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Combat stress reaction
Combat stress reaction, in the past commonly known as shell shock or battle fatigue, is a military term used to categorize a range of behaviours resulting from the stress of battle which decrease the combatant's fighting efficiency. The most common symptoms are fatigue, slower reaction times, indecision, disconnection from one's surroundings, and 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 ratio of stress casualties to battle casualties varies with the intensity of the fighting, but with intense fighting it can be as high as 1:1. In low-level conflicts it can drop to 1:10 (or less).
In World War I, shell shock was considered a psychiatric illness resulting from injury to the nerves during combat. The horrors of WWI 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 56%. Whether a shell-shock sufferer was considered "wounded" or "sick" depended on the circumstances. The large proportion of WWI veterans in the European population meant that the symptoms were common to the culture, although it may not have become popularly known in the US.
Additional recommended knowledge
The history of Combat Stress Reactions (CSRs) has shown a remarkable variation in the interest and knowledge of those whose tasks it has been to deal with them. Kardiner and Spiegel writing in 1947 stated:
During the American Civil War two conditions, “soldier's heart” and “nostalgia”, were basically CSRs. Various epidemics of psychological disorders (e.g. passengers with railway spine) were recognised in the 1800s.
The Russians in the Russo-Japanese War (1904-1905) were the first to specifically diagnose mental disease as a result of war stress and try to treat it. It was not until World War I that the high level of cases with "shell shock" (also referred to as traumatic war neurosis and neurasthenia) really surprised commanders and doctors.
World War I
In 1915 The British Army in France was instructed that:
In August 1916 Charles Myers was made Consulting Psychologist to the Army. He hammered home the notion that it was necessary to create special centres near the line using treatment based on:
He also used hypnosis with limited success.
In December 1916 Gordon Holmes was put in charge of the northern, and more important, part of the western front. He had much more of the tough attitudes of the Army and suited the prevailing military mindset and so his view prevailed. By June 1917 all British cases of “Shell-shock” were evacuated to a nearby neurological centre and were labelled as NYDN – Not Yet Diagnosed Nervous”. "But, because of the Adjutant-General’s distrust of doctors, no patient could receive that specialist attention until Form AF 3436 had been sent off to the man’s unit and filled in by his commanding officer." This created significant delays but demonstrated that between 4-10% of Shell-shock W cases were "commotional" (due to physical causes) and the rest were "emotional". This killed off shell-shock as a valid disease and it was abolished in September 1918.
Proximity by circumstance
Because of the delays AF 3436 was producing, medical officers started keeping their men in their units. This was perhaps the practical beginning of the concept of proximity. Col. Rogers, RMO 4/Black Watch wrote,
The PIE principles were now in place for the "not yet diagnosed nervous" (NYDN) cases:
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.
Effectiveness of PIE approach has not been confirmed by studies of CSR, and there is some evidence that it is not effective in preventing PTSD.
The US services now use the more recently developed BICEPS principles:
The British government produced a Report of the War Office Committee of Enquiry 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.
War correspondent Philip Gibbs wrote:
One British writer between the wars wrote:
Americans and Britons in World War II
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 not have great predictive power.
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.
Unlike the Americans, the lessons of WWI were firmly in British Governmental minds. It was estimated aerial bombardment would kill up to 35,000 a day but the entire Blitz killed 40,000. The expected torrent of civilian mental breakdown did not occur. The Government turned to the WWI doctors for advice on those who did have problems. The PIE principles were used generally.
However, in the British Army, since most of the WWI 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.
Germans in WWII
In a personal interview, Dr Rudolf Brickenstein stated that:
However as the war progressed there was a profound rise in stress casualties from 1% of hospitalisations in 1935 to 6% in 1942. Another German psychiatrist reported after the war that during the last two years, about a third of all hospitalisations 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 in WWII
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 as long as they were willing to return to front line service. Several soldiers suffering from war neurosis were shot from cowardice in 1944.
Developments since WWII
Simplicity was added to the PIE principles by the Israelis. This principle meant that treatment should be brief and supportive and could be provided by those without sophisticated training.
Peacekeeping provides its own stresses with its emphasis on rules of engagement providing a containment of the roles for which soldiers are trained. Causes include witnessing or experiencing the following:
A notable case of CSR in peacekeeping operations is that of Canadian General Roméo Dallaire, commander of the UN-run operation in Rwanda, UNAMIR. Unable to intervene to prevent the ensuing Rwandan Genocide, Major-General Dallaire was forced to watch as almost a million Tutsis (a Rwandan ethnic group) were brutally killed. On return to Canada, feeling that he had not done enough to halt the genocide, and haunted by the images of dismembered victims, Dallaire contemplated suicide; in June 2000 he was found in a public park near Ottawa's Rideau Canal, drunk and overdosing from anti-depressant medication. This very public incident highlighted the impact of difficult sub-combat operations on soldiers and awoke the public's awareness to CSR (or, as it is often referred to by the public, Post-Traumatic Stress Disorder).
Symptoms and signs
The most common stress reactions include slowing of the reaction time, slowness of thought, difficulty prioritising, difficulty initiating routine tasks, preoccupation with minor issues and familiar tasks, indecision and lack of concentration, loss of initiative with fatigue and exhaustion.
Headaches, backaches, inability to relax, shaking and tremors, sweating, nausea and vomiting, loss of appetite, abdominal distress, frequency of urination, urinary incontinence, palpitations, hyperventilation, dizziness, insomnia, nightmares, restless sleep, excessive sleep, excessive startle, hypervigilance, heightened sense of threat, anxiety, irritability, depression, substance abuse, loss of adaptability, suicidality and disruptive behaviour. Loss of beliefs, mistrust, confusion, and extreme feeling of losing control.
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 WWII European Army rate of stress casualties of 101:1,000 troops per annum is biased by data from the last years of the war where the rates were low.
In the military, therapy starts with prevention by training and providing good morale and support. Simple procedures like providing adequate rest, food and shelter are important. Relaxation exercises have a role as does critical event debriefing.
Once a service member has deteriorated beyond this they are usually relieved of duty and given support, dry clothes, food and rest. When appropriate they are given supportive counselling aimed at their speedy recovery. Some are prescribed psychotropic medications and simply discharged.
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.
In Korea 85% of US battle fatigue casualties returned to duty within three days and 10% returned to limited duties after several weeks.
Although the PIE principles were used extensively in the Vietnam War the posttraumatic stress disorder lifetime rate for Vietnam veterans was 30% in a 1989 US study and 21% in a 1996 Australian study.
There is significant controversy with the PIE principles. Throughout wars but notably during the Vietnam War there has been a conflict amongst 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 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.
Notes and references
Categories: Psychological conditions | Military medicine
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Combat_stress_reaction". A list of authors is available in Wikipedia.|