Combat stress reaction (CSR) or combat neurosis is acute behavioral disorganization as a direct result of the trauma of war. Also known as "combat fatigue", "battle fatigue", "operational exhaustion", or "battle/war neurosis", it has some overlap with the diagnosis of acute stress reaction used in civilian psychiatry. It is historically linked to shell shock and is sometimes a precursor to post-traumatic stress disorder.
Combat stress reaction is an acute reaction that includes a range of behaviors resulting from the stress of battle that decrease the combatant's fighting efficiency. The most common symptoms are fatigue, slower reaction times, indecision, disconnection from one's surroundings, and the inability to prioritize. Combat stress reaction is generally short-term and should not be confused with acute stress disorder, post-traumatic stress disorder, or other long-term disorders attributable to combat stress, although any of these may commence as a combat stress reaction. The US Army uses the term/initialism COSR (combat stress reaction) in official medical reports. This term can be applied to any stress reaction in the military unit environment. Many reactions look like symptoms of mental illness (such as panic, extreme anxiety, depression, and hallucinations), but they are only transient reactions to the traumatic stress of combat and the cumulative stresses of military operations.Department of the Army (2009). Field Manual No. 6-22.5. Combat and Operational Stress Control Manual for Leaders and Soldiers. Department of the Army Headquarters, Washington, DC, 18 March 2009. p 12.
In World War I, shell shock was considered a psychiatric illness resulting from injury to the nerves during combat. The nature of trench warfare meant that about 10% of the fighting soldiers were killed (compared to 4.5% during World War II) and the total proportion of troops who became casualties (killed or wounded) was about 57%. Whether a person with shell-shock was considered "wounded" or "sick" depended on the circumstances. Soldiers were personally faulted for their mental breakdown rather than their war experience. The large proportion of World War I veterans in the European population meant that the symptoms were common to the culture.
In World War II it was determined by the US Army that the time it took for a soldier to experience combat fatigue while fighting on the front lines was somewhere between 60 and 240 days, depending on the intensity and frequency of combat. What had been known in previous wars as "nostalgia", "old sergeant's disease", and "shell shock", became known as "combat fatigue".
Signs and symptoms Combat stress reaction symptoms align with the symptoms also found in psychological trauma, which is closely related to post-traumatic stress disorder (PTSD). CSR differs from PTSD (among other things) in that a PTSD diagnosis requires a duration of symptoms over one month, which CSR does not.
Fatigue-related symptoms The most common stress reactions include:
The slowing of reaction time Slowness of thought Difficulty prioritizing tasks Difficulty initiating routine tasks Preoccupation with minor issues and familiar tasks Indecision and lack of concentration Loss of initiative with fatigue Exhaustion
Autonomic nervous system – autonomic arousal
Headaches Back pains Inability to relax Shaking and tremors Sweating Nausea and vomiting Loss of appetite Abdominal distress Frequency of urination Urinary incontinence Heart palpitations Hyperventilation Dizziness Insomnia Nightmares Restless sleep Excessive sleep Excessive startle Hypervigilance Heightened sense of threat Anxiety Irritability Depression Substance abuse Loss of adaptability Attempted suicides Disruptive behavior Mistrust of others Confusion Extreme feeling of losing control
Battle casualty rates The ratio of stress casualties to battle casualties varies with the intensity of the fighting. With intense fighting, it can be as high as 1:1. In low-level conflicts, it can drop to 1:10 (or less). Modern warfare embodies the principles of continuous operations with an expectation of higher combat stress casualties..
The World War II European Army rate of stress casualties of 1 in 10 (101:1,000) troops per annum is skewed downward from both its norm and peak by data by low rates during the last years of the war.Military Psychiatry Ed. Gabriel, R.A., (1986)
Diagnosis The following PIE principles were in place for the "not yet diagnosed nervous" (NYDN) cases: Proximity – treat the casualties close to the front and within sound of the fighting. Immediacy – treat them without delay and not wait until the wounded were all dealt with. Expectancy – ensure that everyone had the expectation of their return to the front after a rest and replenishment.
United States medical officer Thomas W. Salmon is often quoted as the originator of these PIE principles. However, his real strength came from going to Europe and learning from the Allies and then instituting the lessons. By the end of the war, Salmon had set up a complete system of units and procedures that was then the "world's best practice". After the war, he maintained his efforts in educating society and the military. He was awarded the Distinguished Service Medal for his contributions.
Effectiveness of the PIE approach has not been confirmed by studies of CSR, and there is some evidence that it is not effective in preventing PTSD.
US services now use the more recently developed BICEPS principles: Brevity Immediacy Centrality or contact Expectancy Proximity Simplicity
Between the wars The British government produced a Report of the War Office Committee of Inquiry into "Shell-Shock", which was published in 1922. Recommendations from this included:
Part of the concern was that many British veterans were receiving pensions and had long-term disabilities.
By 1939, some 120,000 British ex-servicemen had received final awards for primary psychiatric disability or were still drawing pensions – about 15% of all pensioned disabilities – and another 44,000 or so were getting pensions for 'soldier's heart' or effort syndrome. There is, though, much that statistics do not show, because in terms of psychiatric effects, pensioners were just the tip of a huge iceberg."Shephard, Ben. A War of Nerves: Soldiers and Psychiatrists, 1914–1994. London: Jonathan Cape, 2000.
War correspondent Philip Gibbs wrote:
One British writer between the wars wrote:
World War II
American At the outbreak of World War II, most in the United States military had forgotten the treatment lessons of World War I. Screening of applicants was initially rigorous, but experience eventually showed it to lack great predictive power.
The US entered the war in December 1941. Only in November 1943 was a psychiatrist added to the table of organization of each division, and this policy was not implemented in the Mediterranean Theater of Operations until March 1944. By 1943, the US Army was using the term "exhaustion" as the initial diagnosis of psychiatric cases, and the general principles of military psychiatry were being used. General Patton's slapping incident was in part the spur to institute forward treatment for the Italian invasion of September 1943. The importance of unit cohesion and membership of a group as a protective factor emerged.
John Appel found that the average American infantryman in Italy was "worn out" in 200 to 240 days and concluded that the American soldier "fights for his buddies or because his self respect won't let him quit". After several months in combat, the soldier lacked reasons to continue to fight because he had proven his bravery in battle and was no longer with most of the fellow soldiers he trained with. Appel helped implement a 180-day limit for soldiers in active combat and suggested that the war be made more meaningful, emphasizing their enemies' plans to conquer the United States, encouraging soldiers to fight to prevent what they had seen happen in other countries happen to their families. Other psychiatrists believed that letters from home discouraged soldiers by increasing nostalgia and needlessly mentioning problems soldiers could not solve. William Menninger said after the war, "It might have been wise to have had a nation-wide educational course in letter writing to soldiers", and Edward Strecker criticized "moms" (as opposed to mothers) who, after failing to "wean" their sons, damaged morale through letters.
Airmen flew far more often in the Southwest Pacific than in Europe, and although rest time in Australia was scheduled, there was no fixed number of missions that would produce transfer out of combat, as was the case in Europe. Coupled with the monotonous, hot, sickly environment, the result was bad morale that jaded veterans quickly passed along to newcomers. After a few months, epidemics of combat fatigue would drastically reduce the efficiency of units. Flight surgeons reported that the men who had been at jungle airfields longest were in bad shape: Many have chronic dysentery or other disease, and almost all show chronic fatigue states. ... They appear listless, unkempt, careless, and apathetic with almost mask-like facial expression. Speech is slow, thought content is poor, they complain of chronic headaches, insomnia, memory defect, feel forgotten, worry about themselves, are afraid of new assignments, have no sense of responsibility, and are hopeless about the future.Mae Mills Link and Hubert A. Coleman, Medical support of the Army Air Forces in World War II (1955) p. 851
British Unlike the Americans, the British leaders firmly held the lessons of World War I. It was estimated that aerial bombardment would kill up to 35,000 a day, but the Blitz killed only 40,000 in total. The expected torrent of civilian mental breakdown did not occur. The Government turned to World War I doctors for advice on those who did have problems. The PIE principles were generally used. However, in the British Army, since most of the World War I doctors were too old for the job, young, analytically trained psychiatrists were employed. Army doctors "appeared to have no conception of breakdown in war and its treatment, though many of them had served in the 1914–1918 war." The first Middle East Force psychiatric hospital was set up in 1942. With D-Day for the first month there was a policy of holding casualties for only 48 hours before they were sent back over the Channel. This went firmly against the expectancy principle of PIE.
Appel believed that British soldiers were able to continue to fight almost twice as long as their American counterparts because the British had better rotation schedules and because they, unlike the Americans, "fight for survival" – for the British soldiers, the threat from the Axis powers was much more real, given Britain's proximity to mainland Europe, and the fact that Germany was concurrently conducting air raids and bombarding British industrial cities. Like the Americans, British doctors believed that letters from home often needlessly damaged soldiers' morale.
Canadian The Canadian Army recognized combat stress reaction as "Battle Exhaustion" during the Second World War and classified it as a separate type of combat wound. Historian Terry Copp has written extensively on the subject.Battle Exhaustion. Soldiers and Psychiatrists in the Canadian Army, 1939–1945. Terry Copp and Bill McAndrew. . In Normandy, "The infantry units engaged in the battle also experienced a rapid rise in the number of battle exhaustion cases with several hundred men evacuated due to the stress of combat. Regimental Medical Officers were learning that neither elaborate selection methods nor extensive training could prevent a considerable number of combat soldiers from breaking down."Copp, Terry The Brigade (Stackpole Books, 2007) p. 47
Germans