473

Summation

Chapter 19

SUMMATION

FRANKLIN D. JONES, M.D., F.A.P.A.* AND GREGORY L. BELENKY, M.D.†

LESSONS OF WAR

Role of the Military

Selection of Personnel

Training of Personnel

Rediscovery and Extensive Application of Principles

Discovery of Mediating Principles

Prevention of Psychiatric Casualties

Impediments to Cohesion

Personal Factors in Combat Stress

Stress Inoculation

TREATMENT OF PSYCHIATRIC CASUALTIES

Low-Intensity vs Traditional Combat Stress

Low-Intensity Combat Stress Casualties

PSYCHIATRIC SYNDROMES

Post-Traumatic Stress Disorders

Prevention and Treatment of Low-Intensity Combat Stress Disorders

FUTURE COMBAT

Areas of Current Study and Suggestions for Future Research

Prevention of Combat Stress Casualties: Sustaining the Soldier in Combat

Treatment of Acute Combat Stress and Prevention of PTSD

CONCLUSION

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

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

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

†Colonel, Medical Corps, U.S. Army; Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences,

Bethesda, Maryland; Director, Division of Neuropsychiatry, Walter Reed Army Institute of Research, Washington, D.C.; Secretary, Military

Section, World Psychiatric Association
War Psychiatry

474

Michael Pala Sentinel 1968

Michael Pala was a member of Combat Artist Team #6 in Vietnam during February and March of 1968. His

serene painting depicts the individual soldier, on sentry duty, alone with his thoughts. It is the goal of

combat psychiatry to provide that soldier with every possible psychological defense against the horrors of

the battlefield, and should those defenses fail, to provide him with the timely, caring treatment necessary

for his recovery.

Art: Courtesy of US Army Center of Military History, Washington, DC.
475

Summation

LESSONS OF WAR

ited any prior symptoms of anxiety would be prone

to breakdown, medical personnel were at one point

eliminating almost as many soldiers as were being

recruited.4,5 By contrast, the less stringent screening

of soldiers in World War I resulted in adequate

soldiers for the fight. Furthermore, review of casualty breakdown in World War II6 revealed that

breakdown was largely related to unit and battle

conditions rather than predisposition, while studies of casualties from World War II7

 and the ArabIsraeli wars8 revealed that soldiers who had broken

down in combat, when properly treated, were at no

greater risk of another breakdown than their cohorts who had not broken down.

Menninger9 reviewed World War I and World

War II statistics and showed that the liberal selection policy of World War I resulted in the rejection of about 2% of soldiers at induction for

neuropsychiatric reasons and about 2% breakdown

of the total, while the more stringent policy of

World War II resulted in the rejection of 11% of

inductees but a higher rate of breakdown of 12% of

the total.9

Although about 1,600,000 registrants were classified as unfit for induction during World War II

because of mental disease or educational deficiency

(a disqualification rate about 7.6 times as high as in

World War I), separation rates for psychiatric disorders in World War II were 2.4 times as high as in

World War I.6 Not only was screening ineffective in

preventing breakdown, but also the liberal separation policy for those presenting with neurotic symptoms threatened the war effort.6 For instance, in

September 1943 almost as many soldiers were being

eliminated from the U.S. Army as accessed; most of

those separated were for psychoneurosis (35.6/

1,000/y).6(p740)

Studies attempting to find predisposition to psychiatric breakdown in combat have revealed more

similarities between psychiatric casualties and their

fellow soldiers than differences. For example, in a

comparison of the combat records of 100 men who

suffered psychiatric breakdowns requiring evacuation to a U.S. Army hospital in the continental

United States and an equivalent group of 100 surgical casualties, Pratt10 found no significant difference in numbers of awards for bravery. Glass remarked, “Out of these experiences came an

awareness that social and situational determinants

of behavior were more important than the assets

Role of the Military

The study of civilization is the study of war,

preparation for war, and recovery from war. While

a few fortunate nations have been spared from the

direct ravages of war for a few centuries, most

countries have almost continuously been in one of

war’s stages. Theories of war have considered

individual leaders’ ambitions, instinctual behaviors, economic forces, religious forces, and cultural

forces1,2 in attempts to understand and control what

has largely become not only human but also economic waste. Although in the distant past, wars

may have served the winnowing purpose of evolution, most thinkers believe that the few things solved

by war are better solved by peace. Furthermore,

with the development of atomic weaponry, the existence of humankind itself is threatened. Prevention of war, therefore, is the paramount role of

modern military forces.

The authors take the position that the foreseeable

future includes the potential for conflict, that preparation for war is paradoxically more likely to result

in peace, and that the medical role in this endeavor

is critical to its success. 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 treatment

of casualties when prevention fails. All of these

efforts must be guided by past experience and sound

principles of human behavior. Failures have occurred in all of these categories.

Selection of Personnel

Many studies reviewed by Arthur3 reveal that

mass psychiatric screening of personnel for induction into the military beyond minimal testing for

normal intelligence, absence of psychotic disorders,

and absence of significant criminal behavior is markedly inefficient. Following World War I, which had

resulted in large numbers of psychiatric casualties,

an attempt was made at the beginning of World War

II to reject draft registrants who might break down

in combat.

The identification and elimination of allegedly

mentally unfit personnel threatened the war effort

early in the United States’ entry into World War II.

Guided by the theory that soldiers who had exhib-
War Psychiatry

476

and liabilities of individuals involved in coping

with wartime stress and strain.”7(p1024)

Improvement of marginal personnel to meet standards has been successful in at least two conflicts.

During the Vietnam conflict, Secretary of Defense

McNamara ordered the recruitment of soldiers with

minor unfitting conditions (most were slow learners or soldiers with personality disorders) who were

to be given special training and to serve in combat

(Project 100,000). While a higher percentage of

these soldiers had to repeat basic training and had

general discharges for unfitness, the great majority

served in a satisfactory fashion. The program was

successful enough that the number of drafted lowerfunctioning soldiers exceeded the original 100,000

planned: 320,000 were inducted. While many lowaptitude veterans did well in the military, their

postmilitary civilian adjustment was not as good as

that of a comparable nonveteran civilian comparison group, being disproportionately unemployed,

unmarried, underpaid, and undereducated.11

Israel has developed special programs to train

soldiers who otherwise could not serve. Most of

these men are from families displaced from Arabic

countries. They are often illiterate and don’t speak

Hebrew. Also they are often poorly motivated. The

program utilizes women drill sergeants to inspire

the soldiers’ best efforts. The training includes also

a basic education in Hebrew literacy and Israeli

cultural values. These soldiers have acquitted themselves well in Israel’s ongoing conflicts with Arab

neighbors. An important aspect of soldier support

is the family. It is known that family stress can

adversely affect a soldier and lead to combat breakdown.

Training of Personnel

Training of personnel involves several important

dimensions: technical proficiency, personality characteristics, strength and endurance, group cohesiveness, and stress inoculation. There is considerable overlap in all of these areas; for example,

technical proficiency, which may require strength

and endurance, leads to the personality characteristic of self-confidence, which, along with technical

proficiency, produces a sense of mastery and value

to the group, promoting group cohesion. All of

these characteristics are positively associated with

the ability to withstand combat stress.

Much of military training addresses all of these

dimensions. Shared vigorous training not only

increases strength and endurance and builds selfconfidence, but also increases group affiliation and

cohesion.12 Aware of the importance of cohesion,

the military has kept personnel together in cohort

units from basic training to deployment. In addition, efforts have been made to keep commanders

with the same unit for longer periods of time to

enhance not only horizontal (peers) but also vertical

(hierarchical) cohesion.

An important aspect of combat training is the

need for realism. Troops new to combat are known

to be more vulnerable to combat stress reactions

than experienced troops. Realistic training with

live ammunition and actual danger is believed to

act as an “inoculation” against battlefield stress.

Unfortunately such training inevitably results in an

irreducible small number of casualties. Technical

proficiency is increasingly being accomplished with

computer simulations. With technological innovations involving “virtual reality,” perhaps the desired realism in combat simulations is on the horizon. Or could training with no element of real fear

and physical discomfort lead to a false sense of

confidence which shatters in the face of imminent

life threat? Some combination of “live” and “virtual” reality may be needed.

Rediscovery and Extensive Application of

Principles

The United States became involved in World

War II (1939–1945) 2 years after its outbreak. Over

20 years had passed since the end of World War I,

and at the onset of American involvement in World

War II, military medical personnel were unprepared to carry out the program of forward psychiatry that had been devised by World War I psychiatrists.9 No psychiatrists were assigned to combat

divisions and no provisions for special psychiatric

treatment units at the field army level or communications zone had been made.6

 American planners

had believed that potential psychiatric casualties

could be screened out prior to induction.

World War I style forward treatment was relearned during two battles of the Tunisian Campaign in March and April 1943.13 Captain Fred

Hanson avoided evacuation and returned more than

70% of 494 neuropsychiatric patients to combat

after 48 hours of treatment, which basically consisted of resting the soldier and indicating to him

that he would soon rejoin his unit.13 General Omar

Bradley issued a directive that established a holding period of 7 days for psychiatric patients and

further prescribed the term “exhaustion” as the

initial diagnosis for all combat psychiatric cases.

The World War I principles had been rediscovered!
477

Summation

Discovery of Mediating Principles

In addition to rediscovering the principles of

treatment applied so effectively in World War I, and

the ineffectiveness of large-scale screening, World

War II psychiatrists learned about the epidemiology of combat stress casualties (direct relationship

to intensity of combat, modified by physical and

morale factors) and the importance of unit cohesion

both in preventing breakdown and in enhancing

combat effectiveness.

Another finding during World War II was the

chronology of breakdown in combat. It had long

been recognized that “new” and “old” men in combat units were more prone to breakdown. “New” or

inexperienced troops were more likely to become

stress casualties and have usually accounted for

over three fourths of stress casualties; however,

with increasing exposure to combat after 1 or 2

combat months, an increasing rate of casualty generation also occurs.

From studies of cumulative stress such as these

as well as observations of the efficacy of a “point

system” (so many points of credit toward rotation

from combat per unit of time in combat or so many

combat missions of aircrews) used during World

War II, the value of periodic rest from combat and of

rotation came to be understood and applied in the

Korean and Vietnam conflicts with fixed combat

tours. The final and perhaps most important lesson

of World War II was the importance of group cohesion not only in preventing breakdown, but also in

producing effectiveness in combat.7

Prevention of Psychiatric Casualties

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.

In terms of biological factors, commanders must

enforce salt and water discipline to avoid dehydration and sleep discipline to prevent exhaustion and

to counter time-zone dislocation. During the U.S.

invasion of Grenada, dehydration and accidents

accounted for a majority of U.S. casualties.14

Interpersonal factors may be the most critical in

terms of preventing psychiatric casualties. Soldiers

living and working together in conditions of shared

danger and hardship will foster unit cohesion.

During the 1973 surprise attack by Arab forces, the

Israelis had to be quickly mobilized. This resulted

in some tank crews going into battle with teammates who were strangers. Such crews, who obviously lacked cohesion, had far higher psychiatric

casualty rates than those in which soldiers had

trained together, sometimes for years. The leader

must partake of these dangers and hardships, display concern for his soldiers, and demonstrate expertise in battle. In a survey of Israeli soldier factors

in morale, the commander’s battle competence was

the most highly rated attribute.15

When combat is imminent, the commander

should brief the small unit on what is to be expected. This briefing should be realistic but not

pessimistic. After combat, the commander should

lead the small group in a debriefing in which each

combatant has an opportunity to describe the action. This group debriefing allows correction of

misinterpretations, recognition of individual performance, and consolidation of lessons learned. It

also strengthens cohesive bonds.

Another important aspect of prevention is arranging for rest from battle, preferably on a unit

basis. During World War II, aircrews were relieved

of duty after a fixed number of combat flights,

roughly the number at which on a statistical basis

there was a better than 50% chance of survival.

During the Korean conflict the combat tour was 9

months while the support troops served 13 months.

During the Vietnam conflict the tour for all was 12

months with 4 to 6 days of “R and R” (rest and

recreation) approximately midway through the tour.

Unfortunately, rest from the combat zone and

completion of the tour were on an individual rather

than unit basis, degrading cohesion.

Impediments to Cohesion

Among the alleged impediments to unit cohesion are race, gender, ethnicity, and sexual preference. The military has adopted policies to overcome all of these issues except the last. All units

have been racially integrated since the Korean conflict. Women have entered all military roles other

than ground combat and submarine warfare. Educational programs such as Black History, Hispanic

History, Native American History, and AsianPacific History weeks are overcoming ethnic

stereotypes. Homosexuality remains controversial,

being viewed as detrimental to morale and discipline. Change in this area may occur through

judicial or legislative action; however, President

Clinton has indicated his desire to end discrimination against homosexuals in the military.16 Because

there is no law against homosexuality in the military, this could be accomplished by executive order;

however, the Uniform Code of Military Justice
War Psychiatry

478

describes sodomy, homosexual or heterosexual, as

a felony. Changing this would require an act

of Congress.

There is speculation that the ability to bond in

small groups for relatively brief periods of time for

hunting or fighting is to an extent gender specific.

This might explain the observation that women

have never been a significant element in front line

combat forces in hundreds of societies for which

there are records. The female child-bearing role,

leading ultimately to social role differentiation of

males and females, however, does not allow the

determination of whether there are any biologically

determined differences between males and females

in group bonding. Although averages of physical

differences between males and females such as

upper body strength (greater in males) and rate

of secretion of medullary adrenal hormones

(more rapid in males) may be significant, individuals often excel in feats of skill and strength

regardless of sex.

Future wars may require the military to select

individuals for roles based on innate and learned

differences rather than sexual stereotypes. Such

selections may place women in leadership positions

that involve skills in communication and vigilance

tasks as well as direct combat roles. As an example,

tanks with a lower profile on the horizon are more

difficult to sight and hit. The former Soviets reportedly selected short men for tank crews in order to fit

them into a lower tank profile. Perhaps short women

will some day fill such roles. With the expected

reduction of the combat age demographic pool, the

United States will be under even greater pressure to

utilize women in combat roles. In the assignment of

combat pilots General H. Norman Schwartzkopf,

commander of coalition forces in the Persian Gulf

War, has indicated that women should have been

assigned combat roles.17

Personal Factors in Combat Stress

The soldier brings with him many, sometimes

conflicting, intrapsychic beliefs and attitudes that

must be modified by skillful training to produce the

most effective soldier. The late adolescent soldier

has been a preferred recruit in the past because of

malleability and certain inherent attitudes. The

malleability applies to the normal lack of career

definition and identity of most late adolescents.

Furthermore, these older adolescents usually have

a sense of invulnerability which Masserman18 has

termed one of the Ur-defenses (or delusions) of

humans. The first author has argued in Chapter 1,

Psychiatric Lessons of War, that it is the loss of such

defenses that produces breakdown on an individual

basis. Shaw19 has pointed out that 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.

Stress Inoculation

Another aspect of prevention is exposure to realistic combat training. It is well-known that so called

“green troops” not previously in combat become

stress casualties in disproportionately high numbers. This was recognized by U.S. Civil War commanders who sought to “blood” their men in combat to improve their fighting efficiency.20 It was

argued that this “blooding” increased feelings of

comradeship and desire for revenge against the

enemy. Some forms of severe stress do not inoculate but increase vulnerability to subsequent stress

as seen in a study21 of elderly holocaust survivors

who were exposed to missile strike threats during

the Persian Gulf War. This would be in consonance

with the observation that repeated severe trauma

leads to breakdown as seen in the “old sergeant

syndrome.”22 As mentioned earlier, the advent of

computer simulations exposing combatants to virtual reality (VR) training may be the most realistic

training short of combat.

Another potent effect deriving from our current

understanding of the theory of behavior therapy

involves the process of habituation.23 Exposure to

a situation producing severe anxiety results in

reduction of anxiety when no aversive stimulation occurs. This may account for the observation

that combat veterans are less likely to be overwhelmed by anxiety. Paradoxically, however, repeated exposure to combat may eventually result in

breakdown, presumably due to the erosion of feelings of invulnerability (loss of Ur-defenses) occasioned by the deaths of comrades. Thus an aspect

of prevention is the removal of soldiers from combat periodically to prevent breakdown. A fixed

tour of 12 months in the Vietnam conflict and

a week of “R and R” (rest and recreation) about

one half of the way through the year’s tour may

have resulted in combat stress casualties that were

among the lowest of any conflict (11/1,000/y).24

This rate was about the same as that for soldiers

not in combat stationed in Korea at the same time

(13/1,000/y).24
479

Summation

TREATMENT OF PSYCHIATRIC CASUALTIES

The deceptively simple measures employed since

World War I and embodied in Artiss’4 proximity,

immediacy, and expectancy (“PIE”) conceptualization, broadened into D. Jones’ “BICEPS” acronym (brevity, immediacy, centrality, expectancy,

proximity, simplicity as discussed in Chapter 8,

U.S. Air Force Combat Psychiatry) remain the mainstay of traditional treatment of psychiatric casualties. Chapter 2, Traditional Warfare Combat Stress

Casualties, has shown that the therapeutic basis of

these measures is expectancy. A casualty treated

briefly and immediately has less opportunity to

dwell on the potential for death and maiming. Such

treatment involving simple measures of replenishment of nutrition and sleep, taking place in a safe

area near the battle area (and near the soldier’s own

unit), produces a powerful and explicit expectancy

that after a period of rest the soldier will return to

his own unit for which the cohesive bonds have not

been attenuated. Centrality carries the additional

principle that prior to evacuation out of the combat

zone psychiatric casualties are collected at a centralized location at which skilled mental health

professionals are expected to return a significant

portion of such casualties back to combat zone

duty.

Technological advances have jeopardized the

applicability of these principles in modern warfare.

Sophisticated intelligence gathering (sometimes by

satellites), highly mobile forces, and continuous

fighting even at support levels in the battlefield

may not allow for a safe forward treating area or the

return of a soldier to his own unit. In such circumstances, new principles of intervention involving

prevention, “buddy aid,” and possible use of medications may be required.

In summary, World War II taught combat psychiatrists that psychiatric casualties are an inevitable consequence of life-threatening hostilities; that

they cannot be efficiently screened out ahead of

time; that their numbers depend on individual,

unit, and combat environmental factors; and that

appropriate interventions can return the majority

to combat duty.

Low-Intensity vs Traditional Combat Stress

The authors have used terms such as low-, mid-,

and high-intensity combat somewhat differently

from many military writers. For example, highintensity combat is restricted to nuclear and chemical/biological warfare by some writers. The authors feel that conventional warfare is of high intensity when it involves continuous or near continuous

fighting with numerous pulses of battle in a 24-hour

period. Similarly, the authors feel that battle is of

low intensity when battles are brief and infrequent,

allowing for recuperation between battles. Thus,

terrorist attacks would be of low intensity even

though resulting in large numbers of killed and

wounded as occurred in the bombing of a U.S.

Marine Corps barracks in Beirut in 1985.25

Just as in the initial battles of World War II,

provisions had not been made for psychiatric casualties in the early months of the Korean conflict

(1950–1953). As a result they were evacuated from

the combat zone. Because only 5 years had elapsed,

the lessons of World War II were still well known

and the principles learned during that war were

applied appropriately after the initial period of

confusion, due to the efforts of Colonel Albert J.

Glass, the Neuropsychiatry Consultant and a World

War II veteran.26 Psychiatric casualties accounted

for only about 5% of medical out-of-country evacuations, and some of these (treated in Japan) were

returned to the combat zone. To prevent the “old

sergeant syndrome,” a rotation system was in effect—9 months in combat or 13 months in support

units. Attempts were made to rest individuals (“R

and R” or rest and recreation) and, if tactically

possible, whole units.

In the Korean conflict many soldiers also presented with frostbite, a usually preventable disorder. These physical disorders were often actually

masked psychiatric casualties. It is important to

identify and avoid evacuation of hidden psychiatric

casualties. Such casualties may be as transparent

as one with a helmet headache or as subtle as development of malaria from failure to take chemo-prophylaxis or development of frostbite or immersion

foot from failure to maintain foot hygiene.

Low-Intensity Combat Stress Casualties

An unrecognized portent of psychiatric problems of future wars was the psychiatric problems of

rear-area support troops. As the Korean conflict

progressed, U.S. support troops increased in number until they greatly outnumbered combat troops.

These support troops were seldom in life-endangering situations. Their psychological stresses were

related more to separation from home and friends,
War Psychiatry

480

social and sometimes physical deprivations, and

boredom. Paradoxically, support troops who

may have avoided the stress of combat, according

to a military historian27 and a combat veteran,28

were deprived of the enhancement of self-esteem

provided by such exposure. To an extent the situation resembled that of the nostalgic soldiers of

prior centuries. In these circumstances the soldier

sought relief in alcohol abuse and, in coastal areas,

in drug abuse, and sexual stimulation. These often

resulted in disciplinary infractions. Except for attempts to prevent venereal diseases, these problems were scarcely noticed at the time, a lesson not

learned.

The Korean conflict confirmed that the appropriate use of the principles of combat psychiatry could

result in the return to battle of up to 90% of combat

psychiatric casualties; however, there was a failure

to recognize the types of casualties that can occur

among rear-echelon soldiers. These “garrison casualties” later became the predominant psychiatric

casualties of the Vietnam conflict.29,30 Vietnam and

the Arab-Israeli wars revealed limitations to the

traditional principles of combat psychiatry.

The epidemiology of psychiatric casualties among

troops in battle emphasizes those that resulted from

battlefield stress (eg, anxiety, fatigue, hysterical

syndromes). However, casualties resulting from

less dramatic causes had been recognized since

World War I. These less dramatic casualties, more

common in rear-echelon or garrison settings, presented with problems of alcohol and drug abuse,

disciplinary infractions, venereal diseases, personality disorders, and “self-inflicted” medical disorders (for example, malaria from failure to use prophylaxis). Not until the Vietnam conflict were these

casualties recognized as potentially serious causes

of ineffectiveness.

It is not surprising then that various authors have

called such casualties “garrison casualties”29,31 and

“nostalgic casualties.”32 Nostalgic casualties occur in

soldiers separated from their home environment

with attendant loss of social reinforcement. Rosen33

has pointed out that one need not be a soldier for this

to occur and that displaced persons and other groups

often suffer from this “forgotten” psychological disorder. Situations such as the fighting of an unpopular

war of indefinite duration are likely to increase

these casualties, particularly in the absence of strong

cohesive forces, which usually develop from shared

hardship and danger.12 In combat situations, cohesion needs little encouragement to flourish. Lowintensity warfare, often characterized by long periods of idleness without the shared experience of

cohesion-building danger, should produce more

nostalgic casualties. This situation probably also

accounts for the higher incidence of such casualties

among support than among combat troops.34

PSYCHIATRIC SYNDROMES

Combat fatigue was designed as a nonspecific

label carrying an implication that the soldier is

normal and will recover with rest. It subsumes a

great variety of behaviors that in modern nomenclatures might be given such labels as adjustment

disorders, somatoform disorders (conversion reaction), dissociative disorders, or post-traumatic stress

disorder (PTSD). Because conversion disorders and

PTSD have presented in most wars and their mismanagement can be devastating, they deserve special consideration. Similarly, psychological reactions to maiming injuries and central nervous system

(CNS) injuries were considered separately.

Post-Traumatic Stress Disorders

Chronic PTSD has come to be recognized as a

common sequel of severe stress whether experienced in combat, disasters, prisoner of war or hostage status, torture, or sexual and physical assault.

Perhaps because of the potential for “secondary

gain” or inadvertent positive reinforcement of

the invalid or sickness role, militaries have been

ambivalent about expending medical resources

for such casualties. For example, following World

War I German psychiatrists gave generous treatment and pensions to psychiatric casualties and

were rewarded by seeing their numbers grow. After World War II, however, and based on World

War I experience, German psychiatrists did not

grant pensions for nonpsychotic conditions; their

numbers then were few.35 Despite the potential

for abuse of the PTSD diagnosis, those calculating

the gains and losses from combat must include

these casualties in their deliberations. Figures from

World War I and World War II reveal that about one

fourth of those seeking chronic care in Veterans

Administration hospitals would fall into this group

although they were usually given various neurotic

diagnoses.

To the heterogeneous syndromes of substance

abuse, indiscipline, and sexual problems found
481

Summation

in low-intensity wars that have been labeled disorders of frustration and loneliness or “nostalgic

casualties” should be added chronic and delayed

post-traumatic stress disorders (chronic and delayed PTSD). PTSD is usually and appropriately

thought of in the context of acute overwhelming stress; however, the frequent morale problems

of low-intensity, ambiguous wars may carry over

into the postwar lives of the former combatants.

The current discontents of these war veterans may

find expression in the reappearance or new appearance of symptoms associated with combat: anxiety and fears, autonomic hyperactivity, reliving

of psychologically traumatic events, and a variety

of other malaises. Such symptoms often follow

service in wars of high intensity as well, particularly when the outcome was unsatisfactory or

there is psychological or financial gain from such

symptoms.

Prevention and Treatment of Low-Intensity

Combat Stress Disorders

Although successful treatments for low-intensity combat stress casualties were developed as

early as the Napoleonic Wars, circumstances can

prevent the application of remedies. For example,

during the Vietnam conflict the 1-year rotation

policy, ostensibly for the purpose of preventing

psychiatric casualties due to cumulative stress, the

policy of rotating commanders out of combat units

after 6 (and later only 3) months in order to give

more officers combat experience, and the policy of

individual replacement of losses rather than unit

replacements all interacted to impair unit cohesion,

which might have prevented some of the nostalgic

casualties.

Vietnam revealed the limits of World War II type

psychiatric treatment policy in a low-intensity, prolonged, unpopular conflict. Such conflicts, if they

cannot be avoided, must be approached with primary prevention as the focus. Career soldiers with

strong unit cohesion will not endanger themselves,

their fellows, or their careers by abusing alcohol or

drugs.

While prevention through development of unit

cohesion and morale is as important for disorders

of loneliness and frustration as for combat stress

casualties, likewise treatment follows principles

of disallowing evacuation from the combat zone,

and measures to strengthen unit cohesion. A

preventive measure among support troops

would involve allowing them to function in combat roles. Unlike the handling of combat stress

treatment failures through medical evacuation,

disorders of loneliness and frustration may be

handled through administrative and disciplinary

measures.

Sexually transmitted diseases (venereal diseases

or VD) have been a major cause of lost soldier

strength in wars of the twentieth century. While

modern medicine has markedly reduced the time

lost and complications of venereal diseases, it has

not reduced the infection rates. Although unlikely

to have immediate effects on combat efficiency, the

HIV virus poses severe problems in long-term prevention. Many of the world social tensions and

ongoing wars are occurring in Africa, where the

HIV infection is reaching epidemic proportions.

Unlike in the United States, where the populations

at risk are mainly homosexuals and intravenous

drug abusers and their consorts, the spread of HIV

in Africa is primarily through heterosexual intercourse.

In South America, another politically troubled

area with narcoterrorism, or communist insurgencies, or both, in several countries, acquired immunodeficiency syndrome (AIDS) is emerging as a

difficult public health problem. Because urban areas in these third-world countries are being hit

hardest by AIDS, there is concern that the professional and leadership classes of African, and to a

lesser extent South American, countries could experience severe setbacks in goals of industrialization

and democratic reforms. Internal unrest in Latin

America frequently has led to U.S. military deployment beginning before 1900.

The main lessons from the U.S. experience in

managing substance abuse in Vietnam are that treatment should be in country to prevent an evacuation

syndrome and that the factors that prevent breakdown in general—cohesion, effective leadership,

and good morale—may protect soldiers from substance abuse. Avoidance of idleness and medical

supervision of brothels may further minimize nostalgic casualties.

The appropriate treatment of acute combat stress

casualties will decrease the later development of

chronic post-traumatic stress disorders. Other

measures to prevent chronic PTSD include the previously mentioned combat stress debriefing (see

Chapter 11, Debriefing Following Combat), which

has been adapted to civilian critical incident stress

debriefing. In treating the maimed or disfigured, or

patients with physical losses (amputees, blinded,

paralyzed), prevention of chronic PTSD is assisted

by avoiding an invalid role and emphasizing what

the person can do rather than cannot do.
War Psychiatry

482

FUTURE COMBAT

Future wars may differ drastically from previous

wars. Although the former Soviet nation states are

mostly considered allies or at least neutral to the

North Atlantic Treaty Organization (NATO) allies

and NATO has overwhelming military superiority,

conflicts with nations that have advanced military

technology are possible. This was demonstrated in

the Persian Gulf War in which Iraq launched missiles

resulting in military and civilian casualties and posed

the potential risk of mass casualties.

Future wars that pose the risk of use of weapons

of mass destruction will require dispersion and

mobility of allied forces. Furthermore, a technologically advanced enemy may possess sensors capable of detecting aggregations of materials and

personnel. This scenario would severely challenge

the traditional applications of the principles of combat psychiatry. Prevention and far-forward consultation and intervention must be given maximal

emphasis in the future.

Combat psychiatric treatment requires a relatively safe setting near the battle area in which

mental health personnel can render simple supportive treatment followed by return of the casualty

to his own unit. The ability to target aggregations of

personnel and equipment will mean that treatment

settings must be mobile or be left far from the

battlefield. The dispersion and mobility of tactical

units will make it very difficult to return casualties

to their own units.

Despite strenuous efforts of prevention including strengthening unit cohesion, avoiding physiological deficits, and optimizing personality variables, psychiatric casualties will occur. Treatment

of these casualties requires development of new

principles of management. Combatants will need

to recognize combat stress reactions in themselves

and their comrades and take remedial action. This

may be as simple as arranging for nutritional and

sleep replenishment. It may include reassurance

from a squad leader, commander, or medical

aidman. It is possible that a rapid-acting, nonsedating, nonaddictive antianxiety drug may be

developed to treat soldiers on the battlefield.

Currently buspirone (BuSpar), an azapirone, with

partial serotonin agonist actions, is a nonsedating,

nonaddicting anxiolytic; however, it has an approximately 10-day latency prior to its therapeutic

effects. Furthermore, buspirone’s activating effects

may not be desirable and may interfere with sleep.

It may prove useful in returning refractory cases to

duty. The recent development of a benzodiazepine

antagonist, flumazenil (Romazicon), that can rapidly reverse benzodiazepine hypnotics, may allow

the use of such hypnotics on or near the battlefield.

The notion that medicated soldiers would lack compassion and would release inappropriate aggression36 has little basis in fact or theory.

If a combat stress casualty is evacuated and cannot be returned to his own unit, it may be possible

to incorporate him into a newly created unit of such

casualties under suitably trained senior leaders.

This may be necessary anyway if units are markedly degraded in mass casualty actions. Creating

such units would be a formidable but accomplishable

task utilizing known techniques to create cohesion

and morale; however, it would probably require

several weeks of intensive work with mental health

professionals.

Areas of Current Study and Suggestions for

Future Research

While the military has learned much about sustaining the combat member and treating those who

break down, there are many areas that need clarification. Issues include not only ideal socialization of

the soldier but training targeted to individual

strengths and weaknesses, a full understanding of

the biology at the molecular level of combat sustenance, and breakdown and ideal treatment of the

ineffective combatant. Research in these areas is

ongoing.

Prevention of Combat Stress Casualties:

Sustaining the Soldier in Combat

Anything that improves soldier effectiveness

decreases combat stress casualties and conversely

anything that degrades soldier effectiveness increases combat stress casualties. Thus, the net of

prevention of combat stress casualties can be cast

broadly to include almost all improvements in doctrine, command, control, communications, and intelligence (C3I), training; logistics; rations; and

equipment.

In the biobehavioral area, improvements in the

means of sustaining the soldier physiologically and

psychologically all contribute to increased combat

effectiveness and decreased combat stress casualties. Social psychological research into ways of

enhancing unit morale, leadership, and cohesion

could better sustain the soldier by improving his

unit. Similarly, research into better ways of sustain-
483

Summation

ing the soldier physiologically in terms of nutrition,

hydration, rest, and recuperation could improve

soldier performance and thus enhance the unit.

Neurobiological investigations into brain changes

accompanying acute combat stress reactions and in

particular those associated with the development of

PTSD would be of great value in suggesting new

means of prevention and treatment.

A productive area of current research in the realm

of physiological sustainment is in sleep, sleep deprivation, and continuous operations. It is representative of a number of areas in which advances in

biomedicine are finding application in sustaining

soldiers in combat. Sleep deprivation is a frequent

associated finding in cases of acute combat stress

reaction. Sleep deprivation-induced decrements in

performance frequently contribute to the occurrence of incidents of friendly fire. In the work on

sleep, sleep deprivation, and continuous operations,

experimentation and modeling are being combined

to advance the understanding of the effect of sleep

deprivation on performance.

Recent laboratory work has shown that caffeine

is effective in sustaining performance in continuous

operations and has led to the recommendation that

caffeine-containing bars or tablets be added to the

meal-ready-to-eat (MRE). Recent modeling of company-sized unit performance has shown that although soldiers can fight while averaging 4 hours of

sleep each night, their performance degrades rapidly. For indefinite sustainability of performance

without degradation over time, soldiers need 8 hours

of sleep each night. This suggests that while some

sleep deprivation may be inevitable in continuous

combat operations, depriving soldiers of sleep

should be as a result of the exigencies of the combat

situation, and not a result of deliberate policy.

Work is underway to identify the physiological

changes in the brain that accompany the performance degradation in sleep deprivation. These

studies involve positron emission tomography

(PET), fast magnetic resonance imaging (fMRI), and

other physiological as well as behavioral measures.

Initial findings show that the performance degradation in sleep deprivation is associated with a

decrease in global brain energy metabolism. These

studies of basic mechanisms will lead to the development of novel, safe, and effective pharmaceuticals to sustain soldier performance during continuous operations.

Work is also underway to develop safe and effective sleep-inducing drugs to promote brief, recuperative sleep during continuous operations. As

sleep’s recuperative value depends both upon duration and continuity, the hope is to find a nonaddictive, nonperformance-impairing, sleep-inducing

drug that will initiate and sustain unfragmented

sleep in the nonsleep conducive conditions of continuous combat operations. Work is currently underway, as suggested earlier in this chapter, to

study the effectiveness of triazolam (a benzodiazepine) for initiating and maintaining sleep in combination with flumazenil (a benzodiazepine antagonist) for rapidly restoring alertness upon awakening.

As part of a broad effort to develop unobtrusive,

robust, field-deployable biomedical telemetry to

monitor soldier status during combat operations,

work is underway on the application of artificial

neural networks to the discrimination of alert from

drowsy electroencephalograms, to provide an online, real-time assessment of soldier alertness for

feedback to the soldier and for relay up the chain of

command. These systems would be an integral part

of the soldier computer, which in turn will be standard equipment for the soldier in the 21st century.

Information about each soldier’s status would be

fed back to the soldier and shared with his comrades and his chain of command through a radiofrequency, local area network (RF-LAN).

Treatment of Acute Combat Stress and Prevention of PTSD

As is clear from previous chapters, the treatment

of acute combat stress casualties and the prevention

of PTSD are often one and the same thing. Anecdotal accounts from World War I to the present and

the few formal studies that have been conducted

clearly indicate that successful brief, forward treatment of an acute combat stress casualty reduces the

risk of that casualty’s subsequently developing

PTSD. However, soldiers develop PTSD without

having an antecedent history of an acute combat

stress reaction. Because traumatic events are unavoidable in combat operations, are there means of

preventing the later development of PTSD in soldiers who continue to perform well during the

actual events and hence do not come for immediate

treatment? Here, anecdotally, the routine application of after-action debriefings and event reconstructions after every major battle, engagement, or

otherwise traumatic event, appears to be useful.

Carefully controlled studies of the value of afteraction debriefings and event reconstructions following traumatic events in the prevention of later

PTSD would confirm the value of this technique.

A further, heretofore almost untouched, area for

research is the utility of psychotropic medications
War Psychiatry

484

in the treatment of acute combat stress reactions

and in the prevention of PTSD. Anecdotally, benzodiazepines appear to delay recovery of acute

combat stress reactions and to foster evolution of

the stress reaction into PTSD. Benzodiazepines

may be the pharmacological equivalent of evacuation to the rear in terms of their deleterious effects.

Whether antidepressant drugs, especially the new

selective serotonergic, noradrenergic, and dopaminergic reuptake inhibitors, could play a useful role

in the treatment of acute combat stress reactions

remains to be investigated. Whether these agents

alone, or in combination with after-action debriefing and event reconstruction, could be of use in the

prevention of PTSD is an open question as well and

one well worth investigating.

CONCLUSION

This review of warfare reveals certain recurring

themes concerning soldiers who persevere in combat vs those who break down in combat. Both

groups are often quite similar as individuals (and

may even be the same individuals); however, their

social situations are markedly different. The social

situations consist of a matrix of factors that determine whether the soldier excels or breaks down.

Thus, in adapting to combat, as in all survivalrelevant activities, humans respond holistically.

Their physical, intrapsychic, and social states form

this matrix of factors that influences their responses

to environmental danger. In combat, deep urgings

for individual survival often conflict with socially

conditioned expectations, requirements, and desires for “soldierly conduct,” that have been embodied in ideals such as patriotism, discipline, loyalty to comrades, and identification with the leader.

To prevent combat breakdown the presence of

mission-oriented small group cohesion is essential.

Cohesion is fostered by good leadership and by

having soldiers train, live, and experience stress

together. Further preventive measures include adequate rest, sleep, and nutrition so that chronic or

acute fatigue does not develop. Rest from battle

should ideally occur through small group rotation

so that group support is continuous. Commanders

should be open and honest with their subordinates

to build trust and vertical cohesion and to enhance

the soldier’s understanding of the importance of his

contribution to the unit mission and the national

interest. The soldier must believe that the entire

society supports him in suffering privations and

sacrifices.

Factors that foster psychiatric breakdown are the

negatives of the preventive factors: poor leadership, cohesion, and training; inadequate social support; and the buildup of fatigue. Factors that emphasize perceptions of individual or collective

vulnerability increase the probability of psychiatric

breakdown. This accounts for the strong relationship between intensity of combat (as measured by

wounded and killed in action) and numbers of

stress casualties. It also accounts for the observation that death of a comrade was the most common

precipitant of breakdown during World War II. A

feeling of helplessness in controlling one’s fate also

exacerbates stress and weakens resistance. This is

seen in the increased stress casualties that occur in

circumstances of indirect fire such as artillery or

bombing barrages, or gas attacks compared with

the direct fire situation (even though the wounded

and killed rate may be the same or higher than

under indirect fire).

After a soldier has become a psychiatric casualty,

it is important to restore as many positive factors as

possible: rest, sleep, and nutrition. Bonds to the

unit are kept intact with expectation of return to the

unit, hence the importance of treating as far forward and as quickly as possible. Treatment must be

kept simple to emphasize the normality of the

soldier’s experience rather than give an imputation

of mental illness. In garrison or rear-echelon settings, prevention is even more important because

the disorders that occur (alcohol and drug abuse,

character disorders, and sexual problems) are even

more difficult to treat than combat stress disorders.

In rear-echelon settings, attention should be paid to

discipline, morale-enhancing activities, and recognition of the critical role played by support troops.

Communication between support troops and those

they support should be encouraged. Temporary

assignment to combat units should be available.

Infractions should be dealt with through forward

rather than rearward evacuation to minimize secondary gain from misbehavior.

Prevention of combat stress casualties is primarily a command responsibility but the medical person, through consultation with command and avoidance of medical “evacuation syndromes,” plays a

critical role in this endeavor. The psychiatric lessons of war can profitably be applied to military

communities during peacetime as well as to civilian

communities.
485

Summation

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