History

A Dynamic Approach to the Problem Combat-Induced Anxiety

Major Edwin A. Weinstein (ref 3)
Medical Corps, Army of the United States and

Lieutenant Colonel Calvin S. Drayer (ref 4)
Medical Corps, Army of the United States

The characteristics that distinguish the anxiety neuroses of combat from those of civil life are (1) the extraordinary precipitating factors in the perils and hardships of the environment; (2) its plasticity; (3) the importance of hostility and guilt which is more immediately apparent than in most neuroses in civilians, and (4) the fact that it is in large part a group phenomenon, since the soldier is a member of a closely knit, interdependent group, and group effectiveness and attitude as well as ability to identify with the group modify significantly his capacity to understand the traumas to which he is subjected. These features are here considered in turn, with emphasis on dynamic factors.

ENVIRONMENTAL PRECIPITATING FACTORS

Threat of death. In our experience the psychiatric disability rate, varies directly with the intensity of combat and the battle casualty rate. Offensive combat against an enemy strongly entrenched in difficult terrain produces many neurotic reactions. On the few occasions when the enemy withdrew with little opposition and casualties were low, the psychiatric evacuation rate was correspondingly minimal. The longer the soldier was in combat and the greater the number of scenes of death and mutilation to which he was exposed, the more disabling did his anxiety become. These simple facts are stated in order to emphasize that the forces that threatened the lives of American soldiers far outweighed all other causative factors in producing combat neuroses.

(ref 3) Formerly psychiatrist, 51st Station Hospital; psychiatrist, 114thStation Hospital and chief, Fifth Army Psychiatric Center (601st Medical Clearing Co.).
(ref 4) Formerly chief, Fifth Army Psychiatric Center (601st Medical Clearing Co.); and psychiatrist, Fifth Army.

Fatigue and hunger. Extreme physical hardship and discomfort were the lot of every rifleman, but physical exhaustion and hunger per se never caused the neurotic break. The conditions that produced physical exhaustion were usually those that produced the traumatic situation, and it was difficult to separate them sharply. In a swift advance, however, when wounds and deaths were few, the psychiatric rate was low, despite great expenditure of physical energy. A tired soldier did not endure his anxiety as well as the man who was fresh, but physical exhaustion alone was not the cause of his anxiety. Conversely, a man who developed anxiety felt weaker and complained of fatigue more than his fellows, even though all may have had about equal physical stamina in the beginning. We had opportunity to observe four soldiers with formes frustes types of progressive muscular atrophy involving the lower extremities. These men had driven themselves to the point of sheer physical exhaustion, but none developed pathologic anxiety.

Blast concussion was not a significant primary cause of combat neurosis. Less than one percent of admissions to the Fifth Army Neuropsychiatric Center were for true blast concussion, as manifested by a history of disturbed consciousness, retrograde amnesia, perforated eardrums, and evidence of pulmonary injury. With one exception men who had sustained a concussion did not develop an anxiety neurosis. Although about one-fourth of the soldiers with anxiety neurosis seen in the campaign against the Gothic Line in September and October 1944, gave a history of having been "knocked out" by a shell explosion, they showed no physical signs of injury, their amnesia was not retrograde, and they characteristically told of "coming to" in the comparative safety of a battalion aid station. When necessary for treatment, the forgotten episodes could usually be recovered easily during a pentothal interview. A history of antecedent mounting anxiety was commonly obtained from these men, and their clinical picture did not differ from that of patients with anxiety states who did not report unconsciousness.

This brief evaluation of extrinsic etiologic factors serves to stress the importance of psychodynamic factors. The genesis of combat neuroses is far more dependent on the meaning of the battle experience to the soldier than on physically disturbed bodily functions.

PATHOGENESIS

Combat-induced anxiety is progressive but highly plastic. The process can be controlled by removing the soldier from combat and subjecting him to a therapeutically sound program. Rest, encouragement, explanation, and proper barbiturate therapy serve to slow its

course. Many of those with the milder neuroses can be returned to effective combat. The history of the average soldier with an anxiety neurosis reveals that he was frightened when he went into combat; he trembled during a barrage but recovered when it lifted. After several traumatic episodes his tremor and anxiety continued even when the shelling had stopped. At first he took cover only at the reasonably close approach of a shell, but gradually he tended to rush to a fox hole at the noise of any shell, whether near or distant, enemy or American. He had once thought his chances of survival as good as those of any other soldier, but finally developed the obsessive idea that each enemy shell was aimed directly at him and that no fox hole was deep enough to protect him. He began to think continually of the men who had been killed or wounded. In some soldiers this process led to disability after a few days or weeks, in others only after several months of combat.

The progress of anxiety was clearest in the group of veteran infantrymen afflicted with what Sobel labeled the "old sergeant syndrome." Most striking in these men was their sense of guilt. They often felt personally responsible for casualties occurring in their platoon, and many, ashamed that they had not been able to carry on in command of their units, asked for reduction in grade. In most instances they had not requested evacuation but had been ordered to report to the aid station by their company commanders. All the "old sergeants" had formed close attachments within the platoon or company and had been sustained by pride in themselves and loyalty to their comrades. As the inevitable, losses occurred, these sources of motivation gradually diminished and became insufficient to forestall the eventual disability. Feelings of guilt, expressed by almost all patients with severe anxiety states, seemed most intense and characteristic among the "old sergeants."

The neurotic anxiety reaction usually continued to progress after the soldier was removed from combat, and the clinical picture tended to change strikingly as the patient was evacuated rearward. During the initial stage the soldier was still within the division or army area and his anxiety was in many cases not expressed somatically, but headaches, backaches, and gastrointestinal complaints became common as he was evacuated farther to the rear. Insomnia often became more troublesome and noise sensitivity tended to increase.

In North Africa during the early days of the war the base section hospital patient, hundreds of miles from the front, usually exhibited apathy and lowered morale. He was irritable, listless, disinterested, lacking in concentration, and unresponsive to efforts to interest him in occupational therapy. He seldom liked to discuss his battle experiences

and was resistant or hostile to interviews. When he managed to evade the watchful eye of the ward nurse and became intoxicated, he was often violent and abusive. He had to be persuaded to go to the movies and walked out if the film dealt with war. He rarely wrote to friends still in combat. It was unavailing to assure him that he would not be returned to combat.

There were several reasons for this. The soldier had been removed from the morale-sustaining atmosphere of his combat group and was no longer bolstered by pride in his organization and loyalty to his comrades. He was now a patient, not a soldier. He had exchanged his fighting clothes for a pair of pajamas. His changed status not only caused feelings of failure and inadequacy that required justification, but also intensified his feeling of guilt at having left his comrades. If he was on the ward with patients who were wounded or physically ill, these feelings were aggravated. The development of somatic symptoms was an attempt at justification and gave some relief from his sense of guilt. It can be seen why reassuring these men of their safety did not help them. It was natural for them to be resentful and uncomfortable when combat was mentioned, but fear of returning to the front was not the only factor motivating them. Guilt was rarely expressed openly, but was covered with such rationalizations as "I`d be no good to them, anyway," or "I’d go back if I were able," or "All the old boys are gone."

As these principles became recognized, psychiatric patients were segregated from other groups, hospitalization was shortened, and the "base section hospital syndrome" was largely forestalled. It was not enough merely to remove a man with a moderate anxiety state from combat. He needed desperately to regain his self-respect. As soon as he had been helped to recover some degree of composure—usually a matter of only a few days—his greatest therapeutic need was prompt assignment to a service job in the rear, where he could actively justify himself by giving direct support to the men still in combat.

THE ROLE OF HOSTILITY IN COMBAT

A knowledge of the effective soldier`s method of handling anxiety is essential if the development of incapacitating anxiety in combat is to be understood. Every soldier who enters combat develops anxiety. As this anxiety mounts under stress, the soldier develops hostility and resentment against those whom he considers responsible for his plight. Ideally this hostility is translated into purposive action against the enemy, a course designed to remove the immediate source of anxiety. If the soldier is well led, is adequately trained, and feels that he is part of a potent group, this proper direction of hostility is facilitated.

If the tactical situation is such as to hinder the effective expression of hostility, the soldier`s anxiety increases roughly in proportion to the number and severity of the traumatic episodes he experiences. During many phases of the Italian campaign the nature of the fighting hampered the physical expression of hostility toward the enemy. The rifleman, while "sweating it out" under repeated enemy, and occasionally "friendly," barrages was able to fire at the enemy an average of only four or five times a month. Under these circumstances anxiety rose when the external traumas became severe and frustrating and units were repeatedly decimated.

It is important to emphasize that the level of "normal" anxiety rose in direct proportion to the severity and duration of the external stimuli and diminished when hostility could be expressed successfully or when the soldier was removed from danger. On the other hand, when his control of his anxiety began to fail, his reactions became neurotic in that they were disproportionate to the external peril. The neurotic soldier responded with anxiety not only to the "real" environmental situation, but also to his own internal conflicts as well. Hostility itself took on exaggerated meanings for him and the expression of hostility became more difficult even when the real situation permitted it. Thus the sources of anxiety were multiplied.

The neurotic soldier seemed to evaluate the traumatic episode of battle in terms of his own experience with hostility. Some soldiers had histories of distinctly unsatisfactory efforts to express their normal aggressive trends. In others the combat experience appeared to be their first serious defeat in dealing with their own hostility, though minor reversals, common in the past of everyone, had probably revealed to them earlier the potential perils of aggressive self-expression. In other words, every soldier to some degree carried in his background the sources of vulnerability when confronted with a need to express excessive hostility, and the release of hostility sooner or later became accompanied by neurotic guilt and fear of retaliation. When the events of battle stimulate hostility the ill soldier unconsciously, in the distorted fashion of the neurotic, began to interpret the scenes of death about him as the destructive effects of his own aggression. The shells fired by the enemy became, symbolically, the agents of punishment. When a shell burst near him and he was "knocked out," the event represented the fate he so richly deserved. It was natural for him to feel that each shell had his name written on it and that no fox hole was deep enough to protect him from an avenging fate. Thus a high level of anxiety soon accumulated in the neurotically reacting soldier. He was unsuccessful in coping with the situation by using his hostility. His aggressive pattern, loaded with guilt and fear, could

not be directed successfully against the enemy, and expressions of hostility merely increased his anxiety.

When the external traumas had been extremely severe, when buddy after buddy had been killed and the soldier himself had been wounded, a slightly neurotic predisposition was sufficient to lead him finally to believe that he was being pursued by a vengeful environment, that his "number was up," and that the enemy was aiming shells at him. His magnified guilt was thus expressed clearly and consciously. Although initially the veteran soldier had better defenses against neurosis than the man who developed a neurotic reaction after a few days or weeks of combat, the mechanics of decompensation were in the end much the same for both.

Why was hostility sooner or later expressed so futilely in our patients? We were primarily concerned with the soldier`s acute reaction in combat, but vital clues to this reaction were found in his previous personality make-up, that is, in the set of reactions and patterns of behavior with which he responded to each new situation. The normal healthy person is able to direct his hostility toward the attainment of useful and satisfying goals and accomplishes these aims without significant guilt or fear of punishment. He feels no need to hold his drives constantly in check or do penance for the effects of his own aggression. When he encounters frustration or competition he does not respond with outbursts of rage, nor does he invariably withdraw. Rather, he counters with purposeful, constructive action designed to overcome or circumvent the source of his frustration. The neurotic uses of hostility differ in many ways from the normal. The chief groups observed were the passive-dependent, the overtly aggressive, and the compulsive-obsessive. The various elements of these groups were common components of the histories obtained from acute psychiatric casualties.

Passive-dependent group. This group includes those who shun all overt expression of aggression and withdraw from any situation likely to arouse hostility. They are passive, timid, fearful, and unable to fight or watch a fight. They avoid the scene of an accident, dread entering a hospital to see a sick friend, and in general are unable to face traumatic events or express a purposive aggressiveness that would protect them against anxiety. Their hostility, covered by a rigid shell of timidity and passivity, is entirely unconscious. It is rarely expressed openly. Unsatisfactory family adjustment is characteristic of these men, Despite their resentments, they are usually dependent on one or both parents. Since the expression of hostility toward a person on whom one is dependent produces anxiety, their hostility necessarily remains unconscious, and an ambivalent

attitude is developed toward the parents (ref 5). Enuresis in childhood, an inadequate substitute for a more direct challenge to society, is a common symptom in these men. The pattern of withdrawal in these passive types may make them seem schizoid to the examiner. Anxiety develops early when these men enter combat, and many seek medical aid and evacuation before anxiety becomes severe. They make poor soldiers. Many never fire their rifles in combat. They are the despair of the battalion surgeon and the division psychiatrist, not to mention the company commander. The following case report illustrates their reaction in combat.

CASE 1. A 25-year-old private was admitted to the Center on 8 December1944. He had experienced 3 weeks of combat. A letter written by his platoon sergeant gives a colorful account of his conduct: "He is very high-strung and has no control whatsoever over his nerves or actions. I personally have never seen him fire his rifle. When all the others were out of their holes and in firing position he would seem to be `froze` in his hole with his head down. I know he is a devoted Bible reader and has sworn off drinking and cussing, whereas the rest of men are just the opposite. The more they see of the front, the more they drink and cuss. All in all I believe he does not come up to par with the average infantryman and is decidedly a bad influence on the men in the organization."

On examination 2 days after evacuation from the line he showed very mild anxiety and expressed his fear of returning to combat. His background was that of a timid, passive, fearful person who had never been able to express aggression in any form.

Overtly aggressive group. This group is quite different from the first. Instead of repressing their hostility toward a brutal, alcoholic father, for instance, they have responded with outbursts of temper and violence. They are impulsive, irritable, and resentful of any authority that symbolizes the parental figure. This resentment may be expressed in outbursts of rage, fights, disciplinary infractions, or alcoholism. These men try to gain security and stave off the threats of others by open attacks, which are usually not purposive or constructive. In combat such soldiers may perform feats of bravery, but when their physical expressions of aggression toward the enemy are frustrated, marked fear of retaliation develops and anxiety is produced. The resultant hostility cannot be redirected at the enemy, for the soldier feels that its expression would only bring retaliation. In line with his basic resentment toward parental figures, he is likely to turn his hostility against his own army, which has placed him in this dangerous situation. He develops a neurosis characterized by great hostility, irritability, and little guilt. In contrast to other types of neurotic patients, these men are likely to go AWOL from battle. Many develop anxiety quite early in combat, though some do well for a

(ref 5) Karen Horney : The Neurotic Personality of Our Time. New York: W. W. Norton & Company, 1937.

time. When they decompensate, however, they do so with intensity and suddenness. Case 2 is typical.

CASE 2. A staff sergeant was admitted to the Center on 12 October 1944,after 140 combat days. He was anxious, complained of fearfulness, and had a "jellylike" feeling in his stomach. He was moderately sensitive to noise, and the sound of truck motors bothered him. He thought continually of the Germans he had killed and of our wounded. He slept poorly. Two recurrent dreams were described. In the first a truck was coming down the road and the patient seemed unable to get out of the way. In the second he was shooting a cannon, but only BB shot came out of the barrel. He was a large, muscular man who had been regarded as one of the toughest and most courageous members of his division. He had hitherto experienced little anxiety in combat and had regularly volunteered for patrols, a rather unusual trait among experienced infantrymen. He frequently had spells of anger during which he performed acts of violence. On one occasion he shot some prisoners who were trying to escape, and he enjoyed killing Germans. The incident that precipitated his evacuation was the stabbing of two Germans inclose combat. In an artillery barrage several days later he became extremely anxious. In civil life he had been an amateur boxer and saloon brawler. He left home at the age of 16because he could not get along with his father, who beat him. He had a marked desire to excel others. His philosophy was: "I don`t take nothin` from nobody."

Comment. This overtly aggressive soldier made an excellent adjustment for a time. He "cracked" suddenly when overcome by fear of punishment for his own acts of aggression. The absence of depression and conscious guilt was of interest. A different picture of poorly resolved aggression is presented in case 3, in which there are also features of the passive-dependent type.

CASE 3. A 19-year-old private was admitted to the Center on 15 May 1944.He was one of a group of men who had been severely demoralized by poor leadership and heavy enemy action in the first few days of the break-through of the Gustav Line. He had had 1 month of defensive combat during which he had felt fearful and apprehensive. Three days before his admission his unit had gone into offensive action, and he was evacuated from the line in a state of confusion and agitation. Although oriented, he could not give a coherent account of his battle experiences and was tremulous and tearful. He stated that while going up on the advance he had felt like shooting the man in front of him. He expressed great fear of the dark and begged repeatedly and frantically that he be allowed to return to his ward before evening. "Don`t leave me alone in the dark," he said. "Sometimes I feel as if I could kill the dark."

He had a weak, easily excitable mother who had had "heart attacks" for many years. The patient was extremely devoted to her. His father was also easily upset, and quarrels between the parents were frequent. The patient stated, "Every time they fight I have a fit." The "fits" were severe tantrums in which the patient "saw black" and committed acts of violence. On one occasion he severely injured a fellow pupil in school after an argument. He had had enuresis until the age of 12, had stuttered, and had been mortally afraid of thunder, lightning, and the dark. He was excessively timid in the face of traumatic situations, illness, and accidents. He did not engage in sports and avoided excitement. He had been eager to join the Army and had had a herniorrhaphy performed at

his own expense in order to do so. He was consciously well motivated, but said that it would be impossible for him to shoot a German, and he had never fired his rifle in combat. He was evacuated to a base section hospital where his disturbed state cleared. After 2 months in a reconditioning center he was returned to duty where he promptly became panicky and was again evacuated in a tense, retarded, confused, pseudopsychotic state.

Comment. This soldier was a total loss in combat. He represents an extreme type of poorly resolved aggression. He was overtly fearful and tempestuous. When his hostility was stimulated by the stress of combat, he recoiled in panic from the consequences that would be evoked.

Compulsive-obsessive group. A representative of this group is overcareful, overconscientious, tends to worry, exercises great circumspection, and pays undue attention to detail. While full-blown rituals and phobias are uncommon, a soldier with mild compulsive-obsessive traits may be encountered in the combat zone. Owing to his meticulousness and conscientiousness he makes an excellent garrison soldier. He is amenable to discipline and attentive to details exasperating to others, and so often becomes a noncommissioned officer. He exhibits a strongly ambivalent attitude toward the family situation. While he may be overtly devoted to a neurotically ill mother, he harbors a great deal of unconscious aggression and accompanying guilt, manifested by extreme concern lest the object of affection become ill or injured. In order to curb his hostile impulses and protect those toward whom these impulses are directed, he erects a system of safeguards. He must be considerate, careful, neat, and orderly. He cannot pass a beggar on the street without experiencing a great rush of sympathy, and may give away his last dime. He is overly solicitous of the ill. By these acts and emotions he is unconsciously doing penance for the effect of his own aggression. In combat the dead and wounded are unconsciously regarded as manifestations of his own aggression. Guilt and anxiety arise early in combat (see case 5). A strong sense of duty causes him to endure his anxiety as long as possible, and his feelings of guilt may lead him to perform heroic, acts. When he finally becomes incapacitated, his illness tends to be severe and prolonged, with much depression and conscious guilt. Sometimes he drives himself to a point where his symptoms are almost psychotic (see case 4).

CASE 4. A private in an armored infantry regiment had done well in 4months of combat in Tunisia and at the Anzio beachhead. In the drive on Rome he was subjected to a heavy barrage, became tremulous, "froze" in his fox hole, and was evacuated. After rest and sedation he was still mildly anxious and depressed, but returned to duty. Four weeks later he was readmitted in an extremely tense and retarded state. He described his progressive anxiety in combat, a premonition that his "number was up," and a sensation of difficulty in getting his breath. He had developed severe phobias and obsessions. "Something tells me that if I

stand in a certain place I`m a dead man. If I crack the branch of a tree, it`s like it is bleeding. If a fellow asks me for money I have to give it to him or else I will be punished. All of a sudden I get an idea that if I don`t count up to 100 we’ll all be dead."

He could not get the image of the dead and wounded out of his mind. He had stopped carrying a gun in combat because he was afraid he might accidentally kill one of our own men. His background was characterized by an ambivalent relationship to a chronically ill mother. He was devoted to her. When he left the house he would worry lest she have a "spell" before he returned. He had never married. "My mother came first," he said. Along with this devotion he had feelings of resentment and spells of irritability. At his work he often developed obsessive thinking. "Something would say do it this way, or do it that way.". Anxiety was expressed in restlessness that led to fairly frequent changes of jobs. He had always overreacted to traumatic situations. He could never attend funerals or visit a sick friend in a hospital and was invariably overly sympathetic to cripples and beggars. "I would give them my last dime."

Comment. This illustrates the severe reaction that may develop in a person with unresolved aggression and obsession.

CASE 5. A sergeant in an infantry regiment was admitted to the Center 3days after the start of the offensive thrust across the Garigliano River. He had had 1month of combat duty. He belonged to a platoon disorganized and demoralized by in unfortunate tactical situation. After 2 days of rest and sedation he was still agitated. He expressed vividly his fear and horror of what he had seen, along with it a sense of guilt at having left his comrades. He repeated, "I`ll work, I`ll do anything to help them. Let me dig graves!" His background was that of an extremely compulsive, overscrupulous, conscientious person with a great deal of underlying guilt. He was extremely concerned over his mother`s health. She had had a nervous breakdown after he entered the Army, a misfortune for which he felt responsible. He did not marry until he joined the Army for fear that people might think he was evading the draft. A friend had offered to pay his way through college, but he refused because he feared he would not be able to return the money. His feeling of over sympathy was often preceded by a momentary resentment. An incident while he was a grocery clerk illustrates this reaction. "An old lady would come into the store. I had a feeling I didn`t want to fool with her, but I`d end up by not only waiting on her, but also by carrying her bundles back to the truck." He described his habit of counting. "I could never pick strawberries. It would run me crazy, counting them."

Comment. This meticulous and conscientious man adjusted splendidly in garrison. His sense of guilt, with its underlying unconscious hostility, was expressed in his frantic desire to act as gravedigger for his fallen comrades.

Most neurotic patients show characteristics of more than one group. Thus timid soldiers may have compulsive characteristics or react at times with outbursts of temper. The three types are presented separately for convenience and clarity. Some may prefer to classify the first group as constitutional psychopaths and the second group as inadequate and aggressive. It is more constructive, dynamically, to

consider them in terms of their neurotic drives, rather than on the basis of fixed personality defects. In the second group, particularly, recognition of the underlying dynamics of anxiety is important for proper evaluation and treatment.

GROUP IDENTIFICATION AND MOTIVATION

The soldier`s ability to adjust himself in his group is an index of his defense against anxiety. The normally reacting soldier identifies with his group, partakes of is common culture and aims, and takes on the "protective coloration" of the group. If he is able to form healthy attachments his resistance to the anxiety-provoking stresses of combat will be high. Poorly handled hostility not only handicaps the soldier by preventing him from directing it purposefully against the enemy, but also hinders him in using the group for his protection. Unless motivated otherwise, he carries over to the Army the psychologic reactions he has shown earlier in the family and the community. The Army has assumed the protective and authoritative functions of the family. It directs, clothes, feeds, shelters the soldier, and he tends to responds with the patterns of hostility and resentment and loyalty and devotion that he has shown in the earlier group.

The timid, passive person makes a poor group identification. He does not enter into the common strivings of the group. His schizoid habits make him a poor mixer. When there is need for common aggressive action he retires into his shell of passivity. Whatever attachments he forms are personalized, dependent ones, patterned on those of his past life. When the officer or noncommissioned officer on whom he has relied is removed, his chief source of protection is gone and he is helpless. Furthermore, because of the personalized nature of the relationship, he finds it difficult to turn his loyalties to anew leader. His pattern of dependence is an ambivalent one, with underlying hostility. When the person on whom he is dependent is killed or wounded, he experiences a corresponding measure of guilt, fear, and anxiety.

The overtly aggressive person likewise has difficulties in relation to his group. His individualism and resentment toward authority have been described. With intelligent handling he may make a good adjustment for a time, particularly if he is favorably disposed toward the aims of the group—for example, killing the enemy. It is when the inevitable anxiety produced by combat begins to mount that he develops difficulty. When he is no longer able to direct his hostility against the enemy, he is likely to turn it against those forces of authority,

the company commander, the Army as a whole, or his draft board, which he feels are responsible for his plight.

CASE 6. A private was admitted to the Center after 10 days of combat in the drive against the Gothic Line. A week earlier he had become tense, weak, and shaky when his platoon was immobilized by enemy artillery fire. A disorganized situation arose and the soldier and several others "took off" to the rear. He reported to his battalion aid station in a state of considerable anxiety and was evacuated to the division clearing station. After several days of rest his anxiety was resolved and he was discharge to duty. On his way forward his group was shelled. He wept and trembled and he was again evacuated. On examination at the Center he showed no overt anxiety. He talked at great length about the injustices that he had suffered in the Army. He had been drafted despite the fact that he was married and had a defense job. He should have been a message center clerk but was wrongly placed in the Infantry. He could see no need for our fighting in Italy and felt that we were "stooges for the British." He believed that his officers had mismanaged the tactical situation and that this mismanagement had led to his breakdown. None of his resentment extended to the enemy. He had never fired his rifle in combat, although he had had several opportunities to kill Germans. He said that if he shot a German it would be on his conscience. "They are white, like us," he said. In civil life he had always resented authority and found it difficult to get along with people. He could not endure arguments or competition and avoided situations provoking them. As a child he had had temper tantrums and frequent quarrels. He preferred fishing to team sports. He had never adjusted well in a group. His father was an alcoholic and when inebriated would terrorize the family. The patient, however, protested great affection for him. He got along well with his wife. "She understands me and leaves me alone, "he said. He had never been able to "stand" ill people or beggars, who, be felt, imposed upon him.

Comment. Though possessed of neurotic traits, this soldier had not manifested disabling symptoms in civil life. With his inability to handle any aggression-arousing situation, it is not surprising that he developed overwhelming anxiety in combat. In a person who has resented authority since childhood, the turning of his hostility toward the Army is understandable. The difficulties of motivating such a person and incorporating him into a group are obvious.

The soldier with compulsive-obsessive traits has different problems. Because of his considerateness and conscientiousness he is usually well liked within the group. He makes close friendships, but these relationships are ambivalent, with marked unconscious aggression. When casualties occur he develops great guilt and anxiety. Thus the group, instead of supporting him, multiplies his points of vulnerability. His devotion to duty and his sense of obligation to the group cause him to endure his anxiety, but he is unable to use the group to resolve his anxiety.

The normal soldier may also develop attitudes toward the Army that precipitate anxiety. When a soldier who already has some normal combat-induced anxiety encounters a situation that arouses

resentment he is unable to express constructively, his anxiety increases. If he feels that the group is not working in his interests, his ties with it are loosened and he acts instead as an individual, and so less effectively. When anxiety becomes uncomfortable, the normal soldier directs his hostility toward those responsible for his predicament—the enemy. This transfer is facilitated when the soldier is properly motivated to fight. Although the majority of men who served with the Fifth Army expressed no hatred of the enemy and were not fully aware of the political implications of the struggle, many men with little or no unresolved aggression slowly developed anxiety and were able to carry on in combat for long periods with scarcely any other motivation than small group attachment and loyalty. It was evident, however, that the more directly the soldiers hostility could be channeled against the enemy, the more efficiently was he able to protect himself against anxiety. It was thus highly desirable that the soldier know why the enemy had to be killed. Informing the soldier does not arouse purposeless rage or create undesirable hate but, rather, provides for the proper expression of hostility when it occurs. (Ref 6)

The group with which the average soldier identified was the rifle company or platoon. Within this group he formed the loyalties and friendships that motivated him to endure great dangers and hardships. The company was, however, a notably perishable group, and when great losses occurred the soldier found himself alone and isolated, his sources of motivation nearly exhausted. A more stable and enduring group was needed. Ideally this would be the Nation itself, but the Nation was apparently too large and too intangible a concept for the soldier to grasp in a meaningful way. A more suitable group was the division, and efforts were made to stimulate the soldier`s emotional identification with this durable, but still familiar, unit. Thus it appears that anxiety in combat is best controlled by building up an effective, indestructible group with which the individual soldier can identify, and motivating the soldier strongly to adopt the aims of the group so that he call direct his hostility without reservation against the enemy. In this way many mildly neurotic soldiers are enabled to adjust to combat. It is neither possible nor advisable to screen out all men with neurotic traits, and it is possible to motivate many of them to become an integral part of a potent fighting group.

SUMMARY

The precipitating factors, the typical development and course, the relative importance of certain dynamic processes, and the great

(ref 6) See section on "The Base Section Psychiatric Hospital."

prophylactic value of social pressures all serve to distinguish combat-induced anxiety from the neuroses of civil life. Mortal danger is by far the most important single contributor to disabling anxiety in combat. Psychiatric casualty rates vary more consistently with the intensity of fighting than with any other known etiologic factor. Plasticity and responsiveness to proper handling characterize the early stages of combat-induced anxiety states. Hostility plays an important role in the development of combat anxiety. When aggressive effort arouses feelings of guilt and a sense of impending retribution, the soldier`s anxiety in combat rises and persists disproportionately to the physical peril in his environment. Neurotic anxiety in battle may be rooted in predisposing factors in civil life. Anxiety develops also on a comparable basis in the "normal" veteran whose previously healthy attitudes toward aggressive behavior have been distorted, chiefly by repeated frustrations in battle. Complete identification with a durable group is a valuable prophylaxis against neurotic anxiety.