CHAPTER 6 Combat Stress and Its Effects: Combat’s Bloodless Casualties It is hard to equate our civilian experiences with fear to the combat situation. Here danger is imminent and ever present. It is a constant companion every hour of the day, every day of the week. The enormity of this fear is hard to portray and without such an experience, hard to imagine; later, dispersed with prolonged periods facing this fear, are long periods of sheer boredom and frustration—always with the knowledge that the enemy has to be faced again. Fear and its effects are cumulative . [t]o each experience is added another. [I]f there is no chance at relief or no additional factors to sustain [the soldier], the po- tentiality for combat exhaustion exists. [Or alternatively] his judgment is not as good; his alertness may suffer, and his willingness to take chances may disappear. He and his men may become physical casualties long before they become psychological casualties.1 (pp3–4) Lieutenant Colonel Edwin T Cooke Psychiatrist and Faculty Member, Department of Neuropsychiatry Medical Field Service School, Fort Sam Houston, Texas This is a photograph of a combat fatality taken at the 15th Medical Battalion Clearing Station/1st Cavalry Division at Phouc Vinh in 1970. Although the combat intensity in Vietnam was highest during the early and middle years of the war, apprehensions about be- coming a casualty remained the preeminent psychologi- cal stress factor for Army troops assigned throughout the war. Photograph cour- tesy of Richard D Cameron, Major General, US Army lements of the history of Army psychiatry that addressed the importance of (Retired). the prevention and timely treatment of soldiers affected by combat stress were reviewed in Chapter 2. In particular it was demonstrated that in the high Eintensity wars that preceded Vietnam, rates for soldier attrition and disability from the effects of combat stress could rise to levels sufficient to threaten the outcome of military engagements. For America and its allies, the Vietnam War also started as a high-intensity, main force war. However, shortly after it began the enemy concluded that the allied forces could not be defeated in large-scale attacks, and they resorted mostly to terrorist/guerrilla tactics. What followed was a protracted, bloody, politically charged, low-intensity war that came 146 • US ARMY PSYCHIATRY IN THE VIETNAM waR to be bitterly opposed by the American public and the to the war to estimate the incidence of combat exhaus- international community. In general, and especially tion cases in Vietnam. In addition, it explores some of during heightened combat activity, treatment of acute the unique features of the combat ecology in Vietnam, combat-generated psychiatric casualties, including provides case examples, and presents selected findings what some referred to as classic combat exhaustion, from the 1982 Walter Reed Army Institute of Research was required of medical and mental health personnel (WRAIR) Psychiatrists’ Survey in an effort to further at all levels of care. (In this volume, the term combat define the nature of combat stress there and its various exhaustion is used synonymously with the terms combat symptomatic consequences. fatigue, combat reaction, combat stress reaction [CSR], The material presented in this chapter extends the and, in some instances, combat breakdown.) review of the Army’s forward treatment doctrine for Compared with other psychiatric conditions, how- combat stress casualties begun in Chapter 2. Manage- ever, such combat stress reactions, at least in the forms ment and treatment of combat reactions in Vietnam seen in earlier wars, appeared to be well below expected are discussed in Chapter 7. Finally, psychiatric and levels. This does not mean that they had no clinical behavior problems in Vietnam that were not evidently impact, just that their numbers did not constitute a associated with combat will be addressed in Chapter threat to military effectiveness and success. As a result, 8 as deployment stress reactions (currently called psychiatric attention was redirected to the burgeoning combat misconduct stress behavior). However, it behavior and disciplinary problems, especially racial should be noted that in many instances this distinction tensions and incidents, challenges to military authority, could be a misleading because the war was mostly a drug abuse, and the number of soldiers diagnosed counterinsurgency/guerrilla war with no front lines with character and behavior disorders (ie, personality and no deep, well-defended rear. Many psychiatric and disorders2)—problems not limited to combat troops behavior problems may have etiologically overlapped and thus not regarded as closely tied to participation with overt combat reactions and belong at the other end in combat. However, these behavior problems, as well of the spectrum of psychiatric and behavior disorders as ones that were more obviously combat-specific (ie, generated by the unique collection of combat-related combat refusals and excessive combat aggression), stressors found throughout Vietnam. along with psychosomatic conditions and low-grade psychiatric symptoms (anxiety, depression, and “short- timer’s syndrome”), continued to arise in the theater, BACKGROUND representing “hidden casualties”3—conditions that would not have been considered among the more tradi- The Classic Combat (Stress) Reaction: tional measures of the psychiatric costs of fighting in Psychosocial Regression Under Fire and Vietnam. In fact, the greatest impact may have been the Loss of Combat Effectiveness among veterans. Many have argued that the proportion As indicated in Chapter 2, throughout the of Vietnam veterans with debilitating psychological 20th century there was growing interest by military and social problems greatly exceeded those from earlier psychiatrists and other behavioral scientists regarding American wars, but the connection between combat the physical and psychological limits of troops under stress symptoms in the theater and symptoms arising fire and the prevention of soldier breakdown as well as after the war, including what would come to be called its treatment.5–19 In the wars preceding Vietnam, combat posttraumatic stress disorder (PTSD), has remained reaction symptoms were noted to be diffuse and variable inconclusive.4 (Further discussion of PTSD and the and sometimes spread among soldiers by suggestion.1 postwar adjustment of Vietnam veterans can be found Early-stage combat reaction symptoms progressed later in this chapter as well as in Chapters 2, 11, from normal anticipatory fear and uneasiness to hyper- and 12.) alertness, irritability, difficulty concentrating, insomnia, This chapter begins with a review of the somatic disturbances, and preoccupations with death phenomenological features and etiologic assumptions and disability. Severity often increased if there was no associated with combat exhaustion (currently included relief or intervention, and the disorder advanced to in combat and operational stress reaction [COSR]). It a stage of gross disturbances in mood, thinking, and also utilizes the available psychiatric literature pertaining behavior20 (Table 6-1). CHAPTER 6. COMBAT STRESS AND ITS EFFECTS • 147 TABLE 6-1. Combat Reaction Stages APPREHENSION INCIPIENT PARTIAL COMPLETE “Normal Fear” Combat Reaction Combat Reaction Combat Reaction Social and Appropriate Add: Irritability Reclusive Unstable Behavioral Combat effective Morose Erratic Close with comrades Overdependent and Reckless or overcautious Shares fears with comrades avoids responsibility Savage irritability Reduced initiative Unreasonable and defiant Impulsive Sobbing Decreased interest in: Screaming combat, food, letters, etc. Passive and helpless Unit members alarmed Emotional Increased vigilance Add: Startle reaction Mild disorientation Confused and Cognitive Worries: death/mutilation Reduced judgment Disorganized incapacitating fear, Psychomotor retardation Amnestic losing caste with group Affect blunting through fear Depressed Ruminating regarding: survival, combat failure, excess combat aggression Somatic Tense Add: Major insomnia Severe diarrhea and vomiting Stammering and incoherent Autonomic arousal Somatic preoccupation Tremulous and uncoordinated (gastrointestinal disorders, etc.) Mute and staring Disturbed sleep Conversation symptoms: deaf, (including sleepwalking) blind, paralyzed, convulsive Psychosomatic complaints Drawn from observations made in the closing phases of World War II by a panel of distinguished civilian psychiatrists who visited the European theater. Data source: Bartemeier LH, Kubie LS, Menninger KA, Romano J, Whitehorn JC. Combat exhaustion. J Nerv Ment Dis. 1946;104:358–389. Presenting symptoms for combat reactions were Diagnosis of the Combat Reaction also influenced by the soldier’s specific combat circum- With regard to combat reaction cases, the stances, that is, the “ecology” of the battlefield,21 as well fully affected soldier (“Complete combat reaction” as the military’s medical evacuation requirements.7,22 in Table 6-1) is presumed to have undergone a They were also shaped by which symptom patterns profound psychological regression—a mental and the soldier’s reference group (combat buddies) found social decompensation—as a consequence of having acceptable.23 In this regard, his condition must appear had his psychological endurance, as well as his com- to reflect incapacitation, as opposed to unwillingness, bat motivation24,25 and adaptation, overwhelmed to continue