psychiatric casualties

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These are soldiers who suffer mental trauma and breakdown as a result of the experience of combat and danger on the battlefield. Although the reality of psychiatric casualties has really only been acknowledged by armies during this century, the problem is not a new one. Men in battle have been exposed to very high levels of danger and privation throughout human history and the extreme conditions on the battlefield have always resulted in mental breakdown among soldiers.

Even recognition of the damage that battle can cause to the human mind is not new. Doctors first diagnosed Swiss mercenary soldiers as suffering from ‘nostalgia’ in 1698. The symptoms of this illness were excessive physical fatigue, inability to concentrate, and an unwillingness to eat or drink. These are all now regarded as signs of a psychiatric breakdown but in the 17th century it was believed that these soldiers were suffering from a longing to return home.

The bloody battles of the American civil war produced 5, 213 cases of nostalgia in the first year alone and special hospitals were established to treat soldiers suffering from the problem. Russian army doctors were the first to properly diagnose psychiatric casualties as such during the Russo-Japanese war.

WW I, characterized by the mass use of modern weaponry and vastly destructive artillery bombardments, saw the widespread recognition of the problem in most of the combatants' armies. The increasing range and destructive power of weaponry had given rise to the ‘lonely battlefield’ where men were exposed to much greater danger but due to the new dispersed tactical formations could no longer draw the same level of support from their comrades. Battles often became prolonged from days into weeks and even months. The area in which a soldier was in danger was also vastly increased and infantry soldiers under artillery bombardments were literally helpless, pounded with enormous destructive power and great noise but unable to defend themselves or deal with the threat.

During the first two years of the war, British soldiers suffering from psychiatric breakdown were often executed for cowardice rather than given medical help. However, the number of cases reached such alarming levels that a new term, shell-shock, was coined. It was believed that soldiers with shell-shock had suffered microscopic lesions of the brain from the concussion and blast of a shell explosion and that this physical cause explained their inability to function as soldiers. The fact that many cases of shell-shock had not been in close proximity to shellfire when they broke down was a difficult problem. It was still not accepted that men could suffer emotional or mental damage from combat without any physical cause, and the military authorities of all armies treated the whole matter with suspicion, as they feared that acceptance of the problem would encourage malingering.

In 1922, the British War Office Committee of Inquiry into shell-shock arrived at important conclusions. The committee recognized that there was such a thing as a mental wound, and admitted that it was almost impossible to identify a coward who was shirking his duty from a soldier suffering from shell-shock. This finding supported the abolition of the death penalty for cowardice in 1930.

However, WW II found armies unprepared for the problems of psychiatric breakdown in combat. It was current among civilian Freudian psychiatrists that only people with a weak character (predisposition) would break down under stress. The US army therefore instituted rigorous psychological tests for all recruits in an attempt to weed out those men with character defects who might be predisposed to breakdown. The USA screened 18 million men for military service and rejected 970, 000 for psychiatric and emotional reasons but the screening did not reduce the rate of psychiatric casualties as expected. Psychiatric casualties were still the greatest single category of military disability granted by the US government in WW II. Among American GIs, 1, 393, 000 suffered psychiatric symptoms, and of these 504, 000 had to be discharged from the army. Of the soldiers who were actually involved in combat at least 37.5 per cent suffered severe psychiatric problems.

The trend of high rates of psychiatric casualties has continued in more recent wars. In the Korean war, a GI was twice as likely to become a psychiatric casualty as he was to be killed and during the 1973 Arab-Israeli war, the Israelis found that 30 per cent of their casualties were due to psychiatric breakdown.

Armies suffer these high rates of psychiatric casualties due to the strain placed on soldiers in battle. Fear is the body's natural reaction to danger and virtually all soldiers can exhibit the symptoms of badly frightened human beings from uncontrollable shaking to involuntary urination or defecation. When a human being senses a threat, the autonomic nervous system begins a series of chemical changes to help the body deal with that danger. Blood pressure rises, heartbeat increases, awareness becomes heightened, and reserves of muscular strength are released. These changes, often accompanied with the well-known symptoms of fear such as sweating, dryness in the mouth, vomiting, or urination, prepare the body to fight against the threat, to run away from the danger, or to freeze as a form of camouflage. For early man, as with all animals, this ‘fight or flight’ mechanism was vitally important as whenever there was danger present his nervous system prepared him to deal with the threat.

However, this natural and involuntary reaction to fight or flee in the face of danger was not designed to deal with the pressures of combat. Men in battle have always encountered extreme levels of danger and often suffered from hunger, thirst, and sleep deprivation which all adds to the stress placed on the mind and body of the soldier. Combat is also an extremely noisy, chaotic, confusing, and disorienting place which can overload the soldier's senses. This situation alone leads to intense exhaustion which can seriously affect a soldier's effectiveness, morale, and stamina.

The pressures of combat also put a great deal of strain on the human mind. Under stress, the ability to reason and make decisions declines rapidly, and the soldier is torn between his desire to remain steadfast and to fight bravely and his natural involuntary reaction to fight or to flee. Without a physical release for the stress and anxiety, such as fighting an opponent directly, eventually the mind provides ‘relief’ by converting the anxiety into a physical symptom. By shutting down the body's functions in one way or another, the soldier can no longer take part in the combat and is removed from the situation mentally if not physically. This mental breakdown is involuntary and caused by factors beyond the soldier's control—the natural fight-or-flight mechanism and the intensity of the danger that the soldier has experienced. American studies found that after 30 days of combat in Normandy, 98 per cent of soldiers had manifested severe psychiatric reactions. It is a plain fact that most normal men will suffer some kind of mental damage on exposure to combat.

Nostalgia, shell-shock, neuralgia, battle exhaustion, combat fatigue, battle shock, and post-traumatic stress disorder (PTSD) are all terms which have been used this century to describe the range of mental damage and trauma which soldiers can suffer through exposure to battle. It must be stressed that the human mind is an extremely complex organ and individuals can suffer similar traumatic experiences but exhibit very different symptoms. It is impossible to predict which soldiers will collapse and which will fight on bravely. Some men can cope with the stress of battle for an extended period and then suffer a total breakdown, while other men can go into shock very quickly after a particularly traumatic event. In a similar vein, some soldiers can recover from stress or shock quite quickly while others find it difficult or impossible to recover. The reaction to danger and trauma is very individual, and recovery is also individual and very difficult to predict.

After periods of great stress and activity, soldiers become physically and mentally exhausted, and eventually, if left in combat, a soldier suffering from extreme fatigue will develop deeper mental problems. Studies carried out during the Normandy campaign gave a clear idea of the effect of exhaustion and battle stress on soldiers which developed over a period of 90 to 120 days. After three weeks in combat, soldiers developed permanent fatigue which could not be cured with simple rest. Such soldiers could no longer distinguish sounds and overreacted to noises and unexpected situations. After five weeks in combat these soldiers sunk into a state of extreme exhaustion and lassitude. It was found that if the soldier was not relieved at this stage he would reach a vegetative state and be incapable of any further action. Lord Moran likened a man's courage and mental health to a bank account where every experience of combat draws on the reserve. Eventually, the bank account of courage will be exhausted and the soldier will succumb to the stress of battle.

Some soldiers suffer breakdown due to a single traumatic event which causes the soldier's mind to go into shock. Shock often manifests itself as conversion hysteria, where the mind causes the body to be incapacitated. Paralysis of the limbs, blindness, deafness, or a fugue state (coma) are all symptoms of acute battle shock.

The third main type of mental damage a soldier can suffer from battle was only properly understood after the Vietnam war. Many Vietnam veterans found that they suffered psychiatric problems only once they had returned home. It is believed that 500, 000 to 1, 500, 000 Vietnam veterans suffered from PTSD. In this condition, the soldier experiences such a traumatic event that it has long-term consequences. The traumatic experience has had such an impact that the event is ‘replayed’ over and over again in the soldier's mind. Due to this constant reliving of traumatic events, PTSD sufferers often display severe mood swings, personality changes, and can react violently to otherwise normal situations.

Soldiers have always used various methods to cope with the stress of battle. Alcohol, acting as it does as a relaxant, can reduce anxiety and fear for a limited period thus providing some ‘Dutch courage’. Many soldiers have used other drugs. The Ghazis of Mughal India used marijuana to induce fearlessness while some Vikings used fermented deer urine to induce a berserker fury in battle. Clearly, however, use of drugs, although commonplace in Vietnam, is not helpful for the modern soldier.

However, realistic training which educates the soldier for his role in combat, and gives him confidence in his abilities and that of his comrades and leaders can help to reduce anxiety in battle significantly. During this century the importance of the small group was finally scientifically recognized, although the Roman army had recognized the importance of soldierly comradeship with their use of five-man tents. It has been found that soldiers can derive great comfort and strength from the immediate group of three to five men around them. Just as important is good leadership from officers who can reassure their men, look after their welfare, and inspire troops in combat. However, one of the best and simplest ways of tackling the cumulative effects of battle is to ensure that soldiers are given regular rest from action, shelter from the elements, and are always kept well supplied with food and water. These elements, so often lacking from a front-line soldier's existence, can keep men going in difficult circumstances.

Measures to reduce the strain on soldiers in battle cannot eliminate the problem; there will still be psychological casualties. Lt Col Salmond of the US army first discovered the principles of treatment in 1917 which are still generally accepted today. Most armies still emphasize his three key elements to successful treatment of psychiatric casualties: proximity, immediacy, and expectancy.

Rates of recovery from mental breakdown have been found to be much higher when soldiers have been treated in close proximity to the battle zone which maintains the soldier's bonds of duty and military discipline. Soldiers also have to be treated quickly before their symptoms can deepen and become more permanent. Maintaining the expectancy that the soldier will return to his unit ensures that the bonds of comradeship are maintained and does not stigmatize the soldier as a ‘patient’, but rather ensures that he still sees himself as a soldier. These basic elements of treatment have been found to be effective and, with proper counselling and care, psychiatric casualties can be restored to normal health. Nevertheless, the problem of psychiatric casualties remains a major problem for modern armies and is a subject that demands serious and constant attention to ensure that armies can still function on the extremely dangerous and complex modern battlefield.