Military Medicolegal Problems in Field Psychiatry
Lieutenant Colonel Stephen W. Ranson
Medical Corps, United States Army
Most soldiers must control asocial impulses produced by fear in combat. All must endure the normal battle reaction, of which the highly unpleasant psychologic and psychosomatic symptoms would be considered abnormal in almost any civilian situation. The battalion surgeon relieves from duty any soldier whose symptoms he considers incapacitating. Thus a controlled, acceptable medical route of escape is available. The soldier who believes his limit of tolerance has been reached is, therefore, required to present himself to his battalion surgeon for proper medical disposition. He cannot be allowed to make this decision himself. If he could, military and medical discipline would deteriorate, the soldier would lose an important motivation for enduring, and a situation destructive of the morale of those remaining would be created. Most deserters from combat are poorly motivated soldiers with no psychiatric disease who leave at a time of general deterioration of morale. In an infantry division in Italy the frequency distribution of psychiatric diagnoses in a large series of psychiatric consultations prior to court-martial proceedings is shown in table XIII. It is necessary that the psychiatrist maintains rigid criteria for the diagnosis of the battle-induced psychoneuroses and psychoses and excludes from this category all soldiers who have no psychiatric disease and exhibit only the symptoms of the normal battle reaction. The section on "The Normal Battle Reaction" sets up criteria useful in making this distinction.
TABLE XIII
Psychiatric diagnoses in a series of patients referred for psychiatric examination prior to
court martial (34th Inf. Div., Italy) ref 1
| Diagnosis | Percent |
|
No psychiatric disease |
63 |
|
Constitutional psychopathic state |
12 |
|
Psychoneurosis |
22 |
|
Others (psychoses, etc.) |
3 |
(ref 1) Of these patients less than 5 percent were declared not responsible by the psychiatrist.
CASES WITH NO SIGNIFICANT PSYCHIATRIC DISORDER
The following case history illustrates the most common type of case.
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CASE 35. A 21-year-old rifleman who had never been in the front lines became frightened and shaky on one occasion when he was shelled for about 5 minutes, and remained in his foxhole. About 12 hours later, while his organization prepared to move out on an attack but all was quiet in his area, he deserted. He went to Capua, where he stayed with various Italian families. He spoke Italian. When captured he stated that he had left his organization because his right knee hurt. He had been injured in an auto accident 12years before. His previous history was not remarkable from the psychiatric point of view. Physical examination was negative. The knee was normal. Psychiatric examination showed the soldier to be normal. The psychiatric opinion was that this soldier had no psychiatric disease and was responsible for his acts.
CASES WITH PSYCHIATRIC DISORDERS
Desertion and misbehavior in the face of the enemy occurred also in soldiers with battle-precipitated neuropsychiatric illnesses, especially anxiety states. Some of these soldiers would have merited evacuation through medical channels had they presented themselves for consideration prior to the offense. The situation was altered, however, by the commission of the offense. Under these circumstances the psychiatrist was required to state an opinion, not about suitable medical treatment, but concerning the soldier`s responsibility for his acts. In some instances, when the soldier had a psychosis, it was obvious that he was not responsible for his acts. Similarly, when the soldier had no psychiatric disease it was evident that he was responsible for his acts. Difficulties arose in cases that fell between these two categories. In such cases definite criteria for responsibility had to be established that would fulfill the requirements of justice and so promote morale and the will to fight.
Only those soldiers who, at the time, of the alleged act, were "insane," according to the legal definition of the word, should be considered not responsible for their acts. Thus the psychotic soldier is not responsible for acts committed while acutely psychotic; the epileptic is not responsible for acts committed during an epileptic episode; and the soldier with a neurotic battle reaction characterized by fugue or a panic state, with confusion, is not responsible for acts committed while in such a state. The diagnosis of fugue or panic reaction with confusion is not difficult if all the facts of the case are at hand and the story can be evaluated for internal and external consistency. In practice, however, few such cases are seen in medicolegal consultations, for most soldiers suffering from these disorders are evacuated medically. Except in these instances, neurotic battle reactions do not prevent a soldier from "recognizing the difference between right and wrong," nor do they render him unable to "adhere to the right" if he is adequately motivated. They may in some instances make it more difficult for him to avoid offenses against the military code. The psychiatrist may, therefore, present a soldier`s severe anxiety symptoms to the court for consideration as extenuating his alleged offense, but not as justifying exoneration. The following case histories and opinions illustrate these points.
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Case 36. A 29-year-old private was referred for neuropsychiatric examination prior to trial for desertion. While his organization was awaiting embarkation in Italy for the Anzio operation, he left without permission. He remained AWOL while the organization embarked and until he was arrested by military police. In the interim he whiled away his time in Naples, eating and sleeping with various military units. In 6months of active combat he had developed progressively greater tension and anxiety. Some urinary frequency was present during the entire time, and there was mild but persistent pathologic noise sensitivity. Nineteen days before committing the offense for which he was charged, he left his company while it was being shelled. Although he remained away 5 days, no charges were preferred. He was examined 6 weeks after the alleged offense was committed, during which time he had not been exposed to any enemy action. When examined he showed no objective signs or anxiety. The pulse rate was not elevated, and he had no tremor. His past history was not remarkable. He had shown no important neurotic traits prior to entrance into military service. He had never committed any legal offenses in civil life, but he had been AWOL once during his training period in the United States. The psychiatric opinion given was as follows: "This soldier is suffering from psychoneurosis: anxiety state, mild (battle reaction). This is an emotional disorder in which the soldier may find it difficult but not impossible to control his behavior under certain conditions of battle stress. This man`s disorder is and was mild and had no important effect on his ability to reach a rational decision or to control his behavior in the incident described. He was and is responsible for his acts. Hence the examiner can make no medical recommendations pertinent to the final disposition of the charges."
CASE 37. A 22-year-old rifleman was referred for neuropsychiatric examination prior to trial for desertion in the vicinity of Cassino. He had served about 7months in combat. In this period his tension and anxiety became nearly uncontrollable. He said: "I feel like my nervous system is burning up. My heart jumps. I feel like I`m going to faint. I get so scared I can hardly move." Under shellfire he had exhibited a tendency to run about in a panicky manner. Because of his nervousness his commanding officer had sent him to a rest camp in Caserta. When his stay there came to an end and he was scheduled to entruck to return to the front, he walked away and remained in town. He was arrested by military police and returned to the kitchen area of his organization. He did not report to his company and was arrested in Naples by military police 11 days latter and returned to the regimental stockade.
There was no enemy activity at the time of commission of the alleged offenses. There was no evidence that there had been any confusion, panic, or alteration of consciousness at any period during or after each occasion of desertion. The soldier stated that he left his duties because on repeated occasions he had not obtained what he considered adequate medical care for his complaints (i. e., anxiety symptoms). He was considered sickly in childhood and early adolescence and was enuretic till he was 9 years of age. His father died when he was 7 years of age. There was constant conflict between his mother and stepfather. When examined he appeared tense and anxious. His pulse rate was116 and he exhibited marked coarse tremor. He complained of persistent mild noise sensitivity and of battle dreams.
The following psychiatric opinion was given: "This soldier is suffering from psychoneurosis: anxiety state, moderately severe (battle reaction). This is an
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emotional disorder in which the soldier finds it difficult but not impossible to control his behavior under certain conditions of battle stress. The emotional disorder from which this soldier is suffering did not make it impossible for him to reach a rational decision or to control his behavior in the incidents describe. Hence he was responsible for his acts. It was, however, more difficult for him to control his behavior than had this emotional disorder not been present. It is recommended that this factor be considered by the court in extenuation of the alleged offenses."
CASE 38. A 32-year-old infantry lieutenant had been in combat for a month. He had been in charge of a platoon that had suffered heavy losses under heavy shelling in an isolated position with little food or water. He had finally felt it necessary to go back for further instructions. He remembered little more until he woke far behind the lines on the following day. He was later told that he had passed a wire crew whom he had told that there was a serious battle forward, and that he had appeared confused to them. On the following morning he had talked with a superior officer, who later testified that the patient was completely incoherent. He was charged with having left his troops. Shortly before entering the Army he had experienced an episode in which he suddenly left his wife in a car and walked into the ocean. His remembrance of the occurrence was hazy. He eventually wandered back home and slept until the following day. The following psychiatric opinion was given: "This officer is suffering from psychoneurosis: conversion hysteria, with fugue (battle reaction). This is an emotional disorder that resulted in an episode of altered consciousness with automatic behavior, in which the officer did not know what he was doing and had no actual control of his actions. Since the alleged offense occurred in and as a result of this episode of altered consciousness, he was not responsible for the acts alleged. He was, in the legal sense, temporarily insane at the time of the alleged offenses. Hence it is recommended that charges be dropped. This officer should be medically reclassified and placed in a noncombat assignment."
The recognition of the psychoses and the epileptic equivalents and the formulation of proper medicolegal recommendations in such cases involve no special difficulties. Soldiers suffering from such disorders should be reported to the court as not responsible for acts committed while in such states.
MENTAL DEFICIENCY
It is obvious that mental deficiency may impair the ability of the soldier to understand what military law and his duty require of him; or, if he understands it, he may have difficulty in controlling his acts and finding a legally acceptable release from an intolerable degree of anxiety. It is, however, the general military experience that an appreciable percent of mentally dull soldiers (mental age 8 to 9)exhibit acceptable self-control on the battlefield. Hence mental deficiency cannot be considered automatically to render a soldier legally irresponsible for his acts. The psychiatrist must attempt to estimate for the court the degree of difficulty that the subject may experience in adhering to a legally acceptable course under any given circumstances. The psychiatrist should be careful not to over evaluate the results of mental age determinations. Due weight should be given to evidence
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of intellectual capacity, such as past performance, which lies outside the realm of formal psychometric tests. It can be stated almost as a rule that no mental defective of a grade sufficiently low to be totally irresponsible for his acts is allowed to pass through combat training and become attached to a division in combat. Case 39 is illustrative of this group.
CASE 39. A 27-year-old rifleman was sent to the psychiatrist for opinion prior to court-martial for misbehavior in the face of the enemy. While his company was engaging the enemy he left it without securing permission and proceeded to the rear. He stated that he did so because he was "jittery, scared, and couldn`t keep up." He stated further that he did not at the time realize the serious nature of his offense, although he knew he was disobeying military regulations. During the Tunisian campaign he had worked in a motor pool, but was eventually relieved of his job because his vehicles were found to be in poor repair. He had been engaged in combat as a rifleman for only a short time before committing the alleged offense. At the time of examination he showed neither tension nor anxiety. There was no tremor. It was obvious that he was mentally dull. On the Kent Emergency Scale his mental age was 9 years—a score that, if anything, was high. His grasp of the situation in which he found himself was imperfect. The degree of his mental dullness could be judged by the fact that he did not know how many days there were in a month or how many minutes in an hour. His previous Army performance was consistent with marked intellectual dullness. His school record was poor. He left school in the 8th grade at the age of 18, after failing many grades. His home had been broken by the early death of his father. His childhood behavior pattern was characterized by frequent temper tantrums. In civil life he was employed as a truckdriver. The following psychiatric opinion was given: "This soldier is suffering from mental deficiency (mental age, 9 years, Kent scale), with transient anxiety in combat. Despite this diagnosis he is responsible for his acts. Since his mental deficiency is of such grade that it seriously lessened his ability to comprehend the total military demands of his situation, it is strongly recommended that his mental deficiency be considered in extenuation of the alleged offenses. This man should be reassigned to a service element of his present organization or to some other type of noncombat duty, when his legal status has been clarified. He is psychiatrically unfit for further combat.
MALINGERING
While the Articles of War provide adequately for the punishment of malingerers, proof of malingering that will withstand attack by an enterprising defense counsel is difficult. The problem is most satisfactorily resolved by persuading the soldier to drop his symptoms and return to duty. When suitable means of persuasion were used, all malingerers without exception could be returned to duty if there was no serious underlying psychiatric disease. In this way manpower was conserved.
OTHER PROBLEMS
The psychiatric evaluation of other types of offenders, such as alcoholics, psychopaths, and offenders of civilian type, presented no new or unusual problems in the field. After clarification of their legal status
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and completion of sentence to confinement, when ordered by the court, constitutional psychopaths were recommended by the psychiatrist for administrative discharge from the service under provisions of Sec. VIII, AR 615-360 (now AR 615-368 and AR 615-369).
ORGANIZATION OF MEDICOLEGAL WORK IN THE FIELD
In disciplinary cases all psychiatric opinions within a division should be rendered by the division psychiatrist, who is fully acquainted with the situation in which the alleged offense was committed and can deal with offenders without the delay that occurs when they must be sent out of the division. Consultations are best rendered on an ambulatory outpatient basis. In the Fifth and Seventh Armies all psychiatric opinions in nondivisional troops were given by staff members of the army psychiatric centers, except in unusual circumstances, and offenders were seen strictly on an outpatient basis. As in the division, this policy saved time in obtaining opinions, maintained continued army control over army personnel, provided more adequate liaison between the psychiatrist, the offender’s organization, and the army judge advocate, and insured uniformity of policy. Offenders were not hospitalized for psychiatric opinion unless special circumstances required extensive diagnostic work-up or locked-ward facilities for observation. In such instances they were hospitalized in the base section area, where guard facilities were adequate. When adequate background information was available a single interview was usually sufficient. A report was prepared and dispatched to the proper authorities immediately. These policies resulted in speedy receipt of reports by legal authorities and avoided congestion in the psychiatric wards, where space was usually at a premium.
Technical Aspects of Examination and Report
A written report from the offender`s military organization, stating the exact nature of the charges, the circumstances in which the offense was committed, and certain details of the soldier`s medical and military history should be given the psychiatrist at the time of the examination. In many cases it is impossible to give a satisfactory opinion without such information, and unless it has been placed at his disposal the psychiatrist as a rule should refuse to render an opinion for use in courts martial. The psychiatrist`s opinion was submitted on a standard form devised for that purpose (figure 9). Care was taken to use nontechnical terminology as far as possible, in order that the report should be intelligible and informative to nonmedical authorities who might deal with the case.
PREVENTION
Though the prevention of offenses against military law is a command function, division and army psychiatrists, who are in close touch with problems of morale and motivation, may offer suggestions for reducing the number of such cases. In general, prevention involves: avoidance, as far as militarily possible, of exceeding the physical and moral endurance of the troops, together with proper regard for both positive and negative factors in motivation.
Figure 9. Form used in submitting psychiatric opinion in disciplinary cases (front).
SUBJECT: PSYCHIATRIC REPORT IN DISCIPLINARY CASES
TO: COMMANDING OFFICER
Name: ASN: Org:
Age: Service:
A. The above mentioned man was referred for psychiatric examination because of:
The officer of his unit states that:
He states that:
Findings on examination:
(Date)
In my opinion he is suffering from (medical diagnosis with brief explanation of this condition in lay terminology):
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FIGURE 9. Form used in submitting psychiatric opinion indisciplinary cases (back).
Recommendation:
When answering in detail the questions in B, C, D, and E below, a clear distinction should be drawn between (1) facts observed by the psychiatrist making the report; (2) statements made by the man himself; and (3) the alleged facts communicated by others.
B. Unfitness to plead at the time of the trial.
1. Is he able to understand the nature of the proceedings at a court-martial?
2. Is he able to object to any member of the court?
3. Is he able to instruct his defending officer?
4. Is he able to understand the details of the evidence?
5. Is he able, with advice and assistance of legal counsel, to conduct the defense of his case?
C. Criminal Responsibility.
1. Was he at the time of the alleged offense suffering from a defect of reason resulting from disorder of the
mind?
2. Did such defect of reason prevent him from knowing the nature and quality of the act which he was doing?
3. Did such defect of reason prevent him from knowing the consequences of such an act?
4. Or, if he did know, was his mental state such that he was unable to refrain from such act?
D. Evidence as to Behavior.
1. Was the accused suffering at the time of the offense from any emotional or physical disorder which might have affected his behavior?
If so specify:
State how this might affect his behavior:
2. Is punishment likely to diminish the chances that he will repeat this or similar offenses?
3. Is punishment likely to increase or decrease his efficiency, as a soldier?
E. Medical Disposition.
1. Is any treatment required immediately, during detention, or after release?
2. Is punishment likely to aggravate his mental condition or to precipitate other mental disturbances?
3. Is any other action (e. g. transfer after sentence) recommended?
F. Any further remarks considered desirable.
Signature
