SECTION II
PSYCHIATRIC DISORDERS OF COMBAT
Anxiety-Depressive Reactions After Prolonged Combat
Experience—the "Old Sergeant Syndrome"
Major Raymond Sobel
Medical Corps, Army of the United States
The mechanisms and dynamics of the neurotic battle reaction have been reported in detail in recent years, but little attention has been paid to the means by which the normal soldier develops defenses against the anxiety produced by the combat environment and, more particularly, the manner in which the normal soldier becomes emotionally incapacitated under stress. Since the most striking cases were found among noncommissioned officers who were old in combat experience, we came to refer to the psychiatric disorder of this group as the "old sergeant syndrome." This syndrome, a fairly consistent constellation of attitudes, occurred in well-motivated, previously efficient soldiers as a result of the chronic and progressive breakdown of their normal defenses against anxiety in long periods of combat. It was seen only in those divisions that had experienced prolonged battle commitments without relief. The men in this series had been in continuous combat for periods up to 79 days, and the division had had more than 400 days of combat experience.
Although cases were observed among engineers and artillerymen, 90percent of the men who developed this reaction were infantry soldiers. Those we saw from March through November 1944 were mostly veterans who had fought through both the Tunisian and Italian campaigns with excellent records. They constituted the nucleus of the fighting elements of their units and were considered by their officers to be the backbone of the Infantry—the key men, the "old reliables." A large number had received citations, awards, and medals for outstanding conduct and devotion to duty. Many had been decorated with the highest honors their country could bestow on them. When they were evacuated for psychiatric disturbances the matter became of real interest to all from the company commander to the commanding general of the division, for these men were among the best and most effective of the trained and disciplined combat infantry soldiers. These soldiers eventually developed abnormal tremulousness, sweating, and a tendency to be the first to get in and the last to leave a foxhole. They became useless to their unit
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and had to be removed from the battle zone, even though many of the symptoms that occurred under fire disappeared rapidly when they were removed from shelling.
The men themselves could not adequately explain the cause of their behavior. "I guess I’ve just had too much of it," they said. The terms "burnt out," "worn out," and "beat up" were often applied to them. They expressed their philosophy in terse profanity and with resigned patience born of endless waiting before attacks: "I’m just sweating it out," or "It`s no use trying to beat the percentages," or "I`m waiting for the one with my serial number on it." They continued to endure the horrors of battle, sometimes only partially effective, until they became incapacitated by anxiety and its concomitant impairment of judgment. The ability to make quick decisions involving the lives of others was lost, and with it their self-confidence. Thus a vicious cycle between anxiety and inability to accept responsibility was developed.
The manner in which they were evacuated was directly related to this cycle, for despite their deficiencies they tried to continue with their duties. As a result they were more often than not ordered to the battalion aid station by their company commanders or platoon leaders. Medical officers rarely saw them on routine sick call. When examined by the division psychiatrist they almost always had a written statement attached to their emergency medical tag. A typical report read: "To Battalion Surgeon: Sergeant Smith has been in my company for 13 months. He has fought through both campaigns and has been an excellent soldier, but, he has become so nervous of late that he is of no use to the company. We have no place in our service train for him, as we have already filled our kitchen and motor pool with others like him. I would appreciate it if you could evacuate him as he is unfit for combat in my opinion."
During the battle of the Anzio beachhead, when the majority of these men were seen, an attempt was made to return a substantial number to combat. In all cases there was a recurrence within 3 combat days. Some of the men returned to their units endured less than 10 hours of combat despite their sincere attempts to remain on the line, and were re-evacuated with acute severe anxiety states. These men were either original members of the division or had been with it for an extended period. Their average overseas service was 23 months. Some had had 32 months overseas. They were often the last remaining "old men" in their platoon or company. An unpublished survey of a veteran division showed that after 210 days of combat only 12 percent of the original members of a rifle platoon were still with their units. These men were survivors in the true sense of the word. In many instances a soldier was the only one to emerge from
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a trap or one of the few left from a decimated company. One staff sergeant stated that he had had 8 platoon leaders, 3 company commanders, and 3 battalion commanders in 6 months. Because of their experience, they were acutely aware of their probability of survival, and even those who had not already been wounded had lost any feeling or illusion of personal invulnerability. They possessed a high sense of discipline and duty, and absence without leave was a rarity among them.
Sixty percent had responsible duties as squad or section leaders, platoon guide, or platoon or first sergeant, or held commissions. One reason for their having such positions was their length of service, but the main factor, according to their commanding officers, was that all possessed qualities of leadership. The privates had all been offered ratings but had turned them down because they preferred freedom from responsibility to rank. A small proportion had been demoted at their own request because they felt guilty in holding a rank while unable to carry its responsibility. Another impressive feature of these men was their devotion to their unit. They felt an obligation to train new replacements and teach them how to take care of themselves in combat. They had a fatherly concern for the green men under them, more, it appeared, in the interest of military effectiveness than from true affection. They did not make friends easily, perhaps because they feared to cause themselves pain on losing them in combat. As a result they were sometimes unjustly accused of being callous taskmasters and slave drivers. The majority of the "old sergeants" strongly identified themselves with the group of men with whom they had fought several battles. This consciousness of kind was a bond forged in fire by joint survival. Perhaps for this reason they often spent hours recounting their battle experiences to one another. The reassurance thus given that they had survived—that they were actually still alive—produced in them a certain amount of gratification.
The combat life in this series averaged 180 to 240 combat days. The shortest aggregate combat time was 150 days; the longest, 350 days. Although most of the men stated at first that there was no definite time at which they had begun to feel severe anxiety, close questioning almost always revealed an acute episode, followed by increasingly severe battle reactions. No patients were seen immediately after the first break in tolerance to anxiety. All reported several similar episodes that occurred subsequently, but prior to their evacuation. A wound incurred months previously was often the precipitating factor. As a rule these men had had several rests in kitchen areas without effective relief of symptoms. When interviewed in the safety of the clearing station they were calm and showed none of the vigilance they experienced in combat. We saw but one true startle reaction in well
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over a hundred such patients. The absence of hysterical manifestations and severe psychosomatic complaints was remarkable. Stress dyspepsia was recognized as such, with unusual insight.
The most characteristic features seen when they reached the division psychiatrist were depression and loss of self-confidence. The depression was mild but persistent and was accompanied by discouragement and self-incrimination, expressed by such a remark as: "I feel like a heel, leaving the outfit." There was much variation in individual awareness of the loss of self-confidence, but it was always present to some degree. A common statement was: "I can`t send my men out where I can’t go myself." This feeling, plus the accompanying fear of responsibility, resulted in a lowering of combat efficiency to a point where the soldier might actually become a liability to his unit. The case of a 29-year-old first sergeant of excellent capabilities, who was evacuated for "exhaustion," illustrates this tendency. Although he had previously been extremely careful with secret papers, he had carelessly left his company records strewn about a command post where they had been picked up by a British patrol. Despite diminution of efficiency, as shown by this patient, these men displayed no loss of motivation. Often they continued, sometimes desperately, in a job they had become incapable of handling. Doing so led to severe conflict and guilt feelings, with the result that their anxiety increased until evacuation became imperative. Guilt over letting their comrades down was a constant feature. As a rule these men did not consider themselves sick, and on reaching the rear they were eager to get to work.
In the rear echelon, however, their personality change manifested itself more clearly than in the forward area, and their loss of efficiency and self-confidence persisted. Men who had been in command of 30 to 160 men became willing to do simple tasks. Thus truck driving was particularly in demand as a reassignment, for these men disliked handling men in any capacity. Yet they remained as well motivated as they were before evacuation. Two case histories are presented to illustrate the type of behavior we have called the "old sergeant syndrome." Case 27 illustrates the loss of adaptation to combat following excessive exposure to battle. The reaction to responsibility is clearly demonstrated.
CASE 27. A 29-year-old technical sergeant with 30 months` service who had been overseas 21 months and had an aggregate of 310 days of combat was admitted during a rest period after the battle of the Gothic Line. He had been thrice wounded in action. He stated that he began to have abnormal battle reactions 60 combat days previously. He said: "Now if I get in a hole I just want to stay. It bothers me more now than it ever did before. This last battle my company was ordered to take a house, and within a few hundred yards of the place a couple of my boys got their feet blown off. We withdrew and I
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went to the commanding officer and told him I had a feeling that I was going to get it this time, and that I couldn`t take it any more. He gave me a direct order to, and it was either do that or have a bad record, so I went." This soldier had tried on three occasions to have his rank reduced to that of private. "You see," he said, "as a platoon sergeant, you are more often than not a platoon leader, and I couldn`t lead the men like I did before. Under shelling I got jittery. A platoon sergeant is a leader. If he isn`t out in front it affects the men."
This soldier was born on a ranch in Texas. He stated that his father was epileptic, but that he rarely worried about it and that it had not affected him in anyway. His parents were harmoniously married. There were seven children, of which he was next to the oldest. He had a happy family life and had many friends on nearby ranches. No significant neurotic traits or conflicts were elicited in the history. Enuresis, nail biting, temper tantrums, running away from home, nightmares, and somnambulism were all denied. He left home to work on another ranch at the age of 14, after completing the eighth grade, and had been steadily employed as a rancher until induction. He had always been self-reliant and industrious. Single, he had no significant sexual conflicts. His Army career was characterized by steady promotion after his arrival overseas. He stated that he had been held down in the States by a lack of T/O vacancies. A letter from his battalion commander stated: "It is my opinion, through observation, that he has reached the end of endurance as a combat soldier. Therefore, in recognition of a job well done I recommend that this soldier be released from combat duty and be reclassified in another capacity." This battalion commander, incidentally, was noted for his unyielding attitude toward psychiatric casualties.
Case 28 illustrates the role of pride in self and the effect on such a soldier of losing his group.
CASE 28. A 28-year-old staff sergeant had had 48 months` service, of which 25 months had been overseas, with an aggregate of 280 combat days. He had been wounded twice, once in hand-to-hand combat at Cassino. He stated that he became excessively nervous after the break-through from the Anzio beachhead. "When I lost 11men in one day, that was the beginning," he said. "I lost the medics and had to take care of them myself. I didn`t have no aid bag, no bandage; it was a pretty rough job. It makes me feel pretty sad to lose all those guys at once." Asked why he had continued in combat, he said: "I carried on as best I could manage because I thought I could make it. I was always able to take it, but the captain told me to go back and seethe battalion medics. I was just nervous and couldn`t handle my job. Every time I would get under shellfire I had 40 men to control, and my place wasn`t in the rear of the platoon. I just couldn`t do it. I asked a month and a half ago and a month ago to turn in my stripes, but they said I`d been a good man and they didn`t want to take them away." During his combat career this sergeant had had 5 platoon leaders, 8 company commanders, 5 battalion commanders, and a threefold turnover in squad leaders. He estimated that he had been doing the work of a second lieutenant three-fourths of the time. "Generally, when a lieutenant comes in he gets reclassified or gets wounded quick!" he said. He had twice been offered a commission, but had refused each time. "As an officer you have so much more to go through than an enlisted man," he explained. "I had enough trouble being an acting platoon sergeant." He had noticed an increasing difficulty in making friends: "It seems that I can`t getup and talk to new guys like I should."
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At the interview he presented no evidence of overt anxiety. He described his combat experiences in an emotionless voice and appeared to be somewhat retarded and depressed. To the inexperienced observer, or even experienced observer on casual examination, he would have appeared unaffected by psychiatric disease. On describing the loss of his platoon he became somewhat tense and wept for a short period. Asked for three reasons why he had "stuck it out," he answered: "That’s what I`m over here for"; "so many men look up to me all the time"; and "my job is to stay with the men and help them as much as I can." Past history revealed no evidence of neurotic traits or tendencies. His parents were harmoniously married and well adapted to each other. His father was strict but not severe, and the parents always agreed with each other`s decisions about the children. He graduated front high school in the middle of his class and was extremely active all sports. He was single. His sexual life was normal. He was steadily employed as a farmer and worked with his father. The oldest of four children, he put two of his sisters through high school, paying for their tuition and clothes and providing them with spending money. His Army career was marked by promotion to corporal at Salerno and to staff sergeant at Anzio7 months later. He had not been court-martialed, nor had he committed any disciplinary infractions.
The question these men presented was not "Why did they break?", but "Why did they continue to endure?" They retained a strong desire to continue fighting and if ordered to return to the line they would do so without the excuses and grumbling so common in other patients with war neurosis, even though free-floating anxiety was present in some instances. We concluded that there was a normal "defense in depth" against anxiety and that the normal soldier develops anincapacitating battle reaction when these defenses are broken through or when his natural resources are depleted.
CHARACTERISTICS OF THE "OLD SERGEANTS"
Table 7 gives an analysis of the rank, age, and various factors shown in the histories of 50 soldiers who broke down after prolonged combat. The ability of these men to handle responsibility is demonstrated by the high proportion of non commissioned officer`s ratings (60 percent). It is impossible to give absolute figures, because of voluntary reductions in grade and the refusal of ratings. Furthermore, almost all notes from commanding officers stated that these men had been excellent leaders. This opinion was corroborated in every case by clinical observation. From their assignment status and from clinical observation of the group, it was clear that the old sergeant was, on the whole, a well-adapted, integrated, and efficient soldier before evacuation. Seen in this light, the loss of efficiency and self-confidence among them is even more striking.
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TABLE VII
Analysis of 50 patients who broke down after prolonged combat
Rank
Percent Officer
6
Noncommissioned officer
60
Private
5
Age
20-24
50
25-29
32
30-35
18
Presence of psychosomatic symptoms
Mild (not requiring hospitalization)
43
Severe (requiring hospitalization)
5
None
52
Presence of familial neuropathy or broken homes
34
Enuresis beyond 7 years of age
15
Asocial behavior (e. g., delinquency, marked seclusiveness or withdrawal)
17
Neurotic childhood behavior (e. g., temper tantrums, running away from home, somnambulism, abnormal fears, seclusiveness, persistent nail biting)
20
School record
Grade school graduate
38
High school graduate
62
Failed one or more grades
12
Satisfactory grades
88
Employment record
Steadily employed
93
Erratic employment
7
CRITICAL FACTORS IN BREAKDOWN
Distant ideals. After the first few months of combat those concepts known as "the four freedoms," democracy, and the specific purpose of "keeping the enemy out of the United States" were no longer perceived as goals. It may be stated with certainty that in this group these factors were of small relative importance, either as providing motivation or as constituting a defense against anxiety. Though these men had an intellectual appreciation of the necessity for fighting the war, they almost entirely lacked emotional appreciation. The most common response to the question "What do you think of the four freedoms?" was: "I don`t have time to think of them in a barrage." Religion played a definite role, and many men said that if it were not for prayer they would have found it difficult to keep going.
Hatred of the enemy was the next defense to go, although it was a potent positive defense against anxiety. When fear and anger were molded together and directed against the enemy, the basic components
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were no longer intolerable to the personality. As a group these soldiers had a much higher degree of directed hatred than the other psychiatric casualties seen in combat. This hatred was based primarily on personal experience with enemy brutality, rather than on previous orientation. According to the men, however, it was not of sufficient force to counteract the effects of long sustained combat. In some cases it proved destructive, for a few men developed severe guilt reactions as a result of their hostility.
Short-term goals. After sustained periods of battle the soldier was wont to believe that he would soon be relieved. Such rumors as "If we take the next hill we get a rest," or "When we get Rome we will be out of the line," were eagerly believed and constituted a powerful source of will to "sweat it out. "Often such short-term goals proved to be boomerangs, for if they were not fulfilled morale deteriorated rapidly. Nevertheless, the individual soldier often deluded himself and continued to endure on the strength of such rumored rewards.
Pride in self is of prime importance in defense against anxiety. All the men studied had high sense of what was expected of them and made sincere efforts to live up to this ideal. They felt that a soldier must be manly and courageous and must exhibit endurance and fortitude. They derived tremendous satisfaction from attaining these goals and were proud of their abilities. With pride as the mainstay of their personalities, they were able for a long time to resist the terrific onslaught of the combat environment. In their early combat careers they proved themselves able to "take it," but once a break in efficiency occurred their self-confidence weakened progressively. Nevertheless, their responsibility was not lessened; often it was increased. When these men were forced to carry the same or a heavier load in the face of death and destruction, a cycle was set up between increased responsibility and reluctance to accept it. This conflict tended to produce a progressive and insidious type of anxiety. One staff sergeant described it thus: "I can`t put any definite time on when I felt myself slipping; it is like a flower that grows." In describing the psychoneuroses of World War I, A. F. Hurst (ref26) stated: "Prolonged responsibility was the common cause of breakdown in many men who appeared to be constitutionally absolutely normal and who stood the stress of battle and responsibility without any difficulty at first." In our experience these men did not become panicky, but strove to overcome their disability as best they could. Nevertheless, the role of increased responsibility in producing anxiety is shown by the fact that it was not uncommon to interview a sergeant shortly after he had been offered a commission.
Loyalty to the group in these men was the last and most important line of defense against anxiety. The group with whom the soldier
(ref 26) Hurst, Arthur F.: War Neuroses and the Neuroses of Civil Life, Guy`s Hosp. Rep., 89: 423-440 1939 (Reprint).
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identified was small. It rarely extended beyond the platoon—the group with which the soldier had shared joint survival. These soldiers had learned through experience the necessity of mutual dependence in battle. In a platoon each man must place a portion of his safety in the hands of his comrades, and at the same time must be responsible for a portion of their safety. Failure of any kind during a fight may produce disastrous results in terms of human life. After an attack these veterans realize the importance they have for one another, and leaving the group is tantamount to desertion. The only honorable way out is by way of a wound or death. Thus group loyalty is reinforced with each battle. The intensity of this loyalty forestalls any behavior endangering the group, such as neurotic battle reactions.
Even this last stronghold, however, weakens with the passage of combat time. Group loyalty is lost chiefly through actual physical depletion of the group. The normal attrition of battle produces this depletion in even the most experienced squad. Those who are left then feel themselves helpless without their former comrades to rely on. Being unable or disinclined to form new attachments, the "old sergeants" find themselves running on their depleted reserves of self-confidence. The rapid change of leadership under combat conditions does not allow for identification to a degree sufficient to bolster their self-confidence. Indeed, they often discover that they must assume additional responsibility for the platoon, since the new officer has usually had no combat experience. Under these conditions emotional tension increases, and shortly after some personal loss is sustained an acute episode occurs. It may take the form of a general emotional breakdown, with uncontrollable weeping and rage reactions. The first acute episode soon passes and the soldier continues in his job, but he is no longer able to withstand the environmental threat and the anxiety it produces. With this last defense broken through, failure of adaptation soon becomes complete, and it is then a matter of military necessity that the man be removed from combat.
DISPOSITION AND THERAPY
The progressive breakdown of the adaptive mechanisms of the normal soldier to the point at which his natural resources are exhausted in the struggle against his environment has been traced. His major defense, identification with the squad or platoon, is gradually destroyed with the depletion of the group, and he is forced to rely on energies and self-confidence already sapped by prolonged combat without rest. Therapy was found to be surprisingly simple, but
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administratively difficult. The most effective single therapeutic tool was assigning these men within the army area, out of shellfire but close enough for them to feel that they were actually helping the men "up front." The usual psychotherapeutic procedures were necessary and valuable, but since the "old sergeant syndrome" is primarily a situational reaction, altering the environment by means of reassignment is the most important aid to readjustment and cure. At one time we had several of these men on the cadre of the divisional training and rehabilitation center. Their work over a four-month period was beyond reproach.
