss of smell or taste is rare; however,
needed in long-term treatment centers to help the        complaints of smelling burning flesh, napalm, or
veteran adjust to the disability. A variety of psycho-   other battle smells often occur in chronic post-trau-
logical responses similar to those described by          matic stress disorders. The paralyses frequently
Kubler-Ross34 in the dying patient will be encoun-       involve organs important for combat functions, for
tered: denial, anger, bargaining, depression, and        example, paralysis of the trigger finger. Similarly,
acceptance. Weinstein and Kahn, 35 in their study of     pain complaints may prevent combat function.
brain-injured and amputee patients, found that de-       Helmet headaches were briefly a problem in some


50
                                                                             Traditional Warfare Combat Stress Casualties


units in Vietnam, because this equipment was re-               him to believe that he was alleviating suffering. No follow-
quired for soldiers on ambush or perimeter patrols.            up was available, but similar inappropriate evacuations
It was the author’s experience that the symptom                during World War II led to chronic disability. The appro-
disappeared when soldiers were told that they                  priate treatment was rest, reassurance, and return to
                                                               duty.
would have to do such duty without head protec-
tion.
                                                                  Dissociative reactions classically consisted of
   Conversion symptoms appear to occur more fre-
                                                               somnambulism, amnesia, fugue, and multiple per-
quently in medically naive and medically sophisti-
                                                               sonality. The following example from Vietnam
cated populations. In the latter cases symptoms
                                                               illustrates the manner by which somnambulism
often consist of pain and weakness that may
                                                               became an evacuation syndrome in the unit to which
be difficult to distinguish from neurological or
                                                               the author was assigned.38
musculoskeletal dysfunction. In the former cases,
naive populations may present with classical
                                                               Case Study 4: The Sleepwalkers
hysteroepilepsy, hemipareses, and stocking and
glove anesthesias. Such symptoms were observed,                    A brief “epidemic” of somnambulism occurred in 1966
for example, in the Iraq-Iran War among Iranian                during the early deployment of the 25th Infantry Division
soldiers.36                                                    in Vietnam. The engineer battalion surgeon had sought
   Because conversion reactions indicate a relative            the help of the division psychiatrist to treat soldiers who
breakthrough of primary process thinking, though               were developing sleepwalking (somnambulism). The
disguised, limited, and controlled, treatment may              battalion surgeon was surprised to find a rash of such
be more prolonged than with anxious and fatigued               cases in his relatively small unit. The initial case had
casualties unless corrected early. World War I U.S.            presented with a history of sleepwalking during childhood
                                                               with occasional episodes of falling and injuring himself.
Army psychiatrists reported substantial success with
                                                               His family had been completely dominated by his symp-
strong positive suggestion and simple explanation              toms, being forced to move to a one-story house, placing
when given early and far forward (today called                 a high fence with locked gates around the house, and
“immediacy, proximity and expectancy”).37 In some              making other arrangements for his safety. His sleepwalk-
cases hypnotherapy and abreactive treatments may               ing, however, had disappeared until arrival in Vietnam.
be indicated. The following case, known to the                 Following the example of the soldier’s parents, the battal-
author, illustrates severe anxiety and stuttering in           ion surgeon moved the patient’s sleeping area to the
response to combat.                                            center of the base camp to prevent him from wandering
                                                               into the minefields that surrounded the base camp.
                                                                   This environmental manipulation appeared to suc-
Case Study 3: The Stutterer                                    ceed; however, in the subsequent two weeks three more
                                                               soldiers reported with complaints of sleepwalking. The
   Following an all night mortar attack on the 25th Infantry   battalion surgeon was running out of space in which to
Division base camp in which several soldiers died and          house these men. The division psychiatrist observed that
nearly 100 were wounded, a 20-year-old radio operator          the engineering battalion was located along one perim-
for hospital communications complained of the sudden           eter of the base camp on the side where a pro-Viet Cong
onset of severe stuttering as well as anxiety. On exami-       village had been located and from which sniper fire was a
nation the soldier appeared as a lanky, blond youth            regular occurrence at night. There had also been rumors
wearing glasses, stuttering, and displaying startle reac-      of incidents in other camps during which “sappers” (infil-
tion to outgoing artillery rounds. The soldier had a history   trators) had in nighttime forays cut the throats of sleeping
of briefly suffering from stuttering at about age 5 years      soldiers. The perimeter area had been cleared of trees,
when he first left home to start school (kindergarten).        had been heavily mined, and had nighttime perimeter
Physical exam was normal.                                      guards (only subsequently was it learned that a very
   The author, as division psychiatrist, arranged for the      extensive tunnel system was the source of much of the
soldier to be temporarily relieved from radio operator duty    sniper fire).
but hinted that if symptoms persisted the soldier would            The division psychiatrist recommended that the sleep-
have to revert to his primary specialty of general infantry-   walkers be told that the new policy was to place sleep-
man. After one day the soldier’s symptoms began to             walkers on permanent nighttime perimeter guard duty
abate: however, the division surgeon, a kindly and sympa-      (considered unsafe) or generator maintenance duty (con-
thetic man, evacuated the soldier from the division while      sidered undesirable) to protect them from wandering into
the psychiatrist was away on a MILPHAP (Military Public        the minefield at night.
Health Action Program) mission to a local Vietnamese               Comment: This intervention consisted of preventing
hamlet. The soldier never reurned to the division.             the sleepwalking from allowing the soldiers to escape
   Comment: This case reveals the failure of treatment         hazardous duty. When this was accomplished, the “epi-
because of a physician’s humanitarian instincts’ leading       demic” abruptly ceased.


                                                                                                                        51
War Psychiatry


   Multiple personality has rarely occurred in a                 Case Study 6: The Wild Week
combat setting, and current evidence suggests child-
hood sexual trauma as the etiologic agent in most                   In 1966, a 32-year-old staff sergeant with 12 years of
cases. Soldiers presenting themselves as suffering               active duty was brought to the attention of the Shore
from multiple personality in combat settings are                 Patrol by prostitutes on Tu Do Street in Saigon because of
most often malingering to escape punishment for                  his unresponsive behavior. In a confused state he was
being absent without leave (AWOL). Such presen-                  taken to the Third Field Hospital where it was established
                                                                 that physical examination was normal except for mental
tations tend to wax and wane with mass media
                                                                 status. Mental status examination by the author revealed
publicity of cases.                                              a thin, balding Caucasian man who was dressed in soiled
   Amnesia is often attributed to concussion by the              civilian clothing. He smelled of urine but not alcohol. He
patient with more or less justification. Amnesia is              appeared perplexed and asked where he was. He gave
sometimes used as an excuse to account for AWOL                  the date as November 5, 1965 (it was later established
or other temporary dereliction from duty. Con-                   that he had left the United States on this date and that he
fronting the soldier with disbelief is generally not             was in the last month of his tour in Vietnam). He was
useful. The proper therapeutic stance in most cases              oriented to person and, except for amnesia since coming
is to reassure the soldier that his memory will re-              to Vietnam, mental functions were essentially normal. He
                                                                 was sedated (Librium) and put to bed.
turn but, if not, that the amnesia will not prevent
                                                                    The following day his memory had returned up to about
him from fulfilling some role in combat. A day                   1 week before. He stated that his last memories were of
might be spent teaching the soldier to load, aim, and            coming to Saigon with a convoy from a nearby village,
fire a rifle, for example, with the clear implication            Dian, where he was a mess sergeant with an infantry
that no matter what his original specialty was, he               company. Although he was technically AWOL, the unit
can be an infantryman. The following case illus-                 was tolerant of his absence because he was close to
trates the efficacy of such suggestion in soldiers               the end of his tour and his replacement had already
with psychological amnesia.                                      arrived. The company commander merely thought that
                                                                 “he was having a good time in Saigon.” The commander
                                                                 also stated that the staff sergeant was a devout,
Case Study 5: The Amnesiac                                       nondrinking, married man who attended chaplain’s ser-
                                                                 vices regularly and that “sowing a few wild oats” might be
   In 1968, a 19-year-old single male was evacuated to           helpful to him.
Walter Reed Army Medical Center in Washington, D.C.                 Although all of the details of the missing week were
from a nearby post at which he was in training as a              never discovered, it appeared that the staff sergeant, who
paratrooper. He was scheduled to graduate from “jump             had reportedly never been unfaithful in his 10 years of
school” and had received orders for Vietnam. Following           marriage, succumbed to the charms of a prostitute. En-
his final parachute jump, he was found unconscious, was          sconced in a hotel room, he spent a month’s pay with a
hospitalized locally, and was found to have no neurologi-        succession of prostitutes accompanied by liberal intake of
cal deficit other than amnesia for his entire life. He did not   the local beer, “33” (“Bah moui bah” in Vietnamese). After
know his name and did not recognize friends and family           an additional day of rest during which he was reassured
members. At Walter Reed, where the author was super-             that such an incident was unlikely to occur again if he
vising the case, the soldier underwent Amytal interview          avoided alcohol and prostitutes, he was discharged and
without remission. Collateral history including early de-        returned to his unit where he remained an uneventful 2
velopment was not impressive of psychogenic trauma.              weeks until returning to the United States.
The soldier was told that there would be another attempt            Comment: It is sometimes difficult to determine how
at Amytal; but, that if it failed, he would have to return to    much intoxication contributes to the amnesia in such
basic training and then be sent to Vietnam. It was               fugue cases. In addition to protecting him from guilt-
suggested during Amytal interview that his memory would          inducing memories, the amnesia also protects the patient
begin returning and should be completely normal within a         from having to recount embarrassing behavior.
week.
   Comment: Within a week his memory had returned,
and he was sent on amended orders to Vietnam but not to          Precombat Syndromes
an airborne unit. Although this is not a true combat
breakdown, it does have characteristics of a precombat              Psychological adjustment to combat may begin
syndrome.                                                        long before an actual battle. It begins as soon as the
                                                                 possibility of going into combat is seriously enter-
  Fugue states in military settings are often accom-             tained. It is even possible to conceive of those who
panied by alcohol or drug abuse and licentious                   burned their draft cards as engaging in a long-term
behavior, frequently in contrast with the soldier’s              avoidance maneuver. When the author arrived in
usual personality.                                               Hawaii as the new 25th Infantry Division Psychia-


52
                                                                     Traditional Warfare Combat Stress Casualties


trist, he found the topic of most immediate concern     nearly healed wounds. On a more conscious level,
was whether the 25th Division would stay in Ha-         some individuals report with broken spectacles and
waii as a “strategic reserve” or go to Vietnam. Al-     dentures or, more rarely, with self-inflicted wounds.
though no official confirmation was given until the        Failing to understand the nature of these symp-
day prior to departure, it became increasingly evi-     toms, some commanders have regarded such sol-
dent that the next assignment would be in Vietnam.      diers as malingerers and have taken a punitive
The majority of soldiers began preparing for com-       approach to deterrence of “goldbricking.” One
bat duty. Some took courses in the Vietnamese           support commander in the 25th Infantry Division
language or read books on tropical diseases, in-        ordered that sick call be held outside, exposed to the
sects, and reptiles. Others purchased hunting knives,   weather, which was often inclement, with daily
special water-repellent clothing, and enormous          rains and a hot tropical sun. Unable to gain the
amounts of soap because there were rumors of a          reassurance that nothing serious is wrong and the
shortage. Exercising became fashionable. This           support from the physician, such soldiers may be-
somewhat compulsive behavior served its purpose.        come demoralized and more subject to combat
A soldier who is busy learning a language, practic-     breakdown.
ing with a knife, or running to increase lung and leg      The proper approach to such soldiers is a thor-
power does not have as much time to think about         ough physical examination (especially because some
being killed, crippled, or separated from loved ones.   illnesses, particularly hepatitis, are of insidious onset
   A small minority of soldiers, however, con-          with vague complaints and exacerbation of
sciously or unconsciously sought to evade combat        characterological tendencies) followed by reassur-
duty. Some wives appeared at clinics describing         ance that all is well and expressions of gratitude to
medical conditions in themselves or their children      the soldier for adhering to duty, in spite of pain, for
for which they felt justified in having their hus-      his comrades and country.
bands near. Some soldiers appeared in dispensa-
ries or clinics having discovered physical defects in   Chronic Anxiety-Depressive Syndromes
themselves that they thought would make them
vulnerable in combat. These defects included de-           Continuous or long-term exposure to the lethal
creased hearing, a childhood heart murmur, mild         combat environment in which the emergency “fight-
hypertension, a “trick knee,” and even simple obe-      flight” 40 response is repeatedly invoked eventually
sity. A few individuals inflicted wounds on them-       results in performance decrements in virtually ev-
selves. In one incident, a medical corpsman anes-       ery combatant. Such repeated physiological arousal
thetized a friend’s foot with the local anesthetic,     gradually has a conditioning effect on voluntary
Xylocaine, then shot it with an M-16 rifle. Several     muscles (increased tension, tremors), involuntary
soldiers claimed to be homosexual because this          or autonomic responses (tachycardia, increased
condition called for separation from the military.      blood pressure, increased perspiration and respira-
Others committed military crimes (usually AWOL          tion), and cognitive responses (anxiety, fear). The
or insubordination) in an attempt to achieve medi-      loss of comrades not only provokes anxiety about
cal or administrative separation from the service.      one’s own mortality but also represents a loss of
Their usual comment in the stockade was, “I just        social reinforcement with subsequent anger and
want out. Any kind of discharge will do.” These         depression. During World War II, Sobel41 referred
individuals were few in number, however. A more         to such casualties as “the old sergeant syndrome.”
common response was for a soldier to express relief        In analyzing the factors leading to breakdown in
to finally know for sure that he was going to Viet-     “the old sergeant syndrome,” Sobel traced the “pro-
nam and to begin preparing himself.                     gressive breakdown of the adaptive mechanisms of
   The term “precombat syndrome,” however, has          the normal soldier to the point at which his natural
generally not included these attempts to evade alto-    resources are exhausted in the struggle against his
gether duty in a combat zone. Rather, this term has     environment.”41(p145) In the loss of his defenses
been reserved for combat veterans, often with           against combat anxiety, the soldier successively
lengthy exposure to battle conditions, who on the       lost his ideals about the war (the goals of freedom
eve of combat report to medical officers with hypo-     for Nazi-held peoples and “keeping the enemy out
chondriacal or minor complaints.39 Such persons         of the United States”), his hatred of the enemy
usually believe that their symptoms are real and        (producing vulnerability to guilt), his short-term
significant. Symptoms may include headaches,            goal of being relieved from combat, his pride in
toothaches, indigestion, and worry over healed or       himself (feeling of responsibility to be courageous


                                                                                                              53
War Psychiatry


and to endure), and, finally, loss of loyalty to the              Intrigued by what could have rendered such a change,
group (chiefly through actual physical depletion of           Laughlin spent time with him and gradually pieced to-
the group from death, wounding, and illness).                 gether his history. After loss of the ship in early July 1943,
   When such repeatedly traumatized combat vet-               “the tempo of stress” did not abate but actually increased.
                                                              He continued an unusually extensive combat experience
erans emerge as psychiatric casualties, they usually
                                                              on two subsequent destroyers, each of which had sunk in
present with some variant or mixture of anxiety or            turn. Not until after the second sinking did he have his first
depressive symptoms. The “startle reaction,” for              nervous symptoms (depression and anxiety), which gradu-
instance, may represent conditioned muscle ten-               ally increased during service on the third destroyer and
sion and other physiological arousal to loud noises           after its loss. The culminating traumatic experience oc-
(as from exploding mortar, artillery, or bomb at-             curred on ship number 4 about a month prior to his
tacks). Soldiers presenting with lethargy, decreased          hospitalization. Scouting enemy shore battery positions
self-esteem, and insomnia may be responding with              that had previously been thought silenced on Southern
depression to repeated losses and fatigue from re-            Okinawa, the ship ran aground on a poorly charted ledge.
                                                              At this point the “silenced” shore batteries had suddenly
peated arousal. In one model of depression,42 the
                                                              opened up at point-blank range. Hundreds of rounds were
hormonal regulatory system of the hypothalamus                poured into the helpless ship, until the ship, riddled, dead
has become disturbed from higher cognitive and                in the water and sinking, was ordered abandoned. The
limbic (emotional) inputs. The repeated physi-                patient got off the ship and into the water but was seized
ological and cognitive arousal invoked by combat              by the tide, drawing him, despite his strongest efforts,
exposure would seem appropriate to such a model.              toward a large, burning oil slick from the stricken ship. For
The following cases illustrate some of the symp-              what seemed an eternity, he managed to stay clear of the
tomatology in such casualties.                                fire until the batteries were in fact silenced and he could
                                                              be rescued. The anorexic, apathetic, depressed patient
                                                              resulted from what Laughlin calls “the Final Straw.” 43(p11)
Case Study 7: The Fourth Ship                                     Comment: Laughlin does not discuss treatment in this
                                                              particular case; however, at that time hospitalization with
    Laughlin43 in his “case 184” describes a “severe com-     rest, sedation, insight-oriented psychotherapy or group
bat reaction following maximal stress.” Toward the end of     therapy, and sometimes abreaction, often assisted with
World War II he came across a naval petty officer whom        hypnosis or intravenous barbiturates, would have been
a physician described in disparaging terms as an inferior     the usual treatment for chronic, fixed neurotic states.
and unstable person because he had broken down in
combat. On closer examination Laughlin recognized him
                                                                 Currently, group or individual psychotherapy
as a fellow shipmate of several years before. His service
                                                              with perhaps an abreactive technique might still be
on ship as quartermaster had included “all kinds of strenu-
ous operational and combat conditions.” Laughlin could        called for, but the emphasis in treatment would be
barely recognize him: physically he had shrunk and aged       “here and now” issues (ie, work, relations with
unbelievably. When seen about 2 years earlier, he had         others). Relaxation exercises involving decondi-
been a young, strong, self-possessed person with a “rock-     tioning to noises or battle memories might be used
like quality” of strong leadership; but, now “he was an       as well; and, if nightmares and depression were
aged, palsied, defeated and pathetic figure, shriveled and    prominent, an antidepressant such as phenelzine (a
shrunken to nearly half his former weight.” Laughlin’s        monoamine oxidase [MAO] inhibitor) or imipramine
colleague who espoused character deficits as the cause
                                                              (a tricyclic) would probably be used, since they sup-
of breakdown could not have made a more unjustified
                                                              press dream sleep and hence prevent nightmares.
case for his assumptions of the etiology of such break-
downs.                                                           During World War II, return to a combat role was
    Laughlin had traveled with him from the North Atlantic    usually impossible; however, duty in noncombat
on convoy duty through the North African landing opera-       roles was generally successful. Perhaps a primary
tions finally to the Pacific for the final phase of the       factor in the inability to return “the old sergeant
campaign for Guadalcanal and the Solomon Islands. In          syndrome” patient to duty was the consensus that
the Pacific, enemy air and naval engagements had oc-          the soldier had done his part and deserved release
curred, and finally the ship was sunk during an engage-       from combat service. This is illustrated in Sobel’s
ment of great stress to the crew. Among the survivors “a
                                                              “Case 27”:
fair number developed combat fatigue and various stress
reactions.” The patient, who had been “a tower of strength”
throughout all these exigencies, continued outwardly          Case Study 8: The “Old Sergeant Syndrome”
unfazed and promptly returned to duty, volunteering for
service on another destroyer. Laughlin did not see him           A 20-year-old technical sergeant with 30 months’ ser-
again until the recently described meeting.                   vice who had been overseas 21 months and had an




54
                                                                               Traditional Warfare Combat Stress Casualties


aggregate of 310 days of combat was admitted during a           War II European and Mediterranean theaters, responsible
rest period after the battle of the Gothic Line. He had been    for returning soldiers with combat exhaustion to duty. It
thrice wounded in action. He stated that he began to have       was located close to the division medical clearing station,
abnormal battle reactions 60 combat days previously. He         was supervised by the division psychiatrist, but was staffed
said: “Now if I get in a hole I just want to stay. It bothers   entirely by line officers and NCOs and maintained a
me more now than it ever did before. This last battle my        strictly military atmosphere, including realistic combat
company was ordered to take a house, and within a few           drills.44—JWS, Ed.]
hundred yards of the place a couple of my boys got their            Comment: Given the efficacy of modern drugs in
feet blown off. We withdrew and I went to the commanding        controlling anxiety and depression, it is possible that in
officer and told him I had a feeling that I was going to get    extreme need such skilled soldiers might be returned to
it this time, and that I couldn’t take it any more. He gave     combat roles. The Israelis, always short of manpower,
me a direct order to, and it was either do that or have a bad   treated a few such casualties with tricyclic antidepres-
record, so I went.”                                             sants during the 1982 Lebanon War. Belenky, Tyner, and
    This soldier had tried on three occasions to have his       Sodetz reported that five Israeli soldiers, representing 8%
rank reduced to that of private. “You see,” he said, “as a      of the casualties treated in a third-echelon, longer-term
platoon sergeant, you are more often than not a platoon         treatment facility (total of 60 patients), received tricyclic
leader, and I couldn’t lead the men like I did before. Under    antidepressants.9 Although between one third and one
shelling I got jittery. A platoon sergeant is a leader. If he   half of the total patients returned to their original units, it
isn’t out in front it affects the men.”                         is not known whether these men were among such return-
    This soldier was born on a ranch in Texas. He stated        ees, or whether the units were still in combat. The risks of
that his father was epileptic, but that he rarely worried       returning soldiers on medication to forward deployed duty
about it and that it had not affected him in any way. His       include: side effects profiles which may interfere with
parents were harmoniously married. There were seven             psychomotor performance; impaired judgment in danger-
children, of which he was next to the oldest. He had a          ous situations; medical risks from side effects in the field
happy family life and had many friends on nearby ranches.       environment; problem with resupply; and adjusting dos-
No significant neurotic traits or conflicts were elicited in    age at far-forward medical aid stations.
the history. Enuresis, nail biting, temper tantrums, run-
ning away from home, nightmares, and somnambulism               Atypical Reactions to Combat
were all denied. He left home to work on another ranch at
the age of 14, after completing the eighth grade, and had       Atypical Anxiety/Depressive Cases
been steadily employed as a rancher until induction. He
had always been self-reliant and industrious. Single, he           Men with “pseudopsychotic reactions,” accord-
had no significant sexual conflicts.                            ing to Weinstein,45 appeared to be out of contact
    His Army career was characterized by steady promo-
                                                                with their current physical environment, being “agi-
tion after his arrival overseas. He stated that he had been
held down in the States by a lack of T/O [Table of              tated, hallucinatory, and delusional, performing
Organization] vacancies. A letter from his battalion com-       such stereotypes as digging foxholes with their
mander stated: “It is my opinion, through observation, that     fingers, taking shelter under their cots at any sud-
he has reached the end of endurance as a combat soldier.        den sound and ‘warning’ others of the approach of
Therefore, in recognition of a job well done I recommend        shells.”45(p138) In Italy most such cases occurred in
that this soldier be released from combat duty and be           troops new to battle and to the group who had been
reclassified in another capacity.” This battalion com-          freshly called up before an offensive action. Group
mander, incidentally, was noted for his unyielding attitude     ties had not only been weakly established at the
toward psychiatric casualties.
                                                                outset but also they rapidly dissolved when the
    Therapy was found to be surprisingly simple, but ad-
ministratively difficult. The most effective single thera-      group faced hostile enemy fire. Glass7 reported that
peutic tool was assigning these men within the army area,       such casualties occurred early in World War II when
out of shellfire but close enough for them to feel that they    the designation “psychoneurosis” (abbreviated
were actually helping the men “up front.” The usual             “psycho” by the soldiers) was given to most psychi-
psychotherapeutic procedures were necessary and valu-           atric (stress) casualties. This illustrates the continu-
able, but because the “old sergeant syndrome” is primarily      ing importance of not calling these soldiers “psy-
a situational reaction, altering the environment by means       chiatric casualties” today.
of reassignment is the most important aid to readjustment          The ambiguities of low-intensity, civil-war-type
and cure. At one time we had several of these men on the
                                                                conflicts can produce atypical reactions. The fol-
cadre of the divisional training and rehabilitation center.
Their work over a four-month period was beyond                  lowing two cases illustrate the buildup of personal
reproach.41(p145)                                               problems in a noncombatant in the first case and the
    [The divisional training and rehabilitation center was      issue of ethical conflicts in a new combatant in the
the facility in the rear of each division, in the late World    second case.



                                                                                                                            55
War Psychiatry


Case Study 9: Shots in the Night                                  proaching personnel. Following this incident, the com-
                                                                  manding general asked the provost marshal and division
    After several months in Vietnam, the author had begun         psychiatrist to develop an SOP for dealing with such
taking sick call with the Headquarters (HQ) Company               soldiers. The provost marshal suggested that the area be
surgeon (who had been an “on-the-job-training” psychia-           evacuated and sealed off from all but selected personnel,
trist in Hawaii) due to the lack of significant numbers of        mostly military police, then the division psychiatrist be
psychiatric casualties. He and the surgeon bunked in the          summoned to speak with him. If he continued to be a
back of the dispensary, which was adjacent to the HQ              threat and waiting was not feasible, sharpshooters would
supply tent where the supply sergeant slept. One night            shoot to wound or, if all else failed, to kill. The division
the two physicians were awakened by shots fired at close          psychiatrist agreed with most of the SOP but recom-
range. Dressed only in their underclothing and Colt .45           mended that the person called to negotiate be either a
gunbelts, the two rushed next door to find the supply             known friend of the soldier or his commander if he were
sergeant firing his M-16 rifle in the direction of the division   not hostile to the commander. The division psychiatrist
commander’s tent.                                                 would either accompany the negotiator or be in radiotele-
    The HQ surgeon, who had been treating the sergeant            phone contact with him. After the SOP became known,
for bursitis, was able to talk him into surrendering the rifle.   very few such incidents occurred.
Subsequently the sergeant’s story came out. In his mid-
40s, he had bitterly resented being sent to a combat zone         Case Study 10: The Atrocity
in his last tour of duty after having already been in combat
during the Korean conflict. Furthermore, he suffered from             Several months after the 25th Infantry Division had
bursitis of the shoulder, which he felt should have kept him      been in Vietnam, the division chief of staff requested the
from a combat assignment. Except for some general                 division psychiatrist to evaluate an infantry second lieu-
complaining, however, he had hidden his feelings. The             tenant, a West Point graduate, who had requested that his
HQ surgeon had been treating his bursitis with periodic           military occupational specialty (MOS) be changed to that
injections of hydrocortisone with only minimal relief of          of a chaplain’s assistant. When questioned, the lieuten-
pain. Increasingly despondent, the sergeant began drink-          ant, a single male in his early twenties, was found to have
ing to fall asleep at night. Finally on the night in question,    no evidence of schizophrenia, mood disorder, or any
mildly inebriated, he began firing at the general’s tent in       other significant mental affliction.
expectation that he would be shot: suicide by someone                 He had been in several “search and destroy” missions,
else’s hands.                                                     including some exposure to combat; however, he attrib-
    The following morning, the sergeant was remorseful            uted his change from a warrior to a “man of God” to a
about the event, expressed that he had no suicide inten-          recent incident. His platoon had engaged in a firefight at
tion, and asked to continue his assignment. He was                a small Vietnamese village known to be sympathetic to the
closely followed by the HQ surgeon, steroid injections            Viet Cong. After the shooting stopped, an elderly Viet-
were replaced by large dosages of aspirin, he was given           namese man was found killed with his rifle nearby. The
Librium for sleep (the only nonneuroleptic, nonbarbiturate        soldiers tied his feet to the rear bumper of a jeep and
sedative available) and he discontinued all alcohol intake.       repeatedly dragged his body up and down the main street
His mood gradually improved, and he was able to com-              of the village. This created a sense of revulsion in the
plete the remainder of his tour.                                  lieutenant but he did not stop what he subsequently
    Comment: A number of confounding factors were                 referred to as “the atrocity.” The day after the incident he
present in this case. In the biological area is a chronic pain    requested a change of MOS.
problem compounded by treatment with steroids, which are              Background history revealed that although he had
known to alter mood in many cases. In terms of intrapersonal      followed his father, now a general, into the military, he had
variables, the sergeant had a basically obsessive-com-            always been somewhat ambivalent about doing so. Also,
pulsive personality with passive-aggressive features. The         he was deeply religious, the legacy of his mother. He was
situational variables included some isolation from his            a member of a Christian sect that did not require one to be
fellow soldiers by reason of age and temperament. In              a conscientious objector, but he stated that he had always
interpersonal contacts he frequently had to respond with          felt that he could not kill another human being. The
negatives to demands for clothing and equipment. Also,            division psychiatrist recommended that the lieutenant be
the news from home was sometimes alarming with his                given his requested assignment change. In subsequent
wife’s complaints about the rebellious behavior of their          sessions the consequences of his choice were explored
teenage children. Finally, a few weeks prior to this              (one was that the chief of staff delayed his promotion
incident, the base camp had sustained an all night mortar         because he had “failed the test of battle”).
attack with numerous wounded and a few killed.                        Comment: Although the psychiatrist suspected neu-
    One outcome of this incident was the development of           rotic conflicts concerning his identity involving ambiva-
a Standing Operating Procedure (SOP) for berserk sol-             lence toward his father and the army he represented, the
diers.38 There had been several prior incidents in which          lieutenant was determined to pursue his new career.
soldiers would “go berserk” and start firing indiscrimi-          When the division psychiatrist left the division, the lieuten-
nately or barricade themselves and threaten any ap-               ant was still working as a chaplain’s assistant.



56
                                                                      Traditional Warfare Combat Stress Casualties


   With hindsight regarding the failure of the U.S.       come—and to life-long psychological and physi-
pacification and Vietnamization programs in the           ological injury if he survives. I believe that once a
Vietnam conflict, and of the serious problems of          person has entered the berserk state, he or she is
indiscipline which continued to haunt the U.S. Army       changed forever … If a soldier survives the berserk
through the period of the “hollow Army” of the            state, it imparts emotional deadness and vulner-
1970s, it is apparent that this case was not dealt with   ability to explosive rage to his psychology and a
appropriately by the chain of command. It must be         permanent hyperarousal to his physiology—hall-
noted that the lieutenant was morally and legally         marks of post-traumatic stress disorder in combat
correct in his distress, and in labeling the event “the   veterans.”47(p98)
atrocity.” Desecrating enemy dead (whether com-
batants or noncombatants) is a war crime, punish-         Self-Inflicted Wounds
able under the Uniform Code of Military Justice
(UCMJ). Officers who allow their subordinates to             Glass and Drayer44 reported that at the end of
commit war crimes without intervening or subse-           hostilities in Italy numerous incidents of self-in-
quently bringing charges are also subject to disci-       flicted wounds (SIW) occurred, presumably due to
plinary action. The severity of the disciplinary          carelessness in handling small arms captured from
action may depend on the seriousness of the viola-        the Germans and Italians, although there were some
tion. Dragging the body of an enemy already killed        who felt that underlying guilt about war behaviors
in combat is not as serious an offense as killing a       might have also played a role in these incidents.
disarmed enemy after surrender or an unarmed              The solution adopted by the command structure
civilian, but it cannot be allowed to pass without        involved ordering all captured arms turned over to
firm action by command which makes clear to all           ordnance, where they were tagged and not returned
that such misconduct must never happen again or           until time of departure for home.
worse will happen.
   It is unclear why the lieutenant did not (or was       AWOL from Battle
unable to) intervene at the time to stop the miscon-
duct. It is likely that he had reason to doubt that his      “AWOL from battle,” the informal term, sub-
higher command would back him up in enforcing             sumes charges of desertion, refusal to obey orders,
the Law of Land Warfare,46 as they do not appear to       and misbehavior before the enemy or similar mili-
have validated his sense of wrongness or assisted         tary offenses.48 Such offenders are seldom found to
him in reestablishing discipline after the fact. The      have serious mental illness. In a survey of 200 such
failure of the chain of command in Vietnam to             cases in the 85th Infantry Division in Italy from
clearly state and enforce the standards of conduct        September 13 to November 22, 1944, Glass48 found
contributed to a serious breakdown of civilized           the following characteristics of such cases:
behavior in U.S. soldiers. That, in turn, alienated
the local populations and provided ammunition to           1. The AWOL from combat rate increases with
the antiwar movement at home.                                 the duration of offensive action, a cumula-
   Shay47 has pointed out the parallels between the           tive effect of combat rather than a result of
behavior of the Greek hero Achilles in the Trojan             the intensity of battle and unlike the psychi-
War (as reported in Homer’s Iliad) and Shay’s Viet-           atric casualty rate, which rises and falls
nam veterans now suffering from post-traumatic                with combat intensity.
stress disorder. A common theme is that the loss of        2. The majority of offenders are veterans and
comrades in battle can lead to rage against the               have had relatively long exposure to com-
enemy and a “berserk state” in which the soldier              bat (only 17 of the 200 were in their first
performs feats of both heroism and moral deprav-              combat period).
ity. Like the soldiers in this example, Achilles also      3. In two thirds of cases the offense was initi-
dragged the body of his defeated foe, Hector, by the          ated at a safe rear area—returning from
heels behind his chariot. Achilles did not survive            hospitalization, during a rear area detail, or
his war, but the Vietnam veterans seen by Shay                when the unit was preparing to move for-
came home. Shay writes, “On the basis of my work              ward into combat. In this respect the casual-
with Vietnam veterans, I conclude that the berserk            ties are similar to self-inflicted wounds cases.
state is ruinous, leading to the soldier’s maiming or      4. Age and intelligence seemed to play no
death in battle—which is the most frequent out-               role.



                                                                                                                 57
War Psychiatry


 5. Three fourths admitted that fear of combat              The salvage of some AWOL soldiers was consid-
    motivated their action.                              ered feasible and, with the cooperation of the judge
 6. Only one fourth sought medical or psychi-            advocate general of the 85th Infantry Division, rec-
    atric care prior to the offense and were re-         ommendations as to whether or not the offenders
    fused evacuation. Of this group, in retro-           were reclaimable for combat duty were made.48
    spect, only one fourth (1⁄ 16 of the 200) should     Those without a chronic anxiety state who pre-
    have received such medical care. The ma-             sented a favorable attitude to return to combat were
    jority did not feel they were ill and saw            so recommended. Such individuals were held in
    AWOL as the only way to avoid combat.                the division stockade and released to their units
 7. There was no clear correlation between psy-          after several months of good conduct and work. No
    chiatric and AWOL rates with regiments,              follow-up was available because the 85th Infantry
    with the highest and lowest psychiatric rates        Division did not have any further prolonged com-
    having similar AWOL rates, but the battal-           bat.
    ion with the highest number of AWOL had
    a high psychiatric rate and contained three          Enjoyment of Combat
    of the five officer offenders, indicating a
    leadership element in the behavior of the               Absenting oneself from the dangerous combat
    offenders.                                           situation may be dishonorable but understandable
 8. About one third of the offenders had been            to all; however, what is to be made of the occasional
    recently hospitalized, before AWOL, many             soldier who actually seems to enjoy immersion in
    for wounds, indicating an adverse effect of          combat? Are such men unconsciously suicidal?
    rearward evacuation even when surgically             Does their pleasure stem from unleashing Freud’s
    necessary, but only three of the 200 had             postulated Thanatos, the death instinct? Can such
    received prior psychiatric treatment. [In            behavior be explained on the basis of powerful
    1973, the Israelis experienced similar losses        social reinforcement from peers and command?
    due to psychiatric breakdown in lightly              Like most human behavior, enjoyment of combat
    wounded, evacuated casualties.—Au.]                  may be of multifactorial origin, resulting from sev-
                                                         eral or all of these inputs. The following case is
   One may conclude from these findings that while       typical in that such men are often not well-regarded
both the psychiatric casualty and AWOL offender          by their peers though command often regards them
have a common etiology, the dangers of battle,           highly.
quite different mental mechanisms are operating.
The AWOL soldier consciously elects to avoid com-        Case Study 11: Enjoyment of Combat
bat as a result of chronic anticipatory anxiety deriv-
ing from accumulated battle experiences and goes            Major Glass, while resting in the Alpines after hostili-
AWOL while away from the supportive or sustain-          ties ended in Italy, was confronted by a jeepload of
ing influence of the combat group or when support        sergeants from the 85th Infantry Division. They described
is no longer operative. Conversely, the psychiatric      Sergeant X, a wonderfully resourceful, reliable, cool-in-
casualty arises during the intensity of battle and       combat soldier with several decorations including the
                                                         Silver Star. But now, when there were no longer any
occurs when the individual is bereft of his own
                                                         hostilities, Sergeant X was restless. He was going on
individual sustaining powers or group support by         patrol every night, had shot out the light at their parties,
the traumatic and disruptive forces of combat.           and had been prowling around. They considered him a
   Kirkland, a combat veteran and student of sol-        menace.
dier stress, has commented on the different                 During the interview he appeared embarrassed and
symptomatology between combat and rear-echelon           apologetic, stating he liked the fellows but was bored and
troops: “In a unit in combat a soldier is torn be-       restless and needed something exciting to do. He re-
tween loyalty to his comrades and his identity as a      quested transfer to the Pacific Theater. He told Major
soldier on the one hand and terror on the other.         Glass that he must avoid disciplinary problems because
                                                         he had been paroled to the Army from State prison, where
Fleeing and staying are both unacceptable … un-
                                                         he had been serving a sentence for manslaughter; there-
conscious … symptoms occur [that remove him              fore, he must receive an honorable discharge. He admit-
honorably from combat]. In the rear, however, the        ted he enjoyed the thrill of combat and danger. He was
loyalty and identity factors are not present [but]       easily angered and had no close friends, either civilian or
terror is … [the soldier] … is less conflicted and can   military. No psychosis was present. He was evacuated to
make a conscious choice—go AWOL.”49                      the 601 Hospital; there was no follow-up.48(pp59-60)


58
                                                                              Traditional Warfare Combat Stress Casualties


   Comment: The author saw a few cases similar to this          civilian life was frequently poor. Persons who enjoyed
when directing a research ward for severe character             combat rarely came for treatment; they seldom responded
disorders. Most of these men had severe personality             to psychotherapeutic attempts. It is possible that seroton-
distortions with prominent antisocial aggressive tenden-        ergic antidepressants might be helpful because antisocial
cies. Far from having been created by combat, these men         persons such as arsonists have been found to have
had usually been delinquent and involved in aggressive          decreased spinal fluid levels of breakdown products of
behavior prior to military service. Their adjustment to         serotonin.50


                                                    CONCLUSION


   The diagnosis of psychiatric casualties is made              disorder,” which is used in the interval from 3 days
difficult not only by the protean symptomatology                after the traumatic event to 1 month (when post-
and potential mimicry of “organic” conditions but               traumatic stress disorder [PTSD] becomes appro-
also by the intentional vagueness of the nomencla-              priate). But even organized civilian psychiatry has
ture itself. At a time when psychiatrists are striving          not placed a diagnostic label on the distress and
for increasing precision in diagnosis it may appear             disturbed behavior which may occur within the
anomalous that the military is clinging to the non-             first 3 days after an extremely traumatic (life-threat-
specific term “combat fatigue” to categorize the                ening) event. This is the period of time in which
psychiatric casualties of combat. The glossary                  most battle fatigue symptomatology is detected and
to DSM-III (published separately) even lists                    (ideally, with “immediacy”) treated and resolved.
“combat fatigue” as “an obsolete term for post-                 This temporary disturbance can be described as the
traumatic stress disorder.” That interpretation is              normal human response to very abnormal, threat-
plainly misinformed. Post-traumatic stress disor-               ening conditions. Using a “normalizing” label such
der, by DSM-IV’s own criteria, cannot be diagnosed              as combat fatigue is an important therapeutic ma-
until 1 month after the traumatic event is in the past.         neuver intended to impress the soldier with the
Combat fatigue, by definition, applies to soldiers              idea that he is not mentally ill but just tired and can
who are still in the traumatic (combat) situation. In           expect to recover with rest. As seen with the diag-
prolonged combat, however, some traumatic events                nostic label, expectancy is the critical psychological
may have occurred more than 1 month ago. In                     variable in the recovery of the combat stress casu-
general, “combat fatigue” corresponds more closely              alty. Thus, diagnosis and treatment are inextricably
to the new DSM-IV classification of “acute stress               intertwined.


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      psychiatric services. Presented at Army Medical Department Division and Combat Psychiatry Conference;
      April 28–May 2, 1980; Monterey, Calif.

31.   Swank RL, Marchand F. Combat neuroses: Development of combat exhaustion. Arch Neurol Psychiatry [super-
      seded in part by Arch Neurol and Arch Gen Psychiatry]. 1946;55:236–247.

32.   Menninger WC. Reactions to combat. Psychiatry in a Troubled World. New York: Macmillan; 1948: 134–152.

33.   Ranson SW. The normal battle reaction: Its relation to pathologic battle reaction. Combat Psychiatry. Bull US
      Army Med Dept. 1949;9:3–11.

34.   Kubler-Ross E. On Death and Dying. London: Macmillan; 1969.

35.   Weinstein EA, Kahn RL. Denial of Illness. Springfield, Ill: Charles C Thomas; 1955.

36.   Mohajer M, Mottaghi Y. Psychiatric war casualties in Iran: Presentations. Presented at American Psychiatric
      Association Annual Meeting; May 1985; Dallas, Tex.

37.   Salmon TW, Fenton N, eds. In the American Expeditionary Forces [Section 2]. Neuropsychiatry. Vol. 10. In: The
      Medical Department of the United States Army in the World War. Washington, DC; Office of The Surgeon General,
      US Army; 1929.

38.   Jones FD. Experiences of a division psychiatrist in Vietnam. Milit Med. 1967;132(12):1003–1008.

39.   Johnson AW. Combat psychiatry I: Historical view. Med Bull US Army Europe. 1969;26(10):305–308.

40.   Cannon WB. Bodily Changes in Fear, Hunger, Pain and Rage. 2nd ed. New York: Appleton-Century; 1929.

41.   Sobel R. Anxiety-depressive reactions after prolonged combat experience: The “old sergeant syndrome.”
      Supplement on combat psychiatry. Bull US Army Med Dept. 1949;9:137–146.

42.   Akiskal HS, McKinney WT. Overview of recent research in depression: Integration of ten conceptual models into
      a comprehensive clinical frame. Arch Gen Psychiatry. 1975;32:285–305.

43.   Laughlin HP. The Neuroses. Washington, DC: Butterworths; 1967: 909–911.

44.   Glass AJ, Drayer CS. Italian campaign (1 March 1944–2 May 1945), Psychiatry established at division level. In:
      Glass AJ, ed. Overseas Theaters. Vol 2. In: Neuropsychiatry in World War II. Washington, DC: Office of The Surgeon
      General, US Army; 1973; 47–109.

45.   Weinstein EA. The Fifth US Army Neuropsychiatric Center—”601st.” In: Glass AJ, ed. Overseas Theaters. Vol 2.
      In: Neuropsychiatry in World War II. Washington, DC: Office of The Surgeon General, US Army; 1973: 127–141.

46.   US Department of the Army. Treaties Governing Land Warfare. Washington, DC: DA; 7 December 1956. Pamphlet 27-1.

47.   Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Atheneum; 1994.

48.   Glass AJ. Psychiatry at the division level. Supplement on combat psychiatry. Bull US Army Med Dept. 1949;9:45–73.

49.   Kirkland F. Written Communication, 1991.

50.   Virkkunen M, DeJong J, Bartko J, Goodwin FK, Linnoila M. Relationship of psychobiological variables to recidivism
      in violent offenders and impulsive fire setters: A followup study. Arch Gen Psychiatry. 1989;46:600–603.



                                                                                                                     61
                                                                                                Disorders of Frustration and Loneliness




Chapter 3
DISORDERS OF FRUSTRATION AND
LONELINESS

FRANKLIN D. JONES, M.D., F.A.P.A.*



                                      INTRODUCTION

                                      LOW-INTENSITY VS TRADITIONAL COMBAT STRESS CASUALTIES

                                      NOSTALGIA: REDISCOVERY OF A CONCEPT

                                      LONELINESS AND FRUSTRATION CASUALTIES: PRECIPITANTS
                                        Precipitants for Combat Troops
                                        Precipitants for both Combat and “Service” Troops

                                      LONELINESS AND FRUSTRATION DISORDERS: PRESENTATIONS
                                        Substance Abuse
                                        Sexual Problems
                                        Indiscipline
                                        Stress Disorders

                                      LOW-INTENSITY COMBAT STRESS CASUALTIES: PREVENTION AND
                                       TREATMENT

                                      SUMMARY AND CONCLUSION




* Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
  President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and
  Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                          63
War Psychiatry




Edward J. Bowen                            Bunker on Nuo Ba Dhn Mountain                                 1969

Private Edward J. Bowen, a member of the U.S. Army Artist Program, depicts soldiers in their bunker in
Vietnam. Low-intensity combat is characterized by significant lulls in the fighting, during which soldiers
have time for a variety of activities, as shown in this painting. If not managed properly through constructive
activity, such lulls can give rise to disorders of frustration and loneliness.



Art: Courtesy of US Center of Military History, Washington, DC.




64
                                                                            Disorders of Frustration and Loneliness




                                              INTRODUCTION


   The future may produce many different types of         ity and relative safety for the combatants. Overt
war; however, because of the nuclear stalemate,           combat is brief, and usually involves squads, pla-
modern wars involving industrialized nations are          toons, companies, and rarely battalions, although
increasingly of the low-intensity, intermittent, but      at those levels casualties may be extremely high.
protracted type experienced by the French in Alge-        There is often a civil-war quality. Guerrilla activity
ria and Indochina, by the United States in Vietnam,       may be the predominant form of engagement, with
and by the Soviets in Afghanistan. Such conflicts         small arms and booby traps accounting for most of
range from low-frequency terrorist actions to full-       the wounding and killing rather than artillery and
scale but intermittent warfare. In mid-1986, 42           other indirect fire weapons. Here, too, “low-inten-
conflicts were occurring.1 These ranged from World        sity” does not necessarily mean low-casualty: one
War II-type mid-intensity combat operations (Iraq-        car bomb killed nearly 250 U.S. Marines in their
Iran) to low-intensity counter-terrorist/guerrilla        barracks in Beirut.2 Often the weaker military force
operations. Conflicts of the latter type were occur-      will use terrorist activity to achieve political ends.
ring at that time in Afghanistan, Cambodia, Central       Such conflicts and operations other than war are
America (Nicaragua and El Salvador), Chad, West           often ambiguous with no directly appreciable threat
Irian, Northern Ireland, India, Sri Lanka, Burma,         to the national interests of the more powerful coun-
and Angola. In 1992, the decline of Communism             try, which may be fighting a foreign, proxy war, or
was accompanied by the emergence of factionalism          participating in a multinational peacekeeping or
or civil wars in Yugoslavia, Russia, Azerbaijan,          constabulary operation. As such they often do not
Georgia, Moldavia, and Czechoslovakia. Also,              enjoy full public support. The psychiatric casual-
Kurdish and Shiite minorities are at war in Iraq and      ties of operations other than war differ qualitatively
Turkey and threaten other states. Virtually every         and quantitatively from those of conventional wars
large country and many small countries have the           involving prolonged or intense heavy (mechanized)
potential for such conflicts.                             combat. This chapter will describe these differ-
   These conflicts are of low intensity in the sense      ences and propose methods of preventing and man-
that battles are interspersed with periods of inactiv-    aging such casualties.


                LOW-INTENSITY VS TRADITIONAL COMBAT STRESS CASUALTIES


   The epidemiology of psychiatric casualties among       majority of neuropsychiatric cases in low-intensity
troops in battle has been examined in numerous            combat present a picture similar to those that occur
studies since World War I.3–14 Such studies tended        among rear-echelon troops in wartime and among
to emphasize the psychiatric casualties that resulted     garrison troops during peacetime (venereal dis-
from battlefield stress even though casualties re-        eases, alcohol and drug abuse, and disciplinary
sulting from less dramatic causes had been recog-         problems, often related to personality disorders). It
nized since World War I. These less dramatic casu-        is not surprising then that various authors have
alties presented with problems of alcohol and drug        called such casualties “guerrilla neurosis,”15 “garri-
abuse, disciplinary infractions, venereal diseases,       son casualties,”16 “disorders of loneliness,” 17 and
and “self-inflicted” medical disorders (for example,      “nostalgic casualties.”18,19 U.S. Army field manuals
malaria from failure to use prophylaxis). Not until       refer to them as “misconduct stress behaviors”20–22
the Vietnam conflict were these casualties recog-         (Figure 3-1).
nized as potentially serious causes of ineffective-          Jones23 studied the features distinguishing psy-
ness.                                                     chiatric casualties among combat troops from those
   Although the casualties that occur during actual       among combat-service-support troops not normally
engagement with the enemy may present the tradi-          exposed to combat. (“Combat-service-support” in
tional picture of battle fatigue (eg, anxiety, fatigue,   this context refers to soldiers whose primary mis-
and conversion and dissociative syndromes), the           sion is not to fight the enemy but to assist those




                                                                                                                65
War Psychiatry



                                            Combat Stress Behaviors




                 Adaptive                                   Dysfunctional Combat Stress Behaviors




        Positive Combat Stress           Misconduct: Stress Behaviors                      Battle Fatigue
              Behaviors                       and Criminal Acts



          Unit Cohesion                     Mutilating enemy dead                    Hyperalertness
            Loyalty to buddies              Not taking prisoners                     Fear, anxiety
            Loyalty to leaders              Killing enemy prisoners                  Irritability, anger, rage
            Identification with             Killing noncombatants                    Grief, self-doubt, guilt
              unit tradition                Torture, brutality                       Physical stress complaints
          Sense of eliteness                Killing animals                          Inattention, carelessness
          Sense of mission                  Fighting with allies                     Loss of confidence
          Alertness, vigilance              Alcohol and drug abuse                   Loss of hope and faith
          Exceptional strength              Recklessness, indiscipline               Depression, insomnia
            and endurance                   Looting, pillage, rape                   Impaired duty
          Increased tolerance               Fraternization                              performance
            to hardship,                    Excessively on sick call                 Erratic actions, outbursts
              discomfort, pain,             Negligent disease, injury                Freezing, immobility
              and injury                    Shirking, malingering                    Terror, panic running
          Sense of purpose                  Combat refusal                           Total exhaustion, apathy
          Increased faith                   Self-inflicted wounds                    Loss of skills and memories
          Heroic acts                       Threatening/killing own                  Impaired speech or muteness
            courage,                           leaders ("fragging")                  Impaired vision, touch, and
            self-sacrifice                  Going absent without                        hearing
                                               leave, desertion                      Weakness and paralysis
                                                                                     Hallucinations, delusions




                                        Post-Traumatic Stress Disorder



                                     Intrusive painful memories, "flashbacks"
                                     Trouble sleeping, bad dreams
                                     Guilt about things done or not done
            F 3-1                    Social isolation, withdrawal, alienation
                                     Jumpiness, startle responses, anxiety
                                     Alcohol or drug misuse, misconduct

Fig. 3-1. Combat stress behaviors may be adaptive or dysfunctional. The most serious of these behaviors are those
involving criminal acts. However, all stress behaviors can evolve into PTSD. Reprinted from US Department of the
Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA; September 1994. Field Manual 22-51: 2-12.


doing the fighting.) He concluded that such “garri-            social and sometimes physical deprivation. Con-
son casualties” were found particularly among rear-            sidering their source, Jones17 had labeled these ca-
echelon elements in Vietnam, a conflict in which               sualties as suffering from “disorders of loneliness”;
each combat soldier was supported by about eight               however, since before the Napoleonic Wars, such
noncombat-arms troops. Such troops characteristi-              disorders have been termed “nostalgia.” Obvi-
cally present with behavioral disorders related to             ously, such disorders can and do occur in combat
separation from family and friends, boredom, and               troops as well.




66
                                                                           Disorders of Frustration and Loneliness


                            NOSTALGIA: REDISCOVERY OF A CONCEPT


   Nostalgia was a medical concept recognized even      of health, give a sense of mastery of weapons, and
before 1678, when the Swiss physician Hofer cre-        integrate the unit. This regimen prevents evacua-
ated this term to describe soldiers previously la-      tion home (the treatment approach of earlier physi-
beled as suffering from “Das Heimweh” or home-          cians) and minimizes any secondary gain from
sickness. 24 Earlier in the 17th century, soldiers in   illness.24(p348)
the Spanish Army of Flanders were stated to suffer         During the Civil War, Calhoun, reviewed in
from “mal de corazon” (“illness of the heart”), and     Deutsch,25 ascribed a relationship between nostal-
Swiss mercenaries in France were said to suffer         gia and the recruiting methods of the Union Army
from “maladie du pays” (“homesickness”). Be-            that could have parallels with the “nostalgic casual-
cause the majority of such soldiers were mercenar-      ties” of the Vietnam conflict. Calhoun described
ies uprooted by financial exigencies from their farms   initially enthusiastic soldiers who had expected an
in Switzerland, these soldiers were often described     early end to the conflict and who became disen-
as suffering from “the Swiss disease.” The critical     chanted as the war dragged on. The statistics on
variable was service, often involuntary, far from       desertion, draft dodging, and similar attempts to
one’s country, family, and friends. By the middle of    avoid duty were not much different during World
the 18th century, nostalgia was a well-defined          War II, a more popular war, and the Vietnam
nosologic entity recognized as afflicting not just      conflict (in fact, these rates were generally lower
Swiss soldiers but potentially any soldier displaced    during Vietnam than during World War II). This
from his milieu of origin, and generally was consid-    suggests that the disenchantment toward the end of
ered to be a mental disorder.                           the conflict in Vietnam may not have been as impor-
   The symptomatology associated with nostalgia         tant a factor in generating nostalgic casualties as the
was consistently compatible with modern descrip-        loss of unit cohesion.
tions of depression, with complaints, for example,         Nostalgic casualties occurred in soldiers sepa-
of “moroseness, insomnia, anorexia, and asthenia”       rated from their home environment with attendant
in a report by Sauvages in 1768.24 Even this early      loss of social reinforcement. Rosen24 has pointed
there were observations that nostalgia might be         out that one need not be a soldier for this to occur
feigned as a method of avoiding duty. A French          and that displaced persons and other groups often
physician, De Meyserey, who published a treatise        suffer from this “forgotten” psychological disor-
on military medicine in 1754, observed that war and     der. Situations such as the fighting of an unpopular
its dangers always produced a fruitful crop of ma-      war of indefinite duration are likely to increase
lingerers who must be discriminated from soldiers       these casualties, particularly in the absence of strong
with “true nostalgia.”                                  cohesive forces, which usually develop from shared
   Baron Larrey, Napoleon’s Chief Surgeon, pre-         hardship and danger. Hence, Calhoun cited battle
scribed a course of treatment which, while ostensi-     action as a curative factor in nostalgia:
bly biologically oriented, reveals a keen awareness
of social factors and is surprisingly close to modern     Their thoughts were turned from home, and they
handling of combat psychiatric casualties, both           felt they were men and soldiers, peers of the veter-
preventively and curatively. He stated that it            ans with whom they associated; and from that day
is necessary not to allow individuals who are             to this there has been but little or no sickness, and
                                                          but one or two deaths...When men have passed
predisposed to nostalgia more rest than is neces-
                                                          through the baptism of fire together, they feel they
sary, to vary their occupations, and after military       have something in common. They have a common
exercises to subject them to regular hours, gymnas-       name, a common fame, and a common interest
tic recreation, and some mode of useful instruction.      which diverts their thoughts away from home.25(p376)
He also stated that they should have mutual in-
struction with troops of the line and that warlike         Based on the recollections of Civil War veterans,
music will contribute to preventing gloomy reflec-      Stephen Crane’s The Red Badge of Courage eloquently
tions which can lead to nostalgia. This would en-       described the development of cohesive bonds in
sure physical bodily integrity, produce a conviction    response to the horrors of battle:




                                                                                                                  67
War Psychiatry


     There was a consciousness always of the presence       Vietnam conflict an attempt was made to utilize
     of his comrades about him. He felt the subtle battle   lower-functioning [though not retarded] men as
     brotherhood, more potent even than the cause for       soldiers in the U.S. Army, the so-called “McNamara’s
     which they were fighting. It was a mysterious          100,000.” Such soldiers performed more poorly as
     fraternity born of the smoke and danger of
                                                            a group than normally selected soldiers but some
     death. 26(p31)
                                                            were superior.)
                                                               At a time during World War I when the military
    Unit cohesion is group and self-preservative be-
                                                            population in France of U.S. soldiers averaged
havior that evolves from shared danger in an al-
                                                            200,000 persons, the incidence of hospitalized “psy-
most impersonal manner despite its very personal
                                                            chopathic states” was 5 per 1,000, comparable with
nature. This group cohesion evolves in almost any
                                                            the overall rate for “character and behavior disor-
situation of shared hardship or danger. Belenky
                                                            ders” in overseas areas in World War II of about 4
and Kaufman27 found that vigorous training in-
                                                            per 1,000. 25 However, because diagnostic practices
volving some danger produced cohesion in air as-
                                                            in World War I and World War II differed mark-
sault trainees. In combat situations, cohesion needs
                                                            edly, true comparability may not exist. The differ-
little encouragement to flourish. Recognizing this,
                                                            ence in types of casualties in garrison settings was
one company commander, when asked about cohe-
                                                            observed by Salmon and Fenton, who commented
sion in his unit in West Germany, commented, “I
                                                            that the cessation of hostilities did not reduce the
train my men to be skilled soldiers; I’ll rely on the
                                                            need for psychiatric beds:
enemy to make them cohesive.” Such a laissez-faire
attitude ignores the possibility that noncohesive
                                                              A number of more recent cases showed simple
units may disintegrate in high-stress combat before
                                                              depression…An intense longing for home was char-
cohesive bonds can develop.                                   acteristic of this condition. It resembled a set of
    Low-intensity combat, often characterized by long         reactions to which the term “nostalgia” used to be
periods of idleness without the shared experience             applied and is common in all military expeditions
of cohesion-building danger, should produce more              when a period of intense activity is succeeded by an
nostalgic casualties. This situation probably also            uneventful one. 28(p287)
accounts for the higher incidence of such casualties
among support troops than among combat troops.23               About one half of the U.S. psychiatric casualties
    During World War I, conditions of battle did not        of World War II were unrelated to combat and
lend themselves to producing large numbers of               actually occurred during stateside service.29 Dur-
nostalgic casualties; however, following the Armi-          ing World War II, “homesickness” was listed as a
stice, the Third Army, which remained as an army            factor in the breakdown of 20% of psychiatric casu-
of occupation, was in a garrison-type role. The             alties among U.S. forces.30 At that time, however,
casualties in this situation began to approximate           the relationship of these homesick casualties to
those seen in low-intensity warfare. For example,           combat situations was not explored.
from December 1918 to June 1919 at the hospitals at            The North Pacific Area (Alaska and the Aleutian
Coblenz and Trier, 1,022 psychiatric cases were             Islands) during World War II was almost devoid of
evaluated. 28 In this garrison setting, the largest         combat but was also a situation of extreme social
groups of casualties were those diagnosed as “de-           deprivation. The ubiquitous state of “chronic de-
fect” (presumably retarded) and “psychopathy”               pression” was not reflected in neuropsychiatric
(36.8%). When these are added to alcoholism and             admissions because the overall neuropsychiatric
drug states (6.8%), they account for nearly half of         admission rate was 10.5/1,000/y in the Alaskan
the psychiatric morbidity, and over half if epilepsy        Department, the lowest in any combat area. Of 325
is excluded. There were many disciplinary prob-             neuropsychiatric admissions to the 186th Station
lems in this occupation group. An attempt was made          Hospital at Umnak (Aleutians) from January 1942
by commanders and medical officers to eliminate             through January 1945, 53% were for psychoneurosis,
“misfits—defectives and psychopaths,” which may             14% for constitutional psychopathic state, 12% for
have accounted for the identification of a relatively       dementia praecox, 1% for manic-depressive, 3% for
high number of mentally retarded and epilepsy               mental deficiency, 1% for epilepsy, 3% for unclassi-
patients; however, “Had not many been evacuated             fied psychosis, and the remainder (13%) for miscel-
through other than hospital channels (replacement           laneous, primarily situational reactions.31(p723) De-
depots) the figures would be even higher.”28(p426)          spite a state of “chronic depression” that afflicted
(In a curious parallel with World War II, in the            virtually everyone, hospital admission rates were


68
                                                                             Disorders of Frustration and Loneliness


low.31 Perhaps the fact that alcohol and drugs were          larly those of immature personality or with charac-
scarce in the theater had a salutary effect on these         ter defects.34(pp719–720)
statistics.
                                                              French experience in Indochina and Algeria15
   In the Korean conflict, three fairly distinct phases
                                                           revealed characterological problems among French
are reflected in the varying types of casualties re-
                                                           soldiers in these generally low-intensity campaigns.
ported. The mid- to high-intensity combat from
                                                           Because there is a several-hundred-year history of
June 1950 until November 1951 was reflected in
                                                           colonial wars and occupation forces for many Euro-
traditional anxiety-fatigue casualties and in the high-
                                                           pean countries, it is surprising that reports of these
est rate of combat stress casualties of the war, 209/
                                                           casualties are sparse. It seems plausible that these
1,000/y in July 1950.32 Most of the troops were
                                                           were simply not considered medical, particularly
divisional, with only a small number being less
                                                           psychiatric, problems but rather moral issues simi-
exposed to combat. This was followed by a period
                                                           lar to earlier consideration of active combat stress
of static warfare with maintenance of defensive
                                                           breakdown as cowardice or lack of moral fiber. In
lines until July 1953 when an armistice was signed.
                                                           the French Indochina War (1945–1954), such char-
The gradual but progressive buildup of rear-area
                                                           acter disorders were reportedly responsible for a
support troops was associated with increasing num-
                                                           high number of evacuations, but no statistics are
bers of characterological problems. Norbury33 re-
                                                           available. Crocq and colleagues15 studied French
ported that during active combat periods anxiety
                                                           psychiatric casualties of the French-Algerian War
and panic cases were seen, while during quiescent
                                                           (1954–1962). They used statistics compiled by
periods with less artillery fire the cases were pre-
                                                           LeFebvre and colleagues for 1,280 cases of mental
dominantly characterological. Following the armi-
                                                           disorders at the military hospital at Constantine
stice, obviously, few acute combat stress casualties
                                                           who were then evacuated to France between 1 July
were seen. The major difference in overall casual-
                                                           1958 and 1 July 1962 (second half of the French-
ties other than surgical before and after the armi-
                                                           Algerian War). Diagnostically, 19.7% of the total
stice was a 50% increase in the rate of venereal
                                                           cases were character disorders, and another 14.5%
disease among divisional troops.32
                                                           were organic psychoses, predominantly from alco-
   Commenting on the observation that psychiatric
                                                           holism. Only 20% of all cases were related to a
casualties continued to present in significant num-
                                                           triggering event during combat. Functional psy-
bers following the June 1953 armistice of the Ko-
                                                           choses accounted for 36.7% of cases with approxi-
rean conflict, Marren gives a clear picture of the
                                                           mately one half of these being schizophrenia (224 of
reasons:
                                                           464 cases). The remainder were mentally retarded
  The terrors of battle are obvious in their potentiali-   (14.5%) and neurotic conditions (14.6%).15 Because
  ties for producing psychic trauma, but troops re-        these are evacuation statistics, they only indicate in
  moved from the rigors and stresses of actual com-        a general way relative prevalence because char-
  bat by the Korean armistice, and their replacements,     acterological problems usually are not handled by
  continued to have psychiatric disabilities, some-        medical evacuation. It is unfortunate that actual
  times approximating the rate sustained in combat,        behaviors cannot be examined to determine the
  as in the psychoses. Other stresses relegated to the     comparability of problem behaviors among sol-
  background or ignored in combat are reinforced in
                                                           diers of this war and the Vietnam conflict; however,
  the postcombat period when time for meditation,
  rumination, and fantasy increases the cathexis
                                                           there is a strong suggestion of comparability in that
  caused by such stresses, thereby producing symp-         only a small fraction of alcohol abusers will develop
  toms. Absence of gratifications, boredom, segrega-       brain syndromes. The relatively high percentage of
  tion from the opposite sex, monotony, apparently         such cases among the French suggests that this type
  meaningless activity, lack of purpose, lessened          of substance abuse was widespread.
  chances for promotion, fears of renewal of combat,          For the United States, Vietnam represented the
  and concern about one’s chances in and fitness for       epitome of a conflict in which nostalgic casualties
  combat are psychologic stresses that tend to             occurred. During the early years of the war, the
  recrudesce and to receive inappropriate emphasis
                                                           psychiatric casualty rate of about 12/1,000/y was
  in an Army in a position of stalemate…Sympathy
  of the home folks with their men in battle often
                                                           lower even than that in noncombat overseas areas
  spares the soldier from the problems at home. The        (Europe and Korea) at the same time.9 The average
  soldier in an occupation Army has no such immu-          psychiatric evacuation rate during the first year of
  nity … Domestic problems at home are often re-           the war was 1.8/1,000/y, lower than that from army
  flected in behavior problems in soldiers, particu-       posts in the United States.9 The most intense fight-


                                                                                                                   69
War Psychiatry


ing occurred in 1968 to 1969, with one half of those      [T]he soldier’s future was as much controlled by
killed in action killed during this period. In June       the calendar (DEROS) [date of expected return from
1968, 1,200 were killed, close to the peak number.9       overseas station] as by the outcome of combat
As the war dragged on and the U.S. presence took          with the enemy. The Viet Nam war was particu-
                                                          larly variant in that the enemy lacked a signifi-
on many of the characteristics of an occupation
                                                          cant capacity in weapons of indirect fire, thus pro-
force, characterological problems began to surface.       viding a battlefield ecology that was substantively
Racial incidents began to occur, beginning in the         different both from the past and the anticipated
rear areas. Psychiatric problems initially took pri-      future. 40(p1)
marily the form of alcohol and drug abuse but later,
as the unpopularity of the war intensified, disci-         This battlefield ecology, however, was not new
plinary problems approaching the magnitude of           to other nations. The French forces preceding
mutiny in some cases occurred.                          the United States in Vietnam fought a similar war
   President Nixon announced withdrawal plans           until the decisive defeat at Dien Bien Phù where
on June 9, 1969. Fragging incidents (the murdering      they were beaten by indirect fire weapons artil-
or injuring of a fellow soldier with a fragmentation    lery. The author contends that the casualties of such
grenade) increased from 0.3/1,000/y in 1969 to 1.7/     low-intensity, intermittent campaigns are similar to
1,000/y in 1971. 35 Psychiatric evacuations rose from   nostalgic casualties of the Civil War and of prior
4.4/1,000/y (4% of all evacuations) to 129/1,000/y      wars.
(60% of evacuations) in April 1972. Several authors        The 1982 Lebanon War is an excellent example of
have described these casualties and factors in their    the problems of a war unpopular at home. While
causation.9,23,35–39                                    the 1973 Yom Kippur War has been used as an
   These problems were further aggravated by the        exemplar of modern, high-intensity combat and
“Vietnamization” policy in which U.S. soldiers were     Vietnam as an exemplar of low-intensity combat,
increasingly relegated to garrison settings and roles   Lebanon had elements of both. There were approxi-
in the later phases of the conflict. The subsequent     mately 2 weeks of intense combat in early and late
drug abuse epidemic may have played a decisive          June 1982 with the remainder of the war being more
role in the abrupt withdrawal of U.S. troops and the    of a static situation with Israel as an occupying
ultimate loss of the war. The “garrison neuro-          force. The result in terms of casualties is revealing,
psychiatric casualties” in fact accounted for most of   showing casualties similar to those during the in-
the consumption of mental health resources during       tense battles of World War I, World War II, and the
the Vietnam conflict. When a policy of medically        1973 Yom Kippur War but also symptoms of es-
evacuating soldiers if they were found to have heroin   trangement and delayed stress casualties found in
breakdown products in their urine went into effect,     Vietnam (see Figure 3-1). Recent studies 41 revealed
heroin abuse became an “evacuation syndrome.”           that about two thirds of the psychiatric casualties
   Marlowe40 pointed out that Vietnam was aber-         from the 1982 Lebanon War presented during the
rant compared with World War II and most of the         postcombat period as chronic and delayed post-
Korean conflict:                                        traumatic stress disorder cases.

                 LONELINESS AND FRUSTRATION CASUALTIES: PRECIPITANTS


   In making a diagnosis of combat stress casualty,     treatment” to these casualties was hampered by
the clinician must strive for balance and avoid a       moralizing and punitive regulations42 and by ste-
“recipe” approach. A major failing in the psychiat-     reotyping casualties as drug addicts, alcoholics,
ric management of casualties in the Vietnam con-        cowards, and malingerers. Lost amid a welter of
flict was in not recognizing early enough that psy-     negative reports were occasional successful inter-
chiatric casualties were taking new forms: alcohol      ventions, particularly at the division level. Such
and drug abuse, and venereal disease and malaria        approaches included medical screening of prosti-
from failure to take prophylactic measures. Armed       tutes, making malarial prophylaxis a command re-
with a stereotypical model of combat fatigue and a      sponsibility, and alcohol and drug abuse rehabilita-
recipe for its treatment, psychiatrists were slow to    tion programs at the division level.43
recognize that escape from battle (evacuation syn-         Psychiatric casualties occurring in actual combat
drome) had taken a new form. Even when the              are qualitatively different from those occurring in
recognition occurred, the ability to adapt “forward     soldiers less exposed to combat. Billings reported


70
                                                                            Disorders of Frustration and Loneliness


that 28% of all medical evacuees from the South                tible personality when subjected to fear-
Pacific Command during World War II were sent to               inducing circumstances.
the Zone of the Interior because of personality dis-      5.   Prolonged patrol and reconnaissance work
orders during 1943.44 Billings also described the              in enemy-controlled jungle.
stresses and personality symptoms of combat and           6.   Promotion, in the field, to positions of great
combat-service-support troops. Writing of the men              responsibility.
sent to the South Pacific during World War II and         7.   Grief over loss of “buddies,” or loss of a
subsequently diagnosed as having personality dis-              tactical position taking the form of self-
orders, Billings believed that certain characteristics         condemnatory thinking.
of Americans helped produce this outcome. He              8.   Inadvertent evacuation to a position of
recorded as follows:                                           safety with that [cogitation] noted in para-
                                                               graph 3 resulting.
  Men … were products of our sociology and ideol-         9.   Loss of confidence in leaders.
  ogy. Individualism; the belief in a freedom for all    10.   Mass psychological reactions.
  men to compete on an equal basis; the tendency for     11.   “Snow jobs” or tall tales told often by the
  the American to need tangible evidences of success           veteran combat soldier to the new replace-
  at frequent intervals; the inclination to be too de-
                                                               ment at, or before, a critical time.
  pendent on others for distraction, recreation, and
  maintenance of interest; the assumption that Ameri-    12.   Unwarranted or unexplained evacuation or
  can business philosophy is a matter of “not what             transfer of psychiatric and minor medical
  you do but what you are caught doing,” with the              and surgical casualties ... resulting in loss of
  unconscious realization that the one who does not            the individual’s security in his bodily or
  or cannot do the job gets the benefits and escapes           personality integrity, loss of identification
  unpleasantness whereas the one who accomplishes              with his unit, diminished esprit de corps,
  the task only faces more work or loses his life—all          decreased desire or feeling of need to con-
  stood out as dynamic factors in breakdowns in                tinue fighting—all being replaced by a con-
  morale, occurrence of resentment reactions, ag-
                                                               scious or “subconscious” appreciation that
  gressive tendencies, and hurt feelings. These in
  turn placed certain personalities in considerable            it might be possible to return home and
  jeopardy of psychiatric disability when they were            thereby honorably escape further danger.
  subjected to special circumstances.44(pp479–480)       13.   Ill-considered or poorly-timed statements
                                                               to troops by visiting high-ranking officers,
Precipitants for Combat Troops                                 which lead to misinterpretation of policy,
                                                               or promote loss of confidence in the admin-
   Billings describes such “special circumstances”             istration.
as a variety of precipitants for combat troops.44        14.   Repeated dress parades for visiting digni-
                                                               taries when the combat team is staging for
 1.   Facing impending danger, especially for a                a forthcoming operation.
      period of time without specific happenings
      to break the tension or circumstances per-         Precipitants for both Combat and “Service”
      mitting the venting of physical effort. For        Troops
      example, remaining alert for a prolonged
      period of time in a concealed position or             Billings also describes the “special circumstances”
      foxhole, subjected to the full effects of lone-    that act as precipitants for both combat and “ser-
      liness and jungle sounds; being pinned             vice” (support) troops.44
      down by artillery or heavy mortar fire; or
      being caught in the open by strafing from           1.   Hypochloremia, dehydration, fatigue, and
      the air, especially when immobilized by                  subclinical or clinical illness decreasing the
      impediments or terrain.                                  efficiency and smooth psychobiological
 2.   Subjection to heavy artillery fire.                      functioning of the individual, thereby of-
 3.   Occurrences of a lull, following a period of             ten setting the stage for insecurity, tension,
      danger, which allowed for cogitation and a               and anxiety with personally alarming
      fuller intellectual realization of what was              symptomatology.
      and might be experienced.                           2.   Enemy propaganda.
 4.   Occurrence of transitory, psychobiological          3.   Rumors stemming from isolation, igno-
      disorganization in a particularly suscep-                rance of facts, and inactivity.


                                                                                                                  71
War Psychiatry


 4.   Postponement of the promotion of enlisted               assignment and readjustment of military
      men and officers, and the filling of position           personnel.
      vacancies with new men in grade or rank.           9.   Poor leadership, especially of high-rank-
 5.   Ill-advised promotion of men and officers               ing officers, as evident in the officer look-
      to responsibility beyond their ability.                 ing after his personal comfort and safety
 6.   Discrepancy between War Department and                  before acquiring them for his command.
      politically announced policy and plans for        10.   Apparent “empire building” of general of-
      rotation and redeployment of overseas per-              ficers.
      sonnel.                                           11.   Work or combat under adverse conditions
 7.   Knowledge of the unfair discrepancy in                  prolonged to the breaking point of the “av-
      remuneration to and appreciation for the                erage” man.
      individual in military service and the one        12.   Failure to expedite the elimination of
      in the merchant marine and industry.                    ineffectuals from a unit.
 8.   Seeming ignorance of the average com-             13.   Disturbing news from home, such as of a
      mander and the officer in personnel work                wife’s infidelity, business reversals, deaths,
      either of War Department policy or of how               illness, and encouragement to forego con-
      to comply therewith in regard to proper                 tinuance of further military responsibility.


                 LONELINESS AND FRUSTRATION DISORDERS: PRESENTATIONS


   Soldiers less exposed to combat and presenting       terms many of these casualties “misconduct combat
with personality problems may be called loneliness      stress reactions.” The term suggests that disciplin-
and frustration casualties. Huffman45 reported that     ary action may be indicated. This may be a profit-
only 48 of 610 soldiers (8%) seen in Vietnam from       able approach; however, command-sponsored sub-
1965 to 1966 suffered combat-related stress, while      stance abuse programs, programs to strengthen
Jones 23 found combat-related stress in 18 of 47        morale, and hygiene/prophylaxis programs may
soldiers (38%) seen in a similar hospital setting       be more profitable. These dysfunctional behaviors
(September–December 1966). These 18 cases, how-         often cluster in patterns forming syndromes. Such
ever, were given character and behavior disorder        syndromes typically have many overlapping be-
diagnoses. As the 25th Division psychiatrist, Jones17   haviors; however, it is useful to divide them into the
saw approximately 500 patients from March through       categories of substance abuse, sexual problems, and
October 1966, of whom about one third were              indiscipline.
awaiting legal or administrative action. Of the            These cases (misconduct combat stress reactions)
remaining two thirds, almost all were diagnosed         are ones which violate unit regulations or the Uni-
as having character and behavior disorders includ-      form Code of Military Justice or the Law of Land
ing situational fright reactions. The term “combat      Warfare. The manuals state that such cases require
fatigue” was misleading to the novice psychiatrist      disciplinary action. They cannot simply be treated
with its mistaken implication of prolonged combat       as battle fatigue, with reassurance, rest, physical
and cumulative fatigue. In retrospect, some of          replenishment, and activities to restore confidence.
these cases would more appropriately have been          Depending on the seriousness or criminality of the
so diagnosed; however, the treatment approach           misconduct, disciplinary action ranges from simple
was the same: rest, reassurance, and return to his      verbal correction through assignment of unpleas-
unit.                                                   ant duties and denial of special privileges; written
   The term “loneliness and frustration casualty,”      reprimand; nonjudicial punishment (Article 15);
like “combat stress reaction,” and “battle fatigue,”    judicial punishment (court-martial); less than hon-
is an intentionally vague term describing a variety     orable discharge; confinement and, for extreme
of dysfunctional behaviors, although unlike “battle     misconduct, the death penalty. For criminal cases,
fatigue” it is not readily understood by the average    psychiatric expertise may be called upon to estab-
soldier or his sergeant and junior officer, and so      lish the validity of an insanity defense. In all cases,
should not be used when talking to them. Nostalgic      mental health personnel can advise regarding po-
casualties require interventions much like those for    tential for recurrence or rehabilitation, and treat
managing combat fatigue. U.S. Army doctrine 21,22       any associated mental disorders.



72
                                                                           Disorders of Frustration and Loneliness


Substance Abuse                                          the proportion of habitual users in Vietnam stabi-
                                                         lized at 17% to 18% between 1969 and 1971. Thus,
   During the Civil War, the liberal use of opium        about 9% to 10% of the lower grades of enlisted
caused widespread dependence called the “soldier’s       men first became habitual smokers (daily usage) in
disease.”46 In low-intensity combat and garrison         Vietnam.
settings in which the risks of being intoxicated are        Heroin abuse became significant in early 1970
not as great as in higher-intensity combat, sub-         when 90% to 96% pure heroin derived from the
stance abuse flourishes.                                 “golden triangle” of Thailand, Burma, and Laos
   Froede and Stahl47 evaluated the 174 cases of fatal   became available countrywide. This pure heroin
narcotism retrieved from over 1.3 million surgical       was so cheap that a significant “habit” could be
and autopsy cases sent to the Armed Forces Insti-        maintained for $8 to $10 a day.51 The preferred
tute of Pathology from 1918 through the first 6          route was “snorting” through the nostrils or smok-
months of 1970. Although the data were incom-            ing. Of the small percentage who injected at all, this
plete, some interesting trends were observed that        was only occasionally. At a peak in October 1971,
strengthen the observation that drug abuse is asso-      almost one half of all lower ranking enlisted men (E-
ciated with low-intensity combat situations in geo-      1 to E-4) were using heroin and half of these may
graphical areas in which abuse substances are avail-     have been addicted.52 Like venereal disease rates,
able (about two thirds of the deaths occurred in the     drug abuse rates tend to increase when there are
Far East). In terms of combat intensity, the majority    lulls in combat or when exposure to combat is
of cases in World War II, Korea, and Vietnam oc-         decreased.
curred in the closing years of the wars and in the          Heroin reportedly displaced cannabis because it
postwar periods when fighting had diminished and         had no characteristic strong odor allowing detec-
large numbers of troops were serving in support          tion, made time seem to go faster rather than slower
roles. Their findings are supported by Baker’s48         as with marijuana, and was compact and easily
estimate that there were 75 opiate deaths in Viet-       transportable. However, McCoy53 argues that heroin
nam from August 1, 1970 through October 18, 1970,        did not so much replace marijuana as augment its
11 confirmed by autopsy and 64 suspected.                use and that the real reason for the heroin epidemic
   Alcohol was the first substance of abuse in Viet-     was enormous profits that South Vietnamese offi-
nam. Huffman45 reported that of his 610 patients         cials could make by selling it to Americans.
seen early in the war, 113 (18.5%) suffered from            These findings must be considered in the light of
severe problems associated with alcoholic intoxica-      a nationwide epidemic of drug abuse in American
tion but there were only five cases of unquestion-       youths at that time. The biggest difference between
able nonalcohol substance abuse. As the war pro-         drug abuse in Vietnam and in the United States was
gressed, marijuana came to be preferred because of       the ready availability of very pure, inexpensive
the absence of a “hangover.” Roffman and Sapol49         heroin in Vietnam.54
reported that in an anonymous questionnaire given           Treatment of substance abusers has varied con-
to soldiers departing Vietnam in 1967, 29% admit-        siderably over time. Early approaches were to
ted using marijuana during their tour. Similarly,        consider such casualties problems of a moral nature
a survey of 5,000 enlisted men at Fort Sill, Okla-       and later of a character defect with punishment as
homa who had not served in Vietnam from January          the primary intervention. It was only when such
through April 196950 revealed that 29% admitted          losses of manpower became significant in the Viet-
to using drugs sometime in their lives, 83% of           nam conflict that a nonpunitive, therapeutic ap-
the users identifying marijuana. In the early            proach was undertaken. By 1971, more soldiers
years of the Vietnam conflict marijuana users ap-        were being evacuated from Vietnam for drug use
parently were reflecting the experiences of their        than for war wounds.51 The U.S. Army had adopted
stateside cohorts, but this began to change. In          a countrywide voluntary treatment program in Viet-
a review of studies of drug abuse in Vietnam,            nam in October 1969 aimed primarily at marijuana
Stanton51 found that from 1967 to 1971 the propor-       abusers. This was patterned on an amnesty pro-
tion of enlisted men who used marijuana “heavily”        gram developed in the Fourth Infantry Division in
(20 or more times) in Vietnam increased from 7%          May 1969. Army regulations tended to be slow in
to 34%, while the proportion of “habitual” users         changing to accommodate the therapeutic perspec-
(200 or more times) entering Vietnam remained            tive, sometimes resulting in paradoxical punish-
at 7% to 8% for the years 1968 through 1970 and          ment of recovered abusers.42



                                                                                                               73
War Psychiatry


   The main lessons from the U.S. experience in                 well-liked by the officers and enlisted men with whom he
managing substance abuse in Vietnam are that treat-             worked. In the combat setting he was unable to satisfy his
ment should be in-country to prevent an evacuation              homosexual feelings by “cruising.” Finally he hit upon a
syndrome and that the factors that prevent break-               method that took advantage of the nostalgia and fears of
                                                                the young soldiers. He offered them friendship, alcohol,
down in general—cohesion, effective leadership,
                                                                and marijuana to alleviate their homesickness and fear,
and good morale—may protect soldiers from sub-                  then performed fellatio when they were intoxicated. Most
stance abuse. For example, the Australians serving              victims kept silent from embarrassment or fear of disci-
in Vietnam did not have significant personnel losses            plinary action until a soldier who wanted to be separated
from substance abuse.55,56 Their forces were based              administratively was seduced. He reported the incident.
on a regimental system with unit rather than indi-                 Comment: Examples such as this have been used to
vidual rotations, and officers and troops had usu-              vindicate the military policy of eliminating homosexuals
ally served together for long periods of time. This             from the service; however, a study of homosexual college
may have produced greater unit cohesion, a crucial              students who served in World War II57 revealed that the
                                                                great majority served adequately and some with distinc-
difference from U.S. troops that protected Austra-
                                                                tion.
lian troops from developing nostalgic problems of
substance abuse and indiscipline.                                  Sexually-transmitted diseases (venereal diseases
                                                                or VD) have been a major cause of lost soldier
Sexual Problems                                                 strength in wars of the 20th century. While modern
                                                                medicine has markedly reduced the time lost and
   The most common nostalgic behavior coming to                 complications of venereal diseases, it has not re-
medical attention is sexual intercourse with prosti-            duced the infection rates as seen in Table 3-1.
tutes leading to venereal diseases. The following                  Although the venereal disease rate of the Ameri-
case, known to the author, reveals that officers were           can Expeditionary Forces (AEF) in World War I was
not immune.                                                     a relatively low 34.3/1,000/y,58 there were over 6.8
                                                                million lost man-days and 10,000 discharges.59 Each
Case Study 1: The “No-Sweat” Pill

   When the author was taking sick call in the headquar-
                                                                TABLE 3-1
ters company dispensary, he was approached by Major
INF, who stated that he was going to Saigon overnight and       VENEREAL DISEASE RATES BY WAR/1,000
wanted a “no-sweat pill.” The author was slow to realize        TROOPS/YEAR
that the major wanted penicillin to prevent getting gonor-
rhea or syphilis. When he did understand, he refused and
                                                                War                      Years/Location                     Rate
gave him a lecture on the dangers of incompletely treated
syphilis leading to tertiary lues of the brain and absence of
protection from viral venereal diseases. Later the author       World War I              Expeditionary Force                 34.3
learned that the major purchased antibiotics over the                                    Continental USA                   127.4
counter in Saigon and indulged himself apparently without
                                                                World War II             1941–1945                           42.9
complications.
   Comment: The availability of antibiotics in Vietnam          Post-World War II        1946–1950                           82.3
(and Korea) without prescription may have hastened the
development of resistant strains of gonorrhea that have         Korea                    1951–1955                         184.0
been reported since the Vietnam conflict.                       Vietnam                  1963–1970                         261.9
                                                                                         Peak Jan–Jun 1972                 698.9
   Low-intensity combat operations frequently show
                                                                                         Continental USA                     31.7
an increased incidence of drug abuse and sexual
disorders. The following case from the early phases
                                                                Data sources: [World War I] Michie HC. The venereal diseases.
of the Vietnam conflict reveals both.                           In: Siler JF, ed. Communicable and Other Diseases. In: The Medical
                                                                Department of the United States Army in the World War. Vol 9.
Case Study 2: Seductive Marijuana                               Washington, DC: Medical Department, US Army, Office of The
                                                                Surgeon General; 1928: 263–310. [World War II, post-World War
                                                                II, Korea, Vietnam] Deller JJ, Smith DE, English DT, Southwick
   Sergeant First Class (SFC) MC was the noncommis-             EG. Venereal diseases. In: Ognibene AJ, Barrett O Jr, eds. General
sioned officer in charge (NCOIC) of a technical support         Medicine and Infectious Diseases. In: Ognibene AJ, ed. Internal
battalion assigned to an infantry division. He was given a      Medicine in Vietnam. Vol 2. Washington, DC: Medical Depart-
forensic psychiatric evaluation in the course of a court-       ment, US Army, Office of The Surgeon General and Center of
martial proceeding. SFC MC was a kindly, friendly man,          Military History; 1982: 233–255.



74
                                                                            Disorders of Frustration and Loneliness


case resulted in over a month of lost duty time (from   Indiscipline
1929–1939, lost days per case ranged from 38–50).59
By the time of the Vietnam conflict, 9 of 10 cases          Indiscipline is a psychiatric issue in the sense that
were for gonorrhea (lymphogranuloma venereum,           sociopsychological factors play a paramount role in
chancroid, and syphilis accounted for most of the       its emergence. Furthermore, indiscipline and psy-
rest), and lost duty time averaged only a few hours     chiatric breakdown merge almost imperceptibly as
per case. Deller and colleagues59 echo the observa-     evacuation syndromes. For example, failure to take
tion of Jones23 that rates were greatest in support     preventive hygiene measures in Korea allowed the
troops with little combat exposure, and they add        development of frostbite in some cases. Similarly,
that such troops were most often near population        failure to take the prophylactic chloroquine-
centers. The peak incidence of nearly 700/1,000/y       primaquine pill in Vietnam allowed the infestation
occurred in the period January to June 1972 when        of malarial protozoans. In both cases, indiscipline
almost all U.S. troops were in support roles in         rendered the soldiers unfit for duty.
accordance with the “Vietnamization plan” of us-            Indiscipline may range from relatively minor
ing South Vietnamese forces in combat.                  acts of omission to commission of serious acts
   Prevention through education is a valid approach     of disobedience (mutiny) and even murder
to venereal disease even though some soldiers will      (fragging). In an analysis and historical review,
risk infection no matter what the threat. Prevention    Rose61 indicated that combat refusal has been a
should not be directed at preventing sexual inter-      relatively frequent occurrence in most significant
course, which is an unrealistic goal, but toward the    wars for which there is adequate data. The military
avoidance of high risk (“off limits”) partners and      has often colluded with the perpetrators in hiding
the use of condoms, which should be made readily        the true nature of collective disobedience (mutiny)
available. A study60 that revealed that 50% of all      by using various euphemistic phrases (“unrest,”
prostitutes who have been randomly tested in the        …“incident,” “affair,” “collective protest,” “insub-
United States carry the HIV (human immunodefi-          ordination,” “strike,” and “disaffection”).61(p562) Rose
ciency virus) antibody suggests that this retrovirus,   indicates that there are compelling reasons for com-
which is thought to cause the currently incurable       mand to do this: “…mutiny is the antithesis of
and usually fatal acquired immunodeficiency syn-        discipline,”61(p562) and a commander who “allows” a
drome (AIDS), may be a problem in future wars. In       mutiny to occur jeopardizes his career and those of
battlefield conditions, soldiers may have to donate     his “commanding officers up and down the
blood to each other, and the presence of a soldier      line.”61(p563)
who is HIV positive could prove hazardous not               Most indiscipline, of course, is more subtle than
only to the health but also to the morale of troops.    combat refusal and does not appear to be related to
   Although unlikely to have immediate effects on       it. However, unavailability for combat is a frequent
combat efficiency, the HIV virus poses severe prob-     consequence of indiscipline. The main role of the
lems in long-term prevention. Many of the world         psychiatrist is in prevention because the same con-
social tensions and ongoing wars are occurring in       ditions that give rise to neuropsychiatric casualties
Africa, where the HIV infection is reaching epi-        may produce indiscipline as another evacuation
demic proportions. Unlike in the United States,         syndrome. This section will address primarily clini-
where the populations at risk are mainly homo-          cally observed situations involving indiscipline ac-
sexuals and intravenous drug abusers, the spread        tions.
of HIV in Africa is primarily through heterosexual          The following examples of indiscipline, provided
intercourse. In South America, another politically      by the author, were fairly typical of conditions in
troubled area with insurgencies and narcotics pro-      Vietnam.
duction in several countries, AIDS is emerging as a
difficult public health problem. Because urban ar-      Case Study 3: The Major’s Bullets
eas in these third-world countries are being hit
hardest by AIDS, there is concern that the profes-         During the early phases of the Vietnam conflict Major
sional and leadership classes of African, and to a      MSC was the executive officer in the headquarters of a
                                                        support battalion of an infantry division. Prior to deploy-
lesser extent South American, countries could
                                                        ment to Vietnam he had earned a reputation as a strict
experience severe setbacks in goals of industrializa-   disciplinarian, once having demoted a soldier for having a
tion and democratic reforms. Internal unrest in         pocket unbuttoned. The battalion commander, an alco-
Latin America frequently has led to U.S. deploy-        holic, stayed sequestered in his “hooch” leaving the major
ment beginning before 1900.                             to run the unit despite his lack of expertise in the highly


                                                                                                                75
War Psychiatry


technical field in which most of his subordinates were far      lem. When the psychiatrist refused to label the soldier
more skilled than he was. Feeling threatened by lack of         psychiatrically ill, the medic was transferred to another
proper technical background, the major became increas-          company. The appropriate solution is a consultation with
ingly authoritarian, producing impaired morale in his unit.     the lieutenant’s commander in which assignment manipu-
His authoritarian approach to leadership was not appreci-       lations are recommended.
ated by the troops: he began finding bullets with his name
written on them. This physical threat did not change his           Indiscipline is not limited to subordinate ranks.
behavior. The appropriate intervention would have been          Perhaps the most notorious example of collective
to make higher command aware of the adverse effect on           indiscipline during the Vietnam conflict occurred
morale of Major MSC; however, he was well-regarded by
                                                                in the My Lai atrocity, in which over 100 men,
command for taking over for the incompetent battalion
                                                                women, and children were killed in a village by U.S.
commander and higher command turned a deaf ear.
Eventually, Major MSC made a serious error leading to           forces.
the death of a prisoner of war and he abandoned his
authoritarian approach.                                         Case Study 5: Lieutenant Calley
   Comment: Early in the Vietnam conflict the majority of
U.S. soldiers were volunteers who served together prior to          [Although the author was one of three U.S. Army
deployment to Vietnam. Morale was generally high. In the        psychiatrists who examined First Lieutenant William Calley
later phases of the war an officer as unpopular as Major        and testified at his court-martial, the information given in
MSC would have been a likely fragging victim.                   this case comes from public records of the trial.—Au.]
                                                                Calley testified that he had been ordered to go to My Lai
   Linden 62 reported that there was a progressive              and “kill the enemy”; however, the major who had alleg-
rise in the number of courts-martial for insubordi-             edly given the order was killed before the trial began.
                                                                Several factors are important in understanding this inci-
nation and assaults (including murder) on officers
                                                                dent. First, prior to assignment in Vietnam, Calley was
and senior noncommissioned officers (NCOs)                      stationed in Hawaii where he was exposed to numerous
during the Vietnam conflict. He attributed these                “after-action” and “lessons learned” reports coming from
incidents to disaffection and poor morale because               Vietnam. Many of these emphasized the dangers from
the war was increasingly seen as useless by the                 civilians who were secretly Viet Cong. Many reports
soldiers who were unwilling to risk their lives in a            included descriptions of Vietnamese women and children
lost cause. The specificity of circumstances and the            unexpectedly killing and wounding Americans with gre-
importance of leadership surrounding that form of               nades and satchel bombs. While this intelligence justi-
indiscipline called combat refusal is seen in the               fied heightened awareness and precaution to protect
                                                                against such attack, it in no way justified the rape and
following case.
                                                                murder of unarmed women and children, not even ones
                                                                taken prisoner after committing such an attack, let alone
Case Study 4: The Silver Star Medic                             ones rounded up in a village without resistance.
                                                                    Secondly, Calley identified strongly with his men and
    Specialist 4th Class (SP4) MC was the medical aidman        was quite upset when his company incurred large num-
(“medic”) attached to an infantry company. In several           bers of casualties in the My Lai region (thought to be pro-
battles he had performed with great valor, risking his life     Viet Cong) not long before the killings in My Lai. He was
to treat wounded comrades, resulting in his being recom-        even more upset because he had been away when this
mended for award of the Silver Star. He was referred for        occurred. This concern for his troops is to his credit, and
psychiatric evaluation when he refused to go out on a           qualifies his action as a misconduct stress behavior,
combat mission. The author found no evidence whatever of        rather than as simple criminal misconduct. It does not,
psychiatric impairment or personality disorder. The young       however, excuse it or justify it.
soldier stated that he would not go into combat with a “green       Finally, Calley tended to see things in a black or white,
lieutenant” who had replaced the company commander, a           all-or-none fashion. If the enemy included women and
captain, with whom the medic had deployed. The captain          children and the enemy were supposed to be killed, so be
had been wounded and was currently performing light             it. Had the villagers (men, women, or children) been firing
duties in the division headquarters. The medic stated that      at the American troops, it would have been entirely correct
on the first engagement with the enemy the new lieuten-         to shoot and kill them, but only up until the point where
ant had foolishly risked his troops, resulting in several       they surrendered. If noncombatants had been killed in
wounded soldiers. As much to protect his comrades as            such a firefight, that would have been regrettable but
himself (because the unit could not go out without a            justified. But Calley was convicted of having ordered and
medic), SP4 MC refused to go on a combat mission.               participated in the deliberate massacre of about two
    Comment: This young soldier was actually sent to the        dozen unarmed Vietnamese men, women, and children.
psychiatrist as a ploy on the part of command in hopes that     Evidence in the Peers Investigation Report suggested
a medical solution could be found for a leadership prob-        that over a hundred persons were in fact murdered.63




76
                                                                                   Disorders of Frustration and Loneliness


    One of the soldiers at the My Lai atrocity, rather than     Stress Disorders
participate in killing women, children, and old men, shot
himself in the foot. Although self-inflicted wounds are            To the heterogeneous syndromes found in low-
usually intended to escape combat (in Vietnam this eva-         intensity wars that have been labeled loneliness and
sion was often thwarted by orthopedic surgeons who put
                                                                frustration casualties (“nostalgic casualties”) should
some of these soldiers in “walking casts”), in this case an
altruistic outcome was effected. When the author re-            be added acute stress disorders and chronic and
viewed the testimony of all the U.S. Army participants at       delayed post-traumatic stress disorders (chronic
My Lai in preparation for his testimony at Calley’s court-      and delayed PTSD). PTSD is usually and appropri-
martial, he found most of the soldiers were deeply con-         ately thought of in the context of acute overwhelm-
flicted and some approved the self-inflicted wound solu-        ing stress; however, the frequent morale problems
tion to the conflict. Others, however, felt that this soldier   of low-intensity, ambiguous wars may carry over
was cowardly. His “indiscipline,” via his self-inflicted        into the postwar lives of the former combatants.
wound, prevented worse indiscipline on his part.                The current discontents of these war veterans may
    Comment: Testimony63 indicated that some of the U.S.
                                                                find expression in the reappearance or new appear-
soldiers committed unspeakable acts of sexual assault in
committing the murders. The fact that presumably previ-         ance of symptoms associated with combat: anxiety
ously normal and moral human beings can commit such             and fears, automatic hyperactivity, reliving of psy-
atrocities under the influence of uncontrolled combat           chologically traumatic events, and a variety of other
stress makes clear why it is so important that leadership       malaises. Such symptoms often follow service in
not let such misconduct begin. Calley’s argument that he        wars of high intensity as well, particularly when the
was just obeying the major’s orders is irrelevant. The          outcome was unsatisfactory or there is psychologi-
Uniform Code of Military Justice requires each soldier to       cal or financial gain from such symptoms. This was
refuse to obey a clearly illegal order such as the murder of    seen, for example, in the large numbers of German
unarmed prisoners or noncombatants. The command
                                                                veterans of World War I who developed chronic
climate in Vietnam, and the training prior to the My Lai
atrocity, may have failed to make that clear. No soldier        war neuroses (many of whom would now be la-
appears to have overtly tried to get Calley to rescind his      beled chronic post-traumatic stress disorder) com-
illegal order. Forms of indiscipline in which not only          pared with the small numbers of such cases follow-
military but also international rules for handling prisoners    ing World War II.65 In both cases Germany lost the
and noncombatants are disregarded may be more com-              war, but one difference was that after World War II
mon in low-intensity conflicts. Following the recapture (by     veterans were not given pensions for neurotic
U.S. and South Vietnamese forces) of Hue during the Viet        (nonpsychotic or nonorganic) conditions due to the
Cong and North Vietnamese Tet Offensive, a mass grave           experience of German psychiatrists who knew of
was found containing the bodies of about one thousand
                                                                the World War I findings, and due to the general
men, women, and children presumably slaughtered by the
North Vietnamese. Similarly, torture and killing of prisoners   opprobrium earned by the military because of Nazi
of war (POWs) occurred in the French-Algerian War, in the       atrocities.
guerrilla warfare in Central America (El Salvador and Nica-        Post-traumatic stress disorders evolved from the
ragua) and South America (Argentina), and in 1992 reports       Freudian concept of “traumatic neurosis” and
of POWs in the former Yugoslavia.                               technically are part of the combat stress disorders
                                                                spectrum, of the acute, chronic, or delayed type.
   “Indiscipline” by a high-ranking officer occurred            The chronic and delayed forms of PTSD have as-
in the 1982 Lebanon War when Colonel Eli Geva                   sumed considerable importance as sequelae of
(commander of the Israeli tank force outside Beirut)            combat in Vietnam and in the 1982 Lebanon War.
refused to lead his troops into Beirut, which he                PTSD is explored at length in Chapter 16, Chronic
expected to entail killing civilians. Geva urged that           Post-Traumatic Stress Disorder. Here it is impor-
Beirut not be attacked and asked to be demoted to               tant to recognize that PTSD symptoms can follow
tank crew member if the city were attacked. Geva’s              any serious psychological trauma, such as ex-
courageous act resulted in rapid decisive action                posure to combat, accidents, torture, disasters, crimi-
(Geva’s prompt removal and isolation from other                 nal assault, and exposure to atrocities or to the
military personnel) coupled with the decision to                sequelae of such extraordinary events. POWs ex-
launch a more discriminating attack that would                  posed to harsh treatment are particularly prone to
minimize civilian casualties. This prevented other              develop PTSD. In their acute presentation, these
commanders from following suit.64 Calley showed                 symptoms, which include subsets of a large variety
no concern for civilians; by contrast, Geva was                 of affective, cognitive, perceptual, emotional, and
criticized for showing too much concern.                        behavioral responses delineated in Exhibit 3-1, are



                                                                                                                       77
War Psychiatry



     EXHIBIT 3-1
     APA DIAGNOSTIC CRITERIA FOR 308.3 ACUTE STRESS DISORDER




         Exhibit 3-1 is not shown because the copyright permission granted to the Borden Institute, TMM,
      does not allow the Borden Institute to grant permission to other users and/or does not include usage
      in electronic media. The current user must apply to the publisher named in the figure legend for
      permission to use this illustration in any type of publication media.




     Reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th
     ed. (DSM-IV). Washington, DC: American Psychiatric Press; 1994: 431–432.




relatively normal responses to gross psycholog-                      saw and did. Misperceptions and misunderstand-
ical trauma. If persistent, however, they develop a                  ings are corrected in the process, and feelings and
life of their own and may be maintained by inad-                     reactions are shared openly. After an especially
vertent reinforcement. Early intervention and later                  traumatic event, the small units should receive a
avoidance of positive reinforcement (which may be                    formal critical event debriefing. These sessions
subtle) for such symptoms are critical preventive                    should occur within several days of the event, and
measures.                                                            are led by trained debriefing teams. Critical event
   Current doctrine22 emphasizes the importance of                   debriefings also get everyone to describe the facts of
routine debriefing after any traumatic action to                     the event, and deliberately help everyone verbalize
minimize subsequent post-traumatic stress. These                     and process their thoughts, emotional reactions,
debriefings may involve just the small unit itself, as               and physical stress symptoms. The debriefing team
leader-led after-action debriefings. These sessions                  must emphasize the normality of those reactions,
review lessons learned while clarifying the facts of                 and the value of talking them out now as wise
the event, by getting everyone to describe what they                 preventive maintenance. Units should also con-


78
                                                                            Disorders of Frustration and Loneliness


duct routine end-of-tour debriefings as part of           form of warfare as in higher-intensity combat. The
prehomecoming activities. Chapter 11, Debriefing          dynamics of cohesive units are discussed at length
Following Combat, explores these issues in greater        by Manning.66 The level of material support does
detail.                                                   not appear to be a factor in such units and, by giving
   The only units in which psychiatric casualties of      an appearance that sacrifice is unnecessary, may
either the high-intensity combat stress or of the low-    even be detrimental. While some soldiers benefit
intensity combat stress type appear minimal are           from abundant material support and close commu-
highly cohesive, usually elite units. Thus, the build-    nication with loved ones, many soldiers may para-
ing of cohesive, well-led units is as important in this   doxically benefit from a more austere situation.


      LOW-INTENSITY COMBAT STRESS CASUALTIES: PREVENTION AND TREATMENT


   Although successful treatments for low-inten-          dead comrades’) experiences, accomplishments, and
sity combat stress casualties were developed as           sacrifices.
early as the Napoleonic Wars, circumstances can              Some aspects of treatment have been exemplified
prevent the application of remedies. For example,         in the foregoing cases and in preceding chapters. It
during the Vietnam conflict the 1-year rotation           may be summarized as treatment of acute post-
policy, ostensibly for the purpose of preventing          traumatic stress disorder following combat psychi-
psychiatric casualties due to cumulative stress, the      atric principles, not reinforcing symptoms associ-
policy of rotating commanders out of combat units         ated with chronic and delayed post-traumatic stress
after 6 (and later only 3) months in order to give        disorder, use of evocative therapies emphasizing
more officers combat experience, and the policy of        correcting current maladaptive behaviors, and ju-
individual replacement of losses rather than unit         dicious use of pharmacotherapy in some cases.
replacements, all interacted to impair unit cohe-            A critical component of treating chronic post-
sion, which might have prevented at least some of         traumatic stress disorder is determining associated
the nostalgic casualties. Most combat soldiers and        conditions, especially drug and alcohol abuse, and
marines left the combat zone by commercial air,           treating them as well. The use of a relaxation
without any combat comrades with whom to talk             technique such as one of those described by Benson67
out (debrief) the memories of the tour. Their recep-      can be critical in managing anxiety symptoms with-
tion in the United States also usually discouraged        out resorting to medications or may be adjunctive
further sharing and validation of their (and their        to their use.

                                      SUMMARY AND CONCLUSION


   This chapter has described the emergence of            chronic post-traumatic stress disorder (formerly
symptoms more often encountered in garrison set-          called war neurosis). Studies of American prison-
tings—various character and behavior disorder             ers of war held by the Japanese and North Koreans
problems—as the primary nosologic entities in low-        reveal that harshly treated prisoners of war are at
intensity combat. The resurrection of the ancient         high risk for developing chronic post-traumatic
entity “nostalgia” seems appropriate as a generic         stress disorder.
approach to conceptualize and treat these casual-            In the future, U.S. forces are far more likely to
ties. The postwar emergence of large numbers of           encounter low-intensity combat than high-inten-
veterans suffering from chronic and delayed post-         sity combat. The psychiatric casualties, which un-
traumatic stress disorder following the Vietnam           doubtedly will be unique to the situation, are still
conflict and the 1982 Lebanon War is explored in          likely to resemble in some fashion those of previous
Chapter 16, Chronic Post-Traumatic Stress Disor-          low-intensity wars. The human organism is amaz-
der, in terms of the evolution of the post-traumatic      ingly adaptable, and responds to threats to its exist-
stress disorder concept and approaches to preven-         ence by calling forth the maximum adaptive strate-
tion and treatment. Studies from World War II             gies to escape from the perceived danger. When
reveal that improperly treated cases of acute post-       effective methods for returning combat fatigue cases
traumatic stress disorder (combat fatigue) account        to battle were developed, is it possible that newer
for most of the subsequent postwar disability from        symptom complexes to avoid danger occurred as an


                                                                                                                79
War Psychiatry


adaptive function? Failure to take malarial prophy-             in combat fatigue. Given this difficulty, treatment
laxis, drug abuse, and misconduct defy the applica-             and preventive psychiatric procedures must be flex-
tion of traditional combat psychiatric principles but           ible to optimize the return of such casualties to
may reflect the same psychodynamic processes seen               normal functioning.

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20.   US Department of the Army. Planning for Health Service Support. Washington, DC: DA; 9 September 1994. Field
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30.   Brill NQ, Beebe GW. A Follow-up Study of War Neuroses. Washington, DC: US GPO; 1955: 329–333.

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33.   Norbury FB. Psychiatric admissions in a combat division. US Army Med Bull Far East. July 1953:130–133.

34.   Marren JJ. Psychiatric problems in troops in Korea during and following combat. US Armed Forces Med J.
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35.   Camp NM. 1982. Vietnam military psychiatry revisited. Presented at the annual American Psychiatric
      Association meeting. Toronto, Canada: May 15–21, 1982.

36.   Fleming RH. Post Vietnam syndrome: Neurosis or sociosis? Psychiatry. 1985;48:122–139.

37.   Holloway H, Ursano R. The Vietnam veteran: Memory, social context and metaphor. Psychiatry. 1984;47:103–108.

38.   Renner JA. The changing patterns of psychiatric problems in Vietnam. Compr Psychiatry. 1973;14(2):169–180.

39.   Silsby HD, Cook CJ. Substance abuse in the combat environment: The heroin epidemic. In: Adelaja O, Jones FD,
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40.   Marlowe DH. Cohesion, anticipated breakdown, and endurance in battle: Considerations for severe and high
      intensity combat. Walter Reed Army Institute of Research, Neuropsychiatry Division. Washington, DC:
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 41.   Belenky GL. Varieties of reaction and adaptation to combat experience. Bull Menninger Clin. 1987;51(1):64–79.

 42.   Poirier JG, Jones FD. A group operant approach to drug dependence in the military that failed: Retrospect. Milit
       Med. 1977;142(5):366–369.

 43.   Tischler GL. Patterns of psychiatry attrition and of behavior in a combat zone. In: Bourne PG, ed. The Psychology
       and Physiology of Stress. New York: Academic Press; 1969: 19–44.

 44.   Billings EG. South Pacific base command. In: Glass AJ, ed. Overseas Theaters. Vol 2. In: Neuropsychiatry in World
       War II. Washington, DC: Office of The Surgeon General, US Army; 1973: 473–512.

 45.   Huffman RE. Which soldiers break down: A survey of 610 psychiatric patients in Vietnam. Bull Menninger Clin.
       1970;34:343–351.

 46.   Cohen S. The Drug Dilemma. New York: McGraw-Hill; 1969: 76.

 47.   Froede RC, Stahl CJ. Fatal narcotism in military personnel. J Forensic Sci. 1971;16(2):199–218.

 48.   Baker SL. Drug abuse in the United States Army. Bull NY Acad Med. 1971;47(6):541–549.

 49.   Roffman RA, Sapol E. Marijuana in Vietnam. Int J Addict. 1970;5(1):1–42.

 50.   Black S, Owens KL, Wolff RP. Patterns of drug use. Am J Psychiatry. 1970;4:420–423.

 51.   Stanton MD. Drugs, Vietnam, and the Vietnam veteran: An overview. Am J Drug Alcohol Abuse. 1976;3(4):557–570.

 52.   Robins LN, Helzer JE, Davis DH. Narcotic use in Southeast Asia and afterward. Arch Gen Psychiatry. 1975;32:955–961.

 53.   McCoy AW. The Politics of Heroin in Southeast Asia. New York: Harper & Row; 1972.

 54.   Frenkel SI, Morgan DW, Greden JF. Heroin use among soldiers in the United States and Vietnam: A comparison
       in retrospect. Int J Addict. 1977;12(8):1143–1154.

 55.   Spragg G. Psychiatry in the Australian military forces. Med J Aust. 1972(1):745–751.

 56.   Spragg G. Australian forces in Vietnam. Presented at Combat Stress Seminar, Department of Military Psychia-
       try, Walter Reed Army Institute of Research, Walter Reed Army Medical Center. July 10, 1983; Washington, DC.

 57.   Fry CC, Rostow EG. National Research Council, Interim Report. Washington, DC: GPO; April 1, 1945.

 58.   Michie HC. The venereal diseases. In: Siler JF, ed. Communicable and Other Diseases. In: The Medical Department
       of the United States Army in the World War. Vol 9. Washington, DC: Office of The Surgeon General, US Army; 1928:
       263–310.

 59.   Deller JJ, Smith DE, English DT, Southwick EG. Venereal diseases. In: Ognibene AJ, Barrett O Jr, eds. General
       Medicine and Infectious Diseases. In: Ognibene AJ, ed. Internal Medicine in Vietnam. Vol 2. Washington, DC: Office
       of The Surgeon General, US Army; 1982: 233–255.

 60.   MH staffs need more AIDS education, Pasnau advises. Psychiatr News. 4 July 1986;21(3):1,12.

 61.   Rose E. The anatomy of mutiny. Armed Forces Society. 1982;8(4):561–574.

 62.   Linden E. The demoralization of an army: Fragging and other withdrawal symptoms. Saturday Review. 8 January
       1972:12.

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                                                                                Disorders of Frustration and Loneliness


64.   Gal R. Commitment and obedience in the military: An Israeli case study. Armed Forces Society. 1985;2(4):553–564.

65.   Kalinowski LB. War and post-war neuroses in Germany. Med Bull US Army, Europe. 1950;7(3). [Reprinted Med
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66.   Manning FJ. Morale and cohesion in military psychiatry. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM,
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67.   Benson H. The Relaxation Response. New York: William Morrow; 1975.




                                                                                                                    83
                                                         Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare




Chapter 4

NEUROPSYCHIATRIC CASUALTIES OF
NUCLEAR, BIOLOGICAL, AND
CHEMICAL WARFARE
FRANKLIN D. JONES, M.D., F.A.P.A.*



                                      INTRODUCTION

                                      CHEMICAL WARFARE
                                        Physiological Effects of Nerve Agents
                                        Physiological Effects of Other Agents
                                        Neuropsychiatric Syndromes Associated With Chemical Warfare

                                      BIOLOGICAL WARFARE
                                        Physiological Effects of Biological Agents
                                        Neuropsychiatric Casualties of Biological Agents

                                      NUCLEAR WARFARE AND DISASTERS
                                        Physical Effects of Nuclear Warfare
                                        Electromagnetic Pulse Effects of Nuclear Warfare
                                        Physiological Casualties of Nuclear Warfare
                                        Neuropsychiatric Casualties of Nuclear Warfare
                                        Laser and Microwave Radiation
                                        Treatment of Neuropsychiatric Casualties of Nuclear Warfare

                                      SUMMARY AND CONCLUSION




* Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
 President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and
 Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                          85
War Psychiatry




Kerr Eby                                        Match Sellers, Class of ’17                             1918

Kerr Eby was initially a member of the Ambulance Corps in the U.S. Army in World War I, then transferred
to the Engineers, and went to the front lines in France. His painting depicts a group of soldiers blinded
during a gas attack. Whereas the neuropsychiatric casualties of other forms of warfare may present as
individuals, the casualties of nuclear, biological, and chemical warfare are most often seen as groups
because the agent, whatever it may be, is delivered in a dispersed form to affect as many troops as possible.
The title, Match Sellers, refers to a possible occupation, from a previous era, for these soldiers when they
return home.



Art: Courtesy of US Center of Military History, Washington, DC.




86
                                               Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare




                                               INTRODUCTION


   Although outlawed by both the Hague Conven-              cates that the U.S. armed forces or modern armies
tion1 and the Geneva Convention, 2 chemical war-            must be prepared for the possible use of such agents
fare continues to exist along with potential use of         in future wars.
nuclear and biological warfare. In recent wars it              The use of tactical (battlefield) nuclear weapons
has been alleged that the former Soviets used myco-         is possible not only between the major powers but
toxins against Afghan guerrillas and that Vietnam           also between smaller industrialized and nonindus-
used “yellow rain” (mycotoxins) in Cambodia and             trialized nations. In addition to the nations known
Laos. Iraq used chemical agents against Iranian             to have nuclear arsenals in 1992 (United States,
soldiers and Kurdish rebels, and had the ability to         Russia, Ukraine, Khazakstan, Great Britain, France,
use them against coalition forces in the Persian Gulf       China, and India), a number of countries had nuclear
War. The long history of the use of such agents is          weapons or were developing them (South Africa,
likely to continue. This usage has usually occurred         Israel, Pakistan, Iraq, and possibly North Korea,
when one side has, or believes that it has, superior-       Iran, and Brazil). Most industrialized European
ity in such weaponry. During World War II, the              nations are capable of developing such weapons if
Germans had a superior capability in the form of            they choose to do so. Furthermore, the potential for
nerve agents; but, believing the Allies to have a           terrorists to steal nuclear weapons or to make primi-
similar capability, they did not use them. There is,        tive devices also exists. Mental health workers
therefore, a compelling argument in favor of the            must plan for tactical and strategic nuclear ex-
deterrent effect of parity in chemical warfare capa-        changes.6 Strategic nuclear exchanges will be ad-
bility. Tear gas and nausea-producing agents, which         dressed in terms of disaster planning. This chapter
were not designated as prohibited agents by the             will address the psychiatric aspects of tactical
Hague1 and Geneva 2 conventions, were used by               nuclear weapons and nonnuclear radiation threats
U.S. forces in Vietnam.3–5 Exhibit 4-1 reveals the          after first discussing chemical and biological war-
frequency of alleged usage of chemical and biologi-         fare which appear more likely to exist on the battle-
cal weapons since World War I. This review indi-            field than nuclear warfare.


                                            CHEMICAL WARFARE


   Ancient artwork and documents reveal the use of          and in July 1917, mustard gas. Other gases were
chemical agents. Three-thousand-year-old Assyrian           tried, including arsenic compounds and cyanide,
bas reliefs depict the use of liquid fire. Irritant or      but with limited success. Mustard gas was the most
toxic smoke or fumes were used at the sieges of             successful. During World War I, chlorine and mus-
Syracuse (413 BC) and Rhodes (304 BC ). Such agents         tard gas killed or injured more than a million sol-
were used for both their asphyxiating and incendi-          diers and civilians.
ary effects but were not very effective.7                      Although the U.S. Army entered late in the war,
   At the Hague Congress in 1899, all countries             31% of all American battle casualties were due to
represented, except the United States, pledged to           gas.7 Russian gas casualties amounted to half a
refrain from using suffocating or poisonous gases.          million, of which 10% were fatalities. The Russian
The U.S. delegate felt that it was illogical to say that    Army suffered twice the number of casualties and
gas was inhumane while bombs, bullets, and other            5-fold the number of deaths secondary to gas than
methods of warfare were more humane.7                       any other combatant.8
   Just 15 years later, the modern use of poison gas           The forerunners of modern chemical nerve agents
began in earnest during World War I. In August              were developed by German chemists during
1914, the French used tear gas against German               the 1930s as a by-product of insecticide research.
troops. On the pretext that this was chemical war-          By the end of World War II, about 12,000 tons
fare, in April 1915, the Germans attacked French            of Tabun (Ga) and small amounts of Sarin (Gb)
troops by releasing 180 tons of chlorine in a cloud         and Soman (Gd) were synthesized, most of
north of Ypres. This attack was devastating. In             which fell into Soviet hands. As mentioned, the
December 1915, the Germans introduced phosgene              Germans did not use these weapons because they


                                                                                                                    87
War Psychiatry



     EXHIBIT 4-1
     CHRONOLOGY OF CHEMICAL AND BIOLOGICAL WARFARE ALLEGATIONS


     1899: Hague Council outlawed use of chemical warfare (CW)
     1915–1918: World War I—Both sides used chemical agents extensively
     1919–1921: Russian Civil War—Both sides perhaps, Whites definitely, used CW
     Early 1920s: British forces in Middle East—Both sides allegedly used CW
     Mid 1920s: Morocco—Spanish used mustard gas in 1925; French allegedly used it
     Early 1930s: China—Governor of Manchuria used CW against insurgents
     1935–1936: Ethiopia—15,000 of total 50,000 Ethiopian casualties were from CW agents used by Italy
     1936: Spain—Probably only tear gas used by Fascists
     1937–1945: China—CW used by Japanese but probably irritants initially, mustard later; Japanese experimented
          with bacteria on human prisoners
     1939–1945: World War II—Poles in 1939 used mustard gas defensively; Germans used chemical and bacterial
          agents in crimes against civilians in concentration camps; Japanese used cyanide hand grenades on U.S.
          forces in Pacific; U.S. forces had mustard gas available but the only casualties from its use were Americans
          accidentally exposed.
     1945–1949: China—Civil War—Alleged use of CW by Nationalists
     1947: Indochina—Alleged use of CW by French
     1949: Greece—Civil War—Sulfur dioxide allegedly used by government (first military use of sulfur dioxide was
           in the same area 2300 years earlier when the Peloponnesians besieged Platea)
     1951–1952: Korea—United States allegedly used CW and biological warfare, admits only to tear gas
     1957: Cuba—Castro forces allegedly used mustard gas
     1958: Rio de Oro—French and Spanish allegedly used CW in Sharan, Morocco, area
     1958: China—Nationalists allegedly used CW from Quemoy against the mainland
     1963-1967: Yemen—Egyptian forces allegedly used CW (multiple gases) in Yemeni Civil War
     1965–1971: United States used tear gas in Vietnam; others were alleged
     1968: Guinea and Bissau—Portugal allegedly used gas
     1969: Palestine—Palestine Liberation Organization accused Israel of using gas warfare
     1970: Angola—Portugal was accused of gas warfare
     1970: Rhodesia (now Zimbabwe)—Government was accused of poisoning a rebel water supply
     1980s: Afghanistan—Soviets allegedly used CW, particularly mycotoxins, especially early in the war
     Early 1980s: Cambodia and Laos—Vietnam allegedly used mycotoxins in “yellow rain”
     1980s: Iraq used several chemicals, including mustard gas and nerve agents, against Iranian ground troops. In
          1988, hundreds of Kurdish civilians and Iranian soldiers were killed by Iraqi mustard and cyanide gas in
          territory captured by Iran; Iran allegedly retaliated with CW
     1991: Iraq had chemical agents but did not use them during the U.N. attack on Iraq. Iraq was close to developing
           a nuclear capability.
     Data sources: [1899–1970] Stockholm International Peace Research Institute. The Problem of Chemical and Biological Warfare. Vol 1:
     The Rise of CB Weapons. New York: Humanities Press; 1971: 1–5, 141–212, 212–230. [1980–1991] Author research.




88
                                              Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


mistakenly believed that the Allies also possessed         subject to birth defects). Many of the sufferers (and
them.                                                      one congressman) attribute this “Persian Gulf Syn-
   Many armies expect that chemical weapons will           drome” (which is perhaps more appropriately la-
be used in any major conflict. Modern military             beled “Possible Persian Gulf Illnesses”) on either
doctrine assumes that combat operations will con-          trace quantities of Iraqi chemical or biological agents,
tinue in the presence of toxic chemicals. As of 1990,      or on the U.S. pretreatment drug pyridostigmine or
training in the use of protective masks and clothing       the vaccinations against anthrax. Another suspect
started at the grade school level in schools in the        is radiation from the depleted uranium used as
former Soviet Union and continued through ado-             antitank ammunition or additional armor for tanks.
lescence and into the military service. Soviet troops      The difficulty of confirming or excluding any of
were routinely trained to fight while wearing pro-         these hypotheses illustrates the high ambiguity of
tective masks and clothing, and chemical defense           the NBC threat and the severe stress that ambiguity
personnel were integral to Soviet fighting units           causes.
down to the company level.9 Training of Soviet
troops included exposure in protective gear to ac-         Physiological Effects of Nerve Agents
tive diluted nerve agents. Psychological condition-
ing to fighting in a chemical environment was also            The “nerve agents” are derived from organo-
heavily stressed.8 Soviet chemical weapons were            phosphorus compounds related to commercially
believed to consist predominantly of the nerve             available insecticides such as parathion and
agents (particularly Soman), cyanide and mus-              diazinon. They are extremely toxic. For example,
tard,10,11 and possibly mycotoxins. With the demise        0.8 mg of Soman or 0.4 mg of agent VX can be lethal.
of the Soviet Union and Warsaw Pact, the threat of         Other nerve agents include Sarin and Tabun, which
major warfare and use of NBC warfare is lessened;          can penetrate ordinary clothes with ease, making
however, terrorist use of such weapons remains a           special suits necessary for protection. Nerve agents
real threat. This is exemplified by the March 1995         in the liquid state can penetrate unbroken skin, and
use of Sarin in the Tokyo subway system terrorist          one or two droplets on the skin can be fatal if not
attack, reportedly by the religious cult Aum Su-           removed immediately.15 The addition of thickening
preme Truth. The attack resulted in 10 deaths and          compounds to these agents can increase persis-
over 1,000 injuries.12                                     tence, resulting in a contact hazard that may last for
   Iraq used mustard and nerve agent13 in its war          weeks.11
against Iran after the tide of the war had turned in          Nerve agents are irreversible inhibitors of acetyl-
Iran’s favor. Iraqi Republican Guard units, which          cholinesterase, an enzyme that is present through-
had been trained to fight on the contaminated battle-      out the central nervous system, the skeletal muscles,
field, enabled Iraq to win the limited counteroffen-       numerous glands, and other cholinergically inner-
sive which finally brought Iran to accept a grudging       vated organs. Poisoning with these agents leads to
cease-fire. The threat of Iraqi chemical weapons           an inability to break down acetylcholine. An excess of
was taken seriously during the 1991 Persian Gulf           acetylcholine in the synapses results, leading to a
War. Many troops were given prophylactic pyrido-           functional denervation state or subsensitivity of the
stigmine as pretreatment for nerve agent exposure.         post-synaptic receptor in response to overwhelming
The U.S. units were frequently in mission-oriented         stimulation.16 The resulting symptoms of cholinergic
protective posture (MOPP) gear. No cases of Iraqi          overstimulation include lacrimation, salivation, nau-
chemical weapons’ use were documented, although            sea, hyperpnea, rhinorrhea, bronchoconstriction, vom-
there were numerous chemical alarms sounded.               iting, muscle twitching, progressive respiratory pa-
   Since the Persian Gulf War, the media have re-          ralysis, and death. The usual cause of death is
ported that several thousand veterans have com-            respiratory paralysis, which may be central in ori-
plained of miscellaneous symptoms including fa-            gin.17 Autopsy studies of animals who survived
tigue, trouble concentrating and remembering,              exposure to nerve agents revealed extensive dam-
pares-thesias, hair loss, joint pains, skin rashes,        age to limbic neurons.18 This suggests that human
respiratory and gastrointestinal problems, and caus-       survivors of nerve agent poisoning may suffer seri-
tic (irritating) semen.14 Many show severe emo-            ous, permanent personality changes.
tional distress as they testify before Congress or the        The detailed treatment of acute poisoning with
news media that similar symptoms are affecting             nerve agents is beyond the scope of this book; how-
their spouses and children (who they also fear are         ever, the mainstay of treatment is atropine. Cur-



                                                                                                                   89
War Psychiatry


rently U.S. soldiers are provided with three                 impair performance in the low levels of artificial
autoinjectors, each with 2 mg of atropine, for self-         illumination inside vehicles or tents (tactical opera-
administration in the field. As further therapy,             tions centers) and/or at the critical times of pre-
atropine is administered until significant side ef-          dawn and dusk. Soldiers with pinpoint pupils
fects appear. Atropinization is usually maintained           would be seriously impaired and at a dangerous
for at least 24 to 48 hours. As much as 10 to 40 mg          disadvantage in night operations under blackout
of atropine may be necessary in the first 24 hours.19,20     conditions. At slightly higher doses, the soldiers
Some studies21 indicate that scopolamine, which              also have eye discomfort on focusing, blurred vi-
apparently enters the brain more readily than atro-          sion, headaches, jitteriness, and runny noses to fur-
pine, may be more effective than atropine in treat-          ther distract them.25 These symptoms could involve
ing the central nervous system effects of nerve agent        all members of a squad, platoon, or company, to
poisoning.                                                   greater or lesser degree. The pinpoint pupils re-
   Treatment protocols20,22–24 and military manuals25–28     main marked for 24 hours, before gradually im-
all call for treatment with pralidoxime (Protopam            proving over several days. The soldiers may well be
or 2-PAM chloride), which, by removing the bound             fearful of further NBC or conventional attack, un-
agent from the enzyme, reactivates the enzyme. 23,24         willing to venture out after dark, and prone to
While oximes are effective antagonists to many               overreact to threats until adequate vision returns.
cholinesterase inhibitors, they also produce side               Experience with human exposure to the chemi-
effects. Furthermore, some nerve agents are refrac-          cally related organophosphate insecticides suggests
tory to currently available oximes; this is particu-         that, in cases of chronic exposure to low concentra-
larly true of Soman, the predominant nerve agent in          tions, psychiatric symptoms may predominate over
the former Soviet Union arsenal.29 The current               physical ones. Impaired thinking, judgment, atten-
standard oxime of the U.S. Army, pralidoxime chlo-           tion, and short-term memory are likely, but toxic
ride, is administered by the slow intravenous route          delirium may also be present. The cognitive deficits
along with atropine in the Mark I autoinjector.              may persist many months, even after treatment,
   Plans now include pretreatment with pyrido-               along with irritability, mood changes, depression,
stigmine 30 mg every 8 hours prior to anticipated            and insomnia with nightmares. Acetylcholines-
exposure. This does not prevent symptoms but                 terase inhibitors have been found to precipitate
greatly increases the efficacy of atropine and               psychotic symptoms in predisposed individuals.31
pralidoxime. Pyridostigmine is itself a “nerve agent”           Behavioral manifestations of nerve agent poison-
which temporarily protects some acetylcholinest-             ing that antedate, follow, or occur independently
erase enzyme from deactivation by the enemy’s                of somatic symptoms19 may be most prominent in
nerve agents. Diazepam 10 mg is also issued as               individuals who have been exposed to sublethal
an anticonvulsant to be administered with the                doses or in those who have recovered from the
third autoinjector or if the casualty is convulsing,         somatic effects of poisoning. Acute organophos-
with the goal of decreasing the chances of lasting           phorus intoxication produces cognitive impair-
brain damage. Genetic engineering may allow                  ment with difficulty in concentration, confusion,
the development of a more effective antidote in              and drowsiness. 31,32 Airplane crashes of crop-
the future. This is suggested by the discovery of            duster pilots may be due to acute intoxication with
an enzyme in squid nerves that hydrolyzes and                organophosphorus compounds.33 Chronically-ex-
detoxifies Soman.30                                          posed agricultural workers have complained of for-
   If a nerve agent is used, many soldiers will re-          getfulness, difficulty in thinking, visual impair-
ceive only low doses by virtue of location or protec-        ment, and drowsiness. These deficits were
tive measures; this low-level poisoning may be ac-           quantified by sophisticated testing. 34 Another
cepted as a calculated risk or may even go                   study32 showed that chronically-exposed workers
undetected. If a nerve agent is used, many more              had higher levels of anxiety than matched controls.
soldiers will receive only very low doses than will          Chronic exposure has also been associated with
receive high doses, by virtue of their location or           increased anxiety, possibly causing misdiagnosis of
protective measures. Some low-dose exposure may              combat stress reactions.35 Memory also appears to
be accepted as a calculated risk. The first symptom          be impaired by organophosphate poisoning.20 Sig-
of minimal exposure of the eyes to nerve agent               nificant impairment of cognition, vigilance, and
vapor (at 1⁄30th to 1⁄50th of the lethal dose) is pinpoint   memory may make it difficult for a minimally-
pupils.25 This does not grossly impair vision in             exposed soldier to perform the often complex tasks
bright light, but causes dimming of vision and may           that will be required.


90
                                               Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


   Poisoning with nerve agents may cause other              sions, and visual and tactile hallucinations lasting 8
psychiatric disturbances that mimic psychological           to 16 hours. TAB (TMB-4 [an oxime], atropine, and
as opposed to organic disorders. Depression has             benactyzine), an antidote combination formerly used
been observed as a prominent symptom in acciden-            by the U.S. Air Force and U.S. Navy/Marine Corps,
tal poisoning.22,31,36 The severity of depression seems     was virtually guaranteed to produce psychosis with
to be related to the severity of poisoning and the          visual hallucinations in its standard dose.30 While
degree of acetylcholinesterase inhibition. This             the presence of anticholinesterase nerve agents in
depressogenic effect of nerve agents is suggested by        the body may partially counteract such psychiatric
the observation that the reversible cholinesterase          side effects, it is unlikely that agent and antidote
inhibitor, physostigmine, can normalize mood in             will exactly cancel each other.
manic patients and can cause depression in normal              Studies conducted at the U.S. Army Aeromedical
persons.37,38 Could the same be true for the pretreat-      Research Laboratory demonstrated that experienced
ment drug, pyridostigmine, in some soldiers? Nerve          helicopter pilots can fly helicopters, although seri-
agent toxicity has also been associated with com-           ously impaired, after receiving 4 mg of atropine.
plaints of “excessive” dreaming, nightmares, in-            “Effects were seen most often … in terms of aircraft
somnia, and delirium.22,32 Treatment with anticho-          control problems, vision disturbances, impaired
linergic agents seems to reduce these symptoms.22           tracking, reduced cortical activation, and decreased
Nerve agents may also lower the threshold for con-          cognitive skills. These problems indicate helicopter
vulsive seizures. These could be mimicked by                tactical flight is dangerous after an unchallenged 4
pseudoseizures in tense, anxious persons, creating          mg dose. Other types of flight should also be
a problem for differential diagnosis.                       avoided for at least 12 hours after atropine.”41(p.857)
   It is possible that nerve agents can cause psychosis,       Following the administration of large doses of
by altering the dopaminergic-cholinergic balance in         atropine, symptoms progress from tachycardia and
mesolimbic structures. Anticholinesterases report-          dryness of the mouth to ataxia, hallucinosis, and
edly activate symptoms in schizophrenic patients.36         confusion. In a study performed at Edgewood
One study39 reported that a higher percentage of agri-      Arsenal,42 subjects administered large doses of atro-
cultural workers exposed to toxic agents developed          pine became unable to pay attention, carry out
psychotic illnesses than would have been expected.          instructions, speak coherently, or perform calcula-
These results have not been confirmed, however.             tions. Significantly, soldiers who had impaired
   In summary, the data on the subacute and chronic         judgment failed to recognize their degree of general
physiological effects of exposure to organophos-            impairment and resented assistance. In this study,
phorus poisons reveal substantial risk of depres-           chlorpromazine, strongly anticholinergic itself, po-
sion and sleep disturbances, decreased cognitive            tentiated the adverse mental effects of anticholin-
abilities, and a slight risk of psychosis and anxiety       ergic agents. This takes on added significance in
disorders.40                                                view of the widespread use of phenothiazines to
   Added to the dangers of nerve agent poisoning            treat anxiety symptoms in Vietnam.43,44
are effects of antidotes, which may outweigh the               Treatment of atropine-type psychoses should not
danger of potential exposure to nerve agents. Self-         include phenothiazines, which produce anticholin-
injection of atropine by the soldier after exposure to      ergic side effects of their own, although haloperidol
nerve agents may be lifesaving, but inappropriate           may be used. Current definitive treatment is with
self-injection may lead to a central anticholinergic        the carbamate, physostigmine, but this requires
syndrome with delirium. If a false alarm (or a              careful and prolonged intravenous titration.
deliberate attempt to make oneself a casualty) leads           The effects of atropine resemble those of another
to the administration of chemical warfare antidotes         class of chemical agents, the incapacitants. Agent
in the absence of the appropriate agent, serious            BZ (3-quinuclidinyl Bensylate) is a strong antimus-
psychological symptoms are likely. Atropine in              carinic compound that for some time was kept in
low doses produces blurred vision, tachycardia,             the arsenal of U.S. chemical weapons. It produces
dry mouth, sweat suppression with increased risk            hallucinations and psychological incapacitation
of heat stroke, urinary retention, and perhaps im-          similar to that produced by atropine, but is more
paired thinking, judgment, insight, and short-term          specific and longer lasting (24–48 h) than atropine.
memory. Even in the 2 to 6 mg range available for              The burden of self-diagnosis is formidable, par-
early self-administration, atropine may give some           ticularly considering the fact that other agents or
individuals a toxic anticholinergic delirium with           even anxiety may mimic early symptoms of nerve
disorientation, agitation or stupor, paranoid delu-         agent poisoning. Under battle conditions, with


                                                                                                                    91
War Psychiatry


oncoming shells producing smoke or spreading tear        Physiological Effects of Other Agents
gas, with troops dispersed and communications
strained, the apprehension and ambiguities may           Cyanide
unavoidably lead to individual or group decisions
to administer antidotes when exposure to nerve              Other chemical agents also may be encountered.
agents has not, in fact, occurred.45                     Cyanide gas, a nonpersistent agent, is especially
   Whether due to mistaken self-administration of        dangerous because it may saturate the active mate-
antidotes or exposure to antimuscarinic agents, the      rial in gas mask filters and render them useless. A
possibility of significant numbers of casualties         combination of cyanide and a nerve agent would
with anticholinergic poisoning must be considered.       be particularly deadly. The early symptoms of
One example of troops thus exposed was in 1676,          cyanide exposure are anxiety, confusion, giddiness,
when British troops in Jamestown, Virginia, in-          and hyperventilation. These symptoms can also
gested Jimson (“Jamestown”) Weed (Datura stramo-         be caused by stress, and could lead to unneces-
nium) and suffered mass anticholinergic poison-          sary medication with cyanide antidotes. In civilian
ing.46 Bizarre behavior and amnesia allegedly lasted     situations, antidotes to cyanide have often been
for 11 days. The soldiers, who had to be confined        administered inappropriately.51,52 Chronic exposure
to prevent them from injuring themselves, were           to low levels of cyanide could lead to mental changes
very negligent of personal hygiene. More recently,       as was seen when cyanide compounds were
combativeness or hyperactivity was noted in 10%          used therapeutically. 53 The effects of administra-
of a series of 212 cases of stramonium intoxi-           tion of large doses of anticholinergic agents to
cation. 47 Hallucinations occurred in 99 of the 212      soldiers who have been poisoned with cyanide
cases, and 5 deaths were directly attributable to        is unknown. Atropinization may conceal the
psychosis.                                               symptoms of cyanide poisoning or may increase
   The failure to maintain adequate self-care behav-     its lethality.
ior such as keeping dry, maintaining adequate hy-
dration, and attending to personal hygiene has been      Incapacitating Agents
noted as a cause of soldier ineffectiveness.48,49 Re-
ported effects of high doses of anticholinergic agents      Tear-gas agents have been extensively used in
on soldiers include impaired performance in timing       war as most countries have interpreted the Hague
and vigilance tasks, in firing rifles or running an      and Geneva accords against gas warfare as not
obstacle course; ataxia; blurred vision; inability to    applying to these agents. Intended to be used as
perform calculations; and disruption of communi-         harassing agents, their lethality is very low.
cation between individuals. 42 Possible effects in the      Nonlethal incapacitating agents may exert their
field might include failure to observe discipline,       own direct effects on psychological functioning (like
failure to conserve drinking water, failure to wear      the anticholinergic BZ). Those reportedly used in
protective clothing, misinterpretation of visual or      Afghanistan appear to cause temporary uncon-
auditory signals, misidentification of individuals,      sciousness or immobilization. Incapacitants may
failure to maintain silence, and increased risk of       also provoke inappropriate responses by mimick-
heat stroke. Anticholinergic syndromes can be re-        ing the early symptoms of more lethal agents. The
versed with physostigmine,50 but this drug is not        tear gases may be confused with the lacrimation-
easy to use in the field. There are storage problems     producing nerve gases. Vomiting agents may stimu-
and it requires careful titration in use. Further-       late fears of having been irradiated or exposed to
more, as mentioned earlier, physostigmine can pro-       biological agents. Adamsite, in this class, report-
duce serious depression in normal persons, and the       edly also may cause depression.11
same problem of inappropriate use described with
atropine exists.                                         Mustard
   In summary, nerve agents present numerous
problems in practical therapeutics for the psychia-         Mustard gas was responsible for the majority
trist. Both the agents themselves and their anti-        of gas casualties during World War I. It is consid-
dotes may have significant behavioral effects, and       ered an obsolete agent by the U.S. but the former
the military psychiatrist may be called upon to          Soviets were believed to have stockpiles of it,8 and it
treat, and to advise other physicians on how to          was used by Iraq against Iran. Mustard gas is
treat, these problems.                                   unique for its insidious method of action and its



92
                                             Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


latency of several hours before burns and blisters        Neuropsychiatric Syndromes Associated With
appear. It can present a contact hazard for weeks.        Chemical Warfare
Sulfur mustard (bis[2-chloroethyl] sulfide) is a
powerful alkylating agent that can produce severe            Large-scale gas warfare during World War I pre-
skin burns and pulmonary injury if inhaled. Very          sented special problems. In addition to the “physi-
low doses of mustard produce painful conjunc-             cal” casualties of chemical warfare, there were “psy-
tivitis of the eyes which lasts for days to weeks,        chological” casualties and syndromes. One of these
severely impairing vision.54 As with nerve agent,         was “gas hysteria,” which usually occurred in small
blindness on the battlefield, even if known to be         epidemics, threatening the integrity of entire units
temporary, can produce anxiety, dependency, and           until remedial measures were taken.57,58 This “epi-
other psychological as well as management prob-           demic” effect is seen in the following World War I
lems. Higher-dose contact burns the eyes and causes       episode:
permanent blindness as well as disfiguring facial
burns. The potential psychological impact of these           One morning a large number of soldiers were re-
is discussed in Chapter 14, Disabling and Disfigur-          turned to the field hospital diagnosed as gas casu-
ing Injuries. Blistering of exposed hands could also         alties. The influx continued for about eight days
leave long-term physical and emotional scars. In             and the number of patients reached about 500. The
soldiers without protective overgarments, mustard            divisional gas officer failed to find any clinical
                                                             evidence of gas inhalation or burning…. Most of
tends to produce blisters at the moist creases of the
                                                             the patients had the fixed conviction that they had
body, notably the genital region. Psychological              been gassed and would usually describe all the
reactions to genital injuries are also discussed in          details with convincing earnestness and generally
Chapter 14.                                                  with some dramatic quality of expression…. It was
    Blister agents (mustard gas, Lewisite) have been         obvious on examination that they were not really
noted to produce chronic psychological symptoms              gassed. Further, it was inconceivable that they
of apathy and depression55 in addition to their se-          should be malingerers.57(pp318–319)
vere and delayed dermatologic, pulmonary, and
systemic lesions. Phosgene, a suffocant gas, keeps           Acute symptoms of gas hysteria often mimicked
active the traditional World War I terror of gas          some of the symptoms of gas poisoning and in-
attack as producing a horrible sensation of the lungs     cluded dyspnea, coughing, and burning of the skin.
filling with fluid, with the added threat that it         Aphonia was also seen prominently.59 For those in
permanently inactivates the charcoal in one’s mask        whom the symptoms persisted, the term “gas neu-
or overgarment. Phosgene’s delay of several hours         rosis” was applied.60 The degree of exact exposure
before the first symptoms, and the dangerous wors-        to gas was unrelated to the symptoms presented.
ening of symptoms by physical exercise, was espe-         Dramatic symptoms were seen, such as tics and
cially unnerving, even to those not actually ex-          blepharospasm,59 as well as “unconscious move-
posed.56                                                  ments of the hands like clawing at the throat or
                                                          removing a mask.”60(p214) The patients presented
Mycotoxins                                                with signs of air hunger and anxiety with alter-
                                                          ations of consciousness, but no organic basis for the
   The mycotoxins (thought to have been used by           symptoms was found. One author suggested that
the Soviets and their allies in Southeast Asia and        gas neurosis patients “are particularly amenable to
Afghanistan) produce terrifyingly rapid symptoms          suggestion and rest. Optimism based on exact
of vomiting, tissue necrosis, and failure of blood        diagnosis and sincere faith in ultimate recovery is
coagulation. Psychotic symptoms and bizarre be-           excellent therapy.”60(p214) However, some of the gas
havior have not been mentioned prominently in             neuroses continued until long after the war and
current accounts; however, such psychiatric symp-         were rewarded with compensation.57 It should be
toms have been prominent in historical natural out-       remembered that during World War I there were
breaks of “St. Vitus’ Dance” and “tarantism,” which       approximately twice as many gas neurosis cases as
are now attributed to contamination of food grains        there were gas exposure cases.57
by ergot derivatives from other fungal toxins. Men-          Chemical warfare is still perceived as choking off
tal symptoms may also become significant if myco-         one’s breath. In spite of the complicated chemical
toxin patients are kept alive by treatment of the         properties of modern agents, respiratory symptoms
otherwise rapidly fatal symptoms.                         are likely to predominate in conversion reactions.



                                                                                                                   93
War Psychiatry


This is reinforced by current military training re-        ing (which may be imitated by others), spatial dis-
quiring wearing protective clothing while tear gas         orientation, and paranoid reactions to impaired sen-
agents are used to simulate poison gases.                  sory functioning may also occur. Such adverse
   More recently, similar conversion symptoms have         reactions are exacerbated when visibility is further
been reported in the aftermath of chemical attacks         restricted by darkness, smoke, or vegetation. Gas
in Afghanistan and Cambodia,8 with aphonia and             mask phobia proved to be a significant problem in
catatonic symptoms predominating. More gener-              the Allied invasion of Iraq in 1991.67
ally, the mere act of donning protective gear will            Field studies and training exercises which test
increase the soldier’s sense of isolation from peers       troops in force-on-force battles using the MILES
and decrease intragroup communication and sup-             (multiple integrated laser engagement system) to
port, factors that have been shown to be important         score who “shoots” whom have shown an alarming
in maintaining morale and probably in decreasing           increase in friendly fire casualties (“fratricide”) by
the incidence of psychiatric casualties.61                 insufficiently trained troops in the protective en-
   Gas warfare is perceived much as it was in 1918,        semble. Whereas only about 1 in 20 soldiers or
as “awe inspiring” with “unbelievable horrors.”60          vehicles is “shot” by their own side in conventional
During World War I, units that were otherwise              battles, the rate rises as high as 1 in 5 in full mission-
stressed, having spent long periods in combat un-          oriented protective postures.68,69 This is attribut-
der arduous conditions, were at much higher risk           able to the combination of impaired vision and
for “gas hysteria.” This risk increased still further if   hearing plus the jumpiness this provokes. Fratri-
relief was anticipated but did not arrive on sched-        cide, of course, is very disruptive of morale. Rigor-
ule.57 This aspect will loom large in any future mid-      ous training is needed to reduce the risk.
or high-intensity conflict, with the extremely high-          Factors that predispose to psychiatric casualties
pressure, continuous combat operations that are            include the rates of wounding in the unit, lack of
expected. 48,61                                            sleep, and lack of prior combat experience. 70–72
   As long as the nuclear, biological, and chemical        Chemical attacks might increase psychiatric casual-
(NBC) threat is an active, serious threat, protective      ties by exacerbating all three of these factors. 45,73
masks and overgarments must be worn, certainly             Chemical weapons create fear of the unknown, a
for brief periods and perhaps for prolonged ones.          potent effect in inexperienced troops. Usually,
The protective gear distorts visual, auditory, and         troops entering combat will be, for the most part,
tactile perception; impairs fine motor coordination;       untested in battle. Lack of sleep has produced
increases physical effort, frustration, and fatigue;       hallucinations in troops during extended training
and increases psychiatric casualties in simulation         exercises74–76 and is a factor predisposing to combat
exercises.62,63 These effects may be especially dis-       psychiatric reactions.
ruptive to the performance of medical functions;              With the possibility of high-intensity, continu-
however, modifications of protective gear for medi-        ous combat, psychiatric services will be strained to
cal treatment64,65 as well as approaches to triage         the limit. Because this country is committed against
have been proposed. 66 The protective ensembles            the initial use of chemical weapons, U.S. forces
retain body heat and increase the risk of heat ex-         would be the first to suffer from chemical attacks,
haustion and heat stroke, which may present with           with the concomitant psychiatric casualties. Lack
mental symptoms and be difficult to diagnose in            of experience in chemical warfare and the psychiat-
full MOPP (mission-oriented protective posture)            ric syndromes arising from the physiological effects
gear. During a Scud missile attack by Iraq on Israel       of chemical agents and their antidotes may lead to
in January 1991, several elderly persons died of           misdiagnosis and mistreatment. This may lead to
heart attacks while in gas masks.                          decreased unit effectiveness at critical times. The
   The restrictions on eating, drinking, elimination,      difficulties in decontaminating large numbers of
and hygiene functions, along with other discom-            exposed soldiers may lead to removing them to
forts and interference with sleep, can affect morale       centralized decontamination stations well to the
as well as physiological well-being. Decreased abil-       rear. Many soldiers who might be medically fit to
ity to recognize comrades and gauge their mood or          return to their units might develop an evacuation
resolve may lessen unit cohesion and increase the          syndrome that would increase their resistance to
sense of helpless isolation (a prime factor in battle      returning to combat. In the 1982 Israeli incursion
fatigue). Claustrophobic panic, premature unmask-          into Lebanon, some Israeli combat stress casualties




94
                                              Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


were evacuated by air to Israel, while others were         However, it should be noted that most veteran
appropriately treated in forward areas. Almost all         soldiers in World War I adapted to the threats
of the forward-treated cases, but few of the rear-         and discomforts of chemical warfare. They often
evacuated cases, returned to combat.77                     “preferred” this risk of chemical attack to those of
   In summary, the psychological casualties                high explosive shells and machine gun bullets be-
of chemical warfare may well outnumber and                 cause the protective equipment and good training
prove more costly in personnel losses than the             allowed them to improve their odds of survival
physical casualties, as occurred in World War I.78         better.79


                                         BIOLOGICAL WARFARE


   Reports of biological warfare go back many cen-         some persons in casual contact with victims of the
turies. One example is the introduction of smallpox        practically noncontagious (except through sexual
to the American Indians by early settlers who gave         contact and shared needles) acquired immunodefi-
or sold them infected blankets or trinkets.80 How-         ciency syndrome (AIDS) illustrate the validity of
ever, in modern times the use of biological warfare        this factor.
agents appears to have been rare.
   The United States did not have an offensive or          Physiological Effects of Biological Agents
defensive biological warfare capability until toward
the end of World War II.80 The nascent program                A number of viral, bacterial, and rickettsial agents
focused on anthrax and botulinus toxins primarily.         have been identified as potential weapons, both for
An anthrax plant received authorization to produce         their psychological effects and the terror those ef-
a million bombs and progress was being made in             fects produce in exposed troops. Anticipated psy-
short-range dispersal techniques for botulin in paste      chiatric casualties of biological warfare will be in-
form. Figure 4-1 shows a probable descendent of            cluded in a general discussion. It is, however,
the World War II anthrax dispersal bomb. More-             possible that an enemy could develop neurotropic
over, there is evidence that research was conducted        viral agents that could produce primarily psychiat-
with brucellosis, psittacosis, tularemia, and the res-     ric symptoms. 82 Tables 4-1, 4-2, and 4-3 show agents
piratory disease, glanders. In addition, botanical         considered by Malek80 to have a biological warfare
toxins and viruses were being explored with the            potential.
aim of destroying Japanese vegetable gardens and
rice crops. Tactical, rather than moral, consider-         Neuropsychiatric Casualties of Biological
ations prevented the use of defoliants in World War        Agents
II. They were later used in Vietnam, in the form of
Agent Orange.                                                  Contagious biological organisms, like persistent
   Rumors that a 1979 mishap with anthrax in the           transmissible chemical agents, would require quar-
former Soviet Union produced scores of casualties          antine and special handling. This would surely
at Sverdlovsk have been replaced by verified ac-           have widespread psychological effects on buddy-
counts that such a mishap actually occurred.81 Iraq        care and attitudes toward strangers, stragglers, and
was suspected of working towards developing an-            refugees. Within the medical system, the impact of
thrax as a weapon. That led to the decision of the         invisible, patient-borne threats to other patients
United States to vaccinate many personnel in the           and to the treating personnel would reintroduce an
Persian Gulf campaign with an experimental an-             old but now rarely encountered psychological as
thrax vaccine. Many of the same considerations of          well as occupational stress, which may be difficult
chemical warfare apply to biological warfare; how-         to cope with under field conditions. In World War
ever, a major difference is the self-perpetuating          I, entire medical/surgical teams were temporarily
effect of live biological agents. This can produce         incapacitated by eye damage from mustard vapor
fear of contagion, which may severely impair rela-         brought into the operating room on wounded pa-
tionships among troops and interfere with proper           tients who had not yet shown any effects of their
care of casualties. The near-panic responses of            own exposure.




                                                                                                                   95
War Psychiatry




Fig. 4-1. Patent application of R. L. Le Tourneau for a light high-explosive bomb for dispersing toxic and insecticidal
aerosols, 1955. Le Tourneau’s patent application reveals the technological ingenuity he employed in continuing the
production of gas warfare mechanisms. This technological interest continued for the next several decades with the
development of safer binary weapons (ie, chemicals were inactive until combined at the time of actual use).
Photograph: U.S. Patent and Trademark Office, Arlington, Va.


96
                                                   Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


TABLE 4-1
POSSIBLE BIOLOGICAL WARFARE AGENTS—BACTERIAL




          Table 4-1 is not shown because the copyright permission granted to the Borden Institute, TMM, does
       not allow the Borden Institute to grant permission to other users and/or does not include usage in
       electronic media. The current user must apply to the publisher named in the figure legend for
       permission to use this illustration in any type of publication media.




Adapted with permission from Malek I. Biological weapons. In: Rose S, ed. CBW: Chemical and Biological Warfare. Boston, Mass:
Beacon Press; 1969: 60–61.




TABLE 4-2
POSSIBLE BIOLOGICAL WARFARE AGENTS—VIRAL




             Table 4-2 is not shown because the copyright permission granted to the Borden Institute, TMM, does
          not allow the Borden Institute to grant permission to other users and/or does not include usage in
          electronic media. The current user must apply to the publisher named in the figure legend for
          permission to use this illustration in any type of publication media.




Adapted with permission from Malek I. Biological weapons. In: Rose S, ed. CBW: Chemical and Biological Warfare. Boston, Mass:
Beacon Press; 1969: 60–61.



                                                                                                                          97
War Psychiatry


TABLE 4-3
POSSIBLE BIOLOGICAL WARFARE AGENTS—RICKETTSIAL, FUNGAL, TOXIC




        Table 4-3 is not shown because the copyright permission granted to the Borden Institute, TMM, does
     not allow the Borden Institute to grant permission to other users and/or does not include usage in
     electronic media. The current user must apply to the publisher named in the figure legend for
     permission to use this illustration in any type of publication media.




Adapted with permission from Malek I. Biological weapons. In: Rose S, ed. CBW: Chemical and Biological Warfare. Boston, Mass:
Beacon Press; 1969: 60–61.



                                    NUCLEAR WARFARE AND DISASTERS


   In some countries the use of nuclear weapons is              quently falls to earth to contaminate it (fallout).
a practical rather than a moral issue. An attack                While an air detonation produces the greatest blast
could be launched by tactical missile forces and                damage, few particles are drawn into the atmo-
fighter bombers.73 There is concern that portable               sphere to mix with radioactive bomb debris so there
tactical nuclear weapons from the stockpiles of the             is little residual contamination from fallout. Nuclear
former Soviet Union or from unstable states might               explosions over water produce massive vaporiza-
fall into the hands of terrorists who could use them            tion and an intensely radioactive rainfall as well as
against cities. Industrial disasters like that at               a 50- to 100-foot tidal wave capable of drowning a
Chernobyl could release nuclear radiation to con-               coastal city.
taminate large areas and require military interven-
tion to minimize the damage, evacuate the popula-               Electromagnetic Pulse Effects of Nuclear Warfare
tion, and maintain order.
                                                                  A high altitude electromagnetic pulse (EMP) is a
Physical Effects of Nuclear Warfare                             radiated electromagnetic wave caused by the deto-
                                                                nation of a nuclear weapon above the earth’s atmo-
   The energy generated by a typical tactical nuclear           sphere. A 3.3 megaton nuclear weapon, detonated
explosion consists of blast and shock waves (45% of             400 km above the center of the United States, can
the energy produced), light and heat (35%), initial             produce sufficient electromagnetic radiation to
radiation (5%), and residual fallout radiation (about           cover the entire country; and, if detonated over
15%). 83 A ground detonation, vaporizing soil and               Europe, most of the continent would be affected.84
melting granite and clay, results in large amounts of           Vandre, et al, 84 in simulated EMP tests, showed that
debris drawn by vacuum into the fireball, where it              by creating power surges in standard field medical
is mixed with radioactive bomb debris and subse-                equipment, an EMP would render about 65% of


98
                                              Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


such equipment useless. The more modern and                   There are two major biological effects of radia-
integrated the equipment, the greater the vulner-          tion in excess of 100 rad (a measure of the dose
ability to an EMP power surge.                             absorbed from ionizing radiation equal to 100 ergs
   An American Medical Association (AMA) report            per gram): (1) cell membrane damage leading to
of the Board of Trustees indicated that civilian medi-     cellular and vascular leakage affecting especially
cal facilities would be equally devastated.85 The          brain and lungs, and (2) loss of reproductive capac-
AMA noted that in addition to medical equipment,           ity in stem cells.87 Different tissues of the body show
telephone and other telecommunication equipment,           different sensitivities to ionizing radiation. In gen-
computers and electronic equipment involved in             eral, the radiosensitive cells are found in lymphoid
life support systems, and diagnostic testing and           tissue, bone marrow, spleen, organs of reproduc-
other equipment utilizing solid state components           tion, and gastrointestinal tract. Of intermediate
are particularly vulnerable.                               sensitivity are skin, lungs, and liver. Muscle, nerve,
   In a related paper, Vandre, et al,86 described          and adult bones are least sensitive.88
methods to minimize the vulnerability of equip-               The medical manifestations of radiation damage
ment to EMP effects by keeping wiring near the             can be conveniently divided into three time phases:
ground, keeping it short, unplugging unused power          initial, latent, and final.88 During the initial phase,
equipment, running power cabling and tents in a            exposed persons may experience nausea, vomiting,
north-south direction (thereby avoiding running            headache, dizziness, and malaise. The onset time
power cabling in an east-west direction), and plac-        decreases and the severity of these symptoms in-
ing sensitive equipment in standardized shelters.          creases with increasing dose. During the latent
By following such procedures Vandre, et al86 esti-         phase, exposed persons will experience few, if any,
mated that 88% or more of unplugged field medical          symptoms and will be able to carry on normal
equipment could be kept functional in the event of         functions. The final phase is characterized by illness
EMP. The AMA noted that the increasing use of              that requires hospitalization of people who have
fiber optic components would decrease the effects          received the higher doses. The symptoms experi-
of EMP because they are not vulnerable to the EMP          enced in the initial phase will recur and be accom-
surge. They recommended use of standby diesel              panied by skin hemorrhages, diarrhea, and some-
generators to provide emergency power.85                   times loss of hair. At higher doses, seizures and
                                                           prostration may occur. The final phase is ended by
Physiological Casualties of Nuclear Warfare                either recovery or death. These effects are summa-
                                                           rized in Table 4-4 and Figure 4-2.
   Studies of the effects of nuclear weapons on hu-           Persistent radioactive contamination is quite simi-
mans, with the exception of a few accidental radia-        lar to persistent mustard gas in many of its effects.
tion victims (particularly in Chernobyl), focus on         Presumed “psychological fallout” is an unseen haz-
the effects of the Hiroshima and Nagasaki bomb-            ard that produces delayed illness in all bodily sys-
ings. A useful bibliography has been prepared by           tems that involve rapid cellular reproduction (ie,
the Atomic Bomb Casualty Commission.87                     distressing gastrointestinal symptoms, impaired
   Initial physical casualties are due to the blast and    wound healing, and increased susceptibility to in-
shock, heat, and nuclear radiation. Later, casualties      fection and hemorrhage). Early death may occur
are primarily from nuclear radiation. The initial          unless sophisticated medical support is given. Sur-
effects are most closely related to the proximity and      vivors are at increased risk of death from cancer.
size of the fireball. At Hiroshima and Nagasaki               Acute irradiation from a nuclear explosion (with-
more than 80% of the population within 0.6 of a mile       out concurrent disabling burn or blast injury) puts
of ground zero were casualties, and over 90% of            the military medical-ethical dilemma of these con-
these casualties were killed. In contrast, of indi-        ditions into even starker relief. In the absence of
viduals who were beyond approximately 1.6 miles            quantitative dosimetry for each exposed patient (a
from ground zero, less than 5% were killed.88 These        difficult task in itself), how are the massed casualties
findings suggest that troop dispersal will be the          to be triaged into those who are expected to die
primary defensive strategy in nuclear war. Burns           (“expectant”) and those who can reasonably be saved
accounted for two thirds of the initial deaths at          with the over-used resources that remain? What is to
Hiroshima and for one half of the total deaths.            be done with those fatally exposed who can still
About 30% of those who died in Hiroshima had               function? Should they be told the prognosis? Should
received lethal doses of radiation; however, this          they be discharged “RTDTD” (“Return To Duty To
was not always the immediate cause of death.               Die”), perhaps to carry out high-risk delaying ac-


                                                                                                                   99
War Psychiatry


TABLE 4-4
SUMMARY OF POTENTIAL MILITARY EFFECTIVENESS OF RADIATION CASUALTIES

                         Onset of                                 Duration of                                                        Incidence
Radiation                initial incapacity                       effectiveness                Later incapacity                      of Death
in rems                  from vomiting, etc.                      (latency)                    (onset to duration)                   (time)

0–100                    None                                     100%                         None                                  None
100–200                  3–6 h to 1 d                             1 d to 2 wk                  10–14 d to 4 wk                       None
200–600                  12
                          ⁄ –6 h to 2 d                           1–2 d to 4 wk                1–4 wk to 1–8 wk                       0%–90%
                                                                                                                                     2–12 wk
600–1,000                15–30 min to 2 d                         2 d to 5–10 d                5–10 d to 1–4 wk                      90%–100%
                                                                                                                                     1–6 wk
1,000–5,000              5–30 min to 1 d                          0 to 7 d                     2 to 10 d                             100%
                                                                                                                                     2–14 d
Over 5,000               Almost immediately                       None                         Almost immediately                    100%
                                                                                                                                     1–2 d

Adapted from Glasstone S, Dolan PJ. The Effects of Nuclear Weapons. 3rd ed. Washington, DC: US GPO; 1977: 580–581.




tions, “kamikaze” attacks, and operations in con-                              convey some of the moral and psychological impli-
taminated areas? What medications should they be                               cations that the Army Medical Department
given for symptom relief to improve their efficiency?                          (AMEDD), the line military, and the exposed indi-
Could those who cannot be discharged provide the                               viduals themselves would have to deal with.
answer to the shortage of whole blood in the combat                               Triage by scarce medical resources is obviously
zone? Will there be a place for euthanasia on the                              the best way to preserve lives. This is critical in an
battlefield to end suffering and preserve other lives                          operational sense in that the medical resources
through allocation of medical resources, as sug-                               should be expended in helping those who are most
gested by Swann?89 Such mind-chilling questions                                likely to be able to return to duty.



                                                                                Organs Affected by Ionizing Radiation


Range             0–100 rems Subclinical range        100–1,000 rems Therapeutic range                     Over 1,000 rems Lethal range

                                                  100–200 rems    200–600 rems 600–1,000 rems     1,000–5,000 rems          Over 5,000 rems

                                                  Clinical        Therapy         Therapy
Role of therapy                                    surveillance    effective       promising                  Therapy palliative

Leading organ                                    Hematopoietic tissue                             Gastrointestinal tract    Central nervous system

Characteristic    None below 50 rems              Moderate        Severe leukopenia;              Diarrhea, fever,          Convulsions, tremor,
 signs                                             leukopenia      hemorrhage; infections;         disturbance of            ataxia, lethargy
                                                                   epilation above 300 rems        electrolyte balance

Critical period
postexposure            ——                                        1–6 wk                          2–14 d                    1–48 h



Fig. 4-2. Summary of clinical effects of acute ionizing radiation. Adapted from Glasstone S, Dolan PJ. The Effects of
Nuclear Weapons. 3rd ed. Washington, DC: US GPO; 1977: 580-581.


100
                                              Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


Neuropsychiatric Casualties of Nuclear Warfare                Psychological studies were not conducted until
                                                           years or decades after the event. Furthermore,
   Although nuclear devices have been used twice           disability compensation, social ostracism, and other
in warfare, no one has actually fought a nuclear           factors colored the survivors’ remembrances. Nev-
war. Neuropsychiatric casualties of nuclear war-           ertheless, a fairly common response pattern was
fare, therefore, must be inferred from studies of the      described in the 1952 study by Kubo,90 who studied
primarily civilian victims of the nuclear explosions       54 victims from 1949 to 1952. Most of them had been
at Hiroshima and Nagasaki; from the disasters in           1 to 3 km from the bomb hypocenter. Kubo found
Goiânia, Brazil, and Chernobyl, Ukraine; from a            that most were “startled” by the initial flash and fell
small number of imperfect simulations, such as the         down and covered their eyes in an “instinctive”
Desert Rock I, IV, and V studies; and from extrapo-        withdrawal from the stimulus, while some turned
lations from situations of extreme stress such as that     to face the flash.
during disasters or combat. The following sections            The blast, causing widespread damage, produced
will briefly review some of these studies.                 a feeling of “mental blankness” lasting for a few
                                                           minutes. This was followed by attempts to escape
Hiroshima and Nagasaki                                     the area of destruction and an inability to make
                                                           clear judgments. Many of the victims aimlessly
   There have only been about 20 useful studies of         followed fleeing crowds until eventually they
the psychological reactions to nuclear explosions;         reached places where they felt safe; there they were
many of these are autobiographical accounts. Al-           given food and shelter. Most experienced a degree
though retrospective, one of the best reviews of the       of recovery by the second day, but from 1 to 3 weeks
physical, social, and psychological toll of nuclear        later radiation sickness began to appear. This was,
devices is that of a Japanese committee commis-            to most, a totally mysterious illness with high fever;
sioned by the cities of Hiroshima and Nagasaki.            bleeding from gums, throat, nose, and uterus; loss
This report was first published in Japan in 1979; an       of hair; and fatigue. This produced high levels of
English translation was published in 1981.90 This          anxiety, particularly as apparently uninjured per-
review concluded that organic forms of mental ill-         sons began to die from intercurrent illness or other
ness among survivors were not prominent.                   causes. The need for early treatment to prevent
   In one study91 of 50 survivors at Omura Hospital        irreversible damage and death has been expressed.92
in Japan, psychoneurological observations were
made 2 to 3 weeks after exposure, the following            Goiânia and Chernobyl
month, and about 3 to 4 months after exposure.
Only 4 of the 50 patients were diagnosed as having            Although the focus here is on short-term radia-
mental disorder in the initial stage. In the interme-      tion effects, recognition of the longer-term effects of
diate stage, some patients, especially those suffer-       increased risk for cancer, sterility, and diminished
ing thermal burns, showed neurasthenia-like symp-          life span may play an acute role in demoralizing the
toms. In the later stage, those suffering a specific       combatants. The Goiânia, Brazil, tragedy in which
diathesis tended to develop neuroses. These were           a small town was exposed to cesium isotopes from
considered indirect effects of physical deterioration.     a medical device, reveals the potential for social
Acute radiation illness was considered to be the only      disruption from radiation exposure. Many of the
direct effect of the atomic bomb on the human              exposed individuals were shunned by friends and
psychoneurological system. Konuma91 has argued             neighbors. Exports of produce from Goiânia
that complaints of “agony,” lassitude, fatigability,       dropped precipitously.
and other symptoms constitute a “diencephalic syn-            Similar effects were reported in the Chernobyl
drome,” which can be diagnosed even in the absence         disaster in the Ukraine. Of 148 persons subjected to
of physical examination signs or abnormal labora-          radiation effects of the Chernobyl atomic energy
tory findings. The presumption is that hematologic         electrical plant accident and treated at Kiev Mental
or other direct radiation effects on nerve cell mem-       Hospital from 1986 through 1990, reactive psycho-
branes have damaged the vegetative nervous sys-            ses were observed in only 11 cases and this was
tem. However, the severe losses (of relatives, physi-      mainly during the 2 to 4 months after the disaster
cal capacities, and material resources) experienced        when the production of stress was maximal. It
by many of the victims could readily produce a             appears that stress, resulting in various psycho-
depressive syndrome with many of these character-          pathological conditions including, rarely, psycho-
istics, particularly in a vulnerable personality.          sis, is paramount in producing psychiatric symp-


                                                                                                                  101
War Psychiatry


toms, rather than biological effects of ionizing ra-     aerial explosion in October 1951. Attitude assess-
diation on central nervous system tissue. 93             ment, factual information questionnaires, and poly-
                                                         graph examinations at various times before and
Extrapolation Studies                                    after the explosion were given to the participants
                                                         and to control populations at the same base (Fort
   William James94 appears to have been the first        Campbell, Kentucky) and at another distant base
psychologist to systematically document the reac-        (Fort Lewis, Washington).
tions of persons to disasters in his report of re-          The most significant finding was that anxiety
sponses to the 1906 San Francisco earthquake             concerning some of the bomb’s effects persisted at a
and fire. It was not, however, until the late 1940s      high absolute level throughout the entire experi-
that Tyhurst95 did field studies of two apartment        ment. It was also found that the better-educated
house fires, a marine fire, and a flash flood from       were better informed, expressed more self-confi-
which detailed clinical and actuarial reports could      dence, and experienced less anxiety. A dispropor-
be made. He formulated reactions during three            tionate number of soldiers who experienced physi-
overlapping phases: (1) impact, (2) recoil, and (3)      ological disturbances on the day of the maneuver
post-trauma. During impact, reactions are auto-          were in the lower-educated group. The few higher-
matic and can be separated into three main groups.       educated men with physiological reactions differed
The first of these is an “effective” group of about      from other higher-educated men only in having had
12% to 25% who remain “cool and collected,” and          greater difficulty adjusting to their roles in the U.S.
who appreciate and respond appropriately to the          Army.97
situation. The second group is characterized as a           Desert Rock IV,98 staged in May 1952, differed
“normal” group, because this is the largest number       from Desert Rock I in that the participants were
(three fourths of the survivors), who are stunned        armored infantry troops who were stationed 4 miles
and bewildered. Individuals in this group show a         from ground zero in trenches, and they witnessed
restricted field of attention and lack of awareness of   the explosion of an atomic bomb emplaced on a
subjective feelings or emotion; however, they            tower rather than an aerial bomb. In all, the reac-
display the physiological concomitants of fear,          tions of about 1,200 men from the 1st Armored
and automatic or reflex behavior. The last group of      Division, including those not involved in the ma-
10% to 15%, the “ineffectives,” display manifestly       neuver, were tested from mid-May to mid-June
inappropriate responses: confusion, paralyzing           1952. Findings included the following:
fear, inability to move or “freezing,” and “hysteri-
cal” crying or screaming. During recoil there is a        1. Troops showed marked improvement in
gradual return to normalcy; however, excessive               knowledge about atomic effects as the re-
dependency is common during the first day or two.            sult of a 4-hour indoctrination at Desert
The post-trauma reactions usually involve with-              Rock on the day before the atomic bomb
drawal, nightmares, anxiety, and pressured, repeti-          explosion.
tious recounting of the traumatic event. These            2. The soldiers were most successful in learn-
responses are well known to psychiatrists and will           ing the kind of information that had to do
not be addressed here.                                       with personal injury (eg, blindness, steril-
   Caldwell, Ranson, and Sacks96 discussed poten-            ity, impotence). They tended, just after the
tial reactions of a civilian population under atomic         indoctrination, to overestimate the poten-
attack and applied Tyhurst’s95 formulations of the           tial dangers of the atomic bomb more than
impact of disasters on communities. High among               they did earlier or later.
their considerations were expectations of group           3. The indoctrination appeared to lessen the
panic. Panic, however, occurs only rarely and in             fear the troops felt about being on an atomic
circumstances such that an overwhelming trauma               bomb maneuver.
is experienced or expected and all avenues of pos-        4. In contrast to the changes noted above, sol-
sible escape but one are closed.                             diers’ attitudes other than fear toward
                                                             atomic maneuvers and the U.S. Army were
Simulation Studies: Desert Rock I, IV, V                     not appreciably altered as a result of the
                                                             indoctrination.
   In Desert Rock I97 an augmented airborne battal-       5. There was no evidence that fear made any
ion combat team experienced an atomic bomb burst             troops incapable of carrying out their du-
from a position in the open about 7 miles from the           ties just after the detonation; in fact, no


102
                                              Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


    grossly disorganizing fear was observed at             nuclear warfare would result in a breakdown of
    any time during the research. The spectacle            authority relationships resulting in amoral, law-
    of the blast apparently had complex effects            less, and asocial behavior in civilian or military
    upon soldiers’ fears: In comparison to the             populations. Altogether, the Vineberg Report was
    previous night, less fear was expressed by             reassuring to military commanders. This optimism
    the soldiers in answer to direct questions 15          had been reflected in the earlier “Clark Report,”101
    minutes after the explosion, whereas more              in which Clark had estimated total casualties of
    fear was revealed at this time by indirect             enlisted men in a unit to range from 4% to 23% in an
    (projective) tests.                                    infantry battalion under atomic attack and con-
 6. The troops apparently were neither more                cluded that losses ranging from 40% to 70% would
    nor less afraid of the effects of the bomb             have to occur before the unit would be completely
    after they had seen the damage it had done             demoralized. Perhaps in keeping with this opti-
    in the forward area.                                   mism, the NATO handbook, Emergency War Sur-
 7. A material increase in the proportion of               gery,102 while addressing mass casualties in thermo-
    troops who would volunteer to go on an-                nuclear warfare, was silent about psychiatric
    other atomic bomb maneuver, and to oc-                 casualties.
    cupy a position as close or even closer to                The author does not share the optimism of
    ground zero, was recorded just after the               Vineberg and others that while psychiatric casual-
    bomb explosion.                                        ties must be considered, they will not prove deci-
 8. The high point of troops’ confidence in them-          sive in nuclear warfare. Such factors may well have
    selves and their outfits and in the experts’           been decisive in the defeat of France early in World
    ability to use the atomic bomb safely appar-           War II.103 Since 1965, neutron weapons capable of
    ently was reached just after they had com-             surgically killing living beings in precisely desig-
    pleted the maneuver.                                   nated targets have been developed by the United
                                                           States. Conventional weapons of near-nuclear ca-
   Desert Rock V found similar responses among             pability in terms of blast and overpressure effects
officers.99                                                now exist, and these may be mistaken for nuclear
                                                           devices.
Vineberg Report                                               Furthermore, it would be naive to believe that
                                                           nuclear weapons would not be accompanied by
   The Vineberg Report”100 has remained the stan-          chemical and biological warfare. A particularly
dard reference concerning potential psychiatric ca-        horrible dilemma might face the irradiated soldier
sualties in a nuclear war. Vineberg reviewed the           in a chemical environment who must remove his
relevant literature from a number of stressful situ-       protective mask or die from aspiration of his own
ations including aerial bombing of cities (including       radiation-induced vomitus.
Hiroshima and Nagasaki), the disasters’ literature,
the behavior of personnel in combat, and psycho-           Laser and Microwave Radiation
logical mechanisms involved in coping with ex-
treme stress such as major surgery or terminal ill-           One other form of radiation injury deserves men-
ness. Based on these studies he formulated a model         tion because it will be encountered today on any
for nuclear combat.                                        conventional battlefield. The nonionizing electro-
   Vineberg was reasonably optimistic about the            magnetic radiation of current laser range finders
ability of a well-trained, highly-motivated soldier        and designators (U.S. forces’ as well as the enemy’s)
to hold up, even when facing inevitable death. His         will produce injuries ranging from covert retinal
general conclusion was that a soldier would act in         burns to sudden catastrophic blindness at distances
tactical nuclear combat much as he had always              of several kilometers in unprotected eyes (and fur-
acted in combat. He did feel that because of the           ther in those using optical instruments). Lasers of
greater stress there would be greater numbers of           great power may be developed as direct weapons as
psychological casualties, but he did not foresee a         well. This invisible threat with its especially fright-
sharp quantitative change in responses to such stress.     ening consequences could affect the willingness of
As in conventional warfare, psychiatric casualties         troops to look toward the enemy and use weapons’
would arise as a function of cumulative stress re-         sights, and might stimulate conversion reactions of
lated to the duration of exposure to combat and the        hysterical blindness as an expression of battle fa-
intensity of combat. Vineberg did not believe that         tigue.


                                                                                                                  103
War Psychiatry


Treatment of Neuropsychiatric Casualties of                duces new forms of psychopathology. Long peri-
Nuclear Warfare                                            ods of anxious waiting in shelters or in hermetic
                                                           tanks, and long wearing of masks and NBC protec-
   The nature of modern combat with its high noise         tion cause psychic vulnerability106–109 as reported in
levels, burning flesh, random death, and sleep and         the Persian Gulf War.67,110
sensory deprivation suggests the kinds of psychiat-           In the event of actual nuclear attack, the direct
ric casualties to expect even in the absence of nuclear    effect of nuclear flash and blast would have a terror-
weapons.104 The largest group, unless evacuation is        izing psychological consequence. The extended
possible, is likely to be the “psychological shock” or     material destruction and numerous victims create a
“disaster-fatigue” cases encountered in mass casu-         sense of helplessness and vulnerability that under-
alty incidents. The disaster-fatigue casualties will       mines the fighter’s morale. Observations of
probably occur primarily in the first few hours and        Hiroshima and Nagasaki survivors reveal a collec-
days of the initiation of hostilities. Glass and col-      tive behavior of “shock-inhibition-stupor” followed
leagues105,106 applied Tyhurst’s formulations to the       by attempts to escape. 111 This is similar to behaviors
atomic battlefield and established the concept of          in earthquakes and similar catastrophes.
treating such casualties similarly to combat fatigue;         Even in the case of threatened use of unconven-
hence, their use of the term “disaster fatigue.” This      tional weapons, psychopathological behaviors
treatment consists of replenishing physiological           should be expected. The terror of an unknown
needs (rest, nutrition, sleep) as necessary, and giv-      death with the mythic fantasy of disappearing in
ing the individuals simple tasks to perform. In this       the nuclear flash (like the man from Hiroshima
setting, the expectancy that they are “normal” and         reduced to his shadow) and the conviction that one
effective is just as important as on the nonnuclear        can neither be protected nor cured from radiation
battlefield.                                               sickness are powerful psychological factors. The
   The treatment of disaster-fatigue casualties must       normal ambiguity of the battleground will be mag-
emphasize education and preparation as the critical        nified by dispersal and loss of communications due
elements in minimizing these casualties. Obvi-             to the destruction of all but hard-wire communica-
ously, the main target of psychiatric intervention         tions by the nuclear EMP. In such circumstances
should be the 50% to 80% of “normal” dazed per-            rumors may magnify in a contagious manner lead-
sons who can be given simple tasks to aid their            ing to collective panic. Even well-controlled fight-
recovery from the psychological shock. The small           ers will experience increased levels of anxiety, lead-
hysterical group may require sedation; however,            ing at the minimum to increased numbers of combat
this may fixate symptoms. Glass 105 has pointed out        fatigue casualties, already expected to be as high as
the need in these cases for a positive expectancy just     one-to-one, that is, one combat fatigue to one
as in traditional combat fatigue. The most impor-          wounded in action, due to the stress of modern
tant element in minimizing these casualties, how-          continuous warfare. Added to this stress would be
ever, is prevention. It is well known that psycho-         concern about family (especially when accompany-
logical trauma can be minimized by decreasing the          ing U.S. forces in Europe and Korea), a factor found
suddenness of the traumatic event; for example, a          to be important in Israeli casualties during the 1973
sudden bereavement, as in the death of a spouse in         Yom Kippur War, increasing the likelihood of break-
an accident, is more likely to produce psychiatric         down.
morbidity than death of the spouse following a long           While realistic training and strong unit cohesion
illness. It is as if time were available for a cognitive   fostered by good leadership leading to high levels
desensitization. To prevent these casualties, re-          of fitness and morale will minimize psychiatric
peated exposure to as realistic a battle experience as     casualties in even this hellish combat environment,
possible must be part of the soldier’s training.           concrete steps should be undertaken now to mini-
   Aside from their destructive potential both from        mize such casualties and make best use of all
blast and radiation effects, nuclear weapons pro-          resources in the event of nuclear war. Information
duce in most people a not unwarranted fear verging         on the diagnosis and management of neuropsy-
on hysteria, a fear conditioned by hundreds of me-         chiatric casualties of NBC warfare should be widely
dia exposures to nuclear holocaust. The mere threat,       disseminated. Realistic training in a partially
therefore, of nuclear weapons may result in psychi-        contaminated NBC environment should continue.
atric casualties with a primarily psychological etiol-     This training should involve not only combat arms
ogy. Cataclysmic, unconventional warfare intro-            troops but also combat-support troops, who may



104
                                              Neuropsychiatric Casualties of Nuclear, Biological, and Chemical Warfare


be even more likely than combat troops to suffer           Commanders and medical personnel should be fa-
chemical and nuclear attacks as the enemy attempts         miliar with estimating survival time based on onset
to disrupt logistical support. Education to combat         of vomiting (see Table 4-4). Physicians should be
rumors and fear of the unknown must be empha-              prepared to give medications to alleviate diarrhea,
sized.                                                     and to prevent infection and other sequelae of radia-
   Fatally irradiated soldiers should receive every        tion sickness in order to allow the soldier to serve as
possible palliative treatment, including narcotics,        long as possible. The soldier must be allowed to make
to prolong their utility and alleviate their physical      the full contribution to the war effort. He will already
and psychological distress. Depending on the               have made the ultimate sacrifice. He deserves a
amount of fatal radiation, such soldiers may have          chance to strike back, and to do so while experienc-
several weeks to live and to devote to the cause.          ing as little discomfort as possible.


                                     SUMMARY AND CONCLUSION

   In summary, a wide range of chemical, biologi-          of NBC protective equipment and of sensible pre-
cal, and nuclear threats exist. Many are invisible,        cautions.
persistent, have delayed effects, or are contagious.          Even without “gas hysteria,” the added fear
Delivery means may be nonspecific, ubiquitous, or          and uncertainty about NBC use will probably in-
covert. Detection methods are often inadequate.            crease the incidence of acute stress reactions (“battle
Early signs and symptoms of exposure may be                fatigue”). Rates as high as one case of transitory
nonspecific and common. The consequences of                battle fatigue per one wounded in action have been
delaying treatment may be irreversible and fatal.          projected based on historical data. Medical person-
Since Pavlov’s studies with dogs, scientists have          nel are not immune to battle fatigue and must be-
known that a requirement to discriminate between           come familiar not only with its various presenta-
ambiguous stimuli typically produces severe anxi-          tions and basic treatment but also with its
ety, stereotyped, sometimes bizarre behavior, or           prevention.
both. This behavior must be expected to some                  Psychological stresses that seem unendurable
extent in any combat against a foe known to be             have been described, but history proves that well-
capable of using NBC weapons, even if those weap-          trained, cohesive units can come to accept such
ons are not actually employed.                             horrors as commonplace. Effective deterrence re-
   A variety of maladaptive psychological reactions        quires not only thinking about the unthinkable but
may be evoked by the threat of NBC warfare. Anxi-          obviously being prepared to deal with it. The psy-
ety may lead to heightened susceptibility to rumors        chological threats of NBC warfare have implica-
of the use of NBC warfare. This, in turn, could            tions for psychological preparation that are espe-
provoke undue concern, not only for self and               cially relevant to the medical departments of the
unit, but also for the safety of dependent families if     armed services, and to National Guard and reserve
they are in the area at risk. Preoccupation with           units. For example, training should avoid the tradi-
early warning symptoms may encourage individ-              tional one-shot CS (tear gas) exposure exercise,
ual hypochondriasis and increase the baseline              which classically conditions somatic and anxiety
demand for medical attention. Group amplifica-             symptoms to the protective mask. Such training
tion of stress and hyperventilation symptoms may           resulted in significant gas-mask phobia cases in the
cause epidemics of “gas hysteria,” as seen in World        Persian Gulf War. Instead, frequent practical exer-
War I. Even panic flight may occur if units feel           cises are needed to foster familiarity, confidence,
completely unprepared or if protective measures            and the special skills required to function in an NBC
seem inadequate (as they may in a hysterical               battlefield. Future warfare has aspects similar to
epidemic). There may also be excessive concern             mass-casualty disasters, which produce large num-
with decontamination (perhaps leading to derma-            bers of psychological casualties among uninjured
tologic problems), and overavoidance of possible           witnesses. Perhaps military units should train in
sources of exposure (possibly causing dehydration,         naturally occurring disaster incidents. NBC war-
malnutrition, or even refusal to obey orders).             fare is an exceedingly unpleasant prospect to con-
On the other hand, there may be inappropriate              sider; however, failure to prepare for it only in-
fatalism or overconfidence leading to abandonment          creases the risk of its use.



                                                                                                                  105
War Psychiatry



                                               ACKNOWLEDGEMENT
  The author wishes to acknowledge the assistance of Paul Newhouse, M.D., Department of Psychiatry,
  College of Medicine, University of Vermont; James Stokes, M.D., Colonel, Medical Corps, U.S. Army,
  Chief, Combat Stress Actions Office, Academy of Health Sciences, Army Medical Department Center
  and School, Fort Sam Houston; and Gregory Belenky, M.D., Colonel, Medical Corps, U.S. Army,
  Director, Division of Neuropsychiatry, Walter Reed Army Institute of Research, in portions of this
  chapter.



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Chapter 5

PSYCHIATRIC PRINCIPLES OF
FUTURE WARFARE

FRANKLIN D. JONES, M.D., F.A.P.A.*



                                      INTRODUCTION

                                      CHARACTERISTICS OF FUTURE WARFARE
                                        Low-Intensity Future Warfare
                                        High-Intensity Future Warfare

                                      CHALLENGES TO THE PRINCIPLES OF FORWARD TREATMENT

                                      RESEARCH STUDIES OF COMBAT STRESS
                                        Psychological Factors
                                        Combat Role and Sleep Deprivation
                                        Disrupted Circadian Rhythms
                                        Implications for Future Combat

                                      PRINCIPLES OF COMBAT PSYCHIATRY FOR FUTURE WARFARE
                                        Prevention
                                        Battlefield Treatment in High-Intensity Warfare
                                        Ethical and Practical Issues Concerning Pharmaceuticals
                                        Use of Pharmaceuticals in Combat

                                      SUMMARY AND CONCLUSION




* Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
  President and Secretary and currently Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and
  Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                        113
War Psychiatry




Mario H. Acevedo                                        The Attack                                  1991

Mario H. Acevedo, a U.S. Army Combat Artist deployed to the Persian Gulf, depicts the aerial intensity of
American gunships attacking Iraqi armor in the desert. Future warfare may occur in a variety of settings
and intensity, ranging from the massive troop and materiel deployments of the Persian Gulf War to small
peacekeeping missions. Such rapid and intense combat necessitates flexibility and innovation in the
treatment and restoration of combat stress casualties.



Art: Courtesy of US Center of Military History, Washington, DC.




114
                                                                            Psychiatric Principles of Future Warfare




                                              INTRODUCTION


   Historical reviews of psychiatric interventions in        Psychological and physiological variables inter-
past wars allow the exploration of the implications       act to prevent or promote illness. This can be seen,
of a range of future combat scenarios.1–5 A spectrum      for example, in frostbite, the first combat psychiat-
of combat intensities is possible, ranging from in-       ric disorder described in the British literature dur-
termittent light-infantry combat (low-intensity con-      ing World War I.6 More recently, Sampson 7 has
flict) to continuous, highly-mechanized battle (high-     described this interaction between the physiologi-
intensity conflict), possibly with nuclear, biological,   cal responses to anxiety, particularly vasoconstric-
and chemical (NBC) weapons. Whatever the com-             tion, and to cold, also a vasoconstriction, when the
bat intensity, the underlying stresses of dislocation     soldier is immobile, stressed, and lacking in protec-
from loved ones and home, the fear of the unknown,        tive clothing. Similarly, the disorganized, immobi-
and the stresses of an unfamiliar environment will        lized soldier is less likely to attend to proper protec-
produce disorders of frustration and loneliness.          tive measures such as changing stockings frequently.
Thus, higher-intensity conflict stresses will be su-      This interaction of physiological responses to cold
perimposed on stresses associated with low-inten-         and behavioral and physiological responses to anxi-
sity conflicts.                                           ety produces a cumulative effect of heat loss in
   While the holistic or psychosomatic approach           peripheral tissues and thus of frostbite.
emphasizes the unity of an organism’s response to            A large body of literature has documented the
stress, it is convenient to separate factors producing    clinical relevance of stress not only to traditional
stress and breakdown in battle into physical (or          psychiatric disorders but also to such apparently
physiological) and psychological (or sociopsycho-         “physical” conditions as infections, cardiovascular
logical) categories.                                      diseases, and cancer.8–10 Many of these deleterious
   The psychological factors, because they are po-        effects of stress seem to be mediated by the neu-
tentially the ones more amenable to psychiatric           rotransmitter/neurohumoral and immune systems.
interventions, have been emphasized the most in stud-        Although no one knows precisely what forms
ies of breakdown in battle. Because of the nature of      future warfare will take, the following possible
high-intensity, high-technology, and continuous com-      forms of future warfare and available experimental
bat, the physiological variables may still play a         studies related to combat performance are offered
major role in breakdown in modern wars.                   for consideration.


                               CHARACTERISTICS OF FUTURE WARFARE


   From a historical perspective there appear to be       alienate the local population, the home front, and
two main groupings of combat stress casualties,           world opinion. For the United States, the Vietnam
which are to an extent dependent on the nature of         conflict was the epitome of this type of conflict.
the soldier’s experiences. At one extreme are the         Although it could be argued that they were not
disorders of frustration and loneliness (nostalgic        appropriately utilized, the traditional principles of
casualties) that appear among troops engaged in           treatment (proximity, immediacy, expectancy; re-
intermittent, low-intensity combat, and in rear-ech-      assure, rest, replenish, restore confidence) appear
elon duties. These soldiers share the problems of         to have been less effective with these casualties in
anyone who leaves home to an inhospitable envi-           Vietnam.
ronment; they present with symptoms such as alco-             At the other extreme is the high-intensity, high-
hol and drug abuse, disciplinary infractions, and         lethality, continuous combat fought in some battles
venereal disease. Pre-Vietnam drafted soldiers in         of World War I, World War II, and early in the
garrison settings manifested many of these behav-         Korean conflict, but best seen in the 1973 Yom
iors, and U.S. soldiers in Europe and Korea con-          Kippur War. Such casualties present with symp-
tinue to exhibit them. Terrorist and guerrilla tactics    toms related to anxiety and physical and emotional
are deliberately calculated to maximize ambiguity         exhaustion. The traditional principles of treatment,
and frustration. This provokes misconduct, includ-        if the vicissitudes of battle allowed them to be used,
ing excessive brutality and atrocities which will         worked best with these soldiers in the past; how-


                                                                                                                115
War Psychiatry


ever, the severe stress of future warfare may exert       Critical to these efforts was the use of professional
psychological trauma of such severity as to lessen        soldiers and the ability to isolate the insurgents
the effectiveness of these principles even if battle-     from resupply and indigenous support.
field conditions allow their use.                            In counterinsurgency conflict the forces being
   Being unable to know what type of war the United       allied with must be seen as legitimate to govern by
States will be expected to win in the future, the         the indigenous population. The U.S. troops opti-
armed forces must prepare for conflicts ranging           mally will be professional soldiers (and often Spe-
from worst-case low-intensity operations other than       cial Operations Forces) fighting in cohesive units,
war to very high-intensity wars. These two polari-        thus relatively impervious to the ambiguities uni-
ties will be addressed at this time in terms of psychi-   versally present in civil wars. However, less fre-
atric approaches. If psychiatric casualties can be        quently trained combat-service-support units, some
appropriately treated in these extremes, those of a       from the Reserves, may also be deployed. The troop
medium range of intensity should present no insur-        leaders should regularly explain the goals of the
mountable or unforeseen problems. While future            fighting and those goals should be explicitly formu-
military missions may extend beyond combat, it is         lated by the Commander-in-Chief. The mental
reasonable to expect that the combat intensity di-        health personnel must have a “mental-hygiene ap-
mension will include the major varieties of future        proach,” emphasizing productive use of leisure time,
psychiatric problems.                                     and perhaps assisting in building schools and pub-
                                                          lic works projects. Vigorous approaches to elimi-
Low-Intensity Future Warfare                              nating substance abuse and in-country treatment of
                                                          substance abusers is mandatory. Realistic informa-
   A study of world conflicts since the Vietnam           tion about the risks and prophylaxis of venereal
conflict would lead to the conclusion that the United     diseases should regularly be given by the medical
States is likely to be involved in more low-intensity     personnel to the troops. Bushard-type counsel-
conflicts than high-intensity, 1973 Arab-Israeli-type     ing,11 emphasizing commitment to the mission and
wars. A chemical or biological low-intensity con-         concurrence of one’s fellow-soldiers, should be
flict would seem to be improbable, but chemicals          readily available to temporarily disaffected or de-
have, in fact, most often been used against poorly        moralized soldiers. The emphasis must be on cur-
equipped insurgents or dissidents, as by Spain and        rent issues and on optimistic appraisal of the
France against the Moroccans in the 1920s; by Italy       soldier’s ability to overcome these challenges. Of-
against Ethiopia; by the Soviets or their clients in      ten, the best results occur when a senior sergeant or
Yemen, Cambodia, Laos, and Afghanistan; and by            an officer can take the disaffiliated soldier “under
Iraq against their Kurdish minority. U.S. forces,         his wing” and offer encouragement and support
especially Special Operations Forces, could be on         during a difficult time, a surrogate parenting for an
the receiving end of such weapons under circum-           immature personality.
stances which would be difficult to document.                The devastating effects of drug abuse by soldiers
   In preparing for low-intensity combat stress ca-       in Vietnam is detailed in Chapter 3, Disorders of
sualties, there must be an attempt to strengthen          Frustration and Loneliness. In his novel 1984, George
ameliorating conditions. These include minimiz-           Orwell12 suggested that drugs might be utilized to
ing family stress, enforcing vigorous discipline in       weaken a nation’s fabric and assist a foreign power.
organized camp conditions, setting and enforcing          In 1986, a U.S. Army general reported that commu-
strict but realistic rules of engagement, and promot-     nist Cuba was supporting the smuggling of narcot-
ing unit cohesion and pride in following the rules.       ics into the United States, presumably to that end.13
At the same time, it will be necessary to eliminate or    One of the most alarming terrorism trends in Latin
lessen the impact of aggravating conditions: pre-         America is the alliance between insurgency groups
vent boredom, prepare for cultural differences, and       and narcotics traffickers, particularly in Peru and
strengthen social support from the unit, the family,      Colombia. 14 Most of the evidence supports the view
and the community.                                        that in Vietnam, market factors led to drug traffick-
   Fighting counterterrorist or counterinsurgency         ing rather than deliberate subversion. However, the
conflicts can result in successful outcomes. The          potential for such insidious subversion exists.
British experienced such success in the Boer War in          The mental health implications of drug depen-
South Africa (1899–1902) and in a war in Malaysia         dence are obvious, but only recently have govern-
(1948–1960), and the United States successfully put       ment and industry begun large-scale actions to
down the Moro rebellion in the Philippines (1902).        counter the drug-abuse threat that afflicts primarily


116
                                                                            Psychiatric Principles of Future Warfare


the age group most likely to be conscripted in the       jection military, imagine what it would have been
event of major hostilities. As mentioned, U.S. sol-      like for the lead U.S. contingency force Army and
diers were deployed to Colombia to support that          Marine brigades and divisions if the Iraqi Army in
government’s attempt to disrupt drug trafficking.        September 1990 had been able to press forward with
The military has also assisted the Coast Guard and       a full armor attack, supported by their heavy artil-
Immigration and Naturalization Service in guard-         lery firing chemical shells, while improved Scud
ing the borders against drug importation. Addi-          missiles dropped chemical, biological, and perhaps,
tionally, the U.S. government has used drug screen-      nuclear warheads on the Arabian (and Israeli) ports,
ing of personnel. Some industries have also begun        airfields, and cities (Exhibit 5-1).
such screening.                                             A future regional power (perhaps even one of the
   The senior U.S. Army leadership is aware of the       current major powers under different leadership
potential stress issues in operations other than war,    turned aggressively militaristic) could be tempted
and is actively collecting data and developing poli-     to pull a “high-tech” surprise, counting on an inad-
cies and doctrine to control them. This doctrine         equate political and/or military response from the
includes the early deployment of mental health/          United States. It is conceivable that this could come
combat stress control (clinical) teams and human         after a period of economic hardship when the down-
dimensions (research) teams.15–17 The focus of this      sized U.S. military services were feeling the effects of
chapter, therefore, will be on high-intensity com-       decreased funding for maintenance, training, soldier
bat, which presents formidable obstacles to tradi-       and family benefits, and perhaps shortfalls in weap-
tional treatment delivery. While low-intensity con-      ons research, procurement, and strategic lift capabil-
flicts and operations other than war are more likely     ity. All these factors could have resulted in lowered
than a high-intensity conflict, U.S. forces must be
prepared for the high-intensity conflict (ie, a worst-
case scenario such as NBC warfare). Even in the
absence of NBC warfare, future combat may be
                                                            EXHIBIT 5-1
sustained, highly intense, highly mobile, and highly
technical.                                                  CHARACTERISTICS OF HIGH-
                                                            INTENSITY WARFARE
High-Intensity Future Warfare
                                                            High lethality with mass casualties
   U.S. military forces must prepare for combat of
unprecedented ferocity, lethality, and destructive-            “Disaster-fatigue” casualties
ness. For example, modern combat offensive doc-             Continuous combat
trine calls for continuous operations including con-           Sleep deprivation
ventional, airmobile, and airborne assaults possibly           Increased fatigue
coupled with coordinated chemical strikes (and
perhaps nuclear strikes) throughout the depth of            High mobility
the enemy’s deployment.18 Mobile combat groups                 Radar localization
will attempt to penetrate enemy defenses up to 150             Proportionally fewer forces
miles, into the defender’s rear positions, disrupting
                                                            Dispersal of forces
command, communications, and logistic activities.19
Through the use of night vision devices and supe-              Nuclear/biological/chemical threat
rior numbers, the attacking forces will fight con-             Infrared/radar “signature”
tinuously while allowing adequate rest by rotating             Result of high mobility
spent units. If outnumbered, the defending forces           Absence of air superiority
would be engaged continuously,20 resulting in fa-
                                                               Limited helicopter medical evacuation
tigue and sleep deprivation. If opportunities for
sleep did occur, the extraordinarily high noise lev-        Absence of rear battle-free area
els and ground-shaking artillery and bomb blasts               Limited traditional medical treatment
might make sleep impossible until the soldier ap-
                                                            Adapted from Jones FD. Psychiatric lessons of low-in-
proached physical collapse. This will maximize              tensity wars. Presented at Army Medical Department
mental and physical stress on defending personnel           Division and Combat Psychiatry Conference, 1984; Fort
and increase combat breakdown. If this seems an             Bragg, NC.
implausible scenario for the future U.S. Force Pro-


                                                                                                                117
War Psychiatry


morale and retention of highly-skilled personnel,          weapon—lasting from 30 seconds to 4 to 5 minutes
and lowered quality of new recruits, putting further       depending upon the complexity of the weapon.22
strains on leadership and unit cohesion.                   This would allow first-echelon attacking forces to
   Strategically, the attacker in such a major re-         advance immediately behind the rolling barrage
gional conflict will focus on command, control,            with smoke and flame throwers. Their aim would
communications, and intelligence organs. The con-          be to pass through or bypass defending units rather
tinuous assault will attempt to disrupt the small          than to engage them. First-echelon forces would
combat unit of 3 to 40 persons. Modern military            then proceed rapidly to the rear to disrupt com-
planners are fully aware of the psychological fac-         mand, control, communication, and intelligence
tors in combat. A surprise attack with apparently          functions; to capture airfields, petroleum depots,
overwhelming forces could lead to panic and col-           and fire-support systems; and to link with airmo-
lapse even when the opposing forces are about              bile and airborne forces. Second-echelon forces
equivalent in strength. This occurred, for example,        would then neutralize the remaining forward de-
during the German blitzkrieg of French forces in           fending units to produce a swift and sudden col-
1940; the Israeli surprise attack on Egypt in 1967 21;     lapse. NBC weapons, and even long-range im-
and the coalition attack, led by U.S. Forces, on Iraq      proved conventional weapons, enable senior,
in 1991. It almost occurred with the Arab surprise         rear-echelon military and political figures to influ-
attack on Israel in 1973.                                  ence directly the outcome of the battle.23 Such
   Surprise maximizes the psychological effect of          weapons used against enemy command, control,
an attack. A conventional rolling artillery barrage,       communication, and intelligence, and nuclear means
finished by a salvo of rockets, need not kill the          could paralyze a defending force. The response to
defenders. It will produce a state of “battlefield         such a scenario requires highly-mobile, dispersed
paralysis”—the temporary inability to use one’s            forces.


                  CHALLENGES TO THE PRINCIPLES OF FORWARD TREATMENT

   As discussed in Chapter 2, Traditional Warfare          sity warfare. High-intensity future warfare, there-
Combat Stress Casualties, the appropriate use of           fore, challenges the application of the traditional
the traditional principles of forward treatment has        principles of forward treatment (Exhibit 5-2). There
resulted in the return of about one half to two thirds     may be no safe and stationary forward treatment
(or in optimal circumstances up to nine tenths) of         area, because high technology has resulted in weap-
combat stress casualties back to combat duty within        ons and surveillance systems capable of discover-
days. Forward treatment consists of immediate,             ing aggregations of personnel through the infrared
brief, simple interventions such as rest and nutri-        “signatures” given off by heat radiation from groups
tion in a safe place as near the battle lines as pos-      of persons and their supporting machinery (eg,
sible, with an explicit statement to the soldier that      trucks, generators). Furthermore, rear areas may be
he will soon be rejoining his comrades. This ap-           preferentially attacked because they may be more
proach to treatment also calls for soldiers evacuated      vulnerable than front-line forces, which will be
rearward to be screened at a central collecting point      dispersed, camouflaged, and mobile.
from which they may still be returned to duty if              Even if methods are found to shield and protect
further rearward movement is inappropriate.                rear-area installations, the time needed to restore
   In practice, this approach has required four es-        physiological and emotional needs, plus transpor-
sential elements:                                          tation limitations, will make it difficult or impos-
                                                           sible to return the soldier to his own unit. This is
 1. A relatively safe and stationary place near            because combat units must remain dispersed and
    the battle area (refuge);                              highly mobile to avoid being targeted by their “sig-
 2. A treating person (therapist) or team;                 natures.” However, studies from World War II and
 3. Time and resources for restoration of physi-           Korea make it clear that the returning combat stress
    ological needs (rest); and                             casualty must rejoin his own unit or risk becoming
 4. A method for returning to one’s unit (return).         a casualty again. Furthermore, the possible absence
                                                           of local air superiority by U.S. forces will aggravate
   Each element is critical to the process; and, as will   the difficulty of evacuation and return of casualties
be seen, each is jeopardized by modern, high-inten-        arising from dispersion and mobility of forces.


118
                                                                            Psychiatric Principles of Future Warfare


                                                          would require special consideration without neces-
   EXHIBIT 5-2                                            sarily being held for restoration in medical units.
                                                          Considering that rates were as high as one psychi-
   NEGATION OF PRINCIPLES OF
                                                          atric to one wounded-in-action casualty in some
   FORWARD TREATMENT
                                                          Israeli and Egyptian units in the first high-intensity,
                                                          sustained engagement of the 1973 Yom Kippur War,
   No refuge:                                             this stress casualty estimate may be too conserva-
      Absence of rear battle-free area                    tive.
                                                             Surgical casualties and combat stress casualties
   No therapists:
                                                          in a high-intensity scenario are projected to occur in
      Dispersal of forces                                 such numbers that medical resources must utilize
      Mass casualty situation (triage)                    the triage principles developed for mass-casualty
   No rest:                                               situations. Triage emphasizes treating first those
      Absence of rear battle-free area                    who have the best chance of survival while post-
                                                          poning treatment of those seriously wounded or
      High mobility
                                                          lightly wounded. In current civilian triage situa-
      Lack of time to treat                               tions, surgical casualties have priority over psychi-
   No return:                                             atric casualties in the allocation of medical person-
      Dispersal of forces                                 nel. Combat stress casualties, as the most likely to
      High mobility                                       become effective with minimal intervention, will
                                                          receive attention from division mental health and
  Adapted from Jones FD. Psychiatric lessons of low-in-   combat stress control unit teams. These assets will
  tensity wars. Presented at Army Medical Department
                                                          continue into the future force structure, but that
  Division and Combat Psychiatry Conference, 1984; Fort
  Bragg, NC.                                              alone is not enough to assure success. They must
                                                          also be at the critical places on the fluid battlefield.
                                                          They must be highly trained in peacetime to func-
                                                          tion in such a high-stress setting in a come-as-you-
                                                          are war. Will the military be successful in recruiting
   The psychological stresses of high-intensity com-      and retaining psychiatrists, psychologists, and so-
bat will also be magnified due to the lethality and       cial workers who will enjoy the challenge of being
mass casualty nature of modern warfare. There is          true consultants and members of line units if the job
usually a direct relationship between wounded in          involves this risk? Might it be necessary to train
action (WIA) and psychiatric casualties. The U.S.         physician assistants for combat psychiatry posi-
Army medical planning field manuals24,25 give a           tions? The plans for far-forward combat stress
conservative estimate of 1 psychiatric to 5 wounded-      control in U.S. Army Force XXI are reviewed in
in-action casualties, but point out that some units in    Chapter 7, U.S. Army Combat Psychiatry.
World War II fought battles in which the ratio               If there were a threat of NBC warfare, the rate of
reached 1:2. Being on defense increases stress casu-      stress casualties would rise. Stress casualties which
alties relative to wounded. However, being mobile         mimic the symptoms of chemical, biological, or
tends to protect. Recent official casualty rate pre-      radiation injury may exceed the cases of actual
dictions have reduced the average division’s daily        injury by 2 or 3 to 1, based on World War I experi-
wounded in action during the heaviest weeks of            ence. The chemical protective suit and mask (mis-
fighting from about 150 to 50. The U.S. Army does         sion-oriented protective posture or MOPP gear)
not expect to fight in massed formations with sec-        would create heat buildup even in cool climates
ond-rate weapons, suffering mass casualties. How-         with excessive sweating and loss of salt and water.
ever, war is not fought on the average day, and the       Furthermore, to minimize the need to urinate, sol-
enemy will not fight every division equally every         diers in MOPP gear often do not drink fluids. In
day. The engaged brigade of an engaged division           experiments conducted by Walter Reed Army Insti-
could easily suffer several hundred wounded out of        tute of Research (WRAIR) personnel,26 soldiers in
a total of about 6,000 troops over 1 or 2 high-           MOPP gear were observed to fail to eat and drink in
casualty days. This would result in more than 100         order to minimize excretory functions leading to
stress casualties arriving at the forward support         some degree of urine concentration. Even without
medical company in the brigade support area over          MOPP gear, soldiers often do not eat or drink in the
a few days. At least as many stressed soldiers            early days of combat. During the 1982 invasion of


                                                                                                                119
War Psychiatry


Grenada by U.S. forces, casualties from dehydra-             over from fear.
tion occurred, indicating that U.S. forces need to be            I lay flat under a pandanus tree, telling myself: “It’s
alert to this problem. The Israelis have made water          combat fatigue. You’ve been kidding yourself. You are
drills a standard part of a combat commander’s               too old for the wars.” Being unable to walk and scarcely
                                                             able to think, I decided to stay where I was, wait for a
responsibilities, with failure in this area leading to
                                                             stretcher-bearer to come along and get me back to the
punishment.                                                  Calvert [ship], where I would stay. For possibly ten
   While overt heat prostration presents an unam-            minutes I waited.
biguous syndrome, the effects of mild dehydration                Before any aid man came my way, a rifleman stopped
are not so obvious. S.L.A. Marshall,27 a man ex-             and stared at me. Then he took a bottle of pills from his
posed to battle during World War I, World War II,            jacket pocket and downed a couple of them.
and Korea, described the following incident during               I asked weakly, “What you got?”
the strenuous invasion of a Japanese-held Pacific                “Salt.”
island during World War II:                                      “Gimme some. Nothing can make me feel worse than
                                                             I do.”
                                                                 He gave me the bottle, saying he had another. I
Case Study: SLAM Finds Salt                                  washed down eleven salt tablets with the lukewarm water
                                                             from my canteen as fast as I could swallow. Within the
   The sniper fire had intensified…. When their officers     next ten minutes my nerve and strength were fully re-
got this company going again, I followed along for about     stored, and I was never again troubled; yet that lesson had
a hundred yards into the bush. There, after just a few       to be learned the hard way. No one had ever told me that
stumbling steps, I fell apart. My senses reeled. I was hit   one consequence of dehydration is cowardice in its most
by such weakness that I dropped my carbine and could not     abject form.27(p68)
unbuckle my belt, but that was not the worst of it. Within       Comment: This vignette clearly demonstrates combat
seconds my nerve had gone completely and I shook all         fatigue as a psychophysiological disorder.


                                 RESEARCH STUDIES OF COMBAT STRESS


Psychological Factors                                        that assigned role in a group plays a major part in
                                                             determining stress.
   Combat does not lend itself to experimental stud-            Bourne, Rose, and Mason30 had also studied ste-
ies because most of the variables cannot be con-             roid excretion and obtained behavioral data on seven
trolled; consequently, few studies have been con-            helicopter ambulance medics in combat in Vietnam.
ducted during actual fighting. Perhaps the most              A surprising finding of the study was that compari-
extensive study of the stress of combat was done by          son soldiers in basic combat training camps in the
Stouffer, DeVinney, Star, and Williams28 during              United States, as measured by steroid excretion,
World War II. That study addressed primarily                 experienced greater stress than these soldiers en-
psychological factors and showed that cohesive,              gaged in highly dangerous combat operations (such
well-led units had fewer psychiatric casualties.             ambulance crews averaged more medals for hero-
   During the Vietnam conflict, Bourne, Rose, and            ism than combat arms soldiers). They found that
Mason 29 obtained, over a 3-month period that in-            these combat soldiers utilized a variety of mental
cluded intermittent combat, behavioral data and              mechanisms to defend themselves from the stress of
urine samples from a 12-man Special Forces “A”               potential death and mutilation. These mental ac-
team assigned in an enemy-controlled area. They              tivities were highly individualized. One man was
found that the 2 officers experienced substantially          quite religious, believing that God would protect
higher levels of stress than the 10 enlisted men as          him. Another soldier, who tended to intellectual-
measured by steroid excretion. It was also noted             ize, would make involved mathematical computa-
that on the day of an anticipated attack, an officer         tions as to the probability of his being wounded or
and his radio operator (command and communica-               killed, would come up with figures indicating a low
tions positions) showed a modest rise in steroid             probability, and would dismiss such a low prob-
excretion (increased stress) while the other sub-            ability as being insignificant.
jects, all enlisted men, showed a drop. These find-             Similarly, in the Special Forces team Bourne29
ings (along with clinical observations and theoreti-         also found defensive mental operations but in this
cal studies by Gal and Jones as discussed in Chapter         case the primary mechanism was an overwhelming
6, A Psychological Model of Combat Stress) suggest           emphasis on self-reliance, often to the point of om-


120
                                                                            Psychiatric Principles of Future Warfare


nipotence. In an unpublished study of explosive           day and evening.37 In studies of nuclear submari-
ordnance disposal (EOD) teams, often called “bomb         ners subjected to an 18-hour work-rest cycle, Naitoh
squads,” Bourne found similar mental operations           and coworkers38 found desynchronization of nor-
used to protect the individual from the stress of         mal circadian rhythms, which could have implica-
potential death and maiming. In EOD personnel             tions for stress and health.
the primary defense was a belief that if one followed        The situation is even more complicated in that
established procedures in a careful manner, there         circadian rhythms seem to be regulated by a “deep
would be little danger. A sense of omnipotence and        oscillator,” which changes very little despite exter-
of fatalism (“I won’t die until it’s my time”) were       nal changes in sleep cycle, and a “labile oscillator,”
also frequent coping mechanisms.                          which is more responsive to environmental
                                                          changes.39 The “deep oscillator,” which may be
Combat Role and Sleep Deprivation                         reflected in persistent body temperature patterns,
                                                          is more significant for tasks involving manual dex-
   In a simulated combat exercise the importance of       terity skills, while the “labile oscillator” is more
leadership and cohesiveness was demonstrated in           significant for cognitive tasks.
sustained operations when a good commander pre-              A comprehensive review of the shift-work and
vented soldiers suffering from cold exposure from         jet-lag literature has drawn conclusions on reduc-
disrupting his unit while another commander was           ing negative effects in the event of overseas deploy-
not so effective.31 During this same exercise Belenky32   ment of U.S. forces. 40 They note that manipulation
reported on the importance of physiological degra-        of the carbohydrate and protein components of the
dation of performance, particularly that caused by        soldier’s diet producing relative increases of sero-
lack of sleep. He reported that a majority of soldiers    tonin or catecholamine precursors in the brain can
deprived of sleep for 72 hours would experience           result in a drowsy soldier when sleep is appropriate
visual hallucinations and illusions. However, the         or an alert soldier when this state is appropriate.
same study revealed that 3 or 4 hours of sleep in a       They have devised schedules not only in terms of
24-hour period would prevent most of the degrada-         optimal work-rest cycles but even appropriate diets
tion of cognitive processes.                              of soldiers for sedating or alerting effects. They
   Johnson and Naitoh33 have concluded from a             have suggested, for instance, that a high carbohy-
comprehensive review of the literature that cogni-        drate meal about 1 or 2 hours before sleep is desired
tive processes suffer earlier and more severely than      will facilitate sleep through the insulin effect, which
muscular tasks during sleep deprivation. Experi-          increases L-tryptophan transport through the blood-
menters at the U.S. Army Research Institute of En-        brain barrier. This precursor amino acid of seroto-
vironmental Medicine34,35 have explored the effects       nin increases serotonergic influence and thus sleepi-
of sustained operations on artillery teams in simu-       ness. There is increasing evidence that bright light
lated sustained combat. Their findings confirm            exposure to the retinae can reset the circadian cycle.
earlier reports that cognitive tasks requiring ab-        This can be accomplished by having the individual
stract judgment, preplanning, and vigilance are           exposed to bright light in the new morning and
degraded early and seriously from sleep loss and          decreased exposure at the new night, perhaps by
cumulative fatigue, while the ability to perform          wearing dark sunglasses.
well-practiced, urgent tasks involving motor activ-
ity was preserved best.                                   Implications for Future Combat

Disrupted Circadian Rhythms                                  Future commanders must maximize their sol-
                                                          diers’ fighting ability and resistance to break-
   Experimenters at the Naval Health Research Cen-        down by insuring that the physiological needs of
ter36-38 have shown that performance is also related      their soldiers are met. This involves a sensible
to circadian rhythms that, of course, are particu-        doctrine of rest and sleep (at least 4 h sleep in a 24-
larly susceptible to disruption from travel across        h span), prevention of cumulative fatigue (by rota-
several time zones, as would occur in any distant         tion from combat, preferably as a unit to maintain
deployment of U.S. forces in an easterly or westerly      cohesion), adequate nutrition (especially fluids and
direction. Abstract tasks such as reading compre-         salt), and frequent changes of socks to prevent frost-
hension have been shown to be best performed in           bite in cold weather and fungal infections in hot
the afternoon and evening, while performance speed        weather. When initiating combat, U.S. command-
was high in the morning and steadily fell during the      ers should seek to attack at a time when their sol-


                                                                                                                121
War Psychiatry


diers’ normal circadian rhythms are at a peak. For        be critical to the outcome of a war of short duration.
example, soldiers flown from the East Coast of the        In addition to leadership and cohesion factors dis-
United States to fight in the Middle East could take      cussed previously, there is a need for ongoing edu-
advantage of the time zone dislocation by napping         cational efforts to minimize the effects of expected
on the overseas flight and attacking at 0300 hours        surprise attacks by the enemy. As mentioned in the
Persian Gulf time, physiologically early evening          Desert Rock studies discussed in Chapter 4, Neuro-
time for U.S. forces; and, for alertness, the lowest      psychiatric Casualties of Nuclear, Biological, and
ebb of the biological tide for enemy soldiers accus-      Chemical Warfare, those soldiers most knowledge-
tomed to rhythms appropriate for the Persian Gulf         able about nuclear explosions were least fright-
region.                                                   ened. This need to educate soldiers should not only
   Future combat will also require close attention to     include the usual battle and NBC scenarios but also
psychosocial factors and revision of the principles       the possibility of atypical scenarios. By being famil-
of combat psychiatry. Because stress casualties           iar with such scenarios, the psychiatrist will be able
have typically peaked among troops initially ex-          to educate commanders concerning expected psy-
posed to combat, prevention of these casualties will      chological reactions and potential interventions.


                  PRINCIPLES OF COMBAT PSYCHIATRY FOR FUTURE WARFARE


   Because high-intensity warfare may make imple-         stress casualties; however, in the 1982 Lebanon War,
mentation of the traditional principles of combat         which was not of as high intensity as the 1973 war,
psychiatry unworkable, new principles of treat-           the percentage of acute psychiatric casualties is
ment must be developed (Exhibit 5-3). It is obvious       reported as 23%, mostly occurring during 2 weeks
that preventing these casualties from occurring in        of active combat.48 (A larger number of delayed and
the first place is the preferred course of action;        chronic post-traumatic stress disorder cases have
however, this may be difficult given the intensity of
warfare. Studies41–44 have repeatedly shown that
stress casualties occur in direct proportion to com-
bat intensity and certain physical and morale fac-
                                                             EXHIBIT 5-3
tors. Factors tending to prevent such breakdown
include the absence of fatigue, presence of good             PRINCIPLES OF COMBAT PSYCHIATRY
leadership and its consequence, unit cohesion, con-          IN HIGH-INTENSITY WARFARE
fidence of the soldiers in their weapons and in
themselves, and an advancing or retreating military
                                                             Prevention:
posture. Conversely, the negatives of these factors
would promote psychiatric breakdown. Continu-                   Unit cohesion
ous, high-intensity warfare may prevent sleep and               Realistic training
rest, thus producing fatigue and promoting break-               Doctrine of rest and nutrition
down. Dispersion will interfere with the ability of
                                                             Battlefield treatment:
commanders to lead and may prevent the aggrega-
                                                                Limited evacuation of psychiatric casualties
tion of comrades, impeding cohesion.
   In the 1973 Yom Kippur War, an exemplar of a                 Treatment in the midst of battle
conventional high-intensity war, some of these fac-             Emphasis on buddy care: Reassurance
tors were not appreciated. The hastily assembled                                             Expectancy
(therefore less cohesive) Israeli forces were exposed
                                                             Use of drugs:
to conditions of continuous, high-lethality warfare.
                                                                Nonsedating antianxiety drugs
Estimates45 of Israeli acute psychiatric casualties
were reported as between 30% and 50% of total                   Nondepleting stimulants to reduce fatigue
casualties in some units. According to Egyptian                 Reversible sleep and alerting agents
military psychiatrists, the Egyptian psychiatric ca-
                                                             Adapted from Jones FD. Psychiatric lessons of low-
sualties at least equaled the “surgical”;46,47 that is,      intensity wars. Presented at Army Medical Department
they were at least 50% of the total.                         Division and Combat Psychiatry Conference, 1984; Fort
   After the 1973 Yom Kippur War there was a                 Bragg, NC.
concerted attempt by the Israelis to prevent future


122
                                                                            Psychiatric Principles of Future Warfare


surfaced subsequently.49) It appears likely, then,       original World War I principles of combat psychia-
that the United States must be prepared either to        try must be revitalized (see Exhibit 5-3). The origi-
treat significant numbers of acute stress casualties     nal concept for the care and evacuation of “ner-
in the event of a future war or to develop more          vous” and “mental cases” at the division level was
effective methods of prevention. The most cost-          stated in September 1918 as follows:
effective approach would emphasize prevention.
                                                             1. Each division in the area has a division psy-
Prevention                                                      chiatrist who will be stationed at the triage [ie,
                                                                the ambulance transfer point] when his divi-
   The chronology of combat stress breakdown was                sion is engaged. There he will sort all nervous
                                                                cases, returning directly to their organizations
clearly described by Swank and Marchand.50 It ap-
                                                                those who should not be permitted to go to the
peared that there are two groups of soldiers prone to           rear and resting, warming, feeding, and treat-
become psychiatric casualties: those never before ex-           ing others, particularly exhausted cases, if
posed to combat and those exposed to combat for a               there is opportunity to do so.
prolonged period of time. Swank and Marchand                                       ....
depicted this finding in a chronological chart of com-
                                                             2. The advantages of these provisions for deal-
bat efficiency. Initial exposure finds low efficiency           ing with war neuroses and allied conditions in
and high casualties. Efficiency improves after a few            the divisions are:
weeks with fewer casualties but again declines after 6          (a) Control over the evacuation of cases pre-
to 8 weeks of combat with increased casualties.                      senting no psychoneurotic symptoms.
   During the Korean and Vietnam conflicts the                  (b) Speedy restoration and return to their
main preventive measure for prolonged exposure                       organizations of those in whom exhaus-
casualties, based on World War II experience, con-                   tion is the chief or only factor.
sisted of limiting the period of exposure to combat             (c) Cure of mild psychoneurotic cases by
                                                                     persuasion, rest, and treatment of special
to prevent cumulative stress. Thus, the combat tour
                                                                     symptoms at a time when heightened
in Korea was 9 months and in Vietnam it was 1 year.                  suggestibility may be employed to ad-
In the absence of a lengthy war and with the prob-                   vantage instead of being permitted to
ability of brief, intense future combat, the military                operate disadvantageously.
has more recently focused on preventing the initial                                   ....
or “green troop” casualties. To do this the U.S.
                                                                 (f)   Creating in the minds of troops generally
Army has initiated a number of programs to                             the impression that the disorders grouped
strengthen unit cohesion. This approach in recent                      under the term “shell shock” are rela-
years resulted in keeping commanders with the                          tively simple and recoverable rather than
same unit for 18 months or more and in the CO-                         complex and dangerous, as the indis-
HORT (cohesion, operational readiness, training)                       criminate evacuation of all nervous cases
Program of keeping groups of soldiers together                         [suggests].51(p309)
from the time of basic training through assignment
overseas. However, this program has largely been            Prevention and treatment must merge in a mod-
abandoned because of the administrative difficul-        ern approach to managing stress casualties. Evacu-
ties it creates. Confidence in weapons and selves is     ation of stress casualties must be strictly limited.
being achieved through an emphasis on physical           Becoming a stress casualty would, therefore, not
fitness and realistic weapons training. This training    result in an “evacuation syndrome.”31 Many stress
is accomplished in part through use of laser “hits”      cases, however, would still exist. The primary treat-
in simulated combat, live-fire exercises, and realis-    ing persons must be the soldier’s fellow soldier
tic simulated combat exercises at the Combat Train-      (“buddy”), medic, squad, and platoon leader. If
ing Centers. A more exotic approach to prevention        soldiers are too ineffective to remain in their squad
might consist of the use of performance-enhancing        or team, the next option is to rest them for a night or
and anxiety-blocking pharmaceuticals, which the          two in their battalion’s headquarters and headquar-
author will discuss later.                               ters company (the “field trains” from which the
                                                         maneuver companies receive their nightly resupply
Battlefield Treatment in High-Intensity Warfare          of ammunition, fuel, water, and food). Treatment
                                                         would consist of reassurance, replenishment, ex-
  In view of the problems posed by high-intensity        pectancy, and possibly administration of a
combat for traditional treatment procedures, the         nonsedating antianxiety pharmaceutical. 52 This


                                                                                                                 123
War Psychiatry


would be monitored by the unit medic, physician             The abused drugs include stimulants (cocaine,
assistant, or circuit-riding mental health officer and   amphetamines) which are addictive because they
NCO. These mental health/combat stress control           produce (in high doses) feelings of intense well-
teams are already called for in current doctrine25       being, power, alertness, endurance, and aggres-
provided by the division mental health section or        siveness (as well as other less common but major
the supporting combat stress control detachment.         psychiatric disorders). The abused drugs also in-
   In the future, the team might have a HMMWV            clude “depressants” (alcohol, barbiturates, benzo-
(high mobility multipurpose wheeled vehicle) am-         diazepine tranquilizers) which calm anxiety and
bulance or armored personnel carrier in which they       produce feelings of well-being or promote sleep, as
could provide mobile evaluation and restoration.         well as producing a drunken euphoria, dependence,
For the soldier who appeared fatigued or depressed,      addiction, and other negative effects. The narcotic
nondepleting stimulants might be given. (A               painkiller drugs are abused because they produce a
nondepleting stimulant is one that does not deplete      blissful euphoric state. Anabolic steroids are abused
the neurons of their neurotransmitters. Such deple-      by body-builders and athletes because they increase
tion, which occurs, for example, with amphetamines,      muscle mass, strength, and endurance. They are
eventually results in rebound fatigue and depres-        banned in competitive athletics because they un-
sion as well as the dangers of heart arrhythmias and     questionably increase speed, strength, power, and
psychosis. Currently the amino acids L-tyrosine          endurance, although at a potential (rare) cost of
and L-phenylalanine come closest to being                medical and psychiatric complications including
nondepleting stimulants. These can be defined as a       violent attack behaviors (“‘roid rages”). If the United
“nutritional supplement,” not drugs.) Only the           States has declared war on drugs, how can it possi-
small number of most impaired or diagnostically          bly justify prescribing similar drugs to American
complex cases would be held for observation and          soldiers for use in combat?
restoration treatment by the combat stress control          The obvious answer in favor is that war is not a
team’s psychiatrist (or psychiatric physician assis-     competitive sport. It is bound by the International
tant) at the forward support medical company, usu-       Laws of War, but not by Olympic committee rules.
ally several kilometers from the battalion’s head-       Battles are fought by the nation’s soldiers, at risk of
quarters companies. Because of the requirement for       death, to win the nation’s military, and ultimately
extreme mobility, this restoration might be pro-         political, objectives. In such an environment it is
vided in suitable vehicles, with built-in physiologic    necessary to give American soldiers every safe,
monitoring, biofeedback, and audio-video relax-          feasible, and competitive advantage.
ation equipment. Such vehicles could be used for            But are such drugs safe, especially in the highly
the prophylactic maintenance and enhancement of          unpredictable and unstable physical, logistical, and
combat performance, as well as for restoration of        emotional context of combat? That question re-
soldiers who had already become stress casualties.       quires an empirical, not a philosophical, answer.
Finally, there is growing evidence that the judicious    All drugs are potentially double-edged swords. All
use of pharmaceuticals may enhance combat per-           will have side effects and overdose effects. Some
formance and possibly prevent some forms of com-         may produce additional effects upon withdrawal or
bat breakdown; therefore, the issues of the sanc-        elimination of the drug. Some interact dangerously
tioned use of drugs in combat will be discussed.         with environmental factors, diet, other drugs, or
                                                         specific diseases. All drugs may have idiosyncratic
Ethical and Practical Issues Concerning                  effects on some individuals. It is unwise to dispense
Pharmaceuticals                                          any drug lightly, without first evaluating the recipi-
                                                         ents and briefing them (and their support group) on
   The use of pharmaceuticals to sustain or enhance      what to expect and what to be alert for. It is then
performance in combat is controversial. It raises        wise and ethical to follow them up periodically. For
important ethical and practical considerations. The      these reasons, any use of pharmacologic agents
U.S. government declared a war on drug abuse in          should be kept under appropriate medical supervi-
the 1980s. As part of that effort, the U.S. armed        sion if not necessarily medical control.
forces have been assigned missions of drug inter-           After analysis of the risks, some drugs may be
diction overseas and on United States’ borders to        judged safe enough for “over the counter,” self-
reduce the production and importation of illegal         administered use. Other drugs may be judged safe
drugs.                                                   for routine prescription use with periodic follow-



124
                                                                            Psychiatric Principles of Future Warfare


up. Other drugs still may be so risky that they            Use of Pharmaceuticals in Combat
should be prescribed only in urgent, carefully de-
fined situations. Like some medications used in               Undoubtedly alcohol was the first drug to be
treating highly lethal diseases, it may be reasonable      utilized to enhance combat performance. When
to accept even a high risk of injury from the drug if      Holland became a major source of gin, the wide-
there is little chance that the “patient” can live past    spread use of this alcoholic beverage by soldiers led
the next week without it. Such situations can arise        to the expression “Dutch courage” to express the
in war as well as in the emergency room.                   desired effect. The ancient Assyrians, Egyptians,
   Of course, if such a drug is administered as a          and Greeks reportedly utilized opiates before and
calculated risk and if the soldiers do survive, the        during battles to sustain or enhance bravery and
uniformed services owe it to them to provide long-         courage.53 Other drugs studied or used to enhance
term follow-up, and treatment or compensation for          combat performance include ergot alkaloids, can-
any complications of the therapy that may arise.           nabis, amphetamine and other stimulants; Drama-
   But will the parents and spouses of America             mine and other antihistamines; benzodiazepines;
tolerate soldiers being given drugs to induce them         and L-tryptophan. It is the author’s contention that
to risk their lives and possibly die? It is no longer      the most extensive modern use of performance-
doctrine to intimidate an enemy into surrender by          enhancing drugs occurred among Soviet personnel
the sheer bravery of American fighting forces.             during World War II shortly after amphetamine
Rather, the intention is to “fight smart,” using supe-     was synthesized. Amphetamine was useful not
rior weapons and information technology on the             only to stave off fatigue and drowsiness but also to
future “digitized battlefield” to attack the enemy         improve memory and concentration, particularly
when he is much less capable of striking back.             among Soviet pilots.
   The effective use of those sophisticated weapons           During the Vietnam conflict, methylphenidate
systems requires keeping the operators’ brains and         (Ritalin) and sometimes dextroamphetamine
bodies in fine tune. The continuous operation              (Dexedrine) were standard issue drugs carried by
doctrine of the U.S. military demands initiative,          long-range reconnaissance patrol (LRRP) soldiers.
agility, synchronization, depth, and versatility.          The LRRPs found the most efficacious use to be
Those battlefield imperatives task precisely the           upon completion of a mission when fatigue had
higher mental functions in all soldiers, from general      developed and rapid return to the base camp was
officer to private, which are most susceptible to          desirable. Other than mild rebound depression and
deterioration from sleep-loss, dehydration, fear,          fatigue after the drug was discontinued, no adverse
sensory overload, or sensory deprivation. If syn-          effects were reported. Other investigators54,55 study-
chronization fails, American “high-tech” weapons           ing the drug abuse problem later in the Vietnam
kill other Americans or innocent noncombatants. If         conflict reported problems with abuse of these stimu-
pharmacologic agents (or other technical solutions         lants. Although there was no documented abuse of
such as sensory stimulation, relaxation, or biofeed-       the morphine Syrettes, commanders suggested such
back) can help more than harm, should they not be          abuse might be occurring,56 causing them to be with-
used?                                                      drawn from the soldiers.
   It is desirable to develop in U.S. soldiers such           Sedatives have also been studied as a method to
high levels of unit cohesion and patriotism that they      improve performance in anxiety-producing situa-
will be willing, if necessary, to risk sacrificing them-   tions such as paratroopers making low-altitude
selves to save their buddies and accomplish the            jumps or for reducing the emotional tension of
mission. However, it is not desirable to have any-         young soldiers during the firing of guns.57 Reports
one in the various weapons systems “high,” “spaced         of improved target accuracy through use of the ß-
out,” or indifferent to his own safety. If a drug can      adrenergic blocker, propranolol, and the anxiolytic,
help them sustain unit cohesion, good training, and        diazepam (Valium), have resulted in a U.S. Army
good sense in the face of otherwise overwhelming           ban on use of these drugs by soldiers engaged in
fatigue or arousal, with an acceptable risk of other       marksmanship competition because they would
harmful effects, is it ethical to withhold it? The         confer an unfair advantage.
overriding question is whether the drug can be                In the Vietnam conflict, neuroleptics (antipsy-
taken with an acceptable level of risk both for the        chotic or major tranquilizer drugs) were widely
mission and the soldier. That will require research,       utilized for psychotropic effects but benzodiaz-
which will not be easy to accomplish.                      epines were also used. In the 1982 Falkland Islands



                                                                                                                125
War Psychiatry


War, temazepam (Restoril) and triazolam (Halcion)            cal alertness and efficiency would go a long way
were prescribed by the Royal Air Force (RAF) psy-            toward “curing” the usual battle fatigue syndrome.
chiatrist to British pilots on Ascension Island to           To some extent this occurred in the Vietnam conflict
ensure adequate sleep between the very long, mul-            when physicians treated psychophysiological symp-
tiple refueling flights to the Falklands and back. 58,59     toms of fear and anxiety with neuroleptics and
Triazolam (Halcion) has been studied in U.S. Army            antianxiety agents. 67 In Johnson’s 1-month, mid-
field trials.60 Recent benzodiazepine receptor re-           1967 survey, physicians’ prescribing experience,
search suggests ways that these drugs could be               when generalized to the entire troop population,
used carefully in combat settings not only to allevi-        gave an estimated prescribing rate of 12.5% per year
ate fear and anxiety but also as hypnotic and alert-         of the assigned U.S. Army troops. Compazine, a
ing agents.                                                  major tranquilizer, accounted for 45% of prescrip-
                                                             tions made by nonpsychiatrists, mainly used to
Benzodiazepine Receptor Studies                              treat gastroenteritis. Most of the 56 cases of battle
                                                             fatigue reported in Johnson’s study were treated
   Four functions mediated by benzodiazepines                with major tranquilizers (64%), particularly
have been discriminated: 61,62 (1) antianxiety               chlorpromazine (Thorazine). The neuromuscular,
(anxiolytic), (2) anticonvulsant, (3) muscle-relax-          autonomic nervous system, and cognitive impair-
ant, and (4) sedative-hypnotic functions. A fifth            ments produced by this drug make it a particularly
possible effect, blocking panic, is relatively weak.         questionable choice on the battlefield.
Of drugs available on the U.S. market, a number of
primarily antidepressant medications (eg, tricyclics         Future Sanctioned Pharmaceutical Use
and monoamine oxidase inhibitors) appear to have
greater antipanic effects. 63,64 It is believed that these      The following discussion is offered to stimulate
exert their effects by potentiating the inhibitory           consideration of the potential uses of pharmacologic
effects of γ-aminobutyric acid (GABA), which in              agents in combat. It does not reflect current official
turn is the neurotransmitter of 30% of the inhibitory        policies.
synapses of the brain.65 A careful modification of              The ideal drug to treat combat stress breakdown
the molecular structures involved has resulted in            would be an easily administered, stable compound
the synthesis of experimental drugs that can act as          that would reduce anxiety without significant neu-
agonists or antagonists of all four of the functions         romuscular or cognitive impairments, would be
mediated by benzodiazepines. This selectivity sug-           nonaddictive, and would permit an appropriate
gests numerous clinical and military applications            response to danger. Such a drug is not currently
including both the prevention and treatment of               available in the U.S. market, but drugs selectively
combat stress disorders and enhancement of per-              preventing severe anxiety without sedation are be-
formance in certain circumstances.                           ing studied, and they raise the possibility of devel-
   As mentioned in Chapter 2, Traditional Warfare            oping a combat-appropriate drug.
Combat Stress Casualties, the most consistent symp-             Other drugs for selected purposes may also be
tom of combat stress, whether occurring early in             developed. A drug with a short duration of effect
exposure to combat or after cumulative exposure, is          reversible by an antagonist could prove to be a most
anxiety. Such anxiety may be manifested by fear,             useful battlefield hypnotic. Such antagonist drugs,
hysterical conversion or dissociation, tremors, and          primarily affecting the benzodiazepine receptor,
similar symptoms. In the past, these conditions              are already in the experimental stage61,62 and one,
have been treated with sedatives ranging from chlo-          the benzodiazepine antagonist flumazenil (Romazi-
ral hydrate and bromides in World War I to barbi-            con) is commercially available. This drug, cur-
turates in World War II and even self-prescribed             rently used in surgical procedures, could be given
alcohol, cannabis, and heroin in Vietnam. These              to a soldier who had received a short-acting benzo-
drugs often not only produced unwanted sedation              diazepine, to bring him awake quickly (within min-
but also decreased the probability of return to com-         utes to an hour) if it were necessary for him to
bat due to the fixation of a sickness role suggested         resume critical duties.
by taking medication. Based on their experience in              Studies indicate that buspirone (BuSpar) relieves
1973, the Israelis promoted a policy prohibiting             anxiety without producing cognitive impairment both
forward use of medications and even hypnosis.66              in acute and chronic use and even in the presence of
   A drug, however, which would selectively re-              alcohol.68,69 In fact, buspirone actually appeared to
duce anxiety without diminishing mental or physi-            improve psychomotor skills in alcohol users.


126
                                                                         Psychiatric Principles of Future Warfare


   Buspirone is now available in the United States.     in a vulnerable person is to have him or her
It has the advantage of causing no psychomotor          hyperventilate. In periods of constrained man-
impairment and no muscle relaxant or sedation           power availability, those thought to be suffering
effects greater than placebo. Vigilance tasks are       from panic disorder who are otherwise fit for com-
improved by a slight alerting effect. Addiction         bat might be treated with antidepressants that block
potential seems low because there is no euphoriant      panic attacks. Antidepressants with minimal seda-
effect, and a single large dose (40 mg or above)        tive side effects would have to be selected. The
produces dysphoria. Patients have been given daily      original monoamine oxidase inhibitors which are
doses of over 2 g. One possible drawback is that,       most effective as antipanic drugs are excluded be-
as part of its antianxiety effect, it also decreases    cause of the dietary restrictions against foods con-
anger and hostility, but it is arguable that cool       taining tyramine which trigger hypertensive crisis.
professionalism is better than rage when operating      A new class of monoamine oxidase inhibitors,
modern weapons systems. A more important draw-          RIMAs (reversible inhibitors of monoamine oxi-
back is a latency or delayed-action period of about     dase-A) do not have this problem. Imipramine (a
10 days before the anxiolytic effect develops. The      tricyclic antidepressant) has too many anticholin-
latency of anxiolytic effect also seems to occur with   ergic side effects to be safe in most combat environ-
the benzodiazepines; however, their immediate           ments. The selective serotonin reuptake inhibitors
sedative effects mask this latency effect. 70 The       have fewer side effects and may be demonstrated
latency of effect need not limit buspirone to a pro-    effective for panic disorder.
phylactic use in soldiers with preexisting anxiety         In summary, for millennia soldiers have utilized
disorders or undergoing reconditioning treat-           alcohol and other drugs to relieve the stresses of
ment for return to combat after being evacuated         war. The time may now be opportune for the use of
for battle fatigue. Key individuals or whole units      specifically tailored pharmaceuticals for these pur-
could, hypothetically, be placed on buspirone 10        poses without risking the dangers or decrements
days prior to starting their rapid deployment           experienced in the past.
standby mission cycles, and taken off at the end of        Thus, the revitalized principles of combat stress
the cycle. Buspirone has no adverse withdrawal          treatment involve maximizing preventive efforts
syndrome.                                               and treating in the combat unit. This treatment
   Because certain individuals are vulnerable to        approach eliminates stress reactions as methods to
panic attacks during episodes of heightened arousal     escape combat (evacuation syndromes), would ob-
such as combat, the use of antipanic agents might be    viate the need for large numbers of medical re-
appropriate in such individuals. Estimates of the       sources to treat such casualties (thus allowing them
incidence of panic disorder (repetitive, spontane-      to treat surgical cases), and reduces the problems of
ous panic attacks) range from 1%71 to 6%. 63 At least   returning soldiers to their own units.
two million Americans are thought to be afflicted.         The costs of this approach will be increased num-
Because 25% of first-degree relatives of those with     bers of “psychosomatic” cases, inappropriate treat-
panic disorders are also afflicted in lifetime inci-    ment of some misdiagnosed cases, and, perhaps,
dence and there is high concordance in monozy-          increased death rates among treated cases. As de-
gotic twins, a hereditary vulnerability has been        scribed above, this scenario is developed around
postulated. In over two thirds of such patients, the    one extreme of future combat, the high-intensity,
attack can be brought on by infusing 10 mL/kg of        possibly NBC, war. Lesser-intensity wars will call
0.5 molar sodium lactate solution in a 20-minute        for varying degrees of traditional interventions de-
time period. A simpler method of provoking panic        pending on intensity.


                                    SUMMARY AND CONCLUSION


   This historical review of psychiatric interven-      war the United States will fight in the future, the
tions in past wars has explored the implications of     armed forces must be prepared for both extremes. If
a range of future combat scenarios. The spectrum of     psychiatric casualties can be appropriately treated
combat intensities ranges from intermittent light-      in these extremes, those of a medium-range of in-
infantry combat to continuous, highly-mechanized        tensity should present no insurmountable or un-
battle, possibly with nuclear, biological, and chemi-   foreseen problems. Likewise, the military will be
cal weapons. Being unable to predict what type of       prepared for those future military missions that


                                                                                                             127
War Psychiatry


extend beyond combat into areas of peacekeeping              operational procedures in future warfare. Particu-
or humanitarian relief. However, even in these               lar attention should be given to the interplay of
scenarios it is reasonable to expect that the combat         physical and psychological variables in the preven-
intensity dimension will include the major varieties         tion of combat stress reaction. Obviously, water
of future psychiatric problems.                              and sleep drills should become standard in training
    In preparing for the extreme of low-intensity            scenarios. Perhaps not as obvious is the fact that, if
combat and the stress casualties associated with             feasible, planning sessions for combat should be
it, there must be an attempt to strengthen ameli-            held at the optimum time in the circadian cycle for
orating conditions by minimizing family stress,              highly complex and abstract cognitive tasks. For
enforcing vigorous discipline in organized camp              the soldier who is not experiencing a time zone
conditions, setting and enforcing strict but realistic       dislocation, this would probably be in the afternoon
rules of engagement, and promoting unit cohesion             and evening rather than in the early morning. Op-
and pride in following the rules. At the same time,          timal times might also be considered in attacking
it will be necessary to eliminate or lessen the impact       the enemy. Troops who have rested during a trans-
of aggravating conditions: prevent boredom,                  atlantic flight with proper planning could arrive at
prepare for cultural differences, and strengthen             a battle at an optimum circadian period for them-
social support from the unit, the family, and the            selves and at the least optimal period for an enemy.
community.                                                   The enemy, of course, might not be so accommodat-
    High-intensity future warfare, in particular, chal-      ing in allowing U.S. forces to prosecute the war on
lenges the application of the traditional principles         a favorable timetable.
of forward treatment because there may be no safe               It must be remembered that men have definite
and stationary forward treatment area due to new             physical and emotional limits. A future war will
weapons and surveillance systems capable of dis-             produce levels of stress that unless prepared for in
covering aggregations of personnel. Also, rear ar-           advance, will easily exceed these limits. Through
eas may be easier to target because they are less            thorough preparation and a sensible doctrine of
dispersed, camouflaged, or mobile than front-line            human physical and emotional limits, a country can
forces. Whatever the combat intensity in the future,         hope to deter war but, nonetheless, it must be pre-
the well-known stresses of dislocation from loved            pared to fight and win if necessary. It is not enough
ones and home, the fear of the unknown, and the              that the medical community be aware of the limits
stresses of an unfamiliar environment will produce           of human mental and physical endurance in com-
disorders of frustration and loneliness. Thus, the           bat; the line commanders must be equally aware
promotion or prevention of psychiatric morbidity             and be prepared to shape doctrine to conform to
will have significant implications for training and          these human needs.

                                                   REFERENCES

  1. Rosen G. Nostalgia: A “forgotten” psychological disorder. Psychol Med. 1975;5:340–354.

  2. Jones FD. Lessons of war for psychiatry. In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the
     Art. Vol 6. New York: Plenum; 1985: 515–519.

  3. Salmon TW. The care and treatment of mental diseases and war neurosis (“shell shock”) in the British Army. In:
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  4. Hanson FR. The factor of fatigue in the neuroses of combat. Combat psychiatry. Bull US Army Med Dept.
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 7. Sampson JB. Anxiety as a factor in the incidence of combat cold injury: A review. Milit Med. 1984;149:89–91.

 8. Lipowski ZJ. Consultation-liaison psychiatry: An overview. Am J Psychiatry. 1974;131:623–630.

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10.   Brownell A, Shumaker S. Social support: New perspectives on theory, research and intervention. Part 2:
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12.   Orwell G. 1984. New York: The New American Library of World Literature; 1950: 142.

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16.   Dasey CF. US Army Medical Research and Development Command in support of Desert Shield/Storm. J US
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17.   Gifford RK, Marlowe DH, Wright KM, Bartone PT, Martin JA. Unit cohesion in Operations Desert Shield/Desert
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18.   Belenky GL, Newhouse P, Jones FD. Prevention and treatment of psychiatric casualties in the event of a war in
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 29.   Bourne PG, Rose RM, Mason JW. 17-OHCS levels in combat: Special Forces “A” team under threat of attack.
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 30.   Bourne PG, Rose RM, Mason JW. Urinary 17-OHCS levels: Data on seven helicopter ambulance medics in
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 31.   Belenky GL, Jones FD. Evacuation syndromes in military exercises: A model of the psychiatric casualties of
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 32.   Belenky GL. Unusual visual experiences reported by subjects in the British Army study of sustained operations,
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 33.   Johnson LC, Naitoh P. The Operational Consequences of Sleep Deprivation and Sleep Deficit. London, England:
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 34.   Banderet LE, Stokes JW, Francesconi R. Artillery teams in simulated sustained combat: Performance and other
       measures. In: Johnson LC, Tepas DI, Colquhoun WP, eds. Biological Rhythms, Sleep and Shift Work; New York:
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 35.   Francesconi RP, Stokes JW, Banderet LE, Kowal DM. Sustained operations and sleep deprivation: Effects on
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 36.   Englund CE. The diurnal function of reading rate, comprehension and efficiency. In: Proceedings, XIV Interna-
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 37.   Englund CE. Human chronopsychology: An introduction and report of an autorhythmometric study of
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 38.   Naitoh P, Beare AN, Biersner RJ, Englund CE. Altered Circadian Periodicities in Oral Temperature and Mood in Men
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 39.   Monk TH. Sleep and circadian rhythms. Gerontology. 1991;26(2–3):233–243.

 40.   Hegge FW, Tyner CF. Deployment Threats to Rapid Deployment Forces. Presented to Division of Neuropsychiatry,
       Walter Reed Army Institute of Research; 1982; Washington, DC.

 41.   Appel JW, Beebe GW. Preventive psychiatry. JAMA. 1946;131(18):182–189.

 42.   Glass AJ. Psychotherapy in the combat zone. Am J Psychiatry. 1954;110:725–731.

 43.   Glass AJ. Observations upon the epidemiology of mental illness in troops during warfare. Presented at the
       Symposium on Social Psychiatry; April 1957; Walter Reed Army Institute of Research, Washington, DC: 185–198.

 44.   Glass AJ. Lessons learned. In: Glass AJ, ed. Overseas Theaters. Vol 2. In: Neuropsychiatry in World War II.
       Washington, DC: Office of The Surgeon General, US Army; 1973: 989–1027.

 45.   Noy S. Personal Communication, 1982.

 46.   Mansour F. Manifestations of maladjustment to military service in Egypt after prolonged stress. Int Rev Army
       Navy Air Force Med Serv. 1982;55:291–294.

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48.   Belenky GL, Tyner CF, Sodetz FJ. Israeli Battle Shock Casualties: 1973 and 1982. Washington, DC: Walter Reed
      Army Institute of Research; 1983. [WRAIR Report NP-83-4].

49.   Belenky GL. Varieties of reactions and adaptation to combat experience. In: Menninger WW, ed. Military
      Psychiatry: Learning from Experience. Topeka, Kan: The Menninger Foundation; 1987: 64–79.

50.   Swank RL, Marchand F. Combat neuroses: Development of combat exhaustion. Arch Neurol Psychiatry [super-
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51.   Zabriskie EG, Rhein JH, Strecker EA, Leopold S, Raynor MW, Steckel HA. Division, corps and army
      neuropsychiatric consultants. In: Bailey P, Williams FE, Komora PA, Salmon TW, Fenton N, eds. Neuropsychiatry.
      Vol 10. In: The Medical Department of the United States Army in the World War. Washington, DC: Office of The
      Surgeon General, US Army; 1929: 303–324.

52.   Jones FD. Sanctioned use of drugs in combat. In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State
      of the Art. Vol 6. New York: Plenum; 1985: 489–494.

53.   Goldsmith M. The Trail of Opium (The Eleventh Plague). London, England: Robert Hale; 1939.

54.   Holloway HC. Epidemiology of heroin dependency among soldiers in Vietnam. Milit Med. 1974;139:
      108–113.

55.   Robins LN. A Follow-up of Vietnam Drug Users. Washington, DC: US GPO; 1973. Special Action Office Mono-
      graph, Series A., No. 1.

56.   Holloway HC. Thoughts about modern war. Presented at Army Medical Department Combat and Division
      Psychiatry Course; April 1984; San Antonio, Tex.

57.   Roberts L. Anxiety State and Battlefield Performance: A Negative Correlation. [AST-266OR-031-83]. May 1983.

58.   Pincus W. British got crucial data in Falklands, diary says. Washington Post. 23 December 1984: A1, A20.

59.   Russell G. Falkland Islands: Explosions and breakthroughs. Time. 7 June 1982: 30–36.

60.   Penetar D, Redmond D, Belenky G. Effects of triazolam on sleep and memory during long range deployments
      by air. Aviat Space Environ Med. 1980;60:594–598.

61.   Skolnick P, Paul SM. Benzodiazepine receptors in the central nervous system. Int Rev Neurobiol. 1981;23:102–140.

62.   Skolnick P, Paul S, Crawley J, et al. 3-hydroxymethyl-beta-carboline antagonizes some pharmacologic actions
      of diazepam. Eur J Pharmacol. 1981;69:525–527.

63.   Shader RI, Goodman M, Gever J. Panic disorders: Current perspectives. J Clin Psychopharmacol. 1982;(6):2S–10S.

64.   Muskin PR, Fyer AJ. Treatment of panic disorder. J Clin Psychopharmacol. 1981;1(2):81–90.

65.   Paul SM. Interactions of antidepressants and anxiolytics with neurotransmitter receptors: Clinical implications.
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66.   Noy S. Combat psychiatry series. Presented to Division of Neuropsychiatry, Walter Reed Army Institute of
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 68.   Mattila MJ, Aranko K, Seppala T. Acute effects of buspirone and alcohol on psychomotor skills. J Clin Psychiatry.
       1982;43(12):56–61.

 69.   Moskowitz H, Smiley A. Effects of chronically administered buspirone and diazepam on driving-related skills
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 70.   Newton RE. Personal Communication, 1983.

 71.   Gorman JM, Liebowitz MR, Klein DF. Panic Disorder and Agoraphobia: Current Concepts. Kalamazoo, Mich: The
       Upjohn Company; 1984.




132
                                                                                                A Psychological Model of Combat Stress




Chapter 6
A PSYCHOLOGICAL MODEL OF
COMBAT STRESS

REUVEN GAL, Ph.D.*          AND   FRANKLIN D. JONES, M.D., F.A.P.A. †



                                      INTRODUCTION

                                      BACKGROUND TO THE MODEL

                                      ANTECEDENT VARIABLES
                                        Individual Factors
                                        Unit Factors
                                        Battlefield Factors

                                      MEDIATING VARIABLES

                                      THE APPRAISAL PROCESS

                                      MODES OF RESPONSE

                                      MODES OF COPING

                                      SUMMARY AND CONCLUSION




* Colonel (res), Former Chief Psychologist, Israeli Defence Forces; Current Director, The Israeli Institute for Military Studies, 5 Kadesh St,
  Zikhron Ya’akov 30900 Israel
† Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
  President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and
  Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                         133
War Psychiatry




Manuel Bromberg                      Soldiers Resting on Omaha Beach, Normandy                         1945

Manuel Bromberg was a member of the War Artist Unit for England and Ireland during World War II and
was present during the invasion of Normandy. He does an exceptional job of visualizing the variables of
combat stress (the individual, the unit, and the battlefield) in this watercolor of three exhausted soldiers
from World War II trying to rest amidst the destruction about them.



Art: Courtesy of US Center of Military History, Washington, DC.




134
                                                                           A Psychological Model of Combat Stress




                                             INTRODUCTION


   The model presented in this chapter is a blend of     Israeli Defence Forces (IDF) and the junior author’s
theory and practice. The theoretical approach stems      combat experiences in Vietnam. These ideas were
primarily from the cognitive theories of stress and      subsequently discussed and elaborated with well-
coping, which emphasize the role of cognitive ap-        seasoned IDF field commanders. The model has
praisal and active coping in the individual’s re-        been used in lectures given at various senior com-
sponse to stressful conditions.1–4 The practical ideas   mand courses in the Israeli military and has been a
are derived from the combat experiences of the           useful tool for approaching the complexity of hu-
senior author and those of his colleagues in the         man behavior in groups under stress.


                                     BACKGROUND TO THE MODEL


   A number of studies related to World War II,5,6 to      • Unit factors—cohesion and morale, train-
the Korean and Vietnam conflicts,7–9 and to the              ing, leadership, and commitment.
Arab-Israeli wars10–12 have delineated variables that      • Battlefield factors—type of battle, surprise
prevent or promote the individual’s ability to cope          and uncertainty, environmental factors
with combat stress. These studies and the salient            (weather, terrain, etc).
coping variables have been summarized by several
authors.10,13,14 Although these variables do not lack        These antecedent variables, according to the pro-
face validity, a coherent scheme of their interac-       posed model, do not directly determine the soldier’s
tions and their impact on subsequent combat stress       appraisal of the combat situation; rather, they are
reactions has been lacking. There have been at-          mediated by other variables—the mediating vari-
tempts at a dynamic interpretation of the simple         ables—in an interactive manner. Of paramount
relation between nature, nurture, and combat stress,     importance in the soldier’s expectation or interpre-
beginning as early as Salmon15 and extending as          tation of the immediate situation is the role his
recently as Shaw16 and Milgram.17 Yet the complex-       commanders (or persons in leadership positions)
ity of the combat situation calls for a multi-variable   play in providing the information concerning the
and rather complex, interactive model to account         impending military operation. Thus, the way in
for the multitude of factors involved in the genera-     which he is briefed and the way in which orders are
tion of, and consequent coping with, the stress of       given, interacting with the antecedent variables,
combat.                                                  will strongly color his evaluation (ie, appraisal) of
   The proposed model is interactional in that it        both the nature of the stress and his ability to handle
posits a number of antecedent variables acting           it. The role of the commander, then, becomes that of
through mediating variables to affect the indi-          a lens, that is, either magnifying or minimizing the
vidual’s appraisal of the combat situation and sub-      impact of the (objective) antecedent variables on the
sequently result in the combatant’s modes of re-         soldier’s (subjective) cognitive appraisal.
sponse and coping with the realities of combat               The appraisal process, which is the central notion
(Figure 6-1). Furthermore, the model is also dy-         in this model, may vary along a wide range of
namic wherein the individual’s preferred coping          alternatives: the exact situation may be assessed by
behavior in turn affects his reappraisal of the situ-    different individuals or at different moments as a
ation and thus may further alter his combat re-          terrifying, benign, or challenging situation—de-
sponses.                                                 pending upon the interactive consequences of the
   The antecedent variables pertain to the individual,   given antecedent and mediating factors. The
group, and environmental aspects and may conve-          individual’s initial modes of response to and coping
niently be categorized as follows:                       with a combat situation will reflect his own process
                                                         of cognitive appraisal. Response patterns may be
  • Individual factors—personality, nonmilitary          divided into the traditional categories of physical,
    stress (family, etc), prior combat exposure,         emotional, cognitive, and social. These immediate,
    role in combat.                                      somewhat universal patterns of response will in



                                                                                                             135
War Psychiatry


Antecedent Variables                            Mediating Variables                        Modes of Response   Modes of Coping


                                                                                                    Physical        Activity
  Individual Factors




                                                                                                   Emotional



                                COMMANDER
                                            Interpretations
                                                                        Appraisal
                                                                            of
      Unit Factors                          Expectations                 Combat
                                                                        Situation


                                            Form of
                                             Form of                                                                Inactivity
                                                                                                   Cognitive
                                            Presentation
                                             Presentation



 Battlefield Factors
                                                                                                     Social
                                                                                                                    Breakdown


                                                                                     Reappraisal
                                                                                    Reappraisal


Fig. 6-1. A model of soldier behavior in combat stress conditions. This model is interactional in that it posits a number
of antecedent variables acting through mediating variables to affect the individual’s appraisal of the combat situation
and subsequently result in the combatant’s modes of response and coping with the realities of combat. The model is
dynamic in that the individual’s preferred coping behavior in turn affects his reappraisal of the situation and thus may
further alter his combat responses. The role of the commander becomes that of a lens, magnifying or minimizing the
impact of the (objective) antecedent variables on the soldier’s (subjective) cognitive appraisal.


turn produce individual modes of coping ranging                       factors but consequently reflecting also the initial
from an optimal mode (normally involving a high,                      reactions made by the individual. The new ap-
goal-oriented level of activity) to limited coping                    praisal will then lead to different modes of response
(frequently characterized by passivity) to grossly                    leading to different modes of coping and a further
disturbed coping (breakdown).                                         new and different appraisal.
   The modes of coping actually utilized will influ-                     The following sections will further detail each of
ence, in a feedback manner, the individual’s reap-                    the components of the proposed model and will
praisal of the newly perceived situation and of his                   attempt to empirically substantiate the proposed
already tested capabilities to cope with it. Thus, the                relationships between them. This analysis will in-
cognitive appraisal processes are in a state of dy-                   volve direct combat experience as well as relevant
namic flux, originally affected by the antecedent                     research.


                                               ANTECEDENT VARIABLES


   Two main groups of variables, antecedent and                       Individual Factors
mediating, lead to the initial appraisal of the stress
situation. The antecedent variables comprise those                       Among the individual factors that any combat-
factors that are in the background of the combat                      ant brings along with him to the battlefield are his
situation; they may be categorized as individual                      personality dispositions and his general well-be-
factors, unit factors, and battlefield factors.                       ing. These, together with his previous combat exper-



136
                                                                           A Psychological Model of Combat Stress


ience and his role in combat, determine the first        combat] seemed to be more related to the character-
category of the antecedent variables.                    istics of the group than to the character traits of the
                                                         involved individuals.”13(p995)
Personality Dispositions
                                                         Individual’s Well-Being
    Notwithstanding the almost obvious expecta-
tion that behavior in the face of battle should be          While personality dispositions refer to long-
somehow linked to the warrior’s personality, very        standing traits of the individual himself, well-being
little empirical evidence has been found linking         refers to relationships between the individual and
individual personality factors and combat behav-         his environment.22 Such relationships may directly
ior, either in terms of outstanding performance or       affect combat behavior as shown in the Israeli expe-
breakdown. 18 One extensive study, 19 however,           rience of the 1973 Yom Kippur War.21 In a group of
did find several characteristics that distinguish        40 Israeli soldiers who suffered battle shock, 80%
“fighters” (soldiers who had received, or had been       had prior or ongoing civilian stresses. About one
recommended for, a decoration for valor in combat        half had pregnant wives or were new fathers during
or were evaluated by peers as high performers)           the year preceding the war and about one fourth of
from “nonfighters” (soldiers who were evaluated          them had experienced a recent death in the immedi-
by peers as poor performers, or admitted them-           ate family. Other relevant civil stresses consisted of
selves as such). Among the differences revealed in       being newly married or separated and economic or
that study, the “fighters” tended to be more intelli-    family problems.
gent, “masculine,” and socially mature; and showed          A world War II study23 reported that 20% of
greater emotional stability and stronger leadership      psychiatric cases complained of “homesickness” as
potential.                                               a significant stress. An even more striking differ-
    Indeed, military organizations tend to consider      ence between those who became psychiatric casual-
personality variables in selecting personnel for com-    ties and a nonafflicted comparison group was found
bat roles, particularly leadership roles and special     when variables such as family, school, work, and
operations. This preselection procedure may, in          social, recreational, and community adjustments
fact, by virtue of restricting the range for study,      were examined. Soldiers with impairments in these
account for the difficulties in establishing empirical   areas were found to have about a two to four times
correlations between personality dispositions and        greater likelihood of breaking down.23
combat performance. Gal,20 for example, in a study          More recent studies have shown high levels of
of soldiers awarded medals for bravery in the 1973       self-reported well-being to be a distinct characteris-
Yom Kippur War found only a few differences in           tic of elite combat units.24 Whether operating as a
personality characteristics between the decorated        causal factor in facilitating volunteering to elite
soldiers and a matched sample of combat soldiers         units, or emerging as a concomitant of belonging to
not so recognized. These personality characteris-        such units, personal sense of well-being is evidently
tics were part of the officer selection process that     an important antecedent factor for any combatant
many of the soldiers awarded medals had gone             facing the impending stress of combat.
through. Medal recipients, as compared with their
peers, showed higher scores in leadership, devo-         Previous Combat Experience
tion to duty, decisiveness, and perseverance under
stress. Sociability, social intelligence, and emo-          The effect of previous experience on fear reac-
tional stability did not distinguish the two groups.     tions was demonstrated in studies conducted with
    With regard to psychiatric breakdown among           combat-like performance. Epstein25 and his col-
members of combat units, Noy21 found that while          league26 have demonstrated that experienced para-
personality characteristics did not predict such         chutists showed different patterns of subjective fear
breakdown, they were significant in recovery after       and physiological reactions as compared to novice
breakdown. Men with massive repression of hostil-        jumpers.
ity or anxiety, particularly if coupled with situ-          Actual combat experience obviously has an even
ational stress at home, had a poorer prognosis. It is    stronger effect. Indeed it has been recognized, at
quite evident, then, as concluded by Glass in his        least since World War II, that initial exposure to
summary of the “lessons learned” from World War          combat on the one hand and cumulative combat
II, that “the frequency of psychiatric disorders [in     stress on the other hand result in higher rates of



                                                                                                             137
War Psychiatry


psychiatric breakdown. Units with high percent-         indeed, his role was closer to that of the officers, and
ages of “green” soldiers tended to have higher num-     reflected again the importance of his role assign-
bers of psychiatric casualties.27 Clearly the soldier   ment in combat.
with prior combat experience has less chance of            Unlike Bourne and his colleagues, who equate
breakdown in subsequent exposure, until the point       steroid excretion with levels of psychological stress
(about 30 combat days, defined as days in which a       in combat, the authors believe that the level of
company suffered at least one wounded in action         steroid excretion reflects physiological arousal and
[WIA] or killed in action [KIA]) that cumulative        that the leadership role may actually be less psycho-
stress begins to produce combat inefficiency.28         logically stressful because the leaders are better
   Apparently even the soldier who has broken           prepared for combat and have more control over
down, if properly treated with “forward treat-          combat situations. Support for this hypothesis may
ment,”15 has no greater chance of breakdown again       be seen in the work of Miller,31 and Miller and
than his combat peers. Looking at Israeli soldiers      colleagues,32 with pilots and their radar intercept
who had become psychiatric casualties in 1973 and       officers during stressful aircraft landing procedures.
who subsequently served in the 1982 Lebanon War,        They found that while the radar intercept officers
Solomon, Oppenheimer, and Noy29 found no sig-           had lower levels of steroid excretion, the pilots,
nificant increased recurrence of psychiatric break-     who had active control over the flights, reported
down among those with prior breakdown if they           fewer somatic complaints and significantly lower
had been found fit for combat. It should be recog-      levels of anxiety than the radar intercept officers.
nized, however, that a significantly smaller per-          In support of these studies there are numerous
centage of soldiers who had had psychiatric break-      personal observations that show that the leadership
downs were found fit for combat compared to those       role supports superior combat performance and
who had not (40% versus 75% in nonpsychiatric           protects the leader from disabling psychological
controls) but this may have been a result of lack of    stress. The senior author both personally observed
“forward treatment” in 1973.                            and had many communications from Israeli field
   It might be summarized, then, that previous com-     commanders describing the mastery, confidence,
bat experience may have an enhancing or an inhib-       and even daring they have derived, under fire, from
iting effect on the soldier’s reactions to subsequent   the awareness of their leadership role and the ex-
exposure to combat—depending on whether the             pectations of their men.
previous experience had been a traumatic or a              During the 1973 Yom Kippur War, Israeli com-
nontraumatic one.                                       manders were under the greatest combat danger,
                                                        being in the forefront of the engagement. This
Role in Combat                                          danger is reflected in the fact that a commander had
                                                        four times the chance of being killed compared with
   One’s role in combat, whether formally assigned      his men.33 Despite the presumed increased risk of
or assumed during the vicissitudes of combat, plays     battle stress, Levav and others34 showed that the
a crucial role in his appraisal of the situation and    rate of psychiatric breakdown among officers was
thus in his method of coping. In general, engaging      one fifth that of enlisted men. On the other pole of
in an assigned role that involves some form of          battlefield performance, that of bravery in battle,
mission-oriented tasks will create a sense of mas-      the number of Israeli combat officers awarded med-
tery and control as well as distract the soldier from   als for extraordinary acts of bravery was much
his impending danger.4                                  higher (64% of the total) than their proportion in the
   The leadership role in a combat situation is par-    line units.20 When noncommissioned officers are
ticularly important for coping behavior. Bourne,        included with commissioned officers, the percent-
Rose, and Mason, 30 for example, in studies con-        age of medals for bravery rises to 88% awarded to
ducted during the Vietnam conflict, have shown          persons in leadership roles, thus inverting the ratio
significantly different patterns of hormonal re-        of leaders-to-led.35
sponses (normally associated with stress) between          In conclusion, under battlefield conditions, per-
officers and enlisted men of a 12-man group who         ceived role is a critical factor in both combat effec-
were anticipating engagement in combat. The             tiveness and resistance to breakdown. Perceived
chronic levels of steroid excretion of officers were    role serves adaptive coping purposes through the
higher than those of their enlisted men and rose        interplay of three psychosocial mechanisms: (1) the
even higher on the day of anticipated attack. The       expectations attached to the role (especially the
senior radio operator’s steroid excretion also rose;    leadership role), (2) the sense of mastery and con-


138
                                                                            A Psychological Model of Combat Stress


trol associated with the role, and (3) concentration       nation of 40 IDF soldiers who suffered psychiatric
on the tasks required by the role distracts attention      breakdown in that war, Noy21 found that 40% of
from the realistic dangers of combat.                      these casualties reported minimal group affiliation
   To summarize, one can see that while there are          in contrast to only 10% in a control group of
only limited data to show that personality disposi-        noncasualties. Similarly, Steiner and Neumann39
tions predict combat behavior, there is good evidence      found the following characteristics in 74 reserve
for the importance of background conditions such as        soldiers presenting with acute or late onset of post-
the individual’s well-being, his previous combat           traumatic combat reactions after the 1973 Yom Kip-
experience, and his perceived role in combat.              pur War: low morale, with little or no identification
                                                           with their unit or team; lack of trust in leadership;
Unit Factors                                               frequent transfer or rotation; feelings of loneliness
                                                           and not belonging to their units; and low self-es-
   In most cases the individual will not operate           teem concerning their military performance.
alone but will be part of a group in combat. The              Thus, a low level of morale and weak bonds with
group’s size (significant for the individual combat-       comrades and leaders may elevate the perceived
ant) may vary from three or four (as in a fire team or     stress of combat and ultimately result in severe
tank crew) to larger formations such as companies          combat reactions. This indeed happened in units
or even battalions. These group characteristics,           with low cohesion and low morale. At the other end
similar to individual characteristics, have impor-         of the spectrum, elite units, famous for their high
tant implications for combat behavior. Since the           degree of cohesion and morale, have consistently
1973 Yom Kippur War, the IDF has deployed field            had low psychiatric casualty rates despite frequent
psychologists to all of its line brigades to survey        exposure to high-intensity battle stress.
morale factors at various organizational levels and
report back to unit commanders. Systematic analy-          Confidence in Commanders
sis36 of these surveys revealed four general factors
important in determining unit climate. These con-             The paramount importance of the role of leader-
sisted of unit cohesion and morale; confidence in          ship in combat has been recognized since antiquity.
commanders; confidence in weapons and in one-              The history of battle has always been the history of
self as a combatant; and ideology, values, and com-        leaders building their subordinates’ confidence to
mitment.                                                   achieve victories. Whether the fighting unit is a
                                                           small band of warriors with spears or a vast army
Unit Cohesion and Morale                                   with laser-aimed rifles and bombs, their confidence
                                                           in the leader is essential.
   Unit cohesion and morale have repeatedly been              Contemporary studies40–42 confirm the crucial role
found important in supporting individual coping            of unit commanders in preparing troops for com-
behavior and unit performance both in wartime5             bat, enhancing troop morale, and leading them cou-
and in peacetime.37,38 Among other variables, they         rageously in battle. The soldier’s confidence in the
were found to affect critically the rates of psychiat-     commander is also critical in protecting him from
ric breakdown in combat.13 In the words of Glass:          overwhelming battle stress. In Israeli studies dur-
                                                           ing the 1982 Lebanon War, Kalay43 found three
  Repeated observations indicated that the absence         elements that inspired confidence in the commander:
  or inadequacy of such sustaining influences [which       (1) belief in the professional competence of the
  he termed “group identification,” “group cohe-           commander, (2) belief in his credibility, and (3) the
  siveness,” “the buddy system,” and “leadership”]         perception that he cares about his troops. While in
  or their disruption during combat was mainly re-
                                                           garrison all three components are equally impor-
  sponsible for psychiatric breakdown in battle. These
  group or relationship phenomena explained marked         tant; in combat, trust in the commander’s profes-
  differences in the psychiatric casualty rates of vari-   sional competence becomes primary.
  ous units who were exposed to a similar intensity           In reviews of Israeli morale surveys during both
  of battle stress. 13(p995)                               the 1973 Yom Kippur War and the 1982 Lebanon
                                                           War, the senior author12 compared the levels of
  In recent studies based on Israeli experiences           confidence soldiers had in commanders at various
during the 1973 Yom Kippur War, the relationship           command levels, from platoon to division. While
between unit cohesion and morale and coping be-            assessments before combat showed an almost lin-
havior was reconfirmed. In a retrospective exami-          ear increase in the confidence of troops in their


                                                                                                              139
War Psychiatry


commanders with increasing levels of command                     These aspects of a soldier’s self-confidence—trust
(ie, lowest at the platoon leader and highest at the          in one’s own combat skills, in weapons systems,
division commander levels), after combat the trend            and familiarity with missions and terrain—are
was generally reversed with the highest levels of             all created within the unit framework during train-
confidence shown in the more immediate command-               ing periods. Knowledge of missions and terrain
ers (platoon, company, battalion) and relatively              is not learned during training in the United States
lower confidence at the more remote levels of com-            as it is in Israel because of the wider range of
mand (brigade, division). This difference may be              scenarios. The more realistic the training, the better
accounted for on the basis that prior to battle the           prepared the soldier will be. However, the growing
soldier perceives his welfare and success as being            sophistication (and expense) of modern weaponry
dependent on higher command plans and deci-                   has resulted in the increasing use of training by
sions; but, in actual combat, he finds that his very          simulation devices, which may act against the ac-
survival depends mainly on the actions of his more            complishment of such realistic training. Simulation
immediate leaders.                                            training, while usually accurate in its technical
   It is apparent, then, that despite marked changes          aspects, is quite dissimilar from the arduous and
in the configuration and technology of the battle-            horrifying conditions of combat.44 Military train-
field, the confidence troops have in their command-           ing, therefore, must aim not only at producing
ers at all levels is a critical ingredient in the soldiers’   technical proficiency with one’s weapon but
process of coping with the stresses of battle.                also at developing soldierly skills and proficiency
                                                              to serve the soldier as a psychological defense
Confidence as a Soldier                                       mechanism against the strenuous conditions of the
                                                              battlefield.
   As described earlier, “green troops” suffer higher
rates of psychiatric casualties than battle-experi-           Ideology, Values, and Commitment
enced troops. This may well reflect the importance
of increased confidence of the soldier in his own                It is commonly believed that a strong ideological
battle skills.                                                conviction plays a significant role in combat moti-
   Confidence in one’s weapons and in one’s profi-            vation. Obviously, when a soldier believes that he
ciency as a combatant has been shown to be impor-             is defending his homeland, he may derive addi-
tant for the soldier’s morale. In a morale survey             tional strength to face the horrors of battle. How-
among Israeli soldiers anticipating combat, Gal36             ever, while it is evident that such ideological con-
reported high correlations between their personal             victions foster the joining of a military organization,
level of morale and both confidence in themselves             there is little empirical data supporting the position
as combatants and confidence in the unit’s weapons            that such feelings enhance performance or prevent
system.                                                       breakdown in the midst of a combat situation. In
   Furthermore, Steiner and Neumann,39 studying               fact, observations by acknowledged military ex-
the combat experiences of Israeli veterans of the             perts have deemphasized the importance of ideol-
1973 Yom Kippur War, examined among other vari-               ogy when survival on the battlefield is at stake. For
ables the relationship between self-confidence in             example, S.L.A. Marshall, after visiting Israel and
military performance and the development of post-             discovering the importance of nationalist feelings
traumatic stress disorders. They found that 46% of            to its citizens, gave his own judgment:
74 soldiers suffering traumatic reactions evaluated
their military performance and knowledge as poor.               But for my own part, I reject finally the idea that the
In contrast, only 3% of 100 soldiers in a nonafflicted          extraordinary elan of that Army in combat comes
control group reported such lack of self-confidence.            from self-identification of the individual with the
   Another source of the soldier’s confidence is his            goals of his nation in the hour when his life is in
familiarity with his mission, with the operational              danger. That is not the nature of man under battle;
                                                                his thoughts are as local as is his view of the nearest
terrain, and with the exact location of friendly and
                                                                ground cover, and unless he feels a solidarity with
enemy forces.36 Because one of the well-established             the people immediately around him and is carried
sources of anxiety is fear of the unknown and the               forward by their momentum, neither thoughts about
unfamiliar, introducing the soldier to the details of           the ideals of his country nor reflections on his love
his mission, the terrain, and the deployment of                 for his wife will keep him from diving toward the
forces will ultimately reduce his anxiety level.                nearest protection. 45(p304)




140
                                                                            A Psychological Model of Combat Stress


   In a similar vein, Field Marshall Montgomery, in       chiatric casualties: very high in Okinawa and over-
referring to patriotic feelings and historical roots of   all relatively low in Normandy. The Israeli 1967
combat motivation, deliberately downplayed these          Six-Day War and 1973 Yom Kippur War were both
factors: “[I]n the crisis of battle the majority of men   brief and of high intensity but differed markedly in
will not derive encouragement from the glories of         the impact on troop morale and psychiatric casual-
the past but will seek aid from their leaders and         ties: almost none in the former and relatively high
comrades of the present.” 46(p21)                         in the latter.
   Despite this discounting of idealistic feelings as        The main components in this last category of
a factor in actual combat, there is evidence that         antecedent variables are the type of battle, its length
a soldier’s perception of the legitimacy of his           and intensity, the uncertain elements of battle, and
side’s participation in war is important for his mo-      the physical characteristics of the battlefield.
rale. A morale survey conducted among IDF troops
prior to the Israeli incursion into Lebanon found a       Type of Battle
positive correlation between the soldiers’ morale
level and their belief that invading Lebanon was             Offensive and defensive operations differ in gen-
justified.36                                              erating stress reactions. In defensive operations,
   A similar relationship between morale and per-         especially with impending danger but without ac-
ceived legitimacy of one’s side in a war probably         tive engagement to break the tension, the soldier is
could have been found in Vietnam. Renner47 and            subjected to an enforced passivity and experiences
Gabriel and Savage48 have argued that after 1968,         a feeling of helplessness. By contrast, in offensive
soldiers’ perceptions that the U.S. presence was not      operations, even though the risk may be greater, the
legitimate led to unit disintegration as evidenced        soldier is active, has a vicarious sense of control
by “fragging” (assassination of one’s leaders), de-       over the situation, and is distracted from personal
sertion, drug abuse during combat, and combat             concerns.4 Similarly, during static situations such
refusals.                                                 as being pinned down for long periods, perhaps by
   It was reported49 that Soviet soldiers stationed in    artillery fire or similar situations of immobility,
Afghanistan during the mid-1980s invasion suf-            stress casualties are higher than in mobile situa-
fered low morale and engaged in widespread drug           tions such as advancing or even retreating.50
abuse and some fragging similar to U.S. soldiers in          Day vs night operations may also generate differ-
the late phases of the Vietnam conflict. Defecting        ent stress reactions in synergy with other situations.
soldiers in Afghanistan related this to loss of belief    For example, at nighttime the soldier in a defensive
in the legitimacy of the war: “It’s a stupid war, not     posture may have his feelings of isolation accentu-
useful to anyone.”49                                      ated by darkness. On the other hand, daytime
   Ideological concerns thus seem most important          operations with active engagement of the enemy
when legitimacy is questionable, or in wars of            may allow the soldier to see his wounded and dead
low intensity with intermittent combat, and in            comrades, adding to his battle stress. Unfortu-
the anticipation before battles or during lulls be-       nately, no clear data indicating increased pathoge-
tween battles. In the heat of battle, however,            nicity for either situation exist.
ideological motivation is replaced by other unit
factors such as leadership, unit cohesion, and            Length and Intensity of Combat
combat skillfulness.
                                                             Length of exposure to combat has been corre-
Battlefield Factors                                       lated with cumulative stress28,51 while intensity of
                                                          combat is more related to acute stress.50 In further-
   The third group of antecedent variables, battle-       ing this distinction, some authors refer to the conse-
field factors, may play a decisive role in promoting      quences of cumulative stress as “combat exhaus-
combat stress because they include the nature of the      tion” or “fatigue” and of acute stress as “battle
threat and the environment of the battlefield. Most       shock.”
battlefields have unique features that generate dif-         Several authors have attempted a predictive
ferent levels of stress. The World War II U.S. battles    model of breakdown based on duration of combat
on Okinawa and Normandy, for example, both be-            exposure28,51 or intensity of combat. 52–54 Swank and
ginning as amphibious invasions, had vastly differ-       Marchand28 found that most psychiatric casualties
ent characteristics and quite different rates of psy-     occurred after 30 to 45 days of exposure to combat.



                                                                                                              141
War Psychiatry


Beebe and Appel, on the other hand, predicted that        tion pattern in his study of “incubation of threat.”
“the breaking point of the average rifleman seems         According to Breznitz, two conflicting tendencies
to have been reached at about 88 days of company          may operate simultaneously in an anticipatory pe-
combat [days in which a company casualty                  riod. On the one hand, the person gradually relaxes
occurred].”51(p163)                                       after the initial introduction of the threat. On the
   A number of authors10,13,50,52–55 have observed the    other hand, there is increasing excitation as actual
relationship between combat intensity, as indicated       occurrence of the threatening event approaches. In
by wounded and killed in action (WIA and KIA),            cases where a U-shaped curve is exhibited by stress
and combat breakdown. Normally, the rate of psy-          reactions, this curve may be the net result of these
chiatric casualties will fluctuate in proportion to the   two processes.
WIA. In prior wars this ratio has ranged from 1:3 to         Uncertainty can take two forms: temporal uncer-
1:1; however, in low-intensity, intermittent combat,      tainty in which the time when an event will occur is
psychiatric casualties are less directly related to       unknown and event uncertainty in which the time
combat and take different forms.47,56,57                  is known but the nature of an event is unknown.
   To summarize what is known about the relation-         Situations involving both types of uncertainty are
ship between duration of exposure to combat and           common in combat. In general, the greater the
the likelihood of combat stress breakdown, it ap-         uncertainty, the greater the stress.61,62
pears that some minimum amount of exposure to                Although anticipation and uncertainty create high
combat is necessary to enhance soldiers’ confidence       levels of stress, a surprise aversive event is even
and decrease their vulnerability to breakdown.            more stressful. The initial phase of a surprise attack
Beyond that exposure threshold, increased expo-           may maximize panic and psychiatric breakdown.
sure to combat eventually weakens the soldiers’           According to senior Egyptian Army psychiatrists,
defenses against breakdown.                               this was reflected in high psychiatric casualties
                                                          among Egyptian soldiers in the early period follow-
Battle Anticipation, Uncertainty, and Surprise            ing the 1967 surprise attack by Israel.63 Likewise
                                                          numerous psychiatric casualties among Israeli
   As alluded to earlier, the anticipation of battle      troops occurred in the first hours and days follow-
may be more stressful than actual battle.4 A well-        ing the surprise attack by Arab forces in the 1973
known syndrome described by World War II physi-           Yom Kippur War. 11
cians as the “precombat syndrome”58 consisted of
vague complaints without identifiable physical find-      Environmental Conditions
ings among those scheduled for combat, for ex-
ample, air crews awaiting a bombing run. Further-            Some of the antecedent factors are not necessar-
more, Jones 59 noted that there were numerous             ily born in combat, but they affect combat perfor-
psychiatric complaints in the 25th U.S. Army Divi-        mance. For example, when combatants are rapidly
sion in the several months when deployment to             transported to a new and unfamiliar environment,
Vietnam was uncertain, but fewer when it became           they must first adjust or acclimate before perform-
definitive.                                               ing at their optimum.64 Furthermore, harsh envi-
   Generally, troops prefer to avoid impending            ronments such as arctic or tropical climates, wet, or
threats of combat; however, long periods of antici-       other inclement weather increase combat stress ca-
pation may result in paradoxical positive feelings        sualties, probably through the increased physiologi-
concerning impending combat. The first author has         cal stresses added to the psychological stresses of
monitored the feelings of combat anticipation of a        combat. Numerous authors have commented on
group of infantrymen stationed in a combat zone           the deleterious effects of adverse environmental
for 3 weeks. He found an inverted U-shaped curve          conditions on morale5 (ie, strange terrain such as
peaking at 10 days measuring strong anticipation of       that found in the desert, the jungle, the steppes—
actual engagement with the enemy. This response           lacking usual landmarks) and on the soldier’s abil-
pattern reflects the mounting anticipation during         ity to cope in combat.65
the ascending limb and a growing desire to relieve           Masked psychiatric conditions ranging from frost-
the anticipatory anxiety with action. The descend-        bite or immersion foot in cold or wet climates to
ing limb may reflect a desire to avoid combat alto-       dehydration in hot or dry climates exemplify the
gether because relief was becoming imminent.              relationship between combat breakdown and ad-
   Breznitz,60 among others, has discussed this reac-     verse environments. 66



142
                                                                           A Psychological Model of Combat Stress


                                         MEDIATING VARIABLES


   While antecedent variables are important in the       tion. Like in a telescope, this “lens” works (with
soldier’s appraisal of the combat situation, their       regard to the stress of combat) to amplify the per-
impact on the individual’s response and coping           ceived threat or to reduce it, make it closer or more
behavior is determined by mediating variables.           remote, better focused or more blurred. Though it
These variables are, in the first place, cognitive in    may not be possible to modify many of the anteced-
their nature, involving cognitive interpretations        ent variables, the commander can be trained to
of the antecedents, a logical evaluation of the          present and interpret information regarding these
situation, and a buildup of expectations both of         antecedents in an optimal manner and hence create
one’s behavior and of the consequences of the entire     an expectation of success.
situation.                                                  A third characteristic of the mediating variables
   A second characteristic of these mediating vari-      is their dynamic quality. While the antecedent
ables is that they are largely controlled by the com-    factors may change or remain the same, the inter-
mander who may give them a positive or negative          pretation given to them may vary as new informa-
connotation. For example, a determined, confident        tion becomes available or as behavior changes as a
commander, who conveys to his troops his optimis-        consequence of the appraisal. A heroic or cowardly
tic view, will actually increase the chances of suc-     act by oneself or a comrade, for example, will change
cess, assuming that the optimism is realistic. On the    the initial interpretation of the situation and lead to
other hand, an unenthusiastic, subdued, or fright-       changed responses.
ened presentation will create uncertainty or fear           It must be realized that there are not clear-cut
and result in less resolute, more pessimistic ap-        distinctions between the antecedent and mediating
praisals, increasing the possibility of failure.         variables. Interpretations and expectations may
   The commander plays a central role in creating        stem directly from the individual’s predispositions
the individual’s appraisal of the situation by acting    or be part of a unit characteristic. These antecedent
as a lens (see Figure 6-1) that focuses the antecedent   and mediating variables are schematically presented
variables into a unified interpretation of the situa-    separately in the model for purposes of clarity only.


                                        THE APPRAISAL PROCESS


   The appraisal is the bridge between the external      praisal process in determining the emotional and
conditions and the soldier’s response. It is the         behavioral responses of groups and individuals to
combination of the soldier’s perception and evalu-       stress. In a series of studies3 in which audiences
ation of both the situation and his own capability to    viewed highly distressing films, the responses
cope with it. The same situation may result in a         of the audience were clearly determined by a
whole spectrum of appraisals by various individu-        narrative voice that interpreted the ordeal as rang-
als or by the same individual at different times.        ing from traumatic to neutral, intellectualized,
Thus, a given combat situation may appear lethal,        or benign (through denial-like processes). Though
hazardous, adventurous, or auspicious, while the         the subjects all saw exactly the same film, their
individual reaction to it may range from being ter-      reactions were drastically different as a function
rified or threatened to challenged or excited.           of the sound track the introduction provided
   The appraisal process further determines the          before the film. Using the neutral group as a refer-
course of action that an individual might take when      ence, the trauma group showed marked elevation
faced with a stressful situation. This is reflected      of physiological and psychological distress while
directly, for example, in the work of Grinker and        the intellectual and denial groups showed reduc-
Spiegel on combat stress in World War II. As these       tion in distress. Subsequent experiments using the
authors noted, “appraisal of the situation requires      same paradigm revealed different stress reactions
mental activity involving judgment, discrimination       as a function of the conditions (ie, length of antici-
and choice of activity.”6(p122)                          patory time, level of uncertainty) on which the
   Lazarus and his colleagues3,67 have empirically       appraisal process depended, the type of cognitive
demonstrated the dominance of the cognitive ap-          activities (ie, detachment or involvement) required



                                                                                                             143
War Psychiatry


from the subjects, and as a function of individual       tion to battlefield conditions can be determined by
differences.                                             the mediating variables (interpretations, expecta-
   Thus, the same situation may generate different       tions, form of presentation), which are primarily
responses depending on the type of interpretation        controlled by the commander. From these different
or expectation suggested prior to or during the          appraisals will result the different modes of re-
situation. Likewise, an individual or group reac-        sponse or coping.

                                          MODES OF RESPONSE

   The modes of response to stressful combat situa-          expressed by seeking reassurance and physi-
tions may be categorized as follows:                         cal clustering. Negative aspects may be an
                                                             increased tendency to make demands and
  • Physical: includes autonomic changes                     irritability.
    (tachycardia, vasoconstriction, sweating,
    increased gastrointestinal motility), muscu-            These reactions are universal. Alerting the sol-
    loskeletal changes (increased tonicity and           dier to their anticipated appearance under stress by
    perfusion of blood to muscle), and glandu-           reassuring him that they are normal and are prepar-
    lar changes (release of medullary and corti-         ing the body for combat will serve a preventive and
    cal hormones from the adrenal glands pro-            therapeutic purpose. The appraisal plays a lesser
    ducing many of the foregoing effects).               role in eliciting or controlling these responses than
  • Emotional: includes a variety of affective re-       it does with the coping responses, which will be
    actions varying from enthusiastic excitement         discussed next.
    to apprehensive fear, anxiety, or depression.           While the modes of response (in this model) are
  • Cognitive: includes distortion of perception         relatively involuntary or automatic, immediate, and
    with narrowing of attention span, hyper-             brief, the individual’s modes of coping are more
    alertness to certain stimuli, and increased          flexible, voluntary, and may be delayed and pro-
    utilization of automatic or overlearned re-          longed. The former may only to some extent be
    sponses.                                             conditioned through training; the latter are highly
  • Social: includes increased dependency on             influenced by training and strongly determined by
    leadership and need of affiliation, sometimes        the instant conditions of combat.


                                            MODES OF COPING


   The individual’s appraisal of the situation and          During combat, the active-coping mode is seen in
the variety of modes of response are incorporated        controlled aggression by the combat soldier: seek-
into an integrated or holistic mode of coping, rang-     ing shelter, firing weaponry, scanning or scouting
ing from various levels of activity through passivity    the terrain, etc. Similarly, the combat-support sol-
to actual breakdown. The active mode of coping           dier will stay active in his respective duties. The
may take various forms. During combat anticipa-          consequences of this active mode are usually greater
tion (almost always present on the battlefield), ac-     initiative, innovation, bravery, and successful ac-
tivity may take the form of preparation—checking         complishment of the mission. Rarely, this activity is
gear, plans, or last minute details. Activity may not    not mission-oriented and results in inefficiency in
necessarily be directly related to the threat, and can   combat.
include card playing, book reading, letter writing,         Relative inactivity or even passivity in the com-
and so forth. These activities, nonetheless, serve as    bat situation is manifested by decreased movements,
successful coping behavior because they distract         relative apathy to the surroundings and mission,
the individual from considering the death or wound-      and lack of initiative. The observation during World
ing that may await him in battle, and sustain and        War II and the Korean conflict that only a small
promote cohesion and resolve. This behavior, par-        percentage of soldiers fired their weapons68 prob-
ticularly when it takes the form of combat prepara-      ably applies to this group of combatants. A conse-
tions, also gives the soldier a sense of mastery over    quence of this unsuccessful coping mode is not
the situation, diminishing anxiety.4                     only a failure to perform effectively but also a be-



144
                                                                               A Psychological Model of Combat Stress


ginning of a psychological collapse, exhibited by           coping that further modify the appraisal. Typically,
increasing fatigue, mounting anxiety, and a sense of        if a successful active-coping mode took place, the
burnout. The ultimate result of a passive mode of           reappraisal process tends to be in the direction of
coping may be a complete breakdown, whether                 optimism. Conversely, passive coping usually will
labeled combat fatigue, battle shock, or war neuro-         lead to a pessimistic appraisal, resultant less-effec-
sis. This breakdown occurs when the soldier’s               tive modes of response and coping, and increas-
preoccupation with his own anxieties leads to re-           ingly negative appraisals. Thus, the behavior of the
moval from battle, shutdown, immobility, and er-            soldier in combat is an ongoing process of apprais-
ratic behavior.                                             als and reappraisals (largely unconscious appraisal
   Whatever mode of coping is utilized by the indi-         and reappraisal) that are affected by his perception
vidual, it is not only an outcome of the combat             of the situation on one hand and his initial re-
appraisal and modes of response but also serves as          sponses and coping on the other hand. The leader
an input into the ongoing reappraisal of the situa-         can optimize his own coping by good training,
tion. Based on his own mode of coping, the soldier          keeping himself functioning, and taking care of
may now reinterpret the combat situation. This in           junior leaders, and by intervening at key times and
turn may generate new modes of response and                 places with his troops.


                                      SUMMARY AND CONCLUSION


   This model of combat stress is complex in that           who were combat veterans were presented with the
there are multiple interacting variables in its appli-      model and encouraged to test it against their per-
cation and, furthermore, the variables interact in an       sonal experiences. Almost unanimously, these of-
ongoing, circular fashion. Despite its complexity,          ficers gave positive evaluations of the validity of
the model is operationally applicable. A combat             the model for combat. The best didactic approach
leader who is aware of the multiple variables medi-         seemed to be through an initial presentation of the
ating stress in battle can understand and anticipate        model followed by small-group interaction in which
both the behavior of troops and of himself, and take        instructors guided the discussion. The small-group
preventive measures to diminish the stress. Under-          participants explored the applicability of the model
standing the ongoing, circular nature of these vari-        to their own experiences.
ables, he can intervene to reduce the stresses, the            Students of war and combat agree that the most
anxiety, and ultimately the potential for breakdown.        precious commodity in battle is not armaments but
   This model can be taught in varied types of              people. The understanding and application of this
leadership training. For example, in the Israeli            model may conserve and increase the efficiency of
Defence Forces Staff and Command School, officers           the vital human resource.

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 20.   Gal R. Courage under stress. In: Breznitz S, ed. Stress in Israel. New York: Van Nostrand Reinhold Company;
       1983: 65–91.

 21.   Noy S. Stress and personality as factors in the causation and prognosis of combat reaction. In: Belenky G, ed.
       Contemporary Studies in Combat Psychiatry. Westport, Conn: Greenwood Press; 1987: 21–29.

 22.   Campbell A. The Sense of Well-being in America. New York: McGraw Hill; 1981.

 23.   Brill NQ, Beebe GW. A Follow-up Study of War Neuroses. Washington, DC: US GPO; 22 January 1958.

 24.   Manning FJ, Fullerton TD. Health and well-being in highly cohesive units of the US Army. J Appl Soc Psychol.
       1988;18(6):503–519.

 25.   Epstein S. Toward a unified theory of anxiety. In: Maher BA, ed. Progress in Experimental Personality Research. Vol
       4. New York: Academic Press; 1967.

 26.   Epstein S, Fenz WD. Steepness of approach and avoidance gradients in humans as a function of experience:
       Theory and experiment. J Exp Psychol. 1965;70(1):1–12.

 27.   Drayer CS, Glass AJ. Introduction. In: Glass AJ, ed. Overseas Theaters. Vol 2. In: Neuropsychiatry in World War II.
       Washington, DC: Office of The Surgeon General, US Army; 1973: 1–23.




146
                                                                                   A Psychological Model of Combat Stress


28.   Swank RL, Marchand WE. Combat neuroses: Development of combat exhaustion. Arch Neurol Psychiatry
      [superseded in part by Arch Neurol and Arch Gen Psychiatry]. 1946;55:236–247.

29.   Solomon Z, Oppenheimer B, Noy S. Subsequent military adjustment of combat stress reaction casualties: A nine
      year follow-up study. Milit Med. 1986;151(1):8–11.

30.   Bourne PG, Rose RM, Mason JW. 17-OHCS levels in combat: Special Forces “A” Team under threat of attack.
      Arch Gen Psychiatry. 1968;19:135.

31.   Miller RG. Secretion of 17-OHCS in military aviators as an index of responses to stress: A review. Aerosp Med
      [now Aviat Space Environ Med]. 1968;39:498.

32.   Miller RG, Rubin RT, Clark BR, Crawford WR, Arthur RJ. The stress of aircraft carrier landings: I. Corticosteroid
      responses in naval aviators. Psychosom Med. 1970;32:581–588.

33.   Gabriel RA, Gal R. The IDF officer: Linchpin in unit cohesion. Army. 1984;34(1):42–49.

34.   Levav I, Greenfeld H, Baruch E. Psychiatric combat reactions during the Yom Kippur War. Am J Psychiatry.
      1979;136(5):637–641.

35.   Gal R. Combat stress as an opportunity: The case of heroism. In: Belenky G, ed. Contemporary Studies in Combat
      Psychiatry. Westport, Conn: Greenwood Press; 1987: 31–45.

36.   Gal R. Unit morale: From a theoretical puzzle to an empirical illustration—an Israeli example. J Appl Soc Psychol.
      1986;16(6):549–564.

37.   Manning FJ, Ingraham, LH. An investigation into the value of unit cohesion in peacetime. In: Belenky G, ed.
      Contemporary Studies in Combat Psychiatry. Westport, Conn: Greenwood Press; 1987: 47–67.

38.   Shirom A. On some correlates of combat performance. Admin Combat Q. 1976;21:419–432.

39.   Steiner M, Neumann M. Traumatic neurosis and social support in the Yom Kippur War. Milit Med.
      1978;143(12):866–868.

40.   Bartone PT, Kirkland FR. Optimal leadership in small army units. In: Gal R, Mangelsdorff AD, eds. Handbook of
      Military Psychology. West Sussex, England: John Wiley & Sons; 1991: 393–409.

41.   Hunt JG, Phillips RL. Leadership in battle and garrison: A framework for understanding the differences and
      preparing for both. In: Gal R, Mangelsdorff AD, eds. Handbook of Military Psychology. West Sussex, England: John
      Wiley & Sons; 1991: 411–429.

42.   Donohue KS, Wong L, Jones SM. Leadership. In: Dupuy TN, ed. International Military and Defense Encyclopedia.
      McLean, Va: Brasseys; 1993.

43.   Kalay E. The commander in stress situation in IDF combat units during the “Peace for Galilee” campaign.
      Presented at the Third International Conference on Psychological Stress and Adjustment in Time of War and Peace; 1983;
      Tel Aviv, Israel.

44.   Driskell JE, Salas E. Overcoming the effects of stress on military performance: Human factors, training, and
      selection strategies. In: Gal R, Mangelsdorff AD, eds. Handbook of Military Psychology. West Sussex, England:
      John Wiley & Sons; 1991: 183–193.

45.   Marshall SLA. Combat leadership. In: Symposium on Preventive and Social Psychiatry. Washington, DC: US GPO;
      1957: 303–307.

46.   Montgomery B. Morale in Battle: Analysis. Germany: British Army of the Rhine; 1946.




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 47.   Renner JA. The changing patterns of psychiatric problems in Vietnam. Compr Psychiatry. 1973;14(2):165–181.

 48.   Gabriel RA, Savage PL. Crisis in Command. New York: Hill & Wang; 1978.

 49.   Klose K. Defectors say morale is low in Afghan war. Washington Post. 2 Aug 1984: A1, A28.

 50.   Glass AJ. Observations upon the epidemiology of mental illness in troops during warfare. In: Symposium on
       Preventive and Social Psychiatry. Washington, DC:US GPO; 1957:185–198.

 51.   Beebe GW, Appel JW. Variation in Psychological Tolerance to Ground Combat in World War II. Washington, DC:
       National Academy of Sciences; 1958.

 52.   Glass AJ, Ryan FJ, Lubin A, Ramona CV, Tucker AC. Psychiatric prediction and military effectiveness, Part 1.
       US Armed Forces Med J. 1956;7(10):1427–1443.

 53.   Glass AJ, Ryan FJ, Lubin A, Ramona CV, Tucker AC. Psychiatric prediction and military effectiveness, Part 2.
       US Armed Forces Med J. 1956;7(11):1575–1588.

 54.   Glass AJ, Ryan FJ, Lubin A, Ramona CV, Tucker AC. Psychiatric prediction and military effectiveness, Part 3.
       US Armed Forces Med J. 1957;8(3):346–357.

 55.   Beebe GW, De Bakey ME. Incidence of Hits and Wounds. In: Battle Casualties: Incidents, Mortality and Logistic
       Considerations. Springfield, Ill: Charles C Thomas; 1952: 16–73.

 56.   Crocq L, Crocq MA, Barrois C, Belenky GL, Jones FD. Low-intensity combat psychiatric casualties. In: Pichot P,
       Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the Art. Vol 6. New York: Plenum Publishing; 1985: 545–550.

 57.   Jones FD. Psychiatric lessons of low-intensity warfare. Ann Med Milit Fenn [Finland]. 1985;60(4):128–134.

 58.   Johnson AW. Combat psychiatry, Part 2: The US Army in Vietnam. Med Bull US Army Europe. 1969;25(11):335–339.

 59.   Jones FD. Experiences of a division psychiatrist in Vietnam. Milit Med. 1967;132(12):1003–1008.

 60.   Breznitz S. Incubation of threat: Duration of anticipation and false alarm as determinants of the fear reaction to
       an unavoidable frightening event. J Exp Res Pers [now J Res Pers]. 1967;2:173–179.

 61.   Epstein S, Roupenian A. Heart rate and skin conductance during experimentally induced anxiety: The effect of
       uncertainty about receiving a noxious stimulus. J Pers Soc Psychol. 1970;16:20–28.

 62.   Folkins CH. Temporal factors and the cognitive mediators of stress reaction. J Pers Soc Psychol. 1970;14:173–184.

 63.   Salama A, Mansour F, El Sudany El Rayes M. Personal Communication, 1983.

 64.   Krueger GP. Sustained military performance in continuous operations: Combatant fatigue, rest and sleep needs.
       In: Gal R, Mangelsdorff AD, eds. Handbook of Military Psychology. West Sussex, England: John Wiley & Sons; 1991:
       255–277.

 65.   Lewis NDC, Engle B. Wartime Psychiatry: A Compendium of the International Literature. New York: Oxford
       University Press; 1954.

 66.   Chermol BH. Psychiatric casualties in combat. Milit Rev. 1983;58:26–32.

 67.   Lazarus RS, Averill JR, Opton EM. The psychology of coping: Issues of research and assessment. In: Coelho GV,
       Adams JE, Hamburg DA, eds. Coping and Adaptation. New York: Basic Books; 1974.

 68.   Marshall SLA. Men Against Fire. New York: William Morrow Company; 1950: 54–58.




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                                                                                                          U.S. Army Combat Psychiatry




Chapter 7

U.S. ARMY COMBAT PSYCHIATRY


NICHOLAS L. ROCK, M.D., F.A.P.A.*; JAMES W. STOKES, M.D.†; RONALD J. KOSHES, M.D.‡; JOE FAGAN, M.D.§;
WILLIAM R. CLINE, M.D.¥ ; AND FRANKLIN D. JONES, M.D., F.A.P.A.¶



                                      INTRODUCTION
                                        The Mission of the U.S. Army
                                        The Mission of the U.S. Army Medical Department
                                        The U.S. Army Mental Health/Combat Stress Control Mission
                                        History of U.S. Army Neuropsychiatry in Combat

                                      U.S. ARMY COMBAT ENVIRONMENTS
                                        Combat Troops
                                        Combat Support/Combat Service Support Troops
                                        The Medical Combat Health Support Troops

                                      MEDICAL/PSYCHIATRIC ORGANIZATION AND THE COMBAT STRESS
                                      COMPANY
                                        The Mental Health Program
                                        Basic Principles

                                      THE FUTURE

                                      SUMMARY AND CONCLUSION




* Colonel (ret), Medical Corps, U.S. Army; Formerly Chief, Department Psychiatry, Walter Reed Army Medical Center, Washington, D.C.;
  Formerly Neuropsychiatric Consultant and Chief Drug/Alcohol Abuse, and Psychiatry and Neurology Consultant, Office of The Surgeon
  General, U.S. Army
† Colonel, Medical Corps, U.S. Army; Chief, Combat Stress Actions Office, Department of Preventive Health Services, Academy of Health
  Sciences, Army Medical Department Center and School, Fort Sam Houston, Texas 78234-6133
‡ Assistant Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; President, Society of
  American Military Psychiatrists
§ Colonel, Medical Corps, U.S. Army, Special Assistant to the Deputy Director for Program Operations, Office of the Civilian Health
  (CHAMPUS), Aurora, Colorado 80045-6900; Formerly Psychiatry and Neurology Consultant, Office of The Surgeon General, U.S. Army
¥ Colonel, Medical Corps, U.S. Army, Walter Reed Army Medical Center, Washington, D.C.; formerly Neuropsychiatry Consultant, U.S. Army
  Europe (USAREUR) and 7th Medical Command (MEDCOM)
¶ Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past
  President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; Formerly Psychiatry and
  Neurology Consultant, Office of The Surgeon General, U.S. Army


                                                                                                                                        149
War Psychiatry




Samuel E.Alexander               American Doctor II—Field Force Doctor Examines Vietnamese Child       1968

Samuel E. Alexander was a member of the U.S. Army Artist Program and was in Vietnam in 1967. His
painting depicts the other functions of U.S. Army Psychiatry in the theater of operations. When not
evaluating and treating combat stress casualties, or providing consultation services to commanders,
psychiatrists and other physicians routinely provide medical care to the local civilian population under the
MILPHAP (Military Public Health Action Program) which was unofficially known as the MEDCAP
(Medical Civilian Action Program).



Art: Courtesy of US Center of Military History, Washington, DC.




150
                                                                                      U.S. Army Combat Psychiatry




                                                INTRODUCTION


The Mission of the U.S. Army                                bers as part of sustaining a combat-ready force. U.S.
                                                            Army doctors, researchers, medical administrators,
    The mission of the U.S. Army is to deter potential      and workers of many specialties have led the way in
enemies from using force against the interests and          preventive medicine. Contributions include sanita-
security of the United States and its allies. If deter-     tion and hygiene practices, the prevention and treat-
rence fails, the U.S. Army’s mission is to fight and        ment of infectious diseases (from malaria and yel-
win the nation’s land wars, whether they be waged           low fever to hepatitis and acquired immunodefi-
with conventional weapons or weapons of mass                ciency syndrome [AIDS]), and the identification of
destruction. Throughout its history, and increas-           the hostility (anger) factor as the chief contributor
ingly since the end of the Cold War, the U.S. Army          to the risk of coronary artery disease in persons
has also been tasked with numerous military opera-          with “Type A” personalities.
tions other than war (MOOTW). These include                    U.S. Army experience has stimulated dramatic
humanitarian and civil assistance, infrastructure           improvements in the acute stabilization, evacua-
building, and disaster relief. Such missions can be         tion, and definitive treatment of severe physical
within the United States (classified as “domestic           trauma. Recently, the combat support mission of the
support operations”) or in foreign lands; they do           U.S. Army Medical Department has been distilled
not involve combat; and often involve medical per-          into six battlefield roles. From the front-line medic
sonnel and medical units in lead roles.                     to the continental United States {CONUS) hospital
    Other military operations other than war are:           staff, all AMEDD personnel must be prepared for
peacekeeping; noncombatant evacuation opera-                the personal stress of being in combat and for the
tions; search and rescue; intelligence gathering;           stress of caring for wounded combat casualties.
training missions to assist foreign countries with
internal and external defense; demonstrations or shows      The U.S. Army Mental Health/Combat Stress
of force; and the restoration of public order. In these     Control Mission
missions, it is hoped that U.S. forces can avoid or deter
combat, but must be prepared to defend themselves.             The primary mission of U.S. Army psychiatry
Missions to restore order, training missions in coun-       and the mental health team is to conserve the fight-
tries that are resisting armed insurgencies, and the        ing strength by assuring a sane, stress-tolerant,
ambiguous category of “peace enforcement” can de-           mission-effective force. This must be accomplished
generate into sporadic low-intensity conflicts. The         in considerable part by assisting the chain of com-
U.S. Army must wage and “win” these armed con-              mand (officer commanders), the chain of support
flicts short of war, although in these the political        (noncommissioned officers), and the chain of con-
objectives far outweigh the purely military ones.           cern (chaplains, other special staff, unit medical
Conflicts short of war include counterterrorism,            personnel, rear detachments, and family support
some counternarcotics operations, strikes and raids,        groups) with professional advice, education, and
support for insurgencies, and counterinsurgency             assistance. It also involves screening out the men-
(guerrilla) operations. Whatever the immediate              tally unsuitable and psychiatrically disabled. Di-
mission, all U.S. Army personnel of all branches            rect care involves treating or counseling soldiers
must be ready to perform their duties and defend            with temporarily distracting problems or disabling
themselves in the extreme stress of combat.                 mental disorders to quickly restore them to effec-
                                                            tive duty. It also involves initiating the longer-term
The Mission of the U.S. Army Medical Department             treatment of those who must be separated from the
                                                            military.
   The mission of the U.S. Army Medical Depart-                The U.S. Army Mental Health/Combat Stress
ment (AMEDD) is to “conserve the fighting strength”         Control team in combat fulfills the AMEDD’s six
and to care for the sick and wounded. Patient care          battlefield rules as delineated in Exhibit 7-1. In
responsibility is primarily to the active duty service      1984, Combat Stress Control (CSC) was finally rec-
members, although the U.S. Army and the nation              ognized as an autonomous AMEDD (and U.S. Army)
recognize the importance of assuring quality medi-          battlefield functional area. This was the delayed
cal care to retirees and to U.S. Army family mem-           culmination of an honorable history in which U.S.


                                                                                                              151
War Psychiatry



   EXHIBIT 7-1
   HOW COMBAT STRESS CONTROL FULFILLS THE ARMY MEDICAL DEPARTMENT’S
   IMPERATIVE ROLES


   Maintain presence with the soldier
         The combat stress control concept places behavioral science experts forward on the battlefield and
         throughout the theater, where they provide immediate, on-site training, mentoring and assistance to
         leaders (especially at company grade), medical personnel and unit ministry teams, and the soldiers.
   Maintain the health of the command
         The actions of the combat stress control team prevent stress casualties, and enhance unit cohesion, soldier
         performance, and organizational capability under stress. They enhance mental health effectiveness of the
         command’s Family Support Groups, through regular advice and liaison. By contributing directly to
         mission accomplishment, combat stress control also reduces other types of casualties.
   Save lives
         The combat stress control personnel save lives directly by identifying and stabilizing those neuropsychiatric
         or stress cases whose disturbed behavior endangers themselves or others. In a world of lethal weapons,
         suicidal, homicidal, or psychotic behavior can create mass casualties. Correctly diagnosing surgical and
         medical emergencies which have been mislabeled as psychiatric behavior also directly saves lives. The
         combat stress control personnel save lives indirectly by enhancing decision-making and mission execu-
         tion through command consultation.
   Clear the disabled from the battlefield
         The combat stress control team contributes to clearing the battlefield by identifying and stabilizing for
         transportation those psychiatric cases who need rapid evacuation, while screening out and treating the
         much larger number of stress cases who can quickly return to duty far forward. Without combat stress
         control, these cases overload the limited evacuation assets or interfere with operations.
   Provide quality care
         Combat stress control personnel assure appropriate quality of care at each echelon for battle fatigue and
         psychiatric cases. For battle fatigue cases, premature evacuation can cause permanent disability, and
         constitutes malpractice unless it is unavoidable under the tactical situation. Also, the American people
         clearly expect the Army to take all feasible measures to prevent misconduct stress behaviors and post-
         traumatic stress disorders in our soldiers. Through their top priority consultation-liaison mission, the
         multidisciplinary combat stress control team personnel train, mentor, and provide technical supervision
         throughout the Army medical, combat service support, and combat arms systems to assure quality stress
         and mental health care to all soldiers. Through their advice and liaison mission to unit leaders, family
         support groups, and the supporting medical systems in garrison and Reserve Component units, they
         extend this quality assurance to the Total Army family.
   Return soldiers to duty
         The combat stress control organization returns many soldiers to duty quickly. This reduces the burden
         on the evacuation system and returns trained, seasoned soldiers to their own units, instead of unknown,
         combat-inexperienced replacements who have to be flown into theater. It also benefits the casualties’
         future mental health.

   Adapted from the Draft Concept Statement of the Combat Stress Control Panel, Medical Re-Engineering Initiative, AMEDD
   Center and School, Fort Sam Houston, Texas, April 1994.




Army neuropsychiatry and its allied mental health                 The American soldier of today is highly techni-
professions established doctrine, organization, and            cally trained and not easily replaced in a short time.
an operational concept that was truly distinct from            The prevention of stress casualties and the early
the rest of U.S. Army medicine.                                return to duty of stress-disabled soldiers requires



152
                                                                                   U.S. Army Combat Psychiatry


more focus in peacetime on neuropsychiatry and          assume that insanity has its seat in the mind. And
mental health programs in preparation for mobili-       nevertheless we attempt with remarkable inconsis-
zation. The transition of mental health profession-     tency to cure it by physical methods. The disease
als from a civilian practice to military can take 6     affects the body and mind alike and can be cured
months and may be too late to be effective at a time    only by methods which reach both.”4(p28)
of national emergency. The mental health person-           In the Continental Army and the U.S. Army which
nel must master military-specific clinical and orga-    it became, the importance of morale or “esprit de
nizational skills which have no civilian counter-       corps” was recognized. It was needed to keep
parts. Direct application of civilian mental health     soldiers steady in the line of battle and to prevent
experience to combat stress cases or functioning        desertion in the long periods of inactivity under
military units can cause harm. Military stress con-     deprived conditions far from home, such as the
trol expertise must be acquired by military provid-     winter at Valley Forge during the American Revo-
ers working in the military unit context, not in a      lutionary War. Also recognized were many of the
garrison version of civilian direct-patient care. The   same mental health disorders seen today, although
operational planning and coordination of stress         without the current more elaborated diagnostic
control in war and operations other than war re-        understanding: alcohol abuse and alcoholism
quires that experienced mental health staff officers    (“drunkenness”), homesickness and chronic situ-
and noncommissioned officers (NCOs) be integral         ational depression (“nostalgia”), and more overt
members of medical, U.S. Army, and joint services       psychotic disorders (“insanity” and “melancholia”).
command headquarters.                                   Joseph Lovell, the Surgeon General from 1817 to
                                                        1828 and an advocate of temperance who eventu-
History of U.S. Army Neuropsychiatry in Combat          ally succeeded in abolishing the daily rum ration,
                                                        attributed more than one half of the deaths in the
   The history of U.S. Army neuropsychiatry is cov-     U.S. Army over that period to alcohol.5(p29)
ered in considerable detail in Neuropsychiatry,1 the       In 1852, Dorothea Dix persuaded Congress to
history of neuropsychiatry in World War I, and in       fund the U.S. Government Hospital for the Insane
Neuropsychiatry in World War II,2,3 the two volume      (now St. Elizabeths Hospital). The Government
series. Chapter 1 of this volume, Psychiatric Les-      Hospital was to receive the insane of the U.S. Army
sons of War, also discusses the history of military     and U.S. Navy. However, during the Civil War, so
psychiatry, especially in terms of the evolution of     many insane Union soldiers were discharged lo-
concepts. The following discussion highlights the       cally to find their own way home that complaints
important conceptual and historical developments        led to an 1864 War Department order requiring
in military psychiatry while emphasizing the struc-     transfer to the Government Hospital until the sol-
tural components of the delivery of patient care.       diers’ families could come for them.
The materials presented draw heavily from those            Nostalgia cases in the Civil War numbered 5,547
found in the official histories.1-3                     (with 74 deaths). It is likely that the differentiation
   The U.S. Army began as the Continental Army          between nostalgia (“a species of melancholy or mild
under the leadership of General George Washing-         type of insanity caused by disappointment and long-
ton. There was no subspecialty of psychiatry or         ing for home”) and physical diseases such as tubercu-
other mental health professions at that time, al-       losis was not always made. Little treatment was
though chaplains supported the spiritual and moral      attempted, and most cases were discharged home.6
health of the troops. Dr. Benjamin Rush served as          “Functional heart disease” was described by
the prototype Surgeon General from 1776 to 1778.        DaCosta in 1862, who also termed it “the irritable
Rush advocated abstinence from alcohol. Later, as       heart of the soldier.”7 The condition usually origi-
a civilian physician at the Pennsylvania Hospital,      nated in combat as a prompt and persistent
Rush preceded and paralleled the more famous            tachycardia (120–130 bpm) on slight exertion.
French physician, Philippe Pinel, in championing        DaCosta reported that most cases improved with
the “moral treatment of the insane.” He advocated       hospitalization and tincture of digitalis three times
asylums in the quiet countryside for the mentally       a day. On one occasion when 4,900 soldiers were
ill—clean buildings with bathing facilities, where      discharged from the Union Army, 2,300 were diag-
violent patients were kept separate from passive        nosed as heart disease, of which 1,200 were “func-
ones and all were treated with kindness, work, and      tional.” Today, a patient presenting with a psycho-
diversion (occupational therapy). He wrote “We          physiological manifestation of hyperarousal and



                                                                                                           153
War Psychiatry


conditioned anxiety might well be considered an            chirurgie d’urgence than even at advanced base
“evacuation syndrome.”8                                    hospitals, and better still when encouragement,
   The first formal training in psychiatry to Regular      rest, persuasion, and suggestion could be given at
Army Medical Officers began at the U.S. Army               a combat organization itself. It was for the purpose
                                                           of applying this well-established fact that plans
Medical School, consisting of four clinical sessions
                                                           were made to station a medical officer with special
at the Government Hospital. There were also lec-           training in psychiatry and neurology in each com-
tures in military law and malingering. By 1915, the        bat division, since the division was to be the great
total training in mental illness had increased to 24       combat unit of the American Army in France. It
hours.                                                     was deemed impractical to consider detailing a
   Perhaps the first organized military mental health      consultant in neuropsychiatry to a combat unit
unit was with the Russians in the Russo-Japanese           smaller than the division. 1(p303)
War (1904–1906).9 During this war the Russian Red
Cross established mental health programs and re-            By order of the chief surgeon of the AEF, the
cording of neuropsychiatric cases. In addition phy-      division psychiatrists were under the direction of
sicians, functioning as neuropsychiatrists, were put     the chief surgeons of the division, but were not
as close to the front as possible to perform special     members of the division headquarters staffs. Rather,
evaluations of nervous and mental cases. Eventu-         they were attached to the “sanitary trains” (the
ally other countries developed such programs dur-        equivalent of the current medical units that are
ing World War I.                                         organic to the division). Later, Salmon concluded
   As World War I was waged in 1914 and 1915,            that putting the psychiatrists in the headquarters
newspaper and journal reports of “shell shock” (“le      under the chief surgeons worked better. The
syndrome commotionnel”) aroused interest among           psychiatrist’s specified duties included examining
U.S. psychiatrists. Prominent American psychia-          all cases of mental or nervous diseases (including
trists during World War I advocated to the U.S.          malingering and self-inflicted wounds) and advis-
Army Surgeon General (Major General Gorgas) the          ing on their diagnosis, management, and disposi-
formation of a psychiatric organization. The plan        tion; forensic testimony when requested; giving
included developing psychiatric units in general         “informal clinical talks” to medical officers and
hospitals staffed by psychiatrists throughout the        others on the nature, diagnosis, and management of
United States.                                           the disorders; keeping careful records of all cases;
   Dr. Thomas Salmon,10 medical director of the          and submitting regular reports to and advising the
National Committee for Mental Hygiene, offered           chief surgeon.
the committee’s services to the U.S. Army. He and
others visited U.S. Army medical facilities support-       The division psychiatrist was stationed at the ad-
ing the operations against Pancho Villa in Mexico          vanced field hospital, or triage, and his range of
and Canadian hospitals with psychiatric evacuees           activity extended forward to the ambulance dress-
from France. In 1917, Dr. Salmon visited England           ing stations and beyond as far as he cared to go and
for several months. By then, the psychological             backward as far as the rear field hospital, which
nature of “war neurosis” and the value of forward,         was the unit treatment center [ie, still within the
brief treatment had been well documented by the            division]. The triage, or sorting station, was apt to
                                                           be anywhere from 2 to 9 miles, or more, from the
French and confirmed by the British. Dr. Salmon
                                                           front line, and the treatment field hospital 4 to 7
recommended to the U.S. Army Surgeon General               miles further removed. The former was usually an
that a similar echeloned system of prevention and          abandoned strong barn; and the latter, generally
treatment be adopted. When the United States               under canvas, capable of caring for about 150 pa-
entered the war, Salmon was commissioned a ma-             tients in five or six large tents. At the treatment
jor. He was appointed Director of Psychiatry to the        field hospital the division psychiatrist was gener-
American Expeditionary Forces (AEF) in December            ally able to count on one enlisted man...to care for
1917, and immediately implemented his plan.1               each 15 patients…. An assistant divisional special-
                                                           ist would have proven a valuable adjunct. It is true
                                                           that even with an active combat division there were
  The experience of the French and British medical         times when there was scarcely enough [patient
  services showed, within a very few months after          care] work to keep the division psychiatrist occu-
  the beginning of the war, that patients with war         pied; yet these periods were succeeded by days
  neuroses improved more rapidly when treated in           or weeks of stress and strain...when the services of
  permanent hospitals near the front than at the base,     a trained assistant would have been invaluable.
  better at casualty clearing stations and postes de       The small “pool” of neuropsychiatrists under the


154
                                                                                     U.S. Army Combat Psychiatry


  control of the corps or army [neuropsychiatry]           occupational therapists provided both shop work
  consultant proved a useful means of meeting this         and outdoor work details; the official history em-
  need.1(pp309–310)                                        phasizes the importance of these tasks in restoring
                                                           confidence. In the last weeks of the war, occupa-
   At the forward triage, the division psychiatrist        tional therapists were sent forward to the neuro-
sorted all nervous cases, returning directly to their      logical hospitals where they enabled some soldiers
combat units those who should not be permitted to          to return to duty who otherwise would have been
go to the rear and resting, warming, feeding, and          evacuated to Base Hospital No. 117.
treating others, particularly exhaustion cases, if there      In the continental United States, the American
was opportunity to do so.1                                 Red Cross established a psychiatric social worker
   Salmon had learned from British experience the          program to aid military patients. Clinical psychol-
importance of not using dramatic or diagnostic             ogy programs were not recorded at that time.
labels for stress casualties, and adopted the British         It should be apparent from this brief history that
policy of using “N.Y.D.N.” for “not yet diagnosed          the forbears of military psychiatry during World
(nervous).” This avoided the suggestion of physi-          War I knew much of what is known today about
cal brain injury implied in the dramatic name “shell       combat stress casualties, and practiced prevention
shock” or the implication of mysterious psychiatric        and treatment very well. It was recorded in the
illness implied by the official diagnosis, “war neu-       official history, but then forgotten.
rosis.” Under optimal conditions, over 70% of the             From World War I to World War II hospital
casualties held for treatment at the 150-cot field         psychiatry functions continued, but unlike the as-
hospitals in the division rear returned to duty within     signment of medical and surgical consultants, there
5 days. However, when the tactical situation forced        was no representation of the mental health special-
the emptying of the field hospitals after only two         ties on The Surgeon General’s staff. At the begin-
days of treatment, the return-to-duty percentage           ning of World War II Harry Stack Sullivan, psychi-
dropped to 40%.1(p333)                                     atric consultant to the Selective Service Commission,
   The second echelon, only a few miles behind the         promoted policies that resulted in the rejection of
divisions, was the three neurological hospitals.           young men being conscripted if they showed any
These were located in old French barracks build-           taint of anxiety or neurotic tendencies, including
ings, staffed by general medical personnel and com-        so-called “neuropathic traits” such as nail biting,
manded and supervised by psychiatrists. The sole           enuresis, or running away from home. These poli-
function of these 150-bed units was to provide addi-       cies were also applied to soldiers after induction,
tional brief rest and intensive rehabilitation for those   resulting in what Ginsberg et al11 labeled “lost divi-
NYDN cases who had had to be evacuated from the            sions” of about 2.5 million men. Of 18 million
divisions. About 55% of these cases returned to            screened, nearly 2 million were rejected because of
duty after an average of two weeks.                        an emotional or mental defect and another three
   The third echelon, further to the rear, was Base        quarters of a million were prematurely separated
Hospital No. 117, whose sole purpose was to pro-           for the same reasons. The total ineffective group
vide several weeks of even more intensive recondi-         included approximately one out of every seven men
tioning treatment to the soldiers who had not re-          called for service.11
turned to duty from the neurological hospitals or             Besides the absence of representation at the War
who had somehow slipped through the first two              Department or even the Department of the Army
echelons and been evacuated to regular hospitals.          (DA) staff, the division psychiatric positions were
Another base hospital, No. 116, was the neuro-             abolished in 1939 as unnecessary. In August 1940,
psychiatric specialty hospital dedicated to the “true”     Lieutenant Colonel (later General) Patrick Madigan
neuropsychiatric cases who were judged not suit-           was assigned to the Professional Services Division,
able for return to duty. Base Hospital No. 117 also        Surgeon General’s Office, but his duties were purely
had a high rate of return to duty, although many           routine and administrative. Not until February
were to noncombat jobs in the rear. The staff of Base      1942, after the attack on Pearl Harbor, was he able to
Hospital No. 117 included psychiatrists, U.S. Army         upgrade his position to a Neuropsychiatry Branch
psychiatric nurses, on-the-job-trained enlisted med-       under the Professional Services Division. How-
ics, and civilian volunteer occupational therapists.       ever, in 1941 troop clinics were established outside
The official history describes in detail the impor-        of the hospitals and psychiatrists were assigned. A
tance of the nursing staff in establishing and main-       training center at Fort Monmouth, New Jersey, de-
taining a positive, return-to-duty ward morale. The        veloped a community clinic in early 1942 and had


                                                                                                             155
War Psychiatry


an enlisted social worker and later an enlisted psy-     Later, a 12-week course was conducted to prepare
chologist to assist the psychiatrist. This program       physicians with no psychiatric training to function
led to the establishment of the Mental Hygiene           in psychiatric positions.
Consultation Service (MHCS) at all replacement              By late in the war, the Mediterranean and Euro-
training centers. Its purpose was to help the malad-     pean theaters had psychiatrists assigned to each
justed trainee. This concept of MHCS continues to        division, although some divisions received only
the present in the Community Mental Health Ser-          inexperienced general medical officers. Many ma-
vices in the Medical Activity of each post.12            neuver battalions had “rest centers” in their “kitchen
   World War I style forward treatment was re-           trains,” where exhausted soldiers were monitored
learned during two battles of the Tunisian Cam-          by the nearby battalion surgeon. There were “ex-
paign in March and April 1943.3 Captain Fred             haustion centers” in many regimental or combat
Hanson, who served with Canadian forces prior to         command “trains” (equivalent to today’s brigade
U.S. entry into the war, was assigned with Ameri-        support areas), run by the adjutant but monitored
can forces in North Africa. Hanson may have been         by the regimental surgeons. Combat exhaustion
familiar with Salmon’s principles because the Brit-      cases were rested here for several days. In some
ish were using The Medical Department of the United      divisions, company commanders were even re-
States Army in the World War, Volume 10, Neuro-          quired to select some number of individual soldiers
psychiatry in their planning.1 He avoided evacua-        for rotation back to these centers for brief “R and R”
tion and returned more than 70% of 494 neuropsy-         (rest and recreation). It was the primary duty of the
chiatric patients to combat after 48 hours of            division psychiatrist to train the battalion and regi-
treatment, which basically consisted of resting the      mental surgeons in the principles and practice of
soldier and indicating to him that he would soon         combat psychiatry. Toward the end of the war a
rejoin his unit. On April 26, 1943, in response to the   distinguished group of civilian psychiatrists were
recommendations of his surgeon, Colonel Perrin           commissioned to evaluate U.S. military psychiatric
Long, and psychiatrists, Captain Hanson and Major        treatment in Europe. They found that about half of
Tureen, General Omar Bradley issued a directive          the stress casualties were never recorded because of
that established a holding period of 7 days for          the success of forward treatment at the battalion
psychiatric patients and further prescribed the term     and regimental aid stations and rest centers.13
“exhaustion” as the initial diagnosis for all combat        During combat late in World War II, the division
psychiatric cases. The word exhaustion was chosen        psychiatrists in Europe triaged and treated more
because it conveyed the least implication of mental      severe combat exhaustion cases at the division clear-
disturbance and came closest to describing how the       ing company in the division rear, holding them for
patients really felt. Division psychiatrists were        1 to 2 days. They then supervised their further
hastily reassigned. This move proved its worth in        rehabilitation for 3 to 5 days at the division’s Train-
the Italian campaign.                                    ing and Rehabilitation (T&R) Center. The T&R
   The ineffective psychiatric criteria for screening    Center was controlled by the Adjutant, and staffed
at initial entry were also tightened to disqualify       with combat veteran officers and NCOs, often ones
only the overtly psychotic or seriously mentally         who were on profile with minor wounds or injuries
retarded. A later study demonstrated that the “neu-      (including combat exhaustion!). The soldiers shared
rotics” who would have been screened out by the          pup tents and were led through a program of calis-
earlier criteria were not significantly more likely to   thenics and realistic combat drills, often conducted
become stress casualties or less likely to be deco-      in the ruins of nearby towns that had been recent
rated for valor than the men who had passed that         battlefields. Return-to-duty rates from the T&R
screening.                                               Centers ranged between 50% and 70%.14
   Colonel (later Brigadier General) William C.             Behind the divisions, there were U.S. Army-level
Menninger became The Surgeon General’s Chief of          Neuropsychiatry Centers. These were 250-bed hold-
the Neuropsychiatry Branch in December 1943, and         ing companies with supervisory psychiatric staff.
the branch became a division, on an equal level with     Like the World War I Neurological Hospitals, these
medicine and surgery, in January 1944. A School of       received the cases that the division psychiatrist
Military Psychiatry, plus some civilian schools, ad-     judged too disruptive for the division clearing com-
dressed the serious shortage of psychiatrists. Ini-      pany and T&R Center, plus those who failed to
tially, a 4-week course trained physicians who al-       respond sufficiently to the 5- to 7-day treatment,
ready had more than a year of psychiatric training.      and the overflow caused by tactical demands.



156
                                                                                    U.S. Army Combat Psychiatry


   The Neuropsychiatry Centers continued the             psychiatric casualties occurred, there would be a
highly structured program of physical recondition-       95% depletion by company combat day 260; how-
ing, hot showers, good food and comfortable cots,        ever, due to other causes of attrition (transfer, death,
and recreational and work activities. Some of these      wounding, illness), the unit would be virtually de-
soldiers returned to their original units. Others        pleted by company combat day 80 or 90, approxi-
were sent to nearby combat service support units         mately the breaking point of the median man.18
for further useful “occupational therapy” and re-           From studies of cumulative stress such as these
classification into support roles. The few who failed    as well as observations of the efficacy of a “point
to respond were sent to base hospitals with psychi-      system” (so many points of credit toward rotation
atric wards. Approximately 90% of the stress casu-       from combat per unit of time in combat or so many
alties who received specialized psychiatric care were    combat missions of aircrews) used during World
returned to useful duty in the theater.                  War II, the value of periodic rest from combat and
   In addition to rediscovering the principles of        of rotation came to be understood and applied in
treatment applied so effectively in World War I, and     the Korean and Vietnam conflicts with fixed
the ineffectiveness of large-scale screening, World      combat tours. The fixed tours did, however, result
War II psychiatrists learned about the epidemiol-        in the “short-timer’s syndrome,” an anxious, tense
ogy of combat stress casualties. They documented         state not uncommon in combat participants during
the direct relationship to intensity of combat, modi-    the final weeks of the stipulated tour of combat
fied by physical and morale factors, and the impor-      duty.19,20
tance of unit cohesion both in preventing break-            The final and perhaps most important lesson of
down and in enhancing combat effectiveness.              World War II was the importance of group cohesion
During the war, prospective studies conducted by         not only in preventing breakdown, but also in pro-
Stouffer et al15 conclusively showed that units with     ducing effectiveness in combat.19 Cohesion is so
good morale and leadership had fewer combat stress       important in both prevention and treatment of psy-
casualties than those without these attributes when      chiatric casualties that Matthew D. Parrish, an emi-
variables such as combat intensity were compa-           nent psychiatrist who served in combat aircrews
rable. Regarding combat intensity it was found that      during World War II and as U.S. Army Neuro-
there was a direct relationship between combat           psychiatry Consultant in Vietnam, has suggested it
intensity as measured by rates of wounded and            as another principle of forward treatment that might
killed in action and psychiatric casualties.16           be termed “membership.”21
   Another finding during World War II was the              After World War II key commands kept neuro-
chronology of breakdown in combat. It had long           psychiatric consultants, particularly in Europe and at
been recognized that “new” and “old” men in com-         the Department of the Army. The specialty of social
bat units were more prone to breakdown. “New” or         work officer was established along with the conver-
inexperienced troops were more likely to become          sion of the enlisted psychologist from the Sanitation
stress casualties, and have usually accounted for        Corps to an officer in the Medical Service Corps.
over three fourths of stress casualties; however,           The experience of World War II was documented
with increasing exposure to combat after 1 or 2          in the two-volume official history, Neuropsychiatry
combat months, an increasing rate of casualty gen-       in World War II.2,3 This included the plan for the way
eration also occurs.17 Beebe and Appel18 analyzed        that special neuropsychiatric teams would support
the World War II combat attrition of a cohort of         the division mental health capabilities and provide
1,000 soldiers from the European Theater of Opera-       backup and mobile consultative support in the corps.
tions (ETO) and found that the breaking point of the     However, the U.S. Army was substantially deacti-
average rifleman in the Mediterranean Theater of         vated in the late 1940s, and the invasion of South
Operations (MTO) was 88 days of company combat,          Korea by North Korea caught the United States
that is, days in which the company sustained at          unprepared. Task Force Smith, hastily mobilized
least one casualty. A company combat day aver-           from garrison troops in the Pacific area and rein-
aged 7.8 calendar days in the MTO and 3.6 calendar       forced by reactivated World War II veterans from
days in the ETO. They found that due to varying          the United States, suffered heavy losses in killed,
causes of attrition including death, wounding, and       wounded, and captured during the retreat to the
transfers, by company combat day 50 in both the-         Pusan perimeter. Although the veterans remem-
aters 9 out of 10 “original” soldiers had departed. In   bered that combat exhaustion cases ought to be
their projections Beebe and Appel found that if only     treated in the combat zone close behind their units,



                                                                                                             157
War Psychiatry


most were unavoidably evacuated to Japan. There,         complaints among the service support troops, in
proper treatment at the hospitals salvaged many for      contrast to those in combat units, that was to be-
combat service support duties, but very few re-          come the hallmark and curse of the Vietnam con-
turned to combat duty.                                   flict. With the buildup beginning in July 1965,
   After the first months of the Korean conflict,        divisions deployed to Vietnam, each with their one
Colonel Donald Peterson, the Neuropsychiatry             division psychiatrist, and social work officer, plus
Consultant, assigned Lieutenant Colonel Albert           two enlisted specialists with their medical company
Glass as the Neuropsychiatry Theater Consultant          supporting each brigade. The enlisted specialists
for the forces in Korea. Glass22 immediately estab-      were often college or graduate level draftees with
lished a comprehensive mental health program. He         behavioral science training. They staffed mental health
had served in World War II and was able, based on        consultation services at the division base area and
his experiences, to quickly organize an effective,       went forward when appropriate to the brigade and
forward program that has remained the basis for          battalion fire bases. The theater neuropsychiatrist
current military mental health programs. The divi-       consultant established his office at Headquarters,
sion mental health sections were trained to provide      U.S. Army Vietnam in November 1965.
active training to the regimental and battalion sur-        The first KO team to deploy was activated at
geons. In addition, the Table of Organization and        Valley Forge General Hospital in Pennsylvania in
Equipment (TO&E) was developed for a mobile              October 1965, deployed by ship 29 November 1965,
psychiatric detachment. This new unit was desig-         and was operational by January 1966. It consisted
nated a “KO Team.” “KO” was not an acronym.              of three psychiatrists, one neurologist, two social
Rather, it was only one in a series of “K” teams, with   workers, one clinical psychologist, one psychiatric
“K” arbitrarily indicating that these were hospital      nurse, and 12 to 15 enlisted social work, psychol-
augmentation detachments. The first KO teams             ogy, and neuropsychiatric specialists. Its mission
were deployed to Korea, where they reinforced the        was to establish a “Psychiatry and Neurology Treat-
division mental health sections at times of heavy        ment and Evacuation Center” in Vietnam. (The
fighting, and could enhance the use of a divisional      adoption of this title at that time is interesting in
clearing company as a temporary exhaustion cen-          that it emphasizes the two functions that current
ter. They also provided mobile consultation              doctrine, as practiced in the Persian Gulf War, would
throughout the corps and U.S. Army areas, like the       deemphasize. The more “doctrinally correct” trans-
fictitious psychiatrist, Major Sidney Greenfield, did    lation might be the “Psychiatry and Neurology
on the television series “MASH.”                         Evaluation and Return to Duty Center.”) The center
   In April 1952, a third-echelon treatment facility     provided psychiatric and neurological evaluation
(equivalent to Base Hospital No. 117 in World War        and treatment for up to 30 days as inpatients, if
I) was established near Seoul by adding a psychiat-      necessary, prior to evacuation to the continental
ric detachment to a 300-cot medical holding com-         United States or return to duty. The detachment
pany. This facility had an average census of 45          was assigned to an evacuation hospital 20 miles
soldiers with an average duration of stay of 7.4         northeast of Saigon, where it occupied its own
days. It returned 76% to duty.23                         Quonset buildings. It quickly also established an
   A comparison of treatment efficacy data near the      active MHCS for the many units in the vicinity that
end of World War II and the 1953 Korean conflict         lacked organic mental health services.
reveals the following: World War II—60% of psy-             Despite its title, the Psychiatry and Neurology
chiatric casualties were returned to duty within         Treatment and Evacuation Center aggressively ap-
their own division, while in Korea it was 88%;           plied the time-proven principles of combat psychia-
World War II—90% were returned to duty some-             try and returned about 90% of its inpatients to duty.
where in the combat theater compared to 97% in           It maintained a military-, not patient-, care milieu
Korea.23 In 1957, the first version of Army Regula-      with strong expectation of return to duty. Although
tion 40-216, Neuropsychiatry and Mental Health, codi-    distant from most of the tactical units, the center
fied the roles and responsibilities of division psy-     maintained a psychological proximity and unit iden-
chiatry in wartime and peacetime.                        tity by requesting the parent unit to make regular
   The first U.S. Army psychiatrist to be assigned in    visits to its soldier, bring his mail, and give him his
Vietnam, Major Estes G. Copen24 provided support         pay on the ward. The ubiquitous helicopters made
to approximately 8,000 American advisors. He noted       this possible, and most line commanders cooper-
the prevalence of misconduct and psychosomatic           ated fully with the visitation program.



158
                                                                                   U.S. Army Combat Psychiatry


   Less than 5% of the caseload presented with well-    U.S. Army only reflected that of the nation, where
defined psychiatric illnesses. The majority of sol-     violent political dissension, substance abuse, and
diers referred to the KO team had behavioral diffi-     racial animosity and overt antimilitary demonstra-
culties or somatic complaints. The latter were either   tions were rampant.25
physiologic manifestations of stress (headache, back       Following the withdrawal of all U.S. combat forces
pain, gastrointestinal symptoms, syncope and ver-       from Vietnam after the cease-fire signed by the
tigo conversion-type symptoms affecting vision,         United States, North Vietnam, and South Vietnam
hearing, speech, pseudoseizures, “narcolepsy” or        in Paris (1973), the U.S. Army entered the period of
somnambulism, and amnesias. The KO team also            the “hollow army.” While undergoing a major
provided extensive consultation to medicine and         reduction in force and maintaining supposedly
surgery regarding stress and somatic symptoms in        “fully manned” units to deter Soviet aggression in
soldiers recovering from physical wounds.               Europe, the U.S. Army continued to be plagued by
   As the buildup in Vietnam continued, eventually      drug abuse, indiscipline, low morale, and reduced
two KO teams were assigned in Vietnam. The              readiness. The division mental health sections (now
incidence of traditional “combat exhaustion” re-        also including clinical psychologists) were too pre-
mained very low (below 2%). This was attributed to      occupied with the daily referrals of disturbed, prob-
the rotation policy (365-day tours), scheduled R and    lem soldiers for most to train with their units much
R, the sporadic nature of combat in most of the         in the field. While the mental health team was
heavy artillery, armor, and air weapons support of      valued for their ability to process problem soldiers
U.S. forces, the effectiveness of helicopter evacua-    for administrative or “chapter” discharges, they
tion of the wounded, and the prevention (by divi-       were also to some extent sullied by association with
sion mental health and the KO teams) of a “psychi-      their workload clients.
atric” evacuation syndrome. Another factor in the          The KO team TO&E was redesigned about 1973
low utilization of the “combat exhaustion” label        into the “OM Team.” (“OM” is also not an acronym.
was the criterion that the soldier had to show “fa-     The “O” signifies that it is one of a series of medical
tigue, whether produced by physical causes such as      teams that provide area support.) This designation
exertion, heat, dehydration diarrhea and loss of        more properly defined the units’ mission than
sleep…[or] anxiety and insomnia.” This effectively      had the “K” (hospital augmentation detach-
excluded most of the anxious, depressed, conver-        ments). However, the issue was confounded by
sion and dissociative subtypes who would now be         taking inpatient services out of all the combat zone
counted under the umbrella of “battle fatigue,” as      deployable hospitals and adding it to the OM team.
they would have in World War II.                        The OM team had a small headquarters with a
   As noted elsewhere in this volume, the division      psychiatrist commander, clinical psychologist, field
mental health teams and KO teams were less suc-         medical assistant (officer) and several enlisted. It
cessful in recognizing the contributing causes of       had three mobile consultation teams, each with a
misconduct stress behaviors and in helping the          psychiatrist, social worker, six behavioral science
chain of command to prevent them. Measures such         specialists (91G), and two vehicles. The treatment
as the individual 365-day tour, while protecting        section had a psychiatrist, two psychiatric nurses,
against battle fatigue or combat exhaustion, frag-      eleven psychiatric specialists (91F), and a 91G.
mented unit cohesion. Liberal availability of alco-     Apparently, the plan was for OM detachments to
hol, with frequent excess use, did not set a good       augment one or two evacuation hospitals in a the-
example for the prevention of marijuana, heroin,        ater (reinforcing the evacuation hospital’s one psy-
and other illegal drug abuse, which became epi-         chiatrist, one psychiatric nurse, and two psychiatric
demic by 1970. Those factors, plus an unwise short      specialists) to provide 25-cot psychiatric wards.
rotation policy for junior officers and the unpopu-     Other OM detachments might reinforce a general
larity of the war, led to epidemic indiscipline, in-    hospital or two in the communications zone. In fact,
cluding the threatening and “fragging” of leaders.      only one active component OM detachment was
Failure to instill understanding and respect for the    authorized, and it had no personnel assigned. Six
Vietnamese (both South and North, friend, neutral,      OM detachments were established in the U.S. Army
and foe), the frustrating and ambiguous rules of        Reserves, but no doctrine was written regarding
engagement, and the nature of terrorist guerrilla       their expected employment. Not until 1984 did the
war, led to numerous small and some major acts of       OM teams begin to take part in realistic annual field
brutality and outright atrocity. The turmoil in the     training exercises.



                                                                                                           159
War Psychiatry


   Belated recognition of the Soviet offensive NBC       description of CSC doctrine and units, see Chapter
(nuclear, biological, and chemical) threat to the        10, Joint Operations.
North Atlantic Treaty Organization (NATO), made             In the area of CSC doctrine, paragraphs and
vivid by the intense fighting in the 1973 Yom Kip-       chapters were added to other medical field manuals
pur War and the Israeli experience of stress casual-     starting in 1991.27,28 Field manuals specific to the
ties, led to renewed awareness of combat stress by       combat stress control functional area were written
the senior U.S. Army leadership. Army Regulation         and staffed through multiple revisions starting in
40-216, Neuropsychiatry and Mental Health, 26 was        1989, finally to be printed in September 1994.29,30
updated in 1984, its first revision in 30 years. Staff      Meanwhile, however, events were calling for CSC
studies at the Academy of Health Sciences at Fort        support to U.S. Army combat operations. In De-
Sam Houston, Texas, in the late 1970s and early          cember 1989 through January 1990, Operation Just
1980s, led to recognition of combat stress control as    Cause, the U.S. invasion of Panama, involved a
an autonomous AMEDD functions area in 1984.              night air assault by U.S. Army Ranger battalions;
This finally put the combat mental health doctrine       followed by an 82d Airborne Division brigade; the
organization and employment on a par with pre-           air-landing of 7th Light Infantry Division forces;
ventive medicine, combat dentistry and veterinary        reinforcing elements of those divisions; the 5th
medicine, if still less prestigious than hospitaliza-    Mechanized Infantry Division; a separate brigade;
tion and evacuation.                                     and many other units already in Panama. There
   In an intensive revision of all U.S. Army field       were several days of intense, but brief and local
medical support to meet the Soviet threat and sup-       fighting, that included a number of psychologically
port AirLand Battle (later called Medical Force 2000     traumatic incidents.
or MF2K), the AMEDD was held to a strict person-            No division mental health assets were deployed
nel ceiling. However, within this ceiling, the newly     to theater, although both the 82d and 7th sections
proposed combat stress control (CSC) “companies”         were ready to go. The garrison and hospital psychi-
and “detachments” were authorized a 400% in-             atric/mental health assets already in Panama were
crease in active duty slots and a 280% increase in       not readily adaptable or sufficient to the task of
U.S. Army Reserve slots over those already avail-        postcombat preventive activities. Subsequent prob-
able for modification from the old OM teams.             lems with post-traumatic stress disorder (PTSD) and
   The TO&Es for the 85-person medical company           less obvious attrition or misconduct in a number of
CSC, and the 23-person medical detachment CSC            units confirmed the importance of such activities,
were developed between 1986 and June 1989 and            preferably in the theater of operations, even after
forwarded for Department of Army approval. These         brief, successful contingency operations in which
units have a modular design that packages a psy-         American and local civilian losses are sustained.
chiatrist, social worker, and two enlisted, with ve-        When Iraq invaded Kuwait in August 1990, the
hicle, into a CSC preventive team that can reinforce     new CSC TO&Es were still in queue awaiting their
a division mental health NCO and officer at the          Department of the Army staffing. The new field
maneuver brigade level. A clinical psychologist, a       manuals were circulating in preliminary draft form.
psychiatric nurse (clinical nurse specialist) and an     The mobilization for Operation Desert Shield (the
occupational therapist, with two each of their en-       multinational show of force to deter further Iraqi
listed assistant and two more enlisted, are com-         aggression and encourage withdrawal from Ku-
bined into an 11-person CSC restoration team. This       wait) first deployed the division mental health sec-
team can staff a program of 1- to 3-day restoration      tions with their units, although some personnel had
treatment in the division rear, as well as sending       had little or no prior field training. Each of the
two to three person teams to provide consultation        Psychiatry Consultants was given copies of the
in the vicinity or to reinforce the CSC preventive       drafts of the first five chapters of this volume for
teams forward on short notice.                           distribution. Fortunately they had some time in
   The CSC preventive and restoration teams’ per-        theater to prepare themselves.
sonnel can also be task organized in any combina-           In September, the one active component
tion to provide reconstitution support to units that     OM team was mobilized at Fort Benning, bring-
have been pulled back after suffering heavy attri-       ing together its Professional Officer Filler
tion. The task-organized elements can also conduct       System (PROFIS) officers, levied enlisted comple-
1- to 2-week reconditioning programs in the corps        ment and second-hand equipment for the first
area for slow-improving stress casualties. For more      time. Anticipating the new CSC detachment TO&E,



160
                                                                                   U.S. Army Combat Psychiatry


it incorporated an occupational therapist officer        tively comprised the medical task forces. Most of
and NCO in the place of other, unfilled specialties.     these were directly behind the maneuver brigades,
The unit deployed in late October, set up a res-         leaving the main support medical companies of the
toration program at the one combat support               division support commands far to the rear. Some
hospital then in Saudi Arabia, and immediately           stress control teams in 18th Corps reached the
began sending out mobile consultation teams.             Euphrates valley. Few stress casualties were seen
Within days it had reversed the tendency to evacu-       during the successful offensive, as prior experience
ate all “psychiatric cases” out of theater. As the       predicts.
one preventive psychiatric unit for 18th Airborne           In the conferences that the AMEDD assembled to
Corps, it quickly established a high degree of           formalize lessons learned, the ARCENT surgeon
credibility.                                             stated that combat stress control had been one of the
   Two of the six U.S. Army Reserve OM Detach-           success stories of the Persian Gulf campaign in
ments were activated just after Thanksgiving             preventing unnecessary evacuations and returning
and deployed to Saudi Arabia the first week in           soldiers to duty. However, it was recognized that
December. One became the CSC asset for 7th Corps,        there had been too few assets to simultaneously
that was then arriving from Germany. The second          support the combat divisions and the rear areas that
was assigned to the echelon above corps at Riyadh,       were subject to Scud missile attacks, as well as
and collocated with a general hospital. The              stressful environmental conditions. The medical
neuropsychiatry consultant for U.S. Army Central         leaders of 18th Corps, in particular, strongly en-
Command (ARCENT) also reached Saudi Arabia in            couraged the rapid fielding of the new CSC units,
December. As planning for the expulsion of Iraqi         doctrine, and training. This advocacy assisted the
forces from Kuwait proceeded, the ARCENT psy-            expeditious fielding of these new CSC units, de-
chiatrist and command surgeon concluded that the         spite the downsizing of the U.S. Army following the
OM team assets needed to be divided into their           breakup of the Soviet threat.
mobile teams and sent forward as close behind the           Equally important was that the active duty de-
combat maneuver brigades as the tactical situation       tachments were authorized most of their officers
allowed. Projected estimates for U.S. wounded and        and all of their enlisted personnel full time (not as
chemical injuries were high, if the veteran Iraqi        PROFIS fillers with full-time duties in the hospi-
soldiers were able to put up a stubborn defense and      tals). This enables them to train with the units they
use their chemical arsenal and long-range artillery      support, to provide preventive stress control ser-
despite the planned U.S.-led air campaign. Stress        vices to those units in garrison, and to deploy rap-
casualties in such a scenario could equal one per        idly in war or operations other than war. In fact, the
three or even two wounded, and one or two per            first CSC detachment activated on schedule on 16
chemical injury.                                         December 1991 and one half of its personnel de-
   Accordingly, ARCENT directed the two OM               ployed to Somalia for Operation Restore Hope on 5
detachments, which were allocated one to each            January 1993. It maintained teams in Somalia until
corps, to send their teams to join the “medical task     February 1994.
forces” that would go forward into Iraq behind              Combat stress control detachment teams de-
each division. It was judged that they did not yet       ployed to Haiti in September 1994, early in Opera-
have the logistical capability and field experience to   tion Restore Democracy, and continued to rotate
try to accompany the maneuver brigades medical           there after the mission was turned over to the United
companies, as the draft field manuals advocated.         Nations. Another team deployed to Saudi Arabia in
As the air campaign progressed, the third OM de-         October 1994, supporting a show of force and train-
tachment at Riyadh split into four teams. One team       ing exercise in Kuwait in response to threatening
remained in Riyadh, two were sent to reinforce the       Iraqi troop movements. In December 1994, part of
OM teams supporting the corps, and the fourth            a CSC company, most of a CSC detachment, and the
team established a second-echelon restoration/re-        neuropsychiatric ward of a combat support hospi-
conditioning center at one of the major hospital         tal deployed to Guantanamo, Cuba, to provide in-
complexes.31                                             patient and outpatient treatment to Cuban refu-
   During the short, fast-moving ground campaign,        gees, as well as stress control support to the U.S.
the stress control teams from the OM detachments         troops running the camps. These missions demon-
moved forward with the surgical teams, holding           strated the versatility and value of CSC units in
cots, and preventive medicine teams that collec-         military situations other than war, as well as war.



                                                                                                           161
War Psychiatry


                                 U.S. ARMY COMBAT ENVIRONMENTS

   To be effective combat stress control consultants        The mechanized infantry normally work as inte-
and treaters, the psychiatrist and other mental health   gral members of the “combined arms team” with
officers and NCOs must have an exceptional degree        armor. They travel in infantry fighting vehicles
of military credibility and knowledge of the sup-        (IFVs) or armored personnel carriers (APCs) that
ported units. They must understand and be conver-        enable them to keep up with the tanks. IFVs pro-
sant in the unit’s missions, equipment, internal or-     vide some ability to fire while on the move, but most
ganization, special language and acronyms, and           of the squad dismounts to fight on the ground when
typical stressors and stress profiles. In this regard,   assaulting or defending a position or clearing an
CSC personnel are analogous to flight surgeons (see      area. Mechanized infantry therefore share many of
Chapter 8, U.S. Air Force Combat Psychiatry). They       the stressors discussed below for armor while hav-
can only achieve the necessary expertise and cred-       ing more logistical support (and logistical require-
ibility by “flying” some hours and days with similar     ments) than other infantry.
units in realistic field training and operations. This      Infantry make up the most numerous component
textbook can only provide a brief overview and           of most combat forces. Because of their relative
introduction to a few of the major branches of the       numbers and the degree of unprotected exposure to
U.S. Army.                                               enemy weapons and the elements, they usually
   Within each branch, specific types of units (and      suffer the highest number of casualties and make
specific officer areas of concentration and enlisted     up a large percentage of the battle fatigue cases.
military operational specialties) have their own         However, the percentage of battle fatigue casualties
mission profiles and typical physical and psycho-        to killed and wounded among well-trained infantry
logical stressors. To advise a commander on how to       units is typically lower than in armor, artillery, or
sustain and enhance his unit’s performance, or to        combat services support units. An average rate for
assure him that one of his soldiers is again ready for   conventional combat is one battle fatigue casualty
duty, requires more than a second-hand knowledge         per five wounded, with at least an equal number
of what that performance and duty involves.              treated and returned immediately to duty. Rates of
                                                         1:3 to 1:2 are seen in very prolonged and especially
Combat Troops                                            static combat.
                                                            In the elite special forces, ranger, and airborne
Infantry                                                 units, the ratio has been strikingly low (less than
                                                         1:10 or 1:20) even in mass casualty battles. This is
   Infantrymen (there are as yet no infantrywomen)       attributed to the benefits of tough training, close
are men who engage the enemy in close combat,            contact with trusted leaders and comrades (“verti-
sometimes hand-to-hand, standing on their feet,          cal and horizontal unit cohesion”), and a sense
lying on the ground, or dispersed in holes which         (most of the time) of having some personal control
they have found or dug in the dirt. In battle, and       over one’s fate. The ground is the infantryman’s
sometimes between battles, they must carry every-        protection, allowing dispersion and shelter if wisely
thing they need to fight and survive on their per-       used. To quote a Bill Maudlin World War II cartoon,
sons. Infantry can be categorized by how much            Joe is looking at a tank and says to Willie, “I’d rather
they must rely on their own physical strength and        dig. A moving foxhole attrac’s the eye.” Mines,
endurance, separated from mechanical support.            booby traps, and chemical contamination of the
Special Operations Forces (the “Green Berets”) and       ground (requiring wearing of the protective en-
Rangers are all airborne (parachute) qualified, but      semble) make the ground no longer a reliable friend,
may undertake prolonged and grueling missions,           and are therefore especially stressful.
with only rare, air-dropped supplies. Airborne              Infantry soldiers are especially prone to combat
infantry are delivered by parachute or airlanding,       exhaustion as they are deployed rapidly and are
but are reinforced by heavier units within a few         subject to extreme physical work, sleep loss, and
days and continue to fight as light infantry. Light      limits on available food, water, and hygiene. They
infantry and air assault infantry also must travel       can often feel unprotected or unsupported in the
very light on the ground, but usually have helicop-      field of operations. Communication can get very
ters and a few light trucks for rapid redeployment       difficult, especially at night or in restrictive terrain
and resupply.                                            when visual contact with the rest of the unit may be



162
                                                                                       U.S. Army Combat Psychiatry


nearly impossible. Often moving quickly through              tank has a heavy gun for destroying other tanks and
difficult terrain or behind enemy lines, the special         hard targets by direct (line-of-sight) fire, and ma-
operations forces (SOF), light infantry, or mecha-           chine guns for destroying exposed infantry and
nized infantry soldiers can become separated and             other “soft” targets. Tanks are most effective in the
anxious about being wounded and left on the battle-          offensive in open country where, in combination
field. While this may heighten the soldiers’ sense of        with mechanized infantry and supporting artillery
unit cohesion, the effect of a lost or wounded mem-          and air attacks, they can break through enemy de-
ber on the whole unit can be devastating.                    fenses and spread havoc in the rear.
   It is in the field of battle that unit bonds are often       Much of the time, however, armor works in the
tested and an entire unit can be immobilized or              offense or defense on more restrictive terrain, mov-
destroyed because of the one weak link in commu-             ing from position to position in coordinated move-
nication or trust. Prior to mobilization the unit            ments with each tank much like an individual in-
members must get to know each other and espe-                fantryman. Unlike the infantryman, however, the
cially to be confident in each of their abilities to fight   tank protects against bullets and artillery fragments,
together as a team. No unit should be deployed               giving a relative sense of invulnerability. Modern
without the commander’s having the opportunity               tanks also have collective protection against chemi-
to portray himself as a thoughtful and knowledge-            cal agents. Tanks are disabled (and less often de-
able leader; a unit without confidence in its leader         stroyed) by other tank’s guns, by direct artillery
can fail, generating a large percentage of both emo-         hits, by mines, and by a variety of infantry- or
tional and physical casualties.                              vehicle-carried antitank rockets, many of them now
   Because of the newer weapons technologies and             precision-guided.
the rapidly moving forward edge of the battlefield,             Speed in firing first or in taking protective coun-
fragmentation among infantry units can often oc-             termeasures (measured in seconds, if not split-sec-
cur. Devastation of life by enemy or friendly fire           onds) can be crucial to survival. When the crew
may be great, and the exposure to dead and wounded           compartment of a tank is breached or the tank burns
comrades as well as enemy is magnified. In this              or explodes, escape may also be a matter of seconds,
setting, human soldiers must often charge ahead and          and death can be especially gruesome. Battle fa-
their sense of “neglecting” their buddies is intense.        tigue rates are therefore high among the survivors
Sensory overload under these conditions can only be          or witnesses of the deaths of fellow crew, relative to
countered by the unit cohesiveness and bonding               the number of wounded who get out alive. Battle
developed long before the mission is begun.                  fatigue to wounded ratios of 1:2 and 1:1 have been
   Ongoing development and testing for the “digi-            reported when armored units were caught at a
tal battlefield” of the “Information Age” of the 21st        disadvantage or unexpectedly found themselves
century proposes to give each infantry fire team             outclassed by superior tanks or infantry antitank
leader, and perhaps each infantryman, a global               weapons.
positioning device that gives precise coordinates               Tanks, while giving the soldier a sense of confi-
for his location on the terrain and short-range voice        dence, can be sources of problems. Highly technical
communication with other team members. There                 in today’s U.S. Army, these weapons are at best
may even be a “heads-up” display inside the visor            finicky, subject to heavy vibration and jolting in
to his helmet that advises him of the locations of all       operation, require continuous maintenance, and
other friendly forces and identified enemies in the          demand specialized skills to operate. Armor crews
vicinity, as well as much other information. Assur-          tend to be closely knit units, where deviance, defi-
ing that this technology increases combat effective-         ance, and “specialness” are not readily tolerated.
ness rather than creating distraction and depen-             Individuals working in tank crews have to rely on
dency, especially in tired, fearful soldiers, will be an     the skills of their comrades, live for weeks to months
urgent topic for combat stress control in future field       together in very close proximity, and often get to
trials, training, and combat operations.                     know each other on an intensely personal level. The
                                                             operation of the tank is dependent on each person’s
Armor                                                        doing his job; the tank does not operate fully if one
                                                             member of the crew is incapacitated. Maintenance
   The armor branch soldier fights inside a tank—a           units that take care of the machinery have to be
heavily-armored, tracked vehicle capable of rapid            reliable and known by the operators; “slacking off”
cross-country movement on suitable terrain. The              is not tolerated.



                                                                                                               163
War Psychiatry


    Tankers rarely see their human victims close up.       Field Artillery
The mission of armor units is to neutralize other
similar or smaller-sized enemy weapons. Because               The mission of field artillery is to lob projectiles
of this, tankers are prone to periods of heightened        of high explosives or other munitions to places
enthusiasm and letdowns after the mission is ac-           relatively far away and out of sight on the battle-
complished. Debriefing is especially important and         field. Artillery crews are usually eight to ten people,
the tendency to focus on the mechanical details of         working in sections of three to four crews. Two
the mission, create distance from the destruction, or      sections comprise a battery, the equivalent of an
overpersonalize the killing, may be compelling dy-         infantry or tank company.
namics with these crews that must be dealt with               The towed, tube artillery are wheeled guns (tech-
constructively.                                            nically “howitzers”) that can be air-transported to
    Modern tanks have night vision and infrared sights     support light infantry and are towed behind their
and laser rangefinders that can make true combat           “prime movers” (relatively light-weight trucks).
sensorially much like a complex team computer-             They provide minimal protection for their crews.
simulation task or arcade game. Individual crews           Firing the large shells at a rapid rate is heavy physi-
now train at their tasks in “high-tech” simulators,        cal work. Self-propelled tube artillery are large
“moving” over virtual-reality terrain and engaging         howitzers mounted on tracked vehicles, less ar-
virtual-reality targets that, although still substan-      mored than tanks, but providing some crew protec-
tially abstracted, are not that different from what        tion. They are supported by other tracked vehicles
would actually be seen. Multiple simulators can be         carrying additional ammunition. The latest ver-
linked together so that three to five tanks in a platoon   sions provide more mechanization for moving and
can be maneuvering together on each other’s scopes.        loading the heavy shells. Missile artillery such as
    The combined arms team can even train together         the Multiple Launch Rocket System (MLRS) are also
in virtual reality, with attack helicopter crews and       tracked vehicles with considerable mechanization,
mounted mechanized infantry all in their own simu-         but still require substantial heavy work.
lators (perhaps even located on distant posts) work-          Field artillery batteries and sections may be sta-
ing in concert on the same computer-generated              tionary at “fire bases” in some low-intensity or
terrain, supported by field artillery fire direction       static combat scenarios. In “high-tech” combat,
centers who respond to calls for artillery fire that       they must be highly mobile, whether to keep close
the computer faithfully represents in real time.           behind the moving armor or to avoid the enemy’s
Research and development for the “digital battle-          own “counter-battery fire.” Modern radars can
field” is equipping each tank with global position-        locate the source of artillery fire quickly, perhaps
ing devices linked by computers and computer-              even before the shells (“rounds”) have landed. The
generated displays in each tank and at its higher          addition of global positioning devices and on-board,
headquarters.                                              interactive computers to the most modern howit-
    The successful integration of information tech-        zers or rocket launchers greatly increases their abil-
nology into armored formations may be technically          ity to “shoot and scoot”—to stop, fire rapidly at a
easier than with dismounted infantry, but it will          mathematically determined location, and move else-
still require extensive human factors evaluation           where. Without this enhancement, emplacing the
and training. It must be remembered that ground            battery is a very deliberate and precise process.
war, more than air, sea, or space war, is fought              Like tank crews, soldiers in the field artillery are
under very “dirty” physical and emotional condi-           highly specialized technicians, especially the NCOs
tions. Continuous and even sustained operations            and officers. The potential for destruction by en-
are often required. Strict limits on the size and          emy action, while less than for infantry or armor,
weight of equipment demand compromises: air con-           may be catastrophic when it occurs. The potential
ditioning may be necessary for the computers, but          for error injuring one’s own crew or distant friendly
little has traditionally been invested to provide          units is also great. Artillery units avoid direct
comfort for the crew members. If the “high-tech”           combat with enemy ground forces, but must defend
systems break down under the strain of field opera-        themselves against harassment and, rarely, by di-
tions, the crew must be capable of fixing them or          rect fire against infantry or armor attack (which
carrying on without them. Fear, grief, rage, guilt, or     they are likely to lose). When casualties are suf-
simple sleep loss must not be allowed to impair the        fered, the ratio of battle fatigue casualties to
crucial human components of the system.                    wounded is likely to be higher than in the infantry.



164
                                                                                                 U.S. Army Combat Psychiatry


Certain psychological defenses must be encour-                    Case Study 2: Fire Direction Control Research
aged and supported during these soldiers’ mis-                    Study
sions. Artillery soldiers have to closely rely on each
other for both support and technical expertise. Train-                Fire direction teams of one officer and four enlisted
ing constitutes a large portion of these soldiers’                from an elite unit conducted sustained operations for up to
days. The artillerymen have specific team drills                  42 hours in a realistic mockup of an FDC tent. The
                                                                  scenario provided a detailed sequence of events in a
with built-in double checks to process technical and
                                                                  combined arms operation across a map that provided
mathematical data without error. As long as these                 comparable measures of speed, accuracy, and preplanning
drills are followed, tired and stressed teams are able            every 6 hours. The teams’ tasks (as in combat before the
to function accurately, if perhaps less rapidly. When             fielding of special field artillery digital computers) was to
stress or overconfidence leads to taking short cuts,              manually plot the location of targets called in over the
disasters can occur, as shown in this case known to               radio, and to derive range, bearing, angle of gun eleva-
the second author.                                                tion, and charge. Some targets were called in with
                                                                  requests for immediate fire (“fire missions”) while others
Case Study 1: Live Fire Error                                     were called in to be plotted for firing “on-call” or at a future
                                                                  scheduled time (“preplanned targets”). The FDC was also
                                                                  expected to update its situation map based on messages
    On a U.S. Army post, one artillery shell killed several
                                                                  from the simulated units and to establish that targets were
infantrymen far from the allowable “impact area” on post.
                                                                  not at the locations of friendly units, in no fire areas, or
Investigation revealed that an artillery battery had fired
                                                                  otherwise requiring clearance from higher headquarters
that round with all seven bags of gunpowder instead of the
                                                                  under the rules of engagement. Ammunition requisition
appropriate four bags. The battery was in the last hour of
                                                                  and other self-initiated preplanning was expected.
a 3-day continuous operations field exercise and was
                                                                      Throughout the sustained operations, the teams’ abil-
firing all of the remainder of its ammunition in a sustained
                                                                  ity to perform their highly practiced and precise team
barrage. The enlisted soldier whose job in the drill was to
                                                                  plotting tasks, even under urgent time pressure, was
take three bags out and drop them on the ground had
                                                                  unimpaired. However, after about 24 hours, they fell
simply failed to do so. The second soldier whose task was
                                                                  behind in updating their situation maps and precalculating
to count the bags and throw them into a common pit had
                                                                  the positions and firing data for the preplanned target lists.
fallen behind in his task. Bags had accumulated on the
                                                                  They lost their grasp of their place in the operation. They
ground, so that double-checking was not simple. While
                                                                  no longer knew where they were relative to friendly and
the battery had had a sleep plan, both junior soldiers had
                                                                  enemy units. They no longer checked what they were
stayed awake during their last “down time,” helping out.
                                                                  firing at. When called upon to fire at several urgent targets
The defense lawyer called the second author for advice on
                                                                  concurrently that involved preplanned targets (which they
who was at fault.
                                                                  had accomplished well early in the exercise) long delays
    Comment: This is the type of error of omission that is
                                                                  and random serious errors occurred. Some of those
most likely with sleep loss. The muscular work of rapidly
                                                                  errors involved their fire falling on friendly locations.
loading artillery rounds can have an almost hypnotic
                                                                      Comment: Similar and even worse problems of
rhythm, punctuated by the highly reinforcing “ritual” firing
                                                                  preplanning and internal and external communications
and recoil of the howitzer. The final “crescendo” before
                                                                  can be expected in the headquarters staffs and tactical
going home would have produced a euphoric “adrenalin
                                                                  operations centers of infantry, armor, and higher echelon
high” in the sleep-deprived brain. The ultimate responsi-
                                                                  commands whose tasks do not provide the highly prac-
bility has to fall on the crew chief (with some for the section
                                                                  ticed and double-checked drills of the FDC. The develop-
chief), first for failing to assure that every double-check in
                                                                  ment of automated data processing (computers) will re-
the team drill was being faithfully performed and second,
                                                                  duce the need to depend on memory or make mathematical
for not having enforced the sleep plan. Predictably, the
                                                                  calculations. However, they may compound the problems
officer and senior NCOs had not enforced the sleep plan
                                                                  in communication, decision making, and preplanning by
for themselves, and were substantially more sleep-de-
                                                                  lulling the staff into a false sense of security and conceal-
prived than any of their enlisted soldiers.
                                                                  ing signs of system error until they are irreversible. Sleep
                                                                  plans are essential for all command, control, communica-
  The coordination and computation of the firing                  tions, and intelligence (C3I) staffs.32
data are calculated for the entire battery by a Fire
Direction Center (FDC) team. These teams are                         Artillerymen can feel more important than the
equipped with computers and radios, but can also                  average soldier because of the killing power of their
perform manual (chart) calculations. The following                weapons, the supposed “smarts” required, and the
case illustrates the potential effects of fatigue on              relative “luxury” of being able to transport comfort
these and other types of Tactical Operations Center               items. Conflicts can arise because of this.
(TOC) team performance.                                           Artillerymen may also feel guilt (or defend against



                                                                                                                              165
War Psychiatry


feeling disgust or guilt) at a killing process that, in   kinds of terrain, helicopters are especially suited
most situations, keeps them relatively secure and         to the close support of land battles. Attack helicop-
comfortable. Mental health professionals must pay         ters are well armored and very heavily armed,
attention to the possibility that anger and depres-       with “high-tech” target acquisition and navigation
sion may be present in these soldiers as they alter-      equipment. Scout helicopters are lightly armed
nately feel important and useless in the overall          and armored, and often work in teams with the
mission on the battlefield. Another risk for              attack helicopters. Cargo helicopters are used to
artillerymen is that of fatigue.                          ferry combat troops, ammunition and supplies,
   It should be remembered that forward observer          sometimes into “hot” landing zones. They have
teams of artillery officers and NCOs deploy for-          minimal armor, and may mount machine guns for
ward as integral members of infantry and armor            self-defense. Medevac helicopters are unarmed, in
formations. They share all of their hosts’ environ-       accordance with the Geneva conventions. All heli-
mental risks and stressors, with the additional stres-    copters are vulnerable, to a greater or lesser degree,
sor of being responsible for calling down devasta-        to small arms fire and especially to missiles from
tion out of the sky, sometimes dangerously close to       the ground, as well as to other attack helicopters
themselves or other friendly units.                       and jet fighters.
                                                             A special pride is felt by soldiers who fly aircraft.
Air Defense Artillery                                     Perhaps the most technically trained and respon-
                                                          sible soldiers, these men are proud of their contri-
   This branch is responsible for the defense against     bution to the Persian Gulf War, and believe that
enemy aircraft and ballistic missiles. Small teams        their “machines” are the best, the most sophisti-
with shoulder-held anti-air missiles are attached to      cated, and the most expensive. Fliers also rarely see
infantry, armor, and field artillery units and share      their victims close up. The thrill of hitting the target
most of their hosts’ stress environments. Teams           in a gunship raid, sneaking through enemy lines to
with “high-tech,” mobile missiles and ultra-rapid-        guide troops and spot aggressors may be counter-
fire guns, supported by mobile radar teams, are           balanced by unconscious guilt at the mass destruc-
deployed to protect key targets such as the brigade       tion caused, yet unseen. Aviators have to train as a
and division support areas and corps base defense         group, but when any group of young, highly trained
clusters. Larger missiles such as the Patriot are used    professionals converges, competition can become
to protect key air bases and ports throughout the         quite intense.
theater of operations against ballistic missiles and         Pilots tend to be highly aggressive and individu-
long-range aircraft.                                      alistic, as noted in Chapter 9, U.S. Air Force Combat
   Unlike the field artillery, which are rarely totally   Psychiatry. Many of the author’s observations about
idle, most air defense artillery in recent wars have      U.S. Air Force pilots also apply to U.S. Army pilots.
had to sustain vigilance with little or no opportu-       These soldiers must be subtly reminded that they
nity to fire; the exception was the Patriot missile       are part of a larger organization that they need as
units in the Persian Gulf War, deployed both in           much as it needs them. Fliers can be demanding,
Saudi Arabia and Israel. There, the political impact      privileged individuals who have to rely on the
of their presence far outweighed their actual (sub-       cooperation of air support troops, those who ser-
sequently determined) performance, and placed             vice the craft and provide all logistical support.
upon them a heavy burden of responsibility. Fa-           Like U.S. Air Force aircrews, U.S. Army aircrews
tigue and stress became a significant factor for those    have a unit flight surgeon to monitor their physi-
crews. The deployment of Patriot batteries to South       ologic and mental status and ground them if they
Korea in 1993 as a show of resolve suggests that the      have become unsafe. However, the U.S. Army
responsibility will continue, and become even             environment is more dirty, dispersed, mobile, and
heavier if a potential opponent is known to have          spartan, perhaps leading to more fatigue and physi-
chemical, biological, or nuclear warheads.                ologic stress than in the U.S. Air Force.
                                                             Mental health professionals may have to take a
Army Aviation                                             humble and reassuring stance when interacting with
                                                          pilots and others in the aviation corps to allow for
   U.S. Army Aviation is currently restricted to          adequate ventilation of frustrations and anxieties.
rotary (helicopter) aircraft. Because of their ability    Pilots are very concerned about being taken off
to hover, fly “nap of the earth,” and land on many        flight status if they admit to emotional problems



166
                                                                                       U.S. Army Combat Psychiatry


(especially suicidal thoughts). They will not open         advancing armored formations supplied, or may
up to a mental health officer they do not know and         drive only along well-secured main supply routes
trust, as was also noted in Chapter 8.                     in the rear with military police escort.
                                                               Even the personnel clerks, supply clerks, and
Combat Support/Combat Service Support Troops               cooks may be assigned in an infantry battalion
                                                           headquarters company, performing guard duty at
   There is a poorly defined distinction between the       night for the brigade support area. Alternatively,
“combat arms” (who actively try to kill the enemy, as      they may be in a corps headquarters or quartermas-
attack helicopters do), and the combat support and         ter ordnance or personnel administration unit, in a
combat service support branches. Combat support,           “safe” rear area with only periodic charge-of-quar-
in theory, refers to those who actively facilitate the     ters (CQ) or staff duty at night. The cooks every-
battle (such as the Signal Corps, Military Intelligence,   where work extra-long hours. Of course, on the
Engineers, Military Police, and the Special Operations     modern battlefield, no place is totally safe. Even the
Forces’ Psychological Operations and Civil Affairs         U.S. Army stevedores unloading ships at the port of
units) while combat service support (CSS) refers to        embarkation may be subject to ballistic missile or
those who sustain the ability of the combat arms to        terrorist attack.
fight by transporting the ammunition, fuel, food and           Because most CSS troops are further from direct
water, servicing and repairing the equipment, pro-         contact with the enemy and further from enemy
viding health care, sorting the mail and providing         artillery than the combat arms, fewer CSS troops are
other personnel and administrative services.               killed and wounded in action. However, when they
   The distinctions between “combat” and “sup-             do suffer attack, their ratio of battle fatigue casual-
port” are often arbitrary and inconsistent across          ties to battle casualties is typically higher than in the
soldiers within a branch or corps. The combat              “combat hardened” combat arms.
engineers are a macho “combat arm” who share and               It can be hypothesized (but should never be pre-
often exceed the risks of the infantry and armor as        sumed) that the combat support/service support
they precede them into battle to clear minefields          soldiers who are integral to forward combat units
and bridge or blow up obstacles. They rely on              will take on some of the typical psychological char-
sophisticated armored vehicles or brute strength,          acteristics and stress profiles of their assigned units.
and defend themselves or attack enemy positions            Those who are only habitually attached may be a
with personal and heavy weapons. The civil engi-           little less so inclined. Soldiers or teams who are
neers use military versions of civilian equipment to       only temporarily attached or recently arrived far
build roads, buildings, and other infrastructure in        forward will be in transition and under the highest
the rear. The combat signalman crouches alongside          stress. Personnel who are in familiar units of their
the infantry platoon leader under fire, while signal       own kind in areas with very low probability of
battalions set up and operate the mobile subscriber        attack may come closest to fitting the stereotype of
telephone nodes, satellite uplinks, and other com-         the rear area soldier (the “REMF,” or Rear Echelon
munications throughout the theater of operation.           Mother F—er, as the combat soldiers in Vietnam
The military police may be far forward or far to the       labeled them).
rear, maintaining route security, securing and guard-          The stereotypic REMFs are managers, not lead-
ing enemy prisoners of war, or enforcing the Uni-          ers. At his worst, the REMF is the petty (or senior)
form Code of Military Justice (UCMJ) on U.S. ser-          bureaucrat who enjoys exercising arbitrary power
vice members who misbehave.                                over others and uses the rules and regulations to do
   Mechanics can be found in contact teams operat-         so. The REMFs take advantage of their positions to
ing recovery vehicles on the battlefield, in mainte-       acquire even more benefits and comforts than their
nance companies in the brigade and division sup-           rear-area positions naturally provide them, often at
port areas, and in large depots in the corps rear.         the expense of the combat soldiers for whom those
Truck drivers in infantry battalions drive forward         comforts (supplies, equipment, R and R facilities)
in convoys at night to deliver supplies at a rendez-       were intended. Low-ranking REMFs who have no
vous with the maneuver companies’ first sergeants,         power (and even some higher-ranking REMFs who
scant kilometers from the enemy. Truck drivers of          do) are prone to the disorders of frustration and
division and corps transportation or petroleum dis-        loneliness, as discussed in Chapter 3.
tribution companies may drive cross-country                    The rear-area soldiers (whether REMF or “regu-
through minefields at night, trying to keep the            lar Joe or Jane”) may feel not part of the battle,



                                                                                                                167
War Psychiatry


unappreciated, and left out of both the excitement      However, many CSS units did miss out on the
and tragedy of war. Some secretly wish to partici-      victory parades and felt unappreciated by civilian
pate in the battle and can feel inadequate, cheated,    society when they returned home late after staying
and inauthentic as soldiers. They may take danger-      to clear up the battlefield and store or ship the
ous risks or violate regulations to gain macho sou-     equipment.
venirs such as enemy weapons. They may have too            It should also be remembered that a large per-
much boring time without meaningful duties, and         centage of CSS units are in the reserves, and so face
too much access to the temptations of substance         the additional stressors of seriously disrupted occu-
abuse, unsafe sex, or other misconduct. These mis-      pational, financial, and family affairs. The importance
behaviors need the special intervention of mental       of building high unit cohesion and strong family
health workers because they are contagious, and         support groups in reserve units is obvious, but is not
because without supplies and other logistical sup-      easily accomplished except in units from small towns
port, the combat troops cannot fight.                   with strong roots in the civilian community.
   Some features of the Persian Gulf War worked to         The following disguised case history illustrates
counteract many of the traditional causes of the        inadequacies of leadership and questionable con-
REMF syndrome. The strict prohibitions on alco-         duct in a CSS unit, as revealed in a delayed end-of-
hol, substance abuse, and nonmarital sex of the host    tour debriefing following the Persian Gulf War.
nation, and the deliberate segregation of most U.S.
units from the local population in Saudi Arabia         Case Study 3: Leadership Problems in a CSS Unit
were protective, but will not occur in all future
deployments. The U.S. Army does have a strict               A reserve transportation battalion was deployed to the
drug abuse prevention policy and may adopt a “no        theater shortly before combat began. As expected, its
alcohol-in-theater” or “only 2 beers at unit func-      companies and teams were widely dispersed, attached to
                                                        other units for logistic and administrative support while
tions” policy, very different from the active push-
                                                        performing heavy, sometimes dangerous, duties. The
ing of alcohol in Vietnam.                              dispersed elements felt that their headquarters did not
   The priority of deploying combat forces to           keep track of them or assure their support. The com-
deter further aggression during Operation Desert        mander was perceived as having several favorite officers
Shield (the mobilization phase of the Persian           (all white males), while devaluing minority and female
Gulf War) meant that there was a very low pro-          officers and all NCOs. Rules were applied unfairly; for
portion of combat service support troops, who ac-       example, even married enlisted couples in the unit were
cordingly worked extremely long, hard hours. Liv-       denied conjugal privileges while it is alleged that the
                                                        favorite officers slept with whomever they could “per-
ing conditions were initially as austere for the CSS
                                                        suade.” The battalion chaplain was perceived as the
units as for the combat arms, and the senior U.S.       commander’s spy, since retribution seemed to follow
Army leadership deliberately kept it that way. They     soon after any complaints were shared with him.
did not build up a comfortable supporting base. In          All awards and decorations after the war went to
part that was to reassure the host nation that there    the white male favorites. The unit cooks who had been
was no intention to stay. The logistical system         levied to drive trucks in a heroic night convoy to take
was also too tasked with bringing in war materials      supplies through minefields (illuminated only with black-
to bring in luxuries. The senior leaders also re-       out lights and following in the tread marks of the tanks that
membered, however, how much they and their              had gone before) did not even receive certificates of
                                                        appreciation because “they were just doing their jobs.”
troops had resented the REMFs when they were
                                                        The company commander who had organized the convoy
junior officers and NCOs in Vietnam. They deliber-      but stayed behind at headquarters received the decora-
ately lived spartanly themselves, and required aus-     tion for valor.
terity of all their subordinate CSS units. Some             The unit was late in redeploying home, missing all the
leaders required their rear area CSS soldiers in safe   victory parades. The soldiers rejoined unsympathetic
areas to wear helmets and even flak jackets when        employers, families, and creditors who said they’d “only
there was no threat, as a symbol of solidarity with     been support troops, not in combat.” The commander and
the combat soldiers.                                    favorite officers immediately left the unit, taking their
                                                        awards with them, and leaving the previously devalued
   Finally, when the Scud missile attacks began,
                                                        NCOs plus new officers in charge. Within a year, many
and later when the ground offensive proceeded           unit members were reporting symptoms of fatigue, trouble
with relatively few U.S. casualties, whatever guilt     concentrating, hair loss, joint pains, and other complaints.
or sense of unimportance many CSS personnel may         They attributed their symptoms to exposure to antimissile
have felt was absolved. The senior leadership did       radar emissions (from an installation near their headquar-
praise the logisticians part in winning the war.        ters in the theater) or chemicals.


168
                                                                                          U.S. Army Combat Psychiatry


    Comment: The question of whether the symptoms               their very important morale-sustaining duties and
were caused by some exposure or exposures deserved,             return home feeling proud about what they have
and received, intensive medical evaluation. What was            done without being haunted by the dreams and
unquestionable during the debriefings that these units          memories they may have for the rest of their lives.
participated in over a year after their return was the open
anger and sense of betrayal expressed by the junior
NCOs and enlisted. The senior NCOs retained their               The Medical Combat Health Support Troops
professionalism during the debriefings, but confirmed the
enlisteds’ memories of the events in private conversation.         Combat medics share all of the stressors of the
The role of a sense of betrayal and injustice in the etiology   combat arms units they support. Battalion aid sta-
of PTSD has been emphasized by Shay.33 It was unfair to         tions (Level I care) follow close behind. Medical
accuse the chaplain of violating confidentiality—the com-
                                                                companies maintain clearing stations and treatment
mander could have simply been good at guessing, or
indiscriminately punished every suspect when the chap-
                                                                teams in the brigade support and division support
lain advised him of low morale and the reasons for it.          areas close to the front and at base defense clusters
However, had the unit’s elements been visited routinely         in corps. These companies can move themselves
by mental health/CSC (MH/CSC) teams while in theater,           rapidly, tearing down and setting up within hours.
the original poor leadership and questionable conduct           Although technically privileged against attack by
could have been corrected.                                      the Geneva Convention, they are often forbidden
    Evolving U.S. Army doctrine and organization30 calls        by the tactical commanders from showing the red
for the area support medical battalion mental health sec-       cross on white background emblem.
tion, reinforced by teams from the CSC Company, to visit
                                                                   Forward surgical teams (replacing the current
every company-sized unit every few weeks to conduct unit
survey interviews with the troops. These structured inter-
                                                                Mobile Army Surgical Hospitals) can reinforce the
views serve both a data gathering and a ventilating func-       medical companies as far forward as the brigades.
tion. The MH/CSC teams’ command consultations might             Dental teams set up to support troop concentra-
have inspired the commander to improve his ways or, that        tions. Preventive medicine and veterinary teams
failing, have advised his senior commander.                     routinely visit units to inspect sanitation, disease
    The unit should also have had an end-of-tour debrief-       vectors, and food supplies. Ground and air ambu-
ing and scheduled homecoming debriefings before rede-           lances are prepositioned or deploy forward to bring
ploying home. The family support groups should have             casualties quickly back to the clearing station (Level
been involved in posthomecoming activities that validated
                                                                II) and hospital (Level III) care.
the spouses’, and their own, honorable service under
hardship and (for some) real danger. Those measures
                                                                   The hospitals use Deployable Medical Systems
would have decompressed the anger and facilitated con-          (DEPMEDS) expandable shelters, TEMPER (tent,
structive action a year sooner.                                 extendible, modular, personnel) tents, and pre-
                                                                packed sets to assemble a climate-controlled com-
   One group of CSS troops deserves special atten-              plex of wards, operating rooms, laboratory and x-
tion from the MH/CSC organization and others.                   ray radiographic facilities, pharmacy, admin-
These are the formal Mortuary Affairs units (previ-             istrative, and admission and disposition areas. The
ously called Graves Registration). Those who must               hospital staff are usually quartered in general pur-
recover, process, and transport the bodies of the               pose (GP) large tents without climate control. Hos-
dead and their personal effects are at very high risk           pitals take days to set up and break down, and
of developing post-traumatic stress disorder. This              many trucks from nonmedical sources to move.
is often of the delayed type because of the tough               They also require extensive logistical support to
emotional shell they form to perform their grue-                operate. They are therefore normally located in the
some duties day after day. There are also many                  corps, although some may be close to the divisions.
other soldiers in all other branches and military               Hospitals normally do show the red cross, indicat-
specialties who are temporarily detailed to body                ing privileged status.
recovery and disposition duties, or who are ex-                    Casualties with medical diseases and nonbattle
posed to human remains. These include the tank                  injuries may reach the aid stations, clearing sta-
turret mechanics or ordnance specialists who can-               tions, and hospitals at a fairly steady rate, barring
not repair the tank until they have washed out the              some epidemic illness or mass casualty accident.
remaining blood and pieces of tank’s crew, who had              The war-wound surgical caseload, like battles, are
been lying under the sun for several days. Chapter 10,          likely to come in surges separated by lulls. It is the
Combat Stress Control in Joint Operations, pro-                 role of the medical regulating officer at the medical
vides a summary (information card) on measures                  group headquarters to spread the casualties some-
these people should take to enable them to perform              what evenly, and to direct patients who need spe-


                                                                                                                  169
War Psychiatry


cialty team care to the hospitals that have those        May they be horrified at receiving the victims of
specialty teams. In major battles, all hospitals may     atrocity, including women and small children, who
experience mass casualty conditions. Sick or             are their responsibility to treat, as when the Iraqi
wounded enemy prisoners of war are also brought          Shiite victims of Republican Guard massacres in
to U.S. hospitals. The Geneva Convention34 re-           southern Iraq were air evacuated to U.S. hospitals
quires that they be treated the same as U.S. casual-     in theater after the Gulf War?
ties, according to the same triage categories.               Medical personnel often tend to deny stress in
   What are some of the stressors unique to medical      themselves, and may have to be approached diplo-
units? The AMEDD professionals and specialty             matically or indirectly by mental health/CSC con-
technicians often do not train frequently under field    sultants. Special attention should be given to those
conditions, and so are unfamiliar with the sets, kits,   personnel who are not normally direct patient care
and outfits. They may not appreciate why they do         providers. Those persons usually have less “stress
not have their familiar, latest drugs, sutures, and      inoculation.” They include the food service, main-
diagnostic equipment, in field-portable form. They       tenance, administrative, and laboratory personnel.
may have difficulty acclimatizing to the dirt, dis-      These are the ones most likely to be detailed to be
comfort and primitive hygiene facilities, as well as     litter bearers for the severely injured, attendants for
to the separation from home and the potential of         the expectant patients, or handlers for the bodies in
personal danger. Many are PROFIS or IRR (Indi-           the morgue.
vidual Ready Reserve) individuals who are joining            Hospitals are nominally staffed for two 12-hour
unfamiliar units that may or may not already have        shifts a day, but mass casualties can require con-
a unit cohesion that incorporates them. The highly       tinuous or sustained operations for periods of sev-
specialized professionals and technicians are often      eral days to weeks. Fatigue impacts heavily on
very concerned if they are unable to practice their      patient care as well as on morale and stress toler-
specialized procedures, lest they lose their skills      ance. Medical personnel can become battle fatigue
and their credentials.                                   casualties, and require treatment according to PIES
   Treating seriously wounded casualties is stress-      (proximity, immediacy, expectancy, and simplic-
ful, but justifies to the medical personnel why they     ity), with the five Rs, as discussed in Chapter 10.
themselves are there. It quickly builds and sustains     Stress and fatigue can also disrupt interpersonal
unit cohesion unless something disrupts the patient      communication and cooperation, impairing unit
care. However, the casualties can arouse several         efficiency in subtle ways. Misconduct stress behav-
distressing ethical issues. How do different indi-       iors can occur. These include “self-medication”
viduals deal with the moral dilemma of placing           with alcohol and with the drugs that are available
patients in the “expectant” triage category, espe-       (by pilfering or “skimming”) in medical facilities.
cially the patients they know they could save if they    Seeking solace in sexual relationships is a natural
only had fewer patients, more supplies, or the “high-    reaction to loneliness and “living on the edge.”
tech” equipment back in their stateside hospital?        However, fraternization (heterosexual as well as
How do they face the moral dilemma of saving the         homosexual) and adultery are criminal violations
grossly, pitifully disabled patient when they do         of the UCMJ. Consensual heterosexual misconduct
have the resources to do so, especially if the patient   has rarely been punished, but its occurrence in
begs to be given “grace” (euthanasia)? How do they       medical units adversely impacts upon unit morale,
face the moral dilemma of returning soldiers to          especially when unit leaders are involved. The
duty, perhaps to be wounded again or killed, when        rumors and aftermath of “deployment affairs” can
they themselves do not have to risk direct combat?       also have harmful effects on families back home.
May they become overwhelmed or depressed by                  Monitoring these many stress issues and inter-
their inability to relieve the suffering or save the     vening when indicated is a command and leader-
lives of so many young Americans with whom they          ship responsibility.29 The hospital or battalion chap-
identify? How do they deal with their anger, ha-         lain can often be helpful. Responsibility is also
tred, and perhaps guilt, when treating the injured       given, by doctrine,30 to the neuropsychiatric ward
enemy prisoner who may have been the one who             and consultation service in the hospitals and to the
wounded those not-quite-so-urgently triaged              medical combat stress control company or detach-
American soldiers next to him? May they be upset         ment that is providing area support in the vicinity.
at being forbidden to treat local foreign civilians in   Interventions are reviewed elsewhere in this text-
need who are not the U.S. Army’s responsibility?         book.



170
                                                                                    U.S. Army Combat Psychiatry


       MEDICAL/PSYCHIATRIC ORGANIZATION AND THE COMBAT STRESS COMPANY

   The neuropsychiatric and mental health team              While neurology and psychiatry functions are
consists of neurologists, psychiatrists, clinical psy-   generally separate during peacetime, in mobiliza-
chologists, social workers, psychiatric and mental       tion the neuropsychiatric emphasis collocating neu-
health nurses, occupational therapists, and the vari-    rology with psychiatry is used. Both battle and
ous enlisted technicians in those specialties. Mental    nonbattle injuries and illnesses are thus coded in
health professionals in the Army Medical Depart-         those categories. In addition, the “neuropsychiatric”
ment (AMEDD) are those commissioned officers             term clearly includes the organic (physical) as well
and enlisted personnel specialists trained and           as the functional (mental) types of disorder. This is
credentialed to provide the various mental health        particularly important in trauma, and nuclear, bio-
functions. In addition to those previously men-          logical and chemical (NBC) scenarios. In Medical
tioned, other professionals can be qualified for these   Force 2000, the only neurologist is in the general
specialized services such as physician assistants        hospital. In the proposed Force 21 AMEDD, neu-
(PA), counselors, and chaplains. Para-profession-        rologists may not be included in the TO&E of de-
als or technicians are the behavioral science special-   ployed hospitals or CSC units, but will be available
ists (91G), psychiatric specialists (91F), and occupa-   to provide consultation via telemedicine.
tional therapy specialists (91L).                           In combat, treatment of battle fatigue and other
                                                         types of neuropsychiatric casualties will be insti-
The Mental Health Program                                tuted early, as near the unit of origin as practicable.
                                                         Proper psychiatric treatment of neuropsychiatric
   The mental health program of the military is          casualties requires a military environment rather
somewhat different in peacetime from that during         than a traditional hospital atmosphere. Mild “duty”
mobilization. The U.S. Army regulation that is the       cases should be treated and returned to duty imme-
basis for both is Neuropsychiatry and Mental Health.26   diately from the battalion aid station, brigade, or
The regulation prescribes and refines policies and       division or area support medical company medical
concepts regarding neuropsychiatry (NP) principles       treatment section or hospital admissions and dispo-
for mental health staff and facilities. This directs     sitions section, or in nonmedical units whenever
the neuropsychiatry/mental health staff to advise        the tactical situation permits.
and assist command to conserve and maintain man-            Early return to duty is the therapeutic objective.
power at maximum efficiency. While the emphasis          This can be accomplished only if the medical officer
is on mobilization, it is important during peacetime     accepts full responsibility to make often difficult
to prepare by employing common neuropsychiatry           diagnostic or disposition decisions objectively and
and mental health principles. Neuropsychiatric           without delay. Neuropsychiatric referrals from
and mental health personnel must be ready and            supporting or noncombat troops should be made to
responsive for mobilization and other missions as        the nearest mental health personnel who are often
required.                                                stationed forward of the combat service support
                                                         unit. Moderate “rest” cases who cannot return to
Basic Principles                                         their units immediately but who do not need medi-
                                                         cal or mental health observation and treatment or
   Based on experiences gained during World War          both should be sent to rest for 1 to 2 days.
I and World War II, the Korean conflict, and the            Patients suffering from severe battle fatigue (hold
Vietnam conflict, the following principles have          or refer), or other neuropsychiatric patients who
evolved for the prevention, treatment, and admin-        cannot be returned to duty at the forward facilities,
istrative management of neuropsychiatric and             are to be channeled to the division medical support
stress disorders. Major emphasis is placed on pre-       unit(s) having mental health/CSC capability. These
ventive psychiatry and mental health programs            teams must have a capability of providing rest and
that lead to early recognition and preventive treat-     restorative therapy for up to 72 hours prior to return
ment of potential mental health problems. This is        to duty. Those casualties who prove to need longer
similar to preventive medicine concepts. Neuro-          treatment will be evacuated to a 7- to 14-day recon-
psychiatric personnel make a primary contribution        ditioning program at CSC facilities in direct or
to this program by fulfilling the appropriate re-        general support of the unit. After that period, the
sponsibilities outlined in the U.S. Army mission.        individual will be returned to duty or evacuated to



                                                                                                            171
War Psychiatry


the communications zone or CONUS Level-IV re-                   mental or physical status workup by spe-
conditioning program.                                           cialists.
   In noncombat situations the evaluation, treat-
ment, and disposition of nonpsychotic psychiatric             Each of the five MH/CSC disciplines also brings
patients, except in unusual cases, will be on an           areas of special expertise, which may be partially
outpatient basis. Their retention on duty status fa-       cross-trained to the others. The psychiatrist, as
cilitates therapy and reduces ineffectiveness. In          working physician, practices psychiatry in the tri-
both combat and noncombat situations, direct com-          age, diagnosis, brief intervention treatment, and
munication and liaison among neuropsychiatry (MH           disposition of soldiers and patients. The psychia-
and CSC) staff (for example, between division psy-         trist assists with triage and acute trauma life sup-
chiatrists and the theater neuropsychiatry consult-        port during mass casualties, and assists with rou-
ant) through technical channels as approved by             tine sick call and care of the ill, wounded and
appropriate command surgeons, are indispensable            injured, especially those with return-to-duty poten-
to monitoring evacuation and issuing policy. Such          tial. The psychiatrist should be ATLS- (Advanced
communication must be actively encouraged.                 Trauma Life Support) qualified by the Combat Ca-
   The rapid communication of technical informa-           sualty Care Course, and have completed the NBC
tion, especially in combat, is essential to an effective   casualty care course.
mental health program. It should be recognized                The occupational therapist (OT), assisted by the
that the greater the combat pressure, the more dif-        NCO and enlisted specialist, increases the capabil-
ficult it becomes to maintain necessary communica-         ity to evaluate physical and mental functional capac-
tion. Therefore, maximum use of direct forwarding          ity related to combat duty performance; prescribes
of technical reports must be done, consistent with         and supervises therapeutic work and recreational ac-
good judgment and propriety.                               tivities for recovery battle fatigue cases in support of
   The overall effectiveness of any neuropsychiatry        the host medical facility; and assesses alternative
program is dependent on the proper numbers, distri-        duty assignments for soldiers who cannot return-
bution, and assignment of qualified mental health          to-duty in their original specialty. The OTs also
personnel. It is essential that the staff promote          advise unit commanders regarding work schedule
training and make accurate evaluations of mental           organization and time management, constructive
health personnel to assure their appropriate assign-       structuring of rest and tension-relieving activities,
ment. Neuropsychiatry personnel should ensure              and use of work assignments in preventing battle
that all medical personnel have some familiarity           fatigue and misconduct stress behaviors and in
with basic combat psychiatric principles.                  restoring recovered cases to full duty. The OTs
   All mental health combat stress control person-         provide rehabilitative care for minor orthopedic
nel should be cross-trained in specialized topics          injuries, especially of the upper extremity.
and techniques to include:                                    The psychiatric nurse (66C)/clinical nurse spe-
                                                           cialist (66C7T), assisted by the 91Fs, greatly in-
  • Briefing on CSC unit status, functions and             creases the capability to stabilize and hold poten-
    capabilities.                                          tially disruptive cases at forward locations for
  • Educating leaders, chaplains, and medical              further evaluation. Some cases can be returned to
    personnel on stress casualty identification,           duty at this echelon, if they improve in 24 to 36
    management and disposition; substance                  hours with sleep and a structured military milieu,
    abuse; suicide prevention; family violence             instead of having to be evacuated immediately to a
    prevention.                                            hospital in the corps area. If the position is filled by
  • Teaching stress management, relaxation                 a clinical nurse specialist, as authorized by the TO&E,
    techniques, coping skills, grief and anger             this nurse may be credentialed to prescribe selected
    management, conflict resolution, parenting.            psychotherapeutic drugs. The psychiatric nurses
  • Facilitating small team after-action debrief-          are especially suited for consultation and preven-
    ings by unit leaders.                                  tive interventions with other medical and nursing
  • Leading critical event debriefings of func-            staffs in medical facilities. Psychiatric nurses in the
    tioning military teams.                                corps hospitals provide further stabilization for ei-
  • Conducting individual and small group de-              ther transfer to CSC reconditioning programs or for
    briefing of stress casualties.                         air evacuation out of theater.
  • Assessing interviews, basic mental status,                The social work officer, assisted by the 91Gs,
    and recognition of signs requiring additional          applies the principles, knowledge and skills of


172
                                                                                    U.S. Army Combat Psychiatry


social work to the psychosocial systems of                  The clinical psychologist, assisted by 91Gs, pro-
U.S. Army units and their Family Support Groups.         vides diagnostic assessment, and can administer
They are prepared to coordinate with other Depart-       and interpret psychological and neuropsychological
ment of the Army, Department of Defense, and             tests to diagnose problem cases and assess potential
civilian support agencies. The social worker pro-        for recovery. The psychologist’s treatment and
vides mental health assessment and treatment,            consultation skills include the behavior therapies
coordinates support for division soldiers and            and focused applications of learning theory. Doc-
families, and has expertise in prevention/interven-      toral-level psychology training in research meth-
tion for family violence and substance abuse             ods and statistics contributes in unit surveys and
control.                                                 the analysis of trends.

                                                THE FUTURE


   The U.S. Army’s battlefield tenets of initiative,     the Vincennes. Combat stress control—the con-
agility, synchronization, and depth are designed to      tinual monitoring of stress levels and prompt inter-
surprise and overstress enemy forces.35 They make        vention when indicated—takes on increased im-
the enemy incapable of cohesive action. Those            portance in the “high-tech” environment.
same tenets demand high-level mental skills from            The combination of highly lethal, mobile, and
leaders and soldiers at every echelon. It is these       interspersed weapons systems from different
mental skills that are most vulnerable to degrada-       branches, services, and allies, with interpretation of
tion by stress. The enemy seeks to impose stress on      enemy doctrine and movements, creates an intrin-
U.S. troops, and U.S. Army planners, in turn, accept     sic risk of friendly fire casualties. This risk must be
stress as a calculated risk in the U.S. Army’s plan to   calculated and the stress consequences, which ex-
impose greater stress on the enemy.                      tend far beyond the involved units, must be as-
   Control of stress is the commander’s responsibil-     sessed and controlled. The combat stress control
ity. Before, during, and after operations, the com-      system assists this process.
mander is aided in this responsibility by specialized       Advanced communications technologies so vital
AMEDD CSC/Mental Health personnel. These                 on the battlefield also make modern warfare a very
personnel work in concert with the NCO chain of          public enterprise. News, video, and private tele-
support, the chaplains, unit medical personnel, and      phone can take the battle to the homefront almost
principal and special staff. Commanders and their        instantaneously, complicating operations security
other supporting personnel must give priority to         and bringing battlefield stressors into living rooms
their primary missions. Stress control is so impor-      across the country and around the world. Tele-
tant to mission accomplishment that AMEDD men-           phones and media can also bring homefront stres-
tal health personnel have been assigned in every         sors to the soldier overseas. The interaction be-
war since World War I with combat stress control as      tween unit leaders and their units’ families is vitally
their primary duty.                                      important to mission readiness. Active Family Sup-
   Evolving doctrine calls for the United States to      port Groups have been effective in decreasing the
use technological superiority to win decisively on       historically large percentage of battlefield stress
the digitized battlefield. These weapons systems         related to issues back home.
call for an extremely high level of knowledge, skill,       The U.S. Army will continue to leverage existing
and sustained mental acuity on the part of every         and emerging technological capabilities to enhance
soldier. Human error due to stress can lead to           support operations across the full range of military
devastating failures in “high-tech” systems, such as     operations. Application of technologies to enhance
that seen on the U.S. Navy guided missile cruiser,       and assure communications is vital to the CSC concept.


                                     SUMMARY AND CONCLUSION


   The basic concept in management of neuropsy-          ment and triage at clearing stations by trained spe-
chiatric casualties is increasingly higher, multi-       cialists and professionals is essential. Exercise in
tiered echelons of care. Mental health personnel         peacetime of all elements of the program is impor-
and programs must be flexible and mobile. Assess-        tant. Communication nets are critical if coordina-


                                                                                                            173
War Psychiatry


tion is to be effective. Successful capability of the         must be planned early. Personnel needs above the
various elements to hold and carry transient casual-          standard TO&E requirement must be anticipated if
ties needs planning and practice. Developing a                sufficient augmentation is to be made possible. Train-
personnel program to return soldiers to duty will             ing in basic stress management for neuropsychiatric
require staff action at various headquarters. Ability         problems and cross-training in life saving techniques
to provide rest and restorative care (sleep space,            is essential. Education of all health professionals in
food, and so forth) in a protected but accessible area        basic neuropsychiatric concepts is important.


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     177–193.

 10.   Salmon TW. The care and treatment of mental diseases and war neurosis (“shell shock”) in the British Army. In:
       Bailey P, Williams FE, Komora PA, Salmon TW, Fenton N, eds. Neuropsychiatry. Vol 10. In: The Medical
       Department of the United States Army in the World War. Washington, DC: Office of The Surgeon General, US Army;
       1929: Appendix; 497–523.

 11.   Ginsberg E, Anderson JK, Ginsberg SW, Herma JL. The Ineffective Soldier: Patterns of Performance. New York:
       Columbia University Press; 1959: 11.

 12.   Cohen RR: Mental hygiene for the trainee. Am J Psychiatry. 1943;100: 62–71.

 13.   Bartemeier LH, Kubie LS, Menninger KA, Romano J, Whitehorn JC. Combat exhaustion. J Nervous and Mental
       Disease. 1946;104:358–389.

 14.   Glass AJ, Drayer CS. Italian campaign (1 March 1944–2 May 1945), Psychiatry established at division level. In:
       Glass AJ, ed. Overseas Theaters. Vol 2. In: Neuropsychiatry in World War II. Washington, DC: Office of The Surgeon
       General, US Army; 1973; 47–109.

 15.   Stouffer SA, DeVinney LC, Star SA, Williams RM. The American Soldier. Vol 2. Princeton, NJ: Princeton
       University Press; 1949.


174
                                                                                              U.S. Army Combat Psychiatry


16.   Beebe GW, De Bakey ME. Battle Casualties: Incidence, Mortality, and Logistic Considerations. Springfield, Ill:
      Charles C Thomas; 1952.

17.   Swank RL, Marchand F. Combat neuroses: Development of combat exhaustion. Arch Neurol Psychiatry [super-
      seded in part by Arch Neurol and Arch Gen Psychiatry]. 1946;55:236–247.

18.   Beebe GW, Appel JW. Variation in Psychological Tolerance to Ground Combat in World War II, Final Report.
      Washington, DC: National Academy of Sciences; 1958.

19.   Glass AJ. Lessons learned. In Glass AJ, ed. Overseas Theaters. Vol 2. In: Neuropsychiatry in World War II.
      Washington, DC: Office of The Surgeon General, US Army; 1973: 989–1027.

20.   Jones FD. Experiences of division psychiatrist in Vietnam. Milit Med. 1967;132(12):1003–1008.

21.   Parrish MD. Personal Communication, 27 July 1991.

22.   Glass AJ. Observations upon the epidemiology of mental illness in troops during warfare. Presented at the
      Symposium on Social Psychiatry; April 1957; Walter Reed Army Institute of Research, Washington, DC. 185–198.

23.   Reister FA. Battle Casualties and Medical Statistics: US Army Experience in the Korean War. Washington, DC: Office
      of The Surgeon General, US Department of the Army; 1986: 58–59.

24.   Copen EG. Discussed in: Jones FD, Johnson AW. Medical and psychiatric treatment policy and practice in
      Vietnam. J Soc Issues. 1975;31(4):49–65.

25.   Camp NM. The Vietnam war and the ethics of combat psychiatry. Am J Psychiatry. 1993;150:1000–1010.

26.   US Department of the Army. Neuropsychiatry and Mental Health. Washington, DC: US Government Printing
      Office; 1 September 1984. Army Regulation 40-216.

27.   US Department of the Army. Health Service Support in the Theater of Operations. Washington, DC: DA; 1 March
      1991. Field Manual 8-10.

28.   US Department of the Army. Brigade and Division Surgeon Handbook. Washington, DC: DA; 1991. Field Manual
      8-10-15.

29.   US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA; 29 September 1994.
      Field Manual 22-51.

30.   US Department of the Army. Combat Stress Control in a Theater of Operations. Washington, DC: DA; 29 September
      1994. Field Manual 8-51.

31.   Johnson LB, Cline DW, Marcum JM, Intress JL, Effectiveness of a stress recovery unit during the Persian Gulf
      War. Hosp Community Psychiatry. 1992;43(8):829–833.

32.   Banderet LE, Stokes JW, Francesconi R. Artillery teams in simulated sustained combat: Performance and other
      measures. In: Johnson LC, Tepas DI, Colquhoun WP, eds. Biological Rhythms, Sleep and Shift Work. New York:
      Spectrum; 1981: 459–479.

33.   Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Athenium; 1994.

34.   Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field. 21 April–
      12 August 1949. Geneva, Switzerland: Geneva Convention; 1949: D-1.

35.   US Department of the Army. Force XXI Combat Health Support Operations [draft concept], Annex I, Combat Stress
      Control. Fort Sam Houston, Tex: US Army Medical Department Center and School; May 1995.




                                                                                                                         175
                                                                                                    U.S. Air Force Combat Psychiatry




Chapter 8
U.S. AIR FORCE COMBAT PSYCHIATRY


DAVID R. JONES, M.D., M.P.H. *



                                     INTRODUCTION

                                     SUPPORT OF FLIERS IN COMBAT
                                       “Fear of Flying” and Combat Fatigue
                                       The Use of Rest for Prevention and Treatment
                                       The Role of the Flight Surgeon
                                       Summary

                                     SUPPORT OF NONFLYING PERSONNEL IN COMBAT
                                       First-Echelon Measures
                                       Second-Echelon Measures
                                       Summary

                                     CONCLUSION




* Colonel (ret), Medical Corps, U.S. Air Force; Chief Flight Surgeon, Aeropsych Associates, 4204 Gardendale, Suite 203, San Antonio, Texas
 78229-3132; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Clinical Professor
 of Psychiatry, University of Texas Health Science Center at San Antonio, Texas


                                                                                                                                      177
War Psychiatry




Peter Hurd                                       Aerial Gunner, England                                1944

Peter Hurd was a Life Magazine artist during World War II, assigned to cover the action on Ascension Island
and also in England. His painting depicts a gunner standing in front of his turret on the belly of a bomber.
For sheer terror, few jobs in the U.S. Army Air Forces in World War II could compare to his—relying on his
own composure, wits, and agility to shoot down enemy aircraft, while totally exposed to return fire



Art: Courtesy of US Center of Military History, Washington, DC.




178
                                                                                U.S. Air Force Combat Psychiatry




                                             INTRODUCTION


   The U.S. Air Force mission and its possible com-      role models are available, either through tradition
bat scenarios differ considerably from those of other    or in real life.
services. Traditionally, the people at risk in the          Thus, two differences come immediately into
U.S. Air Force have been the fliers—the pilots, navi-    focus when comparing the U.S. Air Force role to the
gators, weapons systems operators (WSOs),                roles of the other services1:
electronics countermeasure operators, radio opera-
tors, gunners, loadmasters, flying crew chiefs, and       1. In the past, the brunt of battle has been
other highly skilled and carefully selected person-          borne by a select, highly trained small group
nel. These fliers have been the tip of the arrow,            of U.S. Air Force fliers, with whom the mass
supported by the rest of the U.S. Air Force. Thus, at        of troops may not be able to identify person-
a 3,000-person airbase, only the 300 or so fliers            ally.
might be exposed to combat. Security police armed         2. In the event of enemy attack, most U.S. Air
with light weapons provide perimeter security                Force members will have to take cover and
against small attacks, but most of the personnel on          wait while others decide their fate. This
base are usually not even issued personal weapons.           passive role carries with it a particular vul-
The U.S. Air Force has no tradition of arms, little          nerability to combat reactions. [This is fur-
training in the use of rifles and pistols, and essen-        ther discussed in Chapter 6, A Psychologi-
tially no tactical field training in self-defense. In        cal Model of Combat Stress.—Ed.]
case of ground attack, most personnel are expected
to take cover and wait while some other military            The combat stresses borne by the fliers and by
service or the base’s own aircraft and security police   those nonflying members who may have to suffer
fight off the attacking enemy. Leadership training       through a ground attack on the base will be consid-
of U.S. Air Force officers and noncommissioned           ered separately, drawing examples from wars of the
officers (NCOs) does not address handling troops         past in order to develop and discuss future preven-
in deadly peril, and the average service member          tive and therapeutic measures to preserve the fight-
knows little about how to behave under attack. Few       ing strength.

                                    SUPPORT OF FLIERS IN COMBAT


   The nature of war dictates that, certainly in         because of scheduling conflicts, crowded billeting
the beginning phases and perhaps for several             of crews flying different schedules when all fliers
weeks, fatigue is the order of the day. Operation        were brought on base for security reasons, and
Desert Storm, the combat phase of the Persian Gulf       environmental stressors such as heat and isola-
War, followed that rule, and so, no doubt, will the      tion. The pace of the war was so rapid that there
next conflict. As usual, all did not go according to     seemed to be no time to deal with emotional reac-
plans. The uncertainty of the length of deployment       tions to the deaths of squadron mates.2 In brief, the
contributed to general tension. Combat air patrols       emotional aspects of war have not changed much in
up to 8 hours long could be followed by alert            the last 40 years.
scrambles of equal length. Tanker schedules some-            Most of the literature concerning the effects of
times consisted of 12 hours flying, 12 hours rest,       combat stress on fliers derives from World War II;
and 12 hours of alert. Some crews flew 36-hour           little was written on this subject during the Korean
crew days. Sleep was interrupted by aircraft noise       conflict, and there is essentially no psychiatric lit-
and Scud missile alerts. Some line commanders            erature on the U.S. Air Force experience in South-
seemed not to understand the effects of stress and       east Asia during the Vietnam conflict. No signifi-
chronic fatigue. Some flight surgeons felt that air-     cant publications on this topic have emerged from
crews were pushed to the limits of their endurance,      recent U.S. Air Force operations in Libya, Grenada,
to the point where flying safety suffered. Fatigue       Panama, or Kuwait and Iraq. This is a regrettable
was a consideration in at least two noncombat fatal      lack, for several demographic factors have changed
accidents. Other problems included missed meals          during this period.


                                                                                                            179
War Psychiatry


    Fliers today differ considerably from their pre-      fighter pilots were a subgroup of the U.S. Air Force,
decessors. The fliers in World War II were wartime        a tactical cadre that rotated between Southeast Asia,
volunteers, high school graduates or college stu-         the Tactical Air Command in the United States, and
dents commissioned through the Aviation Cadet             tactical fighter wings in the U.S. Air Force, Europe
Program, trained in a specific aircraft, and sent into    (USAFE). Some of these men served two, three, or
combat with perhaps 200 flying hours altogether.          four tours in Southeast Asia. These fliers differed
Most of these fliers separated from the service after     from the U.S. Army helicopter pilots, who were
the war, having no intention of a career in military      younger, less educated, and more like the World
aviation. Some joined the reserves, probably think-       War II volunteers.
ing that they would be recalled to active duty only          The U.S. Air Force today has continued its policy
in the unlikely event of a national emergency.            of producing highly selected, educated, and trained
   The call came sooner than anyone expected. Many        pilots. The increasing complexity of aircraft (fre-
of the reservists were reactivated in 1950 for the        quently called “weapons systems” to underline this
Korean conflict. This “police action” did not gener-      complexity) requires continued high-grade train-
ate the sense of national unity that World War I and      ing. Many frontline pilots, navigators, weapons
World War II had, and many reservists were quite          systems operators, and electronic warfare opera-
bitter about having their lives and careers inter-        tors are in their 30s, and some are in their 40s. They
rupted to fight in a war not linked to a clear threat     are, as stated earlier, considerably different from
to the nation. (Their feelings were expressed in the      their predecessors in World War II, and more like
sardonic song, “Here’s to the Regular Air Force,          those who flew in Southeast Asia. Yet there are
they have such a wonderful plan: They call up the         almost no specific data about combat reactions of
Goddam Reservists, whenever the shit hits the fan!”)      fliers in action in Southeast Asia, the Libya raid, the
Somewhat older, not as committed, and with con-           invasions of Grenada and Panama, or the Persian
siderably less motivation to fly, those recalled fliers   Gulf War, or about the types of support most effec-
became a problem because of their increased inci-         tive in maintaining their morale and fighting spirit.
dence of refusal to fly combat missions due to “fear      Thus, any ideas or plans for furnishing such sup-
of flying.”3–5 Harking back to lessons learned dur-       port in a future conflict must be based on the reports
ing World War II, flight surgeons would check such        of U.S. experiences in World War II and Korea,
fliers to assure that they had no psychopathology,        along with anecdotal data and reminiscences from
and then clear them medically for flying duties.          Southeast Asia, data obtained from the performance
Any further refusal to fly was handled administra-        and support of fliers from the U.S. and other nations
tively rather than medically.                             in the more recent conflicts, and projections of all of
   The demographic characteristics of U.S. Air Force      this information onto present U.S. Air Force fliers.
fliers have continued to change since the mid-1950s.      Added to these changes will be the effects of the
All fliers (indeed, all officers) must have a college     drawdown of the U.S. Air Force since the collapse of
degree, and most obtain their commissions either          the Soviet Union, the increase in the proportion of
through the U.S. Air Force Academy or through             women and their new roles, and the outcome of the
Reserve Officers’ Training Corps programs. Many           present debate about homosexuals and lesbians in
go on to obtain master’s degrees after entry on           the service. Still, one may reasonably assume that
active duty. Except for the few older officers com-       principles of support to morale and flying effi-
missioned through the old Aviation Cadet Program          ciency that have been effective in a variety of past
or Officer Candidate School, this was the complex-        conflicts are probably basic enough to prove useful
ion of the force in Southeast Asia. These young,          when flexibly and thoughtfully adapted to the par-
bright, well-educated fliers had thus spent at least 5    ticular circumstances of future conflicts.
years (4 in college, 1 in flight training) directed          U.S. Air Force fliers may fill a number of roles in
toward the goal of becoming a U.S. Air Force officer      a combat situation. Some tactical fighters will fly
and flier. Many were seriously considering 20-year        air-to-air combat missions to establish air superior-
careers, and most of those who were not were hop-         ity over the battlefield by attacks on enemy aircraft.
ing for careers as airline pilots. Thus they went to      Others will fly tactical air-to-ground missions, at-
war older and better educated, and with a longer          tacking enemy troop concentrations, armor, artil-
career view than their predecessors. Many were            lery, supplies, and equipment. These aircraft may
fairly “high-time” fliers when they arrived in South-     be single-seat (pilot only), or may be crewed by a
east Asia, although the younger ones might arrive         pilot and a weapons system officer. Forward air
with only 200 to 300 flying hours. The professional       controllers will coordinate some strikes and will


180
                                                                                  U.S. Air Force Combat Psychiatry


identify targets. Reconnaissance pilots will take          initial motivation to fly, a strong ego, and well-
photographs before and after air strikes to use in         developed denial skills to defend against personal
planning missions and to assess damage. Tactical           fear and sense of mortality. Magical thinking and
helicopter pilots may fly special missions, inserting      superstition may also be observed. Deaths are
or extracting troops, rescuing downed fliers, and          briefly acknowledged and then consciously sup-
carrying patients to the rear. Tactical transport          pressed in order to continue the squadron mission.
crews will airlift supplies, delivering them from the         Support of tactical fliers in the combat arena has
air by parachute or by special low-altitude extrac-        been similar during each of America’s last four
tion systems, or by landing to off-load in the con-        wars. Airfields have been reasonably free from
ventional way.                                             enemy attack in most cases, and fliers have lived in
   These and other tactical aircrew will be exposed        a base environment in which a great deal of effort
to specific dangers: ground-based small-arms fire,         has been devoted to their personal comfort and
surface-to-air missiles, conventional antiaircraft fire,   support. Nourishing meals available 24 hours a
and attack by enemy aircraft. The threat of chemical       day, specified crew-rest periods with exceptions
or biological warfare at base or just prior to takeoff     granted only by higher headquarters, personal
may act as a stress multiplier. Tactical missions          health care and welfare overseen by a squadron
tend to be fairly short, lasting from 1 to 4 hours, and    flight surgeon and his staff, quiet quarters that are
thus the aircrew may fly two, three, or even four          air-conditioned or heated—all these amenities and
missions in a day. Israeli fighter pilots in the 1967      more are provided by regulation, if not always in
war, expected to fly an average of three or four           fact.
sorties a day, flew an average of seven a day; some           Transport crews will be affected by some but not
pilots flew as many as 10.6 The dangers of such            all of these considerations, with added stresses de-
missions may vary considerably; some are the pro-          riving from their particular mission profiles. Tacti-
verbial “piece of cake” while others may be ex-            cal transport aircraft, particularly the C-130s and
tremely lethal. At times the danger—or lack of             the cargo helicopters, may be used for resupply
danger—will be familiar to the fliers. Other mis-          under fire of troops and bases, or of besieged civil-
sions or target areas will be known as unpredict-          ians receiving humanitarian aid. The resupply of
able, thus adding the considerable stress of uncer-        the besieged Khe Sanh defenders during the Viet-
tainty to all the other stresses of combat.                nam conflict is an example of such an endeavor.
   For the tactical fighter pilot, the success both of     Not only the pilots’ skills count here, but also those
air-to-air and air-to-ground missions depends on           of other aircrew members and even the ground
personal skills. Dual-crewed aircraft such as the F-       crew who must help off-load the aircraft under fire.
15E integrate the weapons system officer into the          The stress of flying in such a large, unarmored,
equation, but the skill of the pilot is still paramount.   defenseless “sitting duck” target during the ap-
Whether a pilot lives or dies in such combat de-           proach, landing, taxiing, off-loading, takeoff, and
pends upon personal prowess to a degree that may           departure under fire is enormous, especially be-
be unique in modern warfare.                               cause each of these activities must take place in
   Such a pilot must have supreme confidence in            a location known in advance to enemy gunners,
personal skills and a strong narcissistic component        whose weapons may already be ranged and sighted
recognized when he is selected for training. This          in. Transport crews may be called upon to make a
narcissism, an almost magical sense of personal            half-dozen or more landings during a day’s mis-
invulnerability, is nourished by the U.S. Air Force’s      sions, and their vulnerability to ground fire leads
system of training. It displays itself in the “typical     to a constant state of arousal; there are only
fighter pilot personality” that is immediately ap-         limited options to counter such fire when it occurs.
parent to the most casual observer of human nature.        Flying such missions when attack by enemy air-
This pilot’s effectiveness in battle depends on bold-      craft is possible will add to the strain. This was
ness, self-sufficiency, situational awareness, and an      exemplified by the slaughter in April 1943 when
internal locus of control. Such pilots may depend to       American fighters caught about 100 JU-52 trans-
some extent upon a wingman and a squadron for              ports carrying troops to reinforce the German Army
support, but deep in their hearts, each knows that         in Tunisia, shooting down 52 of them over the
one can ultimately depend only upon oneself. Main-         Mediterranean Sea. 7
tenance of this narcissism in the face of mounting            Strategic bomber crews may face different perils.
losses to the enemy of friends—fliers who were             Penetration of enemy defenses depends upon sur-
known to be skillful and brave—requires a healthy          prise, electronics countermeasures, such techno-


                                                                                                              181
War Psychiatry


logical advances as the cruise missile, and whatever      medicine.13 Through the years, it has had about as
escort aircraft may be used. The venerable B-52s are      many synonyms as has combat fatigue itself:
neither fast nor maneuverable when compared with          aeroneurosis, chronic fatigue, staleness, aviator’s
air-defense aircraft or with surface-to-air missiles.     neurasthenia, flying phobia, and others.14 The crux
Presumably, their airfields will be far enough from       of the problem appears to be that humans have an
the conflict on the ground to be safe from attack         instinctive fear of falling, which is overcome to
with conventional arms and will be vulnerable only        some extent during the early years of muscular
to long-range missiles, to enemy strategic attacks,       development as children learn to control their envi-
or to saboteurs.                                          ronments by their own efforts. Some youngsters
   Strategic bomber crews had the highest propor-         conceive of flying as the ultimate mastery and power
tion of combat losses among fliers in 1944, 7.7 per       (“Put out my hand, and touched the face of God”)
1,000 hours flown, compared to light bombers (3.4)        and thus present themselves for flying training
and fighters (1.1).8(p10) The B-52 experience in Viet-    saying, “I’ve wanted to fly as long as I can remem-
nam shows the difference in attacking targets with        ber” (ie, since age 5 or so).
and without air defense. Between June 1965 and
August 1973, the Strategic Air Command flew more            The central unifying force through the Air Corps is
than 124,000 B-52 sorties against targets in South-         the intangible yet powerful devotion to aircraft felt
east Asia, losing 29 B-52s altogether. All of the 17 B-     in different degrees by all its members….Planes
                                                            receive an almost libidinal investment of inter-
52s lost to hostile fire were shot down over North
                                                            est…the aircraft became anthropomorphized
Vietnam; none were lost to hostile fire over the            ….This devotion and enthusiasm for aircraft is of
lightly-defended South. (The other 12 were lost             such a compelling force that it to some extent
through accidents or midair collisions.)9                   supercedes military discipline. 1(p99–101)
   Fifteen of these 17 were shot down during the 11
days of Operation Linebacker II, when some 740                Other fliers may be motivated less by such a
sorties were flown against targets in Hanoi and           long-lived desire than by their perception of flying
Haiphong in December 1972.9 These B-52s were              as a way to enhance a career in the U.S. Air Force. In
based on Guam and in Thailand, secure from enemy          other words, motivation to fly may be largely emo-
attack, but the cumulative and rapid losses caused        tional, or it may be largely cognitive. 11 Most fliers
considerable concern among the fliers involved.           are probably motivated by some mixture of the two,
According to their flight surgeon, this concern mani-     and fliers at either end of the motivational spectrum
fested itself as a rapid and forceful statement up the    may serve complete careers in the cockpit, honor-
chain of command of the need to change tactics over       ably and well. Yet the underlying instinct to avoid
the target, a statement that quickly led to the needed    heights persists. Many pilots joke about being mildly
changes.10                                                afraid of heights in the ordinary sense, but show no
   In addition to the operational factors already         carryover of this fear to flying in their aircraft.
mentioned, three other matters distinguish the sup-       Through their desire to fly, they deny, suppress, or
port of U.S. Air Force fliers in combat. One is the       repress their primitive anxiety about heights. “You
similarity between the “fear of flying” syndrome,         can get killed just crossing the street” is their com-
which may occur in peace as well as in wartime, and       mon response to questions about their view of the
the signs and symptoms usually associated with            dangers of flying.
combat fatigue.11 The second is the use of rest as a          Still, the dangers are real and, with continued
primary preventive and therapeutic measure. The           exposure to the world of flying, a military flier’s
third is the specific relationship between the fliers     ability to deny them is slowly eroded. “There are
and the flight surgeon who is directly responsible        old pilots, and there are bold pilots,” goes the old
for furnishing their preventive health measures and       saw, “but there are no old, bold pilots.” Youthful
medical support. These three factors will be consid-      enthusiasm is tempered by maturity and the lessons
ered separately.                                          of experience. “Flying is 99% boredom and 1% pure
                                                          terror.” The jokes and sayings reflect the realities.
“Fear of Flying” and Combat Fatigue                       As youthful fliers begin to comprehend the reali-
                                                          ties, the strength of their motivation is tested. When
  “Fear of flying” has been called a symptom with-        it is flawed, it fails early.
out a disease.12 Recognized early in the history of           A few fliers are driven by psychologically
powered flight, it was the subject of two of the nine     overdetermined factors—an anxiety-driven need to
chapters in one of the first textbooks of aviation        “prove” something to someone (usually father) may


182
                                                                                 U.S. Air Force Combat Psychiatry


be seen in some. When success is near, the primitive         Estimates of the incidence of such cases of fear of
symbolism of succeeding (defeating father) arouses        flying (the U.S. Air Force term for this symptom in
basic anxieties that interfere with successful flying,    the absence of psychiatric disease) are difficult
and the flier either quits, fails through “lack of         because they are not routinely tabulated through
adaptation,” or presents with disabling medical or        medical channels, but the best guess was about
psychiatric symptoms.                                     seven cases per year during the period from 1975 to
   Others fail in less spectacular ways, with symp-       1984.16 Thus, fear of flying may be regarded as a
toms that are similar to the effects of combat on         peacetime paradigm for combat fatigue, admittedly
infantry. They may be restless and irritable, with        on a much smaller scale. Such cases are difficult to
nerves on edge. They may have insomnia, and               handle in the local fishbowl environment of the
whatever sleep comes is light or fitful, disturbed by     squadron.
unpleasant dreams or actual nightmares. They may             The author, in his past capacity as a psychiatrist
report profound dread or apprehension about fly-          at the U.S. Air Force School of Aerospace Medicine,
ing, with tremors, sweating, and palpitations. They       has worked with flight surgeons in the field who
may have difficulty with concentration, begin to          were wrestling with the problem of a flier—and
experience airsickness, or report that they are so        friend—who developed some manifestations of fear
preoccupied with their fears that they must concen-       of flying. Such fliers were not mentally ill, in which
trate on not activating the ejection seat in normal       case they would be medically grounded; they had
flight. Symptoms may be of disabling and phobic           simply lost their motivation to fly and presented
proportions, or they may be mild and only slightly        themselves as no longer safe. Every instinct cries
distressing. At times, symptoms may have begun            out against requiring someone to fly who no longer
with a specific and clearly recognized traumatic event,   wants to do so; such a flier will clearly be unsafe,
such as a personal close call or the crash of a friend.   and requiring one either to fly against his will, or to
Other cases may begin as the accumulation of stresses     face possible adverse administrative action seems
which gradually and finally overcome a strong             the height of folly. How much more difficult, then,
motivation to fly and the flier comes to the reluctant    will it be for a flight surgeon to take similar action
realization that the joy is gone from flying. 11          to require a flier to fly into combat? Yet this is
   Some fearful fliers, having no conscious recogni-      exactly the kind of judgment required, to extract
tion of their underlying anxiety, may also present        from each flier every possible combat mission be-
with psychophysiologic disorders. Headaches, va-          fore allowing him to step down to nonflying duties
sovagal syncope, obscure visual problems, gas-            or to return to noncombat flying. Thus the role of
trointestinal upsets, and many other systemic com-        the flight surgeon in maintaining the operational
plaints may be presented for diagnosis. The astute        strength of the squadron must be considered.
clinician may note that the chief complaint is pre-
sented in a framework of “I’d like to fly, but … “        The Use of Rest for Prevention and Treatment
which indicates that the flier has linked the symp-
toms with a hoped-for result of not flying. This              As fatigue is a primary underlying pathologic
attitude distinguishes this particular flier from the     process, rest is a prime restorative. Rest may be
other fliers who complain about possibly being            used in several ways that may be stated as “rules,”
grounded, or conceal their symptoms, fearing that         if those responsible understand the need for excep-
they will lose their flying status.11                     tions in individual cases.
   All this and more occurs in military flying in
times of peace. U.S. Air Force doctrine15 calls for       Crew Rest
evaluation to determine whether medical or psychi-
atric disease is present. If so, medical grounding           The major problem with research in this area
and treatment are in order. If no physical or mental      derives from the lack of any agreed-upon objective
disease is present, the flier is returned to his or her   measure of fatigue. Many biochemical and behav-
commander as medically cleared to fly. Further            ioral factors have been studied in this regard, and
refusal to fly is handled administratively and may        recently such manifestations as characteristics of
result in simple reassignment to ground duties (es-       eye blinks, voice stress analysis, and rate of mis-
pecially if the precipitating event is acknowledged       takes in flight simulators have been studied to see if
to be catastrophic and the resultant fear under-          they could be quantified. However, the final “gold
standable to all), or may involve adverse adminis-        standard” is the flier’s subjective appraisal of his
trative action.                                           condition. Further adding to the complexity are the


                                                                                                             183
War Psychiatry


numerous combinations of work-rest-sleep cycles            that were not relieved by a single day’s rest and
available.                                                 “tiredness” as the acute effects that were. His prac-
   Hartman 17 reviewed some of the current litera-         tical conclusions, listed below, are applicable to all
ture and discussed some of the differences between         flying circumstances, regardless of their complexi-
various kinds of missions: tactical, strategic, airlift,   ties, because they derive from the subjective effect
and ground-based control centers. Briefly, his opin-       of daily stress, yet allow for a reasonably objective
ions are:                                                  aeromedical judgment.

  • Tactical missions involve brief multiple sor-            • Understand that crew duty limitations are
    ties in one day. The special stresses include              due to variables and must be established by
    high workload environments, highly haz-                    experience and precedent, as well as by local
    ardous missions, acute fatigue effects (the                needs. Be flexible.
    physical results of pulling high-G loading,              • With good motivation and good support,
    for instance), and rapidly cumulative chronic              aircrew members can exceed normal crew-
    fatigue. Circadian factors are also involved               rest requirements for at least 2 months.
    in all-weather aircraft.                                 • Routine aeromedical surveillance suffices for
  • Strategic missions (bombers, AWACS [Air-                   the first month. Extra surveillance (defined
    borne Warning and Control System aircraft],                as the flight surgeon’s meeting each air-
    tankers) may involve longer missions, in                   crew member before each takeoff and after
    some cases extending beyond 24 hours. In-                  each landing) is necessary after that.
    flight work/rest cycles become a factor, as              • Assess fatigue frequently. One may do this
    do reasonable in-flight rest facilities, nutri-            by daily contact; occasional anonymous
    tion, and the different jobs performed by                  questionnaires; aircrew briefings on fatigue
    flight crew and mission crew in AWACS and                  factors; assuring the best available crew-rest
    command post aircraft.                                     quarters, food, and in-flight provisions; and
  • Airlift missions may involve multiple short                establishing rapport with aircrew and su-
    sorties (tactical) or long-range missions cross-           pervisors.
    ing many time zones (strategic). There is                • The decision to restrict an aircrew member
    more scientific information on such flights                temporarily from flying because of fatigue
    and also on the use of multiple crews for one              should be made jointly by the flight surgeon,
    aircraft. One particular problem involves                  the operations officer, and the aircrew mem-
    “ramp-pounding,” a pernicious and frus-                    ber. Remember that grounding one flier
    trating form of nonwork experienced while                  means more work for another.
    waiting for an aircraft to be loaded, repairs            • Aircrew members should be relieved of all
    to be made, passengers to be rounded up, or                additional duties, so as to direct all their
    during any of the many other occurrences                   energies to the flying mission.
    that may delay an aircraft for minutes, hours,           • Bend every effort toward flying the sched-
    or days. Circadian stresses cause a small but              ule as scheduled; avoid needless changes,
    appreciable decrement in performance, but                  delays, and excessive ramp time. Quarters
    may be magnified by other stresses. The                    near the flight line (but not so near as to
    conventional wisdom of the many studies in                 cause the crews to be kept awake by the
    this area is reflected in U.S. Air Force crew-             noise) reduce wasted travel time.
    rest regulations.                                        • Incentive pay for extra effort is a strong
  • Ground-based centers (command posts, tow-                  motivating factor for paramilitary flying.
    ers, radar sites, and the like) may have unique
    stresses based on workload, the facility it-              Each U.S. Air Force major air command has its
    self, its location, its dangers, and other un-         own crew-rest regulations. Variables that contrib-
    foreseen factors.                                      ute to these regulations include size of crews, type
                                                           of aircraft, flying hours each day, hours of rest
   Rayman18 reported on a heavy flying schedule            between flights, hours of nonflying duty, and hours
for C-130 crews during a 2-month emergency airlift.        flown each month. All of these factors may be
The crews flew almost 180 hours per month (the             waived if the exigencies of the situation demand it,
usual limit is 125 h), involving three or four shuttles    but the wise commander will consult with the flight
per day. He defined “fatigue” as cumulative effects        surgeon before doing so, and the wise flight sur-


184
                                                                                  U.S. Air Force Combat Psychiatry


geon will look at the fliers on an individual basis          There is one specific observation, based on the
before giving advice on the subject. The difference       author’s experiences as a flight surgeon, that may
between granting a crew-rest waiver for a single-         not be quite as intuitive as “Alcohol abuse is bad for
seat fighter mission and a similar waiver for a trans-    flying safety,” or “Alcoholics should be identified,
port mission where one pilot may take a nap in a          grounded, and treated.” That observation stems
bunk during the mission is immediately apparent,          from the use of alcohol as a sedative. If a flier takes
even in principle.                                        a couple of drinks late in the evening to help get to
   The literature is specific, however, that one must     sleep, that amount of alcohol may be seen as benign
consider more than the hours of crew rest available.      and insignificant. The flier may, however, go to
Sleep disturbances are a consistent early symptom         sleep easily, dream extravagantly, and awaken feel-
of cumulative combat stress in fliers, and thus the       ing refreshed and invigorated. Glancing at the
flight surgeon must discuss the quality of their          clock, the flier notes that it’s only 0130; 2 hours of
sleep with individual fliers. If sleep is disturbed by    sleep have passed, not a whole night, and there’s
nightmares or insomnia to the point that the flier        plenty of time left to sleep after all. But now the flier
remains as tired upon awakening as when going to          can’t go back to sleep, or sleeps only fitfully, with
bed, the cumulative fatigue after 2 or 3 days may         many awakenings, and much punching of the pil-
well render him or her ineffective at best and unsafe     low. Finally, perhaps about 0430, the flier does fall
at worst.                                                 hard asleep for an hour, only to be awakened at 0530
   The social role of alcohol in the ambiance of          to prepare for the day’s flying. A couple of cups of
combat fliers deserves brief consideration. The           coffee help, although the flier may feel a bit dulled
drinking habits of aircrew are the stuff of legends.      all day.
The stories, the songs, the customs, the supersti-           This is not really a big deal, once. But repeat that
tions, the very social fabric of the squadrons of old     drinking pattern for a week or two, and the flier’s
are celebrated and, in the opinion of this author,        edge is definitely dulled. Fatigued, he continues to
reasonably accurately presented in plays, movies,         take a couple of late evening drinks as a sedative,
books, television, and folklore. For more than 30         not getting drunk, but interfering with the normal
years to which the author can attest, flight surgeons     sleep cycles on a chronic basis.
in training have been urged to go to the bar with            The giveaway is the extravagant dreaming early
“their” fliers in order to meet them socially, to learn   in the night’s sleep. Alcohol may produce a self-
what’s really going on, to find out what makes them       sustaining dysregulation of the normal sleep cycle.
tick. From the 1940s through the 1970s, at least, the     Its effects are complex, but the end result is a dimi-
Officers Club bar was a center of aviation society.       nution of concentration and memory, and an in-
   These habits are changing as American society          crease in fatigue, anxiety, and irritability. These
changes, as the realities of working spouses and          changes can persist even after the drug is no longer
modern family dynamics have affected the social           present.20,21
structures of flying squadrons, and as the incredible        It is this author’s opinion that aircrew should
demands of modern military aviation have demon-           be taught this signal: if they dream and awaken
strated that “you cannot hoot with the owls if you        early in the night, they’ve had too much to drink
want to fly with the eagles.” Still, the tendency of      and should change their pattern. Again, it’s no big
many fliers to treat their fatigue symptoms with alco-    deal once in a while, but common sense indicates
hol has been well-observed in the past, and will prob-    that interfering with the normal sleep cycle on a
ably continue in the future. Many books attest to this.   recurrent basis is not good for the flier who must
Gene Basel’s Pak Six19 contains repeated references to    be sharp and prepared for anything that combat
bar conversations, and the personal experiences of        flying (or, for that matter, ordinary flying) should
the author’s generation of flight surgeons in South-      bring along.
east Asia corroborate Basel’s writings. One does             What should the flight surgeon do to help air-
not need a postgraduate education to understand           crew sleep? Should hypnotic agents be allowed?
that alcohol abuse is dangerous in such circum-           The general rule is that one should not use hypnotic
stances. It is not necessary to belabor the point         agents unless, using mature and informed judg-
beyond observing that drinking serves several pur-        ment, one decides that it is less dangerous to use
poses: as a self-administered and socially accept-        them than it is not to use them. The British used 20
able psychotropic medication, as a social lubricant       mg of temazepam (Restoril) as a hypnotic for fliers
to allow personal conversation among somewhat             during the South Atlantic (Falkland Islands) cam-
emotionally distant people, and as a sedative.            paign. Group Captain Michael Fisher commented:


                                                                                                               185
War Psychiatry


  We were particularly impressed by a short-acting         sion was made “to make sure that what we were
  drug for ensuring our aircrews adequate sleep be-        doing was correct.”25(p3)
  fore flights. Very often they were having to get            Lyons and French et al26 published an aero-medi-
  their sleep at unusual hours of the day under very       cally-oriented review of modafinil, a nonam-
  noisy, cramped conditions. [Temazepam] is rap-
                                                           phetamine stimulant developed in France. Unlike
  idly excreted, though it’s rapid in its effect. People
  were able to sleep and wake up and go flying             the amphetamines, it apparently has a low abuse
  without any sort of hangover effect. Aircrew even-       potential. It also has minimal peripheral side ef-
  tually were permitted to fly within only six hours of    fects at therapeutic doses. The authors concluded
  taking the drug.22(p10)                                  that this medication might be an ideal replacement
                                                           for amphetamines in short-term operations in which
   The decision to use temazepam during the South          fatigue might be a limiting factor. They recommend
Atlantic campaign was based upon British recogni-          further study of modafinil, or a similar alpha 1
tion of demanding operational workloads, the need          receptor agonist.
for extension of permissible flying hours, and the            In the opinion of this author, sedative and stimu-
potential for these conditions to continue for sev-        lant medications should only be used when, in
eral weeks. Their experience included transport            the best judgment of the most operationally
crews logging up to 150 hours in 24 days, with             experienced line and medical authorities avail-
single bomber missions lasting up to 28 hours. Even        able, it is more dangerous not to use them than it
without the use of test doses, they encountered no         is to use them. Further, they should be used only
problems with this medication.23                           by fliers who have been previously ground-tested,
   Temazepam is a short-acting benzodiazepine              and who (a) have had no untoward effects, (b) are
most active 20 to 40 minutes after oral administra-        familiar with their primary effects, and (c) wish to
tion, with peak effect in 2 to 3 hours, and a biphasic     use them.
half-life with a 30-minute short peak and a 10-hour           Also in the author’s opinion, tactical pilots—
terminal half-life. Temazepam does not affect rapid        especially those who fly single-seat aircraft—should
eye movement (REM) sleep and somewhat decreases            be ground-tested regardless of the current policy
slow wave sleep. Exigencies of combat may dictate          allowing or not allowing their use in flight, because
its use, or the use of a similar short-acting benzodi-     such policies can change quickly, and the circum-
azepine, but only after ground testing by adminis-         stances mandating the change may not allow time
tration to the individual flier on a night prior to a      for proper ground-testing.
nonflying day, in order to detect any unusual or              Ground-testing is carried out in the following
idiosyncratic effects on the ground rather than in         manner. Information about the medications to be
flight. A new, nonbenzodiazepine hypnotic,                 used is gathered by the flight surgeon from the most
zolpidem tartrate (Ambien), may offer some advan-          up-to-date sources available. A questionnaire is
tages over benzodiazepines(BDZs). It is important          developed that inquires specifically after primary
to remember that many BDZs induce a retrograde             effects, secondary (“side”) effects, and any signifi-
amnesia that could interfere with last minute in-          cant idiosyncratic reactions. Open-ended and
struction before sleep.24                                  nondirective questions are added for anything else
   Amphetamines have been used by pilots during            the flier may have noticed, desirable or undesirable.
deployments and on prolonged combat missions                  On a Friday when the flier will dependably not
for several decades. Most recently fighter pilots          be flying until the following Monday, he (alone, or
deploying from the United States to Saudi Arabia           in a group briefing) is informed about the ground-
were permitted their use, and 5 mg dextroamphet-           test and its purposes. Alcohol is specifically forbid-
amine tablets were made available to tactical pilots       den during the test, and, needless to say, the flier
for combat air patrol missions. Of 464 fighter pilots      should take no other medications during the test.
surveyed by the Tactical Air Command after the                At the agreed-upon hour (say, 2200), the flier
Persian Gulf War, 65% said they used amphet-               takes the sedative medication and retires 1 hour
amines during Operation Desert Shield (the mobili-         later. Upon awakening the next morning, the flier
zation phase of the war), and 57% during Operation         notes the quality and quantity of sleep, and fills out
Desert Storm (the combat phase of the war). The            the questionnaire regarding medication effects.
U.S. Air Force subsequently decided to reevaluate             If all is well, the flier then takes the first dose of
this policy, and authorization for their use was           stimulant (at, say, 0800). Four hours later, the flier
withdrawn effective 13 March 1992. No untoward             notes any reactions on the questionnaire. If all is
occurrences or reactions were reported, but a deci-        well, the flier then takes the second dose. Four


186
                                                                                   U.S. Air Force Combat Psychiatry


hours subsequent to that, the flier notes any further       more release of anxiety for fliers than will an indi-
observations. He uses no further medications, and           vidual day off. Exigencies of combat, however,
no alcohol, that Saturday evening.                          rarely allow such a policy.
   Sunday, no medications are taken.                            The author’s conversations with Southeast Asia
   Early Monday, the flier sees the flight surgeon (or      combat fliers have underscored the value of trust-
vice versa), individually goes over his question-           ing the flier’s own judgment in determining when
naire, and confirms its information. The flight sur-        one should not fly a given mission because of fa-
geon asks any follow-up questions indicated.                tigue. A flier in a well-run squadron may be al-
   The flier and the flight surgeon both sign the           lowed to take his name off the flying schedule every
questionnaire, which is placed in the flier’s medical       now and then without question if that flier feels not
records. The bottom line (literally) is that the flier is   fit to fly that day. Clearly, any flier whose overuse
signed off as ground-tested and approved for the            of such a privilege points to an unwillingness to do
supervised use of the two medications tested while          his share should be evaluated by the operations
flying, or the flier is not approved for their use.         officer or flight surgeon. Giving the fliers a bit more
   Two points should be stressed. First, not being          control, balanced by the self-policing action of a
approved for their use does not disqualify the flier        well-integrated squadron, may enhance morale and
for anything—any mission, any flight, any profile.          delay combat fatigue.
Second, even if approved for their use, the actual
choice to use medications is always left up to the          Rest and Recreation
flier. The flight surgeon may only offer to make
them available for certain missions. No one—com-                A prolonged combat tour should be split by a 1-
mander, flight surgeon, or anyone else—may order            week rest-and-recreation (“R and R”) break. Real-
the flier to take them. The flier is now familiar with      istic flight surgeons recognized during World War
the medications, and may make up his own mind               II, and again 20 years later in Southeast Asia , that
about their use.                                            fliers do not necessarily rest on R and R. It is wise
                                                            not to schedule them to fly for 1 day after they
The Interval Between Missions                               return from R and R, but to use this period to
                                                            accomplish ground training or administrative du-
   World War II flight surgeon reports generally            ties.29 Some fliers will object to time off, wishing to
agreed that missions should not be flown on more            hurry through their tour and get home. If the rest
than 3 consecutive days.27,28 All involved were             causes more stress than it relieves, such a schedule
aware that standing alert was as wearing as flying          may be modified a bit. In general, though, its
an actual mission, if not more so, in that there was        beneficial effects will be obvious throughout the
no release of anxiety through action. Further, flight       squadron.
surgeons reported that the period between learning
about a mission and flying the mission was the most         Tour Length
stressful. Weather holds, slipped takeoff times, and
scrubbed missions were extremely nerve-wracking                The length of a combat tour is a decision that
and, at least from the point of view of generating          should be made by line commanders at the highest
combat fatigue, should be counted as a mission              level. It is discussed here because of its immense
day.28                                                      importance to fliers’ morale and its epidemiologic
   A day off must be off, with no duty requirements         role in shaping the patterns of susceptibility to
whatsoever. Further, the flier should know about it         combat fatigue.
ahead of time, so that its relaxation may be antici-           In World War II, the tour length for heavy and
pated as a short-term goal. Specific recommenda-            medium bomber crews depended upon the number
tions for time off in the Eighth Air Force area were        of missions flown, with the “magic number” being
10 to 15 hours of operational flying per week, 24           predicated on giving each aircrew member a better-
hours of leave per week, 48 hours of leave every 2          than-even chance of surviving the tour. The Twelfth
weeks, and 7 days of leave per 6 weeks.29 Grinker           Air Force determined “the maximum effort of the
and Spiegel commented on the strength of the group          average flier,” essentially based upon attrition rates,
identification among fliers, that there was little          to be based on a 60% to 80% chance of completing a
relaxation available to a flier on the ground if his        tour, if the military situation permitted.8 Attaining
friends—or especially his crew—were flying.1 Thus,          the desired number of missions or flying hours
if possible, a wing stand down will provide much            became a valued short-term goal for fliers, and the


                                                                                                               187
War Psychiatry


demoralizing effects of shifting the magic number,           At this point, if not removed from operational fly-
always upward, furnished one of the themes for the           ing, the flier would either experience such severe
novel Catch-22. 30 The uncertainties of when person-         symptoms as to develop full-blown combat fatigue,
nel deployed for the Persian Gulf War would re-              or might become so ineffective as to be at special
turn, and the effects of those uncertainties on mo-          risk in combat.
rale, recapitulated this theme.
   The knowledge that the combat tour has a finite           The Role of the Flight Surgeon
duration becomes more important in maintaining
tolerance of the growing anxiety, and                           As this discussion has demonstrated, fliers are
                                                             different from other combat troops. This difference
  [E]xperience…repeatedly demonstrated that this             extends to their medical support, which is provided
  factor has been responsible for many individuals           on a highly personal and individualized basis by
  achieving the expected level of operational mis-           the squadron flight surgeon. Thus, morale support
  sions. Without this certainty of relief, the ego in
                                                             and first-echelon mental health care may well be
  many instances would have succumbed much
  sooner, and an appreciable decrease in the number          furnished by the flight surgeon rather than by en-
  of combat missions flown by available personnel            listed medical technicians or by “buddy care” from
  would have resulted. 31(p9)                                peers. The flight surgeon is an intrinsic part of the
                                                             squadron’s internal support system and should be
   How long should such a tour be? The answer                present on a day-to-day basis to furnish primary
depends on many factors: (a) the type and severity           medical care and to advise the squadron commander
of the flying operation, (b) losses to combat and            on matters of preventive medicine, including mat-
accidents, (c) the physical conditions of the bases,         ters of morale.
and (d) the realities of the combat needs. However,             Flight surgeons have only a few tools with which
once a tour is announced, it should be changed only          to slow the inevitable progress of combat fatigue in
for absolutely critical reasons, and such a change           fliers, but these are powerful therapeutic agents if
should be accompanied by a responsible explana-              properly used. Above all, flight surgeons must
tion to the fliers of the exigencies leading to the          understand that combat fatigue is a normal reaction
decision.                                                    of a normal group of people to a dreadfully abnor-
   From a pragmatic point of view, a combat tour,            mal situation. As a normal reaction, combat fatigue
usually measured in number of missions, should               cannot be prevented or avoided, but may be delayed.
allow each flier at least a better-than-50% chance of        The frame of reference must not be “Does anyone in
going home in one piece. In the author’s opinion,            my squadron have combat fatigue?” but rather, “I
odds less than 50% should apply only in last-ditch           must understand how each of my fliers is dealing
efforts, such as in the Philippines in 1942.                 with this stress and watch for defenses that are
   Completing a combat tour in prior wars was not            crumbling.” With this attitude, the flight surgeon is
without a striking psychological and psychosomatic           ready to support the flying mission by helping each
cost to the fliers. The prolonged tension led to             flier to fly as long and as effectively as possible.
progressive loss of normal personality features.
Aircrew became quieter, more serious and cau-                Combat Flying for Flight Surgeons
tious, sometimes seclusive and depressed, with loss
of interest in other pursuits, loss of spontaneity, and         The flight surgeon must fly combat missions, if at
a decreased love of flying. Sleep disturbances in-           all possible. This sets in motion a complex set of
cluded insomnia and nightmares, with battle scenes           tried-and-true interpersonal dynamics that pay off
a frequent theme. Fliers would have little appetite          with several specific benefits.27(p81)
for food, but their intake of coffee, cigarettes, and           Understanding the Mission. Flying the mission
alcohol would increase. Their increased tension              will enable flight surgeons to understand the stresses
would also be manifested as irritability, jumpiness,         of combat at a visceral level. By thoughtful reflec-
and tremors. Fantasies of omnipotence and invul-             tions upon their own reactions, a level of under-
nerability would be replaced by obsessive fantasies          standing develops that would not otherwise be
of death and ruminations about lost friends. Physi-          possible. Good flight surgeons identify strongly
cal fatigue in periods of prolonged or intense flying        with “my” squadrons and “my” fliers. The use of
would accelerate this process and might lead to a            the possessive pronoun is universal among the
clearly visible decline in a flier’s ability to fly and to   best flight surgeons, who are much like fliers in
fight, which the whole squadron would recognize.             their own personalities. Yet they must recognize


188
                                                                                  U.S. Air Force Combat Psychiatry


that they are not pilots, navigators, electronic war-     ity structure, buttressed by professional skill, and a
fare operators, or gunners. Overidentification can        strong personal value system.31
lead to prostitution of medical ethics and to fuzzy          Intercession. The flight surgeon who flies com-
professional thinking. It can also lead flight sur-       bat missions can see firsthand the reactions of the
geons to think that flying, rather than caring for        troops to real-life combat stress, can observe their
the fliers, is their own mission. How much should         discipline, sees the fliers in vivo, as it were, and can
a flight surgeon fly? That depends on the aircraft,       then use the information to keep the commander
the mission profiles, and the press of other duties.      informed about morale. These words may look a bit
In general, based on the author’s experience in           cynical in print, but the matter is quite practical. As
Vietnam, a flight surgeon should log not less than        a flight surgeon with an Air Commando wing in
one nor more than two missions per week during            Vietnam, the author flew with enough different
duty hours, except in support of aeromedical              crews to appreciate how the fliers behaved in rou-
evacuation. After-hours flights should be nego-           tine flight and in combat. He carefully avoided any
tiable with the squadron or wing commanders, de-          actions that smacked of “informing” on specific
pending upon the flight surgeon’s being able to           fliers, but was able to keep the wing commander up
sleep normally and to be fully functional in all          to date on how well his fliers followed crew rest
medical duties.                                           procedures, in-flight safety measures, and general
   Credibility. By flying the squadron mission, the       flight discipline. Being known and trusted both by
flight surgeon establishes credibility. The fliers        the commander and the fliers, the author was able
know that the flight surgeon flies and the flight         to explain and interpret each to the other, infor-
surgeon can “speak the language” without being            mally and nonthreateningly. He represented a way
awkward or pretentious. More importantly, the             by which petty gripes and problems could be taken
flight surgeon can discuss his own personal fears,        outside the chain of command to the one who could
anxieties, and reactions in such a way as to give         fix things, in matters that might have led to hard
these strong (and often unacknowledged) feelings a        feelings if official action had been necessary. The
legitimacy of expression. Such modeling of open-          credible flight surgeon thus may become a sort of
ness is quite healthy. A flier who is terrified, and      ombudsman within the squadron and the wing,
who is also ashamed of that terror, may experience        able to get things done that need to be done, and to
considerable relief in laughing with the flight sur-      interpret—and occasionally to soften—policies im-
geon who says “I thought I was going to wet my            posed from above. Such an outlet, serving also as a
pants on that one!” Other fliers may have had             safety valve, may contribute considerably to the
precisely the same feeling but were unwilling to          fliers’ morale.
admit it, each feeling like the only coward in a
group of heroes.                                          Ventilation, Observation, and Early Intervention
   Acceptance. The flight surgeon, by flying and by
being accepted by the fliers as “one of us,” assumes         In common with combat troops in other situa-
a symbolic importance within the squadron, per-           tions, some psychological relief may be afforded
haps second only to that of its command echelon.          aircrew by allowing them to ventilate after missions
Such a flight surgeon is a person whose judgment is       and by participating in group activities. These
trusted, a confidant of the commander and the op-         functions are served to some extent by the intelli-
erations officer. Understanding, tolerant, noncriti-      gence debriefing that takes place after combat mis-
cal, realistic, yet firmly committed to the squadron      sions for fighter and bomber crews and by the
goals, the flight surgeon develops an image as an         natural tendency of crews to gather at the bar at the
important person, one whose good opinion the flier        end of a day’s flying. Again, excessive drinking is
values. Giving sympathy, affection, and protection        a danger to be guarded against, but such activities
to the fliers, still the flight surgeon expects of them   in moderation have a cathartic and mutually sup-
dedication, perseverance, and a willingness to con-       portive role for the squadron and are of real value in
tinue the mission. The excellent flight surgeon does      the world of the flier. If conditions allow, an intra-
not overidentify with the squadron, does not fear         mural sports program (softball, volleyball) has a
their rejection (a healthy personal sense of self-        similar value, as well as serving as a physical outlet.
esteem comes from within), and deals adaptively           Such activities must be voluntary, however. Some
with personal internal conflicts between protective       troops can lose themselves in reading, and a library
drives and the need to keep the fliers flying even if     or other source of books and magazines is a useful
some die. This requires a well-integrated personal-       asset. Informal reports from the Persian Gulf War


                                                                                                              189
War Psychiatry


also indicate the value of hand-held computer              invincible, potent one. Some magical feeling of
games. The value of mail from home cannot be               immunity and omnipotence would also help carry
overstated.                                                the flier along, strengthening ego defenses against
   The flight surgeon may also keep in touch with          reality, because many elements in aerial warfare are
the reactions of individual fliers to the combat situ-     truly beyond anyone’s ability to control. 1 Denial of
ation. Any group of fliers reflects the strain of          these realities (“They’ll never get me!”) would bol-
combat, and the flight surgeon will have to become         ster such magical fantasies for a while, but the
acquainted with the ways that fliers show the strain.      accumulation of combat experience would gradu-
Most of the literature on combat fatigue speaks of         ally erode this fantasied invulnerability and the ego
the effects of war on infantrymen who are exposed          would begin to lose its power to protect itself against
to death for days, weeks, or months at a time,             crippling anxiety.
without letup. The flier goes on a mission, faces
death, sees comrades die at a distance (or, rarely, on       Not one man in a hundred looked forward to an
the same aircraft), and returns to a generally safe          operation with relish, although most of them de-
                                                             rived considerable satisfaction from doing an op-
environment.
                                                             eration well and returning safely…all that most
   The ego of the flier uses various strategies to cope      aircrew wanted after furnishing their reports was
with the stress of combat. These strategies are              breakfast and bed and sleep. They did not remem-
familiar from the peacetime environment, but are             ber vividly every detail of all their operations, but
generally discussed only in the context of psycho-           they were conscious of no urgent desire to forget
pathology, rather than as useful adaptive mecha-             them….Their attitude to losses and the death of
nisms. During the prolonged combat tours of World            friends was particularly striking; it was one of
War II, flight surgeons became familiar with a pat-          supreme realism, of matter-of-fact acceptance of
tern of coping mechanisms in fliers progressing              what everyone knew perfectly well was inevitable.
                                                             They did not plunge into outspoken expression of
through their tours. Ignorance or denial of the
                                                             their feelings, nor did they display any compro-
realities of combat protected the fliers’ egos against       mise with conventional reticence about violent
fear at first, because their perceptions of dangers          death. They said “Too bad…sorry about so-and-
were only intellectual and theoretical. This attitude        so…rotten luck.” Their regret was deep and sin-
would disappear after a few flights, as the realities        cere, but not much displayed or long endured.
intruded. Fliers might feel some anxiety, but the            They were apt and able to talk of dead and missing
continued flying, the acquisition of combat survival         friends, before mentioning their fate, just as they
skills, and the reassurance of peers and of the flight       talked of anyone else or of themselves. It took the
surgeon would generally suffice to keep the anxiety          loss of particular friends or leaders, flight com-
                                                             manders or squadron commanders to produce a
tolerable. Successful aggressive action against the
                                                             marked reaction among a squadron. Then they
enemy served as a powerful way to discharge anxi-            might feel collectively distressed, have a few drinks
ety and helped the flier maintain some sense of              because of that, go on a party and feel better.32(p15)
control over the flying environment.
   The individual aircrew member would identify               These words were written about British night
strongly with a unit or with his crew (a small group       bomber crews in World War II, but they apply just
of men to whom he might ascribe almost magical             as well to the Air Commandos (now Special Opera-
powers) or even with a single flier. Similarly, some       tions) and tactical fighter pilots with whom the
would identify strongly with an aircraft as a power-       author worked in Vietnam. The men had seen
ful and deadly champion. It was but a short step to        friends die in aircraft accidents before the war, and
superstitions about flying as magical defenses:            combat losses were regarded in much the same
“lucky” items, rituals, and so forth.32(p16) (The recent   light. There was some corporate acknowledgment
movie Memphis Belle showed several examples of             of those who were killed, but relatively little grief
such superstitions, rituals, and amulets.) Freedom         was expressed. Spontaneous expressions of anger
from anxiety in flight depended upon the fantasy of        or acute grief at the loss were heard as the news was
the aircraft as safe and upon a flier’s identification     delivered, and then the old mechanisms of denial,
with its strength and invulnerability. Fliers also         intellectualization, rationalization, altruism, humor,
identified with leaders and with particularly skill-       and magical thinking reasserted themselves and
ful comrades. Such identification might be badly           the loss was thenceforth discussed more coolly.
shaken if an accident or combat loss claimed these         Toasts might be drunk in the bar; a few (but by no
magical objects, because the identification was now        means all) of the squadron would attend a memo-
with a wounded or dead person, rather than with an         rial service; and the war went on. Symonds33 speaks


190
                                                                                 U.S. Air Force Combat Psychiatry


of the mental state (“confidence”) that carries a flier   toms arise from unresolved internal conflicts.) They
through such experiences, ascribing it to a blend of      may even express their surprise that no one under-
resolution, bravery, and frankness. As frankness          stands their feelings and excuses them. Appeals to
ebbs (as reality intrudes), bravery and resolution to     duty, to squadron or personal loyalty, or to pride
see the job through keep the flier going.                 will have no effect. Such aircrew must be grounded
   Still, fliers did, and will, break down in combat.     in disgrace by their commanders. The wise flight
A number of authors in World War II and Korea             surgeon will counsel administrative authorities that,
commented on a pattern that most likely will be           if these fliers are not punished, they should at least
seen in future prolonged aerial conflicts. 1,3,28,32,33   not be rewarded by being administratively
There will be a few fliers who suffer disabling           grounded and given a job seen as desirable by
symptoms of anxiety early in their combat flying          squadron members.
(Group A). A few of these fliers may be returned              Whether combat fatigue occurs early in the tour
to flying, but most seem not to have the capacity         or toward its midpoint, the first contact of the anx-
to tolerate combat flying and may need to be re-          ious flier will be with the flight surgeon, who cer-
lieved from duty. These fliers may represent the          tainly does not need to be a psychiatrist to deal with
U.S. Air Force equivalent of the U.S. Army’s early        most such cases. The flier may come in of his or her
breakdowns among men with immature, depen-                own accord, or the flight surgeon may have noted
dent, or other maladaptive personality structures34       the classic early symptoms: gradual withdrawal
as discussed in Chapter 1, Psychiatric Lessons            from social contact, loss of sense of humor, lack of
of War, and Chapter 2, Traditional Warfare Com-           spontaneity, passivity leading to moroseness, the
bat Stress Casualties. Other cases of combat fa-          onset of multiple complaints of vague symptoms
tigue tend to occur in two clusters: toward mid           that would hitherto have been ignored or even
-tour (Group B), and as the tour nears its end            hidden from the flight surgeon to avoid grounding,
(Group C). Finally, there will be a scattering of         and diminished energy and appetite. Later symp-
fliers who undergo extremely stressful events, who        toms will almost certainly include irritability; in-
then break down in consequence (Group D). Such            creased use of cigarettes, coffee, and alcohol (which
events may be scattered throughout the tour.              obviously make things worse); digestive distur-
Stafford-Clark32 and Symonds33 concur that the prog-      bances; weight loss; insomnia; and the disturbance
nosis is poor for Groups A and D, and better for          of sleep by bad dreams or nightmares. The flier may
Groups B and C.                                           develop tics, frank tremors, or an increased startle
   Some of the fliers in Group A are described in         reaction. Further symptoms of anxiety, depression,
terms that today would place them among those             and psychophysiological reactions will be superim-
having antisocial personality traits: lack of alle-       posed on these symptoms if matters are not cor-
giance to others than themselves and little regard        rected.
for the social conventions or expectations of the             The best early intervention is to talk things over
squadrons. One would hope that most potential             privately with the troubled flier. Whether the inter-
fliers with such personalities have been detected         view is initiated by the flier, flight surgeon, or
and eliminated by the preselection interview with         squadron commander, the flight surgeon should
the flight surgeon, the Adaptability Rating for Mili-     take the role of a sympathetic and concerned coun-
tary Aviation (ARMA).35 If not, such fliers may           selor who wishes to help the flier regain composure
show their true colors during the extensive flying        and return to the cockpit, once more fully effective.
training and combat crew training process or by           Thus the flight surgeon supports that part of the
their behavior in squadron operations during peace-       conflicted flier that wants to return to effective
time. Failing that, there is no way to treat such an      duty. How long has the flier felt below par? Was it
ingrown personality pattern, and these fliers must        due to a particular event, or to an accumulation of
be administratively eliminated from flying status if      things?
they are detected.                                            If an accident or a particular mission is on his
   It is axiomatic that it is impossible to predict who   mind, allow him to ventilate. What was he doing?
will do well in combat and who will not, until they       Where? When? Then what happened? How did he
are actually exposed to enemy fire. Some fliers will      react? How did others react? How does he think he
be unambiguous in their refusal to fly combat mis-        should have reacted? What is he telling himself now
sions. Because they are not psychologically con-          about the whole thing?
flicted about their determination not to fly into             If it were cumulative stress, how has it affected
danger, they do not become symptomatic. (Symp-            him? What is he afraid of? How does he see others


                                                                                                             191
War Psychiatry


reacting to the situation? How do they react to him?       psychotherapists. Uncovering therapy will help
How much does he feel a part of the group and how          aircrew members express their honest fears; they
much ego support does he derive from them and              frequently lack insight into their own apprehen-
from the leaders? At times one may encounter               sions. The insight gained may be only intellectual;
marked misperceptions about how others feel, how           but, even expressing it verbally gives the emotion
they handle things, and how “I have let them down.”        legitimacy. Furthermore, the flier may be relieved
   In each case, the flight surgeon can reflect the        by no longer being afraid and unwilling to acknowl-
reality of the situations involved, correcting misap-      edge emotions he regards as unworthy. The more
prehensions, clarifying the flier’s status in the squad-   that the anxiety is expressed verbally, the less the
ron, and helping to strengthen the ways in which           need to express it physiologically or psychosomati-
the flier has dealt with the stress so far. An under-      cally; thus, the flier is relieved of the added fear of
standing, noncritical, tolerant acceptance and ex-         bodily disease.
planation of the flier’s anxieties (unrealistic) and
fears (realistic) is essential, so that the flight sur-      The ego, weakened and shaken by anxiety, needs
geon then assumes a warm but firm parental role              strong and repeated doses of reassurance, support
                                                             and encouragement….Many men despise and of-
that allows for sympathy, affection, and protection
                                                             ten condemn fear as unmanly and cowardly, and
while expecting and demanding the utmost dedica-             therefore suppress or repress their own, out of guilt
tion to the mission, to the point of possible self-          or the hurt to self-esteem. These superego tensions
sacrifice.                                                   must be relieved by appropriate explanations.31(p82)
   By allowing the flier to talk about his anxiety,
especially if it is manifested through psychophysi-           If fears are already conscious, uncovering is not
ological mechanisms, the flight surgeon may help           necessary; ventilation and reassurance may suffice.
clarify that which the flier really fears: injury or          Should such fliers be unwilling to tolerate their
death. Verbalizing this fear allows the flier to exam-     fears or somatic concerns, they may respond to an
ine it directly, rather than dealing through a smoke       appeal to pride and conscience by pointing out the
screen of symptoms and vague apprehensions. It             obvious secondary gains. For example, being
also allows the flier to deal realistically with anxiety   grounded would remove them from danger, but
about being seen as afraid, which may be perceived         would transfer the risk to comrades. Use the trans-
as a strong taboo within a “macho” squadron: “Bet-         ference relationship with the flight surgeon and
ter to die than to look bad.”                              squadron for leverage: “We will think better of you
   When the flight surgeon accepts and defines this        if you fly in spite of your feelings.” This may be
fear as natural and universal, the flier’s tendency to     tempered by simultaneously gratifying dependency
view it as an unnatural, exaggerated personal fail-        needs through allowing extra time with the flight
ing may be corrected. Thus he reassures himself            surgeon, or a special system of appointments after
that he is normal and that if his squadron mates are       missions.
dealing with similar feelings and yet can continue            In the case of fliers who attempt to compensate
to function, so can he. Reassurance, accepting sup-        for these needs by denying them and rejecting prof-
port, and firm encouragement to return to duty will        fered help, an especially sensitive and tactful ap-
strengthen his ego and help him deal with the              proach may be necessary. The therapist may en-
doubts, self-criticisms, and guilt with which his          counter displaced hostility, especially if morale in
superego may be taxing him about his not being the         the squadron is low. This symptom may need to be
perfect flier. Remembering that the flier is con-          interpreted to the flier: “I know things are bad in the
flicted (or else he would have quit long ago!) will        squadron, and I know you’re unhappy with them.
help the flight surgeon deal with personal uncer-          Still, we’ve got a mission, and you’re not really sick
tainties about such a therapeutic approach.                and don’t need to be grounded. I know you can fly
   Gratification of the need for the flight surgeon’s      and I’ll be willing to check you over after every
approval may do much to relieve anxiety, particu-          flight to be sure nothing else is going wrong with
larly in the more passive or dependent members of          you. This tension gets to everybody, but I know you
the squadron. The amount of positive feedback              can gut it out for a while longer.”
needed obviously varies from person to person.31,36           Levy,31 whose approach has been paraphrased,
   At a deeper level, an individualized psycho-            noted that no one had good statistics on what went
therapeutic technique must be used. This may be            on within the squadrons. He felt that about 40% of
performed by some particularly adept flight sur-           medical/operational failures were primarily psy-
geons, or may require the services of more skilled         chological and that about half of these failures oc-


192
                                                                                    U.S. Air Force Combat Psychiatry


curred in the first 10 missions. He went on to point           As the second period progressed, Captain Rehm
out, as do all authorities, that all fliers would finally   describes his emotional plateau as being able to
break down if not eventually relieved from duty.            relax over friendly territory and more nervous in
   Captain Robert Rehm27 carried his interest in the        the briefing for a bad target (Ploesti, for example)
progression of responses to combat stress beyond            than during the actual mission. After seeing one of
that of most flight surgeons. After a year as a flight      their planes shot down, he became somewhat anx-
surgeon in Italy, he felt that he had merely scratched      ious and was insomniac for a few nights. However,
the surface in dealing with his fliers’ psychological       his assurance reasserted itself when all went well
problems; therefore, he began flying regularly with         on subsequent flights.
the crews to better understand their experiences.              He comments here on the importance of keeping
Although he does not specify, he was probably               men flying regularly, “regardless of unusual or cata-
assigned to a B-24 heavy bomber squadron. He                strophic episodes … [I] returned a man to duty as soon
reports various common psychological factors oc-            as physically able, following any injuries which he has
curring in three segments (the first 10 missions, the       sustained. The longer he has to think about his inju-
subsequent 30, and the final 10) during his 50-             ries and how they occurred, the more the mental
mission experience. He expresses the certainty that         ‘gremlins’ play on his emotional stability.”27(p8) He
anxiety was the greatest during the initial missions        experienced the effects of a long stand down after his
over the target, especially when the new flier is           35th mission, just after seeing a plane crash and
confronted with serious occurrences such as flak            burn on takeoff, when bad weather grounded the
wounds, aircraft damage, or witnessing the loss of          squadron for 10 days. This exacerbated his growing
another aircraft.27(p5) Such a “mild catastrophic           fear of takeoffs, which was relieved only when a
event” [!] will shake the resolve of unaggressive avia-     trusted pilot had him sit on the flight deck during
tors. Captain Rehm states that he found it necessary        takeoff and explained how little danger they were
to take a firm attitude and not to leave the decision to    in once takeoff speed was attained. (This explana-
continue flying up to the flier, but to explain—            tion is, of course, somewhat irrational when one
repeatedly, if need be—that he had no medical               considers that Captain Rehm had, in 35 rides, seen
reason to ground the flier, who must continue to fly.       two planes crash and burn on takeoff. One sees how
Such a firm stance was usually effective.                   the weight of reassurance from a valued authority
   During his own “tour,” Captain Rehm describes            transcends logic.) The flight surgeon must under-
mostly short and rather easy missions at first, with        stand that a flier who is conflicted about continuing
some exhilaration at actually being in combat and           to fly is just that, conflicted. That part of him that
taking some flak hits. However, a near crash on             wants to fly will seize on any information from a
takeoff laid the basis for a later phobia—he pre-           valued figure, such as the flight surgeon, as an
ferred to sit where he could not see the ground on          excuse to return to what he knows he should be
takeoffs. One such episode was not sufficient to            doing anyway. Flight surgeons must never under-
keep him anxious, but an accumulation of similar            estimate their power in such instances, even though
phobias could become disabling.                             they understand the irrationality involved.
   After his first 10 missions, he found that the              At about this point in a combat tour, Captain
excitement was subsiding as familiarity increased.          Rehm comments upon the “benign hypochondria”
The many novel experiences were now accepted as             in many fliers who develop vague somatic symp-
routine, given that no truly catastrophic event oc-         toms, some real, such as head colds, some not. Wise
curred. He felt less alone in the aircraft and more         flight surgeons will not overemphasize the impor-
homogeneous with the other aircrew members. The             tance of such symptoms by initiating “junior medi-
war was no longer a personal matter between him             cal student” workups for minor complaints, some-
and the enemy, but the cooperative effort of a force        times thereby attempting to exorcise their own
of which he was a part. He also felt a growing blind        anxieties. In others, Captain Rehm observed overuse
faith in his pilot, something quite common in his           of alcohol and tobacco, irritability, insomnia, ner-
squadron. “All the dangers which have been safely           vousness, and temper outbursts. As he began his last
encountered and surmounted are epitomized in                10 missions, he summarized his own situation:
that particular pilot. He stands as a tribute to
experience and a symbol of their safety.”27(p7) This          I realized how all important the factor of physical
statement clearly delineates the identification with          fatigue was. I became nervous and irritable and I
the pilot and the magical powers attributed to him            had a great deal of trouble controlling my emo-
by an ego defending itself against reality.                   tions. I had little zest for the squadron activities.


                                                                                                                  193
War Psychiatry


  My appetite decreased materially and I noted that         The author saw two sorts of reactions in fliers
  during the past two and one-half months my weight      near the ends of their combat tours. The first was a
  had dropped from 178 to 156 pounds. I found that       tendency to “beat up the sky” on the last mission, a
  I was smoking two packs of cigarettes daily instead    tendency that resulted in some unnecessary losses
  of one. The most noticeable factor was my inability
                                                         from enemy fire or from crashes. One squadron
  to sleep, especially before each mission. This was
  most marked on the event of my fiftieth mission.       adopted the policy of suddenly announcing to a
  Missions to (various targets) were met and com-        flier, “That was your last mission—turn in your
  pleted with much trepidation. The easier               gear,” about 10 days before the end of the tour.
  missions…gave much relief but seemed much more            The second reaction was to become progressively
  hazardous than formerly. However, throughout           cautious and super-safe, which at times resulted in
  this entire period, the interest and encouragement     mission ineffectiveness. This reaction may repre-
  of the men in the squadron and group spurred me        sent the flying equivalent of “short-timer’s syn-
  on to greater efforts than before. 27(p10)             drome.” If so, this author agrees with Jones’ ap-
                                                         proach, which is to advise the commander not to
   If a flier must be grounded for combat fatigue,       make special allowances for a flier near the end of
and local treatment is not sufficient, that flier must   the tour, in order to avoid adding a secondary gain
be evacuated to a treatment facility where special-      to the natural tendency to let down right at the end.
ized psychiatric care is available. The author’s            Any person, flier or nonflier, needs a chance to
experience in Vietnam was that the few fliers who        debrief and “decompress” at the end of a combat
were evacuated for psychiatric care to the hospital      experience. This process should be led in a sympa-
at Cam Ranh Bay 25 miles away were returned in a         thetic setting by a knowledgeable practitioner. Ide-
week or two and were able to return to flying duties     ally, the squadron could undergo the process to-
without further difficulty. The author has heard         gether, giving all a chance to achieve closure on
anecdotal reports from multiple sources about sev-       matters of self-esteem, of group validation of indi-
eral fliers who were grounded for similar symp-          viduals’ performances, and of an agreed-upon re-
toms during the Persian Gulf War, and who were           membrance of how things were. This process should
evacuated to the United States for treatment. Upon       be formalized by such elements as a memorial ser-
their hospital discharge, no administrative route        vice for lost comrades and a military parade, with
was available to return them to duty with their          awards and decorations, and a casing of the colors.
squadrons; thus, they were returned to their State-      Ratification of the worthiness of one’s service by a
side bases. There they and their spouses were            valued authority is a powerful antidote for a stress-
shunned by other fliers’ families, and when their        ful experience that may be used to balance the
squadrons returned from overseas, they were not          doubts and emotional reactions yet to come.
accepted back. In essence, their careers are ruined.
While these stories cannot be confirmed, their con-      Summary
sistency among the sources rings true. If so, they
furnish a stark example of the loss of competent            Plans for dealing with combat fatigue in fliers
fliers because of aeromedical evacuation beyond          must be based on experiences of flight surgeons and
the point of return to duty. This provides another       psychiatrists in past wars with the clear caveat that
reason to give treatment as far forward as possible.     conditions in future wars may be quite different.
Medical authorities should also plan to provide an       Flight surgeons must understand the basic prin-
administrative mechanism for return of such fliers       ciples underlying the prevention, or at least the
to their overseas squadrons.                             delay, of combat fatigue; and they must use their
   As combat flying draws to a close, several changes    two major therapeutic modalities wisely: (1) the
may be noted. Jones37 speaks of the “short-timer’s       judicious prescription of rest as a palliative and
syndrome” in soldiers, a mixture of mild anxiety         restorative and (2) their own influence in sympa-
and phobic symptoms near the end of a fixed 1-year       thetic yet authoritative roles that offer understand-
tour. Some commanders kept men off tough patrols         ing while expecting faithful service.
and assignments during their last month, which              Psychiatrists to whom flight surgeons refer fliers
unfortunately tended to move the onset of the symp-      must also understand these principles and must
toms to the 11th month rather than the 12th. Thus,       take care not to preempt the role of the flight sur-
the division psychiatrist discouraged this policy, in    geon, nor to belittle or ignore the need for coordina-
order to maintain consistency in all units and to        tion between the two disciplines in decisions re-
avoid premature onset of symptoms.                       garding flying status.


194
                                                                                   U.S. Air Force Combat Psychiatry


                         SUPPORT OF NONFLYING PERSONNEL IN COMBAT


   U.S. Air Force doctrine currently calls for four       nerve gas or mustard. There is little precedent in
echelons of medical care in combat situations. The        today’s U.S. Air Force for a line chief to tell his
first echelon (1-E) consists of care given before a       armament troops, “You have to upload that F-16
physician becomes involved: preventive measures,          right now! I know there’s persistent nerve gas
first aid, buddy care, and the attention given by         around, but all of you have your chemical assem-
enlisted medical personnel. The second echelon (2-        blages on. We fixed up the rips the best we could
E) is the first care given by a physician’s assistant,    with plastic tape. If any of you get gas symptoms,
nurse practitioner, or physician, perhaps in a base       try to get back here. The rest of you will have to
medical facility or in one located just off-base. Third   keep uploading the plane, so don’t stop to help each
echelon (3-E) care is given in a larger medical facil-    other. We have to get that plane off before they hit
ity (250 to 300 beds) located well off-base, either in    us again!” Grinker and Spiegel1 describe similar
a presited hospital or in a transportable hospital        stress on ground maintenance troops in North Af-
brought in by air or by truck. The fourth echelon (4-     rica who came under attack by German fighters.
E) facilities are larger still, and are located well
away from the primary battle zone. From these               Especially in the early days of the Tunisian cam-
hospitals, patients requiring long-term care will be        paign, although the forward airfields were con-
evacuated back to the United States.                        stantly patrolled by the fighter aircraft, these were
   By the nature of these facilities, psychiatric care      no match for enemy aircraft coming in considerable
                                                            numbers. The planes appear from nowhere, an-
at the 3-E and 4-E level will be given by specialists.
                                                            nouncing their presence by the spatter of machine
Information in this chapter is primarily intended           gun bullets and the thump of explosive cannon
for nonspecialists, and thus it will deal almost ex-        shells. They appear mysteriously, almost magi-
clusively with the 1-E and 2-E care.                        cally, flying out of the sun in the early morning, or
   As mentioned in the Introduction, there is little        diving from behind a cloud to lay a string of bombs
historical information on the effects of combat upon        throughout the dispersal area. One minute all is
the support troops who make up the majority of any          peaceful, a scene of quiet, busy activity. There may
U.S. Air Force base population. In contrast to the          be a roar of motors in the air, but that is the normal
classical estimates of psychological casualties as          state over an airfield. The next minute enemy
                                                            fighter planes are buzzing the field, bullets kick up
comprising about a one fourth to one half of all
                                                            dirt all about, and the tremendous crump [sic] of
battle-induced casualties in combat, during the Per-        exploding bombs deafens the ears. There is no time
sian Gulf War psychiatric diagnoses among U.S. Air          to look for shelter, hardly time to put on a helmet—
Force troops averaged about 3/1,000/wk, about 5%            nothing to do but lie flat on the ground and hope for
of the total morbidity. This may be compared to the         the best. The ack-ack batteries contribute to the
reported average for respiratory diseases of 21/            general noise and confusion—ineffectively in most
1,000/wk, or the nonbattle injuries rate of 12.3/           instances, because the planes usually come in too
1,000/wk. Psychiatric diagnosis peaked at about             low and too fast for effective anti-aircraft fire. In no
5.8/1,000/wk during the third week of the air com-          time at all, the enemy planes are gone, leaving
                                                            behind them a few twisted, burning planes, a few
bat campaign.38(p30)
                                                            injuries and deaths, and a number of incipient
   These relatively low numbers would have un-              anxiety states.
doubtedly been higher had the bases been under              Because in this kind of attack the ego has actually
concerted attack, and one might reasonably assume           no time for defensive activity, its helplessness is
that the particular vulnerability to stress found in        real and actual. There is nothing in the environ-
U.S. Army support troops under fire would apply             ment which can be used to anticipate the approach
here also. Sir Winston Churchill once said, “Noth-          of danger. Under such circumstances, any stimuli,
ing in life is so exhilarating as to be shot at without     any loud noise, even the roar of aircraft motors,
result,” but the more common experience seems to            may actually mean the beginning of an attack.
                                                            Inhibition of anxiety becomes increasingly diffi-
be, “Few things in life are as stressful as being shot
                                                            cult. When enemy attacks become incessant, al-
at and not being able to shoot back.”                       most everyone on the field develops some degree of
   Consider the situation of an overseas U.S. Air           free-floating anxiety. The development of the symp-
Force base under conditions of impending combat             toms of neurosis, aside from those of anxiety, in this
on which troops might come under attack by enemy            situation, is directly dependent on the capacity of the
air and land forces or by missiles that might bear          individual ego to tolerate free anxiety.1(pp103,104)


                                                                                                                   195
War Psychiatry


  Marquez reports a similar scene 25 years later,           health professionals if possible, and, if not, by the
during the Tet attacks on Bien Hoa Air Base in South        senior flight surgeon.
Vietnam, 0200, 29 January 1968.                                This information must be transmitted down
                                                            through the ranks to the working level. Leaders
  People were running around trying to find shelter         should tell their troops ahead of time as much about
  anywhere….The 120-mm rocket was an especially             the combat conditions as possible. They may want
  frightening weapon because, in addition to doing          to say that it is almost certain that everyone, them-
  damage as a fragmentation weapon, it made a lot of        selves included, will be afraid, and that it is normal
  noise….Great fires were started, and the firefighters
                                                            to experience the physical manifestations of that
  were unable to put them out. People were standing
  around staring and were too frightened to
                                                            fear. They must expect dry mouths, sweaty palms,
  act…Through it all, there was rampant confusion           palpitations, rapid heartbeats, breathlessness, stom-
  and no one knew if another attack was im-                 ach flutters, and perhaps even nausea and vomit-
  minent….It’s hard, but important, to keep busy in         ing, urinary frequency, or diarrhea. They will surely
  the aftermath of one of these things. Some were           be tremulous. All these symptoms are to be ex-
  scared; some were totally out of their minds; others      pected, as is a realization of their fear about what is
  were enjoying it!39(p22)                                  about to happen.
                                                               Leaders must also make it clear that they expect
  Marquez goes on to describe that someone issued           all of their troops to do their jobs in spite of their
weapons to the U.S. Air Force troops on the base,           fears and to help each other out. In a phrase, “It is
and suddenly there were                                     all right to be afraid, and your body may let you
                                                            know that it feels the fear, but you must not let that
  500 armed aircraft mechanics running around with          fear keep you from doing your duty.” This may be
  weapons, no enemy to shoot at, and no one in
                                                            compared to an athletic contest in which the players
  charge….They were just firing at noises. It took me
  four hours to retrieve those guns….My reasons were
                                                            know they are nervous and yet go into the game to
  clear—I was afraid my troops would kill each other        do the best they can, knowing that they will lose
  before dawn….Fear drives people to do very irratio-       much of the tension as soon as the first contact is
  nal things … It takes a lot of discipline to get people   made. At that point, they will revert to the skills
  back together and working productively.39(p22)            that they have worked so long to acquire.
                                                               By discussing their feelings ahead of time, each
   What can be done today to prepare for such               individual will know that he or she is not the only
stresses tomorrow? What should be done as the war           one who is aware of being afraid, not the only
begins? General preparation should include atten-           coward in a band of heroes. Each will know that it
tion to education, training, group cohesion, morale,        is all right to feel fear, as long as each performs
and sleep discipline, as well as to other elements          assigned duties when the time comes for action. A
leading to improved or prolonged combat effective-          poll of infantry veterans has shown that, prior to
ness. These preventive measures will be consid-             battle, 69% were aware of a racing, pounding pulse;
ered individually. They serve as prophylaxis and,           45% had sweaty palms; 15% had cold sweats; and a
in a sense, as early treatment measures at the 1-E          lesser percentage felt faint, were nauseated or vom-
level of medical care.                                      ited, or had strong urinary or defecation urges.40(p11)
                                                            Most of these men were aware of the physical symptoms
First-Echelon Measures                                      of fear before they were aware of the emotion which
                                                            caused them!40(p24)
Education and Training                                         This poll also emphasized the importance of the
                                                            control of behavior in action. Of the infantrymen
   The medical officer on base who is most knowl-           surveyed, 94% said that seeing others act calmly un-
edgeable in such matters must be sure that all offic-       der fire helped them to feel better and act better
ers and senior NCOs understand the basic message            themselves. Many found that concentrating on their
of this chapter, that they will have to deal with acute     own duties helped, as did cracking jokes about the
stress reactions from the announcement of deploy-           situation. Some 97% said that knowing morale was
ment through the first few days of combat, and that         high in their unit made them better soldiers.40(p47)
more chronic combat fatigue will inevitably build              All troops must understand the importance of
as time goes on. They must understand that they             the unit mission and must know how their own
should take preventive measures before and during           work helps the unit achieve its goals. They must
the conflict. Briefings should be given by mental           understand how they fit into the big picture and


196
                                                                                   U.S. Air Force Combat Psychiatry


why that picture is important, or they will certainly       sometimes also of cruelty, self-sacrifice, compassion;
not risk their lives to do what must be done. More          above all, it is always a study of solidarity and usu-
concretely, they must understand exactly what they          ally also of disintegration—for it is toward disinte-
are to do under attack, whether by land or air, by          gration of human groups that battle is directed.42(p303)
conventional, chemical, or other means. Warnings
and all-clears must be crystal clear, to avoid unnec-        Understanding these elements of battle, the wise
essary or panicky decisions. All concerned should         physician, who has the commander’s ear, will as-
understand that people tend to regress in their           sure that everyone within the command under-
behavior when under acute stress, and a simple rote       stands them also. It is a message seldom heard in
performance of duty may see them through until            the peacetime U.S. Air Force, and then heard only
they become more accustomed to combat condi-              faintly. Much in battle is sociologic and psychologic,
tions. Actions to be taken under attack should be         and those who understand these factors and can
rehearsed so as to be well-nigh automatic. As noted,      communicate them to the troops in a manner that is
knowing that training is excellent and that readi-        understandable and memorable may have much to
ness is high is a powerful antidote to fear in combat     do with winning.
and will help prevent acute combat stress reactions.         With this background, the junior officers and
   In a study of British unexploded ordnance dis-         senior NCOs should get into the habit of having
posal personnel, Rachman noted qualities of under-        small “how-goes-it” sessions to assure that every-
lying resilience which he described as present in a       one gets “the word” at the working level. Hocking43
great many military individuals. When combined            comments that an excellent indicator of good mo-
with “adequate training, good and reliable equip-         rale among troops is the liberty felt by their officers
ment, high group morale and cohesion,” he found           to tell the truth in times of difficulty or failure.
that a sense of calmness, awareness of physical           Tempering the truth is a sign of distrust of the
fitness, and general psychological health nearly          troops and an attempt to manipulate morale from
completed the picture. The single factor that, he         the outside. As such, it is immediately suspect.
felt, distinguished the “courageous” (decorated)          Morale is a state of faith between the leaders and the
individuals was a singular lack of any hypochon-          troops and must not be abused. If one does not
driacal features at all. Most had “no bodily or           know what the situation is, one should say so and
mental complaints whatsoever.” 41(p102)                   do everything possible to discover what it is, rather
   If one regards the desired outcome of a battle or      than lying about it. Faith, once betrayed, is almost
an attack as the transformation of a disciplined and      impossible to reestablish. Troops who know the
effective enemy military force into a disorganized        truth, and know that they know it, are much better
and powerless rabble [“Inside every army is a crowd       prepared to deal with it than those from whom it
struggling to get out,”42(p175) then this issue of per-   has been concealed.
formance of duty under attack becomes the proper
focus of all military training. People on air bases       Group Cohesion and Morale
under attack must understand that failure to do
their work under the conditions of noise, smoke,             At the lowest unit level, a buddy system (the
confusion, death, and destruction that have accom-        British call it “battle friends”) should be established
panied warfare since the invention of gunpowder,          whereby pairs of troops are specifically instructed
will result in defeat. As different as battles and        to look after each other. This system should reflect
warfare have become from those of the past, what          natural friendships whenever possible, rather than
they retain is the human element:                         being imposed from above. Thus, each person is
                                                          aware that there is another person who will be
  the behavior of men struggling to reconcile their       specifically looking out for his welfare when things
  instinct for self-preservation, their sense of honour   get rough, that no one will be forgotten or unac-
  and the achievement of some aim over which other        counted for. As a corollary, each unit should main-
  men are ready to kill them. The study of battle is      tain small group integrity so that individual bonds
  therefore always a study of fear and usually of cour-
                                                          and loyalties are not arbitrarily disrupted. Such
  age; always of leadership, usually of obedience; al-
  ways of compulsion, sometimes of insubordina-
                                                          small groups should be together off-duty as well as
  tion; always of anxiety, sometimes of elation or        on in order to foster their interdependence. Work-
  catharsis; always of uncertainty and doubt, misin-      ing groups should live together in barracks or shel-
  formation and misapprehension, usually also of          ters, rather than being split up as sometimes occurs
  faith and sometimes of vision; always of violence,      in peacetime living.


                                                                                                                   197
War Psychiatry


   This point was emphasized by Manning and                beyond those that are taking place in the unit as a
Ingraham, 44 who surveyed U.S. Army units to               whole. Troops showing these symptoms should, if
establish some of the underpinnings of unit cohe-          possible, be given a little extra time off, or at least
sion. One element, usually missing but of inesti-          the opportunity for a good night’s sleep (“three hots
mable value when present, was the presence of              and a cot”). A little consideration in these matters
commanders or senior NCOs in after-duty, infor-            may go a long way in prolonging the efficiency of
mal settings if they felt socially at ease doing so. By    the unit, as well as its individual members’ ability to
doing so, they shared experiences other than those         function well.
of the workplace. “The more people interact, the               Richardson went on to report that hundreds of
more varied the settings, and the more time the            British soldiers were sent out of battle in World War
group maintains stable membership, the more the            II by their officers because they were showing physi-
members have in common and the higher the result-          cal signs of fear. This practice not only was a waste
ant cohesion.”44(p65)                                      of manpower, but had the potential for a snowball
                                                           reaction among the troops not yet affected, to whom
Skillful Leadership                                        the secondary gain for the symptoms was all too
                                                           clear. He points out the clear necessity for com-
   The small unit leader must be familiar enough           manders to learn to
with the troops to recognize when an individual’s
stress symptoms are getting out of hand. The leader          distinguish between men who are simply afraid
                                                             and those who are beginning to find fear uncontrol-
should be willing to give a little extra rest and time
                                                             lable. To distinguish between a man who needs to
off to those whose fears are beginning to get the best       be encouraged to carry on and one who should
of them. In his book Fighting Spirit, Major General          quietly be got rid of, for the time being, lest his
F.W. Richardson, a retired British Army physician,           fear become infectious, can test experienced lead-
discusses the here-and-now treatment of acute com-           ers. During the trial by court martial of a soldier
bat stress reactions.45 Two hundred yards behind             for cowardice in Korea, a civilian counsel for the
the battle line he had established                           accused was trying subtly to shift the blame onto
                                                             the shoulders of the platoon commander who,
  a sheltered rest station … at the bottom of the hill …     he claimed, should have seen that the man was on
  (S)omeone had given this place the name of ‘Tran-          the verge of a breakdown. ‘Could you not see,’
  quility House.’ Once its value had been clearly            he demanded aggressively, ‘that Fusilier L…
  recognized and the…medical officers instructed             was trembling involuntarily?’ The young officer’s
  about the early handling of cases of threatened            splendid reply was ‘We were ALL trembling
  breakdown, it was enough for them to mark men’s            involuntarily.’ 45(p111)
  field medical cards ‘T.H.’ After 12 to 24 hours of
  rest and hot meals at this post, many men, who              In the same vein, the leader should provide the
  might otherwise have had to be sent to hospital,         best amenities possible under the circumstances,
  were able to rejoin their units…without loss of          including food, shelter, and cleanliness. The troops
  face.45(p106)                                            who know that their leaders are living up to this
                                                           valuable and venerable military tradition will un-
   Such an arrangement may or may not involve a            derstand the implicit message that underlies it: “As
medical professional, but the circumstances de-            I show that your physical comforts are important to
scribed certainly should not involve a formal ad-          me, you can see that I consider each one of you
mission in the medical sense, which would rein-            valuable, and you know that I will not waste your
force the “sick” role. The message should be “You’re       lives needlessly in battle.” Loyalty in battle is, after
not sick and you’re certainly not a coward; you’re         all, a two-way process.
just worn out and need a bit of rest before you go            Leaders should also be alert to undue confusion
back to duty.”                                             or agitation in their troops while under fire, and
   Obviously, medical advisors should assure that          should set a firm, calm example. The timely joke is
officers and NCOs understand the early symptoms            of inestimable value in this respect. The leader
of combat fatigue, those at the mild end of the            should help turn their minds outward, away from
spectrum that might otherwise be ignored: insom-           their own troubles and toward their comrades, rein-
nia, nightmares, restlessness, decreased appetite,         forcing each other’s efforts, doing the job at hand,
irritability, increased startle reflex, decreased effi-    and supporting the base fighting mission. The
ciency, increased smoking or drinking, loss of sense       emphasis should be on teamwork and accomplish-
of humor, and changes in normal temperament                ment (“We’re all counting on you”) to appeal to that


198
                                                                                 U.S. Air Force Combat Psychiatry


part of each person’s ego that wants to perform          least, they will not be surprised that they feel afraid.
honorably under fire, to be thought well of by           They will understand that there is no disgrace in
comrades, and to be part of the best unit in the         feeling fear, only in giving way to it.
winning force. By setting a calm example, not               Commanders must also be aware of the insidious
minimizing the occasion but instead helping the          effects of prolonged inactivity or unstructured time
troops rise to its demands through pride and loy-        on morale, especially if accompanied by an under-
alty, by making them part of something bigger than       tone of anxiety about what might happen. Several
themselves, the U.S. Air Force leader is following       traditional antidotes are available, tailored to the
the example of the great leaders of history. Morale,     specific circumstances.
in this context, becomes a matter of concentration of       A good sports program is worth its weight in
purpose, competence, honesty, selfless generosity,       gold. The one drawback is a tendency to cause
dignity, and exemplary behavior.43                       injuries, so be careful about activities involving
                                                         physical contact, and provide referees to keep things
Sleep Discipline                                         in hand. Educational offerings will attract some:
                                                         lessons in the local language, history, and customs,
   Medical personnel must impress on command-            or even a formal course program if available. An
ers the importance of making sure that their troops      enlightened leave program may be possible, with
get adequate sleep, to the extent that the situation     tourist-type day or overnight trips to local attrac-
allows. Studies have shown that 4 hours of uninter-      tions. For prolonged campaigns, consider an R and
rupted sleep, especially if it includes the 3 hours      R policy.
between 2 AM and 5 AM, are necessary to maintain            Pay attention to work-alert-rest schedules. Avoid
the efficiency of the troops over the long haul. In      switching personnel on and off night duty; it may
these studies, the 4 hours of sleep consisted of the     be possible to have reasonably stable day and night
total amount of Stage 4 sleep and of REM sleep that      sections, to avoid undue circadian disturbances.
the troops would have gotten under more normal           Rotate tasks. Provide military training and up-
conditions; that is, their sleep became more con-        grade. Cross-train if it is reasonable; this will also
densed and efficient in refreshing them in the field     benefit the organization in case of losses through
conditions of relative sleep deprivation. Less than      combat or illness.
4 hours of sleep led to progressive fatigue and             As Hoffman47 points out, these factors, combined
inefficiency.46                                          with a sense of good leadership, fairness, compe-
   This doctrine may be hardest to apply to the          tence, and caring, will demonstrate to the troops
commanders themselves, who may believe that they         that their commanders are looking out for their
are indefatigable. The military writings of              welfare. Attention to details, alertness to signs of
Wellington, of Napoleon (whose ability to nap was        stress in self and buddies, and open lines of commu-
legendary), and of Montgomery (in contrast with          nication up and down the chain of command during
Rommel, who exhausted himself) all bear witness          lulls will help assure good performance when things
that “the high commander who, under the strain of        get rugged.
a prolonged campaign, can preserve an undisturbed           Medical personnel must assure that line officers
sleep pattern is the right man in the right              and NCOs understand that the best way to counter
place!”45(pp76,77) This may be contrasted with the old   the demoralizing and fearful effects of combat is to
saw that “the military regard sleep as monks do sex:     foster good morale. The wise leader knows that
the really competent ones get along without it!”45       there are clear indicators of poor morale available,
                                                         such as an increase in abuse of alcohol and drugs,
Other Factors                                            venereal disease, fights, AWOLs (absent without
                                                         leave), and similar Article 15 offenses. One may
   Commanders should be aware that there are some        also see an increase in a constellation of medical
specific factors that may increase their troops’ sus-    conditions, the prevention of which is a function of
ceptibility to fear: being alone, darkness, rumors,      personal discipline: sunburn, frostbite, immersion
lack of plans, and insidious silence punctuated by       foot, malaria (the troops are not using insect repel-
loud or unexplained sounds. Knowing ahead of             lent, taking their prophylactic medications, or sleep-
time that such things increase apprehension may          ing under their mosquito netting), food-borne dis-
help to reduce their effects, and the troops should      eases (improper hygiene), and other such maladies.
be warned about them. At best, the men may                  Further, a unit that is well-led, and knows it, will
recognize their own fears and joke about them. At        identify itself with its leader and will begin to use


                                                                                                             199
War Psychiatry


his way of speaking, habits of behavior, and even            cent of this group had recurrence of symptoms and
personal mannerisms. 48 This magical identification          became repeaters.”49(pp306–307)
with a leader who is perceived as wise and power-
ful is a notable indicator that morale is high. Al-           Menninger goes on to describe the treatment of
though a unit with good morale may not display its         those not handled at the clearing station (which, in
discipline in the “snappy salute” sense, it will take      U.S. Air Force terminology, would be an off-base 2-
good care of itself. It will practice the essentials       E facility). The worst casualties, or those not re-
necessary to preserve its own health and its opera-        sponding to brief intervention, were sent to “ex-
tional readiness, and the troops will reinforce each       haustion centers” 16 to 24 km (10–15 mi) behind the
other in following the formal and informal rules           lines. These were staffed by 12 officers and 99
that maintain and increase their collective effective-     enlisted and were equipped to take care of 200 to
ness.                                                      500 psychiatric casualties. Patients remained there
                                                           5 to 8 days and were treated with rest, recreation,
Second-Echelon Measures                                    and narcosynthesis using sodium pentothal. These
                                                           centers developed training platoons, directed by
   Almost all of the literature concerning the initial     line officers, “which provided an additional 2 to 5
care of combat fatigue victims has been written by         days of military activities at a graded tempo to
U.S. Army psychiatrists. One of the clearest de-           prepare the men for return to combat. Of the com-
scriptions of this care was given by W.C. Menninger49      bat casualties, 20 per cent were returned to combat
in his classic monograph, Psychiatry in a Troubled         from these centers.”49(p307)
World, in which he discussed the treatment regimen            Menninger notes specifically that, besides adher-
developed by the psychiatrists in the Mediterra-           ing to the classic treatment principles of proximity-
nean Theater in World War II.                              immediacy-expectancy, the entire program assumed
                                                           that the chief preventive efforts were a function of
  By their plan the battalion aid station surgeons
                                                           commanders, not of the medical personnel, and that
  were indoctrinated with “first aid” psychiatry. It       the active support of the line officers was required
  was they who had to decide whether a man should          in order to assure its success.
  be returned to duty, given a brief respite, or evacu-       Thus the elements of care at the 2-E level include
  ated to the clearing station. It was fully appreciated   the location of the unit, its staffing, its function, the
  that many soldiers, if returned to the battalion         treatment setting, the principles of management,
  kitchen area and permitted a night of sound sleep        the use of medications, and the options available for
  with the aid of a mild sedative and some warm            disposition of those treated there.
  food, would be ready in 24 hours to return to
  combat. No record was ever kept of the men so
  handled, but it is known to be a sizable percentage      Location and Staffing
  of the men seen at the battalion aid station.
  The seriously upset soldiers were sent 2 to 5 miles         Plans for locating the U.S. Air Force 2-E mental
  farther back to the division clearing station where      health services change from time to time, but the
  the division psychiatrist had his headquarters and       doctrine, configuration, and location will probably
  treatment center. This sometimes was in a tent or in     not differ greatly from what will be described be-
  a commandeered building such as a schoolhouse,
                                                           low, and will correspond in function, if not in loca-
  factory, or whatever might be available. The sol-
                                                           tion, to the system of which Menninger wrote.
  dier arrived here from his foxhole within 1 to 3
  hours. Each one was seen initially by the psychia-       Medical personnel remaining on a base under con-
  trist and interviewed briefly. If he was recognized      tinuing attack or threat of attack will probably con-
  to be too sick to benefit from brief rest and such       sist of a few flight surgeons, perhaps a surgical
  psychotherapeutic help as could be given in a short      specialist, some medical technicians and ambulance
  time, he was immediately evacuated farther back.         drivers, and a mental health team consisting of a
  The largest percentage of the soldiers who came to       psychiatrist, a psychologist, a clinical social worker,
  the clearing station remained there for 48 hours.        and some mental health technicians. The remain-
  These men were given sufficient sedation to insure
                                                           der of the local medical and mental health person-
  a good 12 to 24 hours of sleep, only interrupted
                                                           nel, perhaps augmented by others brought in under
  when awakened for food. On the second day, they
  had an opportunity to shave and bathe. Approxi-          mobilization plans, will work at one or more sites
  mately 40 per cent could return to combat on the         located 5 to 10 km (3–6 mi) off-base; each site will be
  third day. Follow-up studies suggest that many of        independently capable of giving stabilizing medi-
  these men carried on indefinitely. Perhaps 25 per        cal care in support of approximately 4,000 troops. It


200
                                                                                U.S. Air Force Combat Psychiatry


should be noted that distances given are rather          the triage decisions concerning patients with psy-
arbitrary. The important concept is “psychological       chiatric symptoms in the hands of the flight surgeon
distance”: far enough from combat to be safe, near       or DBMS, neither of whom is likely to have either
enough to return to one’s own unit.                      combat or psychiatric experience, is to put the troops
   Although preliminary plans call for a psychia-        doubly at risk of the wrong decisions being made.
trist, a psychologist or a clinical social worker, and   Mental health workers must be on-base, making
two mental health technicians to augment some 2-E        every effort toward rapid, effective interventions:
facilities as part of the 50-bed Air Transportable       reassuring, explaining, exhorting, and above all,
Hospital, current U.S. Air Force manning levels          returning troops to their units as rapidly as pos-
make it unlikely that more than one off-base 2-E         sible.
facility per base will be so staffed. Thus, each local      What, then, might be the function of a 2-E site off-
Director of Base Medical Services (DBMS) may well        base? The author sees this as an overflow facility,
have to decide how best to use the available mental      used for patients who are truly mentally ill, or who
health staff, considering the on-base situation, the     have not been able to return to duty as expected and
off-base situation, the adequacy of communication        are awaiting evacuation. This facility may also
and transportation links, the combat/casualty situ-      receive patients when the on-base 2-E facility is
ation, the nature of the threat, and other such vari-    overrun with troops. The realities of the situation
ables. The disposition of local mental health re-        faced by the DBMS and the mental health staff
sources may be changed as the situation dictates,        should quickly result in the available facilities be-
and such local flexibility should not be hampered        ing used in the most efficient manner possible, if the
by excessive doctrinal rigidity. Common sense            tried-and-true principles outlined here are intelli-
should prevail, and all concerned should be aware        gently applied.
that their experience with the realities of the situa-
tion may quickly supersede set-piece planning.           Function of the Second-Echelon Facility
   Why be so insistent that early treatment be given
at the on-base 2-E facility rather than off-base? In        Clearly, the burden of the initial management of
a lecture to U.S. Air Force mental health profes-        acute symptoms immediately after a base is first
sionals in 1983, an Israeli psychologist pointed out     attacked will fall upon whatever medical personnel
the value of having mental health professionals          remain on that base, whether or not they have had
use their knowledge and experience close to the          formal mental health training. Another Israeli De-
fighting:                                                fense Force psychologist has emphasized that such
                                                         reactions may overwhelm unprepared medical per-
  • They can use their professional stature to           sonnel, especially if they themselves have also just
    resist local unit commanders who want to             experienced their first attack.51 Human nature leads
    evacuate troops with symptoms of combat              one to look to any perceived authority for help in
    fatigue. Less knowledgeable people might             crises, and the disaster literature leaves no doubt
    give way to such pressure.                           that anyone who is seen as having special knowl-
  • They can respond realistically to any troops         edge or skills in such a case will quickly be sought
    who say “You don’t know what it’s like,”             out. When confronted with troops having combat
    because they live on the same base and un-           shock reactions, medical personnel will certainly
    der the same conditions. This corresponds            look to colleagues with mental health training—any
    to the principle that flight surgeons should         mental health training—to handle the unwounded
    fly in unit aircraft, both in peace and in war,      stress casualties.51
    to meet the flier on equal footing in terms of          By now the reader must be aware that all military
    understanding the situation personally.              mental health authorities agree on the necessity not
    Although some 2-E facilities off-base may            to overreact to such circumstances by evacuating
    also need a mental health capability, it is          troops to the rear—not even a little bit to the rear—
    crucial that patients with only mild or early        because of the perceived secondary gain. “If they
    symptoms be kept on-base, along with a               ain’t hurt, don’t ship ‘em out!”
    contingent of mental health personnel. 50               This inelegant slogan is easy to remember in a
                                                         crisis, and may be used by medics and line person-
  To his two reasons, a third may be added. Few          nel alike. If the mental health troops on a base
U.S. Air Force medical personnel today, officer or       overwhelmed with somatic casualties are pressed
enlisted, have personal combat experience. To leave      into triage, litter-bearing, or treatment teams, they


                                                                                                            201
War Psychiatry


may join in following the course of least resistance     Principles of Treatment
and shipping the unhurt but stunned and sobbing
troops off-base to a less harassed 2-E facility. This       The treatment of acute combat reactions or of
impulse must be resisted, or there will be an intol-     combat fatigue on-base may be summarized in the
erable loss of unwounded troops to off-base loca-        acronym BICEPS (brevity, immediacy, centrality,
tions from which it may prove very difficult to          expectancy, proximity, and simplicity). The author
reclaim them.                                            coined this acronym in 1980 for use in the U.S. Air
   An on-base holding facility must be provided          Force Surgeon General’s Medical Red Flag training
to the DBMS by a wing commander who under-               program. The principles of proximity, immediacy,
stands the principles involved, explains them to         and expectancy, so named by Artiss, were articu-
the commanders of the various squadrons, and             lated by Glass52 in World War II and were derived
supports the DBMS in their application. Reflecting       from Salmon’s forward treatment during World
upon Richardson’s Tranquility House described            War I.53 The principles of brevity, centrality, and
above, 45 this author recommends that such an            simplicity were discussed by F. Jones, after the war
on-base facility be established in a reasonably          in Southeast Asia.37 Each principle might, of course,
secure location, away from primary targets, and run      be discussed at length, but, in the total context of
by the available mental health personnel. Flexibility    this discussion, they are identified as follows:
in assigning mental health nurses and occupational
therapists to this facility may also prove useful.         • Brevity. Treat briefly, from 12 to 72 hours,
   In the personal communication previously                  with the explicit goal being a rapid return to
noted, 51 Levy commented that the Israeli medical            duty.
service organizes its combat stress casualties along       • Immediacy. Treat as soon as the person’s
military lines, with unit names rather than medical          behavior makes it clear that he or she can no
names. Under this model, each U.S. Air Force                 longer function as a productive squadron
psychiatric technician might direct a “flight” of 10         member. Do not wait for full collapse of
or more casualties. Three or more flights would              function, especially if squadron authorities
comprise a “squadron,” with the squadron com-                or buddies indicate that this individual is
mand element consisting of the psychiatric social            becoming nonfunctional. Do not wait for an
worker, an NCO-in-charge (NCOIC), and, if avail-             outside consultant, either. Begin treatment
able, an occupational or physical therapist. This            now.
latter function might even be filled by a knowledge-       • Centrality. Treat combat fatigue cases who
able physical training technician from the base gym-         are being considered for evacuation in a
nasium.                                                      single location, separate from somatic casu-
   The structure of this local treatment team would          alties and “sick” patients, preferably admin-
thus emphasize the military aspects of the situation         istered by a single individual. At this single
and minimize the medical aspects. At this level,             location skilled personnel may be able to
treatment essentially consists of acknowledging a            prevent further evacuation.34,37
temporary inability to work, without falling into          • Expectancy. Treatment should be aimed at
the medical model (taking a history, writing up a            getting the individual back to duty, and all
chart, making a formal diagnosis), that reinforces           concerned must expect this to be the inevi-
the patient role. Such troops—do not call them               table and only outcome. The therapists
“patients”!—should not be formally admitted to               should ally themselves with the patient’s
the facility. “You’re not a coward, you’re not sick,         conscious will to remain and do the neces-
you’re just worn out, and you’ll be all right in a day       sary duty, and should work together toward
or two” must be the constant theme. A chance to              that goal so the fatigued person can return to
rest, a hot meal (the U.S. Army’s “3 hots and a cot”),       friends, unit, and job. The therapeutic alli-
a physical examination, however perfunctory, to              ance must not allow any other goal to inter-
reassure that there is no physical problem, and an           fere with getting the person well, and the
appeal to honor, group loyalty, and the mission              functional definition of “getting well” is a
may be all that is necessary. In fact, at his first          return to duty.
contact with the medics, all that a scared kid may         • Proximity. Treat close to the unit, so that
need is for someone in authority to tell him that he’s       cohesion continues. This will be most con-
all right, and that he must get back to work, do his         cretely demonstrated by having the person’s
part, and not let his buddies down.                          friends and commander visit, thus proving


202
                                                                               U.S. Air Force Combat Psychiatry


    that they do not reject combat fatigue vic-          increasing frequency in patients with increasingly
    tims as cowardly or unworthy. Those who              disturbed behavior, especially in those for whom
    repudiate their stricken comrades may be             recuperative facilities seemed to be of little use.54
    unable to tolerate any such tendencies in them-          More recent practices contradict these findings.
    selves and thus reject those who symbolize           The Israelis, as has been noted, are much more
    their own fears. Such people will contribute to      interested in behavioral treatment. One source cites
    the problem by increasing the victim’s guilt;        the use of medications, and only tricyclic antide-
    and, if they are leaders themselves, may lose        pressants at that, in only 8% of the 60 soldiers
    troops unnecessarily because of this attitude.       referred for 3-E and 4-E treatment out of the 600
    Close liaison between therapists and the             soldiers who were evacuated as combat fatigue
    parent unit will not only help the troops in         casualties in the 1982 Lebanon War. The treatment
    question, but will demystify the whole expe-         program for the majority consisted of “walking and
    rience for the unit as well, and will show the       talking,” abreactive individual and group psycho-
    lack of secondary gain: becoming symptom-            therapy, individual and group sports activities, and
    atic is not an automatic ticket out of combat.       combat-oriented military training.55 By contrast,
    Here again, the value of keeping this 2-E            the British, in the Falkland Islands War, used short-
    function on-base rather than several kilome-         acting benzodiazepines as a prophylaxis against
    ters away is obvious.                                excessive fatigue due to insomnia, evidently with
  • Simplicity. Treat in the here-and-now, aimed         good results.23
    at a return to duty. This is not the time for a          Two major cautions are offered against the early
    full-scale psychiatric evaluation and formu-         use of medications. First, their use tends to rein-
    lation, or a treatment contract extending into       force the sick role, because the giving of medica-
    the indefinite future.                               tions is one of the hallmarks of the physician-pa-
                                                         tient relationship in American society. Second,
Medications                                              many psychotropic medications have a duration of
                                                         action longer than the 72 hours that a combat fa-
   Psychopharmacology, like other areas of drug          tigue victim may spend in a 2-E facility, especially
therapy, is a dynamic and rapidly changing field.        if one takes into account the active metabolic prod-
Each physician uses medications in a highly per-         ucts of some of the drugs. Sending a person back to
sonal way, and psychiatrists are no exception. Some      combat duty still under the influence of psychoactive
are chemical nihilists, while others write a prescrip-   drugs may be dangerous. Even in peacetime, people
tion for almost every patient they see. Thus, the        in the many combat support positions covered by
precedents for the use or nonuse of medications in       the Personnel Reliability Program would not be
combat situations are by no means applicable to all      allowed to take such medications and continue to
situations or to all therapists.                         work in their sensitive, demanding jobs. The use of
   In World War II, psychiatrists frequently used        such medications under combat conditions must
sodium pentothal or Sodium Amytal1(p52) to help          thus be thoughtfully weighed for the risk-to-benefit
soldiers abreact their emotional turmoil. A review       ratio, both for the individual and for the mission.
of the use of medications in the Vietnam War by              In the end, the decision to use or not to use
some 40 U.S. psychiatrists revealed that a large         psychotropic medications rests with the physician
proportion of them used anxiolytic and neuroleptic       on the scene. There is much information on this
agents, even in early or mild cases of combat fa-        subject elsewhere, and anyone potentially faced
tigue.54 These therapists reported the use of recu-      with this situation would do well to know as much
peration, social therapy (the milieu of expectancy),     as possible about a few psychotropic drugs before
and medications, in that order of frequency, in the      the combat situation occurs, when there will be no
2-E environment.                                         time to look them up. Use such drugs sparingly and
   They used anxiolytics in about 30% of their cases,    for specific target symptoms, with full consider-
mainly for early symptoms, including apprehen-           ation of the two negative factors noted above.
sion (especially the “short-timer’s syndrome”), sleep
disturbances, tremors, and increased startle reac-       Treatment Setting
tions. They used neuroleptics in about 20% for
threatened assaultive behavior, defects in judgment,       Although one may find it impossible to imagine
or other behavioral changes which concerned or           what a 2-E facility might look like, on- or off-base,
alarmed the unit. Neuroleptics were used with            perhaps Enoch’s56 description of such a function in


                                                                                                           203
War Psychiatry


the Israeli campaign in Lebanon will be useful,              while upon reaching the (medical station) they
especially when compared and contrasted with                 complained of difficulties with thoughts and feel-
Menninger’s description of a similar function in             ings—termed “the ticket in” to treatment. The
World War II, cited above.                                   Israelis concluded that severity of initial symptoms
                                                             had little to do with prognosis for recovery; the
                                                             most important indicator of a good prognosis was
  Initially, (the) team would conduct an interview to        the soldier’s labeling himself as healthy, taking
  establish where the soldier had been, what he had          initiative in his own care, helping others, and help-
  done, and what had happened to him. This inter-            ing run the treatment team’s area.56(p14,15)
  view was oriented objectively rather than toward
  thoughts and feelings. The team confirmed two of            With the applications of the BICEPS principles
  the observations made in previous wars. First,           there is a deemphasis on medications and the “sick”
  thoughts and feelings inevitably followed the de-        role. Troops in this ambiance must not be treated as
  scription of the objective events. Second, just de-
                                                           patients. They must spend the day in uniform, not
  scribing what had happened clarified events and
  reduced the emotional turmoil. The team would            in pajamas, unless they are specifically supposed to
  allocate the next 6 to 8 hours of treatment to physi-    be in bed resting for the first 12 to 24 hours. Their
  cal replenishment (water, food, and rest). Then the      days should be structured and should be used pur-
  soldier was given useful tasks to do and invited to      posefully to maintain the identity of each as a func-
  join in supportive individual and group psycho-          tional military person. Daily roll call, announce-
  therapy. Next, the team arranged for comrades            ment of the day’s schedule, physical training, useful
  from the soldier’s unit and for the unit commander       activities such as digging trenches or bunkers, fill-
  to visit the soldier. Then the soldier himself was       ing sandbags, improving the local area, playing
  taken to visit the unit. In these ways, mutual
                                                           sports, and attending meetings should be the order
  confidence between the soldier and his unit was
  restored. When the soldier had recovered enough          of the day. The value of occupational and physical
  to return to the unit, the team would arrange for        therapists in planning and carrying out such activi-
  comrades from his unit to pick him up. This team         ties is clear.
  took advantage of its proximity to the front and the        In the 528th Medical Detachment, already men-
  soldier’s unit to maximize expectation that he would     tioned, the role of occupational therapy personnel
  return and to reinforce the soldier’s link to his        as “environmental managers” both in the consulta-
  comrades and commander. The team observed                tion role and the therapeutic role proved extremely
  that units were happy to receive the soldier back,       valuable during the Persian Gulf War. Presentation
  confirming the finding from other sources that
                                                           as “work therapy” furthers the sick role, so the
  under stress group members prefer someone they
  know to someone they do not know, regardless of          presentation as “work assignment,” “work detail”
  presumed competence. With respect to themselves,         or “work activity,” may be more appropriate to the
  the members of the psychiatric team noted that,          “return to duty” ambiance of this modality.
  because of their proximity to the front, they were       Ellsworth and colleagues57 have presented a review
  all afraid. However, sharing the dangers of combat       of this subject, together with a model schedule for
  with the soldiers being treated reduced their reluc-     patient activities (Exhibit 8-1).
  tance to return a soldier to his unit. They noted that      Group therapy sessions must be carefully moni-
  their fear was diminished to the degree that the         tored and one must be particularly careful not to let
  (medical) commander was competent in ensuring
                                                           them turn into “my experience was worse than your
  their supplies of gasoline and other essentials. When
  this was not the case, they became more afraid,          experience” sessions. Such an ambiance may be
  hoarded supplies, and saw their clinical effective-      perceived as rewarding symptoms, and troops may
  ness decline. The team observed their tendency to        escalate each other into brief reactive psychoses if
  overidentify with the soldier they were treating; to     not restrained.51 Thus, such sessions should be
  want to be the “good father,” and to protect their       goal-directed, here-and-now, and oriented toward
  new-found “son” from harm. This difficulty was           health rather than emphasizing symptoms and dis-
  reduced through once-a-day staff meetings for the        ability. Sports programs, which by their nature
  purpose of discussing cases, providing mutual sup-       reward healthy behavior, are of particular value.
  port, and working through emotional conflicts.
                                                           Coaches urge one to perform in spite of symptoms.
  The Israelis observed that the psychiatric symp-
  toms changed from the time the soldier broke down           The programs of Menninger49 and the Israelis56
  at the front to the time he arrived at the (medical      were reflected in that of the U.S. Army in the Gulf
  station). At the front, soldiers suffering psychiatric   War. “PSYCH-FORCE 90” was the self-designation
  breakdown complained of an inability to perform—         of the 528th Medical Detachment, a psychiatric OM
  termed by the Israelis “the ticket out” of combat,       (combat stress prevention and treatment) organiza-


204
                                                                                    U.S. Air Force Combat Psychiatry


                                                               Their second mission was to triage and treat
   EXHIBIT 8-1                                              dysfunctional soldiers. After one interview, they
                                                            would make disposition: evacuate the truly men-
   SECOND-ECHELON TREATMENT
                                                            tally ill, hold a soldier for treatment if suicidal.
   FACILITY: MODEL SCHEDULE FOR
                                                            Otherwise, they attempted simple ventilation, fo-
   PATIENT ACTIVITIES
                                                            cusing on solutions in the here-and-now. Problems
                                                            involving the family back home were referred to the
                                                            chain of command. (Their experience, and that of
                                                            the author 30 years earlier, was that evacuating
                                                            troops from a combat zone for family reasons was
                                                            folly, and would result in an epidemic of family
                                                            problems within the unit.)
                                                               Soldiers held for duty were kept in a military
     Exhibit 8-1 is not shown because the copyright
                                                            environment—cots in tents. Therapeutic emphasis
  permission granted to the Borden Institute, TMM,
  does not allow the Borden Institute to grant per-
                                                            was on healthy functioning through an intensive
  mission to other users and/or does not include            work-therapy program, promoting adaptation
  usage in electronic media. The current user must          through psychological educational classes and small
  apply to the publisher named in the figure legend         group therapy. This involved only limited ventila-
  for permission to use this illustration in any type of    tion, restructuring problems into here-and-now re-
  publication media.                                        solvable issues, and acquiring adaptational skills.
                                                            Command consultation was obtained when war-
                                                            ranted.
                                                               A common factor associated with developing
                                                            adjustment disorders was the soldier’s assignment
                                                            to a new unit within 90 days of deployment (ie, the
                                                            soldier was not yet strongly bonded to the unit).
                                                            Most soldiers presented for treatment within their
  Adapted with permission from Ellsworth PD, Sinnott        first month in theater, pointing up the need for
  MW, Laedtke ME, McPhee SD. Utilization of occupa-         some stress training prior to deployment. Also,
  tional therapy in combat stress control during the Per-
  sian Gulf War. Milit Med. 1993;58:383.
                                                            problems reflecting troubles at home indicated the
                                                            usefulness of strong family support programs.
                                                               Other patient clusters centered around: (a) moth-
                                                            ers leaving small children, losing their bonding; (b)
tion of 15 officers and 33 enlisted troops deployed to      Reserve or Guard troops taking psychoactive medi-
Saudi Arabia in October, 1990, to support the Per-          cations prescribed by their civilian physicians, be-
sian Gulf War.58 This unit operated three consulta-         ing cut off these medications through lack of avail-
tion teams that made proactive visits to U.S. Army          ability, or contraindicated because they lowered
units, and one base camp treatment team that fur-           heat tolerance; (c) functional symptoms found to be
nished outpatient and inpatient therapy (20 beds).          due to organic conditions; and (d) veterans of prior
Between November 3, 1990 and January 10, 1991,              wars undergoing exacerbations of traumatic stress
the unit performed 600 unit consultations. Several          reactions. This latter situation frequently involved
thousand soldiers were seen altogether. The units           medical troops, and was possibly associated with
performed 387 formal psychiatric evaluations, and           their easy access to psychiatric care.
held 123 soldiers for treatment. Fifteen percent               After the OM team arrived in theater, the evacu-
were evacuated out of theater. (Of all the soldiers         ation of personnel because of personality disorders
evacuated to Europe, less than 6% had psychiatric           fell by 50%; most evacuations after that were for
diagnoses.)59 This effective use of psychiatric treat-      major psychiatric disorders.58 The success of this
ment teams involved two facets. First, in consulta-         unit should light the way for U.S. Air Force mental
tions with commanders, they actively sought to              health professionals.
advise the field units about psychological stress,
work-sleep cycles, heat stress, buddy-aid, critical         Options for Disposition of Troops
event debriefings, and follow-up consultations
when necessary (as with training accidents or firing           Therapists working at on-base or off-base 2-E
weapons in anger).                                          facilities will have a number of choices for disposition


                                                                                                                205
War Psychiatry



   EXHIBIT 8-2
   OPTIONS FOR DISPOSITION OF TROOPS PRESENTING AT 2-E FACILITIES


   1.   Immediate return to duty.
   2.   Hold for a brief period, perhaps with a meal, rest, and return to duty without having been admitted.
   3.   Hold overnight, as in (2) without admission. Possible use of a single dose of short-acting benzodiaz-
        epine for sedation.
   4.   Relieve from duty (admit) and treat as indicated for 2–3 days. Use BICEPS principles. Return to duty.
   5.   Use of (4), with return to limited duty or to less hazardous or less demanding duty. This may be
        especially useful in the “old sergeant’s syndrome.”
   6.   Use of (4), with unsatisfactory results and with subsequent evacuation to a 3-E facility.
   7.   Treatments (1–5), with subsequent return to commander for administrative action, in instances where
        the problem is due to personality disorder rather than to medical or psychiatric problem.
   8.   Evaluation and immediate evacuation to the 3-E level when the diagnosis is a true and severe mental
        disease. This procedure should occur only rarely.
   9.   Evaluation leads to a diagnosis of probable somatic disorder and the patient is transferred to the
        appropriate treatment facility.




of troops who come under their care (Exhibit 8-2).           Summary
Precedent, imagination, and experience suggest
the outcomes delineated in the exhibit; others                  Future wars may replicate past wars in which air
may be developed as the exigencies of the situation          crews carried out transportation, bombing, and
dictate.                                                     fighting missions from a relatively safe support
   In the section on care of fliers, the value of a          base. In this case, little change from prior practices
formal ending to a unit’s combat experience has              in the care of nonflying personnel is required. In a
been mentioned. Current literature also under-               large-scale engagement, however, modern tactics,
scores the value of a stress debriefing of the entire        reflecting technological advances, call for pressing
unit. This is a formal process, and should be under-         the battle to support facilities, perhaps through
taken only by trained professionals, preferably not          long-range missile or air assaults. In such a situa-
assigned to the unit. It is modeled on the Critical          tion (eg, the Persian Gulf War) nonflying U.S. Air
Incident Stress Debriefing,60 used by many civilian          Force personnel may become combat targets and
fire and police departments, and similar organiza-           thus combat stress casualties. Currently, little pro-
tions. This process has been termed the “After-              vision is made for such casualties; however, there is
Action Stress Debriefing.” 61                                good reason to believe that the traditional prin-
   This process is too involved to be discussed here,        ciples of U.S. Army combat psychiatry, as described
but is discussed extensively in Chapter 11, Debrief-         by the “BICEPS” acronym, can be effective in treat-
ing Following Combat. Authors who served in the              ing and returning to duty the majority of these
Gulf War have attested to its value, and to the              casualties. Provision of this treatment will require
consequences of not having such a program avail-             education and training of all personnel and medical
able.62,63 Medical personnel of many disciplines             and mental health personnel assigned “forward” at
know of the concept, and the absence of a chance to          first- and second-echelon support installations. As
process their combat experiences will be missed              always, good leadership and cohesive units will
and commented upon.                                          minimize combat stress casualties.

                                                  CONCLUSION

   The author has studied this topic, lectured on it,        histories, aeromedical reports, and the literature of
and discussed it with colleagues since 1979. He has          military medicine and psychiatry. In a most intro-
also read historical and current military biographies,       spective way, he has reexamined his service as a flight


206
                                                                                   U.S. Air Force Combat Psychiatry


surgeon with the Air Commandos in Vietnam, and                In addition, medical officers and NCOs may well
would add the following remarks to this chapter.           have to exercise command of troops in the combat
   To begin with, physicians and others thinking           ambiance, a fact that may never have occurred to
about combat must understand that they will have           them until now. The responsibility for giving or-
to deal with combat from three points of view. The         ders that may result in the loss of life or limb by
first of these has already been thoroughly dis-            those carrying out the orders is not a subject taught
cussed—the care of others. The second of these is          in medical school or emphasized in unit training
that they must also think about caring for them-           exercises. It is an awesome responsibility, and all
selves. The realities of combat will also reach those      medical personnel would do well to learn a bit more
trying to ameliorate its effects, often in a most intru-   about combat leadership than the service usually
sive and distressing way. Those feelings will have         teaches medics. Military medical officers are accus-
to be dealt with. It is vital that mental health           tomed to maintaining currency in their medical
providers take care of themselves and their col-           literature. It is vital that they maintain currency in
leagues. And the third point of view is that they          the military literature as well. Through long expe-
must care for their colleagues. This includes being        rience, line officers will tend to believe that a medic
alert for the abuse of alcohol as a solvent for pres-      is a good medic unless proven wrong. They will
sures and emotions, and be aware that medics, too,         also tend to believe that a medical officer is not a
need time off, especially those in the surgical arena,     good officer until the medical officer proves that he
confronted daily with carnage beyond comprehen-            is. Medics must be as good at their job as those on
sion. Patients, self, and fellow medics: one must be       the line are at theirs.
aware of all three.                                           Principles of conservation, training, planning, and
   Commander Sandra Yerke’s graphic description            execution of war plans apply to the medical com-
of the difficulties encountered in molding a group         mander as surely as they do to the line commander.
of strangers into a competent staff on a hospital ship
during the Persian Gulf War 64 should be required            (T)he physician-soldier must be able to make the
reading for each medic on active duty. Anyone may            hard decisions that are required … with little time
deploy at any time, if the circumstances are right,          to reflect, depending instead on the education and
and all must be prepared, always.                            training that has led him [or her] to a leadership
                                                             position and the medical intelligence avail-
   Wars tend to be come-as-you-are events, and
                                                             able….The troop commander must be prepared to
there will be little time to read up on them once            make decisions that place the lives of those that he
one starts. Field medical units usually do not in-           is responsible for at risk. So must the physician
clude libraries, and thus mental health providers            who commands others in war.”65(p375)
most often deploy with only the knowledge they
carry in their baggage or in their heads. Base or post         Finally, and most personally, the author recalls
libraries usually have very good military sections         the well-known words of General Robert E. Lee as
and the author urges the reading of some books             he viewed the appalling battlefield at Fredericksburg
written by medical personnel about their experi-           after his victory over General Burnside: “It is well that
ences. The thoughtful perusal of a few such books,         war is so terrible, else we should become too fond of
combined with constructive thinking about what             it.” Having spent a year in Vietnam, and having been
the role of the mental health provider might be in         immersed in the medical literature of war since 1979,
such a situation, may help prepare such personnel          the author agrees. His wish and his prayer are that
in ways that would not otherwise occur to them or          none who read these words may ever have to put into
to those who train them.                                   practice the principles of combat psychiatry.

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  3. Lifton RJ. Psychotherapy with combat fliers. US Armed Forces Med J. 1953;4:525–532.

  4. Schultze HA. Fear of flying. USAF Med Svc Dig. 1952;3:25,51.



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  5. Spiegel FS. Problems of the flight surgeon in Korea. US Armed Forces Med J. 1953;4:1321–1324.

  6. Marshall SLA. Swift Sword. New York: American Heritage Publishing Co Inc; 1967.

  7. Payne LGS. Air Dates. London, England: William Heinemann Ltd; 1967.

  8. Link MM, Coleman HA. Medical Support of the Army Air Forces in World War II. Washington, DC: Office of The
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  9. Berger C, ed. The United States Air Force in Southeast Asia. Washington, DC: Office of Air Force History; 1977.

 10.   Farmer RA. Personal Communication, 1984.

 11.   Jones DR. Flying and danger, joy and fear. Aviat Space Environ Med. 1986;57:131–136.

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