i

WAR PSYCHIATRY
ii

The Coat of Arms

1818

Medical Department of the Army

A 1976 etching by Vassil Ekimov of an

original color print that appeared in

The Military Surgeon, Vol XLI, No 2, 1917
iii

The first line of medical defense in wartime is the combat

medic. Although in ancient times medics carried the caduceus

into battle to signify the neutral, humanitarian nature of

their tasks, they have never been immune to the perils of

war. They have made the highest sacrifices to save the lives

of others, and their dedication to the wounded soldier is

the foundation of military medical care.
iv

Textbook of Military Medicine

Published by

Office of The Surgeon General

United States of America

Editor in Chief

Brigadier General Russ Zajtchuk, MC, U.S. Army

Director, Borden Institute

Commander

U.S. Army Medical Research and Materiel Command

Professor of Surgery

F. Edward Hébert School of Medicine

Uniformed Services University of the Health Sciences

Officer in Charge and Managing Editor

Colonel Ronald F. Bellamy, MC, U.S. Army

Borden Institute

Associate Professor of Military Medicine,

Associate Professor of Surgery,

F. Edward Hébert School of Medicine

Uniformed Services University of the Health Sciences
v

The TMM Series

Part I. Warfare, Weaponry, and the Casualty

Medical Consequences of Nuclear Warfare

(1989)

Conventional Warfare: Ballistic, Blast, and Burn

Injuries (1991)

Military Psychiatry: Preparing in Peace for War

(1994)

War Psychiatry (1995)

Medical Aspects of Chemical and Biological

Warfare

Military Medical Ethics

Part II. Principles of Medical Command and Support

Medicine and War

Medicine in Low-Intensity Conflict

Part III. Disease and the Environment

Occupational Health: The Soldier and the

Industrial Base (1993)

Military Dermatology (1994)

Mobilization and Deployment

Environmental Hazards and Military Operations

Part IV. Surgical Combat Casualty Care

Anesthesia and Perioperative Care of the

Combat Casualty (1995)

Combat Injuries to the Head, Face, and Neck

Combat Injuries to the Trunk

Combat Injuries to the Extremities and Spine

Rehabilitation of the Injured Soldier
vi

Soo Suk Kim War 1966

Soo Suk Kim, a 22-year-old art student, painted War in 1966 as a gift to his brother-in-law, Captain Franklin

D. Jones, who was serving as a division psychiatrist in Vietnam. Soo Kim had experienced war first-hand

as a 6-year-old refugee during the North Korean occupation of Seoul, hiding from a communist edict calling

for the execution of his prominent family. The painting depicts his childhood recollection of the horrors and

chaos of war.
vii

WAR PSYCHIATRY

Specialty Editors

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

LINETTE R. SPARACINO, M.A.

VICTORIA L. WILCOX, Ph.D.

JOSEPH M. ROTHBERG, Ph.D.

JAMES W. STOKES, M.D.

Office of The Surgeon General

United States Army

Falls Church, Virginia

United States Army Medical Department Center and School

Fort Sam Houston, Texas

Walter Reed Army Institute of Research

Washington, D.C.

Uniformed Services University of the Health Sciences

Bethesda, Maryland

1995
viii

Lorraine B. Davis

Senior Editor

This volume was prepared for military medical educational use. The focus of the information

is to foster discussion that may form the basis of doctrine and policy. The volume does not

constitute official policy of the United States Department of Defense.

Dosage Selection:

The authors and publisher have made every effort to ensure the accuracy of dosages cited herein.

However, it is the responsibility of every practitioner to consult appropriate information sources

to ascertain correct dosages for each clinical situation, especially for new or unfamiliar drugs and

procedures. The authors, editors, publisher, and the Department of Defense cannot be held

responsible for any errors found in this book.

Use of Trade or Brand Names:

Use of trade or brand names in this publication is for illustrative purposes only and does not

imply endorsement by the Department of Defense.

Neutral Language:

Unless this publication states otherwise, masculine nouns and pronouns do not refer exclusively

to men

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHT RESTRICTIONS.

ALL RIGHTS RESERVED.

NO COPYRIGHTED PARTS OF THIS PUBLICATION MAY BE REPRODUCED OR

TRANSMITTED IN ANY FORM OR BY ANY MEANS, ELECTRONIC OR MECHANICAL

(INCLUDING PHOTOCOPY, RECORDING, OR ANY INFORMATION STORAGE AND

RETRIEVAL SYSTEM) WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER OR

COPYRIGHT OWNER

Published by the Office of The Surgeon General at TMM Publications

Borden Institute

Walter Reed Army Medical Center

Washington, DC 20307-5001

Library of Congress Cataloging–in–Publication Data

War psychiatry / specialty editors, Franklin D. Jones . . . [et al.].

p. cm. — (Textbook of military medicine. Part I, Warfare,

weaponry, and the casualty)

Includes bibliographical references and index.

1. War Neurosis. 2. Military psychiatry—United States.

I. Jones, Franklin D., 1935- . II. Series.

[DNLM: 1. Combat Disorders. 2. War. 3. Military Psychiatry. WH

390 T355 pt 1 1989 v.4]

RC971.T48 1989

[RC550]

616.9'8023 s—dc20

[616.85'212]

DNLM/DLC

for Library of Congress 95-18334

CIP

PRINTED IN THE UNITED STATES OF AMERICA

04, 03, 02, 01, 00, 99, 98, 97, 96, 5 4 3 2 1
ix

Contents

Foreword by The Surgeon General xi

Frontispiece Plates x

Preface xiii

Patient Flow in a Theater of Operations xv

1. Psychiatric Lessons of War 1

2. Traditional Warfare Combat Stress Casualties 35

3. Disorders of Frustration and Loneliness 63

4. Neuropsychiatric Casualties of Nuclear, Biological,

and Chemical Warfare 85

5. Psychiatric Principles of Future Warfare 113

6. A Psychological Model of Combat Stress 133

7. U.S. Army Combat Psychiatry 149

8. U.S. Air Force Combat Psychiatry 177

9. U.S. Naval Combat Psychiatry 211

10. Combat Stress Control in Joint Operations 243

11. Debriefing Following Combat 271

12. Postcombat Reentry 291

13. Behavioral Consequences of Traumatic Brain Injury 319

14. Disabling and Disfiguring Injuries 353

15. Conversion Disorders 383

16. Chronic Post-Traumatic Stress Disorder 409

17. The Prisoner of War 431

18. Follow-Up Studies of Veterans 457

19. Summation 473

Acknowledgements 487

Acronyms 489

Index 493
x

Frontispiece Plates

Frontispiece War vi

Soo Suk Kim, 1966

Chapter 1 Fighting at Guadalcanal 2

Richard W. Baldwin, 1943

2 Going In, Peleliu 36

Tom Lea, 1944

3 Bunker on Nuo Ba Dhn Mountain 64

Edward J. Bowen, 1969

4 Match Sellers, Class of ‘17 86

Kerr Eby, 1918

5 The Attack 114

Mario H. Acevedo, 1991

6 Soldiers Resting on Omaha Beach, Normandy 134

Manuel Bromberg, 1945

7 American Doctor II—Field Force Doctor Examines Vietnamese Child 150

Samuel E. Alexander, 1968

8 Aerial Gunner, England 178

Peter Hurd, 1944

9 Crew’s Quarters Aboard U.S. Submarine, Pacific 212

Paul Sample, 1943

10 Patients Being Loaded on C-54, England 244

Hans H. Helweg, 1944

11 Killed in Action 272

Burdell Moody, 1968

12 Troops Boarding Homebound Ship 292

Leslie Anderson, 1947

13 Purple Heart 320

John O. Wehrle, 1966

14 Requiem Mass 354

Barse Miller, 1944

15 Tent Hospital 384

Aaron Bohrod, 1943

16 Long Binh 410

David N. Fairrington, 1968

17 Prisoner Interrogation 432

Artist Unknown, circa 1943

18 The Dental Front 458

Marion Greenwood, 1945

19 The Sentinel 474

Michael Pala, 1968
xi

Foreword

This volume of the Textbook of Military Medicine addresses the delivery

of mental health services during wartime. The foreseeable future of the

U.S. military includes the potential for involvement in a variety of conflicts, ranging from peace-keeping missions to massive deployments of

personnel and materiel and possible nuclear, biological, and chemical

threats as was seen in the Persian Gulf War. The medical role in wartime

is critical to success of the mission. For the mental health disciplines, this

role encompasses identification and elimination of unfit personnel, improvement of marginal personnel to standards of acceptability, prevention of psychiatric casualties, and their treatment when prevention fails.

All of these efforts must be guided by past experience and sound principles of human behavior.

The identification and elimination of unfit personnel must be prudently

managed. During World War II, medical personnel mistakenly believed

that soldiers who had exhibited any prior symptoms of anxiety would be

prone to breakdown. However, review of casualty breakdown in World

War II revealed that breakdown was largely related to unit and battle

conditions rather than predisposition.

Prevention of psychiatric casualties must address the factors known to

be important in soldier efficiency and breakdown. These can be grouped

into biological, interpersonal, and intrapsychic factors. Of these, interpersonal factors may be the most critical. Soldiers living and working

together in conditions of shared danger and hardship will foster unit

cohesion, which is known to reduce the risk of psychiatric breakdown.

Thus, producing cohesive combat forces has become a mainstay of psychiatric prevention.

The soldier brings with him many, sometimes conflicting, intrapsychic

beliefs and attitudes, including a strong sense of invulnerability. These

contribute to his psychological defense against the rigors of the battlefield.

It is the loss of such defenses that produces breakdown on an individual

basis. The treatment of the combat psychiatric casualty near the front with

replenishment of physiological deficits and expectation of return to one’s

unit shores up these failing defenses.

I strongly recommend that all commanders and medical officers read

this book and heed its central theme: the stresses of combat are significant,

but with appropriate and timely prophylaxis and treatment, the majority

of these soldiers can be returned to their units as functional members of

their group.

Lieutenant General Alcide M. LaNoue

The Surgeon General

U.S. Army

July 1995

Washington, D.C.
xii
xiii

Preface

July 1995

Washington, D.C.

Brigadier General Russ Zajtchuk

Medical Corps, U.S. Army

The stresses of the military environment are diverse and significant—the

potential for deployment and combat, long and arduous training missions, and

separations from families. A companion volume, Military Psychiatry: Preparing

in Peace for War, addresses these issues in a peacetime military. As stressful as

garrison life can be, it pales when compared to the stresses of combat. These

stresses are greatest during actual combat, but begin with notification of a

deployment, and often continue after the fighting is over as the participants deal

with the aftermath of the battlefield, which may include post-traumatic stress

disorder, especially if they have been prisoners of war or experienced mutilating injuries. This volume discusses the evolution of the concept of combat stress

reaction, the delivery of mental health care on the various battlefields our

soldiers are likely to experience, and the psychological consequences of having

endured the intensity and lethality of modern combat.

The concept of the stress casualty has changed considerably from times past

when the symptoms of stress breakdown were thought to be evidence of

cowardice and thus were punished rather than treated. As our understanding

of the dynamics of the stress casualty and the battlefield environment have

increased, we have discovered that the most important lesson learned from

previous wars is the need for timely and appropriate handling of stress casualties. Psychiatric casualties should be seen as close to the battlefield as possible

(proximity) and as quickly as possible (immediacy), and should be provided with

rest and nutrition. They should be told that their symptoms are normal in combat

and that they will recover (expectancy). These are the principles of proximity,

immediacy, and expectancy, known by the PIE acronym. Psychiatric casualties

treated under these principles are more likely to recover than those for whom

treatment is delayed or occurs far from the battlefield. These principles can also

be utilized in debriefing groups exposed to unusual stress whether in combat or

in disasters (critical incident debriefing). This early intervention often prevents

later development of chronic post-traumatic stress disorders.

While the principles of combat psychiatry are relatively universal, their

application may vary in the different military services, depending on the

mission. Thus, service-specific scenarios and issues are presented in separate

chapters on combat psychiatry in the U.S. Army, the U.S. Air Force, and the U.S.

Navy. An important area addressed in this volume is the need for uniform

psychiatric procedures in joint operations, which will likely be more common in

the future.

The prevention and treatment of combat stress reaction is not simply the

domain of the mental health provider. Commanders must also play an active

role by maintaining contact with soldiers when they are temporary casualties

and welcoming them back to the unit after they have rested and recovered. This

increases the likelihood of continued long-term functioning and enhances unit

cohesion. It is also the honorable thing to do for those individuals who have

temporarily been overcome by the horrors of battle, but are now ready to rejoin

their unit to continue the fight.
xiv

The current medical system to support the U.S. Army at war is a

continuum from the forward line of troops through the continental United States; it serves as a primary source of trained replacements during the early stages of a major conflict. The system is

designed to optimize the return to duty of the maximum number

of trained combat soldiers at the lowest possible level. Farforward stabilization helps to maintain the physiology of injured

soldiers who are unlikely to return to duty and allows for their

rapid evacuation from the battlefield without needless sacrifice

of life or function.
xv

Medical Force 2000 (MF2K)

PATIENT FLOW IN A THEATER OF OPERATIONS

E: Echelon

FH: Field Hospital

FST: Forward Surgical Team

GH: General Hospital

MASF: Mobile Aeromedical Staging Facility,

USAF

Med Co: Medical Company

RTD: Return to Duty

ASF: Aeromedical Staging Facility, USAF

ASMB: Area Support Medical Battalion

ASMC: Area Support Medical Company

BAS: Battalion Aid Station

Cbt Medic: Combat Medic

CSH: Combat Support Hospital

COMMZ: Communication Zone

CZ: Combat Zone

Cbt 

Medic

BAS

Med Co

CSH

MASF

GH

FH

Med Co

ASMC/ASMB

ASMC/ASMB

xx

xxx

x

RTD

RTD

RTD

RTD

RTD

RTD

COMMUNICATION 

ZONE

 CORPS

SUPPORT

AREA

 DIVISION

SUPPORT

AREA

 BRIGADE

SUPPORT

AREA

CZ

1st E

2nd E

3rd E

4th E

 CONUS 

FST

 UNIT

SUPPORT

AREA

COMMZ

ASF