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
Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. See glossary of psychiatry.
Initial psych ...
. It is historically linked to
shell shock
Shell shock is a term coined in World War I by the British psychologist Charles Samuel Myers to describe the type of post-traumatic stress disorder (PTSD) many soldiers were afflicted with during the war (before PTSD was termed). It is a react ...
and can sometimes precurse
post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
.
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
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
, 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/acronym 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
World War I (28 July 1914 11 November 1918), often abbreviated as WWI, was one of the deadliest global conflicts in history. Belligerents included much of Europe, the Russian Empire, the United States, and the Ottoman Empire, with fightin ...
, shell shock was considered a
psychiatric illness
A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
resulting from injury to the nerves during combat. The nature of
trench warfare
Trench warfare is a type of land warfare using occupied lines largely comprising military trenches, in which troops are well-protected from the enemy's small arms fire and are substantially sheltered from artillery. Trench warfare became a ...
meant that about 10% of the fighting soldiers were killed (compared to 4.5% during
World War II
World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposin ...
) 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. When faced with the phenomenon of a minority of soldiers mentally breaking down, there was an expectation that the root of this problem lay in character of the individual soldier, not because of what they experienced on the front lines during the war. The large proportion of World War I
veteran
A veteran () is a person who has significant experience (and is usually adept and esteemed) and expertise in a particular occupation or field. A military veteran is a person who is no longer serving in a military.
A military veteran that has ...
s 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
Psychological trauma, mental trauma or psychotrauma is an emotional response to a distressing event or series of events, such as accidents, rape, or natural disasters. Reactions such as psychological shock and psychological denial are typical. ...
, which is closely related to
post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
(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
*
Headache
Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches.
Headaches can occur as a result ...
s
*
Back pain
Back pain is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area is the most common area ...
s
*Inability to relax
*Shaking and
tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, fa ...
s
*
Sweat
Perspiration, also known as sweating, is the production of fluids secreted by the sweat glands in the skin of mammals.
Two types of sweat glands can be found in humans: eccrine glands and apocrine glands. The eccrine sweat glands are distribut ...
ing
*
Nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
and
vomiting
Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose.
Vomiting can be the result of ailments like Food-poisoning, foo ...
*Loss of appetite
*Abdominal distress
*Frequency of
urination
Urination, also known as micturition, is the release of urine from the urinary bladder through the urethra to the outside of the body. It is the urinary system's form of excretion. It is also known medically as micturition, voiding, uresis, ...
*
Urinary incontinence
Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geria ...
*Heart
palpitations
Palpitations are perceived abnormalities of the heartbeat characterized by awareness of cardiac muscle contractions in the chest, which is further characterized by the hard, fast and/or irregular beatings of the heart.
Symptoms include a rapi ...
*
Hyperventilation
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. ...
*
Dizziness
Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.
Dizziness is a common medical c ...
*
Insomnia
Insomnia, also known as sleeplessness, is a sleep disorder in which people have trouble sleeping. They may have difficulty falling asleep, or staying asleep as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, ...
*
Nightmare
A nightmare, also known as a bad dream, Retrieved 11 July 2016. is an unpleasant dream that can cause a strong emotional response from the mind, typically fear but also despair, anxiety or great sadness. The dream may contain situations of d ...
s
*Restless sleep
*Excessive sleep
*Excessive startle
*
Hypervigilance
Hypervigilance (more accurately understood as Hyper-awareness) is a condition in which the nervous system is filtering sensory information and the individual is in an enhanced state of sensory sensitivity or sensory domination. The name itself is ...
*Heightened sense of threat
*
Anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
*
Irritability
Irritability (also called as crankiness) is the excitatory ability that living organisms have to respond to changes in their environment. The term is used for both the physiological reaction to stimuli and for the pathological, abnormal or excessi ...
*
Depression
*
Substance abuse
Substance abuse, also known as drug abuse, is the use of a drug in amounts or by methods which are harmful to the individual or others. It is a form of substance-related disorder. Differing definitions of drug abuse are used in public health, ...
*Loss of adaptability
*Attempted
suicides
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and subs ...
*Disruptive behavior
*Mistrust of others
*
Confusion
In medicine, confusion is the quality or state of being bewildered or unclear. The term "acute mental confusion"
*Extreme feeling of losing control
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.
[''Military Psychiatry'' Ed. Gabriel, R.A., (1986)]
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 Distinguished Service Medal (DSM) is a high award of a nation.
Examples include:
*Distinguished Service Medal (Australia) (established 1991), awarded to personnel of the Australian Defence Force for distinguished leadership in action
* Distinguishe ...
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:
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
Da Costa's syndrome (also known as "soldier's heart", cardiac neurosis, chronic asthenia, effort syndrome, functional cardiovascular disease, neurocirculatory asthenia, primary neurasthenia, subacute asthenia and irritable heart) is a psychiatr ...
. There is, though, much that statistics do not show, because in terms of psychiatric effects, pensioners were just the tip of a huge iceberg."
[ Shephard, Ben. ''A War of Nerves: Soldiers and Psychiatrists, 1914–1994''. London: Jonathan Cape, 2000. ]
War correspondent Philip Gibbs wrote:
One British writer between the wars wrote:
World War II
American
At the outbreak of
World War II
World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposin ...
, 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
A psychiatrist is a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders. Psychiatrists are physicians and evaluate patients to determine whether their sy ...
added to the table of organization of each division, and this policy was not implemented in the
Mediterranean Theater of Operations
The Mediterranean Theater of Operations, United States Army (MTOUSA), originally called the North African Theater of Operations, United States Army (NATOUSA), was a military formation of the United States Army that supervised all U.S. Army forc ...
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 Military psychiatry covers special aspects of psychiatry and mental disorders within the military context.Temple, M. & Greenberg, N. (2002)Military psychiatry. ''British Medical Journal Career Focus, 324'', S161a.Walter Reed Army Institute of Resear ...
were being used.
General Patton's slapping incident
Slap or slapping may refer to:
* Slapping (strike), a method of striking with the palm of the hand
* Slapping (music), a musical technique used with stringed instruments
* Slap tonguing, a musical technique used on wind instruments
* ''Slap'' (m ...
was in part the spur to institute forward treatment for the
Italian invasion of September 1943. The importance of
unit cohesion
Unit cohesion is a military concept, defined by one former United States Chief of staff in the early 1980s as "the bonding together of soldiers in such a way as to sustain their will and commitment to each other, the unit, and mission accomplishmen ...
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
William Claire Menninger (October 15, 1899 – September 6, 1966) was a co-founder with his brother Karl and his father of The Menninger Foundation in Topeka, Kansas, an internationally known center for treatment of behavioral disorders.
Life ...
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
Edward Adam Strecker, M.D. (1886–1959) was an American physician, a psychiatric educator, a professor of psychiatry at several medical schools, and a leader in American psychiatry during the mid-twentieth century.
Strecker was born in Philadelp ...
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
The Blitz was a German bombing campaign against the United Kingdom in 1940 and 1941, during the Second World War. The term was first used by the British press and originated from the term , the German word meaning 'lightning war'.
The Germa ...
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
The British Army is the principal land warfare force of the United Kingdom, a part of the British Armed Forces along with the Royal Navy and the Royal Air Force. , the British Army comprises 79,380 regular full-time personnel, 4,090 Gurk ...
, 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
The Normandy landings were the landing operations and associated airborne operations on Tuesday, 6 June 1944 of the Allied invasion of Normandy in Operation Overlord during World War II. Codenamed Operation Neptune and often referred to as D ...
for the first month there was a policy of holding casualties for only 48 hours before they were sent back over
the Channel
The English Channel, "The Sleeve"; nrf, la Maunche, "The Sleeve" (Cotentinais) or (Jèrriais), (Guernésiais), "The Channel"; br, Mor Breizh, "Sea of Brittany"; cy, Môr Udd, "Lord's Sea"; kw, Mor Bretannek, "British Sea"; nl, Het Kanaa ...
. 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
The Axis powers, ; it, Potenze dell'Asse ; ja, 枢軸国 ''Sūjikukoku'', group=nb originally called the Rome–Berlin Axis, was a military coalition that initiated World War II and fought against the Allies. Its principal members were ...
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
(, "Free Corps" or "Volunteer Corps") were irregular German and other European military volunteer units, or paramilitary, that existed from the 18th to the early 20th centuries. They effectively fought as mercenary or private armies, regar ...
paramilitary organizations, ''Vanguard of Nazism'', historian
Robert G. L. Waite
Robert George Leeson Waite (February 18, 1919 – October 4, 1999) was a Canadian historian, psychohistorian, and the Brown Professor of History (1949–1988) at Williams College who specialized in the Nazi movement, particularly Adolf Hitler ...
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:
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.
[''Contemporary Studies in Combat Psychiatry'', (1987) ]
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
The Winter War,, sv, Vinterkriget, rus, Зи́мняя война́, r=Zimnyaya voyna. The names Soviet–Finnish War 1939–1940 (russian: link=no, Сове́тско-финская война́ 1939–1940) and Soviet–Finland War 1 ...
, 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
Peacekeeping comprises activities intended to create conditions that favour lasting peace. Research generally finds that peacekeeping reduces civilian and battlefield deaths, as well as reduces the risk of renewed warfare.
Within the United N ...
provides its own stresses because its emphasis on
rules of engagement
Rules of engagement (ROE) are the internal rules or directives afforded military forces (including individuals) that define the circumstances, conditions, degree, and manner in which the use of force, or actions which might be construed as pro ...
contains the roles for which soldiers are trained. Causes include witnessing or experiencing the following:
* Constant tension and threat of conflict.
* Threat of
land mine
A land mine is an explosive device concealed under or on the ground and designed to destroy or disable enemy targets, ranging from combatants to vehicles and tanks, as they pass over or near it. Such a device is typically detonated automati ...
s and
booby trap
A booby trap is a device or setup that is intended to kill, harm or surprise a human or another animal. It is triggered by the presence or actions of the victim and sometimes has some form of bait designed to lure the victim towards it. The trap m ...
s.
* 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
The human immunodeficiency viruses (HIV) are two species of ''Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune ...
.
* Threat of exposure to toxic agents.
* Mission problems.
* Return to service.
Pathophysiology
SNS activation
![Long-range patrolling](https://upload.wikimedia.org/wikipedia/commons/6/64/Long-range_patrolling.jpg)
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 or the fight-flight-or-freeze response (also called hyperarousal or the acute stress response) is a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. It was first des ...
. The fight-or-flight response involves a general
sympathetic nervous system
The sympathetic nervous system (SNS) is one of the three divisions of the autonomic nervous system, the others being the parasympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of th ...
discharge in reaction to a perceived
stressor
A stressor is a chemical or biological agent, environmental condition, external stimulus or an event seen as causing stress to an organism. Psychologically speaking, a stressor can be events or environments that individuals might consider demandin ...
and prepares the body to fight or run from the threat causing the stress.
Catecholamine
A catecholamine (; abbreviated CA) is a monoamine neurotransmitter, an organic compound that has a catechol (benzene with two hydroxyl side groups next to each other) and a side-chain amine.
Catechol can be either a free molecule or a subst ...
hormones, such as
adrenaline
Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
or
noradrenaline
Norepinephrine (NE), also called noradrenaline (NA) or noradrenalin, is an organic chemical in the catecholamine family that functions in the brain and body as both a hormone and neurotransmitter. The name "noradrenaline" (from Latin '' ad'', ...
, facilitate immediate physical reactions associated with a preparation for violent
muscular
Skeletal muscles (commonly referred to as muscles) are organs of the vertebrate muscular system and typically are attached by tendons to bones of a skeleton. The muscle cells of skeletal muscles are much longer than in the other types of muscle ...
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
Stress, either physiological, biological or psychological, is an organism's response to a stressor such as an environmental condition. Stress is the body's method of reacting to a condition such as a threat, challenge or physical and psycholo ...
(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
The United States Marine Corps (USMC), also referred to as the United States Marines, is the maritime land force service branch of the United States Armed Forces responsible for conducting expeditionary and amphibious operations through co ...
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.
*Skills acquisition
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
The 1982 Lebanon War, dubbed Operation Peace for Galilee ( he, מבצע שלום הגליל, or מבצע של"ג ''Mivtsa Shlom HaGalil'' or ''Mivtsa Sheleg'') by the Israeli government, later known in Israel as the Lebanon War or the First L ...
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
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a ...
, 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
A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity (ranging from mild traumatic brain injury TBI/concussionto severe traumatic b ...
and combat stress reaction have very different causes yet result in similar neurologic symptoms, researchers emphasize the need for greater diagnostic care.
[ ]
See also
*
Acute stress disorder
*
Eye movement desensitization and reprocessing (modern treatment)
*
Lack of Moral Fibre
Lack of Moral Fibre or LMF was a punitive designation used by the Royal Air Force during the Second World War to stigmatize aircrew who refused to fly operations.
By early 1940, RAF commanders were concerned about mounting psychological casual ...
*
Shell shock
Shell shock is a term coined in World War I by the British psychologist Charles Samuel Myers to describe the type of post-traumatic stress disorder (PTSD) many soldiers were afflicted with during the war (before PTSD was termed). It is a react ...
*
Social alienation
Social alienation is a person's feeling of disconnection from a group whether friends, family, or wider society to which the individual has an affinity. Such alienation has been described as "a condition in social relationships reflected by (1) ...
– among returning war veterans
References
Further reading
*
*
*
*
*
*
A Review on the Disarm Doctumentary* Corns, Cathryn and Hughes-Wilson, John (2001) ''Blindfold and Alone – British Military Executions in the Great War'' (Cassell)
Lamprecht, Friedhelm and Sack, Martin, "Posttraumatic Stress Disorder Revisited"''Dispatches: Lessons learned for Soldiers; Stress Injury and Operational Deployments'' The Army Lessons Learned Centre, Canadian Forces Base Kingston, Vol. 10, No. 1, February 2004.
* Tyquin, M. ''Madness and the Military: Australia's Experience in the Great War''. AMHP, Sydney, 2006.
External links
Glossary of TraumatologyDCoE National Center for Telehealth and TechnologyMortar attacks becoming routine for troops in Afghanistan''A Matter of Duty: The Continuing War Against PTSD''Documentary produced by the
Maine Public Broadcasting Network
The Maine Public Broadcasting Network (abbreviated MPBN and branded as Maine Public) is a state network of public television and radio stations located in the U.S. state of Maine. It is operated by the Maine Public Broadcasting Corporation, whic ...
{{Authority control
Aftermath of war
Military psychiatry
Psychological stress
Military medicine
Anxiety disorders