Combat stress reaction Totally Explained

Everything about Battle Fatigue totally explained

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 shouldn't 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. Many generals considered those who suffered shell shock to be cowards, and a large number were executed. They were not executed for having shell-shock, they were executed for specific military wartime offenses, such as desertion under fire. The British Army apparently executed a significant number soldiers for such offenses.

History

The history of Combat Stress Reactions (CSRs) has shown a remarkable variation and subvariation in the interest and knowledge of those whose tasks it has been to deal with them. Kardiner and Spiegel writing in 1947 stated:
American Civil War two conditions, “soldier's heart” and “nostalgia”, were basically CSRs. Various epidemics of psychological disorders (for example 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 wasn't 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:

Promptness of action.
Suitable environment.
Psychotherapeutic measures. 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." On 7 November 2006 the government of the United Kingdom gave them all a posthumous conditional pardon.

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,
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.
German soldiers were often became victims of shell shock in the Eastern front, as the Red Army's infamous BM-13 rocket system "were often massed in very large numbers to create a shock effect on enemy forces." (text was taken from this article)

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 unwilling to return to front line service. Several soldiers suffering from war neurosis were shot for cowardice in 1944 .
Earlier, during the Winter War, several Finnish machine gun operators on the Carelian Isthmus theatre became mentally unstable after repelling several unsuccessful Soviet human wave assaults on fortified Finnish positions .

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 stresses

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:

Constant tension and threat of conflict.

Threat of landmines and boobytraps.

Close contact with dead people and the severely injured.

Deliberate maltreatment and atrocities, possibly involving civilians.

Cultural issues, for example male dominant attitudes towards women in different cultures.

Separation and home issues.

Risk of disease including HIV.

Threat of exposure to toxic agents.

Mission problems.

Return to service. 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 hadn't 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's often referred to by the public, Post-Traumatic Stress Disorder).

Symptoms and signs

Fatigue 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.

Autonomic arousal 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.

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 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.

Therapy

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're usually relieved of duty and given support, dry clothes, food and rest. When appropriate they're given supportive counselling aimed at their speedy recovery. Some are prescribed psychotropic medications and simply discharged.

Treatment results

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 post traumatic stress disorder lifetime rate for Vietnam veterans was 30% in a 1989 US study and 21% in a 1996 Australian study.

Controversy

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.
Recent research has caused an increasing number of scientist to believe that there may be a physical rather than psychological basis for blast trauma.

Further Information

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