1

Psychiatric Lessons of War

Chapter 1

PSYCHIATRIC LESSONS OF WAR

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

INTRODUCTION

Case Study: A Combat Crisis in a Marine

Withstanding the Stress of Combat

PRE-20TH CENTURY CONCEPTIONS OF PSYCHIATRIC CASUALTIES

20TH CENTURY COMBAT PSYCHIATRY

Development of Principles

Application of Principles

Rediscovery and Extensive Application of Principles

Discovery of Mediating Principles

Validation and Limitations of Principles

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

2

Richard W. Baldwin Fighting at Guadalcanal 1943

This painting by Richard W. Baldwin, who was a sergeant in the U.S. Army Air Forces, depicts World War

II jungle fighting in the South Pacific at Guadalcanal, which was characterized by environmental deprivation, disease, and isolation. The psychiatric lessons of World War I had to be relearned and expanded

during World War II to include physical stressors.

Art: Courtesy of US Center of Military History, Washington, DC.
3

Psychiatric Lessons of War

INTRODUCTION

War, with its lesser elaborations such as competitive sports, has been an enduring aspect of human

existence. Survival for the prehuman individual

and the species was largely dependent on the evolution of physical attributes until fairly late in human

development. The ability of prehumans and humans

to organize into groups resulted in the supplanting

of biological evolution with social evolution. Social

evolution was so powerful an agency that while modern humans are less well developed physically than

their human and prehuman ancestors, they are nevertheless more capable of survival. Social evolution

has necessarily been accompanied by psychological

evolution such that the two cannot be separated. In

modern wars, beyond a minimal level of physical

fitness and technical learning of how to fight, the

soldier’s most important training is in social-psychological reaction patterns, particularly the handling of fear and aggression and the bonding with a

group for accomplishing the military mission.

While wars differ along many dimensions ranging from ideology to technology, the human element remains the same. After millions of years of

evolutionary molding, the human organism is reasonably well equipped physically to fight the solitary or group combat that our Stone-Age ancestors

endured. This physical development alone, however, would never have allowed humans to achieve

dominion over the natural world. This dominion

resulted from the development of implements of

combat and a social structure that facilitated cooperation in battle. Part of this social structure included the ability of protomen to band together on

hunting expeditions as well as their ability to discover and then propagate the knowledge of how to

make and use weapons. It is a striking observation

that men through all periods of recorded history

have fought ultimately as small groups consisting

of from 2 to 20 or 30 persons.1

The same cultural evolution of groups that maximized warrior skills in the past, however, has

increasingly prepared homo sapiens for peace

rather than war. Individual psychology, reflecting

family and cultural influences, often hinders rather

than facilitates successful adaptation to combat.

This can be seen, for example, in religious prohibitions against violence, which when internalized

by any of a variety of processes, may even overcome near-instinctive behaviors for self-preservation.2(p512)

Erikson3 gave a classic example of the interaction

of the biological, interpersonal, and intrapsychic

factors in the breakdown and later elaborations of

symptoms in a World War II combat veteran.

Case Study: A Combat Crisis in a Marine.

The patient, a young teacher in his thirties, primarily

suffered from severe headaches. History at a veterans’

clinic revealed that he was with a group of medical corpsmen who lay in pitch darkness on a South Pacific beachhead, pinned down by enemy fire, with little supporting fire

from U.S. Navy ships. The group experienced mounting

anger and fear; however, the patient seemed unaffected

by the group anxiety. The patient did not drink, smoke, or

even swear, and had chosen to be a medical corpsman

because he could not bring himself to carry a gun.

During the night, he had only isolated memories of a

dreamlike quality: the corpsmen were ordered to unload

ammunition; the medical officer became angry, swearing

abusively; someone thrust a submachine gun into the

corpsman’s hands. By morning he was a patient sedated

in the improvised hospital, with severe intestinal fever. At

nightfall, the enemy attacked by air. The patient was

immobilized and unable to care for the sick and wounded.

He felt fear, and next day he was evacuated. At the rear

area hospital he was initially calmer, but became upset

and crawled under his sheets when the first meal was

served. The metallic clanging of the mess kits sounded

like salvos of incoming shots. He was plagued by severe

headaches and when not suffering from them remained

apprehensive, jumpy, easily startled. Although the fever

which could have justified the initial headache was cured,

his other symptoms persisted and he was evacuated

home as a “war neurosis.”

Erikson found that the patient’s family had been in

economic and moral decline. At age 14, the patient had

left home after his mother, in a drunken rage, threatened

him with a gun. He had secured the secret help of his

principal, a fatherly man who protected and guided him,

asking in exchange that he never drink, swear, indulge

himself sexually, or touch a gun.

Erikson was able to separate out the biosociopsychological vulnerabilities that produced the breakdown. In

the biological area were exhaustion and sleeplessness

coupled with subliminal infection and fever. In the sociological area were the lowering of group morale and growth

of group panic, immobilization under enemy fire, the

inducement to give up in the hospital bed, and finally

immediate evacuation creating a conflict between the

desire to escape and the call to duty to care for his mates.

In the psychological area were the loss of support for an

idealized father substitute when the medical officer swore,

and conflict over his identity as a noncombatant when a
War Psychiatry

4

submachine gun was pressed on him, for “the gun had

become the symbol of his family’s downfall and represented all ... which he had chosen not to do.”3(p44) The

subsequent headaches represented “the unconscious

wish to continue to suffer in order to overcompensate

psychologically for the weakness of having let others

down; for many of these escapists were more loyal than

they knew. Our conscientious man, too, felt ‘shot through

the head’ by excruciating pain whenever he seemed

definitely better.”3(p44)

Comment: This case illustrates not only the tripartite

elements of combat breakdown but also the sequelae of

improper treatment (evacuation) of such breakdown, in

this case a chronic traumatic neurosis, which would currently be called post-traumatic stress disorder (PTSD). This

chapter will, through historical analysis, show the importance of these elements in understanding combat breakdown and the importance of appropriate interventions.

Withstanding the Stress of Combat

The three groups of factors—biological (inherent

propensities and physical attributes), interpersonal

(cultural, social), and intrapsychic (individual psychological)—can affect positively or negatively the

soldier’s ability to withstand the stresses of combat.

Such stresses are multidimensional: injury; disease;

physical and psychological fatigue; and fears of

death, maiming, showing cowardice, and releasing

aggressive and destructive tendencies. Recognition of these factors was slow to develop. Prior to

the 20th century, most soldiers who broke down in

combat were considered to be cowards or weaklings, an attitude that persists to this day in some

settings. The result of this attitude was usually

unfortunate for the soldier and the unit. The term

“decimate,” for example, originally referred to the

policy of killing every tenth soldier in a unit that

had shown lack of fighting will in combat. When

breakdown was recognized as medically legitimate

before the 20th century, it was considered to be of

organic causation, and terms such as “nostalgia”

and “exhausted heart” were sometimes used. The

recognition of biological/interpersonal/intrapsychic factors and their successful manipulation to

prevent breakdown in combat or disasters and to

facilitate recovery is the special province of military

psychiatry.4

Exhibit 1-1 illustrates a number of stressors found

to be important in combat breakdown, also called

combat stress reaction (CSR). This listing obviously

is not all-inclusive, because the human mind is

infinitely adaptive in the service of physical and

psychological survival. In addition, some stressors

may overlap, they may interact to exacerbate each

other, and specific factors will be of greater or lesser

significance in a given individual and in a particular situation. The history of psychiatry in warfare is

a study of the recognition of stressors that lead to

psychiatric breakdown and the development of preEXHIBIT 1-1

COMBAT STRESS FACTORS

Adapted with permission from Jones FD, Crocq L, Adelaja O, et al. Psychiatric casualties in modern warfare: Evolution of

treatment. In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the Art. Vol. 6. New York: Plenum; 1985: 461.

Exhibit 1-1 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.
5

Psychiatric Lessons of War

PTSD: post-traumatic stress disorder

Adapted with permission from Jones FD, Crocq L, Adelaja O, et al. Psychiatric casualties in modern warfare: Evolution of treatment.

In: Pichot P, Berner P, Wolf R, Thau K, eds. Psychiatry: The State of the Art. Vol. 6. New York: Plenum; 1985: 462, with subsequent updates.

Table 1-1 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.
War Psychiatry

6

ventive and treatment measures to alleviate their

effects. It is most appropriate and logical to discuss

stressors and treatment chronologically as they

have been discovered in the contexts of various

wars.

The historical approach has practical value. An

understanding of how military medicine dealt with

combat stress breakdown in the past can enable

mental health professionals to avoid mistakes made

earlier and to devise new ways to deal with modern

stress. Lessons both learned and not learned but

available are outlined in Table 1-1. One example of

a lesson not learned in the Russo-Japanese War is

that providing a medical label for stress symptoms

results in the development of such symptoms by

other soldiers as an honorable way out of combat.5

PRE-20TH CENTURY CONCEPTIONS OF PSYCHIATRIC CASUALTIES

While combat stress breakdown and some of its

causative factors were described in the epic accounts of early cultural mythology, not until the late

17th century were some of them given a particularly

medical cognizance in the form of the diagnosis, nostalgia. Initially called “the Swiss disease” because of

its prevalence among young Swiss uprooted from

their villages and placed in mercenary armies, it

was soon recognized as a more universal ailment.

By the mid-18th century it was firmly established

in the medical terminology with excellent clinical

descriptions, as was discussed by Leopold

Auenbrugger in his Inventum Novum of 1761:

When young men who are still growing are forced

to enter military service and thus lose all hope of

returning safe and sound to their beloved homeland, they become sad, taciturn, listless, solitary,

musing, full of sighs and moans. Finally, they cease

to pay attention and become indifferent to everything which the maintenance of life requires of

them.

This disease is called nostalgia. Neither medicaments, nor arguments, nor promises nor threats of

punishment are able to produce any improvement.

While all thought is directed toward ungratified

desires, the body wastes away, with a dull sound

(sonitus obscuras) on one side of the chest. [Some

cases of nostalgia were undoubtedly linked with

tuberculosis and other chest diseases. Such diseases were noted in the author’s descriptions of

autopsy reports.—Au.]

Some years ago this disease was rather common

but now occurs very rarely since the wise arrangement was instituted of limiting the period of military service to a definite number of years. As a

result the young men retain the hope of leaving

military service after this period has elapsed, and

of being able to return to their homes and enjoy

their civic rights.6(pp344–345)

French physicians of the Napoleonic Era recognized numerous factors important in producing or

preventing nostalgia; many of the same factors influence combat breakdown in the modern era. These

physicians assessed the importance of conditions

ranging from cultural (rural vs urban conscripts),

and social (boredom vs rigorous activity and organized vs disorganized camp conditions), to environmental (clement vs inclement weather), and

battle (victorious armies suffering few cases of

nostalgia vs those experiencing reverses having

many cases). Exhibit 1-2 discusses factors currently

thought to promote or prevent nostalgic casualties.

Baron Larrey, Napoleon’s Chief Surgeon, prescribed a course of treatment that, 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:

[T]o prevent this sort of cerebral affection in soldiers who have lately joined their corps, it is necessary not to suffer those individuals who are predisposed to it more repose than is necessary to recruit

their strength, exhausted during the day; to vary

their occupations, and to turn their labours and

recreations to their own advantage, as well as to

that of society. Thus, after the accustomed military

exercises, it is desirable that they should be subjected to regular hours, gymnastic amusements,

and some mode of useful instruction. It is in this

manner, especially, that mutual instruction, established among the troops of the line, is beneficial to

the soldier and the state. Warlike music, during

their repasts, or at their hours of recreation, will

contribute much to elevate the spirits of the soldier,

and to keep away those gloomy reflections which

have been traced above.6(p348)

One could hardly ask for a better prescription to

ensure physical bodily integrity and thus to produce a conviction of health, to give a sense of mastery of weapons and, as Larrey points out, especially to effect an integration into the unit through

“mutual instruction, established among the troops

of the line.”6(p348) This regimen prevents evacuation

home (the treatment approach of earlier physicians)

and minimizes any secondary gain from illness.
7

Psychiatric Lessons of War

EXHIBIT 1-2

FACTORS AND CHARACTERISTICS OF NOSTALGIC CASES

Adapted with permission from Jones FD. Psychiatric lessons of low-intensity wars. Ann Med Milit Fenn [Finland]. 1985;60:131.

In parallel with their European colleagues, American physicians considered nostalgia to be a disorder associated with the military. No significant

data are available concerning psychiatric casualties

prior to the American Civil War, except that problems of alcoholism and desertion were not uncommon. Physicians during those times dealt almost

entirely with surgical and infectious cases, leaving

morale and discipline problems for commanders to

handle.7(p4)

The Civil War, however, saw the first appearance

of recognized nostalgic casualties in significant

numbers. Approximately three cases of nostalgia

per 1,000 troops per year were reported among

Union soldiers, mainly among teenage conscripts.8

Apparently lacking any knowledge of Larrey’s published insights, Civil War physicians urged screening as the primary method of preventing nostalgia.

Surgeon General William A. Hammond in 1862

recommended that the minimum age of recruits be

fixed at 20 years to screen out those prone to this

condition; despite this effort, the rate did not change

appreciably.8 It was recognized, however, that group

cohesion was important in preventing nostalgia

and that the battle experience could forge these

cohesive bonds.9 Writing in a textbook of psychiatry 20 years after the Civil War, Hammond10 recommended an army activity program similar to that of

Exhibit 1-2 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.
War Psychiatry

8

Larrey. He wrote: “The best means of preventing

nostalgia is to provide occupation both for the mind

and the body ... soldiers placed in hospitals near

their homes are always more liable to nostalgia than

those who are inmates of hospitals situated in the

midst of or in the vicinity of the army to which they

belong.”10(p34)

 Hammond referred to Bauden’s account of the Crimean War in which similar principles were applied. He further stated that “in some

cases it may be necessary for the military surgeon to

send the nostalgic soldier to his home in order to

save his life. This, however, should be done with all

possible precautions to prevent his comrades becoming acquainted with the fact.”10(p35)

From 1861 to 1865 the Union Army officially

recognized 2,600 cases of “insanity” and 5,200 cases

of “nostalgia” requiring hospitalization at the Government Hospital of the Insane (now St. Elizabeths)

in Washington, D.C.7 Probably still in the realm of

psychiatric casualties, in this same conflict there

were 200,000 Union deserters and 160,000 cases of

“constipation,” the latter reminiscent of the

“precombat syndrome.”11

Other psychiatric entities of the Civil War included

malingering, which usually took the form of exaggerated trivial conditions or neurological symptoms, and

the irritable and exhausted heart of DaCosta.8 This

latter condition was not recognized as a psychiatric

entity and may well have included rheumatic and

other heart disease. However, most cases diagnosed

as exhausted heart were probably functional, secondary to anxiety. They may have resembled the

neurocirculatory asthenia of World War I.7(p3)

In addition to innovations in treatment of surgical wounds and application of similar procedures

pioneered by Florence Nightingale in the Crimean

War a decade earlier, the major medical accomplishment during the Civil War was the establishment of the specialty of neurology by such pioneers

as S. Weir Mitchell, W.W. Keen, G.R. Morehouse,

and William A. Hammond.8 The development of

neurology laid the foundations for differentiating

combat disorders with organic causes from those

with psychological causes.

Following the Civil War, alcoholism, venereal

diseases, and disciplinary infractions continued to

be present in soldiers fighting the Indian Wars, the

Spanish-American War, and the Philippine Insurrection, but these psychiatric problems in U.S. forces

were not so labeled until World War I. Recognition of

these and other aberrant behaviors as psychiatric problems first occurred during the Russo-Japanese War.12

20TH CENTURY COMBAT PSYCHIATRY

In the decade immediately preceding the outbreak of World War I, Russian physicians during

the Russo-Japanese War (1904–1906) reportedly first

utilized psychiatric specialists in the treatment of

combat stress casualties both at the front and upon

return to home territory.12 This war also provided

the first good description of war neurosis. Emphasis was placed on treatment of “insane” soldiers (an

unfortunate term suggesting incurability), and no

distinction was made between psychotic and neurotic soldiers. Although some psychiatric casualties were returned to combat, evacuation home,

usually accompanied by psychiatric personnel, was

the standard treatment. As this evacuation policy

became known among the troops, the number of

psychiatric patients increased 6- to 10-fold at some

collecting points.12 Nevertheless, such psychiatric

casualties were not recognized as a significant source

of personnel lost in battle until World War I.

Development of Principles

“Shell shock” was the popular label given to

most World War I (1914–1918) neuropsychiatric

casualties.2(p311) Jones, Belenky, and Marlowe13(pp1-2)

have discussed the impact of labeling in producing

adverse outcomes in such casualties:

The interaction between label and belief and behavior was particularly striking in the consequences

of the use of the term shell shock in World War I ....

As a metaphor for the new shape of battle that

characterized that war, it was particularly appropriate. In no previous conflict had men, pinned

into place by the stasis of trench warfare, been

subjected to artillery exchanges of such regularity,

intensity and magnitude. The tactics of the day

ensured that artillery shells and other explosive

devices would be the primary cause of death,

wounding, and stress. In a professional world in

which most psychiatry was articulated to a neurological base, shell shock was initially seen as a

species of actual shock to the central nervous system—a “commotional” syndrome that was the result of the effects of a blast pressure wave that was

coupled to the body of the victim. Although the

German, Oppenheim, had hypothesized a “molecular derangement” of brain cells as the pathologic

agency,14 a number of observations discredited this

theory. Soldiers nowhere near an explosion devel-
9

Psychiatric Lessons of War

oped “shell shock.” German prisoners of war exposed to shelling or bombing did not develop “shell

shock” while their allied captors did. Soldiers

exposed, or thinking themselves exposed, to toxic

gases developed “shell shock.” Finally, Farrar,15

after observing scores of Canadian soldiers with

severe head injuries from shrapnel and gunshot

wounds, noted that symptoms of psychosis or traumatic neurosis practically never occurred. He concluded “ ... trench neuroses occur usually in unwounded soldiers.”15(p16)

In spite of the fact that British and French psychiatrists rapidly came to understand that the great

majority of “shell-shocked” soldiers were the victims of transient stress-induced psychological disorders, the label and the beliefs and behaviors associated with it continued to exercise a major influence

on the battlefield. While the clinicians dispensed

with “shell-shock,” the troops did not. It became

part of the self-diagnostic and self-labeling nomenclature of the soldier.13(pp1-2)

British and French forces during World War I

discovered the importance of proximity or forward

treatment. The British had been evacuating

neuropsychiatric casualties back to England and

finding them most refractory to treatment. By 1917,

when Salmon (Figure 1-1) made his famous report

on “shell shock” among British and French soldiers,

one seventh of all discharges for disability from the

British Army had been due to mental conditions; of

200,000 soldiers on the pension list of England, one

fifth suffered from war neurosis.2 However, within

a few months of the onset of hostilities, British and

French physicians had noted that patients with war

neuroses improved more rapidly when treated in

permanent hospitals near the front than at the base,

better in casualty clearing stations than even at the

advanced base hospitals, and better still when encouragement, rest, persuasion, and suggestion could

be given in a combat organization itself. The importance of immediate treatment quickly became obvious when vicissitudes of combat prevented early

treatment of war neuroses even in forward settings.

Those who were left to their own devices due to a

large influx of casualties were found more refractory to treatment and more likely to need further

rearward evacuation.2(p508)

As an emissary of the U.S. Army Surgeon General, Thomas Salmon in 1917 observed and synthesized the British and French experience into a comprehensive program for the prevention and

treatment of shell shock cases, which were renamed

“war neuroses.” Salmon’s program, which involved

placing psychiatrists in the divisions with forward

hospitals to support them, was the first rational

system of echelon psychiatry in U.S. military forces.

American Expeditionary Forces (AEF) physicians

fine-tuned this design based on their own

experiences.16(p313) When fully conceptualized by

Artiss,17 three principles—proximity, immediacy,

and expectancy—became the cornerstones of combat psychiatric casualty treatment. They referred to

treating the combat psychiatric casualty in a safe

place as close to the battle scene as possible (proximity), as soon as possible (immediacy), with simple

treatment such as rest, food, and perhaps a warm

shower (simplicity), and most importantly an explicit statement that he is not ill and will soon be

rejoining his comrades (expectancy). Proximity and

immediacy are important because the soldier’s time

away from his unit weakens his bonds with it and

allows time for consolidation of his rationalization

of his symptoms. The patient’s rationalization may

take many forms but basically consists of a single

line of logic: “If I am not sick, then I am a coward

who has abandoned his buddies. I cannot accept

being a coward, therefore I am sick.” The psychiatrist offers an alternative hypothesis: “You are

neither sick nor a coward. You are just tired and

will recover when rested.”

Fig. 1-1. Thomas Salmon inaugurated the principles of

forward treatment of combat psychiatry casualties and

was the Neuropsychiatry Consultant to the American

Expeditionary Forces in World War I. He subsequently

held many distinguished positions, including Presidency

of the American Psychiatric Association, and is remembered for championing the mental health movement

started by Clifford Beers.
War Psychiatry

10

Expectancy is the central principle from which

the others derive. A soldier who is treated near

his unit in space (proximity) and shortly after leaving it (immediacy) can expect to return to it. Distance in space or time decreases this expectancy.

Similarly, the principle of simplicity derives from

the concept of expectancy. The application of

involved treatments such as narcosynthesis or

electroshock treatment may only strengthen the

soldier’s rationalization that he is ill physically or

mentally. The occasional use of these more elaborate procedures in refractory cases actually reinforces the preeminent role of expectation; they convey the message: “Yes, you had a mild ailment;

however, we have applied a powerful cure, and you

are well.”

The role of expectancy can be seen in the labeling

of these psychiatric casualties. Soldiers in World

War I who were called “shell-shocked” indeed acted

as though they had sustained a shock to the central

nervous system. As recounted by Bailey, Williams,

and Komora, “There were descriptions of cases

with staring eyes, violent tremors, a look of terror,

and blue, cold extremities. Some were deaf and

some were dumb; others were blind or paralyzed.”18(p2) When it was realized that concussion

was not the etiologic agent, the term “war neurosis”

was used. This was hardly an improvement because even the lay public was aware that Freud had

used William Cullen’s 1777 nonspecific term, “neurosis,” to describe chronic and sometimes severe

mental illnesses. The soldier could readily grasp

this medical diagnosis as proof of illness. This

problem was remedied when medical personnel

were instructed to tag such casualties as “N.Y.D.

(nervous)” for “not yet diagnosed (nervous).” The

term “N.Y.D. (nervous)” gave soldiers nothing definite to cling to and no suggestion had been made to

help them in formulating their disorder into something that was generally recognized as incapacitating and requiring hospital treatment, thus honorably releasing them from combat duty. This left

them open to the suggestion that they were only

tired and a little nervous and with a short rest

would be fit for duty. Eventually, many of these

cases began to be referred to simply as “exhaustion,” then, with the rediscovery of the principles

during World War II, as “combat exhaustion.” Finally, during World War II, the term “combat fatigue” came to be preferred in that it conveyed more

exactly the expectation desired.19(p993)

Another finding of World War I was the “contagiousness” of medical disorders that allow honorable escape from combat. This occurs particularly

in situations of ambiguity when such escape behavior can become an “evacuation syndrome,” as described by Belenky and Jones:

An evacuation syndrome develops in combat or in

field training exercises when through accident or

ignorance an evacuation route, usually through

medical channels, opens to the rear for soldiers

displaying a certain constellation of symptoms and

signs.... In the First World War, lethal gases were

used in combat. In one battle, an incident occurred

in which soldiers from a certain division came to

their medical aid stations in large numbers complaining of being gassed. This division had taken

heavy casualties, but now was involved in a desultory holding action, with no particular aim or object. The soldiers in the division had been expecting to be relieved following the previous heavy

fighting and when they had not been, morale had

declined precipitously. During the current action,

there was some gas shelling, but not of sufficient

intensity to produce any serious casualties. Nevertheless, soldiers usually in groups of comrades

were coming to their battalion aid stations complaining of cardiorespiratory symptoms. The medical personnel seeing these men evacuated them to

the rear. An initial trickle of soldiers turned into a

flood, and very soon this inappropriate evacuation

of men—for symptoms only—turned into a significant source of manpower loss. Once the line commanders became aware of the magnitude of the ongoing loss they intervened and sought consultation

from the division psychiatrist. The psychiatrist

reorganized the system of evacuation by treating

the soldiers coming to the aid station with a complaint of gas exposure and cardiorespiratory symptoms as psychiatric casualties. He gave them a brief

rest, a warm drink, and a change of clothes, and

rapidly returned them to their unit. The flow of

men with cardiorespiratory complaints slowed and

finally stopped. Overall the incident lasted over a

week before it was finally terminated.20(pp140–141)

[Similarly, during the Vietnam conflict, Jones reported an “epidemic” of sleepwalking, which is

described in Chapter 2, Traditional Warfare Combat Stress Casualties.—Au.]

Following World War I, the principles of forward

treatment were gradually lost to the U.S. military.

The psychoanalytic notion that the origin of psychiatric disorders could be traced to childhood trauma

prevailed. A natural consequence of this theory

was that evidence of such trauma could be detected,

and such potential casualties screened out. The

Spanish Civil War revealed an interesting admixture of this faith in screening along with a pragmatic

application of forward treatment of combat stress

casualties.
11

Psychiatric Lessons of War

Application of Principles

The Spanish Civil War (1936–1939) was a struggle

between a monarchist-military faction supported

with money, equipment, and volunteers by Germany and Italy and a republican-socialist faction

supported by France, the United States, and the

Soviet Union. Much of the combat psychiatry

learned in this war was not available until after

World War II because those who learned the proper

handling of psychiatric casualties were on the losing side and were scattered. Mira, the psychiatrist

who set up the mental health program for the Spanish Republican Army, gave the Thomas W. Salmon

Memorial Lecture in 1942 and later expanded it into

a book. His work was not published until late in

World War II, by which time U.S. forces had relearned the lessons of World War I. Mira made two

main contributions to the literature of combat psychiatry: (1) the revalidation of forward treatment

for psychiatric casualties, and (2) the value of psychiatric screening. The latter point will be addressed first.

Mira21 described a written psychiatric questionnaire to be filled out by potential recruits for the

Spanish Republican Army. The 17 questions, when

skillfully interpreted, allowed the physician to assess motivation, intelligence, and, it was believed,

the probability that men were “likely to suffer from

war neurosis.” After demographic questions, the

following were then asked: “Do you ever faint?”

“Do you suffer from dizziness?” “How often do

you have sexual relations?” “How often would you

like to have a 7-day leave if it were possible? Where

and how would you spend the time?”21(p68)

According to Mira,

Broadly speaking, the cases of mental and neurotic

disorders occurring subsequently in the group of

approximately twenty thousand troops selected in

this way were three times less frequent than among

those not given any such examination. This suggests that considerable value would be derived

from the adoption of this or similar methods of

selection and group testing at the recruiting

centers.21(p69)

Although Mira attributed the very low rate of

psychiatric casualties to screening, it seems more

likely, based on U.S. experience in World War II and

Vietnam, that the policy of forward treatment, including “forward evacuation,” was far more critical

than screening in accounting for the low figures.

The forward treatment program reported by Mira

seems to have worked well.

Late in the war (July 1938), Mira organized the

various psychiatric services that had developed

during the war into a coordinated program of 5

centers with 32 psychiatrists.21(p73) Not all of the rear

area military psychiatric casualties were evacuated

to the central psychiatric clinic (in the civilian zone)

but some were sent toward the forward emergency

psychiatric center of the corresponding battle sector. In Mira’s words, “They were surprised that

instead of going backward they were moved ahead

when they complained of mental disorder! The

purpose was to avoid the encouragement of malingering or the exaggeration of nervous symptoms as

a means of escape from the hardships of military

life.”21(p74) Psychiatric casualties in the front lines

were “not to be put to bed but treated boldly by

suggestive measures and directly transferred ...

where much gymnastic and kinetic exercise was the

basis of their readjustment.”21(p75) The average percentage of recovery of psychiatric casualties from

the front centers was reported to be 93.6%, and the

total percentage of men temporarily discharged

because of war neurosis was not greater than

1.5%.21(p73) Subsequent experience with similar procedures suggests that the high recovery and low

discharge rates were primarily attributable to forward evacuations. The Israelis in the 1982 Lebanon

War also successfully utilized “forward evacuation” and a stringent physical fitness program for

psychiatric casualties.22

Unfortunately, the forward treatment methods

used in the Spanish Civil War were unknown by

U.S. physicians at the inception of World War II and

had to be painfully relearned. Furthermore, American recruiters shared Mira’s view of the efficacy of

psychiatric screening, resulting in the rejection of

hundreds of thousands of potentially effective soldiers during World War II. World War II studies

suggest that beyond minimal screening to eliminate

severe mental disorders such as schizophrenia or

brain deficits, mass screening is inefficient.23

Rediscovery and Extensive Application of

Principles

The United States became involved in World War

II in 1941, 2 years after its outbreak in Europe. At

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

divisions and no provisions for special psychiatric

treatment units at the field army level or communications zone had been made.24 American planners
War Psychiatry

12

under the guidance of Harry Stack Sullivan had

believed that potential psychiatric casualties could

be screened out prior to induction.7(p21)

To minimize these casualties, physicians at the

outset of hostilities did not select draft registrants

who had any significant history of psychiatric disturbance, especially those with anxiety symptoms.

Furthermore, soldiers showing symptoms after induction were expeditiously discharged. In effect,

production of psychiatric symptoms as an honorable way of avoiding induction produced a massive

loss of manpower reminiscent of an evacuation

syndrome.

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

because of mental disease or educational deficiency

(a disqualification rate about 7.6 times as high as in

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

World War I.24 Not only was screening ineffective in

preventing breakdown, but also the liberal separation

policy for those presenting with neurotic symptoms

threatened the war effort. For instance, in September

1943 more soldiers were being eliminated from the

U.S. Army than accessed; most of those separated

were for psychoneurosis (35.6/1,000/y).24(p740)

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

similarities between psychiatric casualties and their

fellow soldiers than differences. For example, in a

comparison of the combat records of 100 men who

suffered psychiatric breakdowns requiring evacuation to a U.S. Army hospital in the United States and

an equivalent group of 100 surgical casualties, Pratt25

found no significant difference in numbers of awards

for bravery. Glass remarked, “Out of these experiences came an awareness that social and situational

determinants of behavior were more important than

the assets and liabilities of individuals involved in

coping with wartime stress and strain;...”19(p1024) The

reliance on screening to prevent psychiatric casualties was recognized as a failure when large numbers

of these casualties occurred during fighting in North

Africa. Because no provision for treatment had

been made, they were shipped to distant centers

from which they never returned to combat.

World War I-style forward treatment was relearned during two battles of the Tunisian Campaign in March and April 1943.26 Captain Fred

Hanson (Figure 1-2), a U.S. Army psychiatrist from

Canada who may have been familiar with the Salmon

Lectures, avoided evacuation and returned more

than 70% of 494 neuropsychiatric patients to combat after 48 hours of treatment, which basically

consisted of resting the soldier and indicating

to him that he would soon rejoin his unit.26(p9) On

April 26, 1943, in response to the recommendations

of his surgeon, Colonel Long, and psychiatrists,

Captain Hanson and Major Tureen, General Omar

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

further prescribed the term “exhaustion” as the

initial diagnosis for all combat psychiatric

cases.26(pp9–10) The word exhaustion was chosen because it conveyed the least implication of mental

disturbance and came closest to describing how the

patients really felt. The World War I principles had

been rediscovered!26(p10)

Discovery of Mediating Principles

In addition to rediscovering the principles of

treatment applied so effectively in World War I, and

the ineffectiveness of large-scale screening, World

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

to intensity of combat, modified by physical and

morale factors) and the importance of unit cohesion

both in preventing breakdown and in enhancing

combat effectiveness. During the war, prospective

Fig. 1-2. Frederick Hanson, an American who volunteered for duty with the Canadian military before entry

of the United States into World War II, was later assigned

to the U.S. Army as a consultant to General Omar Bradley’s

forces. He rediscovered the principles of forward treatment in the North Africa campaign.
13

Psychiatric Lessons of War

Fig. 1-3. Relation between rates for neuropsychiatric and wounded admissions in World War II. These figures illustrate

the dependent relationship of combat stress casualties to combat intensity, as measured by rates of wounded in action.

The absence of such a relationship in the Southwest Pacific Theater may represent a phenomenon of sporadic combat

or may represent a data collection problem. Reprinted with permission from Beebe GW, De Bakey ME. Battle Casualties:

Incidence, Mortality, and Logistic Considerations. Springfield, Ill: Charles C Thomas; 1952: 28.

Figure 1-3 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.
War Psychiatry

14

Anxiety A. Soldier in First Battle B. Experienced Veteran C. Overstressed Veteran

(1)

 (2)

(3) (1)

(2)

(3)

(1)

(2)

(3)

Mid

High

Low

Battle Action Battle Action Battle Action

Fig. 1-4. Anxiety, fear, and arousal at different stages in combat tour. A soldier new to battle is more likely to break

down than an experienced soldier; however, a soldier exposed to combat for a long period of time is also likely to be

a stress casualty. Reprinted from US Department of the Army. Leaders’ Manual for Combat Stress Control. Washington

DC: DA; 1994. Field Manual 22-51: 2-10.

studies conducted by Stouffer and colleagues27 conclusively showed that units with good morale and

leadership had fewer combat stress casualties than

those without these attributes when variables such

as combat intensity were comparable.

The dependent relationship of combat stress casualties to combat intensity, as measured by rates of

wounded in action, can be seen in Figure 1-3 taken

from Beebe and De Bakey.28(p28) The absence of such

a relationship in the Southwest Pacific Theater was

explained by Beebe and De Bakey as a collection

problem; however, this may be a phenomenon of

sporadic combat. In such warfare, neuropsychiatric

casualties take the form of venereal disease, alcohol

and drug abuse, and disciplinary problems. This

phenomenon, which has been detailed by Jones29

for subsequent wars, will be discussed later.

Another finding during World War II was the

chronology of breakdown in combat. It had long

been recognized that inexperienced troops were

more likely to become stress casualties. Green troops

have usually accounted for over three fourths of

stress casualties; however, with increasing exposure to combat after 1 or 2 combat months, an

increasing rate of casualty generation also occurs.

Figure 1-4 addresses battle stress relative to combat

experience. Sobel30 described the anxious, depressed

soldier who broke down after having lived through

months of seeing friends killed, as “the old sergeant

syndrome.” Today, it would probably be called

chronic post-traumatic stress disorder. Swank and

Marchand31 discussed the relationship of combat

exposure and combat effectiveness. The author has

x

x x

x

x

x

x

Predeployment

Garrison

Deployment

Precombat

Combat

Postcombat

Relative Risk

devised a graph showing the relationship of psychiatric morbidity to experiences in battle and nonbattle settings (Figure 1-5). Thus, the theory of

ultimate vulnerability was promulgated and usually expressed as “everyone has his breaking point.”

Hanson and Ranson32 found that while a soldier

Fig. 1-5. Relationship of psychiatric morbidity to experiences in battle and nonbattle settings. This figure illustrates the risk of psychiatric breakdown in troops ranging from garrison settings through combat and

postcombat situations. As is apparent, troops are at greatest risk during combat; however, increased risk of breakdown precedes and follows combat.
15

Psychiatric Lessons of War

who broke down after his unit experienced 4 to 51⁄2

months of combat exposure could be returned to

full combat duty in 70% to 89% of cases, those

exposed over 1 year returned in only 32% to 36% of

cases.

Beebe and Appel33 analyzed the World War II

combat attrition of a cohort of 1,000 soldiers from

the European Theater of Operations (ETO). They

found that the breaking point of the average rifleman in the Mediterranean Theater of Operations

(MTO) was 88 days of company combat, that is,

days in which the company sustained at least one

casualty. A company combat day averaged 7.8

calendar days in the MTO and 3.6 calendar days

in the ETO. They found that due to varying causes

of attrition in both theaters, including death, wounding, and transfers, by company combat day 50, nine

of 10 “original” soldiers had departed. In their

projections, Beebe and Appel found that if only

psychiatric casualties occurred, there would be

a 90% depletion by company combat day 210;

however, due to other causes of attrition (transfer,

death, wounding, illness), the unit would be virtually depleted by company combat day 80 or 90,

approximately the breaking point of the median

man.33(p92)

Noy34 reviewed the work of Beebe and Appel and

found that soldiers who departed as psychiatric

casualties had actually stayed longer in combat

duties than medical and disciplinary cases and that

their breakdowns were more related to exposure to

battle trauma than were medical and disciplinary

cases.

From studies of cumulative stress such as these

as well as observations of the efficacy of a “point

system” (so many points of credit toward rotation

from combat per unit of time in combat or so many

combat missions of aircrews) used during World

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

rotation came to be understood.19(p1002)

The final and perhaps most important lesson of

World War II was the importance of group cohesion

not only in preventing breakdown,19 but also in

producing effectiveness in combat. This latter point

is demonstrated by Marshall’s35 account of soldiers

parachuted into Normandy. The imprecision of

this operation resulted in some units being composed of soldiers who were strangers to each other

and others with varying numbers who had trained

together. Uniformly, those units of strangers were

completely ineffective. In Men Against Fire,

Marshall36 had also observed that only a small percentage (about 15%) of soldiers actually fired their

rifles at the enemy during World War II but that in

group firing activities, among members of crewserved weapons teams such as machine guns, the

percentage was much higher.

This element of group cohesion has already been

alluded to in terms of morale and leadership.

Marshall again probably made the point best in

reviewing his experiences in World War I, World

War II, Korea, and various Arab-Israeli wars:

When fire sweeps the field, be it in Sinai, Pork Chop

Hill or along the Normandy coast, nothing keeps a man

from running except a sense of honor, of bound

obligation to people right around him, of fear of failure

in their sight which might eternally disgrace him.37(p304)

Cohesion is so important in both prevention and

treatment of psychiatric casualties that Matthew D.

Parrish, an eminent psychiatrist who served in combat aircrews during World War II and as U.S. Army

Neuropsychiatry Consultant in Vietnam, has suggested it as another principle of forward treatment.38

Parrish observed that combat fatigue patients who

had regular visits from their units in which they

were welcomed to return, were far more likely to do

so. He suggested that this preventive and curative

principle be termed “membership.”

In the words of Parrish,

[T]he principles of proximity, immediacy, simplicity,

expectancy ... seem to imply that the medics are

trying to get the individual so strong within his

own separate self that he will be an effective soldier. Thus we would have a newly pre-combat

person with a strong character and therefore could

be predicted to perform well. There is no ... mention of the principle [of] ... the maintenance of his

bonded membership in his particular crew, squad

or team (at least no larger than company). This

bonding maintained, he never faces combat alone.

In Vietnam, when possible, the entire such primary

group would visit the casualty, keep him alive to

the life of the group and show him the other members’ need for him. Often an “ambassador” would

visit and leave a sign on the casualty’s bed announcing that he was a proud member of his unit.

(This sort of thing was effective for some medical

and surgical casualties too, who could easily have

developed the evacuation syndrome.)

What did we call this 5th principle? All I can think

of is membership. Of course, like everything else in

psychiatry, it is ultimately a command responsibility—yet its effectiveness is in the hands of team

leaders and the troops themselves....38

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

16

generally functioning well.39 Since only 5 years had

elapsed, the lessons of World War II were still well

known and the principles learned during that war

were applied appropriately. Combat stress casualties were treated forward, usually by battalion surgeons and sometimes by an experienced aidman or

even the soldiers’ “buddies,” and returned to duty.

Psychiatric casualties accounted for only about 5%

of medical out-of-country evacuations, and some of

these (treated in Japan) were returned to the combat

zone.39 To prevent psychiatric casualties, a rotation

system was in effect (9 months in combat or 13

months in support units).39 In addition, attempts

were made to rest individuals (“R and R” or rest and

recreation) and, if tactically possible, whole units.

Marshall40 warned of the dangers to unit cohesion

of rotating individuals, but this lesson was not to be

learned until the Vietnam conflict.

These procedures appear to have been quite effective with two possible exceptions. One was the

development of frostbite as an evacuation syndrome.

This condition, which was the first psychiatric

condition described in the British literature during World War I,41 was almost completely preventable, yet accounted for significant numbers of

“ineffectives.”

The other problem was an unrecognized portent

of the psychiatric problems of rear-area support

troops. As the war progressed, U.S. support troops

increased in number until they greatly outnumbered combat troops. These support troops were

seldom in life-endangering situations. Their psychological stresses were related more to separation

from home and friends, social and sometimes physical deprivations, and boredom. Paradoxically, support troops who may have avoided the stress of

combat, according to a combat veteran and military

historian, were deprived of the enhancement of

self-esteem provided by such exposure.42 To an

extent the situation resembled that of the nostalgic

soldiers of prior centuries. In these circumstances

the soldier sought relief in alcohol abuse (and, in

coastal areas, in drug abuse)43 and sexual stimulation. These often resulted in disciplinary infractions. Except for attempts to prevent venereal diseases, these problems were scarcely noticed at the

time, a lesson not learned.

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

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

psychiatric casualties; however, there was a failure

to recognize the types of casualties that can occur

among rear-echelon soldiers.11 These “garrison casualties” later became the predominant psychiatric

Fig. 1-6. Albert Julius Glass taught and popularized the

principles of forward treatment throughout his life. He

was a division psychiatrist in World War II, where his

experiences shaped his views of appropriate care of stress

casualties. In the Korean conflict, as Theater Neuropsychiatry Consultant, he instituted policies that maximized the effectiveness of treatment of psychiatric casualties. Subsequently, he applied these principles to the

garrison military as Psychiatry and Neurology Consultant to the U.S. Army Surgeon General, resulting in closure of five of the six U.S. Army prisons. After his retirement from the military, he edited Neuropsychiatry in

World War II, the two-volume official history of

neuropsychiatry in the Zone of the Interior (Vol 1) and

the Overseas Theaters (Vol 2).

they cannot be efficiently screened out ahead of

time, that their numbers depend on individual,

unit, and combat environmental factors, and that

appropriate interventions can return the majority

to combat duty.

Validation and Limitations of Principles

Just as in the initial battles of World War II,

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

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

the combat zone. Due largely to the efforts of

Colonel Albert J. Glass (Figure 1-6), a veteran of

World War II, who was assigned as Theater

Neuropsychiatry Consultant, the U.S. combat psychiatric treatment program was soon in effect and
17

Psychiatric Lessons of War

TABLE 1-2

SELECTED CAUSES OF ADMISSION TO HOSPITAL AND QUARTERS AMONG ACTIVE DUTY

U.S. ARMY PERSONNEL IN VIETNAM, 1965–1970

Rate Expressed as Number of Admissions

(per 1,000 Average Strength)

Cause 1965 1966 1967 1968 1969 1970

Wounded in Action 61.6 74.8 84.1 120.4 87.6 52.9

Neuropsychiatric Conditions 11.7 12.3 10.5 13.3 15.8 25.1

Viral Hepatitis 5.7 4.0 7.0 8.6 6.4 7.2

Venereal Disease (includes CRO*) 277.4 281.5 240.5 195.8 199.5 222.9

Venereal Disease (excludes CRO*) 3.6 3.8 2.6 2.2 1.0 1.4

*CRO: Carded for record only, ie, not hospitalized

Adapted from Neel S. Vietnam Studies: Medical Support of the US Army in Vietnam, 1965–1970. Washington, DC: US Department of the

Army; 1973: 36.

casualties of the Vietnam conflict.11 Vietnam and

the Arab-Israeli wars revealed limitations to the

traditional principles of combat psychiatry.

America’s longest conflict, Vietnam (1961–1975),

can best be viewed from a psychiatric perspective as

encompassing three phases: (1) an advisory period

with few combatants and almost no psychiatric

casualties; (2) a build-up period with large numbers

of combatants but few psychiatric casualties; and

(3) a withdrawal period in which relatively large

numbers of psychiatric casualties took forms other

than traditional combat fatigue symptomatology.

During the initial phases of the build-up in Vietnam, the psychiatric program was fully in place,

with abundant mental health resources and psychiatrists fairly conversant with the principles of

combat psychiatry. Combat stress casualties, however, failed to materialize. Throughout the entire

conflict, even with a liberal definition of combat

fatigue, less than 5% (and nearer to 2%) of casualties

were placed in this category.11

The Vietnam conflict produced a number of paradoxes in terms of the traditional understanding of

psychiatric casualties. Most spectacular was the

low rate of identified psychiatric casualties generally and, in particular, the relative absence of the

transient anxiety states currently termed combat

fatigue or combat reaction. Table 1-2, taken from

statistics compiled by Neel,44 reveals that the Vietnam conflict was unusual in that the psychiatric

casualty rate did not vary directly with the woundedin-action rate. Despite the decline of the woundedin-action rate by more than half in 1970 compared

with the high in 1968, the neuropsychiatric casualty

rate in 1970 was almost double the 1968 rate. In

other words, wounded-in-action and neuropsychiatric casualty rates showed an inverse relationship that was unique to the Vietnam conflict until

the 1982 Lebanon War.

This was contrary to prior experience and expectations. For example, Datel,45 in reviewing neuropsychiatric rates since 1915, showed that in the U.S.

Army the rates had previously peaked coincidentally with combat intensity (1918, 1943, and 1951)

but in the Vietnam conflict they peaked after the

war was over (1973), as seen in Figure 1-7.

In one study of combat psychiatric casualties in

Vietnam46 during the first 6 months of 1966, less

than 5% of cases were labeled “combat exhaustion.”

Most cases presented with behavioral or somatic

complaints.

This initially (1965–1967) low incidence of

neuropsychiatric cases in Vietnam was posited by

Jones47 to reflect the low incidence of combat fatigue

in Vietnam compared to other wars. This low incidence of combat fatigue was in turn attributed to

the 12-month rotation policy, the absence of heavy

and prolonged artillery barrages, and the use of

seasoned and motivated troops. Because the rate of

psychiatric cases did not increase with increased

utilization of drafted troops in 1966 as compared to

1965, the latter consideration seems less important.

Other explanations of the low incidence of psychiatric cases included thorough training of troops,
War Psychiatry

18

Fig. 1-7. Incidence of neuropsychiatric disorders, U.S. Army worldwide, active duty, 1915–1975. The incidence of

neuropsychiatric disorders peaks during and immediately after major wars. Reprinted from Datel WE. A Summary of

Source Data in Military Psychiatric Epidemiology. Alexandria, Va: Defense Technical Information Center (ADA 021265);

1976.

troops’ confidence in their weapons and means of

mobility, helicopter evacuation of wounded, early

treatment of psychiatric casualties in an atmosphere

of strong expectation of rapid return to duty, and a

type of combat that consisted largely of brief skirmishes followed by rests in a secure base camp.

Fatigue and anxiety did not have a chance to build

up.11

Huffman48 suggested that a factor in the low

incidence of psychiatric cases was the effectiveness

of stateside psychiatric screening of troops being

sent to Vietnam. This possibly affected in a sporadic way the initial deployment of troops because

some company level commanders did attempt to

eliminate “oddballs” from their units in anticipation of future noneffectiveness; however, no organized screening program beyond basic combat and

advanced individual training was in effect.

In an interesting sociological and psychodynamic

analysis of 1,200 U.S. Marine Corps and U.S. Navy

personnel serving in the Vietnam combat zone,

Renner49 suggested that the true picture was not one

of diminished psychiatric casualties but rather of

hidden casualties manifested in various character

and behavior disorders. These character and behavior disorders were “hidden” in the sense that

they did not present with classical fatigue or

anxiety symptoms but rather with substance abuse

and disciplinary infractions. Renner developed

evidence supporting an explanation of character

191519201925193019351940194519501955

1960

196519701975

0

5

10

15

20

25

30

35

40

45

50

x

x

x

x

x

x

x

x

x x

x x

x

x

x

x

x x

x x

x

x x

x

x

x

x

x

x

x

x

x

x

x x

x x

x x

x

x

x

x

x x

x x x x x x

x x x

x

Hospital Diagnosis/1,000 Men/Year

40

25

0

5

10

20

15

30

35

45

50
19

Psychiatric Lessons of War

and behavior disorders based on a general alienation of the soldier from the goals of the military

unit. He contrasted support units with combat

units, noting that the former faced less external

danger, allowing greater expression of the basic

alienation that he regarded as present among virtually all U.S. troops in Vietnam. He attributed this

alienation to the lack of group cohesiveness largely

resulting from the policy of rotating individuals

and disillusionment with the war after 12 months.

The result was that the prime motivative behaviors

became personal survival, revenge for the deaths of

friends, and enjoyment of unleashing aggression.

These in turn produced not only disordered behavior reflected in increased character and behavior

disorder rates but also feelings of guilt and depression. Alienation from the unit and the U.S. Army

led to the formation of regressive alternative groups

based on race, alcohol or drug consumption, delinquent and hedonistic behavior, and countercultural

life styles.

A second paradox in the Vietnam conflict was the

development of greatly increased rates of psychosis

in U.S. Army troops11 (Figure 1-8). Datel45 showed

that this was a worldwide phenomenon of all active

duty personnel, but especially of U.S. Army troops

(see Figure 1-7). Like the total neuropsychiatric

incidence rate previously mentioned, the psychosis

rate also peaked after active combat. Previous experience had shown only minor increases in the

psychosis rate during wartime. In both combat and

noncombat situations the psychosis rate had remained stable at approximately two or three per

1,000 troops per year.7

Hayes50 suggested two hypotheses to explain the

increase in psychoses. One was the increased precipitation of schizophrenia and other psychotic reactions in predisposed persons by their use of

psychoactive drugs. The other was the tendency of

recently trained psychiatrists to classify borderline

syndromes as latent schizophrenia, while more experienced psychiatrists would have chosen a different nosological category (presumably character and

behavior disorders).

Jones and Johnson11 suggested that the doubling

of the psychosis rate in the U.S. Army Vietnam

(USARV) troops in 1969 was due not to drug precipitation of schizophrenia or styles of diagnosis

per se but rather due to the influence of drugs in

confusing the diagnosis. Holloway51 showed that

large scale abuse of drugs other than marijuana and

alcohol began about 1968. Approximately 5% of

departing soldiers were excreting detectable heroin

products in the summer of 1971; however, this fell

Fig. 1-8. Annual psychosis rates, U.S. Army Vietnam, per

1,000 strength, 1966–1972. In all kinds of military settings, combat and noncombat, the rate of psychosis in

troops averaged about 2 per 1,000 per year until the war

in Vietnam. The paradox, that is the doubling of the

normal psychosis rate of military troops in Vietnam in

1969 and 1970, was thought by the author to be due to the

influence of illegal drugs in confusing the diagnosis. This

rate declined when drug abuse treatment facilities became available in 1971. Adapted with permission from

Jones FD, Johnson AW. Medical and psychiatric treatment policy and practice in Vietnam. J Soc Issues.

1975;31(4):63.

to about 3% when the screening became publicized.

Soldiers frequently took potent hallucinogens as

well as marijuana and heroin. Jones and Johnson11

showed that out-of-country evacuations were essentially reserved for psychotics until the beginning of 1971 (Figure 1-9) but with the advent of

emphasis on drug abuse identification and rehabilitation, often by detoxification and evacuation to

stateside rehabilitation programs, an alternative

diagnosis was available. Finding a new diagnostic

category for soldiers who just did not belong in a

combat zone, namely, drug dependence, the evacuating psychiatrists stopped using the schizophrenia

label. This is reflected in the decline in psychosis

back to approximately two per 1,000 troops per

year.11 Also, fluctuation began to increase due to

the smaller samples.

Figure 1-8 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.
War Psychiatry

20

Vietnam revealed the limits of World War II-type

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

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

strong unit cohesion will not endanger themselves,

their fellows, or their careers by abusing alcohol or

drugs. When casualties do occur, the Larrey treatment for nostalgia, mentioned earlier, can be used

as a model.6

Since World War II (as, indeed, long before World

War II), the Middle East has experienced essentially

continual conflict of every conceivable nature. Exhibit 1-3 illustrates the variety of these conflicts,

ranging from state-sponsored terrorism, in which

countries fight indirectly and often by proxy,

through low-intensity and guerrilla warfare to highintensity and even chemical warfare. The significance of terrorist activities should not be minimized. In 1983, a single terrorist suicide attack

killed 241 U.S. Marines on a peace-keeping mission

In other overseas areas the U.S. Army policy

of not evacuating persons with character and

behavior problems, including drug dependence,

still held; therefore, the psychiatrist seeing a patient who did not belong overseas might label

him with a psychosis, especially if the patient described perceptual distortions and unusual experiences. Such a psychiatrist might be applying

a broad categorization of schizophrenia as

Hayes suggests. Because U.S. Air Force and U.S.

Navy psychiatrists have generally had more latitude in being permitted to evacuate patients with

character and behavior problems than have U.S.

Army psychiatrists, one would expect their rates

of psychosis to be lower, and, in fact, they were.

This may explain the discrepancy between Datel’s

worldwide psychosis rate with diagnoses by

U.S. Navy, U.S. Air Force, and U.S. Army psychiatrists and Jones and Johnson’s Vietnam psychosis rate with diagnoses by U.S. Army psychiatrists only.

Fig. 1-9. Quarterly psychosis and out-of-country psychiatric evacuation rates, U.S. Army Vietnam, per 1,000 strength,

1966–1972. This figure illustrates that out-of-country evacuations were predominantly reserved for psychotics until

the beginning of 1971. With the advent of emphasis on drug abuse identification and rehabilitation, often by

detoxification and evacuation to stateside drug programs, an alternative diagnosis was available. The result was a

decline of the psychosis rate to its expected level of about 2 per 1,000 troops per year, but an exponential increase in

out-of-country evacuations, primarily drug-abusing patients, to a level exceeding 100 per 1,000 troops per year.

Adapted with permission from Jones FD, Johnson AW. Medical and psychiatric treatment policy and practice in

Vietnam. J Soc Issues. 1975;31(4):62.

Figure 1-9 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.
21

Psychiatric Lessons of War

EXHIBIT 1-3

POST-WORLD WAR II MIDDLE-EAST CONFLICTS

1948: Israel fought the Arab League in a civil war which became Israel’s war of independence

1956: Egypt fought the tripartite powers (France, Great Britain, and Israel) when they attempted to prevent

Egypt from asserting sovereignty over the Suez Canal; ie, repulsion of former colonial powers

1962: Egypt fought against the Royalists in the Yemen Civil War, somewhat similar to the U.S. involvement

in Vietnam, a guerrilla war

1967: Israel launched a preemptive surprise attack on Egypt and her allies, a conventional medium-intensity

war but of brief duration

1968–1970: Arab-Israeli War of Attrition, a war with a static front and primarily indirect fire, thus having

some similarity to World War I

1973: Egypt launched a surprise attack on the Israelis in what became an example of high-intensity, hightechnology, continuous combat

1982: Israel bombed a nuclear reactor in Iraq, thus even a “nuclear” war (but radioactive material had not

yet been acquired by Iraq)

1982: Israel attacked Palestine Liberation Organization forces in Lebanon, a state within a state. This was a

war fought in an area of high-density civilian population, with besieged cities reminiscent of the latter

phases of World War II

1982–1987: Iraq-Iran War, primarily a conventional war but with the use of chemical agents

1989–1990: Intifada in Israeli-occupied Palestinian territories. Urban guerrilla war carried out largely by

adolescents repressed by Israeli army

1991: Persian Gulf War; U.S.-led coalition war against Iraq was primarily an uncontested aerial attack for 5

weeks followed by a 4-day ground assault using conventional weapons

1991: Iraqi war between the established government and Shiite and Kurdish minorities

Adapted from Jones FD. Lessons of the Middle Eastern Wars. Originally presented at Grand Rounds, Psychiatry Department,

Walter Reed Army Medical Center; March 15, 1984 with subsequent updates; Washington, DC.

in Beirut, producing nearly as many deaths as the

Spanish-American War.52,53

The periodic wars between Israel and its Arab

neighbors have served as a human factors laboratory as well as a testing ground for technological

developments in weapons systems (see Exhibit 1-3).

In 1967, Egyptian ground troops, surprised by Israel with its air superiority, had a feeling of helplessness that resulted in large numbers of psychiatric casualties. Having been surprised by Israel in

the 1967 Six Day War, the Arabs had learned the

effectiveness of surprise so well that Israel was

almost defeated before it could organize its defenses against the sudden 1973 Arab attack. From

the perspective of psychiatric breakdown, the 1973

Yom Kippur War is most instructive. For the first

time Israel suffered significant combat stress casualties, initially reported as 10% of total casualties,

but later estimated to be from 30% to 50%.54 The

10% rate was artificially low because casualties

treated at forward medical facilities and returned to

duty were not counted; only those disabled longer

than 4 days and sent to rear hospitals were counted.

In addition, soldiers who were psychiatrically disabled but also had light wounds were not counted

as psychiatric casualties but as wounded in action.

Finally, psychiatric casualties occurring after 26

October 1973 (2 days after the cease-fire) were not

counted.

The Egyptians also reported high psychiatric casualties, but most occurred later when the tide of

battle began to favor Israel. El Sudany El Rayes55

reported that in some units “the surgical and psychiatric casualties were equal.” The Egyptians

treated psychiatric casualties according to thenSoviet doctrine, which called for forward treatment

similar to that advocated by the U.S. Army. They

were unable to apply this doctrine, however, because there was no safe forward area. As a result,

casualties were sent to distant facilities where they

became chronically disabled. The author saw some

of these patients on a consultant visit to Maadhi
War Psychiatry

22

Military Hospital, Cairo in 1984. Their symptoms

were of severe PTSD.

Unexpectedly, the rate of the 1973 Israeli combat

stress casualties was highest among support personnel who, although sometimes exposed to hostile

fire, were probably responding primarily to the

trauma of seeing their dead and mutilated comrades. Israeli support troops additionally felt comparatively helpless during this threat to national

survival. According to a former Deputy Surgeon

General of the Israeli Defence Forces,56 many support personnel took up weapons and fought alongside combat troops. These Israeli combat support

soldiers have traditionally been considered to have

less aptitude for the military; those with higher

intelligence and leadership ability are allocated to

combat units.

Factors contributing to psychiatric casualties in

all units in the 1973 war were surprise, fear of

national destruction, lack of expectation or preparation for psychiatric casualties, and the hasty constitution of reserve units by personnel who had not

trained together (impaired cohesion).22

However, the primary generator of initial stress

casualties may be the unparalleled intensity of sustained combat with numerous mutilated victims.

This is suggested by results in the June 1982

Lebanon War, which again saw a relatively high

(23%) stress casualty rate.57 Because the factors of

combat other than intensity (surprise, lack of cohesion, and national vulnerability) were absent, intensity alone may be a predominant factor in producing combat stress casualties. It must be noted

that the majority of acute combat stress casualties

occurred during 2 weeks early in June when fighting was intense though not as intense as that during

the first week of the 1973 war. The role of expectancy may have contributed to the relatively high

rates of psychiatric casualties in Lebanon, where

frequent visits of field psychologists to units may

have produced an expectancy that psychiatric casualties would occur. This may have led to

overdiagnosis of soldiers with normal battle reaction symptoms as casualties and may have conveyed the impression that becoming a psychiatric

casualty was acceptable.57

As in the 1973 Yom Kippur War, during the 1982

Lebanon War, some psychiatric casualties were

evacuated to civilian treatment facilities far rearwards, bypassing the forward treatment teams. Very

few of these soldiers returned to combat. In contrast, about half of the stress casualties were treated

in forward facilities, and almost all of these soldiers

returned to their combat units.22

After the Lebanon War, large numbers of delayed or chronic post-traumatic stress disorders

appeared, perhaps similar to the experience after

Vietnam. Both were wars in which many civilian

bystanders became casualties. Belenky57 has reported that after the initial casualties related to the

active combat in June 1982 (25%, with most occurring during the 2 weeks of active combat), there was

a continuing influx of psychiatric patients among

the participants. Ultimately the majority of cases

developed subsequent to combat.

The Arab-Israeli conflicts have continued to validate the significance of factors preventing or promoting breakdown in combat, and they have validated the efficacy of forward treatment.58 These

conflicts have also revealed the weaknesses of this

treatment approach in high-intensity, high-technology, mobile, and sustained combat in which

there may be no relatively safe forward area at

which rest and recuperation can occur. Treatment

is further jeopardized by inadequate capability to

return the casualty to his unit because of the high

mobility and wide dispersion of combat units in

actions. These conflicts have not yielded treatment

approaches that can prevent chronic and delayed

post-traumatic stress disorders.

As in so many prolonged wars, the 1980 Soviet

military assistance to the unpopular leaders of its

client state, Afghanistan (1980–1989), led not to a

quick return to ante-bellum stability but rather to a

prolonged conflict with no foreseeable resolution.

The Soviet lack of military success against determined guerrilla forces, despite sophisticated weaponry including chemical agents,59 has been likened

to the U.S. experience in Vietnam. In fact, Soviet

combat casualties have been reported at about

70,000, of which approximately 13,000 were killed.60

Afghan partisans viewed the presence of over

110,000 Soviet soldiers as just another invasion by

their ancient Russian enemies, thus their morale in

protecting their homeland remained high. Soviet

soldiers, fighting on foreign soil against elusive

enemies remarkably similar to the friends whom

they came to help, reportedly experienced problems with alcoholism, drug abuse, and disciplinary

infractions.61 Similarly, returning soldiers have

suffered from PTSD.62

An adverse morale factor for combatants on both

sides of a conflict consists of observing the displacement of friendly or enemy civilians, usually women,

children, and the elderly, from their homes. This

was seen in the dislocation of large numbers of

Vietnamese civilians by the strategic hamlet policy

to neutralize the guerrilla support bases. Similarly,
23

Psychiatric Lessons of War

the Afghan War resulted in the generation of hundreds of thousands of refugees, most of whom fled

to Pakistan.63 Thus, Afghanistan is an object lesson

in the problems met by industrialized nations in

fighting low-intensity, unpopular foreign wars

against indigenous guerrilla forces. Except with

strictest government censorship (not available in a

democratic country), refugee flight engenders antiwar sentiments, lack of public support for the war,

and ultimately poor soldier morale.

In the midst of the turmoil that characterized the

Iranian revolution in 1980, forces from neighboring

Iraq seized control of disputed border territories,

thereby initiating a conflict that raged about 8 years

(1980–1988). An unusual mixture of high- and lowtechnology fighting, the Iraq-Iran War resembled

World War I in the use of chemical agents and the

relatively static front. Casualty patterns initially

were similar to those in World War I. Early reports

of Iranian psychiatric casualties indicated that many

of them suffered from “explosion blow,” which

resembled the “shell shock” of World War I. Initially attributed to concussion, these cases were

later viewed by Iranian psychiatrists as having

psychogenic causes and requiring treatment similar to that given combat fatigue cases of more recent

wars.64 An additional similarity of this war to

World War I was the report of the Iraqi use of

chemical agents.65 This may have been particularly

terrifying to Islamic soldiers who believed that for

death in battle in a holy war to lead them to the

Islamic paradise, the combat must involve the shedding of blood. Anecdotal reports indicate that

this morale problem was alleviated by Islamic holy

men who informed the soldiers that the chemicals

altered the blood to render it useless in a way

analogous to its being shed. Post-traumatic stress

disorders occurred primarily among displaced

civilians.66

Although low-intensity, guerrilla-type conflicts

have recently occurred or are occurring in numerous parts of the world (Ulster, Cambodia, Angola,

Sri Lanka, Nicaragua, El Salvador, Peru, Colombia,

West Irian, and the Philippines, to name a few),

there are no data to suggest that psychiatric casualties have been a significant variable even though

many of these conflicts might be characterized as

psychological warfare. Some psychiatric lessons

and casualty figures are presented below from the

Falkland Islands War in 1982, the U.S. invasion of

Grenada in 1983, the U.S. invasion of Panama in

1989, and the Persian Gulf War in 1991.

The Falkland Islands War lasted only 73 days, 45

of which involved significant combat.67–69 This conflict involved high-technology weaponry in the

midst of harsh environmental conditions and primitive hand-to-hand combat. Apparently intending

only a limited police action to publicize their territorial claims, Argentine forces occupied the major

part of the Falkland Islands. While this action

quelled political unrest at home, it was so popular

that public opinion did not allow the Argentine

forces to withdraw expeditiously. The result was a

short, bitterly fought land, sea, and air war with

Britain.

Most of the British soldiers had ample opportunity to prepare and acclimate in the leisurely 2-

week transatlantic cruise from England. British

troops were also able to practice amphibious assault landings on St. George’s Island, which was

still under British control.70 Airplane pilots, however, often flew directly to the combat zone. Benzodiazepine hypnotics were successfully used to regulate sleep and prevent fatigue in pilots.67

Major casualties on both sides occurred from

naval fighting. Of the over 1,700 Argentine forces

killed and wounded, 368 seamen (of the 1,000

aboard) were killed when a British nuclear submarine sank an Argentine cruiser.68 Most of the approximately 1,000 British casualties (250 dead, 750

wounded69) occurred during the destruction of five

ships by air-launched bombs and missiles.71

Psychiatric casualties among combatants on both

sides were surprisingly low. This may have been

due to the fact that becoming a psychiatric casualty

did not result in evacuation. In British forces psychiatric casualties were reported as less than 2% of

total casualties; however, 20% of the land forces

casualties were from immersion foot.67 The latter

probably resulted more from the terrain and weather

than from psychogenic causes. Collazo72 reported

that psychiatric casualties were also quite low in

Argentine forces, representing about 4% to 5% of

total combat casualties (wounded in action [WIA]

and killed in action [KIA]). These figures are probably equivalent to the British figures if the British

figures were to exclude medical casualties (immersion foot, infections, etc.) and include WIA and KIA

only. In one Argentine unit exposed to heavy naval

and air bombardment for 45 days, however, psychiatric casualties represented 14% of total casualties.72 One surprise among Argentine psychiatric

casualties was that the age of officers afflicted was

higher than that of enlisted men. This may simply

reflect the greater likelihood of enlisted to be

wounded compared with officers. Significant numbers of post-traumatic stress disorder cases were

reported among British forces after the war.73
War Psychiatry

24

The Falkland Islands War reveals again that while

psychiatric casualties are rare in elite forces (British), they do occur. Furthermore, the absence of an

evacuation route for psychiatric casualties (Argentine forces) contributes to low rates of such casualties. When becoming a psychiatric casualty does

not offer an evacuation from combat, there is little

reinforcement for becoming a casualty. In future

wars, the possible use of drugs to regulate sleep and

improve performance in combatants who have been

rapidly deployed across multiple time zones is suggested by the British use of temazepam (Restoril)

and triazolam (Halcion) for some of their airplane

pilots.

In late October 1983, American forces invaded

the small Caribbean island country of Grenada,

whose leadership had been assassinated by a Communist splinter group. Operation Urgent Fury was

undertaken to insure the safety of about 1,000 Americans, including 700 medical students, and to restore

order as requested by Grenada’s neighboring island countries.74 Most of the 19 Americans killed in

Grenada died from accidents, although U.S. forces

did meet stiff resistance from 600 well-armed and

professionally trained Cuban soldiers.74 Because

elite forces (Rangers, SEALS [SEa Air Land commandos], and airborne units) made the assault, few

psychiatric casualties were expected, and few occurred (three so designated in 3,000 invading troops

with 19 KIA and 73 WIA).52

Dehydration and heat exhaustion casualties accounted for most of the preventable casualties.

Fullerton74 debriefed most of the commanders after

combat had ended. He reported that one battalion

suffered 29 heat casualties in a single day but another battalion suffered only two heat casualties on

the same day, while both engaged in virtually identical tasks. The commander of the latter battalion

had emphasized water discipline.

Some of the wounded soldiers suffered delayed

post-traumatic stress disorders.74,75 Mateczun and

Holmes-Johnson52 had an interesting opportunity

to compare the psychological adjustment of U.S.

Marines wounded in the Grenada invasion with

those wounded in the Beirut massacre when casualties from both incidents arrived almost simultaneously at Bethesda Naval Hospital in Maryland.

About 25 U.S. Marines, more from Beirut than

Grenada, were treated in a psychiatric consultation-liaison model with “group therapy” as the

primary intervention. The group therapy was modeled after Marshall’s76 group debriefing technique;

however, the Beirut casualties had less to recount

because they were sleeping when the bomb exploded. Their memories centered on feelings of

helplessness and fear of dying before rescuers could

reach them. Survivor guilt was high among Beirut

casualties but almost absent among Grenada casualties. Both groups had post-traumatic stress symptoms (nightmares, intrusive thoughts, anxiety), but

Grenada casualties had high morale and a strong

desire to return to the combat unit. In contrast, the

Beirut casualties wanted to go home. These differences in symptoms are attributable to the different

forms of combat. In Beirut, the U.S. Marines had no

clear enemies or mission, and some viewed themselves as vulnerable targets, whereas U.S. forces in

Grenada had a clear mission with a known enemy

and had numerical and logistical superiority.

Belenky75 interviewed a dozen men wounded in

Grenada who had been evacuated to Walter Reed

Army Medical Center in Washington, D.C. The

main lessons reported from Belenky’s observations

included the need to emphasize self/buddy aid,

communication, and water discipline. He also noted

that clear evacuation channels for the wounded

were necessary.

In December 1989, U.S. combined forces invaded

Panama in Operation Just Cause to oust the military

dictator Manuel Noriega and his loyal soldiers. The

experience was similar to that of Grenada. One

difference was the presence of women in military

police units who engaged in combat. With few

exceptions they acquitted themselves well.

Stokes,77 in his capacity as the Combat Stress

Action Officer for the U.S. Army Medical Department Center and School, reviewed mental health

issues in Operation Just Cause. He reports that no

unit mental health personnel or formal stress holding capability was deployed to Panama in conjunction with the operation due to the priority given to

combatants and weaponry. During the combat

phase of the operation, which lasted only a few

days, some soldiers evidencing symptoms of combat stress reaction were given nonstressful duties in

their units without being evacuated. Stokes reports

only one case in which medical personnel (U.S. Air

Force nurses at Howard Air Force Base in Panama)

successfully held and returned to duty a “classic”

battle fatigue casualty. This occurred on the third

or fourth night of Operation Just Cause (after the

surgical mass casualty was over).77

Many soldiers with potentially “return to duty”

medical conditions, including Rangers and Airborne, were evacuated to military hospitals in San

Antonio, Texas through the mobile aeromedical

staging facility (MASF) at Howard Air Force Base

over the first several days. These cases included
25

Psychiatric Lessons of War

minor orthopedic injuries (most parachute-assault

related), heat exhaustion, and other conditions such

as headache in a soldier whose helmet had been

struck by a bullet (but not penetrated) while he was

shielding his dead buddy who had been killed by a

sniper. These evacuations were because Howard

Air Force Base had only surgical teams, very limited

x-ray and laboratory capability, no holding personnel, and many surgical casualties.77

Many of these elite soldiers were mortified that

they had been evacuated to San Antonio for what to

them were “dishonorable” or “shameful” injuries.

One broke down crying on being told that his ankle

was only sprained. One officer was going to refuse

the Purple Heart he was to receive on television, on

grounds that he didn’t deserve it (although the

combat assault in which he had injured himself was

from 250 feet altitude, on a moonless night, under

fire, with full combat load, onto a concrete runway).

He was finally persuaded by the chief ward nurse to

take it without making a scene. Some soldiers left

behind the decorations they had been given when

they were evacuated further to home base. Informal follow-up has indicated that some of these elite

soldiers suffered post-traumatic stress symptoms

and sought treatment covertly at a Department of

Veterans Affairs center or left the service.77

Two soldiers were sent to a nearby U.S. military

hospital several days after they had presented with

stress-type symptoms. The hospital was not staffed,

configured, or geographically located to function as

a combat stress recovery unit or restoration center.

These two soldiers were evaluated in the busy admissions area and admitted on the psychiatric ward.

After several more days, both were administratively/medically evacuated to the continental

United States via Brooke Army Medical Center in

Texas with psychiatric labels. Stokes interviewed

both at Brooke Army Medical Center, and considered both evacuations to have been inappropriate,

although one became inevitable once the soldier

was admitted to the psychiatric ward and reacted

by behaving like the adolescent psychiatric patient

she was expected to be.

After soldiers returned to their home bases, there

were several instances in which units consulted

with mental health professionals to deal with lingering issues pertaining to experiences in Panama.

For instance, Fort Bragg and the XVIII Corps called

in an outside consultant in post-Vietnam PTSD to

give training, because of symptoms among a unit

that had performed mortuary duties for Panamanian civilian casualties. The division and U.S. Army

Medical Department mental health staff treated

cases of post-traumatic stress disorder, especially

from small units which had had especially horrible

experiences such as the death of a pregnant woman

at a roadblock. Stokes also noted that a military

police company at Fort Drum requested and received stress debriefing from the division social

work officer about 1 month after homecoming.77

The Department of Military Psychiatry of the

Walter Reed Army Institute of Research, as part of

their ongoing research relating unit cohesion and

combat readiness, sent debriefing teams to the 7th

Infantry Division (Light), the 5th Infantry Division

(Mountain), and the 82d Airborne Division, all units

that had been part of Operation Just Cause. The

teams found numerous examples of unresolved

combat memories which could become post-traumatic stress disorder months after returning from

Panama.77

Anecdotal evidence suggests that a Ranger

battalion’s attrition rate from the U.S. Army was

high after return from Panama. Attrition was also

high in the months following Urgent Fury (Grenada),

according to a physician assistant who jumped in

with one of the Ranger battalions. The physician

assistant told Stokes that he had talked with many

of his Ranger comrades during their preretirement

medical outprocessing. A common explanation for

retiring was, “My wife wants me to; she worried

about me in Grenada.” Only with careful questioning would it become clear that the wife had accepted the danger in Grenada, but was worried that

her husband had come home changed, with symptoms of PTSD. She felt that if he left the military, he

would get back to being the man she had married.

Finally, some of the Rangers shared with the physician assistant their traumatic memories, often involving survivor guilt.

Stokes reported a number of lessons learned in

Panama,77 which have subsequently been incorporated into U.S. Army doctrine.78,79

 

Very short, victorious campaigns such as Operation Urgent Fury in

Grenada and Operation Just Cause in Panama are

just long enough for soldiers (especially the highlytrained elite units) to experience the “Stage of

Alarm”80 and suboptimal combat performance.31

The combat is not long enough to achieve the “Stage

of Resistance”80 and the enhanced combat skills of

the experienced veteran. The soldiers, including

the leaders, often return with their confidence in

themselves and their comrades shaken, but are hesitant to share such thoughts with anyone (even their

peers) for fear of being thought weaklings. This

observation supports the need for routine afteraction debriefing within the units themselves.
War Psychiatry

26

Stokes77 suggested that even a very austere holding capability could enable keeping stress casualties and highly motivated minor disease/nonbattle

injury (DNBI) cases in theater for return to duty.

Many of the elite soldiers with minor injuries in

Operation Just Cause would have volunteered to

sleep on the ground, in an airfield hanger or keep

watch in a foxhole, M16 in hand, with their ankle

wrapped and ibuprofen (or nothing) for the pain.

If, after 1 to 2 days, they were not able to return to

their units’ headquarters for limited duty and required further x-rays or treatment, they could have

been evacuated without shame. This would decrease post-traumatic stress disorder, guilt over

failure, and attrition of good soldiers from the U.S.

Army.

Doctrine79 now states that division mental health

sections (and the new combat stress control units)

should be deployed in brief contingency operations

such as Operation Just Cause. Even if they don’t

arrive until after combat is over (due to limited

space on aircraft), they can debrief units in theater,

soon after action, at the scene of the action. This is

far more effective than waiting until after the units

come home and return from family leave with problems already locked in. The mental health personnel also gain the knowledge, experience, and credibility with the units that will enable them to be

much more helpful to soldiers who are experiencing difficulty over the following months.

Stokes77 also reviewed deployment of mental

health resources during the Persian Gulf War which

involved the largest deployment of U.S. forces in

the 20 years since the withdrawal of U.S. forces from

Vietnam. The Persian Gulf War rivaled the Vietnam

conflict in total forces in a combat zone at a given

time. It was reported that during the Persian Gulf

War the 540,000-member U.S. forces had 148 killed

in action and 467 wounded.81 Of these, 35 were

killed and 78 wounded in fratricidal incidents. Iraq’s

military is estimated to have lost between 30,000

and 100,000 killed and 100,000 to 300,000 wounded.

There were an estimated 60,000 to 70,000 Iraqi prisoners of war by war’s end.82

During the peacetime interim between the Vietnam conflict and the Persian Gulf War, division

mental health sections had been preoccupied with

clinic mental health and U.S. Army Medical Department PROFIS (Professional Officer Filler System)

duties. Thus they lacked field experience and cohesion with their divisions. Fortunately, the prolonged mobilization phase (Operation Desert Shield)

of the Persian Gulf War allowed most to correct this

before combat started.

Most division mental health sections found it

advisable to send one of the mental health officers

(social worker, psychologist, or psychiatrist) forward to augment the behavioral science specialist

(91G NCO) which doctrine said should be with

every brigade. In the Persian Gulf War, the brigades were the principal fighting element. The

division’s main support medical companies were

often left far to the rear.

Ideally the function of these officer/NCO combat stress control teams was like that of the original

World War I division psychiatrists: to educate, triage, and prevent the evacuation of any stress cases

who could be managed in their own organizations.

The ability to hold for treatment at that forward

echelon is minimal, which is why expert triage

to prevent overevacuation is so crucial. Like the

World War I psychiatrists, the mental health

personnel’s place in the Persian Gulf War during

combat was at the main triage point (now the medical company in the brigade support area, and sometimes forward at the ambulance exchange points).83,84

These teams also provided preventive debriefings

and consultation to command following traumatic

incidents.

Stokes77provided several examples of the appropriate treatment of combat stress casualties during

the Persian Gulf War. For instance, the Tiger Brigade was attached to a U.S. Marine Division for the

frontal assault on Iraqi defenses around Kuwait

City. Four stress casualties were evacuated to the

U.S. Marine’s Surgical Support Company, which

had been augmented by the U.S. Navy with a Combat Stress Center. Three of the four soldiers were

returned to duty to their units shortly after the brief

campaign was over. The remaining case, who had

more severe psychopathology, was evacuated.

The U.S. Navy’s creative improvisation in support of the U.S. Marines is another example. In midJanuary, the U.S. Navy psychiatrist aboard the USNS

Comfort began a move in concert with the Specialty

Advisor for Psychiatry and the Medical Officer of

the U.S. Marine Corps to move neuropsychiatric

resources forward of the hospital ships and fleet

hospitals.85 Four combat stress centers, each with a

psychiatrist and a psychologist (or two psychologists, under the supervision of the nearby combat

stress center which had a psychiatrist), were established at each of the four surgical support companies. These were assisted by a mix of psychiatrically-trained or on-the-job-trained corpsmen and

nurses. The combat stress centers had a 40-cot

holding capability. Fortunately, the battle did not

require weeks of fighting in chemically-contami-
27

Psychiatric Lessons of War

nated trenches, which could have generated mass

stress casualties to fill those cots.

The regimental surgeon of one U.S. Army armored cavalry regiment requested and received a

combat stress control team from the corps, which

consisted of two psychiatrists, a social worker, and

an enlisted technician.86 The team accompanied the

medical troop into Iraq, went forward to interact

with the line troops, and conducted debriefings

following traumatic incidents. They also advised

the command regarding pre- and post-homecoming activities.

Three medical (psychiatric) detachments (OM

teams) were activated and deployed to the Persian

Gulf War. The one active component detachment,

the 528th, became XVIII Corps’ combat stress control asset. It did not reach Saudi Arabia until late

October, but immediately set up a brief restoration

program collocated with a combat support hospital

and sent mobile teams to provide consultation/

education at the battalion aid stations and dispensaries. This produced a marked decrease in the

evacuation of “psychiatric” cases, and also of cases

with stress-related somatic complaints who were

being evacuated with other tentative diagnoses.

Most of the cases held for treatment and returned to

duty by this detachment were from the corps-level

combat support/combat service support units. This

may have been in part because the division personnel were geographically more distant, and had their

own division mental health sections to prevent unnecessary evacuation or referral. The combat support/combat service support personnel in corps

were also often reservists who had been called up

unexpectedly, with unresolved homefront problems.

The combat support/combat service support

personnel were also working the hardest during the

buildup phase of the Persian Gulf War. Some

worked extremely long hours under difficult and

dangerous environmental conditions. When the

528th psychiatric detachment deployed forward in

late December and divided into teams to provide

backup support to each division in 18th Corps (in

accordance with evolving doctrine79) the evacuation of “psychiatric casualties” began to rise again.77

Two Reserve OM teams were activated and deployed in December 1990. The 531st from Baltimore, Maryland became the combat stress control

asset for 7th Corps, and divided into teams to provide backup support for each division. The 467th

from Madison, Wisconsin was initially assigned to

provide echelon above corps support at Riyadh,

Saudi Arabia. As the ground campaign approached,

it continued that mission while splitting off three

teams. One team established a combat stress control restoration/reconditioning center collocated

with a hospital at King Khalid Military City. The

other two teams reinforced the 528th and 531st

psychiatric detachments which were supporting

the two corps. The stress control teams were integrated into the medical task forces which deployed

forward behind the ground offensive. Along with

surgical and preventive medicine teams, some of

them reached the Euphrates River. Hospital psychiatry was not neglected by the forward deployment of these teams. The neuropsychiatry sections

of two evacuation hospitals combined to form a

stress recovery unit which followed the principles

of combat psychiatry. Between 16 February 1991

and 9 March 1991, it admitted 22 cases and returned

21 to duty after an average stay of 4 days.87

Stokes77 observed that total stress casualties in

the Persian Gulf War from 16 January 1991 (the start

date of the air war against Iraq) through early March

1991 would include all those held in division clearing stations for over 24 hours, in the OM team

facilities collocated with hospitals, and in the hospitals themselves. These have not been tabulated and

may never be fully counted. However, it requires

only 94 cases from all the services held for treatment

in the theater between 16 January 1991 and midMarch 1991 to constitute the “standard” one to five

ratio for the 467 wounded in action. The distinction

between “combat stress” and “noncombat stress”

casualties becomes unclear when the Scud missile

threat was greater in the rear than near the front,

and driving a truck long distances on the Tapline

Road was at least as likely to result in death as

driving a tank against Iraqi armor and infantry.77

Nostalgic casualties were few because the host

country (Saudi Arabia), in keeping with Muslim

tradition, did not allow importation of alcoholic

beverages or prostitution. Accidents reportedly

were one third the rate of other U.S. forces due to

absence of alcohol. However, casualties secondary

to substance abuse did occur when soldiers attempted to make homemade alcohol and died from

methanol ingestion. Clear grain alcohol was available at stores along the Tapline Road, disguised as

bottles of drinking water, for those who knew how

to ask and were willing to pay.77 Only a few drugrelated incidents occurred, including that of a U.S.

Air Force pharmacist who used and distributed

drugs illegally.

Some of the lessons learned from the Persian

Gulf War appear to have been of a negative nature.

On the evening of 21 February 1991, a Scud missile
War Psychiatry

28

holding a ton of explosives struck the 14th

Quartermaster’s barracks at Dhahran, Saudi Arabia,

killing or mortally wounding 13 members of the 69-

member unit, including the first woman soldier

killed in Persian Gulf combat. The missile wounded

37 others. The doctrinal requirement to send the

combat stress control teams forward to support the

combat arms had left the corps area with little

combat stress control support for such a large area.

Consequently, when the Scud missile caused mass

casualties in Dhahran, there was no mobile combat

stress control team available to provide immediate

command consultation and debriefing. A critical

incident debriefing did not occur. There was also

ambivalence by unit officers and troops’ suspicion

of military mental health officers. Even worse, days

later the survivors were shipped far from the front

to a European-based hospital for evaluation and

eventual evacuation to the United States.88 One

official U.S. Army Medical Department lesson

learned from the Persian Gulf War was to support

the fielding of the new TO&E (Table of Organization and Equipment) combat stress control units

and their doctrine. At one of the lessons-learned

conferences, the senior U.S. Army Medical Department leaders in the Persian Gulf War declared combat stress control “one of the success stories” of the

operation, but added that there were not enough

combat stress control units to be everywhere they

were needed. It was also recommended that each

divisional brigade, separate brigade, and armored

cavalry regiment should have a predesignated (if

not organic) officer/NCO combat stress control

team.77

The Persian Gulf deployment left 17,000 children

of single parents or two-soldier couples temporarily without any parents during the war. How

significant this will be in the subsequent development of these children is unknown.89 Schneider and

Martin discuss these issues in greater detail.90

The United States has continued involvement in

mercy and peacekeeping roles in Somalia (Operation Restore Hope), Macedonia (to contain the civil

war in Bosnia), and Haiti. These relatively small

and brief operations may be the main role of the

military in the future as the responsibilities of the

U.S. military are expanded to add peacekeeping

and humanitarian missions to those of fighting wars

and deterring aggression.91 However, these operations will not necessarily be without combat stress

casualties. At least one Ranger who was in the

battle of the Olympic Hotel in Mogadishu, Somalia

(October 1994) was dropped from the Rangers (although not from the U.S. Army) as a result of misconduct that was clearly related to undiagnosed

post-traumatic stress disorder.77 The cause of his

survivor guilt was identified (and quickly dispelled)

during a group debriefing one year later.

SUMMARY AND CONCLUSION

This history of warfare reveals certain recurring

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

groups are often quite similar as individuals (and

may even be the same individuals); however, their

social situations are markedly different. The social

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

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

Their physical, intrapsychic, and social states form

this matrix of factors, which influences their responses to environmental danger. In combat, deep

urgings for individual survival often conflict with

socially conditioned expectations, requirements, and

desires for “soldierly conduct,” which have been

embodied in ideals such as patriotism, discipline,

loyalty to comrades, and identification with the

leader.

To prevent combat breakdown, the presence of

mission-oriented small group cohesion is essential.

Cohesion is fostered by good leadership and by

having soldiers train, live, and experience stress

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

acute fatigue does not develop. Rest from battle

should ideally occur through small group rotation

so that group support is continuous. Commanders

should be open and honest with their subordinates

to build trust and vertical cohesion, and to enhance

the soldier’s understanding of the importance of

his contribution to the unit mission and the national interest. The soldier must believe that his

entire society supports him in his privations and

sacrifices.

Factors that foster psychiatric breakdown are the

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

vulnerability increase the probability of psychiatric

breakdown. This accounts for the strong relation-
29

Psychiatric Lessons of War

ship between intensity of combat (as measured by

wounded and killed in action) and numbers of

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

common precipitant of breakdown during World

War II. A feeling of helplessness in controlling

one’s fate also exacerbates stress and weakens resistance. This is seen in the increased stress casualties

that occur in circumstances of indirect fire such as

artillery or bombing barrages, or gas attacks compared with the direct fire situation (even though the

wounded and killed rate may be the same or higher

than under indirect fire).

After a soldier has become a psychiatric casualty,

it is important to restore as many positive factors as

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

unit are kept intact with expectation of return to the

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

kept simple to emphasize the normality of the

soldier’s experience rather than give an imputation

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

the disorders that occur (alcohol and drug abuse,

character disorders, and sexual problems) are even

more difficult to treat than combat stress disorders.

In rear-echelon settings, attention should be paid to

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

Communication between support troops and those

they support should be encouraged. Temporary

assignment to combat units should be available.

Infractions should be dealt with through forward

rather than rearward evacuation to minimize secondary gain from misbehavior.

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

critical role in this endeavor.

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