Psychiatry at the Division Level
Lieutenant Colonel Albert J. Glass (ref 10)
Medical Corps, United States Army
In considering the neuropsychiatric program at the level of the division treatment center it should be remembered that many soldiers showing the milder neurotic reactions and states of physical fatigue are returned to duty by the forward medical services, i. e., by the battalion and regimental surgeons. Accordingly, at the division treatment center there is a greater concentration of the more severe reactions than is found at the forward stations, and at the same time less concentration than is found at the army psychiatric center. In the early part of World War I both the British and French medical services learned that war neuroses were more successfully treated at forward areas than at rear installations. In order to put this well-established fact into practice, psychiatric specialists were added to the staffs of American divisions in January 1918. They achieved excellent results, and, as they gained in experience, were able to return as many as 50 to 60 percent of soldiers with acute war neuroses to combat duty. These results were achieved by simplified methods at forward installations. Their methods, experience, and achievements were duly noted and included in the medical annals of World War I. At the beginning of World War II no provision was made for the forward treatment of psychiatric casualties. Again we learned the hard way. The neuropsychiatric casualties were at first treated at rear installations, and only about 5 percent were returned to combat. The demonstration by Hanson and Tureen in 1943 of a successful return to combat duty of 70 percent of the patients treated in forward areas reestablished the principle recognized 25 years before. In October 1943 the War Department authorized the addition of a psychiatrist to the staff of the division surgeon, and thus began psychiatry at the division level.
It is the special concern of the division psychiatrist to prevent the loss of manpower from psychiatric causes, including not only the obvious cases of "battle neurosis," but also all disease in which the functional component is the primary cause for the soldier`s removal from combat. Many of these cases are loosely grouped under the term
(ref 10) Formerly division psychiatrist, 85th Infantry Division; and currently chief, Psychiatric Branch, Neuropsychiatric Service, Letterman General Hospital.
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"psychosomatic." The psychiatrist is also concerned with morale and disciplinary problems that entail the loss of manpower. Self-inflicted wounds, another evidence of functional escape from battle, and their number and frequency, become his concern. The maintenance of fighting efficiency, insofar as it depends on mental health, lies in his province. It is an important part of his work to diagnose and eliminate promptly those soldiers who are mentally and emotionally unfit for their duties. The psychiatrist must not limit himself to the narrow realm of obvious mental disorders. He should have close contact with the medical officers who treat and evacuate medical and surgical casualties. He must be familiar with the workings of the division medical evacuation system. His work is closely linked with that of G-1 (personnel), G-3 (operations and training), AG(classification and assignment), and the judge advocate. If he is to be of greatest help to his unit, he must know and confer with these various departments. The duties and functions of the division psychiatrist vary according to the tactical situation. In combat he is mainly occupied with the treatment of combat-induced anxiety states. As the division goes into rest areas his work shifts to medicolegal examinations and the instruction of medical and line officers in the diagnosis, management, and prevention of neuropsychiatric casualties. His duties are best understood in relation to the precombat, combat, and postcombat periods of the division.
THE PRECOMBAT PERIOD
During the precombat period the psychiatrist, like other staff officers, must make preparation for impending battle. The first consideration is to insure ample facilities for the sorting and treatment of acute battle casualties. The neuropsychiatric treatment unit should have equipment and personnel to accommodate 100 patients at a time. A planned effort should be aimed at the prevention of combat psychiatric casualties. Since the majority of such casualties arise from the infantry, the psychiatrist’s efforts should be mainly directed toward this branch. A series of lectures and informal talks should be given to the medical and line officers of the infantry regiments, who are indirect contact with the solders and are thus in a position to influence their behavior.
Informal discussions with the battalion surgeons offer an excellent means of meeting these men and acquainting them with the neuropsychiatric program. It is important not to create the impression that the psychiatrist is another "rear echelon officer," and thus presumably an unpractical person who intends to keep every neurotic soldier on full duty-status. The battalion surgeon will appreciate
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information on how to deal with the neurotic casualty, the criteria for evacuation, and the ways of differentiating the normal battle reaction from the abnormal reaction. The battalion surgeon should be urged to treat mildly neurotic and physically exhausted patients at his aid station when it is conveniently located. He should be assured that if a soldier referred to the division psychiatrist is returned to duty, a complete report will follow. Consultations with the psychiatrist during rest periods should be encouraged.
The psychiatrist`s basis of procedure should be described to the battalion surgeons. It should be made clear that if a man is disabled, whether from wound, injury, disease, or neuropsychiatric causes, he should be evacuated. If, however, his complaints are mainly subjective, the objective findings are negative, and his disability is questionable, he should not be evacuated. The combat period is no time for diagnostic surveys or hospitalization for insufficient cause. Stress should be placed on the "gain in illness" syndrome, which often occurs with evacuation and the subsequent fixation of symptoms that may render the soldier neurotically disabled. The majority of subjective complainers are returned to duty after hospitalization and become constant "sick book riders." There is an inevitable lowering of morale in any unit in which the medical channels become the easy way out. Such units have as high an AWOL rate during combat as units whose medical officers have a fair, but firm, policy.
The unhappy and discontented soldier who returns from the hospital stating that "they did nothing for me," whose talk is of reclassification, and whose poor morale is contagious to the other men should be considered. After two or three such ineffectual hospitalizations even the volitionally sick soldiers cannot be deterred by disciplinary means, and become useless to their units. They either become disciplinary problems (AWOL) or are evacuated as "exhaustion" cases with a note from the company commander pleading that they not be returned to combat. It is especially dangerous to evacuate such men during a combat period, when the gain in illness is most operative and others are stimulated to act in a similar manner.
The psychiatrist should be aware that the battalion surgeon feels, for good reasons, that he is the "forgotten man" in military medicine. He endures more physical hardship and mental trauma than his medical colleagues in the rear, his promotional opportunities are limited, and he has many duties. Naturally be does not take to additional problems. He does understand clearly the necessity of conserving the fighting forces, however, and will cooperate when properly informed and motivated.
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The importance of the regimental surgeon in the neuropsychiatric program should not be overlooked. As a staff officer he is concerned with the neuropsychiatric rate of his unit and is therefore sympathetic toward the preventative program; he controls the medical evacuation policy of his regiment; he directly influences and controls the procedures of his battalion surgeons; and in short, is the key figure in the intraregimental treatment of psychiatric casualties.
Line officers are best approached through a formal lecture given at an assembly of all company grade officers of a regiment. At the onset, after the purpose of the lecture is stated, such terms as "psychoneurosis" should be defined in simple language. The normal battle reaction and its difference from the abnormal reaction should be explained. It should be emphasized that the disabled soldier must be removed from combat, but that when the soldier shows only the normal battle reaction the line officer should be the psychiatrist and by reassurance or exhortation maintain the soldier on duty status. It is essential not to leave the impression that all men should be kept on duty at all costs. Rather, officers should be assured of cooperation in removing from combat the neurotically disabled soldier who is a menace to the security of others and communicates his panic reaction to others. It is important that the line officer realize the role of leadership in producing or preventing psychiatric casualties. The contagious nature of fear should be explained. Examples of the disastrous effects of panic in an officer may be cited, of the possibility that 50 percent of the men in a platoon may become psychiatric casualties, with the consequent peril to the rest of the men and to those in adjacent units when a unit is suddenly deprived of much of its fire power.
Psychosomatic disease, "goldbricking," and the problem of soldiers of poor character—the constitutionally inadequate—should be discussed, along with the line officer`s part in keeping such soldiers on duty status. The danger of aiding the evacuation of these men by notes that state only their subjective complaints should be mentioned, but it should be made clear that the medical officer welcomes the line officer`s comments concerning the soldier`s ability to perform. A plea should be made for fair treatment of the soldier returned after psychiatric treatment, that he be given a fair trial of duty and not be subjected to discouraging or disparaging remarks from officers and others. There should be some discussion of the Army Regulations (AR 615-368and AR 615-369) that provide for the administrative, as opposed to medical, discharge of alcoholics, drug addicts, trouble making psychopaths, and of the inept, untrainable, incompetent and enuretic soldier. Line officers should be warned that such men, if hospitalized, will only be returned to duty.
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The psychiatrist can operate most effectively at the level of the clearing company, which is the funnel through which all patients are evacuated from the division. It is important that he identify himself with this unit in order that its medical officers may understand and further the psychiatric program. Much will depend on his personality. As he meets other medical officers at meals and recreation the congenial psychiatrist can do much toward influencing their attitude toward the neuropsychiatric program and increasing their understanding of the psychogenic factors that are an inevitable part of military medicine.
A plan evolved from such informal discussions in one division clearing company may be of interest. Two goals were set up: to do better and more diagnostic work at the clearing company, and to reduce unnecessary hospitalization of soldiers with psychogenic disease. A division medical disposition board, consisting of all medical officers assigned to the clearing company, was established to examine and dispose of patients coming to the station with mainly subjective complaints. The psychiatrist acted as recorder. Patients were selected by the admitting officer and held in the clearing station ward on quarters status. Board meetings were held daily if necessary, but usually every other day. The soldier was brought before the board to be questioned and examined. The psychiatrist remained in the background and made no attempt to dominate the proceedings. After the soldier left, the board considered the disposition of the case. Discussion was free and often prolonged. The psychiatrist waited patiently and then, pencil in hand, asked for the board`s diagnosis and decision. This procedure had a sedative effect on the medical guessing of some officers, who in such cases were often squarely confronted with the psychogenic aspects or volitional motivations of disease.
When a decision was made to evacuate a soldier to a hospital for further study, a copy of the board findings accompanied him, with a request that the hospital`s findings be communicated to the board. Soldiers considered unfit for combat duty were evacuated directly to a hospital for reclassification. Those returned to duty were accompanied by a copy of the board proceedings for the battalion surgeon, a procedure that strengthened his hand in refusing subsequent evacuation for the same complaint and at the same time removed from him the onus of blame for such a refusal. This plan was successful in preventing up to 50 percent of unnecessary hospitalizations. Such a plan has the disadvantage that it operates less satisfactorily during combat periods, when the medical personnel is busily engaged in evacuation and other duties and the facilities for such patients are limited.
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Consultations and routine admissions are part of the work of the precombat period. Many of the neuropsychiatric patients admitted to the clearing company are recurrent combat casualties. Others are referrals from the medical disposition board. Referrals from battalion surgeons make up about one-half of these admissions. It is well for the psychiatrist not to be over conscientious about his return to duty rate at the time. A soldier who develops a chronic anxiety state in ordinary garrison existence will inevitably become a battle casualty. If administrative discharge appears to be indicated a detailed letter must be sent to the soldier`s commanding officer, giving the reasons for discharge, recommending the proper disposition, and explaining why evacuation through medical channels is impossible.
THE COMBAT PERIOD
During the combat period, when the psychiatrist is mainly occupied with acute neuropsychiatric casualties, his work will be facilitated by a knowledge of the tactical situation. Such information can be obtained readily through the intelligence and operations sections of the medical battalion and from tactical maps showing which units are engaged and the names of towns and nature of the terrain through which fighting is progressing. With this knowledge he will be in a better position to assess the degree of physical exhaustion and mental trauma of his patients and to understand their stories. He will also know when to prepare for a sudden increase of psychiatric casualties.
The principle of the greater success of forward treatment of psychiatric casualties can be carried to absurdity. The truth is that the needed relaxation and rest for the patient must be obtained, either by heavy sedation in a "hot spot" or by removing him to a safe area. There are disadvantages in heavy sedation at this level: more personnel is needed to care for heavily sedated patients; the patient required a longer time to require from the influence of the drug; and even when used for only two days, heavy sedation like alcoholic intoxication has a demoralizing effect—the patient tends to drown in self-pity and is less likely to re-establish motivating factors as loyalty to his unit, pride, and other superego forces that keep him in combat.
The disadvantage of an extremely noisy and potentially dangerous site for the care of psychiatric patients was demonstrated when the neuropsychiatric unit of one division was located at the clearing company during the beginning of the Gothic Line offensive. About 40 patients were under treatment. Mild anxiety states became more severe with the continuous roaring of friendly artillery around the clearing company, and matters became much worse when the familiar
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whistle of incoming shells was heard. Some patients rushed to slit trenches, others became more tremulous and tearful, and sedation had to be kept at a point of narcosis to make sleep possible. There was real danger that the site might be shelled, and protection of patients profoundly asleep is difficult under these circumstances unless they are deposited in slit trenches. On the following day, when the patients were removed to a safer area several miles to the rear, there was a prompt subsidence of acute symptoms, sedation became unnecessary, and after several days many of the soldiers were able to return to combat. A suitable area for such treatment is not necessarily one free of artillery noise. Friendly artillery rumbling in the distance and occasionally nearby is not necessarily a disadvantage, but may even be helpful in reminding the soldier that he is still in the war. During the period of recovery from physical exhaustion and acute anxiety patients should, however, be relatively free from actual danger.
Similar experiences were reported by a regimental surgeon who instituted intraregimental treatment of mildly psychoneurotic patients at the service company. This treatment proved a valuable adjunct in the preventive therapy plan of the battalion. Under this plan a soldier who became excessively fatigued or showed signs of impending neurotic disability was sent by the company commander with an explanatory note to the battalion surgeon, who examined him. If the battalion surgeon agreed, the soldier was sent to the regimental aid station, usually situated at the service company, without medical categorization. There he was given facilities to clean up and sleep, usually with slight sedation. Normally he was not counted as a casualty. After 36 to 48 hours he was returned to his unit, refreshed and relieved of much of his anxiety. The regimental surgeon supervised this installation, but since no real medical therapy of the orthodox variety was undertaken, the whole procedure was accomplished by nonmedical personnel. The object of the scheme was to prevent the occurrence of a disabling neurotic reaction in a stableperson by allowing him a period of stabilization in relative safety to aid in rebuilding his psychologic defenses. The results obtained were excellent.
Experience indicates that during combat the division neuropsychiatric unit should operate as a separate installation, with its own mess and administrative facilities, and that it is best located 3 to 5 miles to the rear of the clearing company, on the ambulance route. Under these circumstances heavy sedation will not be needed and the training program can be conducted without hinderance. Even if the evacuation hospital is not far removed from the neuropsychiatric
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unit, there is a definite symbolic difference between being sent to a hospital and being treated within the division, which is important in view of the secondary gain mechanism.
The psychiatrist need spend only a few hours a day at the neuropsychiatric unit. He should spend most of his time at the clearing company where he will be available for consultation and where his presence will serve as a reminder of the psychogenic element in illness. Here he can provide psychiatric opinions when asked "What do you think of this fellow?" or when he is invited to "take a look at this patient." As he undergoes the same trials and tribulations as others at the station the medical and administrative officers will be more inclined to accept his work as an important medical function and to cooperate by providing him with supplies and personnel.
Management of the combat psychiatric casualty begins immediately after his admission to the clearing station. The first step is the screening of cases and the prompt evacuation of severe and recurrent casualties to the army psychiatric center, with or without further sedation, as indicated. Only the mild and moderate cases are retained for treatment at the division level. This preliminary screening removes as many as 25 to30 percent of the psychiatric admissions to the army psychiatric center, which can deal with them more effectively when they are "fresh," and leaves the slim resources of the division unit available for dealing with the less affected group. Actual results demonstrate that less than 10 percent of such screened cases were returned to combat from the army psychiatric center. The rest of the patients with mild or moderate reactions are housed in a special tent at the clearing company where they are given enough sedation to induce sound sleep for 12 to 24 hours. The initial dose of sodium amytal, the drug most frequently employed, varies from 0.2 to 0.6 gm. An additional 0.2 to 0.4 gm. may be necessary every 6 hours. For some patients no sedation is necessary. All they crave is a suitable place and an opportunity and they are asleep before the ward attendant arrives with the medication. Patients who arrive wet, hungry, and cold are promptly stripped of their clothing, wrapped in blankets, and given a hot drink and enough sedation to put them to sleep. Temperatures are taken on admission and again on the following morning.
Occasionally patients labeled "exhaustion" are found to have organic disease, such as infectious hepatitis, appendicitis, or malaria, with a fever of 101? F. or more. Such cases are promptly transferred to the medical section of the clearing company. The psychiatrist should be on the alert for such diagnostic errors, since in the hurry and confusion of the battalion aid station some errors are unavoidable.
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Patients are interviewed briefly on admission and again more intensively the following day, or after they have slept for 12 to 24 hours. A thorough past history is seldom attempted, except when further information is needed for diagnosis or disposition. After an interview of 10 to 20 minutes the psychiatrist decides whether the soldier is suitable for treatment at the division level. Those selected for intradivisional treatment are told that they are physically and mentally tired. They are given some explanation of their symptoms in simple terms, assured in a sympathetic but positive manner that they are suffering only a mild temporary disability, and told that they deserve a few days of rest before returning to their units and will be taken to the division rest area that day. Occasionally a soldier voices doubt as to his ability to "stand" combat. He is reassured in a firm manner that only rest is required to restore him to normal. Often the soldier agrees with the opinion and leaves the interview expressing gratitude for the several days of promised relief from combat. It is important that the decision should appear to be made at this time in order to prevent "dispositional anxiety" during the rest period.
Patients considered unsuitable for treatment at this level are told merely that they will be given treatment at another installation. It is a sound and time-saving policy not to engage in argument with these patients since to do so merely creates a more difficult therapeutic problem for the next echelon. Experience proves that when a comment is written on the reverse of the emergency medical tag, the tag should be placed in a sealed envelope and given to the ambulance driver with instructions to deliver it to the admitting clerk at the next installation. Any other method gives the soldier an opportunity to read and be influenced by his own diagnosis. Even in dealing with the acute psychiatric casualty it is unwise for the division psychiatrist to state positively that the soldier is totally unfit for further combat, since because of the changing nature of battle neuroses, recovery for combat may be accomplished at the next echelon. Soldiers treated at the division neuropsychiatric unit comprise 60 to 70 percent of the total neuropsychiatric admissions to the clearing company. Most of them can be returned to duty.
The first day at the treatment center is set aside for rest and relaxation. Reading and writing materials are provided. Shaving is required and the necessary utensils and hot water are made available. During this 24-hour period patients are housed in ward tents and sleep on cots. On the following day they are placed in pup tents and the training regimen, consisting of short marches, calisthenics, and organized athletics, varied by lectures, orientation, and motion
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pictures, is started. This regimen, continued for 2 days, is supervised by a line officer, and assisted by non commissioned infantry officers. Inclement weather may restrict the program. When possible, patients are taken to a shower unit where they can also obtain a change or clothing. No sedation is given at any time during the training regimen. A duty atmosphere is fostered and maintained by the fact that the majority will be returned to combat. A soldier who has completed 3 days at the training center is briefly interviewed by the psychiatrist on the fourth day. He is questioned about his general condition at this time. The ward attendants and the line officer keep notes on the sleep, appetite, general demeanor, attitude, and sociability of each soldier. These notes are relied on to indicate the general condition of the soldier. About 75 percent of these soldiers, constituting about one-half the total psychiatric admissions to the clearing company, were returned to combat. Recurrences from this group averaged less than 25 percent of the total number returned to duty from the division training center.
To summarize the various operations of the division neuropsychiatric unit: When not in combat the unit remains at or near the clearing company. During combat it is separated into a forward and a rear section. The forward section, consisting of the psychiatrist with several ward attendants, located at the forward clearing station and using its equipment, sorts all incoming psychiatric casualties. The work includes the prompt evacuation of patients with severe reactions, the detection and proper disposition of soldiers with organic illness who have been labeled "exhaustion," and the preliminary management of those deemed suitable for treatment at the division level. The psychiatrist is available at the clearing station for consultation the greater part of the day. The rear section of the unit, with its own mess and administrative facilities, located 3 to 5 miles to the rear of the forward clearing station, has the function of training and rehabilitation. It is nominally commanded by an infantry officer. The psychiatrist spends a few hours each day at this section, primarily to interview patients who are considered ready for return to duty.
Criteria for Return to Duty from the Division Level
The psychiatrist must be methodical in deciding which soldiers are to return to combat. It has been made clear that severe anxiety states, terror reactions, severe depressive states, and gross hysterical manifestations are not suitable for treatment at the division level. The soldier with a moderate anxiety state, who reiterates that he "can`t stand those shells," or "can`t stand it any more," offers the most difficult problem in disposition at this level.
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Objective Criteria
The psychiatrist experienced in handling acute combat casualties is often able to arrive at a decision for noncombat status disposition after a few minutes of observation. How the patient looks is most important. The following signs are discussed in order of their importance.
Apathy is often confused with fatigue. If it is the sole objective finding it is wise to defer all opinion until the soldier has had 24 hours of rest and sleep. Mild apathetic states are not unusual on admission and disappear rapidly with recovery from physical fatigue. If, after the soldier has recovered from fatigue, he continues to be preoccupied, takes little interest in ordinary activities, appears withdrawn, and sits alone, apparently absorbed in battle memories, he should be evacuated for further treatment.
Information received from others. Observations of the soldier`s behavior by other observers, trained and untrained, are a valuable aid in evaluating his condition. For example, a note from the platoon leader or company commander stating that the soldier endangers the safety and morale of others by going into a panic state when there is shelling in the vicinity is of utmost importance and takes precedence over any other single sign or symptom. Such soldiers are almost invariably evacuated. On the other hand, a note that merely reiterates the soldier`s symptoms has little value. Information obtained from trained observers in the neuropsychiatric unit isof great importance in determining the usual attitude and behavior of the patient. Thus a soldier whose behavior is observed to be within normal limits is returned to duty with less consideration of his subjective complaints.
Tremor and tremulousness. Mild to moderate degrees of fine tremor, as a single sign, should not be considered a bar to useful combat duty. Tremor of a coarse type or a generalized state of increased tension, even when moderate, indicates much unresolved anxiety and is an ominous sign of unfitness for combat.
Depression. True depressive reaction, if continued after 3 or 4days, is a cause for removal from combat duty. Mild degrees of depression are common in soldiers faced with return to combat, and should not be considered disabling.
Restlessness and irritability. Some soldiers pace restlessly about, complain of insomnia, and cannot be interested in reading, writing letters, or other ordinary activities. This condition, when persistent, indicates a continuing state of tension and offers a poor prognosis for combat duty.
Noise sensitivity exceeding the limits of the normal battle reaction is indicative of a severe anxiety state. In the mild and moderate
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anxiety reactions such sensitivity is pathologic. The on-guard reaction, however, is common and quite normal in useful combat troops.
Emotional lability is one of the least reliable signs. Tearfulness alone should not be considered an indication of disability, but in conjunction with restlessness and irritability it is it significant sign.
Vasomotor lability. Elevated blood pressure, up to 160(systolic), increase in pulse rate up to 120, and excessive sweating are not infrequent on admission. There is usually a return to normal limits after rest and sedation. The persistence of such findings in the absence of other findings should not be considered disabling.
The general attitude of the soldier is closely related to his motivation and willingness to return to combat. Neither resentfulness nor belligerency, on the one hand, nor the behavior of the sympathy-seeking soldier who endeavors to prove the sincerity of his symptoms by being overly polite and cooperative, on the other, should play any part in determining the soldier`s ability to perform in combat.
Subjective Criteria
Symptoms. Although what the patient tells the psychiatrist is of less importance than the objective signs, there are characteristic symptom and tales of incidents in battle with which the psychiatrist should be familiar in order to evaluate the degree of psychic trauma in his patients. Without discussing the psychodynamics of combat neurosis, it is pertinent at this point to explain the episodic nature of the conditions under which soldiers fight and the episodic manner in which psychic battle traumas are delivered. Some of the literature on combat psychiatry leads one to suppose that battle anxiety gradually and constantly increases to a point of saturation, at which time the soldier becomes a casualty. This may be true in some instances, but the majority of soldiers do not experience a gradual rise of anxiety, but, rather, an episodic increase of the anxiety level, with intervening partial remission.
Combat soldiers manage fairly well until a close shell hit is encountered, causing nearby casualties. At this point abnormal anxiety emerges and becomes part of the soldier`s burden. With another close encounter his phantasy of invulnerability is still further weakened, and the anxiety level may now become disabling. The number of traumatic episodes the soldier can bear without becoming a casualty depends on the severity of the trauma and on his personal pride, motivation, and loyalty. The anxiety state evolves when the soldier suffers a narrow escape, at a time when casualties about him are heavy, and emerges from the episode feeling that, "it almost got me that time.``
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The intermittent nature of combat determines the manner in which the soldier develops anxiety. Units seldom attack continuously. After 3 or 4 days the company is placed in battalion reserve; after 6 or 7 days the battalion goes into regimental reserve; and after 2 or 3 weeks the regiment is moved into division reserve.
During these reserve periods the soldier experiences some degree of relief from battle dangers. It is true that he is within artillery range; yet the casualties of units in reserve areas, beginning within the battalion reserve, decrease sharply as they move into division reserve. A soldier may go through many days of a campaign without having a severe psychic trauma, such as the "close shell hit, casualty-producing episodes" described. Under these conditions he seldom experiences severe battle-induced anxiety, for he still retains his phantasy of invulnerability.
It is important, therefore, for the psychiatrist to know how many combat days the soldier has experienced, in order to evaluate the severity of the psychic trauma he describes. Often he has not experienced psychic trauma at all, but is merely expressing distaste for battle. Particularly is this true of the new replacement, whose anxiety is mainly anticipatory. On the other hand, a genuine account of severe psychic battle trauma, repeated over a period of time, may indicate true disability, even in the good soldier.
Background. At this level background is of relatively little importance in considering a case. Seldom is there time to take a thorough past history, and so frequently are neurotic traits and tendencies admitted that the psychiatrist becomes aware that soldiers answer leading questions with the interpretation most useful to their situation. Certain easily elicitable facts are of course important, and mental deficiency is one such factor. Mentally deficient soldiers usually do not react to anxiety well. They have little ability to erect defense mechanisms or to adjust themselves when terrified. They cannot grasp or feel motivated by ideals—honor, pride, or loyalty to their unit. Their intellectual immaturity is often paralleled bye motional immaturity.
In a similar category are those soldiers with lifelong somatic complaints, who are often somewhat mentally deficient as well. These "poor miserable souls" have little defense against environmental anxiety thrusts, and are useless in combat. They have a lifelong habit of evasion, and it is not surprising that they become early psychiatric casualties. One learns that exhortation and persuasion are of little avail with them. They seldom present a severe clinical picture, but in the main they are unsalvageable for combat.
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Motivation as used here denotes the soldier`s willingness to return to combat. Those in whom motivation is poor usually inform the psychiatrist of that fact at the beginning of the interview. Those in whom it is fair do not commit themselves, but in general are lukewarm toward the idea of further combat. Good motivation is rare and lifts the spirit of the psychiatrist whenever encountered. It is a melancholy fact, however, that in soldiers who demand return to duty one must take care to rule out psychosis and severe guilt reaction.
Criteria for Disposition
In using these criteria to determine the disposition of a case, the following factors should be taken into account.
1. All signs and symptoms must be evaluated in relation to the combat-induced anxiety states. It has been pointed out that the standards application to the civilian type of neurosis are not relevant in judging battle reactions. The important factors in determining fitness for combat are the amount and intensity of external fear and their effect on the soldier. Little consideration need be given to background, except in mentally defective and constitutionally inadequate soldiers, who are unusually soldiers who are unusually susceptible to anxiety. No doubt there are other susceptible types, but to detect them is difficult. Moreover, uncovering latent anxiety-bearing material when it cannot be adequately analyzed and treated is of little value and may be harmful. In almost all cases at this level it is best to keep psychotherapy on a superficial and environmental plane.
2. Physical fatigue produces exhaustion but not anxiety. Only fear can produce the anxiety state. Fatigue decreases resistance and in many cases permits a low level of anxiety to become disabling; that is, the threshold for the ability to handle anxiety is lowered by physical exhaustion. Since rest is the only treatment needed to eliminate fatigue, soldiers who are suffering predominantly from physical exhaustion offers the best prognosis for return to combat. Every division psychiatrist learned that during a period of offensive combat the return-to-duty rate rose when the fatigue factor became prominent in producing casualties. When anxiety is the larger component and physical fatigue a minor one, the problem is not so easily solved. No simple measure, such as rest, will remove the genuine fear of being killed or wounded. If physical fatigue played a large role in causing anxiety it would be difficult to explain why cases of extreme fatigue have so low an anxiety component, or why, on the other hand, one sees so many cases of severe anxiety without physical fatigue. In fact, one rarely sees severe anxiety reactions in men who have been in combat long enough to incur a marked degree of physical fatigue.
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3. Lack of motivation is a potent factor in the cause, treatment, and recurrence of the neuropsychiatric casualty. The unwilling soldier does not want to withstand even the normal battle reaction. He will rationalize, exaggerate, indulge in self-pity, and fairly well convince himself that he is sick. If lack of motivation is the only disabling factor the psychiatrist is obligated to return the soldier to duty, even though he may later become a disciplinary problem.
4. A continuing state of tension indicates that the disabling effects of psychic battle trauma are still operative. It is the most important objective criterion in determining that the soldier not be returned to duty; for a soldier who is returned while he is still sick will be a liability to his unit or will soon be returned for further treatment. An absence of objective signs of trauma, indicates that the soldier has at least recovered from the acute episode.
5. The subjective symptoms often indicate the degree of severity of the psychic trauma. Since they are subjective, they must be evaluated by the psychiatrist in terms of his knowledge of the tactical situation and other correlative and corroborative information.
These criteria are intended only as a guide. They should not be used mechanically or too rigidly. As the psychiatrist becomes experienced in handling combat psychiatric casualties he learns to use strict rules almost intuitively. As a practical guide these rules may be summarized as follows:
All soldiers who show moderate to severe objective signs of psychic trauma are unfit for return to duty at the division level. If the soldier "looks bad" the prognosis for return to combat is poor. If he "looks good" (no objective signs) or "fairly good" (mild objective signs), return to duty should be considered. The decision then rests on other factors. When, for example, the patient after a rest period shows no objective signs of trauma and has a history of minimal battle trauma, a good background (negative for mental deficiency and inadequacy), and good motivation, either the case was one of pure physical exhaustion or the soldier was sent to the unit by mistake and has no psychiatric disease. If motivation is poor in such a case and the other evidences are the same, one is dealing with an unwilling soldier who is merely verbalizing the normal combat fears and sensations. If there are mild objective signs (tremor or apathy), a history of repeated battle trauma, and good background, but motivation is poor or only fair, the prognosis is poor and the soldier should be evacuated. A common type is the soldier who has few or no objective signs, a history of one traumatic event, a good background, and fair motivation. Such a soldier offers a good prognosis and should be returned to duty, even if his motivation is poor. If both the background and motivation are poor, the prognosis for useful combat duty is poor.
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Psychosomatic Disorders
Psychosomatic disorders occurring in battle may be acute or fixed. The acute type is simply the usual battle anxiety state with the presenting symptoms concentrated in some part of the body. The symptom is not fixed and the soldier readily admits his main difficulty to be fear. Treatment is the same as for other anxiety states. The fixed type is represented by those well-known soldiers who state in an indignant and resentful tone, "I’m not afraid of shell fire! Cure my back and I’ll go up there!" or "It’s my stomach, there is something wrong with it. I’m not afraid of shell fire!" Often these soldiers have been hospitalized before for the same complaints and are hostile toward the medical officer. In such cases it is important that the psychiatrist make as thorough a physical examination as possible. An explanation of the psychogenic factors involved should be given, though it is usually wasted. The psychiatrist should then proceed to give the patient the "you’ve got to live with it" theory, stating in effect that no serious condition is present, and that, while it is known that the patient has pain or discomfort, he will have to put up with it, since it does not impair his combat usefulness. It is best not to become embroiled in acrimonious disputed with such soldiers. In the end they should be sent firmly back to duty.
Officer Psychiatric Casualties
There are few psychiatric casualties among officers, but their disposition is important, owing to the effect it may have on other officers and on the morale of combat troops. Poor morale is indicated when there is a marked increase in the proportion of officer casualties over the numerical ratio of officers to enlisted men in the combat troops. These officer patients are almost invariably of company grade. The stress and strain of battle lie heavily on these men, and their casualty rate is high. The clinical picture in officers differs somewhat from that in enlisted men, in that they show more depression. The feelings of failure and subsequent loss of pride and honor heavily color the anxiety state. Some officers break early in combat and clearly demonstrate that they have never been emotionally stable. They have obtained their commissions on the basis of pure ambition or vanity, with the hope that they will obtain some noncombat job and avoid the hazards of combat infantry. This type is characterized by quick failure, the absence of episodic psychic trauma, and frank admission that they cannot lead men in combat: "I cannot do that kind of work, I am good at other things."
In dealing with officers proper disposition is far more important than with enlisted men, for the officer is in a position not only
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to spread panic and occasion many psychiatric casualties in his unit, but also to cause many unnecessary deaths of men under him. Consequently it is important not to return to duty officers who have more than an even chance of breaking down in battle. When the indication is clearly against the return of an officer to combat, the psychiatrist has in obligation to his division in dealing with the case. If the officer performed his combat duties satisfactorily, until he broke down under the stress of some battle episode, he properly comes under the protecting arm of the neuropsychiatrist and should be reclassified. If, on the other hand, he has never shown fitness for combat and has clearly shown that he cannot handle his job, then, regardless of his past emotional or character disturbances, it is only fair to the men who continue fighting that his failure should not be rewarded. Such an officer should bere turned to duty with a letter stating that he is emotionally incompetent for the duties of a combat officer, but has no mental disease that warrants medical reclassification, and recommending administrative reclassification. That he is unsuited for combat and may become a detriment to his unit should be emphasized; otherwise be may be returned for another trial of duty where he may cause further harm.
Such a policy may cause the officer to lose his commission and may seem harsh, but it must be remembered that no one is forced to accept a commission in the infantry. When an officer has shown himself unfit for his job the psychiatrist who recommends administrative reclassification is asking, not for his punishment, but merely for the correction of an administrative error. Such a policy prevents the loss of morale among junior officers that is occasioned when such an officer is medically reclassified and thereby "rewarded." Aiding and abetting the officer who follows the plan outlined in the old refrain— "foul up, get a nice job in the rear, and got promoted"—should not be laid at the door of the division psychiatrist. The officer suffering from a severe anxiety state or other genuine illness should be promptly evacuated for treatment.
Hazards of the Psychiatrist
The psychiatrist himself is likely to become weary and emotionally exhausted in combat. He sees literally hundreds of tearful, depressed, stubborn, sympathy-seeking, self-pitying soldiers. In each case a decision that may mean life or death for the soldier must be reached. Under these conditions the psychiatrist may at times lose his diagnostic sense and emotional balance. All patients then begin to lookalike to him, and he may identify himself with his patients and see them as all equally deserving of evacuation; or, seeing them all as volitionally motivated, he may adopt a harsh policy, assume a severe
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and caustic manner, and return to duty soldiers who are completely unfit for combat. When the psychiatrist observes himself becoming angry with his patients or figuratively crying with them, it is a good rule to stop work and see no patients for an hour or two and to force himself on returning to work to follow methodically the criteria outlined above for the disposition of cases.
The Absent from Battle Without Leave
The increasing incidence of soldiers who illegally avoided hazardous duty focused special attention on this problem. The division psychiatrist was required to interview such offenders prior to general court-martial in order to determine the degree of mental responsibility. Such interviews afford an opportunity to evaluate the underlying causes of this phenomenon and to make positive recommendations to units whose AWOL rate was above average for the division. This ancient method of avoiding a hazardous situation is one of the inevitable concomitants of battle. Many such offenders are not criminals. Punishment involving disgrace and imprisonment often impairs their future usefulness and happiness. Thus "justice" is as much a horror of war as are incapacitating wounds, severe battle neuroses, and the misery of the soldiers who remain in combat. Apparently the incidence of such offenses increases as the division becomes older in combat day. In the second severe combat period of one division about 250 soldiers were AWOL. During the same period there were about 4,000 battle casualties (KIA, MIA, and WIA)and 550 neuropsychiatric casualties. In view of the fact that these offenders and casualties originated from 36 infantry companies whose strength and replacements numbered about 9,000 men, it is evident that the offenders formed but a small percent of the total number of troops required to face hazardous duty.
From a study of 200 offenders, examined in the usual manner prior to general courts-martial the following conclusions were reached:
1. During a campaign the incidence of AWOL cases increases with the number of offensive combat days. Absence without leave is not an immediate result of intense battle trauma, but is the product of cumulative days of combat.
2. About two-thirds of the offenses were committed from relatively safe areas, such as reserve positions, casual companies, replacement centers and hospitals.
3. The majority of offenders were men who had been in the unit for sometime.
4. About one-third of the offenders had been recently hospitalized forwounds or illness. About 10 percent had been treated for neuropsychiatric illness since they had come overseas.
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5. Age and intelligence played no significant role in this phenomenon.
6. While the offenders were almost unanimous in stating that they were motivated by nervousness or fear of combat, only 25 percent had requested medical evacuation shortly before the offense. These requests had been refused.
7. Twenty-five percent were found to have a disabling mental illness that made it difficult for them to control their behavior and 10 percent were classified as psychopaths. The rest could not be considered abnormal from the psychiatric point of view.
8. No definite correlation between the psychiatric and AWOL rates could be demonstrated by analysis in all three regiments. The regiment with the highest psychiatric rate had the highest AWOL rate, but the regiment with the lowest psychiatric rate had the second highest AWOL rate. A similar study of infantry battalions disclosed that the battalion with the highest AWOL rate had three of the five AWOL officers of the division; and the second highest AWOL rate occurred in a battalion maintaining the lowest psychiatric rate, and thus the best "medical discipline."
9. Both the psychiatric and the AWOL rates were strongly affected by morale factors, but it was far more important in the case of absence without leave. Most psychiatric patients were unable to endure the terrors of combat, whereas most AWOL offenders were unwilling to endure the hardships of combat. The occurrence in a unit of AWOL officers was an important factor in raising the incidence among soldiers of the unit. A too rigid medical discipline with respect to the evacuation of psychiatric casualties may also be a factor in increasing the AWOL rate.
Absence without leave presents another source of manpower loss through functional causes. It is the duty of the psychiatrist to study the problem in his division and to make positive efforts and recommendations to maintain a low incidence of such offenses.
THE POSTCOMBAT PERIOD
In the postcombat period the division units leave the combat zone tired and worn with mingled sensation of relief and fatigue. There is a general let down. Everyone seeks some sort of relaxation or recreation, including alcoholic oblivion. The division psychiatrist, however, has work to do. The records and statistics of the combat period must be compiled. The psychiatrist must ever seek to improve the facilities of his unit and to make good the shortcomings revealed in the combat period. He must use the cold figures of the fighting period to prove the need for better equipment and personnel. Even
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if he is disposed to neglect such work, he cannot escape the long line of men awaiting examination on charges of illegally avoiding combat.
Estimating the Psychogenic Casualties of Battle
To arrive at some estimate of the manpower loss caused by the psychogenic component of injuries and disease, a diagrammatic representation of the correlation of the wound rate and casualties from other causes was attempted. It appears that most battle casualties of psychogenic origin occur at a time when other battle casualties are produced. One must envision a shell exploding among or near a group of men. Some are killed, some are wounded, one or two are stunned and awaken trembling and tearful, and one may jump for safety and sprain an ankle or bruise some part of the body. Another soldier may think this is a good time to have that "cold" taken care of, and still another may decide he does not "feel right generally" and there must be something wrong with him because his heart is pounding, his head aches, and he is tired out.
Figure 2 represents the casualties of the entire 85th Infantry Division(15,000 average strength, all combat troops except 3,000 to 4,000 service troops) inactive combat for about 46 days. A precombat period of 10 days is shown. The battle wound rate does not include MIA (missing in action) or KIA (killed in action). LIA (lightly injured in action) refers to those walking patients who had such emergency medical tag diagnoses as concussion, contusion, or sprain. These were considered battle casualties by the MRU (machine records unit), but in none was there an element of wound by a missile. The most striking feature shown is the close similarity between the curves of LIA and the psychiatric rate, which are almost twins in their rise and fall. These curves retain their similarity in relation to the smaller units. In actual practice these patients were often labeled "exhaustion" as a secondary diagnosis, and many LIA cases when returned to duty from hospitals were promptly re-evacuated as "exhaustion." The disease rate showed a steady rise as combat progressed, with a decline in the later stages of combat parallel with the battle wound rate. It is difficult to arrive at a true correlation of the disease rate with battle casualties, since many elements of the division are at rest while others are in action. The solid line (noncombat evacuation curve) follows the wound curve and illustrates graphically the relationship of combat and noncombat casualties that were evacuated. The longer a unit was in action the greater was the ratio of noncombat to combat casualties.
Figures 3, 4, and 5 represent the three infantry regiments of the 85thDivision. The LIA and NP (neuropsychiatric) curves are similar in the three graphs. The disease rate followed the same course as the psychiatry rate. When the psychiatric ratewas high the disease rate increased and vice versa.
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Figure 3 shows a low psychiatric, LIA, and disease rate. Consequently, the noncombat evacuation curve for this regiment was well below the battle casualty peak. This unit conserved its fighting strength far better than the other two regiments. This regiment was well known for its high morale and good medical discipline, and the regimental surgeon had instituted a well-supervised intra regimental treatment of mild psychiatric, medical, and surgical cases. None of the successfully treated patients are represented on this graph, for the curves represent only those that reached the clearing company. The treated patients were, however, never lost to the regiment for more than a few days, and for practical purposes the fighting strength of the unit was preserved.
Figure 4 illustrates an interesting phenomenon. For the first three weeks of the campaign there was a marked increase in noncombat casualties, in which all three constituents (LIA, NP, and other nonwounded casualties) participated. Then something occurred to bring about a change; the three noncombat curves assumed lower levels, resembling those of figure 3, with a consequent decrease in the noncombat evacuation curve. It is known that this regiment shortly before the time of this change was assigned a new surgeon who obtained preliminary training under the regimental surgeon whose results are demonstrated in figure 7, and who followed his policies and methods.
Figure 5 shows the marked increase in the noncombat evacuation curve as the campaign progressed, and the coincidental rise of the rates for disease and battle wounds. The sick casualties were often evacuated one day later than the battle casualties.
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In figure 6, representing an infantry battalion, the correlation between the rates for battle wounds and disease is more clearly seen. Again the LIA and psychiatric rates were almost identical. In this battalion, the noncombat evacuation rate was high in the initial phase. It should be expected that this disproportion would increase, since nothing was done about the situation, and this increase did occur. That this kind of a curve coincided with a loss of morale is indicated by the fact that the commanding officer was relieved later in the campaign.
Figure 7 illustrates the situation in a battalion in which the disease rate was fairly high and there was a gradual increase in the noncombat evacuation curve, which at the close of the campaign was high in proportion to the battle wound rate. An interesting phenomenon may be observed here. In relation to the initial wound peak the LIA rate shows a striking rise, while the psychiatric curve is flat and the disease rate is only slightly elevated. One may confidently infer that many of the patients evacuated as LIA were actually psychiatric casualties, since it is improbable that with so many wounds there should not be more combat neuroses.
Figure 8 illustrates the situation in a battalion in which wound casualties were high, while the noncombat evacuation curves were fairly low. It is not surprising, therefore, to find an increased number of self-inflicted wounds and absences without leave in this battalion as compared to the number in other battalions of the same regiment. Such a situation illustrates the results of a too rigid medical discipline. This battalion, one of those represented in figure 3 was, however, said to have done very well in its tactical missions.
These graphs demonstrate (1) that there are psychogenic factors in all these curves, (Ref 11) (2) a need for investigation of LIA casualties, which probably call for a special method of handling and therapy, (3) that there is a large loss of manpower from psychogenic causes other than avowed psychiatric illnesses. When the noncombat evacuation curve exceeds the wound rate the cause should be investigated. The rise may be caused by poor morale or incompetent leadership, or it may be the fault of a battalion surgeon who has opened wide the door of medical escape. Graphs of this kind show where trouble exists, but they do not necessarily indicate the cause.
(ref 11.) It seems likely that the LIA curve, so similar to the psychiatric curve, is mainly functional. The disease rate, which shows some correlation with the wound curve, also has a strong functional component, latent when the soldier is evacuated to the hospital, but revealed during hospitalization or when discharge is contemplated by persistence of the presenting symptomatology or by the development of overt psychiatric complaints and manifestations.
