35

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
War Psychiatry

36

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.
37

Traditional Warfare Combat Stress Casualties

INTRODUCTION

not unusual for sheer numbers of surgical casualties to overwhelm the forward treatment capabilities and result in evacuation rearward of stress

casualties. High-intensity warfare, in addition to

making forward treatment difficult because of the

absence of a safe treatment area, will likely overwhelm the forward treatment facility with very

large numbers of surgical and psychiatric casualties.1 Low-intensity warfare can also produce psychiatric casualties and misconduct stress casualties

(drug abuse, disciplinary infractions, venereal diseases) that may be difficult to treat—as was seen in

Vietnam.

The types of casualties and their treatment depend on the type of war. It is, therefore, appropriate

to discuss them in this context after first defining

stress and psychiatric casualties.

The diagnosis and treatment of combat stress

casualties range from the easily accomplished to the

highly difficult. Diagnosis may be apparent when

a fatigued, anxious, otherwise intact soldier says,

“Doc, I can’t take it anymore.” Diagnosis may be

more difficult when the casualty is mute and unresponsive, or aggressive. Making the diagnosis is

complicated not only by the heterogeneity of symptoms in the unwounded but also by potential wounding agents that can present with or mimic psychiatric symptoms. In addition to bullets, fragments,

and burns, such wounding agents include biological and chemical agents, and radiation, both nuclear

and microwave.

Treatment involving rest, nutrition, and expectancy, while generally easy in concept, may be difficult in application. During World War II, it was

DEFINITION AND MANIFESTATIONS

ment of which will be best for the mission, the unit,

and the individual soldier. This textbook will distinguish the psychiatric, stress, and misconduct

categories except when making historical references

and citations where “psychiatric” is historically

accurate.

Manifestations of combat stress overlap at both

ends of the psychobiological spectrum, and one role

of the psychiatrist is to separate out particularly the

neurological cases that require a different, sometimes

surgical form of treatment. Sometimes it is important

also to separate out the conscious malingerers, but

this is not always the case because the treatment

involving rest, expectancy, and strengthening the

desire, however attenuated, of the soldier to return

to his unit is generally the same in cases of combat

fatigue and malingering. In the latter instance,

however, a more coercive stance (threat of courtmartial) may be required if early rest, expectation of

recovery, and talking therapy do not produce willingness (however reluctant) to return to duty.

It is important to remember that most psychiatric

casualties are soldiers who, because of the influence

of negative psychological, social, and physiological

factors, unconsciously seek a medical exit

from combat. Most cases, therefore, will mimic

features of other medical disorders that would be

“legitimate” forms of escape from combat, thus

Historically, since late World War I, a combat

psychiatric casualty has been defined as any militarily ineffective soldier (or organization) in whom

the predominant factors producing ineffectiveness

were of psychological (as opposed to physical)

or neuropsychiatric origin. Although partly fulfilling this definition, disorders involving structural

damage or major physiological disturbances of

brain tissue were normally excluded from this category. Nonconflicted malingering was also excluded.

Current U.S. Army doctrine2 distinguishes psychiatric from stress casualties. Psychiatric casualties are those with standard Diagnostic and Statistical Manual (DSM-IV)3 diagnoses which are not

simply the temporary consequence of the intense

psychological and/or physiological stress of combat or other highly stressful missions. These latter

are labeled “stress casualties,” “battle fatigue,” or

“contingency fatigue.” The U.S. Army classification also defines the “misconduct stress behaviors”

as violations of regulation or law which require

disciplinary action even though they are largely

attributable to stressful conditions. It is recognized

that psychiatric disorders, battle fatigue, and misconduct stress behaviors can coexist in the same

soldier, with some grey areas where any of these

labels can be used, based on the command’s judg-
War Psychiatry

38

becoming “evacuation syndromes.”4 Improperly

treated through evacuation, the symptoms

may persist or worsen, developing characteristics

of traumatic neurosis (chronic post-traumatic stress

disorder).

The symptoms displayed are those considered

more acceptable by fellow soldiers, commanders,

and medical personnel. The symptoms often

have a neurological or psychophysiological flavor,

which in the past led to their classification as neuroses (anxiety and somatoform disorders). The absence of “neurotic” personality patterns and

the transience of the syndrome when properly

treated indicate a more appropriate categorization

as a transient or situational stress or adjustment

disorder.

Based on World War II experience, Weinstein

and Drayer5 distinguished the anxiety states of combat from those of civilian life by the following characteristics of combat anxiety: (a) the extraordinary

precipitating factors in the perils and hardships of

the combat environment, (b) symptom plasticity, (c)

the importance of hostility and guilt, which is more

immediately apparent than in most neuroses in

civilians, and (d) the fact that they are in large part

group phenomena. The soldier is a member of a

closely knit, interdependent group, and group effectiveness and attitudes as well as ability to identify with the group modify significantly the soldier’s

capacity to withstand the traumas to which he is

subjected. Failure in group membership may result

in symptom formation.

From this discussion it is obvious that the symptom complex may be quite heterogeneous and fluid.

During the early years of World War I, when it was

believed that many soldiers were suffering from

concussion caused by exploding shells or bombs, a

diagnosis of “shell shock” was given and the symptoms mimicked those of persons who had suffered

from a blow to the central nervous system. In the

words of Bailey, Williams, and Komora: “There

were descriptions of cases with staring eyes, violent

tremors, a look of terror, and blue, cold extremities.

Some were deaf and some were dumb; others were

blind or paralyzed.”6(p2)

Later, after the use of poison gas had become

widespread, many soldiers presented with respiratory symptoms, particularly “choking” and hyperventilation, and they were often labeled “gas hysteria.” As the psychological nature of the syndromes

became known and the term “war neurosis” came

into vogue, soldiers would present themselves as

suffering from neurosis and latch onto this label as

a legitimate escape from combat, leading to a policy

by medical personnel of using a cryptic label,

“N.Y.D. (nervous)” which stood for “not yet diagnosed (nervous),” as described in Chapter 1, Psychiatric Lessons of War.

Similarly, in the early phases of U.S. involvement

in World War II, medical personnel used the term

“psychoneurosis.” Soldiers abbreviated this unfamiliar term to “psycho,” and the casualties

frequently displayed bizarre and regressive symptoms similar to those often seen in psychotic

patients.7

 With the rediscovery of the principles

of treatment by Hanson in North Africa,8 and

the use of the term “exhaustion,” the bizarre symptoms receded to be replaced by symptoms of fatigue.

Glass7 explained the efficacy of the term “exhaustion” compared with the diagnosis of psychoneurosis. Psychoneurosis implied unresolved intrapsychic conflict with unconsciously derived

symptoms. The linkage between the symptoms and

the conditions of combat was lost, and such casualties would not be accepted by the soldier’s combat

reference group as a normal result of battle. Instead, such soldiers were considered weaker, predisposed persons who had not been properly

screened out at induction. Exhaustion was selected

because it best described the appearance of most

psychiatric casualties and of most combat participants of the time. Exhaustion was readily accepted

by the casualty and his combat reference group.

They could appreciate that anyone could become

exhausted by the stress and strain of continual combat. The psychiatric casualty became a rational

consequence of battle conditions. The new terminology communicated that the casualty was afflicted with a temporary, situationally-induced disorder that only required rest for restoration of

function.

Despite the variability of symptoms in combat

breakdown, some groups of symptoms have predominated in various wars. Bar-On and colleagues,

as cited in Belenky,9 have reviewed the predominant symptoms described in U.S. and Israeli casualties in World War I, World War II, Vietnam, and the

Arab-Israeli wars of 1973 and 1982. These symptoms were grouped by Jones10 in Table 2-1. These

listings are not actuarial and should be viewed as

showing tendencies only. When the anxiety and

fear categories are collapsed, these symptoms are

found to predominate in all U.S. wars except the

Vietnam conflict. Even in the Vietnam conflict, an

examination of psychiatric syndromes among sol-
39

Traditional Warfare Combat Stress Casualties

TABLE 2-1

SYMPTOM CLUSTERS IN VARIOUS WARS

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

mobile psychiatric detachment (KO Team) early in

the war before drug abuse and disillusion became

widespread reveals a large number of anxiety-type

symptoms. This is evident in Exhibit 2-1. In

nonwounded soldiers, Bowman11 found a predominance of dissociative, anxiety, and conversion symptoms, and in wounded soldiers anxiety dreams and

neurological symptoms.

Similarly, Jones12 found that anxiety and fear

symptoms predominated in combat soldiers in Vietnam. In contrast, combat-support soldiers were

more likely to present with what Jones referred to as

“disorders of loneliness,” which may be the modern

analog of the “nostalgia” of previous centuries.

Copen described the psychiatric stresses of military

advisory soldiers in Vietnam in 1962 before largescale U.S. involvement:

Support troops, although exposed to little physical

danger or hardship, nevertheless were stressed by

separation from family, boredom, and job frustration. These men were frequently seen because of

excessive drinking, psychosomatic complaints, and

behavioral problems. Such individuals from support units were contrasted with advisors to combat

units in which there was constant physical danger

and far less comfortable environmental surroundings. These stresses resulted in casualties referred

to as combat fatigue, although this entity tended

frequently to be disguised in the form of antisocial

behavior or vague physical symptoms.4(p50)

Thus, it appears that some manifestations of psychiatric difficulty are related to frequency and intensity of exposure to combat. The relationship of

breakdown and its psychiatric manifestations to

combat conditions will now be examined.

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.
War Psychiatry

40

EXHIBIT 2-1

STRESS SYMPTOMS IN WOUNDED AND NONWOUNDED SOLDIERS AT THE 93RD EVACUATION HOSPITAL, VIETNAM, JANUARY–JUNE 1966 (Not listed in order of prevalence)

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.

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.

ETIOPATHOGENESIS

The etiopathogenesis (origin and process of disability) of the stress casualties of mid- to highintensity combat was well known by the French and

British during World War I and became the basis for

Salmon’s “forward treatment.” Strecker describes

Salmon’s etiological concept as follows:

His visualization of the concept of the emotional

conflict underlying war conversion hysteria (the

moving demands of the instinct of self-preservation stirring deep and strong affective currents vs.

the conscious expectations, desires, and requirements of “soldierly-ideals” imbedded in an emotional matrix of discipline, patriotism, and the like)

was so dynamic and stimulating that it served as a

beacon light to every psychiatrist in France, no

matter how dark the outlook.13(p386)

Appel and Beebe put it more starkly in describing psychiatric casualties of World War II:
41

Traditional Warfare Combat Stress Casualties

[T]he danger of being killed or maimed imposes a

strain so great that it causes men to break down ...

Each man (up there) knew that at any moment he

may be killed, a fact kept constantly before his

mind by the sight of dead and mutilated buddies

around him. Each moment of combat imposes a

strain so great that men will break down in direct

relation to the intensity and duration of their exposure. Thus psychiatric casualties are as inevitable

as gunshot and shrapnel wounds in warfare.14(p185)

Psychiatric Casualties and Combat Intensity

Glass has described the relationship of intensity

and breakdown as following a bell-shaped or

Gaussian curve:

Very obviously, if you raise the destructive power

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

such as bows and arrows, or rifles, more people can

cope with it. This is why men tell you in combat

they don’t mind small arms fire; what they detest is

artillery fire or mortar or other high explosives. So

if you diminish the destructiveness, your curve

looks different; if you raise it, then you have more

non-effective people.15(p4)

Marlowe16 has discussed the concept that combat

stress casualties occur as a function of various “battle

ecologies” in which the most important variable is

the lethality of the environment. The stress casualties more directly related to combat have been shown

in numerous studies to occur in a direct ratio to

combat intensity as measured by killed-in-action

(KIA) or wounded-in-action (WIA) casualties.17 This

ratio usually is about one stress casualty per three

or four WIA casualties; however, other factors related to morale, training, physical fatigue, prior

exposure, and combat success can markedly change

this ratio. It, therefore, becomes appropriate to

group stress casualties according to combat intensity. Combat intensity has generally been measured by numbers of WIA and KIA per combat day

(any day in which one or more soldiers per company was killed or wounded). Because some injuries are combat-related but not caused by wounding, statisticians often combine the rate of battle

injury and wounding (BI & W), usually given per

1,000 troops per year. Based on BI & W rates, World

War II and most of the Korean conflict may be

considered mid-intensity combat, and much of the

Vietnam conflict may be considered low-intensity

combat,18 as seen in Table 2-2.

Data sources: [US Civil War, World War I, and World War II]

Beebe GW, De Bakey ME. Battle Casualties: Incidence, Mortality,

and Logistic Considerations. Springfield, Ill: Charles C Thomas; 1952:

21. [Korea] Office of the Surgeon General. Korea: A summary of

medical experience July 1950–December 1952. In: Health of the

Army, January, February, and March 1953. Washington, DC: US

Department of the Army; 1953. [Vietnam] Neel S. Vietnam Studies:

Medical Support of the U.S. Army in Vietnam, 1965–1970. Washington, DC: US Department of the Army; 1973: 33, 36.

War Year Nonbattle Battle Injuries

Injuries and Wounds

U.S. Civil War 1861–1865 — 97

World War I 1917–1918 — 238

World War II

Pacific 1942–1945 122 39

Europe 1942–1945 101 108

Mediterranean 1942–1945 131 80

Korea 1950 242 460

1951 151 170

1952 102 57

Vietnam 1965 67 62

1966 76 75

1967 69 84

1968 70 120

1969 63 87

TABLE 2-2

BATTLE INJURY AND WOUNDING RATES/

1,000 TROOPS/YEAR DURING VARIOUS

U.S. WARS

Obviously, during some periods of engagement

with the enemy, BI & W rates for the engagement

may be quite high but may or may not reflect significant changes in the overall rate. For example, during the first 6 months of the Korean conflict, casualties were higher than in any other American war by

a factor of two due to the surprise North Korean

invasion, the retreat to Pusan, the amphibious U.S.

counterattack at Inchon, and the surprise Chinese

attack from Manchuria. Because of the large numbers of U.S. casualties and relatively small numbers

of U.S. troops in Korea, the annual rate approaches

that of a high-intensity conflict.19

Similarly, during much of the Vietnam conflict,

battle intensity as measured by BI & W rates was

low; however, during the several months of the Tet

offensive of 1968, casualties were relatively high,
War Psychiatry

42

resulting in an annual BI & W rate for 1968 of

120, above the World War II (1942–1945) European

rate of 108. Despite some intense battles, U.S. Civil

War (1861–1865) casualties among Union troops

were only 97/1,000/y,15(p6) making it a low- to

mid-intensity conflict, while the American Expeditionary Forces’ World War I (1917–1918) rate of

238 would place it in the mid- to high-intensity

range.17(p6)

Another factor in intensity is total number of

casualties per unit of time. The suddenness and

intensity of the 1973 Yom Kippur War resulted in

the compression of the amount of casualties normally occurring in the first 20 days of combat in

World War II battles into the first 24 to 72 hours of

combat.1

To take into account this factor of large numbers

of casualties in a brief period of time, combat intensity has also been measured by the numbers of

“pulses” of fighting in a given time period. During

most of the battles of World War II and the Korean

conflict, the number of battle pulses per day of

combat did not exceed 4 or 5, whereas during the

1973 Yom Kippur War there were 10 to 12 battle

pulses per day for the first week.1

Battle pulses of high-intensity combat are accompanied not only by high rates of killing and wounding but also by high rates of stress casualties. In the

1973 Yom Kippur War, some units, for example,

had as many stress casualties as surgical casualties

among both the Israeli and Egyptian forces.20,21 There

is much overlap not only in combat environments

but also in symptom complexes.

In general, however, when one compares the

symptoms predominating in various wars during

the past century, a clustering can be seen based to a

degree on the intensity of combat. For example, in

addition to venereal diseases and “voluntary casualties”—those caused by failure to take antimalarial

pills, engaging in substance abuse, presenting discipline problems (including refusal to fight and

assassination of superiors)—are the primary characteristics of low-intensity, unpopular wars: explosive aggressive behavior, social estrangement, and

constricted affect. Depressive affect reported by

Bar-On and colleagues22 as occurring in World War

I, the 1973 Yom Kippur War, and the 1982 Lebanon

War psychiatric casualties may also fit into this lowintensity war symptom complex depending on how

it is defined.

During World War I, stress casualties presented

with hysterical syndromes, psychomotor disturbances, and fear, as well as depressed affect. The

high-intensity combat of the 1973 Yom Kippur War

produced similar casualties, and the roughly

2-week period of intense warfare during the

1982 Lebanon War also produced these casualties.

Except for that 2-week period, which produced

most of the “traditional” (anxiety and fear) stress

casualties, engagements in Lebanon were more of a

low-intensity, insurgency nature with snipers and

booby traps accounting for many casualties.9

 In

this situation the development of symptom overlap

between Vietnam, overall a classic low-intensity

conflict, and the 1982 Lebanon War (ie, social estrangement) is seen. In a review of follow-up studies, Belenky23 has detected another similarity between Israeli casualties from the 1982 Lebanon War

and U.S. casualties from the Vietnam conflict,

namely, the development of delayed stress casualties, which are reported as high in both groups of

veterans.

These low-intensity warfare casualties, who

present with problems that suggest a depressive

core and depressive symptoms, were the primary

presentation of nostalgia in preceding centuries.24

Unchecked, these casualties can significantly degrade the combat efficiency of a unit as was seen in

the latter phases of the Vietnam conflict.4

The “short-timer’s syndrome,” the development

of superstitious dread that one’s chances of being

killed are increased followed by phobic anxiety and

attempts to avoid all risks even when called for by

the military mission, was described as a frequent

occurrence in most combat and many combat-support soldiers in Vietnam in the final weeks before

rotation home.25 This syndrome had been described

in other situations in which exposure to combat is

limited by length of time (9 mo of combat in the

Korean conflict) or number of missions (a fixed

number of bombing runs by aircrews during World

War II). Its appearance in Vietnam was, therefore,

not surprising; however, its widespread occurrence,

affecting even those in minimal danger, may have

reflected disaffection and a sense of hopelessness in

fighting the war.

Stress casualties of low-intensity combat differ

substantially from those of mid- to high-intensity

combat, which present primarily with anxiety and

conversion and dissociative symptoms. In contrast,

low-intensity combat casualties tend to present with

“nostalgic” symptoms such as alcohol and drug

abuse, venereal diseases, and character and behavior problems of indiscipline. Nostalgic casualties,

for the purposes of this chapter, will be defined as

the psychiatric symptom clusters that predominated

in the behavior leading to ineffectiveness in Vietnam (see Table 2-1). Venereal diseases may be
43

Traditional Warfare Combat Stress Casualties

included because, like failure to take malarial prophylaxis or to protect oneself from frostbite, psychological ineffectiveness is often manifested by

their appearance.

Prediction of Psychiatric Casualties

From this discussion one may conclude that there

is a certain degree of predictability of numbers and

types of stress casualties when one knows the intensity of warfare (WIA rate) and composition of the

soldier population (combat vs combat-support

troops). In a general way this is true. In a mid- to

high-intensity battle, soldiers will present with combat stress disorders, but in low-intensity or nonbattle

conditions, “garrison neuropsychiatric” casualties

will predominate. As combat intensity increases

the number of combat stress casualties also increases.

There are not yet enough data to predict with confidence the incidence of garrison stress casualties,

but the subject is treated extensively in Chapter 3,

Disorders of Frustration and Loneliness.

This generalization is, however, an oversimplification that does not take into account the numerous

factors that protect a soldier from or predispose him

to breakdown. The protective factors include unit

cohesion, good leadership, experience with and

confidence in one’s weapons, absence of fatigue,

and prior exposure to combat. Predisposing factors

would be the negatives of these. The progress and

type of battle also influence the rate of stress casualties. Advancing victorious and retreating defeated armies usually have few stress casualties. In

static warfare, with much indirect fire from heavy

artillery barrages or aerial attack, stress casualties

are increased.15

A recently identified factor found to be significant in producing Israeli stress casualties in the

1973 Yom Kippur War is the presence of concurrent

nonspecific stress.26 The stress usually is a product

of situations in the soldier’s nonmilitary life; for

example, pregnancy of spouse, birth of offspring,

an ill relative, or financial adversity.

Many of these factors would be unknown to the

clinician under usual battle conditions, and, even if

they were known, it would be difficult to assign

them a particular weight for prediction purposes.

Their importance lies in preventive programs. Judging from historical review and recent experience of

Israeli medical personnel in the 1982 Lebanon War

(23% stress casualties despite attempts to prevent

the influence of predisposing factors), the factor of

combat intensity seems to outweigh most of the

other factors in generating combat stress casualties.

In future wars, therefore, the battle ecology can be

expected to produce high or low stress casualty

rates. A “Yom Kippur” (sustained, high-intensity)

war may result in large numbers of combat stress

cases, while a “Vietnam” (low-intensity, garrison)

war may produce “nostalgic” disorders. Military

psychiatry must have the flexibility to respond to

either circumstance and to the possibility of nuclear,

biological, and chemical (NBC) warfare. The latest

U.S. Army neuropsychiatry doctrine2,27–29 addresses

the distribution of mental health resources to respond to all scenarios.

Both traditional combat stress casualties (“combat fatigue,” “battle shock,” or “combat reaction”)

and low-intensity combat casualties (“nostalgic”)

will occur in most protracted conflicts. The traditional casualties will occur proximate to the battles

and the nostalgic will occur among rear-area troops

or when combat troops rotate back to rear areas.

The principles of combat psychiatry were developed during World War I and refined during World

War II and the Korean conflict, but not until the

Vietnam conflict were nostalgic casualties recognized as a serious cause of ineffectiveness in U.S.

forces. It seems appropriate to address first the

traditional combat stress casualties that predominate in mid- to high-intensity conflicts. Low-intensity combat stress casualties will be addressed in

Chapter 3, Disorders of Frustration and Loneliness;

NBC combat stress casualties in Chapter 4, Neuropsychiatric Casualties of Nuclear, Biological, and

Chemical Warfare; and high-intensity combat stress

casualties in Chapter 5, Psychiatric Principles of

Future Warfare, of this textbook.

The principles of forward treatment were developed and refined during the mid-intensity battles

of World War I, World War II, and the Korean

conflict. For the casualties of such conflicts they

worked reasonably well. Treatment failures, when

they occurred, were generally because the principles were not applied. This usually occurred

when the conflict took on the characteristics of

high-intensity battles, overwhelming forward medical resources and forcing evacuation of casualties,

or the characteristics of low-intensity battles, making evacuation more feasible. With future battle

TREATMENT
War Psychiatry

44

circumstances uncertain, all medical personnel and

unit leaders should become familiar with the traditional principles of combat psychiatry and be prepared to adapt them to a variety of evolving situations, ranging from low-intensity insurgency actions

to high-intensity NBC actions.

The treatment of combat stress casualties depends on a variety of circumstances impossible

to foresee until actual engagement with the

enemy. These circumstances include the type of

battle, the length and location of the war, the type

of soldier, the manifestations of ineffectiveness, the

type of treating person, and other unforeseen

conditions.

The treatment setting depends on the type of

war, the type of evacuation (if any), and the availability of resources. Possible treatment settings

range from the active battle scene to a medical

center in the United States, as shown in Table 2-3.

Treatment of battle fatigue cases begins with

their identification. Battle fatigue casualties should

never be referred to as psychiatric casualties. The

term battle fatigue is more appropriate because it

suggests a normal response to the extreme mental

and emotional demands of combat.

Treatment of identified combat stress casualties

begins with casualty sorting, as shown in Figure 2-

1. Battle fatigue cases may be labeled to indicate

where they are being treated, with labels such as

light, heavy, duty, rest, hold, and refer. These labels

do not indicate the presumed cause of the symptoms or the likely response to treatment; they merely

designate where the soldier is being treated. While

these labels can be useful, there are two compelling

reasons to avoid making judgments early in treatment about the presumed etiology and prognosis of

individual cases of battle fatigue. First, the initial

appearance and symptoms of soldiers may reveal

little about the cause or the course of their condition. Second, in time of battle and during the initial

interviews, it may not be possible to obtain complete and accurate information about the casualty’s

personal history. Therefore, all battle fatigue casualties should receive immediate treatment guided

by the expectation of rapid and full recovery, as far

forward as possible without jeopardizing the mission. As the soldier improves or arrives at a new

echelon of care, the label should be modified accordingly.

Casualties are labeled as light or heavy battle

fatigue casualties to designate their initial treatment. Battle fatigue cases designated as “light”

continue on duty or rest in the unit. Treatment can

be provided through buddy aid, unit medics, or

leader actions, or can be self-administered. Most

soldiers exposed to combat will experience light

battle fatigue at some time. Light battle fatigue

includes the normal, common signs of battle fatigue, as shown in Exhibit 2-2. It also includes the

warning or more serious symptoms, as shown in

Exhibit 2-3, if the symptoms respond quickly to

treatment. Even soldiers with relatively serious

symptoms can often continue on duty and do not

necessarily need immediate medical attention. If

the symptoms continue despite rest, the soldiers

should be sent to their unit surgeon or physician

TABLE 2-3

PSYCHIATRIC ECHELON CARE

Site Level Holding Time

Battle 1. Self/buddy 4 h

2. Small unit leader 4 h

3. Medical aidman 4 h

Forward area 4. Battalion aid station 8 h

5. Brigade clearing station 3 d

Rear area 6. Division clearing station 4 d

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
45

Traditional Warfare Combat Stress Casualties

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

battle fatigue casualty.

In contrast to light battle fatigue, heavy battle

fatigue requires immediate medical attention. In

addition to failure to respond to initial treatment,

the “heavy” label can indicate that the soldier’s

symptoms disrupt the mission of the unit, or that

the casualty has a medical condition such as heat

stroke that may require emergency treatment.

The triage medic sorts soldiers experiencing

heavy battle fatigue based on where they can be

treated, as indicated by the labels duty, rest, hold,

and refer. Duty cases are heavy battle fatigue

casualties who are treated immediately by a physician, physician assistant, or mental health officer

and returned to duty. Rest cases do not require

continual medical attention and are sent to their

unit’s nonmedical combat service support elements

for brief rest and light duties. Hold cases are heavy

battle fatigue casualties who are held for treatment

at the triage medic’s own medical facility if the

tactical situation and the symptoms permit. Refer

cases are those who must be treated at a medical

facility that is more secure or better-equipped than

the triage medic’s own facility due to the tactical

situation or the casualties’ symptoms. Refer cases

are relabeled as hold cases when they reach a medical facility where they can be treated.

The decision to label an individual soldier as a

case of duty, rest, hold, or refer battle fatigue is not

a simple one. Rather, it must be guided by a combination of factors, including the soldier’s characterContinue on Duty Rest in Unit

Fails to

Improve

Reevaluate Reevaluate

Reclassify MOS Evacuate

Sorted by Leader, Medic

Reevaluate

Evaluate

Return to Duty

MOS: Military Occupational Specialty

Duty Rest Hold Refer

Treated and Released Battle Fatigue Casualty

Light Heavy

Battle Fatigued Soldier

Sorted by

Physician, Physician

Assistant, or Mental Health

Officer
War Psychiatry

46

EXHIBIT 2-2

NORMAL, COMMON SIGNS OF BATTLE FATIGUE

Physical Signs*

Tension: aches, pains; tremble, fidget, fumble

things.

Jumpiness: startle at sudden sounds or movement.

Cold sweat; dry mouth; pale skin; eyes hard to

focus.

Pounding heart; may feel dizzy or light-headed.

Feel out of breath; may breathe too much until

fingers and toes start to tingle, cramp, and go

numb.

Upset stomach; may throw up.

Diarrhea or constipation; frequent urination.

Emptying bowels and bladder at instant of

danger.

Fatigue: feel tired, drained; takes an effort to

move.

Distant, haunted (“1000 yard”) stare.

Mental and Emotional Signs*

Anxiety: keyed up, worrying, expecting the

worst.

Irritability: swearing, complaining, easily

bothered.

Difficulty paying attention, remembering details.

Difficulty thinking, speaking, communicating.

Trouble sleeping; awakened by bad dreams.

Grief: tearful, crying for dead or wounded

buddies.

Feeling badly about mistakes or what had to be

done.

Anger: feeling let down by leaders and others in

unit.

Beginning to lose confidence in self and unit.

*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

to treatment, the tactical situation, and the resources

available. Furthermore, once the decision is made,

it may need to be modified to reflect changing

conditions. Successful treatment of combat stress

casualties prevents unnecessary evacuation and

shifts battle fatigue casualties from refer to hold,

from hold to rest, and from rest to duty. The lowest

level of treatment likely to be effective should be

administered, since holding or evacuating casualties may delay or prevent recovery.

Since World War I, the appropriate use of the

principles of forward treatment has resulted in the

return of 40% to 90% (optimal conditions) of combat

stress casualties to combat duty within days.7

 Forward treatment consists of immediate, brief, simple

interventions (immediacy, brevity, simplicity) such

as rest and nutrition in a safe place as near the battle

lines as possible (proximity), with an explicit statement to the soldier that he will soon be rejoining his

comrades (expectancy). These measures create in

the soldier a sense that he is only temporarily disabled by fatigue and further create the expectancy

that he will quickly return to duty. This expectancy

is strengthened when the casualty’s small unit comrades can visit him and indicate that they need him

and will welcome him back. Treatment is kept

simple to foster this expectancy by giving the message that nothing is seriously amiss. Glass30 has

characterized Salmon’s approach as a three-tiered

(division psychiatrist, front-line specialized hospital, rear-area specialized hospital) related echelon

treatment system that takes into account individual

and battlefield hindrances to recovery and maximizes the return of the casualty to combat. A

further aspect of this echelon approach to treatment

calls for soldiers evacuated rearward to be screened

at a central collecting point from which they may

still be returned to duty if further rearward movement is inappropriate (centrality).

In practice this approach requires four essential

elements: (1) a safe place near the battle area (refuge), (2) a treating person (therapist), (3) time for

restoration of physiological needs (rest), and (4) a

method for returning to one’s unit (return). Each

element is critical to the process; and each is potentially jeopardized by modern, high-intensity warfare.
47

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 psychiatric interventions are most successful in handling

the typical stress casualties of mid-intensity, conventional conflicts, they will be addressed first.

Such casualties may be grouped roughly in order of

increasing exposure to combat as follows: (1) normal battle reactions (not counted as a casualty), (2)

acute anxiety syndromes, (3) precombat syndromes

(hypochondriasis/following prior combat), (4)

chronic anxiety-depressive syndromes (old sergeant

syndrome), and (5) atypical syndromes (occurring

at all levels of exposure).

Although these symptom constellations may appear at any level of combat intensity, they have been

most apparent in World War I and World War II,

now considered to be mid-intensity conflicts, based
War Psychiatry

48

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 following: rapid heart rate (DaCosta’s “soldier’s heart” of

the U.S. Civil War), profuse sweating, muscle tension, shaking and cramps, nausea, vomiting, diarrhea, and involuntary defecation and urination. At

times the casualty may present with minimal anxiety 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 (blindness, deafness, anesthesia, or pain). As with the

anxiety symptoms, the unstated but implicit meaning is clear: the soldier has a recognizable medical

condition that, he believes, prevents him from further engagement in combat and is thus an honorable escape from battle.

Although malingering might be suspected in

some cases, most soldiers present with unconsciously derived symptoms similar to those found

in the neurotic conditions of civilian life. During

World War I and thereafter, able clinicians have

found that interpreting this temporary defection as

malingering only forces the soldier to strengthen,

usually unconsciously, the symptoms to disprove

such an allegation, making restoration to duty less

likely.

Normal Reactions to Combat

Transient fear reactions are universal and should

not be considered pathological. In fact, such responses came to be called the normal battle reaction. During World War II a number of surveys

were made of physical symptoms experienced by

infantry soldiers in combat. According to several

studies reviewed by Menninger,32 (Figure 2-2) and

summarized by the author, of infantry soldiers in

combat for any length of time, approximately 50%

would experience a pounding heart, 45% a sinking

stomach, 30% cold sweat, 25% nausea, 25% shakiness and tremulousness, 25% stiff muscles, 20%

vomiting, 20% general weakness, 10% involuntary

bowel movement, and 6% involuntary urination.

Menninger refers to this group of symptoms as the

normal battle reaction. The author will detail a

number of cases from his experience as a division

psychiatrist in Vietnam to illustrate various kinds

of stress reactions to combat. The following case

illustrates physiological (involuntary urination) and

Fig. 2-2. William C. Menninger, from a family of famous

psychiatrists, was Neuropsychiatry Consultant to the

Army Surgeon General during most of World War II.

Among many accomplishments, he arranged for appropriate treatment of psychiatric casualties and established

a psychiatric nomenclature that formed the basis for the

first Diagnostic and Statistical Manual of the American

Psychiatric Association.

psychological (mutism) responses to combat that

led to psychiatric intervention.

Case Study 1: The Tunnel Rat

Corporal A, a 20-year-old single man who had come to

Vietnam by troopship in late February 1966 was brought

to the 25th Infantry Division Base Hospital in late March

1966 by his platoon sergeant and lieutenant in a mute and

unresponsive, but tense and alert condition. On a “search

and destroy” mission he had volunteered as a “tunnel rat”

to enter part of the extensive Viet Cong underground

tunnels near Cu Chi, where the 25th had its base camp.

Jumping into an 8-foot hole, he found himself facing a Viet

Cong (VC) soldier , who was lying in a side tunnel. The VC

aimed a pistol at CPL A’s head and pulled the trigger. The

pistol misfired, and CPL A’s platoon sergeant shot the VC

in the head with several blasts from his M16 rifle, splattering CPL A with blood and brain tissue. Examination at the

base hospital revealed no wound, other than a small facial

scratch from a bone fragment, despite CPL A’s gory

appearance. The 25th Division psychiatrist (the author)

was called to see a “catatonic” patient.
49

Traditional Warfare Combat Stress Casualties

The psychiatrist saw CPL A alone in a shielded area of

the hospital tent (the “Mental Hygiene tent” had not yet

been erected), and a repeat physical exam was performed. During the examination the physician soothingly

pointed out that CPL A was safe and that he had normally

functioning body parts and the ability to cooperate in the

examination. He was then told that his “vocal cords,”

which had been temporarily “stunned,” were back to

normal and that he could say anything he wished. After a

brief hesitation CPL A broke into a long, pressured explosion of profanity, ending with, “Damn, I peed my pants.”

He was told that his reactions were completely normal and

that after resting that night in his own bed, he would wake

up fully able to return to his usual duties tomorrow.

Comment: The psychiatrist did not see CPL A again;

however, informal follow-up with the corporal’s platoon

leader a few months later revealed that he became cheerful the following day when told that he would get a Purple

Heart medal for the wound to his face. CPL A did not

volunteer for “tunnel rat” duty again.

The labeling of such normal reactions to battle as

abnormal can create psychiatric casualties who may

become “evacuation syndrome” patients. Such soldiers are best handled by enlightened commanders

and senior noncommissioned officers (NCOs) who

can reassure them that their responses are normal

for the situation. Should such soldiers come to

medical attention, a brief but thorough physical

exam (to rule out brain injury, internal hemorrhage,

or spinal cord injury) followed by reassurance usually suffices. The following case illustrates the need

for a physical exam.

Case Study 2: The Mortar Attack Victim

During the course of an all-night mortar attack on the

25th Infantry Division base camp by Viet Cong guerrillas,

the author, as division psychiatrist, was assisting the

headquarters surgeon in treating casualties presenting

with minor injuries (most caused by small pieces of fragmentation devices or bruises and abrasions sustained

when soldiers were hastily seeking shelter). A military

policeman (MP) brought his youthful fellow MP for treatment of complaints of apprehensiveness. The two of them

were driving across the compound when a mortar landed

just behind their jeep, momentarily “stunning” the patient,

who had been sitting in the back seat. The patient had

been “jarred” by the concussion but was unaware of any

injury.

Examination revealed a pale (even in the subdued light

used to avoid targeting the dispensary tent), apprehensive young man who was sweating profusely. His muscles

were tense, and his skin was cool and clammy (“cold

sweat”). He had no complaints of pain and no apparent

injury; however, his pulse was rapid and weak (low pulse

pressure). He was allowed to rest, but his condition

deteriorated with development of marked apprehensiveness. Reexamination in better light revealed a small tear

in his field jacket, which had been covered by his MP belt.

Removing the jacket and undershirt revealed a small

puncture wound of the left lower back. A diagnosis of

hemorrhagic shock was made, and the Division Psychiatrist accompanied the patient to the division surgical unit

where the patient received blood transfusions. Subsequently he was evacuated to a field hospital where abdominal surgery revealed massive hemorrhage from a

ruptured spleen.

Comment: This patient had typical symptoms found in

acute anxiety or fear reactions in combat: apprehensiveness, sweating and peripheral vasoconstriction (producing the “cold sweat”), tachycardia, and increased muscle

tension. The weak pulse, presumably due to impending

hypovolemic shock with decreased pulse pressure, should

have been a clue to the internal hemorrhaging. Had this

patient been uninjured, reassurance and return to his unit

would be the treatment procedure.

Ranson has described a spectrum of symptomatology in combat ranging from “the normal battle

reaction” to “the pathologic battle reaction.” He

observes that:

[T]he normal battle reaction is made up of a variable set of symptoms that arise from (1) moderate

to extreme physical fatigue; and (2) extreme, repeated, and continued battle fear, with (a) marked

psychosomatic symptoms resulting from this fear

and (b) certain psychologic symptoms resulting

therefrom.33(p3)

Ranson describes normal psychosomatic response

patterns to combat stress to include muscular tension, “freezing” or temporary immobility, shaking

and tremors, excessive perspiration, anorexia or

nausea, occasionally vomiting, abdominal distress,

mild diarrhea and urinary frequency including incontinence of feces or urine, tachycardia and palpitation, hyperventilation to the point of giddiness

and syncope, weakness and lassitude, and aches

and pains. He also described special psychologic

considerations in the normal battle reaction including combat sensitization with anticipatory anxiety,

sensitization to combat noises, insomnia, diminished drive and initiative, irritability and increasing fear, including fear of showing fear.33

This normal reaction may be mislabeled as abnormal. This may have occurred in Israeli forces in

the 1982 Lebanon War. Despite relatively lowintensity combat, 23% of Israel’s total casualties

were labeled as psychiatric. Israel, following the

1973 Yom Kippur War, had devised a system of

early identification of psychiatric casualties with an

increased expectancy that such casualties would

occur.10 Furthermore, by labeling such casualties
War Psychiatry

50

“combat reaction,” Israeli mental health personnel

created an expectancy that combat alone would

create such casualties. Early in World War II American medical personnel, by eliminating soldiers who

exhibited symptoms of anxiety, had created a similar expectancy that was further compounded by the

evacuation of such soldiers out of combat. Management, therefore, requires informing the soldier that

his symptoms, while calling for rest, are not a reason for evacuation.

Inappropriate evacuation of the lightly wounded

not only creates an evacuation syndrome but often

results in a psychiatric casualty. Lightly-wounded

Israeli soldiers in the 1973 Yom Kippur War were

found to respond similarly to psychiatric casualties

when evacuated from battle,21 that is, they developed complaints that prevented them from returning to combat. These complaints were both physical

(eg, pain, weakness) and psychological (eg, anxiety,

fear, depression). As seen in Bowman’s11 listing of

psychiatric casualties in Vietnam (see Exhibit 2-1), a

significant number were wounded soldiers. Wounding always elicits psychological responses, though

not always negative. During World War II, soldiers

spoke with elation of receiving “the golden wound,”

one that would honorably excuse the soldier from

battle but not produce permanent disability.

Bowman’s patients, for instance, developed symptoms as the time drew near for them to return to

combat. Such symptoms were usually physical

complaints—pain in healed wounds, weakness, and

even frank conversion reactions.

In treating the lightly wounded, it is important to

treat forward and attempt to avoid rearward evacuation. If evacuation has occurred, “forward evacuation” nearer the battle area with application of the

principles of combat psychiatry was found effective

by the Israelis in the 1982 Lebanon War.9

 The more

seriously wounded who have recovered to the point

of return to combat must be managed with the same

expectancy approach utilized with recognized

psychiatric casualties.

By contrast, severely disabled soldiers—those

with amputations, severe thoracic or abdominal

wounds, widespread burns, blindness, and brain or

spinal cord injuries—generally cannot be returned

to combat; thus early psychiatric treatment is often

needed in long-term treatment centers to help the

veteran adjust to the disability. A variety of psychological responses similar to those described by

Kubler-Ross34 in the dying patient will be encountered: denial, anger, bargaining, depression, and

acceptance. Weinstein and Kahn,35 in their study of

brain-injured and amputee patients, found that denial remains the predominant, underlying mechanism in such patients with manifestations such as

phantom limb, amnesia, confabulation, reduplication, and other often bizarre responses. These are

discussed in Chapter 14, Disabling and Disfiguring

Injuries.

In summary, it has been shown that the normal

psychological reactions to combat when inappropriately labeled and evacuated lead to actual disability. Such inappropriate evacuation of the lightly

wounded likewise often results in psychiatric decompensation.

Pathological Reactions to Combat

Ranson33 argues that these normal responses to

battle shade into pathological responses usually as

prolonged or exaggerated normal responses. Examples include the immobilized soldier who remains so for several hours or when the immobility

poses a danger to himself or his comrades; autonomic overactivity symptoms that persist long after

the danger; noise sensitization that generalizes to

innocuous noises; lassitude that becomes persistent

apathy and depression; and fear that develops into

panic. Such symptoms in response to the threat of

death are normal and virtually universal. A variety

of personal and interpersonal interactions can result in the transformation of the normal battle reaction into a pathological battle reaction. Also, if the

soldier lacks the adaptive capacity to handle the

anxiety, it may be expressed through mental defense mechanisms as conversion or dissociative reactions.

Acute Anxiety Syndromes

As suggested earlier, the symptoms in such cases

are the same as those occurring in the normal battle

reaction—basically exaggerated physiological responses of autonomic overactivity combined with

mental states of fear or apprehension.

Conversion reactions generally involve interference with voluntary muscle (paralysis, convulsions,

muteness, ataxia, movement disorders) or sensory

(anesthesia, blindness, deafness, pain) function.

Psychogenic loss of smell or taste is rare; however,

complaints of smelling burning flesh, napalm, or

other battle smells often occur in chronic post-traumatic stress disorders. The paralyses frequently

involve organs important for combat functions, for

example, paralysis of the trigger finger. Similarly,

pain complaints may prevent combat function.

Helmet headaches were briefly a problem in some
51

Traditional Warfare Combat Stress Casualties

units in Vietnam, because this equipment was required for soldiers on ambush or perimeter patrols.

It was the author’s experience that the symptom

disappeared when soldiers were told that they

would have to do such duty without head protection.

Conversion symptoms appear to occur more frequently in medically naive and medically sophisticated populations. In the latter cases symptoms

often consist of pain and weakness that may

be difficult to distinguish from neurological or

musculoskeletal dysfunction. In the former cases,

naive populations may present with classical

hysteroepilepsy, hemipareses, and stocking and

glove anesthesias. Such symptoms were observed,

for example, in the Iraq-Iran War among Iranian

soldiers.36

Because conversion reactions indicate a relative

breakthrough of primary process thinking, though

disguised, limited, and controlled, treatment may

be more prolonged than with anxious and fatigued

casualties unless corrected early. World War I U.S.

Army psychiatrists reported substantial success with

strong positive suggestion and simple explanation

when given early and far forward (today called

“immediacy, proximity and expectancy”).37 In some

cases hypnotherapy and abreactive treatments may

be indicated. The following case, known to the

author, illustrates severe anxiety and stuttering in

response to combat.

Case Study 3: The Stutterer

Following an all night mortar attack on the 25th Infantry

Division base camp in which several soldiers died and

nearly 100 were wounded, a 20-year-old radio operator

for hospital communications complained of the sudden

onset of severe stuttering as well as anxiety. On examination the soldier appeared as a lanky, blond youth

wearing glasses, stuttering, and displaying startle reaction to outgoing artillery rounds. The soldier had a history

of briefly suffering from stuttering at about age 5 years

when he first left home to start school (kindergarten).

Physical exam was normal.

The author, as division psychiatrist, arranged for the

soldier to be temporarily relieved from radio operator duty

but hinted that if symptoms persisted the soldier would

have to revert to his primary specialty of general infantryman. After one day the soldier’s symptoms began to

abate: however, the division surgeon, a kindly and sympathetic man, evacuated the soldier from the division while

the psychiatrist was away on a MILPHAP (Military Public

Health Action Program) mission to a local Vietnamese

hamlet. The soldier never reurned to the division.

Comment: This case reveals the failure of treatment

because of a physician’s humanitarian instincts’ leading

him to believe that he was alleviating suffering. No followup was available, but similar inappropriate evacuations

during World War II led to chronic disability. The appropriate treatment was rest, reassurance, and return to

duty.

Dissociative reactions classically consisted of

somnambulism, amnesia, fugue, and multiple personality. The following example from Vietnam

illustrates the manner by which somnambulism

became an evacuation syndrome in the unit to which

the author was assigned.38

Case Study 4: The Sleepwalkers

A brief “epidemic” of somnambulism occurred in 1966

during the early deployment of the 25th Infantry Division

in Vietnam. The engineer battalion surgeon had sought

the help of the division psychiatrist to treat soldiers who

were developing sleepwalking (somnambulism). The

battalion surgeon was surprised to find a rash of such

cases in his relatively small unit. The initial case had

presented with a history of sleepwalking during childhood

with occasional episodes of falling and injuring himself.

His family had been completely dominated by his symptoms, being forced to move to a one-story house, placing

a high fence with locked gates around the house, and

making other arrangements for his safety. His sleepwalking, however, had disappeared until arrival in Vietnam.

Following the example of the soldier’s parents, the battalion surgeon moved the patient’s sleeping area to the

center of the base camp to prevent him from wandering

into the minefields that surrounded the base camp.

This environmental manipulation appeared to succeed; however, in the subsequent two weeks three more

soldiers reported with complaints of sleepwalking. The

battalion surgeon was running out of space in which to

house these men. The division psychiatrist observed that

the engineering battalion was located along one perimeter of the base camp on the side where a pro-Viet Cong

village had been located and from which sniper fire was a

regular occurrence at night. There had also been rumors

of incidents in other camps during which “sappers” (infiltrators) had in nighttime forays cut the throats of sleeping

soldiers. The perimeter area had been cleared of trees,

had been heavily mined, and had nighttime perimeter

guards (only subsequently was it learned that a very

extensive tunnel system was the source of much of the

sniper fire).

The division psychiatrist recommended that the sleepwalkers be told that the new policy was to place sleepwalkers on permanent nighttime perimeter guard duty

(considered unsafe) or generator maintenance duty (considered undesirable) to protect them from wandering into

the minefield at night.

Comment: This intervention consisted of preventing

the sleepwalking from allowing the soldiers to escape

hazardous duty. When this was accomplished, the “epidemic” abruptly ceased.
War Psychiatry

52

Multiple personality has rarely occurred in a

combat setting, and current evidence suggests childhood sexual trauma as the etiologic agent in most

cases. Soldiers presenting themselves as suffering

from multiple personality in combat settings are

most often malingering to escape punishment for

being absent without leave (AWOL). Such presentations tend to wax and wane with mass media

publicity of cases.

Amnesia is often attributed to concussion by the

patient with more or less justification. Amnesia is

sometimes used as an excuse to account for AWOL

or other temporary dereliction from duty. Confronting the soldier with disbelief is generally not

useful. The proper therapeutic stance in most cases

is to reassure the soldier that his memory will return but, if not, that the amnesia will not prevent

him from fulfilling some role in combat. A day

might be spent teaching the soldier to load, aim, and

fire a rifle, for example, with the clear implication

that no matter what his original specialty was, he

can be an infantryman. The following case illustrates the efficacy of such suggestion in soldiers

with psychological amnesia.

Case Study 5: The Amnesiac

In 1968, a 19-year-old single male was evacuated to

Walter Reed Army Medical Center in Washington, D.C.

from a nearby post at which he was in training as a

paratrooper. He was scheduled to graduate from “jump

school” and had received orders for Vietnam. Following

his final parachute jump, he was found unconscious, was

hospitalized locally, and was found to have no neurological deficit other than amnesia for his entire life. He did not

know his name and did not recognize friends and family

members. At Walter Reed, where the author was supervising the case, the soldier underwent Amytal interview

without remission. Collateral history including early development was not impressive of psychogenic trauma.

The soldier was told that there would be another attempt

at Amytal; but, that if it failed, he would have to return to

basic training and then be sent to Vietnam. It was

suggested during Amytal interview that his memory would

begin returning and should be completely normal within a

week.

Comment: Within a week his memory had returned,

and he was sent on amended orders to Vietnam but not to

an airborne unit. Although this is not a true combat

breakdown, it does have characteristics of a precombat

syndrome.

Fugue states in military settings are often accompanied by alcohol or drug abuse and licentious

behavior, frequently in contrast with the soldier’s

usual personality.

Case Study 6: The Wild Week

In 1966, a 32-year-old staff sergeant with 12 years of

active duty was brought to the attention of the Shore

Patrol by prostitutes on Tu Do Street in Saigon because of

his unresponsive behavior. In a confused state he was

taken to the Third Field Hospital where it was established

that physical examination was normal except for mental

status. Mental status examination by the author revealed

a thin, balding Caucasian man who was dressed in soiled

civilian clothing. He smelled of urine but not alcohol. He

appeared perplexed and asked where he was. He gave

the date as November 5, 1965 (it was later established

that he had left the United States on this date and that he

was in the last month of his tour in Vietnam). He was

oriented to person and, except for amnesia since coming

to Vietnam, mental functions were essentially normal. He

was sedated (Librium) and put to bed.

The following day his memory had returned up to about

1 week before. He stated that his last memories were of

coming to Saigon with a convoy from a nearby village,

Dian, where he was a mess sergeant with an infantry

company. Although he was technically AWOL, the unit

was tolerant of his absence because he was close to

the end of his tour and his replacement had already

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,

nondrinking, married man who attended chaplain’s services regularly and that “sowing a few wild oats” might be

helpful to him.

Although all of the details of the missing week were

never discovered, it appeared that the staff sergeant, who

had reportedly never been unfaithful in his 10 years of

marriage, succumbed to the charms of a prostitute. Ensconced in a hotel room, he spent a month’s pay with a

succession of prostitutes accompanied by liberal intake of

the local beer, “33” (“Bah moui bah” in Vietnamese). After

an additional day of rest during which he was reassured

that such an incident was unlikely to occur again if he

avoided alcohol and prostitutes, he was discharged and

returned to his unit where he remained an uneventful 2

weeks until returning to the United States.

Comment: It is sometimes difficult to determine how

much intoxication contributes to the amnesia in such

fugue cases. In addition to protecting him from guiltinducing memories, the amnesia also protects the patient

from having to recount embarrassing behavior.

Precombat Syndromes

Psychological adjustment to combat may begin

long before an actual battle. It begins as soon as the

possibility of going into combat is seriously entertained. It is even possible to conceive of those who

burned their draft cards as engaging in a long-term

avoidance maneuver. When the author arrived in

Hawaii as the new 25th Infantry Division Psychia-
53

Traditional Warfare Combat Stress Casualties

trist, he found the topic of most immediate concern

was whether the 25th Division would stay in Hawaii as a “strategic reserve” or go to Vietnam. Although no official confirmation was given until the

day prior to departure, it became increasingly evident that the next assignment would be in Vietnam.

The majority of soldiers began preparing for combat duty. Some took courses in the Vietnamese

language or read books on tropical diseases, insects, and reptiles. Others purchased hunting knives,

special water-repellent clothing, and enormous

amounts of soap because there were rumors of a

shortage. Exercising became fashionable. This

somewhat compulsive behavior served its purpose.

A soldier who is busy learning a language, practicing with a knife, or running to increase lung and leg

power does not have as much time to think about

being killed, crippled, or separated from loved ones.

A small minority of soldiers, however, consciously or unconsciously sought to evade combat

duty. Some wives appeared at clinics describing

medical conditions in themselves or their children

for which they felt justified in having their husbands near. Some soldiers appeared in dispensaries or clinics having discovered physical defects in

themselves that they thought would make them

vulnerable in combat. These defects included decreased hearing, a childhood heart murmur, mild

hypertension, a “trick knee,” and even simple obesity. A few individuals inflicted wounds on themselves. In one incident, a medical corpsman anesthetized a friend’s foot with the local anesthetic,

Xylocaine, then shot it with an M-16 rifle. Several

soldiers claimed to be homosexual because this

condition called for separation from the military.

Others committed military crimes (usually AWOL

or insubordination) in an attempt to achieve medical or administrative separation from the service.

Their usual comment in the stockade was, “I just

want out. Any kind of discharge will do.” These

individuals were few in number, however. A more

common response was for a soldier to express relief

to finally know for sure that he was going to Vietnam and to begin preparing himself.

The term “precombat syndrome,” however, has

generally not included these attempts to evade altogether duty in a combat zone. Rather, this term has

been reserved for combat veterans, often with

lengthy exposure to battle conditions, who on the

eve of combat report to medical officers with hypochondriacal or minor complaints.39 Such persons

usually believe that their symptoms are real and

significant. Symptoms may include headaches,

toothaches, indigestion, and worry over healed or

nearly healed wounds. On a more conscious level,

some individuals report with broken spectacles and

dentures or, more rarely, with self-inflicted wounds.

Failing to understand the nature of these symptoms, some commanders have regarded such soldiers as malingerers and have taken a punitive

approach to deterrence of “goldbricking.” One

support commander in the 25th Infantry Division

ordered that sick call be held outside, exposed to the

weather, which was often inclement, with daily

rains and a hot tropical sun. Unable to gain the

reassurance that nothing serious is wrong and the

support from the physician, such soldiers may become demoralized and more subject to combat

breakdown.

The proper approach to such soldiers is a thorough physical examination (especially because some

illnesses, particularly hepatitis, are of insidious onset

with vague complaints and exacerbation of

characterological tendencies) followed by reassurance that all is well and expressions of gratitude to

the soldier for adhering to duty, in spite of pain, for

his comrades and country.

Chronic Anxiety-Depressive Syndromes

Continuous or long-term exposure to the lethal

combat environment in which the emergency “fightflight”40 response is repeatedly invoked eventually

results in performance decrements in virtually every combatant. Such repeated physiological arousal

gradually has a conditioning effect on voluntary

muscles (increased tension, tremors), involuntary

or autonomic responses (tachycardia, increased

blood pressure, increased perspiration and respiration), and cognitive responses (anxiety, fear). The

loss of comrades not only provokes anxiety about

one’s own mortality but also represents a loss of

social reinforcement with subsequent anger and

depression. During World War II, Sobel41 referred

to such casualties as “the old sergeant syndrome.”

In analyzing the factors leading to breakdown in

“the old sergeant syndrome,” Sobel traced the “progressive breakdown of the adaptive mechanisms of

the normal soldier to the point at which his natural

resources are exhausted in the struggle against his

environment.”41(p145) In the loss of his defenses

against combat anxiety, the soldier successively

lost his ideals about the war (the goals of freedom

for Nazi-held peoples and “keeping the enemy out

of the United States”), his hatred of the enemy

(producing vulnerability to guilt), his short-term

goal of being relieved from combat, his pride in

himself (feeling of responsibility to be courageous
War Psychiatry

54

and to endure), and, finally, loss of loyalty to the

group (chiefly through actual physical depletion of

the group from death, wounding, and illness).

When such repeatedly traumatized combat veterans emerge as psychiatric casualties, they usually

present with some variant or mixture of anxiety or

depressive symptoms. The “startle reaction,” for

instance, may represent conditioned muscle tension and other physiological arousal to loud noises

(as from exploding mortar, artillery, or bomb attacks). Soldiers presenting with lethargy, decreased

self-esteem, and insomnia may be responding with

depression to repeated losses and fatigue from repeated arousal. In one model of depression,42 the

hormonal regulatory system of the hypothalamus

has become disturbed from higher cognitive and

limbic (emotional) inputs. The repeated physiological and cognitive arousal invoked by combat

exposure would seem appropriate to such a model.

The following cases illustrate some of the symptomatology in such casualties.

Case Study 7: The Fourth Ship

Laughlin43 in his “case 184” describes a “severe combat reaction following maximal stress.” Toward the end of

World War II he came across a naval petty officer whom

a physician described in disparaging terms as an inferior

and unstable person because he had broken down in

combat. On closer examination Laughlin recognized him

as a fellow shipmate of several years before. His service

on ship as quartermaster had included “all kinds of strenuous operational and combat conditions.” Laughlin could

barely recognize him: physically he had shrunk and aged

unbelievably. When seen about 2 years earlier, he had

been a young, strong, self-possessed person with a “rocklike quality” of strong leadership; but, now “he was an

aged, palsied, defeated and pathetic figure, shriveled and

shrunken to nearly half his former weight.” Laughlin’s

colleague who espoused character deficits as the cause

of breakdown could not have made a more unjustified

case for his assumptions of the etiology of such breakdowns.

Laughlin had traveled with him from the North Atlantic

on convoy duty through the North African landing operations finally to the Pacific for the final phase of the

campaign for Guadalcanal and the Solomon Islands. In

the Pacific, enemy air and naval engagements had occurred, and finally the ship was sunk during an engagement of great stress to the crew. Among the survivors “a

fair number developed combat fatigue and various stress

reactions.” The patient, who had been “a tower of strength”

throughout all these exigencies, continued outwardly

unfazed and promptly returned to duty, volunteering for

service on another destroyer. Laughlin did not see him

again until the recently described meeting.

Intrigued by what could have rendered such a change,

Laughlin spent time with him and gradually pieced together his history. After loss of the ship in early July 1943,

“the tempo of stress” did not abate but actually increased.

He continued an unusually extensive combat experience

on two subsequent destroyers, each of which had sunk in

turn. Not until after the second sinking did he have his first

nervous symptoms (depression and anxiety), which gradually increased during service on the third destroyer and

after its loss. The culminating traumatic experience occurred on ship number 4 about a month prior to his

hospitalization. Scouting enemy shore battery positions

that had previously been thought silenced on Southern

Okinawa, the ship ran aground on a poorly charted ledge.

At this point the “silenced” shore batteries had suddenly

opened up at point-blank range. Hundreds of rounds were

poured into the helpless ship, until the ship, riddled, dead

in the water and sinking, was ordered abandoned. The

patient got off the ship and into the water but was seized

by the tide, drawing him, despite his strongest efforts,

toward a large, burning oil slick from the stricken ship. For

what seemed an eternity, he managed to stay clear of the

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)

Comment: Laughlin does not discuss treatment in this

particular case; however, at that time hospitalization with

rest, sedation, insight-oriented psychotherapy or group

therapy, and sometimes abreaction, often assisted with

hypnosis or intravenous barbiturates, would have been

the usual treatment for chronic, fixed neurotic states.

Currently, group or individual psychotherapy

with perhaps an abreactive technique might still be

called for, but the emphasis in treatment would be

“here and now” issues (ie, work, relations with

others). Relaxation exercises involving deconditioning to noises or battle memories might be used

as well; and, if nightmares and depression were

prominent, an antidepressant such as phenelzine (a

monoamine oxidase [MAO] inhibitor) or imipramine

(a tricyclic) would probably be used, since they suppress dream sleep and hence prevent nightmares.

During World War II, return to a combat role was

usually impossible; however, duty in noncombat

roles was generally successful. Perhaps a primary

factor in the inability to return “the old sergeant

syndrome” patient to duty was the consensus that

the soldier had done his part and deserved release

from combat service. This is illustrated in Sobel’s

“Case 27”:

Case Study 8: The “Old Sergeant Syndrome”

A 20-year-old technical sergeant with 30 months’ service who had been overseas 21 months and had an
55

Traditional Warfare Combat Stress Casualties

aggregate of 310 days of combat was admitted during a

rest period after the battle of the Gothic Line. He had been

thrice wounded in action. He stated that he began to have

abnormal battle reactions 60 combat days previously. He

said: “Now if I get in a hole I just want to stay. It bothers

me more now than it ever did before. This last battle my

company was ordered to take a house, and within a few

hundred yards of the place a couple of my boys got their

feet blown off. We withdrew and I went to the commanding

officer and told him I had a feeling that I was going to get

it this time, and that I couldn’t take it any more. He gave

me a direct order to, and it was either do that or have a bad

record, so I went.”

This soldier had tried on three occasions to have his

rank reduced to that of private. “You see,” he said, “as a

platoon sergeant, you are more often than not a platoon

leader, and I couldn’t lead the men like I did before. Under

shelling I got jittery. A platoon sergeant is a leader. If he

isn’t out in front it affects the men.”

This soldier was born on a ranch in Texas. He stated

that his father was epileptic, but that he rarely worried

about it and that it had not affected him in any way. His

parents were harmoniously married. There were seven

children, of which he was next to the oldest. He had a

happy family life and had many friends on nearby ranches.

No significant neurotic traits or conflicts were elicited in

the history. Enuresis, nail biting, temper tantrums, running away from home, nightmares, and somnambulism

were all denied. He left home to work on another ranch at

the age of 14, after completing the eighth grade, and had

been steadily employed as a rancher until induction. He

had always been self-reliant and industrious. Single, he

had no significant sexual conflicts.

His Army career was characterized by steady promotion after his arrival overseas. He stated that he had been

held down in the States by a lack of T/O [Table of

Organization] vacancies. A letter from his battalion commander stated: “It is my opinion, through observation, that

he has reached the end of endurance as a combat soldier.

Therefore, in recognition of a job well done I recommend

that this soldier be released from combat duty and be

reclassified in another capacity.” This battalion commander, incidentally, was noted for his unyielding attitude

toward psychiatric casualties.

Therapy was found to be surprisingly simple, but administratively difficult. The most effective single therapeutic tool was assigning these men within the army area,

out of shellfire but close enough for them to feel that they

were actually helping the men “up front.” The usual

psychotherapeutic procedures were necessary and valuable, but because the “old sergeant syndrome” is primarily

a situational reaction, altering the environment by means

of reassignment is the most important aid to readjustment

and cure. At one time we had several of these men on the

cadre of the divisional training and rehabilitation center.

Their work over a four-month period was beyond

reproach.41(p145)

[The divisional training and rehabilitation center was

the facility in the rear of each division, in the late World

War II European and Mediterranean theaters, responsible

for returning soldiers with combat exhaustion to duty. It

was located close to the division medical clearing station,

was supervised by the division psychiatrist, but was staffed

entirely by line officers and NCOs and maintained a

strictly military atmosphere, including realistic combat

drills.44—JWS, Ed.]

Comment: Given the efficacy of modern drugs in

controlling anxiety and depression, it is possible that in

extreme need such skilled soldiers might be returned to

combat roles. The Israelis, always short of manpower,

treated a few such casualties with tricyclic antidepressants during the 1982 Lebanon War. Belenky, Tyner, and

Sodetz reported that five Israeli soldiers, representing 8%

of the casualties treated in a third-echelon, longer-term

treatment facility (total of 60 patients), received tricyclic

antidepressants.9 Although between one third and one

half of the total patients returned to their original units, it

is not known whether these men were among such returnees, or whether the units were still in combat. The risks of

returning soldiers on medication to forward deployed duty

include: side effects profiles which may interfere with

psychomotor performance; impaired judgment in dangerous situations; medical risks from side effects in the field

environment; problem with resupply; and adjusting dosage at far-forward medical aid stations.

Atypical Reactions to Combat

Atypical Anxiety/Depressive Cases

Men with “pseudopsychotic reactions,” according to Weinstein,45 appeared to be out of contact

with their current physical environment, being “agitated, hallucinatory, and delusional, performing

such stereotypes as digging foxholes with their

fingers, taking shelter under their cots at any sudden sound and ‘warning’ others of the approach of

shells.”45(p138) In Italy most such cases occurred in

troops new to battle and to the group who had been

freshly called up before an offensive action. Group

ties had not only been weakly established at the

outset but also they rapidly dissolved when the

group faced hostile enemy fire. Glass7 reported that

such casualties occurred early in World War II when

the designation “psychoneurosis” (abbreviated

“psycho” by the soldiers) was given to most psychiatric (stress) casualties. This illustrates the continuing importance of not calling these soldiers “psychiatric casualties” today.

The ambiguities of low-intensity, civil-war-type

conflicts can produce atypical reactions. The following two cases illustrate the buildup of personal

problems in a noncombatant in the first case and the

issue of ethical conflicts in a new combatant in the

second case.
War Psychiatry

56

Case Study 9: Shots in the Night

After several months in Vietnam, the author had begun

taking sick call with the Headquarters (HQ) Company

surgeon (who had been an “on-the-job-training” psychiatrist in Hawaii) due to the lack of significant numbers of

psychiatric casualties. He and the surgeon bunked in the

back of the dispensary, which was adjacent to the HQ

supply tent where the supply sergeant slept. One night

the two physicians were awakened by shots fired at close

range. Dressed only in their underclothing and Colt .45

gunbelts, the two rushed next door to find the supply

sergeant firing his M-16 rifle in the direction of the division

commander’s tent.

The HQ surgeon, who had been treating the sergeant

for bursitis, was able to talk him into surrendering the rifle.

Subsequently the sergeant’s story came out. In his mid40s, he had bitterly resented being sent to a combat zone

in his last tour of duty after having already been in combat

during the Korean conflict. Furthermore, he suffered from

bursitis of the shoulder, which he felt should have kept him

from a combat assignment. Except for some general

complaining, however, he had hidden his feelings. The

HQ surgeon had been treating his bursitis with periodic

injections of hydrocortisone with only minimal relief of

pain. Increasingly despondent, the sergeant began drinking to fall asleep at night. Finally on the night in question,

mildly inebriated, he began firing at the general’s tent in

expectation that he would be shot: suicide by someone

else’s hands.

The following morning, the sergeant was remorseful

about the event, expressed that he had no suicide intention, and asked to continue his assignment. He was

closely followed by the HQ surgeon, steroid injections

were replaced by large dosages of aspirin, he was given

Librium for sleep (the only nonneuroleptic, nonbarbiturate

sedative available) and he discontinued all alcohol intake.

His mood gradually improved, and he was able to complete the remainder of his tour.

Comment: A number of confounding factors were

present in this case. In the biological area is a chronic pain

problem compounded by treatment with steroids, which are

known to alter mood in many cases. In terms of intrapersonal

variables, the sergeant had a basically obsessive-compulsive personality with passive-aggressive features. The

situational variables included some isolation from his

fellow soldiers by reason of age and temperament. In

interpersonal contacts he frequently had to respond with

negatives to demands for clothing and equipment. Also,

the news from home was sometimes alarming with his

wife’s complaints about the rebellious behavior of their

teenage children. Finally, a few weeks prior to this

incident, the base camp had sustained an all night mortar

attack with numerous wounded and a few killed.

One outcome of this incident was the development of

a Standing Operating Procedure (SOP) for berserk soldiers.38 There had been several prior incidents in which

soldiers would “go berserk” and start firing indiscriminately or barricade themselves and threaten any approaching personnel. Following this incident, the commanding general asked the provost marshal and division

psychiatrist to develop an SOP for dealing with such

soldiers. The provost marshal suggested that the area be

evacuated and sealed off from all but selected personnel,

mostly military police, then the division psychiatrist be

summoned to speak with him. If he continued to be a

threat and waiting was not feasible, sharpshooters would

shoot to wound or, if all else failed, to kill. The division

psychiatrist agreed with most of the SOP but recommended that the person called to negotiate be either a

known friend of the soldier or his commander if he were

not hostile to the commander. The division psychiatrist

would either accompany the negotiator or be in radiotelephone contact with him. After the SOP became known,

very few such incidents occurred.

Case Study 10: The Atrocity

Several months after the 25th Infantry Division had

been in Vietnam, the division chief of staff requested the

division psychiatrist to evaluate an infantry second lieutenant, a West Point graduate, who had requested that his

military occupational specialty (MOS) be changed to that

of a chaplain’s assistant. When questioned, the lieutenant, a single male in his early twenties, was found to have

no evidence of schizophrenia, mood disorder, or any

other significant mental affliction.

He had been in several “search and destroy” missions,

including some exposure to combat; however, he attributed his change from a warrior to a “man of God” to a

recent incident. His platoon had engaged in a firefight at

a small Vietnamese village known to be sympathetic to the

Viet Cong. After the shooting stopped, an elderly Vietnamese man was found killed with his rifle nearby. The

soldiers tied his feet to the rear bumper of a jeep and

repeatedly dragged his body up and down the main street

of the village. This created a sense of revulsion in the

lieutenant but he did not stop what he subsequently

referred to as “the atrocity.” The day after the incident he

requested a change of MOS.

Background history revealed that although he had

followed his father, now a general, into the military, he had

always been somewhat ambivalent about doing so. Also,

he was deeply religious, the legacy of his mother. He was

a member of a Christian sect that did not require one to be

a conscientious objector, but he stated that he had always

felt that he could not kill another human being. The

division psychiatrist recommended that the lieutenant be

given his requested assignment change. In subsequent

sessions the consequences of his choice were explored

(one was that the chief of staff delayed his promotion

because he had “failed the test of battle”).

Comment: Although the psychiatrist suspected neurotic conflicts concerning his identity involving ambivalence toward his father and the army he represented, the

lieutenant was determined to pursue his new career.

When the division psychiatrist left the division, the lieutenant was still working as a chaplain’s assistant.
57

Traditional Warfare Combat Stress Casualties

With hindsight regarding the failure of the U.S.

pacification and Vietnamization programs in the

Vietnam conflict, and of the serious problems of

indiscipline which continued to haunt the U.S. Army

through the period of the “hollow Army” of the

1970s, it is apparent that this case was not dealt with

appropriately by the chain of command. It must be

noted that the lieutenant was morally and legally

correct in his distress, and in labeling the event “the

atrocity.” Desecrating enemy dead (whether combatants or noncombatants) is a war crime, punishable under the Uniform Code of Military Justice

(UCMJ). Officers who allow their subordinates to

commit war crimes without intervening or subsequently bringing charges are also subject to disciplinary action. The severity of the disciplinary

action may depend on the seriousness of the violation. Dragging the body of an enemy already killed

in combat is not as serious an offense as killing a

disarmed enemy after surrender or an unarmed

civilian, but it cannot be allowed to pass without

firm action by command which makes clear to all

that such misconduct must never happen again or

worse will happen.

It is unclear why the lieutenant did not (or was

unable to) intervene at the time to stop the misconduct. It is likely that he had reason to doubt that his

higher command would back him up in enforcing

the Law of Land Warfare,46 as they do not appear to

have validated his sense of wrongness or assisted

him in reestablishing discipline after the fact. The

failure of the chain of command in Vietnam to

clearly state and enforce the standards of conduct

contributed to a serious breakdown of civilized

behavior in U.S. soldiers. That, in turn, alienated

the local populations and provided ammunition to

the antiwar movement at home.

Shay47 has pointed out the parallels between the

behavior of the Greek hero Achilles in the Trojan

War (as reported in Homer’s Iliad) and Shay’s Vietnam veterans now suffering from post-traumatic

stress disorder. A common theme is that the loss of

comrades in battle can lead to rage against the

enemy and a “berserk state” in which the soldier

performs feats of both heroism and moral depravity. Like the soldiers in this example, Achilles also

dragged the body of his defeated foe, Hector, by the

heels behind his chariot. Achilles did not survive

his war, but the Vietnam veterans seen by Shay

came home. Shay writes, “On the basis of my work

with Vietnam veterans, I conclude that the berserk

state is ruinous, leading to the soldier’s maiming or

death in battle—which is the most frequent outcome—and to life-long psychological and physiological injury if he survives. I believe that once a

person has entered the berserk state, he or she is

changed forever ... If a soldier survives the berserk

state, it imparts emotional deadness and vulnerability to explosive rage to his psychology and a

permanent hyperarousal to his physiology—hallmarks of post-traumatic stress disorder in combat

veterans.”47(p98)

Self-Inflicted Wounds

Glass and Drayer44 reported that at the end of

hostilities in Italy numerous incidents of self-inflicted wounds (SIW) occurred, presumably due to

carelessness in handling small arms captured from

the Germans and Italians, although there were some

who felt that underlying guilt about war behaviors

might have also played a role in these incidents.

The solution adopted by the command structure

involved ordering all captured arms turned over to

ordnance, where they were tagged and not returned

until time of departure for home.

AWOL from Battle

“AWOL from battle,” the informal term, subsumes charges of desertion, refusal to obey orders,

and misbehavior before the enemy or similar military offenses.48 Such offenders are seldom found to

have serious mental illness. In a survey of 200 such

cases in the 85th Infantry Division in Italy from

September 13 to November 22, 1944, Glass48 found

the following characteristics of such cases:

1. The AWOL from combat rate increases with

the duration of offensive action, a cumulative effect of combat rather than a result of

the intensity of battle and unlike the psychiatric casualty rate, which rises and falls

with combat intensity.

2. The majority of offenders are veterans and

have had relatively long exposure to combat (only 17 of the 200 were in their first

combat period).

3. In two thirds of cases the offense was initiated at a safe rear area—returning from

hospitalization, during a rear area detail, or

when the unit was preparing to move forward into combat. In this respect the casualties are similar to self-inflicted wounds cases.

4. Age and intelligence seemed to play no

role.
War Psychiatry

58

5. Three fourths admitted that fear of combat

motivated their action.

6. Only one fourth sought medical or psychiatric care prior to the offense and were refused evacuation. Of this group, in retrospect, only one fourth (1⁄16 of the 200) should

have received such medical care. The majority did not feel they were ill and saw

AWOL as the only way to avoid combat.

7. There was no clear correlation between psychiatric and AWOL rates with regiments,

with the highest and lowest psychiatric rates

having similar AWOL rates, but the battalion with the highest number of AWOL had

a high psychiatric rate and contained three

of the five officer offenders, indicating a

leadership element in the behavior of the

offenders.

8. About one third of the offenders had been

recently hospitalized, before AWOL, many

for wounds, indicating an adverse effect of

rearward evacuation even when surgically

necessary, but only three of the 200 had

received prior psychiatric treatment. [In

1973, the Israelis experienced similar losses

due to psychiatric breakdown in lightly

wounded, evacuated casualties.—Au.]

One may conclude from these findings that while

both the psychiatric casualty and AWOL offender

have a common etiology, the dangers of battle,

quite different mental mechanisms are operating.

The AWOL soldier consciously elects to avoid combat as a result of chronic anticipatory anxiety deriving from accumulated battle experiences and goes

AWOL while away from the supportive or sustaining influence of the combat group or when support

is no longer operative. Conversely, the psychiatric

casualty arises during the intensity of battle and

occurs when the individual is bereft of his own

individual sustaining powers or group support by

the traumatic and disruptive forces of combat.

Kirkland, a combat veteran and student of soldier stress, has commented on the different

symptomatology between combat and rear-echelon

troops: “In a unit in combat a soldier is torn between loyalty to his comrades and his identity as a

soldier on the one hand and terror on the other.

Fleeing and staying are both unacceptable ... unconscious ... symptoms occur [that remove him

honorably from combat]. In the rear, however, the

loyalty and identity factors are not present [but]

terror is ... [the soldier] ... is less conflicted and can

make a conscious choice—go AWOL.”49

The salvage of some AWOL soldiers was considered feasible and, with the cooperation of the judge

advocate general of the 85th Infantry Division, recommendations as to whether or not the offenders

were reclaimable for combat duty were made.48

Those without a chronic anxiety state who presented a favorable attitude to return to combat were

so recommended. Such individuals were held in

the division stockade and released to their units

after several months of good conduct and work. No

follow-up was available because the 85th Infantry

Division did not have any further prolonged combat.

Enjoyment of Combat

Absenting oneself from the dangerous combat

situation may be dishonorable but understandable

to all; however, what is to be made of the occasional

soldier who actually seems to enjoy immersion in

combat? Are such men unconsciously suicidal?

Does their pleasure stem from unleashing Freud’s

postulated Thanatos, the death instinct? Can such

behavior be explained on the basis of powerful

social reinforcement from peers and command?

Like most human behavior, enjoyment of combat

may be of multifactorial origin, resulting from several or all of these inputs. The following case is

typical in that such men are often not well-regarded

by their peers though command often regards them

highly.

Case Study 11: Enjoyment of Combat

Major Glass, while resting in the Alpines after hostilities ended in Italy, was confronted by a jeepload of

sergeants from the 85th Infantry Division. They described

Sergeant X, a wonderfully resourceful, reliable, cool-incombat soldier with several decorations including the

Silver Star. But now, when there were no longer any

hostilities, Sergeant X was restless. He was going on

patrol every night, had shot out the light at their parties,

and had been prowling around. They considered him a

menace.

During the interview he appeared embarrassed and

apologetic, stating he liked the fellows but was bored and

restless and needed something exciting to do. He requested transfer to the Pacific Theater. He told Major

Glass that he must avoid disciplinary problems because

he had been paroled to the Army from State prison, where

he had been serving a sentence for manslaughter; therefore, he must receive an honorable discharge. He admitted he enjoyed the thrill of combat and danger. He was

easily angered and had no close friends, either civilian or

military. No psychosis was present. He was evacuated to

the 601 Hospital; there was no follow-up.48(pp59-60)
59

Traditional Warfare Combat Stress Casualties

Comment: The author saw a few cases similar to this

when directing a research ward for severe character

disorders. Most of these men had severe personality

distortions with prominent antisocial aggressive tendencies. Far from having been created by combat, these men

had usually been delinquent and involved in aggressive

behavior prior to military service. Their adjustment to

civilian life was frequently poor. Persons who enjoyed

combat rarely came for treatment; they seldom responded

to psychotherapeutic attempts. It is possible that serotonergic antidepressants might be helpful because antisocial

persons such as arsonists have been found to have

decreased spinal fluid levels of breakdown products of

serotonin.50

CONCLUSION

The diagnosis of psychiatric casualties is made

difficult not only by the protean symptomatology

and potential mimicry of “organic” conditions but

also by the intentional vagueness of the nomenclature itself. At a time when psychiatrists are striving

for increasing precision in diagnosis it may appear

anomalous that the military is clinging to the nonspecific term “combat fatigue” to categorize the

psychiatric casualties of combat. The glossary

to DSM-III (published separately) even lists

“combat fatigue” as “an obsolete term for posttraumatic stress disorder.” That interpretation is

plainly misinformed. Post-traumatic stress disorder, by DSM-IV’s own criteria, cannot be diagnosed

until 1 month after the traumatic event is in the past.

Combat fatigue, by definition, applies to soldiers

who are still in the traumatic (combat) situation. In

prolonged combat, however, some traumatic events

may have occurred more than 1 month ago. In

general, “combat fatigue” corresponds more closely

to the new DSM-IV classification of “acute stress

disorder,” which is used in the interval from 3 days

after the traumatic event to 1 month (when posttraumatic stress disorder [PTSD] becomes appropriate). But even organized civilian psychiatry has

not placed a diagnostic label on the distress and

disturbed behavior which may occur within the

first 3 days after an extremely traumatic (life-threatening) event. This is the period of time in which

most battle fatigue symptomatology is detected and

(ideally, with “immediacy”) treated and resolved.

This temporary disturbance can be described as the

normal human response to very abnormal, threatening conditions. Using a “normalizing” label such

as combat fatigue is an important therapeutic maneuver intended to impress the soldier with the

idea that he is not mentally ill but just tired and can

expect to recover with rest. As seen with the diagnostic label, expectancy is the critical psychological

variable in the recovery of the combat stress casualty. Thus, diagnosis and treatment are inextricably

intertwined.

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