63

Disorders of Frustration and Loneliness

Chapter 3

DISORDERS OF FRUSTRATION AND

LONELINESS

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

INTRODUCTION

LOW-INTENSITY VS TRADITIONAL COMBAT STRESS CASUALTIES

NOSTALGIA: REDISCOVERY OF A CONCEPT

LONELINESS AND FRUSTRATION CASUALTIES: PRECIPITANTS

Precipitants for Combat Troops

Precipitants for both Combat and “Service” Troops

LONELINESS AND FRUSTRATION DISORDERS: PRESENTATIONS

Substance Abuse

Sexual Problems

Indiscipline

Stress Disorders

LOW-INTENSITY COMBAT STRESS CASUALTIES: PREVENTION AND

TREATMENT

SUMMARY AND CONCLUSION

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

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

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

64

Edward J. Bowen Bunker on Nuo Ba Dhn Mountain 1969

Private Edward J. Bowen, a member of the U.S. Army Artist Program, depicts soldiers in their bunker in

Vietnam. Low-intensity combat is characterized by significant lulls in the fighting, during which soldiers

have time for a variety of activities, as shown in this painting. If not managed properly through constructive

activity, such lulls can give rise to disorders of frustration and loneliness.

Art: Courtesy of US Center of Military History, Washington, DC.
65

Disorders of Frustration and Loneliness

INTRODUCTION

The future may produce many different types of

war; however, because of the nuclear stalemate,

modern wars involving industrialized nations are

increasingly of the low-intensity, intermittent, but

protracted type experienced by the French in Algeria and Indochina, by the United States in Vietnam,

and by the Soviets in Afghanistan. Such conflicts

range from low-frequency terrorist actions to fullscale but intermittent warfare. In mid-1986, 42

conflicts were occurring.1 These ranged from World

War II-type mid-intensity combat operations (IraqIran) to low-intensity counter-terrorist/guerrilla

operations. Conflicts of the latter type were occurring at that time in Afghanistan, Cambodia, Central

America (Nicaragua and El Salvador), Chad, West

Irian, Northern Ireland, India, Sri Lanka, Burma,

and Angola. In 1992, the decline of Communism

was accompanied by the emergence of factionalism

or civil wars in Yugoslavia, Russia, Azerbaijan,

Georgia, Moldavia, and Czechoslovakia. Also,

Kurdish and Shiite minorities are at war in Iraq and

Turkey and threaten other states. Virtually every

large country and many small countries have the

potential for such conflicts.

These conflicts are of low intensity in the sense

that battles are interspersed with periods of inactivity and relative safety for the combatants. Overt

combat is brief, and usually involves squads, platoons, companies, and rarely battalions, although

at those levels casualties may be extremely high.

There is often a civil-war quality. Guerrilla activity

may be the predominant form of engagement, with

small arms and booby traps accounting for most of

the wounding and killing rather than artillery and

other indirect fire weapons. Here, too, “low-intensity” does not necessarily mean low-casualty: one

car bomb killed nearly 250 U.S. Marines in their

barracks in Beirut.2 Often the weaker military force

will use terrorist activity to achieve political ends.

Such conflicts and operations other than war are

often ambiguous with no directly appreciable threat

to the national interests of the more powerful country, which may be fighting a foreign, proxy war, or

participating in a multinational peacekeeping or

constabulary operation. As such they often do not

enjoy full public support. The psychiatric casualties of operations other than war differ qualitatively

and quantitatively from those of conventional wars

involving prolonged or intense heavy (mechanized)

combat. This chapter will describe these differences and propose methods of preventing and managing such casualties.

LOW-INTENSITY VS TRADITIONAL COMBAT STRESS CASUALTIES

The epidemiology of psychiatric casualties among

troops in battle has been examined in numerous

studies since World War I.3–14 Such studies tended

to emphasize the psychiatric casualties that resulted

from battlefield stress even though casualties resulting from less dramatic causes had been recognized since World War I. These less dramatic casualties presented with problems of alcohol and drug

abuse, disciplinary infractions, venereal diseases,

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.

Although the casualties that occur during actual

engagement with the enemy may present the traditional picture of battle fatigue (eg, anxiety, fatigue,

and conversion and dissociative syndromes), the

majority of neuropsychiatric cases in low-intensity

combat present a picture similar to those that occur

among rear-echelon troops in wartime and among

garrison troops during peacetime (venereal diseases, alcohol and drug abuse, and disciplinary

problems, often related to personality disorders). It

is not surprising then that various authors have

called such casualties “guerrilla neurosis,”15 “garrison casualties,”16 “disorders of loneliness,”17 and

“nostalgic casualties.”18,19 U.S. Army field manuals

refer to them as “misconduct stress behaviors”20–22

(Figure 3-1).

Jones23 studied the features distinguishing psychiatric casualties among combat troops from those

among combat-service-support troops not normally

exposed to combat. (“Combat-service-support” in

this context refers to soldiers whose primary mission is not to fight the enemy but to assist those
War Psychiatry

66

Unit Cohesion 

Loyalty to buddies

 Loyalty to leaders

 Identification with

 unit tradition

Sense of eliteness

Sense of mission

Alertness, vigilance

Exceptional strength

and endurance

Increased tolerance

 to hardship,

discomfort, pain,

 and injury

Sense of purpose

Increased faith

Heroic acts

courage,

self-sacrifice

Mutilating enemy dead

Not taking prisoners

Killing enemy prisoners

Killing noncombatants

Torture, brutality

Killing animals

Fighting with allies

Alcohol and drug abuse

Recklessness, indiscipline

Looting, pillage, rape

Fraternization

Excessively on sick call

Negligent disease, injury

Shirking, malingering

Combat refusal

Self-inflicted wounds

Threatening/killing own

leaders ("fragging")

Going absent without

 leave, desertion

Hyperalertness

Fear, anxiety

Irritability, anger, rage

Grief, self-doubt, guilt

Physical stress complaints

Inattention, carelessness

Loss of confidence

Loss of hope and faith

Depression, insomnia

Impaired duty

performance

Erratic actions, outbursts

Freezing, immobility

Terror, panic running

Total exhaustion, apathy

Loss of skills and memories

Impaired speech or muteness

Impaired vision, touch, and

hearing

Weakness and paralysis

Hallucinations, delusions

Combat Stress Behaviors

Adaptive

Positive Combat Stress

Behaviors

Misconduct: Stress Behaviors

and Criminal Acts Battle Fatigue

Post-Traumatic Stress Disorder

Intrusive painful memories, "flashbacks"

Trouble sleeping, bad dreams

Guilt about things done or not done

Social isolation, withdrawal, alienation

Jumpiness, startle responses, anxiety

Alcohol or drug misuse, misconduct

Dysfunctional Combat Stress Behaviors

F 3-1

Fig. 3-1. Combat stress behaviors may be adaptive or dysfunctional. The most serious of these behaviors are those

involving criminal acts. However, all stress behaviors can evolve into PTSD. Reprinted from US Department of the

Army. Leaders’ Manual for Combat Stress Control. Washington, DC: DA; September 1994. Field Manual 22-51: 2-12.

doing the fighting.) He concluded that such “garrison casualties” were found particularly among rearechelon elements in Vietnam, a conflict in which

each combat soldier was supported by about eight

noncombat-arms troops. Such troops characteristically present with behavioral disorders related to

separation from family and friends, boredom, and

social and sometimes physical deprivation. Considering their source, Jones17 had labeled these casualties as suffering from “disorders of loneliness”;

however, since before the Napoleonic Wars, such

disorders have been termed “nostalgia.” Obviously, such disorders can and do occur in combat

troops as well.
67

Disorders of Frustration and Loneliness

NOSTALGIA: REDISCOVERY OF A CONCEPT

of health, give a sense of mastery of weapons, and

integrate the unit. This regimen prevents evacuation home (the treatment approach of earlier physicians) and minimizes any secondary gain from

illness.24(p348)

During the Civil War, Calhoun, reviewed in

Deutsch,25 ascribed a relationship between nostalgia and the recruiting methods of the Union Army

that could have parallels with the “nostalgic casualties” of the Vietnam conflict. Calhoun described

initially enthusiastic soldiers who had expected an

early end to the conflict and who became disenchanted as the war dragged on. The statistics on

desertion, draft dodging, and similar attempts to

avoid duty were not much different during World

War II, a more popular war, and the Vietnam

conflict (in fact, these rates were generally lower

during Vietnam than during World War II). This

suggests that the disenchantment toward the end of

the conflict in Vietnam may not have been as important a factor in generating nostalgic casualties as the

loss of unit cohesion.

Nostalgic casualties occurred in soldiers separated from their home environment with attendant

loss of social reinforcement. Rosen24 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. Hence, Calhoun cited battle

action as a curative factor in nostalgia:

Their thoughts were turned from home, and they

felt they were men and soldiers, peers of the veterans with whom they associated; and from that day

to this there has been but little or no sickness, and

but one or two deaths...When men have passed

through the baptism of fire together, they feel they

have something in common. They have a common

name, a common fame, and a common interest

which diverts their thoughts away from home.25(p376)

Based on the recollections of Civil War veterans,

Stephen Crane’s The Red Badge of Courage eloquently

described the development of cohesive bonds in

response to the horrors of battle:

Nostalgia was a medical concept recognized even

before 1678, when the Swiss physician Hofer created this term to describe soldiers previously labeled as suffering from “Das Heimweh” or homesickness.24 Earlier in the 17th century, soldiers in

the Spanish Army of Flanders were stated to suffer

from “mal de corazon” (“illness of the heart”), and

Swiss mercenaries in France were said to suffer

from “maladie du pays” (“homesickness”). Because the majority of such soldiers were mercenaries uprooted by financial exigencies from their farms

in Switzerland, these soldiers were often described

as suffering from “the Swiss disease.” The critical

variable was service, often involuntary, far from

one’s country, family, and friends. By the middle of

the 18th century, nostalgia was a well-defined

nosologic entity recognized as afflicting not just

Swiss soldiers but potentially any soldier displaced

from his milieu of origin, and generally was considered to be a mental disorder.

The symptomatology associated with nostalgia

was consistently compatible with modern descriptions of depression, with complaints, for example,

of “moroseness, insomnia, anorexia, and asthenia”

in a report by Sauvages in 1768.24 Even this early

there were observations that nostalgia might be

feigned as a method of avoiding duty. A French

physician, De Meyserey, who published a treatise

on military medicine in 1754, observed that war and

its dangers always produced a fruitful crop of malingerers who must be discriminated from soldiers

with “true nostalgia.”

Baron Larrey, Napoleon’s Chief Surgeon, prescribed a course of treatment which, while ostensibly biologically oriented, reveals a keen awareness

of social factors and is surprisingly close to modern

handling of combat psychiatric casualties, both

preventively and curatively. He stated that it

is necessary not to allow individuals who are

predisposed to nostalgia more rest than is necessary, to vary their occupations, and after military

exercises to subject them to regular hours, gymnastic recreation, and some mode of useful instruction.

He also stated that they should have mutual instruction with troops of the line and that warlike

music will contribute to preventing gloomy reflections which can lead to nostalgia. This would ensure physical bodily integrity, produce a conviction
War Psychiatry

68

There was a consciousness always of the presence

of his comrades about him. He felt the subtle battle

brotherhood, more potent even than the cause for

which they were fighting. It was a mysterious

fraternity born of the smoke and danger of

death.26(p31)

Unit cohesion is group and self-preservative behavior that evolves from shared danger in an almost impersonal manner despite its very personal

nature. This group cohesion evolves in almost any

situation of shared hardship or danger. Belenky

and Kaufman27 found that vigorous training involving some danger produced cohesion in air assault trainees. In combat situations, cohesion needs

little encouragement to flourish. Recognizing this,

one company commander, when asked about cohesion in his unit in West Germany, commented, “I

train my men to be skilled soldiers; I’ll rely on the

enemy to make them cohesive.” Such a laissez-faire

attitude ignores the possibility that noncohesive

units may disintegrate in high-stress combat before

cohesive bonds can develop.

Low-intensity combat, 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 troops than among combat troops.23

During World War I, conditions of battle did not

lend themselves to producing large numbers of

nostalgic casualties; however, following the Armistice, the Third Army, which remained as an army

of occupation, was in a garrison-type role. The

casualties in this situation began to approximate

those seen in low-intensity warfare. For example,

from December 1918 to June 1919 at the hospitals at

Coblenz and Trier, 1,022 psychiatric cases were

evaluated.28 In this garrison setting, the largest

groups of casualties were those diagnosed as “defect” (presumably retarded) and “psychopathy”

(36.8%). When these are added to alcoholism and

drug states (6.8%), they account for nearly half of

the psychiatric morbidity, and over half if epilepsy

is excluded. There were many disciplinary problems in this occupation group. An attempt was made

by commanders and medical officers to eliminate

“misfits—defectives and psychopaths,” which may

have accounted for the identification of a relatively

high number of mentally retarded and epilepsy

patients; however, “Had not many been evacuated

through other than hospital channels (replacement

depots) the figures would be even higher.”28(p426)

(In a curious parallel with World War II, in the

Vietnam conflict an attempt was made to utilize

lower-functioning [though not retarded] men as

soldiers in the U.S. Army, the so-called “McNamara’s

100,000.” Such soldiers performed more poorly as

a group than normally selected soldiers but some

were superior.)

At a time during World War I when the military

population in France of U.S. soldiers averaged

200,000 persons, the incidence of hospitalized “psychopathic states” was 5 per 1,000, comparable with

the overall rate for “character and behavior disorders” in overseas areas in World War II of about 4

per 1,000.25 However, because diagnostic practices

in World War I and World War II differed markedly, true comparability may not exist. The difference in types of casualties in garrison settings was

observed by Salmon and Fenton, who commented

that the cessation of hostilities did not reduce the

need for psychiatric beds:

A number of more recent cases showed simple

depression...An intense longing for home was characteristic of this condition. It resembled a set of

reactions to which the term “nostalgia” used to be

applied and is common in all military expeditions

when a period of intense activity is succeeded by an

uneventful one.28(p287)

About one half of the U.S. psychiatric casualties

of World War II were unrelated to combat and

actually occurred during stateside service.29 During World War II, “homesickness” was listed as a

factor in the breakdown of 20% of psychiatric casualties among U.S. forces.30 At that time, however,

the relationship of these homesick casualties to

combat situations was not explored.

The North Pacific Area (Alaska and the Aleutian

Islands) during World War II was almost devoid of

combat but was also a situation of extreme social

deprivation. The ubiquitous state of “chronic depression” was not reflected in neuropsychiatric

admissions because the overall neuropsychiatric

admission rate was 10.5/1,000/y in the Alaskan

Department, the lowest in any combat area. Of 325

neuropsychiatric admissions to the 186th Station

Hospital at Umnak (Aleutians) from January 1942

through January 1945, 53% were for psychoneurosis,

14% for constitutional psychopathic state, 12% for

dementia praecox, 1% for manic-depressive, 3% for

mental deficiency, 1% for epilepsy, 3% for unclassified psychosis, and the remainder (13%) for miscellaneous, primarily situational reactions.31(p723) Despite a state of “chronic depression” that afflicted

virtually everyone, hospital admission rates were
69

Disorders of Frustration and Loneliness

low.31 Perhaps the fact that alcohol and drugs were

scarce in the theater had a salutary effect on these

statistics.

In the Korean conflict, three fairly distinct phases

are reflected in the varying types of casualties reported. The mid- to high-intensity combat from

June 1950 until November 1951 was reflected in

traditional anxiety-fatigue casualties and in the highest rate of combat stress casualties of the war, 209/

1,000/y in July 1950.32 Most of the troops were

divisional, with only a small number being less

exposed to combat. This was followed by a period

of static warfare with maintenance of defensive

lines until July 1953 when an armistice was signed.

The gradual but progressive buildup of rear-area

support troops was associated with increasing numbers of characterological problems. Norbury33 reported that during active combat periods anxiety

and panic cases were seen, while during quiescent

periods with less artillery fire the cases were predominantly characterological. Following the armistice, obviously, few acute combat stress casualties

were seen. The major difference in overall casualties other than surgical before and after the armistice was a 50% increase in the rate of venereal

disease among divisional troops.32

Commenting on the observation that psychiatric

casualties continued to present in significant numbers following the June 1953 armistice of the Korean conflict, Marren gives a clear picture of the

reasons:

The terrors of battle are obvious in their potentialities for producing psychic trauma, but troops removed from the rigors and stresses of actual combat by the Korean armistice, and their replacements,

continued to have psychiatric disabilities, sometimes approximating the rate sustained in combat,

as in the psychoses. Other stresses relegated to the

background or ignored in combat are reinforced in

the postcombat period when time for meditation,

rumination, and fantasy increases the cathexis

caused by such stresses, thereby producing symptoms. Absence of gratifications, boredom, segregation from the opposite sex, monotony, apparently

meaningless activity, lack of purpose, lessened

chances for promotion, fears of renewal of combat,

and concern about one’s chances in and fitness for

combat are psychologic stresses that tend to

recrudesce and to receive inappropriate emphasis

in an Army in a position of stalemate...Sympathy

of the home folks with their men in battle often

spares the soldier from the problems at home. The

soldier in an occupation Army has no such immunity ... Domestic problems at home are often reflected in behavior problems in soldiers, particularly those of immature personality or with character defects.34(pp719–720)

French experience in Indochina and Algeria15

revealed characterological problems among French

soldiers in these generally low-intensity campaigns.

Because there is a several-hundred-year history of

colonial wars and occupation forces for many European countries, it is surprising that reports of these

casualties are sparse. It seems plausible that these

were simply not considered medical, particularly

psychiatric, problems but rather moral issues similar to earlier consideration of active combat stress

breakdown as cowardice or lack of moral fiber. In

the French Indochina War (1945–1954), such character disorders were reportedly responsible for a

high number of evacuations, but no statistics are

available. Crocq and colleagues15 studied French

psychiatric casualties of the French-Algerian War

(1954–1962). They used statistics compiled by

LeFebvre and colleagues for 1,280 cases of mental

disorders at the military hospital at Constantine

who were then evacuated to France between 1 July

1958 and 1 July 1962 (second half of the FrenchAlgerian War). Diagnostically, 19.7% of the total

cases were character disorders, and another 14.5%

were organic psychoses, predominantly from alcoholism. Only 20% of all cases were related to a

triggering event during combat. Functional psychoses accounted for 36.7% of cases with approximately one half of these being schizophrenia (224 of

464 cases). The remainder were mentally retarded

(14.5%) and neurotic conditions (14.6%).15 Because

these are evacuation statistics, they only indicate in

a general way relative prevalence because characterological problems usually are not handled by

medical evacuation. It is unfortunate that actual

behaviors cannot be examined to determine the

comparability of problem behaviors among soldiers of this war and the Vietnam conflict; however,

there is a strong suggestion of comparability in that

only a small fraction of alcohol abusers will develop

brain syndromes. The relatively high percentage of

such cases among the French suggests that this type

of substance abuse was widespread.

For the United States, Vietnam represented the

epitome of a conflict in which nostalgic casualties

occurred. During the early years of the war, the

psychiatric casualty rate of about 12/1,000/y was

lower even than that in noncombat overseas areas

(Europe and Korea) at the same time.9 The average

psychiatric evacuation rate during the first year of

the war was 1.8/1,000/y, lower than that from army

posts in the United States.9 The most intense fight-
War Psychiatry

70

ing occurred in 1968 to 1969, with one half of those

killed in action killed during this period. In June

1968, 1,200 were killed, close to the peak number.9

As the war dragged on and the U.S. presence took

on many of the characteristics of an occupation

force, characterological problems began to surface.

Racial incidents began to occur, beginning in the

rear areas. Psychiatric problems initially took primarily the form of alcohol and drug abuse but later,

as the unpopularity of the war intensified, disciplinary problems approaching the magnitude of

mutiny in some cases occurred.

President Nixon announced withdrawal plans

on June 9, 1969. Fragging incidents (the murdering

or injuring of a fellow soldier with a fragmentation

grenade) increased from 0.3/1,000/y in 1969 to 1.7/

1,000/y in 1971.35 Psychiatric evacuations rose from

4.4/1,000/y (4% of all evacuations) to 129/1,000/y

(60% of evacuations) in April 1972. Several authors

have described these casualties and factors in their

causation.9,23,35–39

These problems were further aggravated by the

“Vietnamization” policy in which U.S. soldiers were

increasingly relegated to garrison settings and roles

in the later phases of the conflict. The subsequent

drug abuse epidemic may have played a decisive

role in the abrupt withdrawal of U.S. troops and the

ultimate loss of the war. The “garrison neuropsychiatric casualties” in fact accounted for most of

the consumption of mental health resources during

the Vietnam conflict. When a policy of medically

evacuating soldiers if they were found to have heroin

breakdown products in their urine went into effect,

heroin abuse became an “evacuation syndrome.”

Marlowe40 pointed out that Vietnam was aberrant compared with World War II and most of the

Korean conflict:

[T]he soldier’s future was as much controlled by

the calendar (DEROS) [date of expected return from

overseas station] as by the outcome of combat

with the enemy. The Viet Nam war was particularly variant in that the enemy lacked a significant capacity in weapons of indirect fire, thus providing a battlefield ecology that was substantively

different both from the past and the anticipated

future.40(p1)

This battlefield ecology, however, was not new

to other nations. The French forces preceding

the United States in Vietnam fought a similar war

until the decisive defeat at Dien Bien Phù where

they were beaten by indirect fire weapons artillery. The author contends that the casualties of such

low-intensity, intermittent campaigns are similar to

nostalgic casualties of the Civil War and of prior

wars.

The 1982 Lebanon War is an excellent example of

the problems of a war unpopular at home. While

the 1973 Yom Kippur War has been used as an

exemplar of modern, high-intensity combat and

Vietnam as an exemplar of low-intensity combat,

Lebanon had elements of both. There were approximately 2 weeks of intense combat in early and late

June 1982 with the remainder of the war being more

of a static situation with Israel as an occupying

force. The result in terms of casualties is revealing,

showing casualties similar to those during the intense battles of World War I, World War II, and the

1973 Yom Kippur War but also symptoms of estrangement and delayed stress casualties found in

Vietnam (see Figure 3-1). Recent studies41 revealed

that about two thirds of the psychiatric casualties

from the 1982 Lebanon War presented during the

postcombat period as chronic and delayed posttraumatic stress disorder cases.

treatment” to these casualties was hampered by

moralizing and punitive regulations42 and by stereotyping casualties as drug addicts, alcoholics,

cowards, and malingerers. Lost amid a welter of

negative reports were occasional successful interventions, particularly at the division level. Such

approaches included medical screening of prostitutes, making malarial prophylaxis a command responsibility, and alcohol and drug abuse rehabilitation programs at the division level.43

Psychiatric casualties occurring in actual combat

are qualitatively different from those occurring in

soldiers less exposed to combat. Billings reported

LONELINESS AND FRUSTRATION CASUALTIES: PRECIPITANTS

In making a diagnosis of combat stress casualty,

the clinician must strive for balance and avoid a

“recipe” approach. A major failing in the psychiatric management of casualties in the Vietnam conflict was in not recognizing early enough that psychiatric casualties were taking new forms: alcohol

and drug abuse, and venereal disease and malaria

from failure to take prophylactic measures. Armed

with a stereotypical model of combat fatigue and a

recipe for its treatment, psychiatrists were slow to

recognize that escape from battle (evacuation syndrome) had taken a new form. Even when the

recognition occurred, the ability to adapt “forward
71

Disorders of Frustration and Loneliness

that 28% of all medical evacuees from the South

Pacific Command during World War II were sent to

the Zone of the Interior because of personality disorders during 1943.44 Billings also described the

stresses and personality symptoms of combat and

combat-service-support troops. Writing of the men

sent to the South Pacific during World War II and

subsequently diagnosed as having personality disorders, Billings believed that certain characteristics

of Americans helped produce this outcome. He

recorded as follows:

Men ... were products of our sociology and ideology. Individualism; the belief in a freedom for all

men to compete on an equal basis; the tendency for

the American to need tangible evidences of success

at frequent intervals; the inclination to be too dependent on others for distraction, recreation, and

maintenance of interest; the assumption that American business philosophy is a matter of “not what

you do but what you are caught doing,” with the

unconscious realization that the one who does not

or cannot do the job gets the benefits and escapes

unpleasantness whereas the one who accomplishes

the task only faces more work or loses his life—all

stood out as dynamic factors in breakdowns in

morale, occurrence of resentment reactions, aggressive tendencies, and hurt feelings. These in

turn placed certain personalities in considerable

jeopardy of psychiatric disability when they were

subjected to special circumstances.44(pp479–480)

Precipitants for Combat Troops

Billings describes such “special circumstances”

as a variety of precipitants for combat troops.44

1. Facing impending danger, especially for a

period of time without specific happenings

to break the tension or circumstances permitting the venting of physical effort. For

example, remaining alert for a prolonged

period of time in a concealed position or

foxhole, subjected to the full effects of loneliness and jungle sounds; being pinned

down by artillery or heavy mortar fire; or

being caught in the open by strafing from

the air, especially when immobilized by

impediments or terrain.

2. Subjection to heavy artillery fire.

3. Occurrences of a lull, following a period of

danger, which allowed for cogitation and a

fuller intellectual realization of what was

and might be experienced.

4. Occurrence of transitory, psychobiological

disorganization in a particularly susceptible personality when subjected to fearinducing circumstances.

5. Prolonged patrol and reconnaissance work

in enemy-controlled jungle.

6. Promotion, in the field, to positions of great

responsibility.

7. Grief over loss of “buddies,” or loss of a

tactical position taking the form of selfcondemnatory thinking.

8. Inadvertent evacuation to a position of

safety with that [cogitation] noted in paragraph 3 resulting.

9. Loss of confidence in leaders.

10. Mass psychological reactions.

11. “Snow jobs” or tall tales told often by the

veteran combat soldier to the new replacement at, or before, a critical time.

12. Unwarranted or unexplained evacuation or

transfer of psychiatric and minor medical

and surgical casualties ... resulting in loss of

the individual’s security in his bodily or

personality integrity, loss of identification

with his unit, diminished esprit de corps,

decreased desire or feeling of need to continue fighting—all being replaced by a conscious or “subconscious” appreciation that

it might be possible to return home and

thereby honorably escape further danger.

13. Ill-considered or poorly-timed statements

to troops by visiting high-ranking officers,

which lead to misinterpretation of policy,

or promote loss of confidence in the administration.

14. Repeated dress parades for visiting dignitaries when the combat team is staging for

a forthcoming operation.

Precipitants for both Combat and “Service”

Troops

Billings also describes the “special circumstances”

that act as precipitants for both combat and “service” (support) troops.44

1. Hypochloremia, dehydration, fatigue, and

subclinical or clinical illness decreasing the

efficiency and smooth psychobiological

functioning of the individual, thereby often setting the stage for insecurity, tension,

and anxiety with personally alarming

symptomatology.

2. Enemy propaganda.

3. Rumors stemming from isolation, ignorance of facts, and inactivity.
War Psychiatry

72

4. Postponement of the promotion of enlisted

men and officers, and the filling of position

vacancies with new men in grade or rank.

5. Ill-advised promotion of men and officers

to responsibility beyond their ability.

6. Discrepancy between War Department and

politically announced policy and plans for

rotation and redeployment of overseas personnel.

7. Knowledge of the unfair discrepancy in

remuneration to and appreciation for the

individual in military service and the one

in the merchant marine and industry.

8. Seeming ignorance of the average commander and the officer in personnel work

either of War Department policy or of how

to comply therewith in regard to proper

assignment and readjustment of military

personnel.

9. Poor leadership, especially of high-ranking officers, as evident in the officer looking after his personal comfort and safety

before acquiring them for his command.

10. Apparent “empire building” of general officers.

11. Work or combat under adverse conditions

prolonged to the breaking point of the “average” man.

12. Failure to expedite the elimination of

ineffectuals from a unit.

13. Disturbing news from home, such as of a

wife’s infidelity, business reversals, deaths,

illness, and encouragement to forego continuance of further military responsibility.

LONELINESS AND FRUSTRATION DISORDERS: PRESENTATIONS

terms many of these casualties “misconduct combat

stress reactions.” The term suggests that disciplinary action may be indicated. This may be a profitable approach; however, command-sponsored substance abuse programs, programs to strengthen

morale, and hygiene/prophylaxis programs may

be more profitable. These dysfunctional behaviors

often cluster in patterns forming syndromes. Such

syndromes typically have many overlapping behaviors; however, it is useful to divide them into the

categories of substance abuse, sexual problems, and

indiscipline.

These cases (misconduct combat stress reactions)

are ones which violate unit regulations or the Uniform Code of Military Justice or the Law of Land

Warfare. The manuals state that such cases require

disciplinary action. They cannot simply be treated

as battle fatigue, with reassurance, rest, physical

replenishment, and activities to restore confidence.

Depending on the seriousness or criminality of the

misconduct, disciplinary action ranges from simple

verbal correction through assignment of unpleasant duties and denial of special privileges; written

reprimand; nonjudicial punishment (Article 15);

judicial punishment (court-martial); less than honorable discharge; confinement and, for extreme

misconduct, the death penalty. For criminal cases,

psychiatric expertise may be called upon to establish the validity of an insanity defense. In all cases,

mental health personnel can advise regarding potential for recurrence or rehabilitation, and treat

any associated mental disorders.

Soldiers less exposed to combat and presenting

with personality problems may be called loneliness

and frustration casualties. Huffman45 reported that

only 48 of 610 soldiers (8%) seen in Vietnam from

1965 to 1966 suffered combat-related stress, while

Jones23 found combat-related stress in 18 of 47

soldiers (38%) seen in a similar hospital setting

(September–December 1966). These 18 cases, however, were given character and behavior disorder

diagnoses. As the 25th Division psychiatrist, Jones17

saw approximately 500 patients from March through

October 1966, of whom about one third were

awaiting legal or administrative action. Of the

remaining two thirds, almost all were diagnosed

as having character and behavior disorders including situational fright reactions. The term “combat

fatigue” was misleading to the novice psychiatrist

with its mistaken implication of prolonged combat

and cumulative fatigue. In retrospect, some of

these cases would more appropriately have been

so diagnosed; however, the treatment approach

was the same: rest, reassurance, and return to his

unit.

The term “loneliness and frustration casualty,”

like “combat stress reaction,” and “battle fatigue,”

is an intentionally vague term describing a variety

of dysfunctional behaviors, although unlike “battle

fatigue” it is not readily understood by the average

soldier or his sergeant and junior officer, and so

should not be used when talking to them. Nostalgic

casualties require interventions much like those for

managing combat fatigue. U.S. Army doctrine21,22
73

Disorders of Frustration and Loneliness

Substance Abuse

During the Civil War, the liberal use of opium

caused widespread dependence called the “soldier’s

disease.”46 In low-intensity combat and garrison

settings in which the risks of being intoxicated are

not as great as in higher-intensity combat, substance abuse flourishes.

Froede and Stahl47 evaluated the 174 cases of fatal

narcotism retrieved from over 1.3 million surgical

and autopsy cases sent to the Armed Forces Institute of Pathology from 1918 through the first 6

months of 1970. Although the data were incomplete, some interesting trends were observed that

strengthen the observation that drug abuse is associated with low-intensity combat situations in geographical areas in which abuse substances are available (about two thirds of the deaths occurred in the

Far East). In terms of combat intensity, the majority

of cases in World War II, Korea, and Vietnam occurred in the closing years of the wars and in the

postwar periods when fighting had diminished and

large numbers of troops were serving in support

roles. Their findings are supported by Baker’s48

estimate that there were 75 opiate deaths in Vietnam from August 1, 1970 through October 18, 1970,

11 confirmed by autopsy and 64 suspected.

Alcohol was the first substance of abuse in Vietnam. Huffman45 reported that of his 610 patients

seen early in the war, 113 (18.5%) suffered from

severe problems associated with alcoholic intoxication but there were only five cases of unquestionable nonalcohol substance abuse. As the war progressed, marijuana came to be preferred because of

the absence of a “hangover.” Roffman and Sapol49

reported that in an anonymous questionnaire given

to soldiers departing Vietnam in 1967, 29% admitted using marijuana during their tour. Similarly,

a survey of 5,000 enlisted men at Fort Sill, Oklahoma who had not served in Vietnam from January

through April 196950 revealed that 29% admitted

to using drugs sometime in their lives, 83% of

the users identifying marijuana. In the early

years of the Vietnam conflict marijuana users apparently were reflecting the experiences of their

stateside cohorts, but this began to change. In

a review of studies of drug abuse in Vietnam,

Stanton51 found that from 1967 to 1971 the proportion of enlisted men who used marijuana “heavily”

(20 or more times) in Vietnam increased from 7%

to 34%, while the proportion of “habitual” users

(200 or more times) entering Vietnam remained

at 7% to 8% for the years 1968 through 1970 and

the proportion of habitual users in Vietnam stabilized at 17% to 18% between 1969 and 1971. Thus,

about 9% to 10% of the lower grades of enlisted

men first became habitual smokers (daily usage) in

Vietnam.

Heroin abuse became significant in early 1970

when 90% to 96% pure heroin derived from the

“golden triangle” of Thailand, Burma, and Laos

became available countrywide. This pure heroin

was so cheap that a significant “habit” could be

maintained for $8 to $10 a day.51 The preferred

route was “snorting” through the nostrils or smoking. Of the small percentage who injected at all, this

was only occasionally. At a peak in October 1971,

almost one half of all lower ranking enlisted men (E1 to E-4) were using heroin and half of these may

have been addicted.52 Like venereal disease rates,

drug abuse rates tend to increase when there are

lulls in combat or when exposure to combat is

decreased.

Heroin reportedly displaced cannabis because it

had no characteristic strong odor allowing detection, made time seem to go faster rather than slower

as with marijuana, and was compact and easily

transportable. However, McCoy53 argues that heroin

did not so much replace marijuana as augment its

use and that the real reason for the heroin epidemic

was enormous profits that South Vietnamese officials could make by selling it to Americans.

These findings must be considered in the light of

a nationwide epidemic of drug abuse in American

youths at that time. The biggest difference between

drug abuse in Vietnam and in the United States was

the ready availability of very pure, inexpensive

heroin in Vietnam.54

Treatment of substance abusers has varied considerably over time. Early approaches were to

consider such casualties problems of a moral nature

and later of a character defect with punishment as

the primary intervention. It was only when such

losses of manpower became significant in the Vietnam conflict that a nonpunitive, therapeutic approach was undertaken. By 1971, more soldiers

were being evacuated from Vietnam for drug use

than for war wounds.51 The U.S. Army had adopted

a countrywide voluntary treatment program in Vietnam in October 1969 aimed primarily at marijuana

abusers. This was patterned on an amnesty program developed in the Fourth Infantry Division in

May 1969. Army regulations tended to be slow in

changing to accommodate the therapeutic perspective, sometimes resulting in paradoxical punishment of recovered abusers.42
War Psychiatry

74

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. For example, the Australians serving

in Vietnam did not have significant personnel losses

from substance abuse.55,56 Their forces were based

on a regimental system with unit rather than individual rotations, and officers and troops had usually served together for long periods of time. This

may have produced greater unit cohesion, a crucial

difference from U.S. troops that protected Australian troops from developing nostalgic problems of

substance abuse and indiscipline.

Sexual Problems

The most common nostalgic behavior coming to

medical attention is sexual intercourse with prostitutes leading to venereal diseases. The following

case, known to the author, reveals that officers were

not immune.

Case Study 1: The “No-Sweat” Pill

When the author was taking sick call in the headquarters company dispensary, he was approached by Major

INF, who stated that he was going to Saigon overnight and

wanted a “no-sweat pill.” The author was slow to realize

that the major wanted penicillin to prevent getting gonorrhea or syphilis. When he did understand, he refused and

gave him a lecture on the dangers of incompletely treated

syphilis leading to tertiary lues of the brain and absence of

protection from viral venereal diseases. Later the author

learned that the major purchased antibiotics over the

counter in Saigon and indulged himself apparently without

complications.

Comment: The availability of antibiotics in Vietnam

(and Korea) without prescription may have hastened the

development of resistant strains of gonorrhea that have

been reported since the Vietnam conflict.

Low-intensity combat operations frequently show

an increased incidence of drug abuse and sexual

disorders. The following case from the early phases

of the Vietnam conflict reveals both.

Case Study 2: Seductive Marijuana

Sergeant First Class (SFC) MC was the noncommissioned officer in charge (NCOIC) of a technical support

battalion assigned to an infantry division. He was given a

forensic psychiatric evaluation in the course of a courtmartial proceeding. SFC MC was a kindly, friendly man,

well-liked by the officers and enlisted men with whom he

worked. In the combat setting he was unable to satisfy his

homosexual feelings by “cruising.” Finally he hit upon a

method that took advantage of the nostalgia and fears of

the young soldiers. He offered them friendship, alcohol,

and marijuana to alleviate their homesickness and fear,

then performed fellatio when they were intoxicated. Most

victims kept silent from embarrassment or fear of disciplinary action until a soldier who wanted to be separated

administratively was seduced. He reported the incident.

Comment: Examples such as this have been used to

vindicate the military policy of eliminating homosexuals

from the service; however, a study of homosexual college

students who served in World War II57 revealed that the

great majority served adequately and some with distinction.

Sexually-transmitted diseases (venereal diseases

or VD) have been a major cause of lost soldier

strength in wars of the 20th century. While modern

medicine has markedly reduced the time lost and

complications of venereal diseases, it has not reduced the infection rates as seen in Table 3-1.

Although the venereal disease rate of the American Expeditionary Forces (AEF) in World War I was

a relatively low 34.3/1,000/y,58 there were over 6.8

million lost man-days and 10,000 discharges.59 Each

TABLE 3-1

VENEREAL DISEASE RATES BY WAR/1,000

TROOPS/YEAR

War Years/Location Rate

World War I Expeditionary Force 34.3

Continental USA 127.4

World War II 1941–1945 42.9

Post-World War II 1946–1950 82.3

Korea 1951–1955 184.0

Vietnam 1963–1970 261.9

Peak Jan–Jun 1972 698.9

Continental USA 31.7

Data sources: [World War I] Michie HC. The venereal diseases.

In: Siler JF, ed. Communicable and Other Diseases. In: The Medical

Department of the United States Army in the World War. Vol 9.

Washington, DC: Medical Department, US Army, Office of The

Surgeon General; 1928: 263–310. [World War II, post-World War

II, Korea, Vietnam] Deller JJ, Smith DE, English DT, Southwick

EG. Venereal diseases. In: Ognibene AJ, Barrett O Jr, eds. General

Medicine and Infectious Diseases. In: Ognibene AJ, ed. Internal

Medicine in Vietnam. Vol 2. Washington, DC: Medical Department, US Army, Office of The Surgeon General and Center of

Military History; 1982: 233–255.
75

Disorders of Frustration and Loneliness

case resulted in over a month of lost duty time (from

1929–1939, lost days per case ranged from 38–50).59

By the time of the Vietnam conflict, 9 of 10 cases

were for gonorrhea (lymphogranuloma venereum,

chancroid, and syphilis accounted for most of the

rest), and lost duty time averaged only a few hours

per case. Deller and colleagues59 echo the observation of Jones23 that rates were greatest in support

troops with little combat exposure, and they add

that such troops were most often near population

centers. The peak incidence of nearly 700/1,000/y

occurred in the period January to June 1972 when

almost all U.S. troops were in support roles in

accordance with the “Vietnamization plan” of using South Vietnamese forces in combat.

Prevention through education is a valid approach

to venereal disease even though some soldiers will

risk infection no matter what the threat. Prevention

should not be directed at preventing sexual intercourse, which is an unrealistic goal, but toward the

avoidance of high risk (“off limits”) partners and

the use of condoms, which should be made readily

available. A study60 that revealed that 50% of all

prostitutes who have been randomly tested in the

United States carry the HIV (human immunodeficiency virus) antibody suggests that this retrovirus,

which is thought to cause the currently incurable

and usually fatal acquired immunodeficiency syndrome (AIDS), may be a problem in future wars. In

battlefield conditions, soldiers may have to donate

blood to each other, and the presence of a soldier

who is HIV positive could prove hazardous not

only to the health but also to the morale of troops.

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, the spread

of HIV in Africa is primarily through heterosexual

intercourse. In South America, another politically

troubled area with insurgencies and narcotics production in several countries, 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. deployment beginning before 1900.

Indiscipline

Indiscipline is a psychiatric issue in the sense that

sociopsychological factors play a paramount role in

its emergence. Furthermore, indiscipline and psychiatric breakdown merge almost imperceptibly as

evacuation syndromes. For example, failure to take

preventive hygiene measures in Korea allowed the

development of frostbite in some cases. Similarly,

failure to take the prophylactic chloroquineprimaquine pill in Vietnam allowed the infestation

of malarial protozoans. In both cases, indiscipline

rendered the soldiers unfit for duty.

Indiscipline may range from relatively minor

acts of omission to commission of serious acts

of disobedience (mutiny) and even murder

(fragging). In an analysis and historical review,

Rose61 indicated that combat refusal has been a

relatively frequent occurrence in most significant

wars for which there is adequate data. The military

has often colluded with the perpetrators in hiding

the true nature of collective disobedience (mutiny)

by using various euphemistic phrases (“unrest,”

...“incident,” “affair,” “collective protest,” “insubordination,” “strike,” and “disaffection”).61(p562) Rose

indicates that there are compelling reasons for command to do this: “...mutiny is the antithesis of

discipline,”61(p562) and a commander who “allows” a

mutiny to occur jeopardizes his career and those of

his “commanding officers up and down the

line.”61(p563)

Most indiscipline, of course, is more subtle than

combat refusal and does not appear to be related to

it. However, unavailability for combat is a frequent

consequence of indiscipline. The main role of the

psychiatrist is in prevention because the same conditions that give rise to neuropsychiatric casualties

may produce indiscipline as another evacuation

syndrome. This section will address primarily clinically observed situations involving indiscipline actions.

The following examples of indiscipline, provided

by the author, were fairly typical of conditions in

Vietnam.

Case Study 3: The Major’s Bullets

During the early phases of the Vietnam conflict Major

MSC was the executive officer in the headquarters of a

support battalion of an infantry division. Prior to deployment to Vietnam he had earned a reputation as a strict

disciplinarian, once having demoted a soldier for having a

pocket unbuttoned. The battalion commander, an alcoholic, stayed sequestered in his “hooch” leaving the major

to run the unit despite his lack of expertise in the highly
War Psychiatry

76

technical field in which most of his subordinates were far

more skilled than he was. Feeling threatened by lack of

proper technical background, the major became increasingly authoritarian, producing impaired morale in his unit.

His authoritarian approach to leadership was not appreciated by the troops: he began finding bullets with his name

written on them. This physical threat did not change his

behavior. The appropriate intervention would have been

to make higher command aware of the adverse effect on

morale of Major MSC; however, he was well-regarded by

command for taking over for the incompetent battalion

commander and higher command turned a deaf ear.

Eventually, Major MSC made a serious error leading to

the death of a prisoner of war and he abandoned his

authoritarian approach.

Comment: Early in the Vietnam conflict the majority of

U.S. soldiers were volunteers who served together prior to

deployment to Vietnam. Morale was generally high. In the

later phases of the war an officer as unpopular as Major

MSC would have been a likely fragging victim.

Linden62 reported that there was a progressive

rise in the number of courts-martial for insubordination and assaults (including murder) on officers

and senior noncommissioned officers (NCOs)

during the Vietnam conflict. He attributed these

incidents to disaffection and poor morale because

the war was increasingly seen as useless by the

soldiers who were unwilling to risk their lives in a

lost cause. The specificity of circumstances and the

importance of leadership surrounding that form of

indiscipline called combat refusal is seen in the

following case.

Case Study 4: The Silver Star Medic

Specialist 4th Class (SP4) MC was the medical aidman

(“medic”) attached to an infantry company. In several

battles he had performed with great valor, risking his life

to treat wounded comrades, resulting in his being recommended for award of the Silver Star. He was referred for

psychiatric evaluation when he refused to go out on a

combat mission. The author found no evidence whatever of

psychiatric impairment or personality disorder. The young

soldier stated that he would not go into combat with a “green

lieutenant” who had replaced the company commander, a

captain, with whom the medic had deployed. The captain

had been wounded and was currently performing light

duties in the division headquarters. The medic stated that

on the first engagement with the enemy the new lieutenant had foolishly risked his troops, resulting in several

wounded soldiers. As much to protect his comrades as

himself (because the unit could not go out without a

medic), SP4 MC refused to go on a combat mission.

Comment: This young soldier was actually sent to the

psychiatrist as a ploy on the part of command in hopes that

a medical solution could be found for a leadership problem. When the psychiatrist refused to label the soldier

psychiatrically ill, the medic was transferred to another

company. The appropriate solution is a consultation with

the lieutenant’s commander in which assignment manipulations are recommended.

Indiscipline is not limited to subordinate ranks.

Perhaps the most notorious example of collective

indiscipline during the Vietnam conflict occurred

in the My Lai atrocity, in which over 100 men,

women, and children were killed in a village by U.S.

forces.

Case Study 5: Lieutenant Calley

[Although the author was one of three U.S. Army

psychiatrists who examined First Lieutenant William Calley

and testified at his court-martial, the information given in

this case comes from public records of the trial.—Au.]

Calley testified that he had been ordered to go to My Lai

and “kill the enemy”; however, the major who had allegedly given the order was killed before the trial began.

Several factors are important in understanding this incident. First, prior to assignment in Vietnam, Calley was

stationed in Hawaii where he was exposed to numerous

“after-action” and “lessons learned” reports coming from

Vietnam. Many of these emphasized the dangers from

civilians who were secretly Viet Cong. Many reports

included descriptions of Vietnamese women and children

unexpectedly killing and wounding Americans with grenades and satchel bombs. While this intelligence justified heightened awareness and precaution to protect

against such attack, it in no way justified the rape and

murder of unarmed women and children, not even ones

taken prisoner after committing such an attack, let alone

ones rounded up in a village without resistance.

Secondly, Calley identified strongly with his men and

was quite upset when his company incurred large numbers of casualties in the My Lai region (thought to be proViet Cong) not long before the killings in My Lai. He was

even more upset because he had been away when this

occurred. This concern for his troops is to his credit, and

qualifies his action as a misconduct stress behavior,

rather than as simple criminal misconduct. It does not,

however, excuse it or justify it.

Finally, Calley tended to see things in a black or white,

all-or-none fashion. If the enemy included women and

children and the enemy were supposed to be killed, so be

it. Had the villagers (men, women, or children) been firing

at the American troops, it would have been entirely correct

to shoot and kill them, but only up until the point where

they surrendered. If noncombatants had been killed in

such a firefight, that would have been regrettable but

justified. But Calley was convicted of having ordered and

participated in the deliberate massacre of about two

dozen unarmed Vietnamese men, women, and children.

Evidence in the Peers Investigation Report suggested

that over a hundred persons were in fact murdered.63
77

Disorders of Frustration and Loneliness

One of the soldiers at the My Lai atrocity, rather than

participate in killing women, children, and old men, shot

himself in the foot. Although self-inflicted wounds are

usually intended to escape combat (in Vietnam this evasion was often thwarted by orthopedic surgeons who put

some of these soldiers in “walking casts”), in this case an

altruistic outcome was effected. When the author reviewed the testimony of all the U.S. Army participants at

My Lai in preparation for his testimony at Calley’s courtmartial, he found most of the soldiers were deeply conflicted and some approved the self-inflicted wound solution to the conflict. Others, however, felt that this soldier

was cowardly. His “indiscipline,” via his self-inflicted

wound, prevented worse indiscipline on his part.

Comment: Testimony63 indicated that some of the U.S.

soldiers committed unspeakable acts of sexual assault in

committing the murders. The fact that presumably previously normal and moral human beings can commit such

atrocities under the influence of uncontrolled combat

stress makes clear why it is so important that leadership

not let such misconduct begin. Calley’s argument that he

was just obeying the major’s orders is irrelevant. The

Uniform Code of Military Justice requires each soldier to

refuse to obey a clearly illegal order such as the murder of

unarmed prisoners or noncombatants. The command

climate in Vietnam, and the training prior to the My Lai

atrocity, may have failed to make that clear. No soldier

appears to have overtly tried to get Calley to rescind his

illegal order. Forms of indiscipline in which not only

military but also international rules for handling prisoners

and noncombatants are disregarded may be more common in low-intensity conflicts. Following the recapture (by

U.S. and South Vietnamese forces) of Hue during the Viet

Cong and North Vietnamese Tet Offensive, a mass grave

was found containing the bodies of about one thousand

men, women, and children presumably slaughtered by the

North Vietnamese. Similarly, torture and killing of prisoners

of war (POWs) occurred in the French-Algerian War, in the

guerrilla warfare in Central America (El Salvador and Nicaragua) and South America (Argentina), and in 1992 reports

of POWs in the former Yugoslavia.

“Indiscipline” by a high-ranking officer occurred

in the 1982 Lebanon War when Colonel Eli Geva

(commander of the Israeli tank force outside Beirut)

refused to lead his troops into Beirut, which he

expected to entail killing civilians. Geva urged that

Beirut not be attacked and asked to be demoted to

tank crew member if the city were attacked. Geva’s

courageous act resulted in rapid decisive action

(Geva’s prompt removal and isolation from other

military personnel) coupled with the decision to

launch a more discriminating attack that would

minimize civilian casualties. This prevented other

commanders from following suit.64 Calley showed

no concern for civilians; by contrast, Geva was

criticized for showing too much concern.

Stress Disorders

To the heterogeneous syndromes found in lowintensity wars that have been labeled loneliness and

frustration casualties (“nostalgic casualties”) should

be added acute stress disorders and 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, automatic 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. This was

seen, for example, in the large numbers of German

veterans of World War I who developed chronic

war neuroses (many of whom would now be labeled chronic post-traumatic stress disorder) compared with the small numbers of such cases following World War II.65 In both cases Germany lost the

war, but one difference was that after World War II

veterans were not given pensions for neurotic

(nonpsychotic or nonorganic) conditions due to the

experience of German psychiatrists who knew of

the World War I findings, and due to the general

opprobrium earned by the military because of Nazi

atrocities.

Post-traumatic stress disorders evolved from the

Freudian concept of “traumatic neurosis” and

technically are part of the combat stress disorders

spectrum, of the acute, chronic, or delayed type.

The chronic and delayed forms of PTSD have assumed considerable importance as sequelae of

combat in Vietnam and in the 1982 Lebanon War.

PTSD is explored at length in Chapter 16, Chronic

Post-Traumatic Stress Disorder. Here it is important to recognize that PTSD symptoms can follow

any serious psychological trauma, such as exposure to combat, accidents, torture, disasters, criminal assault, and exposure to atrocities or to the

sequelae of such extraordinary events. POWs exposed to harsh treatment are particularly prone to

develop PTSD. In their acute presentation, these

symptoms, which include subsets of a large variety

of affective, cognitive, perceptual, emotional, and

behavioral responses delineated in Exhibit 3-1, are
War Psychiatry

78

EXHIBIT 3-1

APA DIAGNOSTIC CRITERIA FOR 308.3 ACUTE STRESS DISORDER

Reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th

ed. (DSM-IV). Washington, DC: American Psychiatric Press; 1994: 431–432.

relatively normal responses to gross psychological trauma. If persistent, however, they develop a

life of their own and may be maintained by inadvertent reinforcement. Early intervention and later

avoidance of positive reinforcement (which may be

subtle) for such symptoms are critical preventive

measures.

Current doctrine22 emphasizes the importance of

routine debriefing after any traumatic action to

minimize subsequent post-traumatic stress. These

debriefings may involve just the small unit itself, as

leader-led after-action debriefings. These sessions

review lessons learned while clarifying the facts of

the event, by getting everyone to describe what they

saw and did. Misperceptions and misunderstandings are corrected in the process, and feelings and

reactions are shared openly. After an especially

traumatic event, the small units should receive a

formal critical event debriefing. These sessions

should occur within several days of the event, and

are led by trained debriefing teams. Critical event

debriefings also get everyone to describe the facts of

the event, and deliberately help everyone verbalize

and process their thoughts, emotional reactions,

and physical stress symptoms. The debriefing team

must emphasize the normality of those reactions,

and the value of talking them out now as wise

preventive maintenance. Units should also conExhibit 3-1 is not shown because the copyright permission granted to the Borden Institute, TMM,

does not allow the Borden Institute to grant permission to other users and/or does not include usage

in electronic media. The current user must apply to the publisher named in the figure legend for

permission to use this illustration in any type of publication media.
79

Disorders of Frustration and Loneliness

duct routine end-of-tour debriefings as part of

prehomecoming activities. Chapter 11, Debriefing

Following Combat, explores these issues in greater

detail.

The only units in which psychiatric casualties of

either the high-intensity combat stress or of the lowintensity combat stress type appear minimal are

highly cohesive, usually elite units. Thus, the building of cohesive, well-led units is as important in this

form of warfare as in higher-intensity combat. The

dynamics of cohesive units are discussed at length

by Manning.66 The level of material support does

not appear to be a factor in such units and, by giving

an appearance that sacrifice is unnecessary, may

even be detrimental. While some soldiers benefit

from abundant material support and close communication with loved ones, many soldiers may paradoxically benefit from a more austere situation.

LOW-INTENSITY COMBAT STRESS CASUALTIES: PREVENTION AND TREATMENT

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 at least some of

the nostalgic casualties. Most combat soldiers and

marines left the combat zone by commercial air,

without any combat comrades with whom to talk

out (debrief) the memories of the tour. Their reception in the United States also usually discouraged

further sharing and validation of their (and their

dead comrades’) experiences, accomplishments, and

sacrifices.

Some aspects of treatment have been exemplified

in the foregoing cases and in preceding chapters. It

may be summarized as treatment of acute posttraumatic stress disorder following combat psychiatric principles, not reinforcing symptoms associated with chronic and delayed post-traumatic stress

disorder, use of evocative therapies emphasizing

correcting current maladaptive behaviors, and judicious use of pharmacotherapy in some cases.

A critical component of treating chronic posttraumatic stress disorder is determining associated

conditions, especially drug and alcohol abuse, and

treating them as well. The use of a relaxation

technique such as one of those described by Benson67

can be critical in managing anxiety symptoms without resorting to medications or may be adjunctive

to their use.

This chapter has described the emergence of

symptoms more often encountered in garrison settings—various character and behavior disorder

problems—as the primary nosologic entities in lowintensity combat. The resurrection of the ancient

entity “nostalgia” seems appropriate as a generic

approach to conceptualize and treat these casualties. The postwar emergence of large numbers of

veterans suffering from chronic and delayed posttraumatic stress disorder following the Vietnam

conflict and the 1982 Lebanon War is explored in

Chapter 16, Chronic Post-Traumatic Stress Disorder, in terms of the evolution of the post-traumatic

stress disorder concept and approaches to prevention and treatment. Studies from World War II

reveal that improperly treated cases of acute posttraumatic stress disorder (combat fatigue) account

for most of the subsequent postwar disability from

chronic post-traumatic stress disorder (formerly

called war neurosis). Studies of American prisoners of war held by the Japanese and North Koreans

reveal that harshly treated prisoners of war are at

high risk for developing chronic post-traumatic

stress disorder.

In the future, U.S. forces are far more likely to

encounter low-intensity combat than high-intensity combat. The psychiatric casualties, which undoubtedly will be unique to the situation, are still

likely to resemble in some fashion those of previous

low-intensity wars. The human organism is amazingly adaptable, and responds to threats to its existence by calling forth the maximum adaptive strategies to escape from the perceived danger. When

effective methods for returning combat fatigue cases

to battle were developed, is it possible that newer

symptom complexes to avoid danger occurred as an

SUMMARY AND CONCLUSION
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80

adaptive function? Failure to take malarial prophylaxis, drug abuse, and misconduct defy the application of traditional combat psychiatric principles but

may reflect the same psychodynamic processes seen

in combat fatigue. Given this difficulty, treatment

and preventive psychiatric procedures must be flexible to optimize the return of such casualties to

normal functioning.

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