113

Psychiatric Principles of Future Warfare

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

Chapter 5

PSYCHIATRIC PRINCIPLES OF

FUTURE WARFARE

INTRODUCTION

CHARACTERISTICS OF FUTURE WARFARE

Low-Intensity Future Warfare

High-Intensity Future Warfare

CHALLENGES TO THE PRINCIPLES OF FORWARD TREATMENT

RESEARCH STUDIES OF COMBAT STRESS

Psychological Factors

Combat Role and Sleep Deprivation

Disrupted Circadian Rhythms

Implications for Future Combat

PRINCIPLES OF COMBAT PSYCHIATRY FOR FUTURE WARFARE

Prevention

Battlefield Treatment in High-Intensity Warfare

Ethical and Practical Issues Concerning Pharmaceuticals

Use of Pharmaceuticals in Combat

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

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

114

Mario H. Acevedo The Attack 1991

Mario H. Acevedo, a U.S. Army Combat Artist deployed to the Persian Gulf, depicts the aerial intensity of

American gunships attacking Iraqi armor in the desert. Future warfare may occur in a variety of settings

and intensity, ranging from the massive troop and materiel deployments of the Persian Gulf War to small

peacekeeping missions. Such rapid and intense combat necessitates flexibility and innovation in the

treatment and restoration of combat stress casualties.

Art: Courtesy of US Center of Military History, Washington, DC.
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Psychiatric Principles of Future Warfare

INTRODUCTION

Historical reviews of psychiatric interventions in

past wars allow the exploration of the implications

of a range of future combat scenarios.1–5 A spectrum

of combat intensities is possible, ranging from intermittent light-infantry combat (low-intensity conflict) to continuous, highly-mechanized battle (highintensity conflict), possibly with nuclear, biological,

and chemical (NBC) weapons. Whatever the combat intensity, the underlying stresses of dislocation

from loved ones and home, the fear of the unknown,

and the stresses of an unfamiliar environment will

produce disorders of frustration and loneliness.

Thus, higher-intensity conflict stresses will be superimposed on stresses associated with low-intensity conflicts.

While the holistic or psychosomatic approach

emphasizes the unity of an organism’s response to

stress, it is convenient to separate factors producing

stress and breakdown in battle into physical (or

physiological) and psychological (or sociopsychological) categories.

The psychological factors, because they are potentially the ones more amenable to psychiatric

interventions, have been emphasized the most in studies of breakdown in battle. Because of the nature of

high-intensity, high-technology, and continuous combat, the physiological variables may still play a

major role in breakdown in modern wars.

Psychological and physiological variables interact to prevent or promote illness. This can be seen,

for example, in frostbite, the first combat psychiatric disorder described in the British literature during World War I.6 More recently, Sampson7 has

described this interaction between the physiological responses to anxiety, particularly vasoconstriction, and to cold, also a vasoconstriction, when the

soldier is immobile, stressed, and lacking in protective clothing. Similarly, the disorganized, immobilized soldier is less likely to attend to proper protective measures such as changing stockings frequently.

This interaction of physiological responses to cold

and behavioral and physiological responses to anxiety produces a cumulative effect of heat loss in

peripheral tissues and thus of frostbite.

A large body of literature has documented the

clinical relevance of stress not only to traditional

psychiatric disorders but also to such apparently

“physical” conditions as infections, cardiovascular

diseases, and cancer.8–10 Many of these deleterious

effects of stress seem to be mediated by the neurotransmitter/neurohumoral and immune systems.

Although no one knows precisely what forms

future warfare will take, the following possible

forms of future warfare and available experimental

studies related to combat performance are offered

for consideration.

CHARACTERISTICS OF FUTURE WARFARE

From a historical perspective there appear to be

two main groupings of combat stress casualties,

which are to an extent dependent on the nature of

the soldier’s experiences. At one extreme are the

disorders of frustration and loneliness (nostalgic

casualties) that appear among troops engaged in

intermittent, low-intensity combat, and in rear-echelon duties. These soldiers share the problems of

anyone who leaves home to an inhospitable environment; they present with symptoms such as alcohol and drug abuse, disciplinary infractions, and

venereal disease. Pre-Vietnam drafted soldiers in

garrison settings manifested many of these behaviors, and U.S. soldiers in Europe and Korea continue to exhibit them. Terrorist and guerrilla tactics

are deliberately calculated to maximize ambiguity

and frustration. This provokes misconduct, including excessive brutality and atrocities which will

alienate the local population, the home front, and

world opinion. For the United States, the Vietnam

conflict was the epitome of this type of conflict.

Although it could be argued that they were not

appropriately utilized, the traditional principles of

treatment (proximity, immediacy, expectancy; reassure, rest, replenish, restore confidence) appear

to have been less effective with these casualties in

Vietnam.

At the other extreme is the high-intensity, highlethality, continuous combat fought in some battles

of World War I, World War II, and early in the

Korean conflict, but best seen in the 1973 Yom

Kippur War. Such casualties present with symptoms related to anxiety and physical and emotional

exhaustion. The traditional principles of treatment,

if the vicissitudes of battle allowed them to be used,

worked best with these soldiers in the past; how-
War Psychiatry

116

ever, the severe stress of future warfare may exert

psychological trauma of such severity as to lessen

the effectiveness of these principles even if battlefield conditions allow their use.

Being unable to know what type of war the United

States will be expected to win in the future, the

armed forces must prepare for conflicts ranging

from worst-case low-intensity operations other than

war to very high-intensity wars. These two polarities will be addressed at this time in terms of psychiatric approaches. If psychiatric casualties can be

appropriately treated in these extremes, those of a

medium range of intensity should present no insurmountable or unforeseen problems. While future

military missions may extend beyond combat, it is

reasonable to expect that the combat intensity dimension will include the major varieties of future

psychiatric problems.

Low-Intensity Future Warfare

A study of world conflicts since the Vietnam

conflict would lead to the conclusion that the United

States is likely to be involved in more low-intensity

conflicts than high-intensity, 1973 Arab-Israeli-type

wars. A chemical or biological low-intensity conflict would seem to be improbable, but chemicals

have, in fact, most often been used against poorly

equipped insurgents or dissidents, as by Spain and

France against the Moroccans in the 1920s; by Italy

against Ethiopia; by the Soviets or their clients in

Yemen, Cambodia, Laos, and Afghanistan; and by

Iraq against their Kurdish minority. U.S. forces,

especially Special Operations Forces, could be on

the receiving end of such weapons under circumstances which would be difficult to document.

In preparing for low-intensity combat stress casualties, there must be an attempt to strengthen

ameliorating conditions. These include minimizing family stress, enforcing vigorous discipline in

organized camp conditions, setting and enforcing

strict but realistic rules of engagement, and promoting unit cohesion and pride in following the rules.

At the same time, it will be necessary to eliminate or

lessen the impact of aggravating conditions: prevent boredom, prepare for cultural differences, and

strengthen social support from the unit, the family,

and the community.

Fighting counterterrorist or counterinsurgency

conflicts can result in successful outcomes. The

British experienced such success in the Boer War in

South Africa (1899–1902) and in a war in Malaysia

(1948–1960), and the United States successfully put

down the Moro rebellion in the Philippines (1902).

Critical to these efforts was the use of professional

soldiers and the ability to isolate the insurgents

from resupply and indigenous support.

In counterinsurgency conflict the forces being

allied with must be seen as legitimate to govern by

the indigenous population. The U.S. troops optimally will be professional soldiers (and often Special Operations Forces) fighting in cohesive units,

thus relatively impervious to the ambiguities universally present in civil wars. However, less frequently trained combat-service-support units, some

from the Reserves, may also be deployed. The troop

leaders should regularly explain the goals of the

fighting and those goals should be explicitly formulated by the Commander-in-Chief. The mental

health personnel must have a “mental-hygiene approach,” emphasizing productive use of leisure time,

and perhaps assisting in building schools and public works projects. Vigorous approaches to eliminating substance abuse and in-country treatment of

substance abusers is mandatory. Realistic information about the risks and prophylaxis of venereal

diseases should regularly be given by the medical

personnel to the troops. Bushard-type counseling,11 emphasizing commitment to the mission and

concurrence of one’s fellow-soldiers, should be

readily available to temporarily disaffected or demoralized soldiers. The emphasis must be on current issues and on optimistic appraisal of the

soldier’s ability to overcome these challenges. Often, the best results occur when a senior sergeant or

an officer can take the disaffiliated soldier “under

his wing” and offer encouragement and support

during a difficult time, a surrogate parenting for an

immature personality.

The devastating effects of drug abuse by soldiers

in Vietnam is detailed in Chapter 3, Disorders of

Frustration and Loneliness. In his novel 1984, George

Orwell12 suggested that drugs might be utilized to

weaken a nation’s fabric and assist a foreign power.

In 1986, a U.S. Army general reported that communist Cuba was supporting the smuggling of narcotics into the United States, presumably to that end.13

One of the most alarming terrorism trends in Latin

America is the alliance between insurgency groups

and narcotics traffickers, particularly in Peru and

Colombia.14 Most of the evidence supports the view

that in Vietnam, market factors led to drug trafficking rather than deliberate subversion. However, the

potential for such insidious subversion exists.

The mental health implications of drug dependence are obvious, but only recently have government and industry begun large-scale actions to

counter the drug-abuse threat that afflicts primarily
117

Psychiatric Principles of Future Warfare

the age group most likely to be conscripted in the

event of major hostilities. As mentioned, U.S. soldiers were deployed to Colombia to support that

government’s attempt to disrupt drug trafficking.

The military has also assisted the Coast Guard and

Immigration and Naturalization Service in guarding the borders against drug importation. Additionally, the U.S. government has used drug screening of personnel. Some industries have also begun

such screening.

The senior U.S. Army leadership is aware of the

potential stress issues in operations other than war,

and is actively collecting data and developing policies and doctrine to control them. This doctrine

includes the early deployment of mental health/

combat stress control (clinical) teams and human

dimensions (research) teams.15–17 The focus of this

chapter, therefore, will be on high-intensity combat, which presents formidable obstacles to traditional treatment delivery. While low-intensity conflicts and operations other than war are more likely

than a high-intensity conflict, U.S. forces must be

prepared for the high-intensity conflict (ie, a worstcase scenario such as NBC warfare). Even in the

absence of NBC warfare, future combat may be

sustained, highly intense, highly mobile, and highly

technical.

High-Intensity Future Warfare

U.S. military forces must prepare for combat of

unprecedented ferocity, lethality, and destructiveness. For example, modern combat offensive doctrine calls for continuous operations including conventional, airmobile, and airborne assaults possibly

coupled with coordinated chemical strikes (and

perhaps nuclear strikes) throughout the depth of

the enemy’s deployment.18 Mobile combat groups

will attempt to penetrate enemy defenses up to 150

miles, into the defender’s rear positions, disrupting

command, communications, and logistic activities.19

Through the use of night vision devices and superior numbers, the attacking forces will fight continuously while allowing adequate rest by rotating

spent units. If outnumbered, the defending forces

would be engaged continuously,20 resulting in fatigue and sleep deprivation. If opportunities for

sleep did occur, the extraordinarily high noise levels and ground-shaking artillery and bomb blasts

might make sleep impossible until the soldier approached physical collapse. This will maximize

mental and physical stress on defending personnel

and increase combat breakdown. If this seems an

implausible scenario for the future U.S. Force Projection military, imagine what it would have been

like for the lead U.S. contingency force Army and

Marine brigades and divisions if the Iraqi Army in

September 1990 had been able to press forward with

a full armor attack, supported by their heavy artillery firing chemical shells, while improved Scud

missiles dropped chemical, biological, and perhaps,

nuclear warheads on the Arabian (and Israeli) ports,

airfields, and cities (Exhibit 5-1).

A future regional power (perhaps even one of the

current major powers under different leadership

turned aggressively militaristic) could be tempted

to pull a “high-tech” surprise, counting on an inadequate political and/or military response from the

United States. It is conceivable that this could come

after a period of economic hardship when the downsized U.S. military services were feeling the effects of

decreased funding for maintenance, training, soldier

and family benefits, and perhaps shortfalls in weapons research, procurement, and strategic lift capability. All these factors could have resulted in lowered

EXHIBIT 5-1

CHARACTERISTICS OF HIGHINTENSITY WARFARE

High lethality with mass casualties

“Disaster-fatigue” casualties

Continuous combat

Sleep deprivation

Increased fatigue

High mobility

Radar localization

Proportionally fewer forces

Dispersal of forces

Nuclear/biological/chemical threat

Infrared/radar “signature”

Result of high mobility

Absence of air superiority

Limited helicopter medical evacuation

Absence of rear battle-free area

Limited traditional medical treatment

Adapted from Jones FD. Psychiatric lessons of low-intensity wars. Presented at Army Medical Department

Division and Combat Psychiatry Conference, 1984; Fort

Bragg, NC.
War Psychiatry

118

morale and retention of highly-skilled personnel,

and lowered quality of new recruits, putting further

strains on leadership and unit cohesion.

Strategically, the attacker in such a major regional conflict will focus on command, control,

communications, and intelligence organs. The continuous assault will attempt to disrupt the small

combat unit of 3 to 40 persons. Modern military

planners are fully aware of the psychological factors in combat. A surprise attack with apparently

overwhelming forces could lead to panic and collapse even when the opposing forces are about

equivalent in strength. This occurred, for example,

during the German blitzkrieg of French forces in

1940; the Israeli surprise attack on Egypt in 196721;

and the coalition attack, led by U.S. Forces, on Iraq

in 1991. It almost occurred with the Arab surprise

attack on Israel in 1973.

Surprise maximizes the psychological effect of

an attack. A conventional rolling artillery barrage,

finished by a salvo of rockets, need not kill the

defenders. It will produce a state of “battlefield

paralysis”—the temporary inability to use one’s

weapon—lasting from 30 seconds to 4 to 5 minutes

depending upon the complexity of the weapon.22

This would allow first-echelon attacking forces to

advance immediately behind the rolling barrage

with smoke and flame throwers. Their aim would

be to pass through or bypass defending units rather

than to engage them. First-echelon forces would

then proceed rapidly to the rear to disrupt command, control, communication, and intelligence

functions; to capture airfields, petroleum depots,

and fire-support systems; and to link with airmobile and airborne forces. Second-echelon forces

would then neutralize the remaining forward defending units to produce a swift and sudden collapse. NBC weapons, and even long-range improved conventional weapons, enable senior,

rear-echelon military and political figures to influence directly the outcome of the battle.23 Such

weapons used against enemy command, control,

communication, and intelligence, and nuclear means

could paralyze a defending force. The response to

such a scenario requires highly-mobile, dispersed

forces.

As discussed in Chapter 2, Traditional Warfare

Combat Stress Casualties, the appropriate use of

the traditional principles of forward treatment has

resulted in the return of about one half to two thirds

(or in optimal circumstances up to nine tenths) of

combat stress casualties back to combat duty within

days. Forward treatment consists of immediate,

brief, simple interventions such as rest and nutrition in a safe place as near the battle lines as possible, with an explicit statement to the soldier that

he will soon be rejoining his comrades. This approach to treatment also calls for soldiers evacuated

rearward to be screened at a central collecting point

from which they may still be returned to duty if

further rearward movement is inappropriate.

In practice, this approach has required four essential elements:

1. A relatively safe and stationary place near

the battle area (refuge);

2. A treating person (therapist) or team;

3. Time and resources for restoration of physiological needs (rest); and

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

Each element is critical to the process; and, as will

be seen, each is jeopardized by modern, high-intensity warfare. High-intensity future warfare, therefore, challenges the application of the traditional

principles of forward treatment (Exhibit 5-2). There

may be no safe and stationary forward treatment

area, because high technology has resulted in weapons and surveillance systems capable of discovering aggregations of personnel through the infrared

“signatures” given off by heat radiation from groups

of persons and their supporting machinery (eg,

trucks, generators). Furthermore, rear areas may be

preferentially attacked because they may be more

vulnerable than front-line forces, which will be

dispersed, camouflaged, and mobile.

Even if methods are found to shield and protect

rear-area installations, the time needed to restore

physiological and emotional needs, plus transportation limitations, will make it difficult or impossible to return the soldier to his own unit. This is

because combat units must remain dispersed and

highly mobile to avoid being targeted by their “signatures.” However, studies from World War II and

Korea make it clear that the returning combat stress

casualty must rejoin his own unit or risk becoming

a casualty again. Furthermore, the possible absence

of local air superiority by U.S. forces will aggravate

the difficulty of evacuation and return of casualties

arising from dispersion and mobility of forces.

CHALLENGES TO THE PRINCIPLES OF FORWARD TREATMENT
119

Psychiatric Principles of Future Warfare

EXHIBIT 5-2

NEGATION OF PRINCIPLES OF

FORWARD TREATMENT

No refuge:

Absence of rear battle-free area

No therapists:

Dispersal of forces

Mass casualty situation (triage)

No rest:

Absence of rear battle-free area

High mobility

Lack of time to treat

No return:

Dispersal of forces

High mobility

Adapted from Jones FD. Psychiatric lessons of low-intensity wars. Presented at Army Medical Department

Division and Combat Psychiatry Conference, 1984; Fort

Bragg, NC.

The psychological stresses of high-intensity combat will also be magnified due to the lethality and

mass casualty nature of modern warfare. There is

usually a direct relationship between wounded in

action (WIA) and psychiatric casualties. The U.S.

Army medical planning field manuals24,25 give a

conservative estimate of 1 psychiatric to 5 woundedin-action casualties, but point out that some units in

World War II fought battles in which the ratio

reached 1:2. Being on defense increases stress casualties relative to wounded. However, being mobile

tends to protect. Recent official casualty rate predictions have reduced the average division’s daily

wounded in action during the heaviest weeks of

fighting from about 150 to 50. The U.S. Army does

not expect to fight in massed formations with second-rate weapons, suffering mass casualties. However, war is not fought on the average day, and the

enemy will not fight every division equally every

day. The engaged brigade of an engaged division

could easily suffer several hundred wounded out of

a total of about 6,000 troops over 1 or 2 highcasualty days. This would result in more than 100

stress casualties arriving at the forward support

medical company in the brigade support area over

a few days. At least as many stressed soldiers

would require special consideration without necessarily being held for restoration in medical units.

Considering that rates were as high as one psychiatric to one wounded-in-action casualty in some

Israeli and Egyptian units in the first high-intensity,

sustained engagement of the 1973 Yom Kippur War,

this stress casualty estimate may be too conservative.

Surgical casualties and combat stress casualties

in a high-intensity scenario are projected to occur in

such numbers that medical resources must utilize

the triage principles developed for mass-casualty

situations. Triage emphasizes treating first those

who have the best chance of survival while postponing treatment of those seriously wounded or

lightly wounded. In current civilian triage situations, surgical casualties have priority over psychiatric casualties in the allocation of medical personnel. Combat stress casualties, as the most likely to

become effective with minimal intervention, will

receive attention from division mental health and

combat stress control unit teams. These assets will

continue into the future force structure, but that

alone is not enough to assure success. They must

also be at the critical places on the fluid battlefield.

They must be highly trained in peacetime to function in such a high-stress setting in a come-as-youare war. Will the military be successful in recruiting

and retaining psychiatrists, psychologists, and social workers who will enjoy the challenge of being

true consultants and members of line units if the job

involves this risk? Might it be necessary to train

physician assistants for combat psychiatry positions? The plans for far-forward combat stress

control in U.S. Army Force XXI are reviewed in

Chapter 7, U.S. Army Combat Psychiatry.

If there were a threat of NBC warfare, the rate of

stress casualties would rise. Stress casualties which

mimic the symptoms of chemical, biological, or

radiation injury may exceed the cases of actual

injury by 2 or 3 to 1, based on World War I experience. The chemical protective suit and mask (mission-oriented protective posture or MOPP gear)

would create heat buildup even in cool climates

with excessive sweating and loss of salt and water.

Furthermore, to minimize the need to urinate, soldiers in MOPP gear often do not drink fluids. In

experiments conducted by Walter Reed Army Institute of Research (WRAIR) personnel,26 soldiers in

MOPP gear were observed to fail to eat and drink in

order to minimize excretory functions leading to

some degree of urine concentration. Even without

MOPP gear, soldiers often do not eat or drink in the

early days of combat. During the 1982 invasion of
War Psychiatry

120

Grenada by U.S. forces, casualties from dehydration occurred, indicating that U.S. forces need to be

alert to this problem. The Israelis have made water

drills a standard part of a combat commander’s

responsibilities, with failure in this area leading to

punishment.

While overt heat prostration presents an unambiguous syndrome, the effects of mild dehydration

are not so obvious. S.L.A. Marshall,27 a man exposed to battle during World War I, World War II,

and Korea, described the following incident during

the strenuous invasion of a Japanese-held Pacific

island during World War II:

Case Study: SLAM Finds Salt

The sniper fire had intensified.... When their officers

got this company going again, I followed along for about

a hundred yards into the bush. There, after just a few

stumbling steps, I fell apart. My senses reeled. I was hit

by such weakness that I dropped my carbine and could not

unbuckle my belt, but that was not the worst of it. Within

seconds my nerve had gone completely and I shook all

over from fear.

I lay flat under a pandanus tree, telling myself: “It’s

combat fatigue. You’ve been kidding yourself. You are

too old for the wars.” Being unable to walk and scarcely

able to think, I decided to stay where I was, wait for a

stretcher-bearer to come along and get me back to the

Calvert [ship], where I would stay. For possibly ten

minutes I waited.

Before any aid man came my way, a rifleman stopped

and stared at me. Then he took a bottle of pills from his

jacket pocket and downed a couple of them.

I asked weakly, “What you got?”

“Salt.”

“Gimme some. Nothing can make me feel worse than

I do.”

He gave me the bottle, saying he had another. I

washed down eleven salt tablets with the lukewarm water

from my canteen as fast as I could swallow. Within the

next ten minutes my nerve and strength were fully restored, and I was never again troubled; yet that lesson had

to be learned the hard way. No one had ever told me that

one consequence of dehydration is cowardice in its most

abject form.27(p68)

Comment: This vignette clearly demonstrates combat

fatigue as a psychophysiological disorder.

RESEARCH STUDIES OF COMBAT STRESS

that assigned role in a group plays a major part in

determining stress.

Bourne, Rose, and Mason30 had also studied steroid excretion and obtained behavioral data on seven

helicopter ambulance medics in combat in Vietnam.

A surprising finding of the study was that comparison soldiers in basic combat training camps in the

United States, as measured by steroid excretion,

experienced greater stress than these soldiers engaged in highly dangerous combat operations (such

ambulance crews averaged more medals for heroism than combat arms soldiers). They found that

these combat soldiers utilized a variety of mental

mechanisms to defend themselves from the stress of

potential death and mutilation. These mental activities were highly individualized. One man was

quite religious, believing that God would protect

him. Another soldier, who tended to intellectualize, would make involved mathematical computations as to the probability of his being wounded or

killed, would come up with figures indicating a low

probability, and would dismiss such a low probability as being insignificant.

Similarly, in the Special Forces team Bourne29

also found defensive mental operations but in this

case the primary mechanism was an overwhelming

emphasis on self-reliance, often to the point of omPsychological Factors

Combat does not lend itself to experimental studies because most of the variables cannot be controlled; consequently, few studies have been conducted during actual fighting. Perhaps the most

extensive study of the stress of combat was done by

Stouffer, DeVinney, Star, and Williams28 during

World War II. That study addressed primarily

psychological factors and showed that cohesive,

well-led units had fewer psychiatric casualties.

During the Vietnam conflict, Bourne, Rose, and

Mason29 obtained, over a 3-month period that included intermittent combat, behavioral data and

urine samples from a 12-man Special Forces “A”

team assigned in an enemy-controlled area. They

found that the 2 officers experienced substantially

higher levels of stress than the 10 enlisted men as

measured by steroid excretion. It was also noted

that on the day of an anticipated attack, an officer

and his radio operator (command and communications positions) showed a modest rise in steroid

excretion (increased stress) while the other subjects, all enlisted men, showed a drop. These findings (along with clinical observations and theoretical studies by Gal and Jones as discussed in Chapter

6, A Psychological Model of Combat Stress) suggest
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Psychiatric Principles of Future Warfare

nipotence. In an unpublished study of explosive

ordnance disposal (EOD) teams, often called “bomb

squads,” Bourne found similar mental operations

used to protect the individual from the stress of

potential death and maiming. In EOD personnel

the primary defense was a belief that if one followed

established procedures in a careful manner, there

would be little danger. A sense of omnipotence and

of fatalism (“I won’t die until it’s my time”) were

also frequent coping mechanisms.

Combat Role and Sleep Deprivation

In a simulated combat exercise the importance of

leadership and cohesiveness was demonstrated in

sustained operations when a good commander prevented soldiers suffering from cold exposure from

disrupting his unit while another commander was

not so effective.31During this same exercise Belenky32

reported on the importance of physiological degradation of performance, particularly that caused by

lack of sleep. He reported that a majority of soldiers

deprived of sleep for 72 hours would experience

visual hallucinations and illusions. However, the

same study revealed that 3 or 4 hours of sleep in a

24-hour period would prevent most of the degradation of cognitive processes.

Johnson and Naitoh33 have concluded from a

comprehensive review of the literature that cognitive processes suffer earlier and more severely than

muscular tasks during sleep deprivation. Experimenters at the U.S. Army Research Institute of Environmental Medicine34,35 have explored the effects

of sustained operations on artillery teams in simulated sustained combat. Their findings confirm

earlier reports that cognitive tasks requiring abstract judgment, preplanning, and vigilance are

degraded early and seriously from sleep loss and

cumulative fatigue, while the ability to perform

well-practiced, urgent tasks involving motor activity was preserved best.

Disrupted Circadian Rhythms

Experimenters at the Naval Health Research Center36-38 have shown that performance is also related

to circadian rhythms that, of course, are particularly susceptible to disruption from travel across

several time zones, as would occur in any distant

deployment of U.S. forces in an easterly or westerly

direction. Abstract tasks such as reading comprehension have been shown to be best performed in

the afternoon and evening, while performance speed

was high in the morning and steadily fell during the

day and evening.37 In studies of nuclear submariners subjected to an 18-hour work-rest cycle, Naitoh

and coworkers38 found desynchronization of normal circadian rhythms, which could have implications for stress and health.

The situation is even more complicated in that

circadian rhythms seem to be regulated by a “deep

oscillator,” which changes very little despite external changes in sleep cycle, and a “labile oscillator,”

which is more responsive to environmental

changes.39 The “deep oscillator,” which may be

reflected in persistent body temperature patterns,

is more significant for tasks involving manual dexterity skills, while the “labile oscillator” is more

significant for cognitive tasks.

A comprehensive review of the shift-work and

jet-lag literature has drawn conclusions on reducing negative effects in the event of overseas deployment of U.S. forces.40 They note that manipulation

of the carbohydrate and protein components of the

soldier’s diet producing relative increases of serotonin or catecholamine precursors in the brain can

result in a drowsy soldier when sleep is appropriate

or an alert soldier when this state is appropriate.

They have devised schedules not only in terms of

optimal work-rest cycles but even appropriate diets

of soldiers for sedating or alerting effects. They

have suggested, for instance, that a high carbohydrate meal about 1 or 2 hours before sleep is desired

will facilitate sleep through the insulin effect, which

increases L-tryptophan transport through the bloodbrain barrier. This precursor amino acid of serotonin increases serotonergic influence and thus sleepiness. There is increasing evidence that bright light

exposure to the retinae can reset the circadian cycle.

This can be accomplished by having the individual

exposed to bright light in the new morning and

decreased exposure at the new night, perhaps by

wearing dark sunglasses.

Implications for Future Combat

Future commanders must maximize their soldiers’ fighting ability and resistance to breakdown by insuring that the physiological needs of

their soldiers are met. This involves a sensible

doctrine of rest and sleep (at least 4 h sleep in a 24-

h span), prevention of cumulative fatigue (by rotation from combat, preferably as a unit to maintain

cohesion), adequate nutrition (especially fluids and

salt), and frequent changes of socks to prevent frostbite in cold weather and fungal infections in hot

weather. When initiating combat, U.S. commanders should seek to attack at a time when their sol-
War Psychiatry

122

diers’ normal circadian rhythms are at a peak. For

example, soldiers flown from the East Coast of the

United States to fight in the Middle East could take

advantage of the time zone dislocation by napping

on the overseas flight and attacking at 0300 hours

Persian Gulf time, physiologically early evening

time for U.S. forces; and, for alertness, the lowest

ebb of the biological tide for enemy soldiers accustomed to rhythms appropriate for the Persian Gulf

region.

Future combat will also require close attention to

psychosocial factors and revision of the principles

of combat psychiatry. Because stress casualties

have typically peaked among troops initially exposed to combat, prevention of these casualties will

be critical to the outcome of a war of short duration.

In addition to leadership and cohesion factors discussed previously, there is a need for ongoing educational efforts to minimize the effects of expected

surprise attacks by the enemy. As mentioned in the

Desert Rock studies discussed in Chapter 4, Neuropsychiatric Casualties of Nuclear, Biological, and

Chemical Warfare, those soldiers most knowledgeable about nuclear explosions were least frightened. This need to educate soldiers should not only

include the usual battle and NBC scenarios but also

the possibility of atypical scenarios. By being familiar with such scenarios, the psychiatrist will be able

to educate commanders concerning expected psychological reactions and potential interventions.

PRINCIPLES OF COMBAT PSYCHIATRY FOR FUTURE WARFARE

Because high-intensity warfare may make implementation of the traditional principles of combat

psychiatry unworkable, new principles of treatment must be developed (Exhibit 5-3). It is obvious

that preventing these casualties from occurring in

the first place is the preferred course of action;

however, this may be difficult given the intensity of

warfare. Studies41–44 have repeatedly shown that

stress casualties occur in direct proportion to combat intensity and certain physical and morale factors. Factors tending to prevent such breakdown

include the absence of fatigue, presence of good

leadership and its consequence, unit cohesion, confidence of the soldiers in their weapons and in

themselves, and an advancing or retreating military

posture. Conversely, the negatives of these factors

would promote psychiatric breakdown. Continuous, high-intensity warfare may prevent sleep and

rest, thus producing fatigue and promoting breakdown. Dispersion will interfere with the ability of

commanders to lead and may prevent the aggregation of comrades, impeding cohesion.

In the 1973 Yom Kippur War, an exemplar of a

conventional high-intensity war, some of these factors were not appreciated. The hastily assembled

(therefore less cohesive) Israeli forces were exposed

to conditions of continuous, high-lethality warfare.

Estimates45 of Israeli acute psychiatric casualties

were reported as between 30% and 50% of total

casualties in some units. According to Egyptian

military psychiatrists, the Egyptian psychiatric casualties at least equaled the “surgical”;46,47 that is,

they were at least 50% of the total.

After the 1973 Yom Kippur War there was a

concerted attempt by the Israelis to prevent future

stress casualties; however, in the 1982 Lebanon War,

which was not of as high intensity as the 1973 war,

the percentage of acute psychiatric casualties is

reported as 23%, mostly occurring during 2 weeks

of active combat.48 (A larger number of delayed and

chronic post-traumatic stress disorder cases have

EXHIBIT 5-3

PRINCIPLES OF COMBAT PSYCHIATRY

IN HIGH-INTENSITY WARFARE

Prevention:

Unit cohesion

Realistic training

Doctrine of rest and nutrition

Battlefield treatment:

Limited evacuation of psychiatric casualties

Treatment in the midst of battle

Emphasis on buddy care: Reassurance

Expectancy

Use of drugs:

Nonsedating antianxiety drugs

Nondepleting stimulants to reduce fatigue

Reversible sleep and alerting agents

Adapted from Jones FD. Psychiatric lessons of lowintensity wars. Presented at Army Medical Department

Division and Combat Psychiatry Conference, 1984; Fort

Bragg, NC.
123

Psychiatric Principles of Future Warfare

surfaced subsequently.49) It appears likely, then,

that the United States must be prepared either to

treat significant numbers of acute stress casualties

in the event of a future war or to develop more

effective methods of prevention. The most costeffective approach would emphasize prevention.

Prevention

The chronology of combat stress breakdown was

clearly described by Swank and Marchand.50 It appeared that there are two groups of soldiers prone to

become psychiatric casualties: those never before exposed to combat and those exposed to combat for a

prolonged period of time. Swank and Marchand

depicted this finding in a chronological chart of combat efficiency. Initial exposure finds low efficiency

and high casualties. Efficiency improves after a few

weeks with fewer casualties but again declines after 6

to 8 weeks of combat with increased casualties.

During the Korean and Vietnam conflicts the

main preventive measure for prolonged exposure

casualties, based on World War II experience, consisted of limiting the period of exposure to combat

to prevent cumulative stress. Thus, the combat tour

in Korea was 9 months and in Vietnam it was 1 year.

In the absence of a lengthy war and with the probability of brief, intense future combat, the military

has more recently focused on preventing the initial

or “green troop” casualties. To do this the U.S.

Army has initiated a number of programs to

strengthen unit cohesion. This approach in recent

years resulted in keeping commanders with the

same unit for 18 months or more and in the COHORT (cohesion, operational readiness, training)

Program of keeping groups of soldiers together

from the time of basic training through assignment

overseas. However, this program has largely been

abandoned because of the administrative difficulties it creates. Confidence in weapons and selves is

being achieved through an emphasis on physical

fitness and realistic weapons training. This training

is accomplished in part through use of laser “hits”

in simulated combat, live-fire exercises, and realistic simulated combat exercises at the Combat Training Centers. A more exotic approach to prevention

might consist of the use of performance-enhancing

and anxiety-blocking pharmaceuticals, which the

author will discuss later.

Battlefield Treatment in High-Intensity Warfare

In view of the problems posed by high-intensity

combat for traditional treatment procedures, the

original World War I principles of combat psychiatry must be revitalized (see Exhibit 5-3). The original concept for the care and evacuation of “nervous” and “mental cases” at the division level was

stated in September 1918 as follows:

1. Each division in the area has a division psychiatrist who will be stationed at the triage [ie,

the ambulance transfer point] when his division is engaged. There he will sort all nervous

cases, returning directly to their organizations

those who should not be permitted to go to the

rear and resting, warming, feeding, and treating others, particularly exhausted cases, if

there is opportunity to do so.

. . . .

2. The advantages of these provisions for dealing with war neuroses and allied conditions in

the divisions are:

(a) Control over the evacuation of cases presenting no psychoneurotic symptoms.

(b) Speedy restoration and return to their

organizations of those in whom exhaustion is the chief or only factor.

(c) Cure of mild psychoneurotic cases by

persuasion, rest, and treatment of special

symptoms at a time when heightened

suggestibility may be employed to advantage instead of being permitted to

operate disadvantageously.

. . . .

(f) Creating in the minds of troops generally

the impression that the disorders grouped

under the term “shell shock” are relatively simple and recoverable rather than

complex and dangerous, as the indiscriminate evacuation of all nervous cases

[suggests].51(p309)

Prevention and treatment must merge in a modern approach to managing stress casualties. Evacuation of stress casualties must be strictly limited.

Becoming a stress casualty would, therefore, not

result in an “evacuation syndrome.”31 Many stress

cases, however, would still exist. The primary treating persons must be the soldier’s fellow soldier

(“buddy”), medic, squad, and platoon leader. If

soldiers are too ineffective to remain in their squad

or team, the next option is to rest them for a night or

two in their battalion’s headquarters and headquarters company (the “field trains” from which the

maneuver companies receive their nightly resupply

of ammunition, fuel, water, and food). Treatment

would consist of reassurance, replenishment, expectancy, and possibly administration of a

nonsedating antianxiety pharmaceutical.52 This
War Psychiatry

124

would be monitored by the unit medic, physician

assistant, or circuit-riding mental health officer and

NCO. These mental health/combat stress control

teams are already called for in current doctrine25

provided by the division mental health section or

the supporting combat stress control detachment.

In the future, the team might have a HMMWV

(high mobility multipurpose wheeled vehicle) ambulance or armored personnel carrier in which they

could provide mobile evaluation and restoration.

For the soldier who appeared fatigued or depressed,

nondepleting stimulants might be given. (A

nondepleting stimulant is one that does not deplete

the neurons of their neurotransmitters. Such depletion, which occurs, for example, with amphetamines,

eventually results in rebound fatigue and depression as well as the dangers of heart arrhythmias and

psychosis. Currently the amino acids L-tyrosine

and L-phenylalanine come closest to being

nondepleting stimulants. These can be defined as a

“nutritional supplement,” not drugs.) Only the

small number of most impaired or diagnostically

complex cases would be held for observation and

restoration treatment by the combat stress control

team’s psychiatrist (or psychiatric physician assistant) at the forward support medical company, usually several kilometers from the battalion’s headquarters companies. Because of the requirement for

extreme mobility, this restoration might be provided in suitable vehicles, with built-in physiologic

monitoring, biofeedback, and audio-video relaxation equipment. Such vehicles could be used for

the prophylactic maintenance and enhancement of

combat performance, as well as for restoration of

soldiers who had already become stress casualties.

Finally, there is growing evidence that the judicious

use of pharmaceuticals may enhance combat performance and possibly prevent some forms of combat breakdown; therefore, the issues of the sanctioned use of drugs in combat will be discussed.

Ethical and Practical Issues Concerning

Pharmaceuticals

The use of pharmaceuticals to sustain or enhance

performance in combat is controversial. It raises

important ethical and practical considerations. The

U.S. government declared a war on drug abuse in

the 1980s. As part of that effort, the U.S. armed

forces have been assigned missions of drug interdiction overseas and on United States’ borders to

reduce the production and importation of illegal

drugs.

The abused drugs include stimulants (cocaine,

amphetamines) which are addictive because they

produce (in high doses) feelings of intense wellbeing, power, alertness, endurance, and aggressiveness (as well as other less common but major

psychiatric disorders). The abused drugs also include “depressants” (alcohol, barbiturates, benzodiazepine tranquilizers) which calm anxiety and

produce feelings of well-being or promote sleep, as

well as producing a drunken euphoria, dependence,

addiction, and other negative effects. The narcotic

painkiller drugs are abused because they produce a

blissful euphoric state. Anabolic steroids are abused

by body-builders and athletes because they increase

muscle mass, strength, and endurance. They are

banned in competitive athletics because they unquestionably increase speed, strength, power, and

endurance, although at a potential (rare) cost of

medical and psychiatric complications including

violent attack behaviors (“‘roid rages”). If the United

States has declared war on drugs, how can it possibly justify prescribing similar drugs to American

soldiers for use in combat?

The obvious answer in favor is that war is not a

competitive sport. It is bound by the International

Laws of War, but not by Olympic committee rules.

Battles are fought by the nation’s soldiers, at risk of

death, to win the nation’s military, and ultimately

political, objectives. In such an environment it is

necessary to give American soldiers every safe,

feasible, and competitive advantage.

But are such drugs safe, especially in the highly

unpredictable and unstable physical, logistical, and

emotional context of combat? That question requires an empirical, not a philosophical, answer.

All drugs are potentially double-edged swords. All

will have side effects and overdose effects. Some

may produce additional effects upon withdrawal or

elimination of the drug. Some interact dangerously

with environmental factors, diet, other drugs, or

specific diseases. All drugs may have idiosyncratic

effects on some individuals. It is unwise to dispense

any drug lightly, without first evaluating the recipients and briefing them (and their support group) on

what to expect and what to be alert for. It is then

wise and ethical to follow them up periodically. For

these reasons, any use of pharmacologic agents

should be kept under appropriate medical supervision if not necessarily medical control.

After analysis of the risks, some drugs may be

judged safe enough for “over the counter,” selfadministered use. Other drugs may be judged safe

for routine prescription use with periodic follow-
125

Psychiatric Principles of Future Warfare

up. Other drugs still may be so risky that they

should be prescribed only in urgent, carefully defined situations. Like some medications used in

treating highly lethal diseases, it may be reasonable

to accept even a high risk of injury from the drug if

there is little chance that the “patient” can live past

the next week without it. Such situations can arise

in war as well as in the emergency room.

Of course, if such a drug is administered as a

calculated risk and if the soldiers do survive, the

uniformed services owe it to them to provide longterm follow-up, and treatment or compensation for

any complications of the therapy that may arise.

But will the parents and spouses of America

tolerate soldiers being given drugs to induce them

to risk their lives and possibly die? It is no longer

doctrine to intimidate an enemy into surrender by

the sheer bravery of American fighting forces.

Rather, the intention is to “fight smart,” using superior weapons and information technology on the

future “digitized battlefield” to attack the enemy

when he is much less capable of striking back.

The effective use of those sophisticated weapons

systems requires keeping the operators’ brains and

bodies in fine tune. The continuous operation

doctrine of the U.S. military demands initiative,

agility, synchronization, depth, and versatility.

Those battlefield imperatives task precisely the

higher mental functions in all soldiers, from general

officer to private, which are most susceptible to

deterioration from sleep-loss, dehydration, fear,

sensory overload, or sensory deprivation. If synchronization fails, American “high-tech” weapons

kill other Americans or innocent noncombatants. If

pharmacologic agents (or other technical solutions

such as sensory stimulation, relaxation, or biofeedback) can help more than harm, should they not be

used?

It is desirable to develop in U.S. soldiers such

high levels of unit cohesion and patriotism that they

will be willing, if necessary, to risk sacrificing themselves to save their buddies and accomplish the

mission. However, it is not desirable to have anyone in the various weapons systems “high,” “spaced

out,” or indifferent to his own safety. If a drug can

help them sustain unit cohesion, good training, and

good sense in the face of otherwise overwhelming

fatigue or arousal, with an acceptable risk of other

harmful effects, is it ethical to withhold it? The

overriding question is whether the drug can be

taken with an acceptable level of risk both for the

mission and the soldier. That will require research,

which will not be easy to accomplish.

Use of Pharmaceuticals in Combat

Undoubtedly alcohol was the first drug to be

utilized to enhance combat performance. When

Holland became a major source of gin, the widespread use of this alcoholic beverage by soldiers led

to the expression “Dutch courage” to express the

desired effect. The ancient Assyrians, Egyptians,

and Greeks reportedly utilized opiates before and

during battles to sustain or enhance bravery and

courage.53 Other drugs studied or used to enhance

combat performance include ergot alkaloids, cannabis, amphetamine and other stimulants; Dramamine and other antihistamines; benzodiazepines;

and L-tryptophan. It is the author’s contention that

the most extensive modern use of performanceenhancing drugs occurred among Soviet personnel

during World War II shortly after amphetamine

was synthesized. Amphetamine was useful not

only to stave off fatigue and drowsiness but also to

improve memory and concentration, particularly

among Soviet pilots.

During the Vietnam conflict, methylphenidate

(Ritalin) and sometimes dextroamphetamine

(Dexedrine) were standard issue drugs carried by

long-range reconnaissance patrol (LRRP) soldiers.

The LRRPs found the most efficacious use to be

upon completion of a mission when fatigue had

developed and rapid return to the base camp was

desirable. Other than mild rebound depression and

fatigue after the drug was discontinued, no adverse

effects were reported. Other investigators54,55 studying the drug abuse problem later in the Vietnam

conflict reported problems with abuse of these stimulants. Although there was no documented abuse of

the morphine Syrettes, commanders suggested such

abuse might be occurring,56 causing them to be withdrawn from the soldiers.

Sedatives have also been studied as a method to

improve performance in anxiety-producing situations such as paratroopers making low-altitude

jumps or for reducing the emotional tension of

young soldiers during the firing of guns.57 Reports

of improved target accuracy through use of the ßadrenergic blocker, propranolol, and the anxiolytic,

diazepam (Valium), have resulted in a U.S. Army

ban on use of these drugs by soldiers engaged in

marksmanship competition because they would

confer an unfair advantage.

In the Vietnam conflict, neuroleptics (antipsychotic or major tranquilizer drugs) were widely

utilized for psychotropic effects but benzodiazepines were also used. In the 1982 Falkland Islands
War Psychiatry

126

War, temazepam (Restoril) and triazolam (Halcion)

were prescribed by the Royal Air Force (RAF) psychiatrist to British pilots on Ascension Island to

ensure adequate sleep between the very long, multiple refueling flights to the Falklands and back.58,59

Triazolam (Halcion) has been studied in U.S. Army

field trials.60 Recent benzodiazepine receptor research suggests ways that these drugs could be

used carefully in combat settings not only to alleviate fear and anxiety but also as hypnotic and alerting agents.

Benzodiazepine Receptor Studies

Four functions mediated by benzodiazepines

have been discriminated: 61,62 (1) antianxiety

(anxiolytic), (2) anticonvulsant, (3) muscle-relaxant, and (4) sedative-hypnotic functions. A fifth

possible effect, blocking panic, is relatively weak.

Of drugs available on the U.S. market, a number of

primarily antidepressant medications (eg, tricyclics

and monoamine oxidase inhibitors) appear to have

greater antipanic effects.63,64 It is believed that these

exert their effects by potentiating the inhibitory

effects of γ-aminobutyric acid (GABA), which in

turn is the neurotransmitter of 30% of the inhibitory

synapses of the brain.65 A careful modification of

the molecular structures involved has resulted in

the synthesis of experimental drugs that can act as

agonists or antagonists of all four of the functions

mediated by benzodiazepines. This selectivity suggests numerous clinical and military applications

including both the prevention and treatment of

combat stress disorders and enhancement of performance in certain circumstances.

As mentioned in Chapter 2, Traditional Warfare

Combat Stress Casualties, the most consistent symptom of combat stress, whether occurring early in

exposure to combat or after cumulative exposure, is

anxiety. Such anxiety may be manifested by fear,

hysterical conversion or dissociation, tremors, and

similar symptoms. In the past, these conditions

have been treated with sedatives ranging from chloral hydrate and bromides in World War I to barbiturates in World War II and even self-prescribed

alcohol, cannabis, and heroin in Vietnam. These

drugs often not only produced unwanted sedation

but also decreased the probability of return to combat due to the fixation of a sickness role suggested

by taking medication. Based on their experience in

1973, the Israelis promoted a policy prohibiting

forward use of medications and even hypnosis.66

A drug, however, which would selectively reduce anxiety without diminishing mental or physical alertness and efficiency would go a long way

toward “curing” the usual battle fatigue syndrome.

To some extent this occurred in the Vietnam conflict

when physicians treated psychophysiological symptoms of fear and anxiety with neuroleptics and

antianxiety agents.67 In Johnson’s 1-month, mid1967 survey, physicians’ prescribing experience,

when generalized to the entire troop population,

gave an estimated prescribing rate of 12.5% per year

of the assigned U.S. Army troops. Compazine, a

major tranquilizer, accounted for 45% of prescriptions made by nonpsychiatrists, mainly used to

treat gastroenteritis. Most of the 56 cases of battle

fatigue reported in Johnson’s study were treated

with major tranquilizers (64%), particularly

chlorpromazine (Thorazine). The neuromuscular,

autonomic nervous system, and cognitive impairments produced by this drug make it a particularly

questionable choice on the battlefield.

Future Sanctioned Pharmaceutical Use

The following discussion is offered to stimulate

consideration of the potential uses of pharmacologic

agents in combat. It does not reflect current official

policies.

The ideal drug to treat combat stress breakdown

would be an easily administered, stable compound

that would reduce anxiety without significant neuromuscular or cognitive impairments, would be

nonaddictive, and would permit an appropriate

response to danger. Such a drug is not currently

available in the U.S. market, but drugs selectively

preventing severe anxiety without sedation are being studied, and they raise the possibility of developing a combat-appropriate drug.

Other drugs for selected purposes may also be

developed. A drug with a short duration of effect

reversible by an antagonist could prove to be a most

useful battlefield hypnotic. Such antagonist drugs,

primarily affecting the benzodiazepine receptor,

are already in the experimental stage61,62 and one,

the benzodiazepine antagonist flumazenil (Romazicon) is commercially available. This drug, currently used in surgical procedures, could be given

to a soldier who had received a short-acting benzodiazepine, to bring him awake quickly (within minutes to an hour) if it were necessary for him to

resume critical duties.

Studies indicate that buspirone (BuSpar) relieves

anxiety without producing cognitive impairment both

in acute and chronic use and even in the presence of

alcohol.68,69 In fact, buspirone actually appeared to

improve psychomotor skills in alcohol users.
127

Psychiatric Principles of Future Warfare

Buspirone is now available in the United States.

It has the advantage of causing no psychomotor

impairment and no muscle relaxant or sedation

effects greater than placebo. Vigilance tasks are

improved by a slight alerting effect. Addiction

potential seems low because there is no euphoriant

effect, and a single large dose (40 mg or above)

produces dysphoria. Patients have been given daily

doses of over 2 g. One possible drawback is that,

as part of its antianxiety effect, it also decreases

anger and hostility, but it is arguable that cool

professionalism is better than rage when operating

modern weapons systems. A more important drawback is a latency or delayed-action period of about

10 days before the anxiolytic effect develops. The

latency of anxiolytic effect also seems to occur with

the benzodiazepines; however, their immediate

sedative effects mask this latency effect.70 The

latency of effect need not limit buspirone to a prophylactic use in soldiers with preexisting anxiety

disorders or undergoing reconditioning treatment for return to combat after being evacuated

for battle fatigue. Key individuals or whole units

could, hypothetically, be placed on buspirone 10

days prior to starting their rapid deployment

standby mission cycles, and taken off at the end of

the cycle. Buspirone has no adverse withdrawal

syndrome.

Because certain individuals are vulnerable to

panic attacks during episodes of heightened arousal

such as combat, the use of antipanic agents might be

appropriate in such individuals. Estimates of the

incidence of panic disorder (repetitive, spontaneous panic attacks) range from 1%71 to 6%.63 At least

two million Americans are thought to be afflicted.

Because 25% of first-degree relatives of those with

panic disorders are also afflicted in lifetime incidence and there is high concordance in monozygotic twins, a hereditary vulnerability has been

postulated. In over two thirds of such patients, the

attack can be brought on by infusing 10 mL/kg of

0.5 molar sodium lactate solution in a 20-minute

time period. A simpler method of provoking panic

in a vulnerable person is to have him or her

hyperventilate. In periods of constrained manpower availability, those thought to be suffering

from panic disorder who are otherwise fit for combat might be treated with antidepressants that block

panic attacks. Antidepressants with minimal sedative side effects would have to be selected. The

original monoamine oxidase inhibitors which are

most effective as antipanic drugs are excluded because of the dietary restrictions against foods containing tyramine which trigger hypertensive crisis.

A new class of monoamine oxidase inhibitors,

RIMAs (reversible inhibitors of monoamine oxidase-A) do not have this problem. Imipramine (a

tricyclic antidepressant) has too many anticholinergic side effects to be safe in most combat environments. The selective serotonin reuptake inhibitors

have fewer side effects and may be demonstrated

effective for panic disorder.

In summary, for millennia soldiers have utilized

alcohol and other drugs to relieve the stresses of

war. The time may now be opportune for the use of

specifically tailored pharmaceuticals for these purposes without risking the dangers or decrements

experienced in the past.

Thus, the revitalized principles of combat stress

treatment involve maximizing preventive efforts

and treating in the combat unit. This treatment

approach eliminates stress reactions as methods to

escape combat (evacuation syndromes), would obviate the need for large numbers of medical resources to treat such casualties (thus allowing them

to treat surgical cases), and reduces the problems of

returning soldiers to their own units.

The costs of this approach will be increased numbers of “psychosomatic” cases, inappropriate treatment of some misdiagnosed cases, and, perhaps,

increased death rates among treated cases. As described above, this scenario is developed around

one extreme of future combat, the high-intensity,

possibly NBC, war. Lesser-intensity wars will call

for varying degrees of traditional interventions depending on intensity.

This historical review of psychiatric interventions in past wars has explored the implications of

a range of future combat scenarios. The spectrum of

combat intensities ranges from intermittent lightinfantry combat to continuous, highly-mechanized

battle, possibly with nuclear, biological, and chemical weapons. Being unable to predict what type of

war the United States will fight in the future, the

armed forces must be prepared for both extremes. If

psychiatric casualties can be appropriately treated

in these extremes, those of a medium-range of intensity should present no insurmountable or unforeseen problems. Likewise, the military will be

prepared for those future military missions that

SUMMARY AND CONCLUSION
War Psychiatry

128

extend beyond combat into areas of peacekeeping

or humanitarian relief. However, even in these

scenarios it is reasonable to expect that the combat

intensity dimension will include the major varieties

of future psychiatric problems.

In preparing for the extreme of low-intensity

combat and the stress casualties associated with

it, there must be an attempt to strengthen ameliorating conditions by minimizing family stress,

enforcing vigorous discipline in organized camp

conditions, setting and enforcing strict but realistic

rules of engagement, and promoting unit cohesion

and pride in following the rules. At the same time,

it will be necessary to eliminate or lessen the impact

of aggravating conditions: prevent boredom,

prepare for cultural differences, and strengthen

social support from the unit, the family, and the

community.

High-intensity future warfare, in particular, challenges the application of the traditional principles

of forward treatment because there may be no safe

and stationary forward treatment area due to new

weapons and surveillance systems capable of discovering aggregations of personnel. Also, rear areas may be easier to target because they are less

dispersed, camouflaged, or mobile than front-line

forces. Whatever the combat intensity in the future,

the well-known stresses of dislocation from loved

ones and home, the fear of the unknown, and the

stresses of an unfamiliar environment will produce

disorders of frustration and loneliness. Thus, the

promotion or prevention of psychiatric morbidity

will have significant implications for training and

operational procedures in future warfare. Particular attention should be given to the interplay of

physical and psychological variables in the prevention of combat stress reaction. Obviously, water

and sleep drills should become standard in training

scenarios. Perhaps not as obvious is the fact that, if

feasible, planning sessions for combat should be

held at the optimum time in the circadian cycle for

highly complex and abstract cognitive tasks. For

the soldier who is not experiencing a time zone

dislocation, this would probably be in the afternoon

and evening rather than in the early morning. Optimal times might also be considered in attacking

the enemy. Troops who have rested during a transatlantic flight with proper planning could arrive at

a battle at an optimum circadian period for themselves and at the least optimal period for an enemy.

The enemy, of course, might not be so accommodating in allowing U.S. forces to prosecute the war on

a favorable timetable.

It must be remembered that men have definite

physical and emotional limits. A future war will

produce levels of stress that unless prepared for in

advance, will easily exceed these limits. Through

thorough preparation and a sensible doctrine of

human physical and emotional limits, a country can

hope to deter war but, nonetheless, it must be prepared to fight and win if necessary. It is not enough

that the medical community be aware of the limits

of human mental and physical endurance in combat; the line commanders must be equally aware

and be prepared to shape doctrine to conform to

these human needs.

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