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A Psychological Model of Combat Stress

Chapter 6

A PSYCHOLOGICAL MODEL OF

COMBAT STRESS

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

INTRODUCTION

BACKGROUND TO THE MODEL

ANTECEDENT VARIABLES

Individual Factors

Unit Factors

Battlefield Factors

MEDIATING VARIABLES

THE APPRAISAL PROCESS

MODES OF RESPONSE

MODES OF COPING

SUMMARY AND CONCLUSION

*Colonel (res), Former Chief Psychologist, Israeli Defence Forces; Current Director, The Israeli Institute for Military Studies, 5 Kadesh St,

Zikhron Ya’akov 30900 Israel

†Colonel (ret), Medical Corps, U.S. Army; Clinical Professor, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past

President and Secretary and current Honorary President of the Military Section, World Psychiatric Association; formerly Psychiatry and

Neurology Consultant, Office of The Surgeon General, U.S. Army
War Psychiatry

134

Manuel Bromberg Soldiers Resting on Omaha Beach, Normandy 1945

Manuel Bromberg was a member of the War Artist Unit for England and Ireland during World War II and

was present during the invasion of Normandy. He does an exceptional job of visualizing the variables of

combat stress (the individual, the unit, and the battlefield) in this watercolor of three exhausted soldiers

from World War II trying to rest amidst the destruction about them.

Art: Courtesy of US Center of Military History, Washington, DC.
135

A Psychological Model of Combat Stress

INTRODUCTION

The model presented in this chapter is a blend of

theory and practice. The theoretical approach stems

primarily from the cognitive theories of stress and

coping, which emphasize the role of cognitive appraisal and active coping in the individual’s response to stressful conditions.1–4 The practical ideas

are derived from the combat experiences of the

senior author and those of his colleagues in the

Israeli Defence Forces (IDF) and the junior author’s

combat experiences in Vietnam. These ideas were

subsequently discussed and elaborated with wellseasoned IDF field commanders. The model has

been used in lectures given at various senior command courses in the Israeli military and has been a

useful tool for approaching the complexity of human behavior in groups under stress.

BACKGROUND TO THE MODEL

A number of studies related to World War II,5,6 to

the Korean and Vietnam conflicts,7–9 and to the

Arab-Israeli wars10–12 have delineated variables that

prevent or promote the individual’s ability to cope

with combat stress. These studies and the salient

coping variables have been summarized by several

authors.10,13,14 Although these variables do not lack

face validity, a coherent scheme of their interactions and their impact on subsequent combat stress

reactions has been lacking. There have been attempts at a dynamic interpretation of the simple

relation between nature, nurture, and combat stress,

beginning as early as Salmon15 and extending as

recently as Shaw16 and Milgram.17 Yet the complexity of the combat situation calls for a multi-variable

and rather complex, interactive model to account

for the multitude of factors involved in the generation of, and consequent coping with, the stress of

combat.

The proposed model is interactional in that it

posits a number of antecedent variables acting

through mediating variables to affect the individual’s appraisal of the combat situation and subsequently result in the combatant’s modes of response and coping with the realities of combat

(Figure 6-1). Furthermore, the model is also dynamic wherein the individual’s preferred coping

behavior in turn affects his reappraisal of the situation and thus may further alter his combat responses.

The antecedent variables pertain to the individual,

group, and environmental aspects and may conveniently be categorized as follows:

• Individual factors—personality, nonmilitary

stress (family, etc), prior combat exposure,

role in combat.

• Unit factors—cohesion and morale, training, leadership, and commitment.

• Battlefield factors—type of battle, surprise

and uncertainty, environmental factors

(weather, terrain, etc).

These antecedent variables, according to the proposed model, do not directly determine the soldier’s

appraisal of the combat situation; rather, they are

mediated by other variables—the mediating variables—in an interactive manner. Of paramount

importance in the soldier’s expectation or interpretation of the immediate situation is the role his

commanders (or persons in leadership positions)

play in providing the information concerning the

impending military operation. Thus, the way in

which he is briefed and the way in which orders are

given, interacting with the antecedent variables,

will strongly color his evaluation (ie, appraisal) of

both the nature of the stress and his ability to handle

it. The role of the commander, then, becomes that of

a lens, that is, either magnifying or minimizing the

impact of the (objective) antecedent variables on the

soldier’s (subjective) cognitive appraisal.

The appraisal process, which is the central notion

in this model, may vary along a wide range of

alternatives: the exact situation may be assessed by

different individuals or at different moments as a

terrifying, benign, or challenging situation—depending upon the interactive consequences of the

given antecedent and mediating factors. The

individual’s initial modes of response to and coping

with a combat situation will reflect his own process

of cognitive appraisal. Response patterns may be

divided into the traditional categories of physical,

emotional, cognitive, and social. These immediate,

somewhat universal patterns of response will in
War Psychiatry

136

Individual Factors

Unit Factors

Battlefield Factors

Physical

Antecedent Variables Mediating Variables Modes of Response Modes of Coping

Activity

Inactivity

Breakdown

Expectations

Reappraisal

Cognitive

Social

Emotional

Appraisal

of

Combat

Situation

Form of 

Presentation

Interpretations

C O M M A N D E R

Fig. 6-1. A model of soldier behavior in combat stress conditions. This model is interactional in that it posits a number

of antecedent variables acting through mediating variables to affect the individual’s appraisal of the combat situation

and subsequently result in the combatant’s modes of response and coping with the realities of combat. The model is

dynamic in that the individual’s preferred coping behavior in turn affects his reappraisal of the situation and thus may

further alter his combat responses. The role of the commander becomes that of a lens, magnifying or minimizing the

impact of the (objective) antecedent variables on the soldier’s (subjective) cognitive appraisal.

turn produce individual modes of coping ranging

from an optimal mode (normally involving a high,

goal-oriented level of activity) to limited coping

(frequently characterized by passivity) to grossly

disturbed coping (breakdown).

The modes of coping actually utilized will influence, in a feedback manner, the individual’s reappraisal of the newly perceived situation and of his

already tested capabilities to cope with it. Thus, the

cognitive appraisal processes are in a state of dynamic flux, originally affected by the antecedent

factors but consequently reflecting also the initial

reactions made by the individual. The new appraisal will then lead to different modes of response

leading to different modes of coping and a further

new and different appraisal.

The following sections will further detail each of

the components of the proposed model and will

attempt to empirically substantiate the proposed

relationships between them. This analysis will involve direct combat experience as well as relevant

research.

Individual Factors

Among the individual factors that any combatant brings along with him to the battlefield are his

personality dispositions and his general well-being. These, together with his previous combat experTwo main groups of variables, antecedent and

mediating, lead to the initial appraisal of the stress

situation. The antecedent variables comprise those

factors that are in the background of the combat

situation; they may be categorized as individual

factors, unit factors, and battlefield factors.

ANTECEDENT VARIABLES

Reappraisal

Form of

Presentation
137

A Psychological Model of Combat Stress

ience and his role in combat, determine the first

category of the antecedent variables.

Personality Dispositions

Notwithstanding the almost obvious expectation that behavior in the face of battle should be

somehow linked to the warrior’s personality, very

little empirical evidence has been found linking

individual personality factors and combat behavior, either in terms of outstanding performance or

breakdown.18 One extensive study,19 however,

did find several characteristics that distinguish

“fighters” (soldiers who had received, or had been

recommended for, a decoration for valor in combat

or were evaluated by peers as high performers)

from “nonfighters” (soldiers who were evaluated

by peers as poor performers, or admitted themselves as such). Among the differences revealed in

that study, the “fighters” tended to be more intelligent, “masculine,” and socially mature; and showed

greater emotional stability and stronger leadership

potential.

Indeed, military organizations tend to consider

personality variables in selecting personnel for combat roles, particularly leadership roles and special

operations. This preselection procedure may, in

fact, by virtue of restricting the range for study,

account for the difficulties in establishing empirical

correlations between personality dispositions and

combat performance. Gal,20 for example, in a study

of soldiers awarded medals for bravery in the 1973

Yom Kippur War found only a few differences in

personality characteristics between the decorated

soldiers and a matched sample of combat soldiers

not so recognized. These personality characteristics were part of the officer selection process that

many of the soldiers awarded medals had gone

through. Medal recipients, as compared with their

peers, showed higher scores in leadership, devotion to duty, decisiveness, and perseverance under

stress. Sociability, social intelligence, and emotional stability did not distinguish the two groups.

With regard to psychiatric breakdown among

members of combat units, Noy21 found that while

personality characteristics did not predict such

breakdown, they were significant in recovery after

breakdown. Men with massive repression of hostility or anxiety, particularly if coupled with situational stress at home, had a poorer prognosis. It is

quite evident, then, as concluded by Glass in his

summary of the “lessons learned” from World War

II, that “the frequency of psychiatric disorders [in

combat] seemed to be more related to the characteristics of the group than to the character traits of the

involved individuals.”13(p995)

Individual’s Well-Being

While personality dispositions refer to longstanding traits of the individual himself, well-being

refers to relationships between the individual and

his environment.22 Such relationships may directly

affect combat behavior as shown in the Israeli experience of the 1973 Yom Kippur War.21 In a group of

40 Israeli soldiers who suffered battle shock, 80%

had prior or ongoing civilian stresses. About one

half had pregnant wives or were new fathers during

the year preceding the war and about one fourth of

them had experienced a recent death in the immediate family. Other relevant civil stresses consisted of

being newly married or separated and economic or

family problems.

A world War II study23 reported that 20% of

psychiatric cases complained of “homesickness” as

a significant stress. An even more striking difference between those who became psychiatric casualties and a nonafflicted comparison group was found

when variables such as family, school, work, and

social, recreational, and community adjustments

were examined. Soldiers with impairments in these

areas were found to have about a two to four times

greater likelihood of breaking down.23

More recent studies have shown high levels of

self-reported well-being to be a distinct characteristic of elite combat units.24 Whether operating as a

causal factor in facilitating volunteering to elite

units, or emerging as a concomitant of belonging to

such units, personal sense of well-being is evidently

an important antecedent factor for any combatant

facing the impending stress of combat.

Previous Combat Experience

The effect of previous experience on fear reactions was demonstrated in studies conducted with

combat-like performance. Epstein25 and his colleague26 have demonstrated that experienced parachutists showed different patterns of subjective fear

and physiological reactions as compared to novice

jumpers.

Actual combat experience obviously has an even

stronger effect. Indeed it has been recognized, at

least since World War II, that initial exposure to

combat on the one hand and cumulative combat

stress on the other hand result in higher rates of
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138

psychiatric breakdown. Units with high percentages of “green” soldiers tended to have higher numbers of psychiatric casualties.27 Clearly the soldier

with prior combat experience has less chance of

breakdown in subsequent exposure, until the point

(about 30 combat days, defined as days in which a

company suffered at least one wounded in action

[WIA] or killed in action [KIA]) that cumulative

stress begins to produce combat inefficiency.28

Apparently even the soldier who has broken

down, if properly treated with “forward treatment,”15 has no greater chance of breakdown again

than his combat peers. Looking at Israeli soldiers

who had become psychiatric casualties in 1973 and

who subsequently served in the 1982 Lebanon War,

Solomon, Oppenheimer, and Noy29 found no significant increased recurrence of psychiatric breakdown among those with prior breakdown if they

had been found fit for combat. It should be recognized, however, that a significantly smaller percentage of soldiers who had had psychiatric breakdowns were found fit for combat compared to those

who had not (40% versus 75% in nonpsychiatric

controls) but this may have been a result of lack of

“forward treatment” in 1973.

It might be summarized, then, that previous combat experience may have an enhancing or an inhibiting effect on the soldier’s reactions to subsequent

exposure to combat—depending on whether the

previous experience had been a traumatic or a

nontraumatic one.

Role in Combat

One’s role in combat, whether formally assigned

or assumed during the vicissitudes of combat, plays

a crucial role in his appraisal of the situation and

thus in his method of coping. In general, engaging

in an assigned role that involves some form of

mission-oriented tasks will create a sense of mastery and control as well as distract the soldier from

his impending danger.4

The leadership role in a combat situation is particularly important for coping behavior. Bourne,

Rose, and Mason,30 for example, in studies conducted during the Vietnam conflict, have shown

significantly different patterns of hormonal responses (normally associated with stress) between

officers and enlisted men of a 12-man group who

were anticipating engagement in combat. The

chronic levels of steroid excretion of officers were

higher than those of their enlisted men and rose

even higher on the day of anticipated attack. The

senior radio operator’s steroid excretion also rose;

indeed, his role was closer to that of the officers, and

reflected again the importance of his role assignment in combat.

Unlike Bourne and his colleagues, who equate

steroid excretion with levels of psychological stress

in combat, the authors believe that the level of

steroid excretion reflects physiological arousal and

that the leadership role may actually be less psychologically stressful because the leaders are better

prepared for combat and have more control over

combat situations. Support for this hypothesis may

be seen in the work of Miller,31 and Miller and

colleagues,32 with pilots and their radar intercept

officers during stressful aircraft landing procedures.

They found that while the radar intercept officers

had lower levels of steroid excretion, the pilots,

who had active control over the flights, reported

fewer somatic complaints and significantly lower

levels of anxiety than the radar intercept officers.

In support of these studies there are numerous

personal observations that show that the leadership

role supports superior combat performance and

protects the leader from disabling psychological

stress. The senior author both personally observed

and had many communications from Israeli field

commanders describing the mastery, confidence,

and even daring they have derived, under fire, from

the awareness of their leadership role and the expectations of their men.

During the 1973 Yom Kippur War, Israeli commanders were under the greatest combat danger,

being in the forefront of the engagement. This

danger is reflected in the fact that a commander had

four times the chance of being killed compared with

his men.33 Despite the presumed increased risk of

battle stress, Levav and others34 showed that the

rate of psychiatric breakdown among officers was

one fifth that of enlisted men. On the other pole of

battlefield performance, that of bravery in battle,

the number of Israeli combat officers awarded medals for extraordinary acts of bravery was much

higher (64% of the total) than their proportion in the

line units.20 When noncommissioned officers are

included with commissioned officers, the percentage of medals for bravery rises to 88% awarded to

persons in leadership roles, thus inverting the ratio

of leaders-to-led.35

In conclusion, under battlefield conditions, perceived role is a critical factor in both combat effectiveness and resistance to breakdown. Perceived

role serves adaptive coping purposes through the

interplay of three psychosocial mechanisms: (1) the

expectations attached to the role (especially the

leadership role), (2) the sense of mastery and con-
139

A Psychological Model of Combat Stress

trol associated with the role, and (3) concentration

on the tasks required by the role distracts attention

from the realistic dangers of combat.

To summarize, one can see that while there are

only limited data to show that personality dispositions predict combat behavior, there is good evidence

for the importance of background conditions such as

the individual’s well-being, his previous combat

experience, and his perceived role in combat.

Unit Factors

In most cases the individual will not operate

alone but will be part of a group in combat. The

group’s size (significant for the individual combatant) may vary from three or four (as in a fire team or

tank crew) to larger formations such as companies

or even battalions. These group characteristics,

similar to individual characteristics, have important implications for combat behavior. Since the

1973 Yom Kippur War, the IDF has deployed field

psychologists to all of its line brigades to survey

morale factors at various organizational levels and

report back to unit commanders. Systematic analysis36 of these surveys revealed four general factors

important in determining unit climate. These consisted of unit cohesion and morale; confidence in

commanders; confidence in weapons and in oneself as a combatant; and ideology, values, and commitment.

Unit Cohesion and Morale

Unit cohesion and morale have repeatedly been

found important in supporting individual coping

behavior and unit performance both in wartime5

and in peacetime.37,38 Among other variables, they

were found to affect critically the rates of psychiatric breakdown in combat.13 In the words of Glass:

Repeated observations indicated that the absence

or inadequacy of such sustaining influences [which

he termed “group identification,” “group cohesiveness,” “the buddy system,” and “leadership”]

or their disruption during combat was mainly responsible for psychiatric breakdown in battle. These

group or relationship phenomena explained marked

differences in the psychiatric casualty rates of various units who were exposed to a similar intensity

of battle stress.13(p995)

In recent studies based on Israeli experiences

during the 1973 Yom Kippur War, the relationship

between unit cohesion and morale and coping behavior was reconfirmed. In a retrospective examination of 40 IDF soldiers who suffered psychiatric

breakdown in that war, Noy21 found that 40% of

these casualties reported minimal group affiliation

in contrast to only 10% in a control group of

noncasualties. Similarly, Steiner and Neumann39

found the following characteristics in 74 reserve

soldiers presenting with acute or late onset of posttraumatic combat reactions after the 1973 Yom Kippur War: low morale, with little or no identification

with their unit or team; lack of trust in leadership;

frequent transfer or rotation; feelings of loneliness

and not belonging to their units; and low self-esteem concerning their military performance.

Thus, a low level of morale and weak bonds with

comrades and leaders may elevate the perceived

stress of combat and ultimately result in severe

combat reactions. This indeed happened in units

with low cohesion and low morale. At the other end

of the spectrum, elite units, famous for their high

degree of cohesion and morale, have consistently

had low psychiatric casualty rates despite frequent

exposure to high-intensity battle stress.

Confidence in Commanders

The paramount importance of the role of leadership in combat has been recognized since antiquity.

The history of battle has always been the history of

leaders building their subordinates’ confidence to

achieve victories. Whether the fighting unit is a

small band of warriors with spears or a vast army

with laser-aimed rifles and bombs, their confidence

in the leader is essential.

Contemporary studies40–42 confirm the crucial role

of unit commanders in preparing troops for combat, enhancing troop morale, and leading them courageously in battle. The soldier’s confidence in the

commander is also critical in protecting him from

overwhelming battle stress. In Israeli studies during the 1982 Lebanon War, Kalay43 found three

elements that inspired confidence in the commander:

(1) belief in the professional competence of the

commander, (2) belief in his credibility, and (3) the

perception that he cares about his troops. While in

garrison all three components are equally important; in combat, trust in the commander’s professional competence becomes primary.

In reviews of Israeli morale surveys during both

the 1973 Yom Kippur War and the 1982 Lebanon

War, the senior author12 compared the levels of

confidence soldiers had in commanders at various

command levels, from platoon to division. While

assessments before combat showed an almost linear increase in the confidence of troops in their
War Psychiatry

140

commanders with increasing levels of command

(ie, lowest at the platoon leader and highest at the

division commander levels), after combat the trend

was generally reversed with the highest levels of

confidence shown in the more immediate commanders (platoon, company, battalion) and relatively

lower confidence at the more remote levels of command (brigade, division). This difference may be

accounted for on the basis that prior to battle the

soldier perceives his welfare and success as being

dependent on higher command plans and decisions; but, in actual combat, he finds that his very

survival depends mainly on the actions of his more

immediate leaders.

It is apparent, then, that despite marked changes

in the configuration and technology of the battlefield, the confidence troops have in their commanders at all levels is a critical ingredient in the soldiers’

process of coping with the stresses of battle.

Confidence as a Soldier

As described earlier, “green troops” suffer higher

rates of psychiatric casualties than battle-experienced troops. This may well reflect the importance

of increased confidence of the soldier in his own

battle skills.

Confidence in one’s weapons and in one’s proficiency as a combatant has been shown to be important for the soldier’s morale. In a morale survey

among Israeli soldiers anticipating combat, Gal36

reported high correlations between their personal

level of morale and both confidence in themselves

as combatants and confidence in the unit’s weapons

system.

Furthermore, Steiner and Neumann,39 studying

the combat experiences of Israeli veterans of the

1973 Yom Kippur War, examined among other variables the relationship between self-confidence in

military performance and the development of posttraumatic stress disorders. They found that 46% of

74 soldiers suffering traumatic reactions evaluated

their military performance and knowledge as poor.

In contrast, only 3% of 100 soldiers in a nonafflicted

control group reported such lack of self-confidence.

Another source of the soldier’s confidence is his

familiarity with his mission, with the operational

terrain, and with the exact location of friendly and

enemy forces.36 Because one of the well-established

sources of anxiety is fear of the unknown and the

unfamiliar, introducing the soldier to the details of

his mission, the terrain, and the deployment of

forces will ultimately reduce his anxiety level.

These aspects of a soldier’s self-confidence—trust

in one’s own combat skills, in weapons systems,

and familiarity with missions and terrain—are

all created within the unit framework during training periods. Knowledge of missions and terrain

is not learned during training in the United States

as it is in Israel because of the wider range of

scenarios. The more realistic the training, the better

prepared the soldier will be. However, the growing

sophistication (and expense) of modern weaponry

has resulted in the increasing use of training by

simulation devices, which may act against the accomplishment of such realistic training. Simulation

training, while usually accurate in its technical

aspects, is quite dissimilar from the arduous and

horrifying conditions of combat.44 Military training, therefore, must aim not only at producing

technical proficiency with one’s weapon but

also at developing soldierly skills and proficiency

to serve the soldier as a psychological defense

mechanism against the strenuous conditions of the

battlefield.

Ideology, Values, and Commitment

It is commonly believed that a strong ideological

conviction plays a significant role in combat motivation. Obviously, when a soldier believes that he

is defending his homeland, he may derive additional strength to face the horrors of battle. However, while it is evident that such ideological convictions foster the joining of a military organization,

there is little empirical data supporting the position

that such feelings enhance performance or prevent

breakdown in the midst of a combat situation. In

fact, observations by acknowledged military experts have deemphasized the importance of ideology when survival on the battlefield is at stake. For

example, S.L.A. Marshall, after visiting Israel and

discovering the importance of nationalist feelings

to its citizens, gave his own judgment:

But for my own part, I reject finally the idea that the

extraordinary elan of that Army in combat comes

from self-identification of the individual with the

goals of his nation in the hour when his life is in

danger. That is not the nature of man under battle;

his thoughts are as local as is his view of the nearest

ground cover, and unless he feels a solidarity with

the people immediately around him and is carried

forward by their momentum, neither thoughts about

the ideals of his country nor reflections on his love

for his wife will keep him from diving toward the

nearest protection.45(p304)
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A Psychological Model of Combat Stress

In a similar vein, Field Marshall Montgomery, in

referring to patriotic feelings and historical roots of

combat motivation, deliberately downplayed these

factors: “[I]n the crisis of battle the majority of men

will not derive encouragement from the glories of

the past but will seek aid from their leaders and

comrades of the present.”46(p21)

Despite this discounting of idealistic feelings as

a factor in actual combat, there is evidence that

a soldier’s perception of the legitimacy of his

side’s participation in war is important for his morale. A morale survey conducted among IDF troops

prior to the Israeli incursion into Lebanon found a

positive correlation between the soldiers’ morale

level and their belief that invading Lebanon was

justified.36

A similar relationship between morale and perceived legitimacy of one’s side in a war probably

could have been found in Vietnam. Renner47 and

Gabriel and Savage48 have argued that after 1968,

soldiers’ perceptions that the U.S. presence was not

legitimate led to unit disintegration as evidenced

by “fragging” (assassination of one’s leaders), desertion, drug abuse during combat, and combat

refusals.

It was reported49 that Soviet soldiers stationed in

Afghanistan during the mid-1980s invasion suffered low morale and engaged in widespread drug

abuse and some fragging similar to U.S. soldiers in

the late phases of the Vietnam conflict. Defecting

soldiers in Afghanistan related this to loss of belief

in the legitimacy of the war: “It’s a stupid war, not

useful to anyone.”49

Ideological concerns thus seem most important

when legitimacy is questionable, or in wars of

low intensity with intermittent combat, and in

the anticipation before battles or during lulls between battles. In the heat of battle, however,

ideological motivation is replaced by other unit

factors such as leadership, unit cohesion, and

combat skillfulness.

Battlefield Factors

The third group of antecedent variables, battlefield factors, may play a decisive role in promoting

combat stress because they include the nature of the

threat and the environment of the battlefield. Most

battlefields have unique features that generate different levels of stress. The World War II U.S. battles

on Okinawa and Normandy, for example, both beginning as amphibious invasions, had vastly different characteristics and quite different rates of psychiatric casualties: very high in Okinawa and overall relatively low in Normandy. The Israeli 1967

Six-Day War and 1973 Yom Kippur War were both

brief and of high intensity but differed markedly in

the impact on troop morale and psychiatric casualties: almost none in the former and relatively high

in the latter.

The main components in this last category of

antecedent variables are the type of battle, its length

and intensity, the uncertain elements of battle, and

the physical characteristics of the battlefield.

Type of Battle

Offensive and defensive operations differ in generating stress reactions. In defensive operations,

especially with impending danger but without active engagement to break the tension, the soldier is

subjected to an enforced passivity and experiences

a feeling of helplessness. By contrast, in offensive

operations, even though the risk may be greater, the

soldier is active, has a vicarious sense of control

over the situation, and is distracted from personal

concerns.4 Similarly, during static situations such

as being pinned down for long periods, perhaps by

artillery fire or similar situations of immobility,

stress casualties are higher than in mobile situations such as advancing or even retreating.50

Day vs night operations may also generate different stress reactions in synergy with other situations.

For example, at nighttime the soldier in a defensive

posture may have his feelings of isolation accentuated by darkness. On the other hand, daytime

operations with active engagement of the enemy

may allow the soldier to see his wounded and dead

comrades, adding to his battle stress. Unfortunately, no clear data indicating increased pathogenicity for either situation exist.

Length and Intensity of Combat

Length of exposure to combat has been correlated with cumulative stress28,51 while intensity of

combat is more related to acute stress.50 In furthering this distinction, some authors refer to the consequences of cumulative stress as “combat exhaustion” or “fatigue” and of acute stress as “battle

shock.”

Several authors have attempted a predictive

model of breakdown based on duration of combat

exposure28,51 or intensity of combat.52–54 Swank and

Marchand28 found that most psychiatric casualties

occurred after 30 to 45 days of exposure to combat.
War Psychiatry

142

Beebe and Appel, on the other hand, predicted that

“the breaking point of the average rifleman seems

to have been reached at about 88 days of company

combat [days in which a company casualty

occurred].”51(p163)

A number of authors10,13,50,52–55 have observed the

relationship between combat intensity, as indicated

by wounded and killed in action (WIA and KIA),

and combat breakdown. Normally, the rate of psychiatric casualties will fluctuate in proportion to the

WIA. In prior wars this ratio has ranged from 1:3 to

1:1; however, in low-intensity, intermittent combat,

psychiatric casualties are less directly related to

combat and take different forms.47,56,57

To summarize what is known about the relationship between duration of exposure to combat and

the likelihood of combat stress breakdown, it appears that some minimum amount of exposure to

combat is necessary to enhance soldiers’ confidence

and decrease their vulnerability to breakdown.

Beyond that exposure threshold, increased exposure to combat eventually weakens the soldiers’

defenses against breakdown.

Battle Anticipation, Uncertainty, and Surprise

As alluded to earlier, the anticipation of battle

may be more stressful than actual battle.4

 A wellknown syndrome described by World War II physicians as the “precombat syndrome”58 consisted of

vague complaints without identifiable physical findings among those scheduled for combat, for example, air crews awaiting a bombing run. Furthermore, Jones59 noted that there were numerous

psychiatric complaints in the 25th U.S. Army Division in the several months when deployment to

Vietnam was uncertain, but fewer when it became

definitive.

Generally, troops prefer to avoid impending

threats of combat; however, long periods of anticipation may result in paradoxical positive feelings

concerning impending combat. The first author has

monitored the feelings of combat anticipation of a

group of infantrymen stationed in a combat zone

for 3 weeks. He found an inverted U-shaped curve

peaking at 10 days measuring strong anticipation of

actual engagement with the enemy. This response

pattern reflects the mounting anticipation during

the ascending limb and a growing desire to relieve

the anticipatory anxiety with action. The descending limb may reflect a desire to avoid combat altogether because relief was becoming imminent.

Breznitz,60 among others, has discussed this reaction pattern in his study of “incubation of threat.”

According to Breznitz, two conflicting tendencies

may operate simultaneously in an anticipatory period. On the one hand, the person gradually relaxes

after the initial introduction of the threat. On the

other hand, there is increasing excitation as actual

occurrence of the threatening event approaches. In

cases where a U-shaped curve is exhibited by stress

reactions, this curve may be the net result of these

two processes.

Uncertainty can take two forms: temporal uncertainty in which the time when an event will occur is

unknown and event uncertainty in which the time

is known but the nature of an event is unknown.

Situations involving both types of uncertainty are

common in combat. In general, the greater the

uncertainty, the greater the stress.61,62

Although anticipation and uncertainty create high

levels of stress, a surprise aversive event is even

more stressful. The initial phase of a surprise attack

may maximize panic and psychiatric breakdown.

According to senior Egyptian Army psychiatrists,

this was reflected in high psychiatric casualties

among Egyptian soldiers in the early period following the 1967 surprise attack by Israel.63 Likewise

numerous psychiatric casualties among Israeli

troops occurred in the first hours and days following the surprise attack by Arab forces in the 1973

Yom Kippur War.11

Environmental Conditions

Some of the antecedent factors are not necessarily born in combat, but they affect combat performance. For example, when combatants are rapidly

transported to a new and unfamiliar environment,

they must first adjust or acclimate before performing at their optimum.64

 Furthermore, harsh environments such as arctic or tropical climates, wet, or

other inclement weather increase combat stress casualties, probably through the increased physiological stresses added to the psychological stresses of

combat. Numerous authors have commented on

the deleterious effects of adverse environmental

conditions on morale5 (ie, strange terrain such as

that found in the desert, the jungle, the steppes—

lacking usual landmarks) and on the soldier’s ability to cope in combat.65

Masked psychiatric conditions ranging from frostbite or immersion foot in cold or wet climates to

dehydration in hot or dry climates exemplify the

relationship between combat breakdown and adverse environments.66
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A Psychological Model of Combat Stress

MEDIATING VARIABLES

While antecedent variables are important in the

soldier’s appraisal of the combat situation, their

impact on the individual’s response and coping

behavior is determined by mediating variables.

These variables are, in the first place, cognitive in

their nature, involving cognitive interpretations

of the antecedents, a logical evaluation of the

situation, and a buildup of expectations both of

one’s behavior and of the consequences of the entire

situation.

A second characteristic of these mediating variables is that they are largely controlled by the commander who may give them a positive or negative

connotation. For example, a determined, confident

commander, who conveys to his troops his optimistic view, will actually increase the chances of success, assuming that the optimism is realistic. On the

other hand, an unenthusiastic, subdued, or frightened presentation will create uncertainty or fear

and result in less resolute, more pessimistic appraisals, increasing the possibility of failure.

The commander plays a central role in creating

the individual’s appraisal of the situation by acting

as a lens (see Figure 6-1) that focuses the antecedent

variables into a unified interpretation of the situation. Like in a telescope, this “lens” works (with

regard to the stress of combat) to amplify the perceived threat or to reduce it, make it closer or more

remote, better focused or more blurred. Though it

may not be possible to modify many of the antecedent variables, the commander can be trained to

present and interpret information regarding these

antecedents in an optimal manner and hence create

an expectation of success.

A third characteristic of the mediating variables

is their dynamic quality. While the antecedent

factors may change or remain the same, the interpretation given to them may vary as new information becomes available or as behavior changes as a

consequence of the appraisal. A heroic or cowardly

act by oneself or a comrade, for example, will change

the initial interpretation of the situation and lead to

changed responses.

It must be realized that there are not clear-cut

distinctions between the antecedent and mediating

variables. Interpretations and expectations may

stem directly from the individual’s predispositions

or be part of a unit characteristic. These antecedent

and mediating variables are schematically presented

separately in the model for purposes of clarity only.

THE APPRAISAL PROCESS

The appraisal is the bridge between the external

conditions and the soldier’s response. It is the

combination of the soldier’s perception and evaluation of both the situation and his own capability to

cope with it. The same situation may result in a

whole spectrum of appraisals by various individuals or by the same individual at different times.

Thus, a given combat situation may appear lethal,

hazardous, adventurous, or auspicious, while the

individual reaction to it may range from being terrified or threatened to challenged or excited.

The appraisal process further determines the

course of action that an individual might take when

faced with a stressful situation. This is reflected

directly, for example, in the work of Grinker and

Spiegel on combat stress in World War II. As these

authors noted, “appraisal of the situation requires

mental activity involving judgment, discrimination

and choice of activity.”6(p122)

Lazarus and his colleagues3,67 have empirically

demonstrated the dominance of the cognitive appraisal process in determining the emotional and

behavioral responses of groups and individuals to

stress. In a series of studies3 in which audiences

viewed highly distressing films, the responses

of the audience were clearly determined by a

narrative voice that interpreted the ordeal as ranging from traumatic to neutral, intellectualized,

or benign (through denial-like processes). Though

the subjects all saw exactly the same film, their

reactions were drastically different as a function

of the sound track the introduction provided

before the film. Using the neutral group as a reference, the trauma group showed marked elevation

of physiological and psychological distress while

the intellectual and denial groups showed reduction in distress. Subsequent experiments using the

same paradigm revealed different stress reactions

as a function of the conditions (ie, length of anticipatory time, level of uncertainty) on which the

appraisal process depended, the type of cognitive

activities (ie, detachment or involvement) required
War Psychiatry

144

from the subjects, and as a function of individual

differences.

Thus, the same situation may generate different

responses depending on the type of interpretation

or expectation suggested prior to or during the

situation. Likewise, an individual or group reaction to battlefield conditions can be determined by

the mediating variables (interpretations, expectations, form of presentation), which are primarily

controlled by the commander. From these different

appraisals will result the different modes of response or coping.

MODES OF RESPONSE

The modes of response to stressful combat situations may be categorized as follows:

• Physical: includes autonomic changes

(tachycardia, vasoconstriction, sweating,

increased gastrointestinal motility), musculoskeletal changes (increased tonicity and

perfusion of blood to muscle), and glandular changes (release of medullary and cortical hormones from the adrenal glands producing many of the foregoing effects).

• Emotional: includes a variety of affective reactions varying from enthusiastic excitement

to apprehensive fear, anxiety, or depression.

• Cognitive: includes distortion of perception

with narrowing of attention span, hyperalertness to certain stimuli, and increased

utilization of automatic or overlearned responses.

• Social: includes increased dependency on

leadership and need of affiliation, sometimes

expressed by seeking reassurance and physical clustering. Negative aspects may be an

increased tendency to make demands and

irritability.

These reactions are universal. Alerting the soldier to their anticipated appearance under stress by

reassuring him that they are normal and are preparing the body for combat will serve a preventive and

therapeutic purpose. The appraisal plays a lesser

role in eliciting or controlling these responses than

it does with the coping responses, which will be

discussed next.

While the modes of response (in this model) are

relatively involuntary or automatic, immediate, and

brief, the individual’s modes of coping are more

flexible, voluntary, and may be delayed and prolonged. The former may only to some extent be

conditioned through training; the latter are highly

influenced by training and strongly determined by

the instant conditions of combat.

MODES OF COPING

The individual’s appraisal of the situation and

the variety of modes of response are incorporated

into an integrated or holistic mode of coping, ranging from various levels of activity through passivity

to actual breakdown. The active mode of coping

may take various forms. During combat anticipation (almost always present on the battlefield), activity may take the form of preparation—checking

gear, plans, or last minute details. Activity may not

necessarily be directly related to the threat, and can

include card playing, book reading, letter writing,

and so forth. These activities, nonetheless, serve as

successful coping behavior because they distract

the individual from considering the death or wounding that may await him in battle, and sustain and

promote cohesion and resolve. This behavior, particularly when it takes the form of combat preparations, also gives the soldier a sense of mastery over

the situation, diminishing anxiety.4

During combat, the active-coping mode is seen in

controlled aggression by the combat soldier: seeking shelter, firing weaponry, scanning or scouting

the terrain, etc. Similarly, the combat-support soldier will stay active in his respective duties. The

consequences of this active mode are usually greater

initiative, innovation, bravery, and successful accomplishment of the mission. Rarely, this activity is

not mission-oriented and results in inefficiency in

combat.

Relative inactivity or even passivity in the combat situation is manifested by decreased movements,

relative apathy to the surroundings and mission,

and lack of initiative. The observation during World

War II and the Korean conflict that only a small

percentage of soldiers fired their weapons68 probably applies to this group of combatants. A consequence of this unsuccessful coping mode is not

only a failure to perform effectively but also a be-
145

A Psychological Model of Combat Stress

ginning of a psychological collapse, exhibited by

increasing fatigue, mounting anxiety, and a sense of

burnout. The ultimate result of a passive mode of

coping may be a complete breakdown, whether

labeled combat fatigue, battle shock, or war neurosis. This breakdown occurs when the soldier’s

preoccupation with his own anxieties leads to removal from battle, shutdown, immobility, and erratic behavior.

Whatever mode of coping is utilized by the individual, it is not only an outcome of the combat

appraisal and modes of response but also serves as

an input into the ongoing reappraisal of the situation. Based on his own mode of coping, the soldier

may now reinterpret the combat situation. This in

turn may generate new modes of response and

coping that further modify the appraisal. Typically,

if a successful active-coping mode took place, the

reappraisal process tends to be in the direction of

optimism. Conversely, passive coping usually will

lead to a pessimistic appraisal, resultant less-effective modes of response and coping, and increasingly negative appraisals. Thus, the behavior of the

soldier in combat is an ongoing process of appraisals and reappraisals (largely unconscious appraisal

and reappraisal) that are affected by his perception

of the situation on one hand and his initial responses and coping on the other hand. The leader

can optimize his own coping by good training,

keeping himself functioning, and taking care of

junior leaders, and by intervening at key times and

places with his troops.

SUMMARY AND CONCLUSION

This model of combat stress is complex in that

there are multiple interacting variables in its application and, furthermore, the variables interact in an

ongoing, circular fashion. Despite its complexity,

the model is operationally applicable. A combat

leader who is aware of the multiple variables mediating stress in battle can understand and anticipate

both the behavior of troops and of himself, and take

preventive measures to diminish the stress. Understanding the ongoing, circular nature of these variables, he can intervene to reduce the stresses, the

anxiety, and ultimately the potential for breakdown.

This model can be taught in varied types of

leadership training. For example, in the Israeli

Defence Forces Staff and Command School, officers

who were combat veterans were presented with the

model and encouraged to test it against their personal experiences. Almost unanimously, these officers gave positive evaluations of the validity of

the model for combat. The best didactic approach

seemed to be through an initial presentation of the

model followed by small-group interaction in which

instructors guided the discussion. The small-group

participants explored the applicability of the model

to their own experiences.

Students of war and combat agree that the most

precious commodity in battle is not armaments but

people. The understanding and application of this

model may conserve and increase the efficiency of

the vital human resource.

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