From Wikipedia, the free encyclopedia
| Combat stress reaction |
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| A U.S. Marine, Pvt. Theodore J. Miller, exhibits a "thousand-yard stare", an unfocused, despondent and weary gaze which is a frequent manifestation of "combat fatigue" |
| Specialty | Psychiatry |
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Combat stress reaction (CSR) is acute behavioral
disorganization as a direct result of the trauma of war. Also known as
"combat fatigue", "battle fatigue", or "battle neurosis", it has some
overlap with the diagnosis of acute stress reaction used in civilian psychiatry. It is historically linked to shell shock and can sometimes precurse post-traumatic stress disorder.
Combat stress reaction is an acute reaction that includes a range
of behaviors resulting from the stress of battle that decrease the
combatant's fighting efficiency. The most common symptoms are fatigue,
slower reaction times, indecision, disconnection from one's
surroundings, and the inability to prioritize. Combat stress reaction is
generally short-term and should not be confused with acute stress disorder, post-traumatic stress disorder,
or other long-term disorders attributable to combat stress, although
any of these may commence as a combat stress reaction. The US Army uses
the term/initialism COSR (Combat Stress Reaction) in official medical
reports. This term can be applied to any stress reaction in the military
unit environment. Many reactions look like symptoms of mental illness
(such as panic, extreme anxiety, depression, and hallucinations), but
they are only transient reactions to the traumatic stress of combat and
the cumulative stresses of military operations.
In World War I, shell shock was considered a psychiatric illness resulting from injury to the nerves during combat. The nature of trench warfare meant that about 10% of the fighting soldiers were killed (compared to 4.5% during World War II) and the total proportion of troops who became casualties (killed or wounded) was about 57%.
Whether a person with shell-shock was considered "wounded" or "sick"
depended on the circumstances. Soldiers were personally faulted for
their mental breakdown rather than their war experience. The large
proportion of World War I veterans in the European population meant that the symptoms were common to the culture.
Signs and symptoms
Combat stress reaction symptoms align with the symptoms also found in psychological trauma, which is closely related to post-traumatic stress disorder (PTSD). CSR differs from PTSD (among other things) in that a PTSD diagnosis requires a duration of symptoms over one month, which CSR does not.
Fatigue-related symptoms
The most common stress reactions include:
- The slowing of reaction time
- Slowness of thought
- Difficulty prioritizing tasks
- Difficulty initiating routine tasks
- Preoccupation with minor issues and familiar tasks
- Indecision and lack of concentration
- Loss of initiative with fatigue
- Exhaustion
Autonomic nervous system – Autonomic arousal
Battle casualty rates
The
ratio of stress casualties to battle casualties varies with the
intensity of the fighting. With intense fighting, it can be as high as
1:1. In low-level conflicts, it can drop to 1:10 (or less).
Modern warfare embodies the principles of continuous operations with an
expectation of higher combat stress casualties.
The World War II European Army rate of stress casualties of 1 in
10 (101:1,000) troops per annum is skewed downward from both its norm
and peak by data by low rates during the last years of the war.
Diagnosis
The following PIE principles were in place for the "not yet diagnosed nervous" (NYDN) cases:
- Proximity – treat the casualties close to the front and within sound of the fighting.
- Immediacy – treat them without delay and not wait until the wounded were all dealt with.
- Expectancy – ensure that everyone had the expectation of their return to the front after a rest and replenishment.
United States medical officer Thomas W. Salmon is often quoted as the
originator of these PIE principles. However, his real strength came
from going to Europe and learning from the Allies and then instituting
the lessons. By the end of the war, Salmon had set up a complete system
of units and procedures that was then the "world's best practice". After the war, he maintained his efforts in educating society and the military. He was awarded the Distinguished Service Medal for his contributions.
Effectiveness of the PIE approach has not been confirmed by
studies of CSR, and there is some evidence that it is not effective in
preventing PTSD.
US services now use the more recently developed BICEPS principles:
- Brevity
- Immediacy
- Centrality or contact
- Expectancy
- Proximity
- Simplicity
Between the wars
The British government produced a Report of the War Office Committee of Inquiry into "Shell-Shock", which was published in 1922. Recommendations from this included:
- In forward areas
- No soldier should be allowed to think that loss of nervous or mental
control provides an honorable avenue of escape from the battlefield,
and every endeavor should be made to prevent slight cases leaving the
battalion or divisional area, where treatment should be confined to
provision of rest and comfort for those who need it and to heartening
them for return to the front line.
- In neurological centers
- When cases are sufficiently severe to necessitate more scientific
and elaborate treatment they should be sent to special Neurological
Centers as near the front as possible, to be under the care of an expert
in nervous disorders. No such case should, however, be so labelled on
evacuation as to fix the idea of nervous breakdown in the patient's
mind.
- In base hospitals
- When evacuation to the base hospital is necessary, cases should be
treated in a separate hospital or separate sections of a hospital, and
not with the ordinary sick and wounded patients. Only in exceptional
circumstances should cases be sent to the United Kingdom, as, for
instance, men likely to be unfit for further service of any kind with
the forces in the field. This policy should be widely known throughout
the Force.
- Forms of treatment
- The establishment of an atmosphere of cure is the basis of all
successful treatment, the personality of the physician is, therefore, of
the greatest importance. While recognizing that each individual case
of war neurosis must be treated on its merits, the Committee are of
opinion that good results will be obtained in the majority by the
simplest forms of psycho-therapy, i.e., explanation, persuasion and
suggestion, aided by such physical methods as baths, electricity and
massage. Rest of mind and body is essential in all cases.
- The committee are of opinion that the production of deep
hypnotic sleep, while beneficial as a means of conveying suggestions or
eliciting forgotten experiences are useful in selected cases, but in the
majority they are unnecessary and may even aggravate the symptoms for a
time.
- They do not recommend psycho-analysis in the Freudian sense.
- In the state of convalescence, re-education and suitable
occupation of an interesting nature are of great importance. If the
patient is unfit for further military service, it is considered that
every endeavor should be made to obtain for him suitable employment on
his return to active life.
- Return to the fighting line
- Soldiers should not be returned to the fighting line under the following conditions:
- (1) If the symptoms of neurosis are of such a character that the
soldier cannot be treated overseas with a view to subsequent useful
employment.
- (2) If the breakdown is of such severity as to necessitate a long period of rest and treatment in the United Kingdom.
- (3) If the disability is anxiety neurosis of a severe type.
- (4) If the disability is a mental breakdown or psychosis requiring treatment in a mental hospital.
- It is, however, considered that many of such cases could, after
recovery, be usefully employed in some form of auxiliary military duty.
Part of the concern was that many British veterans were receiving pensions and had long-term disabilities.
By 1939, some 120,000 British ex-servicemen had received final
awards for primary psychiatric disability or were still drawing
pensions – about 15% of all pensioned disabilities – and another 44,000
or so were getting pensions for 'soldier's heart' or Effort Syndrome.
There is, though, much that statistics do not show, because in terms
of psychiatric effects, pensioners were just the tip of a huge iceberg."
War correspondent Philip Gibbs wrote:
Something was wrong. They put on
civilian clothes again and looked to their mothers and wives very much
like the young men who had gone to business in the peaceful days before
August 1914. But they had not come back the same men. Something had
altered in them. They were subject to sudden moods, and queer tempers,
fits of profound depression alternating with a restless desire for pleasure. Many were easily moved to passion where they lost control of themselves, many were bitter in their speech, violent in opinion, frightening.
One British writer between the wars wrote:
There should be no excuse given for
the establishment of a belief that a functional nervous disability
constitutes a right to compensation. This is hard saying. It may seem
cruel that those whose sufferings are real, whose illness has been
brought on by enemy action and very likely in the course of patriotic
service, should be treated with such apparent callousness. But there
can be no doubt that in an overwhelming proportion of cases, these
patients succumb to 'shock' because they get something out of it. To
give them this reward is not ultimately a benefit to them because it
encourages the weaker tendencies in their character. The nation cannot
call on its citizens for courage and sacrifice and, at the same time,
state by implication that an unconscious cowardice or an unconscious
dishonesty will be rewarded.
World War II
American
At the outbreak of World War II,
most in the United States military had forgotten the treatment lessons
of World War I. Screening of applicants was initially rigorous, but
experience eventually showed it to lack great predictive power.
The US entered the war in December 1941. Only in November 1943 was a psychiatrist added to the table of organization of each division, and this policy was not implemented in the Mediterranean Theater of Operations
until March 1944. By 1943, the US Army was using the term "exhaustion"
as the initial diagnosis of psychiatric cases, and the general
principles of military psychiatry were being used. General Patton's slapping incident was in part the spur to institute forward treatment for the Italian invasion of September 1943. The importance of unit cohesion and membership of a group as a protective factor emerged.
John Appel found that the average American infantryman in Italy
was "worn out" in 200 to 240 days and concluded that the American
soldier "fights for his buddies or because his self respect won't let
him quit". After several months in combat, the soldier lacked reasons to
continue to fight because he had proven his bravery in battle and was
no longer with most of the fellow soldiers he trained with. Appel helped implement a 180-day limit for soldiers in active combat
and suggested that the war be made more meaningful, emphasizing their
enemies' plans to conquer the United States, encouraging soldiers to
fight to prevent what they had seen happen in other countries happen to
their families. Other psychiatrists believed that letters from home
discouraged soldiers by increasing nostalgia and needlessly mentioning
problems soldiers could not solve. William Menninger said after the war, "It might have been wise to have had a nation-wide educational course in letter writing to soldiers", and Edward Strecker criticized "moms" (as opposed to mothers) who, after failing to "wean" their sons, damaged morale through letters.
Airmen flew far more often in the Southwest Pacific than in
Europe, and although rest time in Australia was scheduled, there was no
fixed number of missions that would produce transfer out of combat, as
was the case in Europe. Coupled with the monotonous, hot, sickly
environment, the result was bad morale that jaded veterans quickly
passed along to newcomers. After a few months, epidemics of combat
fatigue would drastically reduce the efficiency of units. Flight surgeons reported that the men who had been at jungle airfields longest were in bad shape:
- Many have chronic dysentery or other disease, and almost
all show chronic fatigue states. … They appear listless, unkempt,
careless, and apathetic with almost mask-like facial expression. Speech
is slow, thought content is poor, they complain of chronic headaches,
insomnia, memory defect, feel forgotten, worry about themselves, are
afraid of new assignments, have no sense of responsibility, and are
hopeless about the future.
British
Unlike
the Americans, the British leaders firmly held the lessons of World War
I. It was estimated that aerial bombardment would kill up to 35,000 a
day, but the Blitz
killed only 40,000 in total. The expected torrent of civilian mental
breakdown did not occur. The Government turned to World War I doctors
for advice on those who did have problems. The PIE principles were
generally used. However, in the British Army,
since most of the World War I doctors were too old for the job, young,
analytically trained psychiatrists were employed. Army doctors "appeared
to have no conception of breakdown in war and its treatment, though
many of them had served in the 1914–1918 war." The first Middle East
Force psychiatric hospital was set up in 1942. With D-Day for the first month there was a policy of holding casualties for only 48 hours before they were sent back over the Channel. This went firmly against the expectancy principle of PIE.
Appel believed that British soldiers were able to continue to
fight almost twice as long as their American counterparts because the
British had better rotation schedules and because they, unlike the
Americans, "fight for survival" – for the British soldiers, the threat
from the Axis powers
was much more real, given Britain's proximity to mainland Europe, and
the fact that Germany was concurrently conducting air raids and
bombarding British industrial cities. Like the Americans, British
doctors believed that letters from home often needlessly damaged
soldiers' morale.
Canadian
The
Canadian Army recognized combat stress reaction as "Battle Exhaustion"
during the Second World War and classified it as a separate type of
combat wound. Historian Terry Copp has written extensively on the
subject.
In Normandy, "The infantry units engaged in the battle also experienced
a rapid rise in the number of battle exhaustion cases with several
hundred men evacuated due to the stress of combat. Regimental Medical
Officers were learning that neither elaborate selection methods nor
extensive training could prevent a considerable number of combat
soldiers from breaking down."
Germans
In his history of the pre-Nazi Freikorps paramilitary organizations, Vanguard of Nazism, historian Robert G. L. Waite describes some of the emotional effects of World War I on German troops, and refers to a phrase he attributes to Göring: men who could not become "de-brutalized".
In an interview, Dr Rudolf Brickenstein stated that:
... he believed that there were no
important problems due to stress breakdown since it was prevented by the
high quality of leadership. But, he added, that if a soldier did break
down and could not continue fighting, it was a leadership problem, not
one for medical personnel or psychiatrists. Breakdown (he said) usually
took the form of unwillingness to fight or cowardice.
However, as World War II progressed there was a profound rise in
stress casualties from 1% of hospitalizations in 1935 to 6% in 1942. Another German psychiatrist reported after the war that during the last
two years, about a third of all hospitalizations at Ensen were due to
war neurosis. It is probable that there was both less of a true problem
and less perception of a problem.
Finns
The Finnish
attitudes to "war neurosis" were especially tough. Psychiatrist Harry
Federley, who was the head of the Military Medicine, considered shell
shock as a sign of weak character and lack of moral fibre. His treatment
for war neurosis was simple: the patients were to be bullied and
harassed until they returned to front line service.
Earlier, during the Winter War,
several Finnish machine gun operators on the Karelian Isthmus theatre
became mentally unstable after repelling several unsuccessful Soviet human wave assaults on fortified Finnish positions.
Post-World War II developments
Simplicity was added to the PIE principles by the Israelis: in their view, treatment should be brief, supportive, and could be provided by those without sophisticated training.
Peacekeeping stresses
Peacekeeping provides its own stresses because its emphasis on rules of engagement contains the roles for which soldiers are trained. Causes include witnessing or experiencing the following:
- Constant tension and threat of conflict.
- Threat of land mines and booby traps.
- Close contact with severely injured and dead people.
- Deliberate maltreatment and atrocities, possibly involving civilians.
- Cultural issues.
- Separation and home issues.
- Risk of disease including HIV.
- Threat of exposure to toxic agents.
- Mission problems.
- Return to service.
Pathophysiology
SNS activation
A U.S. Long Range Reconnaissance Patrol leader in Vietnam, 1968.
Many of the symptoms initially experienced by people with CSR are effects of an extended activation of the human body's fight-or-flight response. The fight-or-flight response involves a general sympathetic nervous system discharge in reaction to a perceived stressor and prepares the body to fight or run from the threat causing the stress. Catecholamine hormones, such as adrenaline or noradrenaline, facilitate immediate physical reactions associated with a preparation for violent muscular
action. Although the flight-or-fight-response normally ends with the
removal of the threat, the constant mortal danger in combat zones
likewise constantly and acutely stresses soldiers.
General adaptation syndrome
The process whereby the human body responds to extended stress is known as general adaptation syndrome
(GAS). After the initial fight-or-flight response, the body becomes
more resistant to stress in an attempt to dampen the sympathetic nervous
response and return to homeostasis. During this period of resistance,
physical and mental symptoms of CSR may be drastically reduced as the
body attempts to cope with the stress. Long combat involvement, however,
may keep the body from homeostasis and thereby deplete its resources
and render it unable to normally function, sending it into the third
stage of GAS: exhaustion. Sympathetic nervous activation remains in the
exhaustion phase and reactions to stress are markedly sensitized as
fight-or-flight symptoms return. If the body remains in a state of
stress, then such more severe symptoms of CSR as cardiovascular and
digestive involvement may present themselves. Extended exhaustion can
permanently damage the body.
Treatment
7 Rs
The British Army treated Operational Stress Reaction according to the 7 R's:
- Recognition – identify that the individual has an Operational Stress Reaction
- Respite – provide a short period of relief from the front line
- Rest – allow rest and recovery
- Recall – give the individual the chance to recall and discuss the experiences that have led to the reaction
- Reassurance – inform them that their reaction is normal and they will recover
- Rehabilitation – improve the physical and mental health of the patient until they no longer show symptoms
- Return – allow the soldier to return to their unit
BICEPS
Modern
front-line combat stress treatment techniques are designed to mimic the
historically used PIE techniques with some modification. BICEPS is the
current treatment route employed by the U.S. military and stresses
differential treatment by the severity of CSR symptoms present in the
service member. BICEPS is employed as a means to treat CSR symptoms and
return soldiers quickly to combat.
The following subsections on the BICEPS program are adapted from the USMC combat stress handbook:
Brevity
Critical Event Debriefing should take 2 to 3 hours. Initial rest and
replenishment at medical CSC (Combat Stress Control) facilities should
last no more than 3 or 4 days. Those requiring further treatment are
moved to the next level of care. Since many require no further
treatment, military commanders expect their service members to return to
duty rapidly.
Immediacy
CSC should be done as soon as possible when operations permit. Intervention is provided as soon as symptoms appear.
Centrality/Contact
Service members requiring observation or care beyond the unit level
are evacuated to facilities in close proximity to, but separate from the
medical or surgical patients at the BAS, surgical support company in a
central location (Marines) or forward support/division support or area
support medical companies (Army) nearest the service members' unit. It
is best to send service members who cannot continue their mission and
require more extensive respite to a central facility other than a
hospital, unless no other alternative is possible. The service member
must be encouraged to continue to think of themselves as a war fighter,
rather than a patient or a sick person. The chain of command remains
directly involved in the service member's recovery and return to duty.
The CSC team coordinates with the unit's leaders to learn whether the
over-stressed individual was a good performer prior to the combat stress
reaction, or whether they were always a marginal or problem performer
whom the team would rather see replaced than returned. Whenever
possible, representatives of the unit, or messages from the unit, tell
the casualty that they are needed and wanted back. The CSC team
coordinates with the unit leaders, through unit medical personnel or
chaplains, any special advice on how to assure quick reintegration when
the service member returns to their unit.
Expectancy
The individual is explicitly told that he is reacting normally to
extreme stress and is expected to recover and return to full duty in a
few hours or days. A military leader is extremely effective in this area
of treatment. Of all the things said to a service member experiencing
combat stress, the words of his small-unit leader have the greatest
impact due to the positive bonding process that occurs during combat.
Simple statements from the small-unit leader to the service member that
he is reacting normally to combat stress and is expected back soon have
positive impact. Small-unit leaders should tell service members that
their comrades need and expect them to return. When they do return, the
unit treats them as every other service member and expects them to
perform well. Service members experiencing and recovering from combat
stress disorder are no more likely to become overloaded again than are
those who have not yet been overloaded. In fact, they are less likely to
become overloaded than inexperienced replacements.
Proximity
In mobile war requiring rapid and frequent movement, treatment of
many combat stress cases takes place at various battalion or regimental
headquarters or logistical
units, on light duty, rather than in medical units, whenever possible.
This is a key factor and another area where the small-unit leader helps
in the treatment. CSC and follow-up care for combat stress casualties
are held as close as possible to and maintain close association with the
member's unit, and are an integral part of the entire healing process. A
visit from a member of the individual's unit during restoration is
effective in keeping a bond with the organization.
A service member experiencing combat stress reaction is having a
crisis, and there are two basic elements to that crisis working in
opposite directions. On the one hand, the service member is driven by a
strong desire to seek safety and to get out of an intolerable
environment. On the other hand, the service member does not want to let
their comrades down. They want to return to their unit. If a service
member starts to lose contact with their unit when he enters treatment,
the impulse to get out of the war and return to safety takes over. They
feel that they've failed their comrades who have already rejected them
as unworthy. The potential is for the service member to become more and
more emotionally invested in keeping their symptoms so they can stay in a
safe environment. Much of this is done outside the service member's
conscious awareness, but the result is the same. The more out of touch
the service member is with their unit, the less likely they will
recover. They are more likely to develop a chronic psychiatric illness
and get evacuated from the war.
Simplicity
Treatment is kept simple. CSC is not therapy. Psychotherapy is not
done. The goal is to rapidly restore the service member's coping skills
so that he functions and returns to duty again. Sleep, food, water,
hygiene, encouragement, work details, and confidence-restoring talk are
often all that is needed to restore a service member to full operational
readiness. This can be done in units in reserve positions, logistical
units or at medical companies. Every effort is made to reinforce service
members' identity. They are required to wear their uniforms and to keep
their helmets, equipment, chemical protective gear, and flak jackets
with them. When possible, they are allowed to keep their weapons after
the weapons have been cleared. They may serve on guard duty or as
members of a standby quick reaction force.
Predeployment preparation
Screening
Historically,
screening programs that have attempted to preclude soldiers exhibiting
personality traits thought to predispose them to CSR have been a total
failure. Part of this failure stems from the inability to base CSR
morbidity on one or two personality traits. Full psychological work-ups
are expensive and inconclusive, while pen and paper tests are
ineffective and easily faked. In addition, studies conducted following
WWII screening programs showed that psychological disorders present
during military training did not accurately predict stress disorders
during combat.
Cohesion
While
it is difficult to measure the effectiveness of such a subjective term,
soldiers who reported in a WWII study that they had a "higher than
average" sense of camaraderie and pride in their unit were more likely
to report themselves ready for combat and less likely to develop CSR or
other stress disorders. Soldiers with a "lower than average" sense of
cohesion with their unit were more susceptible to stress illness.
Training
Stress
exposure training or SET is a common component of most modern military
training. There are three steps to an effective stress exposure program.
- Providing knowledge of the stress environment
Soldiers with a knowledge of both the emotional and physical signs
and symptoms of CSR are much less likely to have a critical event that
reduces them below fighting capability. Instrumental information, such
as breathing exercises that can reduce stress and suggestions not to
look at the faces of enemy dead, is also effective at reducing the
chance of a breakdown.
Cognitive control strategies can be taught to soldiers to help them
recognize stressful and situationally detrimental thoughts and repress
those thoughts in combat situations. Such skills have been shown to
reduce anxiety and improve task performance.
- Confidence building through application and practice
Soldiers who feel confident in their own abilities and those of their
squad are far less likely to develop combat stress reaction. Training
in stressful conditions that mimic those of an actual combat situation
builds confidence in the abilities of themselves and the squad. As this
training can actually induce some of the stress symptoms it seeks to
prevent, stress levels should be increased incrementally as to allow the
soldiers time to adapt.
Prognosis
Figures from the 1982 Lebanon war
showed that with proximal treatment, 90% of CSR casualties returned to
their unit, usually within 72 hours. With rearward treatment, only 40%
returned to their unit. It was also found that treatment efficacy went
up with the application of a variety of front line treatment principles
versus just one treatment.
In Korea, similar statistics were seen, with 85% of US battle fatigue
casualties returned to duty within three days and 10% returned to
limited duties after several weeks.
Though these numbers seem to promote the claims that proximal PIE
or BICEPS treatment is generally effective at reducing the effects of
combat stress reaction, other data suggests that long term PTSD effects
may result from the hasty return of affected individuals to combat. Both
PIE and BICEPS are meant to return as many soldiers as possible to
combat, and may actually have adverse effects on the long-term health of
service members who are rapidly returned to the front-line after combat
stress control treatment. Although the PIE principles were used
extensively in the Vietnam War, the post traumatic stress disorder
lifetime rate for Vietnam veterans was 30% in a 1989 US study and 21% in
a 1996 Australian study. In a study of Israeli Veterans of the 1973 Yom
Kippur War, 37% of veterans diagnosed with CSR during combat were later
diagnosed with PTSD, compared with 14% of control veterans.
Controversy
There
is significant controversy with the PIE and BICEPS principles.
Throughout a number of wars, but notably during the Vietnam War, there
has been a conflict among doctors about sending distressed soldiers back
to combat. During the Vietnam War this reached a peak with much
discussion about the ethics of this process. Proponents of the PIE and
BICEPS principles argue that it leads to a reduction of long-term
disability but opponents argue that combat stress reactions lead to
long-term problems such as post-traumatic stress disorder.
The use of psychiatric drugs to treat people with CSR has also
attracted criticism, as some military psychiatrists have come to
question the efficacy of such drugs on the long-term health of veterans.
Concerns have been expressed as to the effect of pharmaceutical
treatment on an already elevated substance abuse rate among former
people with CSR.
Recent research has caused an increasing number of scientists to
believe that there may be a physical (i.e., neurocerebral damage) rather
than psychological basis for blast trauma. As traumatic brain injury
and combat stress reaction have very different causes yet result in
similar neurologic symptoms, researchers emphasize the need for greater
diagnostic care.
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