History

SECTION I

PSYCHIATRIC TREATMENT AT VARIOUS ECHELONS

The Normal Battle Reaction: Its Relation to the Pathologic Battle Reaction

Lieutenant Colonel Stephen W. Ranson (ref 1)
Medical Corps, United States Army

Despite the unpleasant nature of many reactions to combat, soldiers whose responses are within normal limits must be subjected to normal military demands. Only thus can morale and discipline be maintained and unjustifiable leakage of combat manpower through medical channels be prevented. When this principle is violate by the psychiatrist the combat soldier`s complaint is reasonable: "Why did you send that man to the rear? If he is psychoneurotic, so am I, and so is everybody who has been up here any length of time." An understanding of the normal battle reaction is as important to the Army psychiatrist as knowledge of normal physiology is to the internist. The pathologic battle reaction can be understood only in terms of the normal battle reaction. The psychiatrist inexperienced in evaluating combat reactions is likely to judge manifestations of fear and anxiety by civilian standards, in relation to which the combat normal is distinctly pathologic.

The trite saying "everybody is afraid in combat" is unilluminating. The untried soldier has never experienced repeated fear-producing stimuli of such intensity as those he will endure in combat, superimposed on fatigue of extreme grade and duration. Both he and the inexperienced medical officer whom he may ask to review his case are often quite unprepared to recognize his symptoms as lying within the range of the normal reaction to combat fear and fatigue. The normal battle reaction is made up of a variable set of symptoms that arise from (1) moderate to extreme physical fatigue; and (2) extreme, repeated, and continued battle fear, with (a) marked psychosomatic symptoms resulting from this fear and (b) certain psychologic symptoms resulting therefrom. Not all soldiers experience these symptoms to any important degree. Within a group of average or normal soldiers many have some of the symptoms described in the following discussion, a few have many of them, and some have few or none.

(ref 1) Formerly psychiatrist, Fifth Army Psychiatric Center (601stMedical Clearing Co.) chief, Seventh Army Psychiatric Center (616th Medical Clearing Co.);and currently, assistant chief, Neuropsychiatry Consultants Division, S. G. O.

NORMAL PSYCHOSOMATIC RESPONSE PATTERNS TO COMBAT STRESS

Combat stress and the fear resulting from it may produce certain psychosomatic responses, most of which can be included in the category of overresponse of the autonomic nervous system. These responses are here described and discussed on the symptomatic level, with little discussion of the well-known physiologic mechanisms.

Muscular tension normally increases under combat stress. From this elevated base line it is exaggerated momentarily by the impact of more acute combat stresses. Statements that "I tighten up" or "I can’t relax up here" indicate entirely normal combat responses. Tension headache of moderate degree results in some normal soldiers from increased muscle tension. It is typically described as a sensation of pulling or pressure over the cranial vertex and the back of the head and neck. "Freezing," a soldier`s term denoting temporary immobilization while subjected to heightened combat stress, is a normal reaction if extremely transitory. It is abnormal if more than transitory, if inappropriately induced, or if it prevents the soldier from accomplishing movements necessary to his own safety or that of others.

Shaking and tremor accompany the greatly heightened muscle tension under the impact of special stress. They occur not infrequently in normal soldiers subjected to close shelling or bombing, particularly after they have been sensitized to combat stimuli, and disappear rather rapidly after cessation of the stimulus. Tremor may be more persistent. It is common at all times under combat conditions in the normal soldier who has endured combat for 4 months or more. These transient reactions are most likely to develop when the soldier is forced to remain passive and "take it"; for example, while taking cover in his fox hole during a shelling. They must not be evaluated as symptoms of pathologic battle reaction. The abnormal shaking response is grosser, more incapacitating, and tends to last for hours after the immediate combat stimulus has ceased. The soldier is, therefore, not necessarily describing an abnormal reaction when he says: "The sound of those shells gets me. Every time I hear them I get shaky. When they`re shelling my rifle shakes in my hands."

Excessive perspiration is a not uncommon psychosomatic response to combat stress. "Sweating it out," the soldier`s apt term, has its source in this phenomenon. Beads of sweat may stand out on the soldier`s hands. The axillas may bedrenched. Some soldiers may feel chilly under combat stress, while others feel too warm. Sometimes these sensations alternate. Soldiers may mistake these sensations for the chill and fever of a febrile illness.

Under stress of battle some soldiers experience anorexia or nausea. Neither is sufficient indication for removing a soldier from combat.

Vague abdominal distress and mild diarrhea are frequent under these conditions. Vomiting is rarely normal, except when provoked by certain odors, particularly of the dead. Urinary frequency is one of the most common normal responses to combat stress. It is often accompanied by urgency and nocturia. Under the impact of catastrophic combat stress, incontinence of urine or feces is not abnormal. In the veteran, urinary frequency often continues beyond periods of actual contact with combat stimuli, and in that setting is not abnormal. Repeated incontinence or repeated episodes of enuresis in soldier not previously thus afflicted lie beyond the normal range of response.

Tachycardia is a frequent battle response. Under battle stress soldiers are sometimes conscious of the action of their hearts. Tachycardia and palpitation alone do not justify removing the soldier from combat. Breathlessness, a sense of thoracic oppression, and sensations of faintness and giddiness may occur in moments of extreme stress. Giddiness can easily be distinguished from true vertigo. A history of oneor two episodes of syncope under extreme stress, while not a common response, does not lie sufficiently beyond normal limits to justify evacuation. When generalized muscular weakness and lassitude caused by extreme physical fatigue are added to the symptoms already described, a transitory picture resembling neurocirculatory asthenia may develop. The physical demands made on a normal combat soldier may eventually produce not only some weakness and lassitude, but also numerous aches and pains. These symptoms are valid indications for an appropriate amount of rest, but not for a diagnosis of physical or psychiatric abnormality.

The best descriptions of the normal combat reaction, more vivid than those available from psychiatric sources, have been written by authors who have accompanied the Infantry in combat. Ernie Pyle wrote: (ref 2)

"A narrow path comes like a ribbon over a hill miles away. .. . Along the length of this ribbon there is now a thin line of men. For four days and nights they have fought hard, eaten little, washed none, and slept hardly at all. Their nights have been violent with attack, fright, butchery, and their days sleepless and miserable with the crash of artillery. The men are walking. . . . Their walk is slow, for they are dead weary, as you can tell even when looking at them from behind. Every line and sag of their bodies speaks their inhuman exhaustion. On their shoulders and backs they carry heavy steel tripods, machine-gun barrels, leaden boxes of ammunition. Their feet seem to sink into the ground from the overload they are bearing. They don`t slouch. It is the terrible deliberation of each step that

(ref 2) From "Here is Your War," pp. 247-248. New York: Henry Holt and Co., publishers.

spells out their appalling tiredness. Their faces are black and unshaven. They are young men, but the grime and whiskers and exhaustion make them look middle-aged. In their eyes as they pass is not hatred, not excitement, not despair, not the tonic of their victory—there is just the simple expression of being here as though they had been here doing this forever, and nothing else."

Management of psychosomatic complaints in the forward area. A soldier present himself to his battalion surgeon with the following complaints: "I can`t stand them shells. My stomach hurts. They tear my stomach to pieces" If unaccompanied by more ominous symptoms or by physical findings, these complaints merely describe in emotional phraseology one of the normal psychosomatic reaction patterns to battle stress. The soldier is saying in effect that he feels he cannot subject himself further to this reaction. Management consists in pointing out to the soldier that these sensations represent a normal response to combat not differing greatly from that experienced by men who have remained in the lines. The physiologic mechanisms may perhaps be explained in simple terms. Then the soldier must return to duty, either immediately or after it few hours of rest at the aid station. Neither he nor the physician should expect that he will be relieved of the symptoms, since they are merely the normal autonomic response to fear in this soldier. It is as irrational to expect psychotherapy to relieve or remove such symptoms as to expect it to prevent dampness and chilling during combat in inclement weather. The soldier must "learn to live with it."

If, however, the soldier is hospitalized as a result of these symptoms and receives a thorough diagnostic work-up, this originally nonpurposive symptom pattern becomes associated with a "gain"—that is, the soldier is removed from combat. The symptoms will continue beyond the period of battle stress to perpetuate that gain and will be reinforced by the mechanism of self-justification and compensation for guilt feelings. The symptom, pattern then becomes an abnormal reaction, not consistent with the meaning of present stimuli, and hence neurotic. Thus a neurosis is elaborated and crystallized.

When the soldier is returned to duty immediately, the symptoms continue as nonpurposive somatic expressions of anxiety, but they remain reasonably consistent with the situation and tend to disappear when the stimulus ceases, and no neurosis develops. Here, in a nutshell, is the basis of the successful management of psychosomatic complaints in the forward areas, and the reason for the hopeless picture of the psychosomatic combat reaction when it has crystallized at the general hospital.

SPECIAL PSYCHOLOGIC CONSIDERATIONS IN THE NORMAL COMBAT REACTION

Anticipatory anxiety: combat sensitization of normal type. Before entering a dangerous situation the normal soldier experiences anticipatory uneasiness, varying in intensity according to his previous experience or lack of it. The average untested soldier enters combat with an intellectual appreciation of the dangers he will face, but the situation has little emotional immediacy. After he has experienced battle this pattern changes. Thereafter his anticipatory uneasiness increases, and succeeding entries into battle will cause him to feel greater apprehension. Such a statement is only superficially at variance with accepted theories about the superiority of troops trained and tested in battle. The battle-tested soldier is better trained because he is battle trained. He knows how to perform his duties efficiently and to take proper precautions. He can and does act rapidly and adaptively when the battle situation develops. In short, he is superior to the untried soldier in combat. Nevertheless, it is normal for him to become progressively more apprehensive before entering combat and to calculate and verbalize the odds on survival through serial battle experiences, as he sees comrade after comrade killed in action. The psychiatrist should regard his expressions of anxiety as normal and must not over evaluate them. "Once I was able to look forward to battle calmly," the soldier may say in effect. "Now I feel very jittery at the thought of going into an attack." Such a soldier shows only the normal sensitization to combat.

The meaning of combat stimuli; noise sensitivity; the principle of specificity of stimulus; the principle of abnormal continuance of specific reaction; sleep difficulties. After close bombing or shelling the soldier becomes sensitized to combat noises, especially if his group has suffered casualties. Certain noises will then evoke an on-guard reaction. The soldier will analyze the threat presented with a view to taking protective measures. In conjunction with these on-guard reactions and investigative responses the normal combat-sensitized soldier may experience such psychosomatic responses as sweating and palpitation. In this sense only, every normal soldier becomes "noise sensitive." Such a constellation of reactions, frequently described by soldiers questioned about noise sensitivity, must not be evaluated as abnormal. True abnormal noise sensitivity involves the factor of nonspecificity of stimulus or an abnormal increase in the response pattern, or both. Nonspecificity of stimuli implies a reaction to a noise that obviously does not represent a threat. Abnormal increase in the response pattern involves responding to meaningful and threatening combat noises, but with gross startle and other psychosomatic

overreactions. Or the soldier may both noises that carry no threat and show an abnormal increase in the response pattern.

A noise stimulus may be nonspecific for any one of several reasons. It may be one that the normal soldier of similar combat experience could be expected to distinguish from that made by an enemy weapon or missile—for example, the noise made by kicking over a tin can. It may be nonspecific because a normal soldier would readily recognize it as nonthreatening because of its distance or direction—for example, the sound of shells passing into the distance, overhead, or to one side, or the sound of friendly guns or shells. It may be nonspecific if it is obviously not threatening because of the place and time. Thus in a rear or base area any noise of close gunfire must obviously be that of friendly artillery, mortar, or small-arms practice; or in a base so far removed from the enemy that hostile air action is out of the question, or by day when friendly air, coverage is complete, the sound of airplanes represent no threat. Finally, the stimulus may be nonspecific by virtue of a combination of these factors—for example, the noise caused by kicking over a tin can in a base area.

Sleep difficulties may represent an entirely normal reaction to combat under certain circumstances. They result from tension, the need to remain alert, lack of comfort, and the presence of combat noises that interrupt sleep and call forth in the normal, combat-sensitized soldier an on-guard reaction. Under such conditions a history of some insomnia does not indicate an abnormal combat reaction or justify medical removal from the combat area, although a period of rest may certainly be indicated. To the normal soldier combat noises are more meaningful at night than by day and more provocative of the on-guard reaction. This normal pattern shades over into the abnormal, when the night becomes terrifying in itself, without other stimuli. Abnormal insomnia entails abnormal continuance or nonspecificity of stimulus. Thus, continued insomnia after return to a quiet area is abnormal.

Some diminution in drive, flow of speech, initiative, readiness to undertake new tasks or problems, range of interests, and feeling of well-being is a frequent, even usual, response to combat stress. A soldier will say that in combat he "just doesn`t feel well," that he "isn`t up to doing things he would usually do," that he "can`t get interested in anything except his personal safety," that he has mild difficulty in concentrating and that he finds it difficult to write letters. Such complaints must be of considerable magnitude—that is, constitute true apathy or depression—or involve the principle of abnormal continuance by continuing well beyond the period of battle stress, before they pass out of the range of normal response. A certain mild

depression and a lack of humor and spontaneity are characteristic of many veteran troops.

Irritability is a normal characteristic in the soldier subjected to long-continued battle. Resentment arises normally in many soldiers who have lost close friends and withstood privations and dangers. It tends to increase with anxiety and is potentiated by any evident lack of equality in sacrifices made by combat soldiers as compared with rear-echelon military personnel and those or the home front. The healthy and socially desirable direction of the major part of this resentment is toward the enemy but when any real or fancied justification exists for the impression that there is shirking or discrimination against the combat soldier in the rear echelons, base areas, or home front, resentment is strong. There is much truth in the old dictum that "the infantryman always gripes," but it is important to give these "gripes" a socially desirable direction. Sociability and dependence on the presence and group action of others are heightened in combat. Men prefer to share fox holes and beds with their comrades, and many tend to develop feelings of insecurity when unsupported by the presence of others. Comradeship develops as a normal feature of combat life. Artificial barriers drop in response to the soldier`s need to attain the security and solace of companionship.

Postcombat behavior. Immediately after relief from combat various temporary patterns of behavior are seen. If the action has been of long duration the most striking element of the picture is overwhelming physical fatigue combined with apathy and subnormal reactiveness to stimuli. As a variant picture, there may be irritability or occasionally, moderate euphoria, and psychomotor overaction with laughing and pressure of speech. Some soldiers pace about restlessly; others sit and stare blankly. Eventually the tension under which the soldier has operated, and which continues to assert itself, may make a "letdown" seem essential. Thus arise the common reactive alcoholic, sexual, and social excesses of the soldier relieved from combat.

FEAR AND PANIC

Normal combat fear may be broken down into three manifest components: (1) fear of death, pain, injury, or mutilation; (2) fear of gross incapacitation by fear reactions, with resulting inability to guard one`s self or discharge duties adequately; and (3) fear of exhibiting fear and thus losing caste with the combat group. The first component is obvious, but the force of the last two components in the normal soldier is not always appreciated. Thus it is not necessarily abnormal if a soldier fears that he may "blow his top," lose composure, be incapacitated by fear, or become a burden to

others because of his fear reactions. It is not abnormal for the new soldier to feel that he is exhibiting undue concern and leaning too much on others for advice and help. Yet the medical officer sometimes evaluates the mere verbalization of such relations as evidence of an abnormal battle response. Panic, the pathologic counterpart of normal fear, involves temporary major disorganization of thinking and control by fear. Consciousness is usually clouded. The soldier’s actions are usually wholly un adaptive and often compromise his safety. The most common expression of true panic on the battlefield is the panic run in which usually during a shelling, the soldier deserts cover and dashes about impulsively, exposing himself to flying shell fragments.

THE PRINCIPLE OF QUANTIFICATION OF THE BATTLE REACTION

It is important that the psychiatrist recognize two important quantitative points in the evaluation of symptoms of combat stress. The first, fixed by definition of terms, is the point at which the symptoms and signs exceed quantitatively, and in certain respects differ qualitatively from, those of the normal soldier of similar combat experience and therefore constitute a pathologic battle reaction. The second, determined by policy, is the point at which the pathologic battle reaction becomes an indication for evacuation. This point lies much higher on the scale than the first. Experience indicates that it should probably be equated with total incapacity in the combat situation. The soldier who has survived 5 or 6 months of combat usually develops symptoms that pass beyond the limits of the normal reaction. In the veteran soldier such symptoms representing a mild pathologic battle reaction as continued tremor, moderate insomnia, urinary frequency and urgency, various other semipersistent psychosomatic complaints, and mild depression, with lack of humor and spontaneity, are frequent. These symptoms are not incapacitating, and the value of the veteran`s increased combat experience far outweighs them. Except under special circumstances the only treatment called for is rest on duty status. The soldier with a mild battle reaction remains effective for a longer time if he stays with his organization, and further symptoms are less likely to develop. The fact that a soldier presents himself to his medical officer with a battle reaction complex does not necessarily indicate that it is of pathologic quality, and still less that it is of incapacitating grade, warranting medical removal from combat. Hard-won experience dictates that only when the battle reaction becomes truly and objectively incapacitating should the soldier be medically removed from combat.

SUMMARY

In combat most soldiers experience symptoms that would be considered abnormal in a civilian setting. Normality of reactions must be defined in relation to the situation in which these reactions take place. This article attempts to describe and define the normal battle reaction. Pathologic battle reactions must be evaluated against such a base-line.