Psychology

Military history reflects that no matter how physically strong a person is, one could never be immune to no one was immune to combat stress.  Soldiers were still human beings and human beings are fragile.  Despite the fact that a soldier was well-trained and no matter how good their commanders were, if human beings were placed into battle, they would succumb to stress in one way or another because of the destructive environment they are exposed to (Gabriel, 1987).  Thus, a significant measure in the effectiveness of a soldier was how well soldiers could endure the stress and strains of a military environment.   Thus, the focus of military planners was not to eliminate every possibility of stress but to prevent soldiers from battle-shock breakdown to the point that they would be incapable of functioning (Gabriel, 1987).  Military psychiatry was designed to help soldiers that suffer stress to quickly return to the service.

There were numerous instances in military history that brought about weakness to the armies in important wars.  In the World War II, the American soldiers lost more than half a million men because of psychiatric breakdown and were unable to fight because of it (Gabriel, 1987).  This was a number that was enough to make up combat divisions.  Due to the similar reasons, a third of Israeli casualties was said to be

History of Combat Stress Reactions
Combat stress reaction (CSR) used to be known as shell shock or battle fatigue.  These terms were military terms that were used to describe a set of behavior that was a product of battle stress.  The effect of battle usually resulted in the soldiers decreased fighting competence.  Mandel (n.d.) described the common psychological symptom of CSR to include fatigue, delayed or slower reaction time, indecision, detachment from the group and the inability to present appropriate priorities.  On the other hand, the physical effects of this condition included experiences of headaches, dizziness, shortness of breath, palpitations and exertional chest pain (Mandel, n.d.).  However, CSR was also described to occur for a short time only and was different with post-traumatic stress disorder and other long-term psychological conditions that were associated to combat stress.  Nevertheless, it could not be taken for granted because the rational probability of experiencing stress casualties and battle casualties could reach a 11 ratio when the fighting was intense (Kardiner  Spiegel, 1947).

Marlowe (2000) described the history of psychological consequences form warfare in the West to be decoupling and perceived combat effects from combat itself.  For the longest time, if men break down from battle or experience psychological dysfunction afterwards, the fault was found in themselves and was not considered as a consequence of war.  The decoupling perspective directed the way of thinking about combat stress reactions throughout the World War I and it was known to continue today (Marlowe, 2001).

The issue regarding the acceptance of psychological injury from combat was disregarded because combat stress reactions were commonly associated with the fighters failure in battle.  It followed Biblical tradition and Greek concepts of warfare, wherein a soldier was either a man of courage or cowardice (Marlowe, 2001).  Men that fail in battle, regardless of whatever reason, were traditionally deprived of acceptance and any form of honor throughout classical history.  Thus, in order to prevent failure, they focus on improving disciplinary techniques, tactical strategies, and increased combat group cohesion.  Instead of considering the fact that men could experience weakness in battle because of psychological stress, they simply disregard psychological injury as spinelessness.  In the Middle Ages, it was indispensable for warriors to be courageous and anything that showed weakness to the lack of it (Marlowe, 2001).

In the Swiss military, when a soldier was fleeing or spreading panic during battle, the code was for the nearest companion to strike that person dead (Marlowe, 2001).  Thus, the division was made simplistic enough to exclude any consideration for the power of psychological injury.  There was a rejection of the idea that combat stress could alter the behavior of soldiers during battle.  There existed only the line between those with courage and cowardice (Marlowe, 2001).  If a man breaks down, he is not considered wounded he is just a coward.  A courageous soldier did not acknowledge the traditional perception of psychological breakdown or injury from war as a valid response.  Instead of being a psychological or a physical issue, it became a moral one (Marlowe, 2001).  The main question that remained was why did human beings broke down in war or after a battle.  Over time, it has either been placed in a simple set of categories, either in medicine or in the Western belief systems (Marlow, 2000).

Studying the history of CSR revealed various elements and consideration because of the numerous perspectives that emerged to discuss it.  This was due to the different interest groups and knowledge bases by which combat stress was discussed in. Kardiner and Spiegel (1947) depicted studies about CSR to be exposed to a great deal of fickleness because the public and scholars of psychiatry do not sustain interest in the pursuit of this subject.  Each scholar that takes on the task of exploring the topic of neurotic disturbances as a result of war find it necessary to always start from scratch and not to build on other researchers work because of the complex nature of this subject.

The earliest CSR conditions were known as soldiers heart and nostalgia (Doyle, 2000).  However, it was the Russians, during the Russo-Japanese war in the early 1900s that pioneered the discovery for mental disease that resulted from stress form war and treated it in that context (Global Oneness, 2010).   In 1915, the British Army in France delegated different kinds of shell shock.  If a soldier experiences shock from a shell explosion and if it was due to the enemy, the case would be entitled to the rank of wounded, as shell shock W, and he can have a wounded stripe on his arm (Global Oneness, 2010).  However, if the mans breakdown did not occur after a shell explosion and the enemy did not cause it, they would be labeled with S for sickness and was not entitled to a wounded stripe and the pension that came with it.

However, the events leading up to September 1918 abolished shell shock as a valid disease (Global Oneness, 2010).  The Adjutant-General had a general distrust of doctors and no patient could receive their attention until Form AF 3436 has been signed by his commanding officer.  Evidently, this resulted in the delays.  One of the reasons why shell shock was written off was because only 4 to 10 were due to physical cause and the rest were classified as emotional.

Doyle (2000) described the motivation of society to disregard psychological injury or breakdown as a result to the stress of war because of the heroism that was associated with context of battle.  Combat leaders have the crucial task of managing their soldiers ability to function in the midst of the most stressful and unpredictable environments of war.  Combat leaders also need to be able to recognize, and at the same time empower them not to run.  Twentieth century warfare experienced the increase in the awareness of the balancing act between recognizing stress and keeping the soldiers courageous among combat leaders.  However, the slow progress towards the acceptance of psychological injury or breakdown was characterized by historical battles from all over the world.  

Civil War
In the Civil War of the United States of America, American Army physicians reported mass casualties that resulted from the stress soldiers experienced from war.  Most of these casualties were spurned by the experience of nostalgia or homesickness among the soldiers and resulted in the reduced in the efficiency of the fighting force (Doyle, 2000).

Lande (2003) declared, The Civil War forced the nation to grudgingly recognize the emotional cost of the war (p. 192).  Lande (2003) narrated the tale of Dr. William Chester Minor, a 37-year old man who shot and killed a man he had never met in his life in the streets of Lambeth, London.  This occurred seven years after the American Civil War ended.  During the Civil War, he worked as a surgeon in the Union Army.  He moved to London a year before the shooting in order to recuperate from Posttraumatic Stress Disorder (PTSD), which during that time was called Soldiers Heart.  He was said to have most likely experienced a case of delusion, paranoia and was psychotic because of the bizarre mental state he was in.  There was no motive, and no other reason by which he could have killed a stranger.  During that time, legal insanity was already a psychiatric criminal defense and thus Dr. Minor was tried and found to be not guilty by reason of insanity and was detained in the Broadmoor Hospital (Greenfield, 2006).

Jacob Da Costa was a significant figure in the study of CSR, as he studied the phenomenon that was related to the symptoms of the heart during the Civil War (Johns Wessely, 2005).  There was no organic cause that was found for the heart disorders during that time.  Da Costa finally concluded that there was really no specific cause, based on his analysis of 200 cases.  This analysis revealed that 38.5 per cent had been subjected to hard field service and excessive marching and 30.5 per cent suffered from diarrhoea (John  Wessely, 2005).  For well-disciplined troops, the practice of falling out at drill or on the line of march was discouraged, as soldiers were trained to bear and endure suffering, to save themselves of the risk of being considered soft.

It was the American Civil War that marked the cultural and medical recognition of the effects of war upon the soldiers.  Since this war, a set of symptoms has been built based on the culturally formed biases of that time and the medical knowledge that was acquired, as well as the apprehensions that developed about the inherent risks of combat that soldiers were exposed to (Marlowe, 2001).   Thus, the American Civil War, which occurred from 1861-1865, was considered as the first modern war.   However, during this war the scientific terminologies that were created to pertain to complex psychological and psycho-physiological consequences of warfare were insufficient.  Nevertheless, it was from the offshoot of experiences from this war that 20th century warfare learned about the psychological consequences of war.

It was noted that throughout the Civil War, there was a widespread of blind panic as a response to first shock battle.  There were members of the unit that were observed to break, turn and run thus breaking cohesion of the line (Marlowe, 2001).  However, it was still prevalent during that time to view flight and the inability to overcome fear as cowardice or moral weakness.  The only acceptable factor for the breakdown of behavior and the inability to continue fighting was physical disability.  True enough, disease and illness claimed majority of the lives of those who fought in the Civil War.  However, those who were incapable of becoming effective soldiers, despite the fact that they did not flee from battle, were indicative of psychogenic symptoms that were commonly reported during this war (Marlowe, 2001).  There were also unexplainable cardiac conditions that occurred in large numbers during this time, which was more popularly known as soldiers heart, effort syndrome, which later on became the DaCostas Syndrome.  This was a condition that was characterized by high palpitations and heart rate increase upon exertion.  There were also the symptoms for weakness and fatigue.  There were limited diagnostic procedures during that time and this left military surgeons baffled as to its cause (Marlowe, 2001).

Peterson, Monty, Baker, McCarthy (2008a) described the first organized system for medical evacuation to have occurred during the Civil War, which served as the model for the current system.  Members of the psychiatric team are always included in the evacuation procedure because of the need to debrief all the patients from the military, including psychiatric patients, medical and surgical patients.  Thus, it was in the Civil War when the importance of medical evacuation was first recognized in a more or less, holistic perspective of the soldiers health.

Lande (2003) stressed that even after the last bullet from the Civil War was fired, the impact still continued to affect its soldiers.   After the South capitulated, the armies that fought in this war were demobilized.  As the soldiers went back to their families, they brought with them emotional and physical scars (Lande, 2003).

WWI  WWII
Shell shock was also known as war neurosis during World War I (1914-1918) (Doyle, 2000).  This was addressed by evacuating far from the front.  However, this practice was described to bring about a greater number of casualties and evacuation did not improve the decrease of casualties and those that were lost to combat.  It was reported that by 1917, one seventh of the British soldiers that were discharged from duty were unfit because of their medical conditions (Doyle, 2000).

Jones and Wessely (2005) described the experience of combat damages servicemens physical and mental health. Combat disorders such as shell shock, disordered action of the heart (DAH), effort syndrome and the like were characterized by unexplained symptoms, such as fatigue, weakness, sleep difficulties, headache, muscle pain, joint pain, problems with memory, attention and concentration, nausea and other gastro-intestinal symptoms, anxiety, depression, irritability, palpitations, shortness of breath, dizziness, sore throat and dry mouth (Jones  Wessely 2005, p. 56).   In the context of war, these disorders became medically unexplained.

Marlowe (2001) described the World War I to have a separate category for psychological and psychiatric casualty. At the end of the First World War, there had been a complex set of variables for combat stress that have dominant symptom sets, in comparison to the American Civil War.   During this time, the notion of war around the globe was both glamorous and desirable for the parties involved.  It served as the test of the countrys toughness, character and worth, as the world would perceive it throughout history.  Thus, the picture of war for the individual soldiers tended to be different in the reality of combat that what it was sold as.

Shell shock was among the few reports of casualties that were categorized under a psychological nature.  As mentioned before, this was first recognized during the Russo-Japanese War and during the year 1915, there were already a number of changes that were made in terms of how it can be recognized and how new illness of the similar nature can be evaluated.  Marlowe (2001) called World War I as a watershed period for CSR effects recognition.

Initially, the military medical system viewed shell shock as a physically induced illness. In the classical model of Western medicine, they determined a single causal agent and shell shock was characterized by commotional illness.  The so-called physical ailment was said generated by the shock wave of explosion that came into contact with head.

It was in 1915 that British and French physicians, by which the neurologists were referred, that most soldiers were diagnosed to be suffering from shell shock did not encounter any artillery burst or explosion that could have caused them to suffer from physical commotional damage.   There was no external event that brought about the symptoms that were supposed to be caused by some level of physical injury. In fact, Marlowe (2001) the autopsy of the casualties that died had no evidence of brain hemorrhages, even at a microscopic level or lesions that could have caused shell shock symptoms.

This moved the physicians to consider the logical alternative.  It was during the World Wars wherein the alternative was characterized by emotional and psychological stresses that were brought about by the strains of the battlefield and the war zone (Marlowe, 2001).  They discovered sources that revealed it along the lines of standard categories for hysteria, neurasthenia and traumatic neuroses.

The pioneers in providing a psychological association with shell shock was the French Physicians and described it as the product of the strains of terrifying battlefield experiences.  The British military medicine came up with the same conclusion and provided classifications such as shell shocked wounded, which referred to those who were exposed to conditions of physical trauma, and the opposite kind, which was shell shocked sick. The problem was similarly described within the context of hysteria and the other with the construct of suggestibility.  However, the missing element that was discovered was the fact that even in the absence of physical trauma, shell shock could be diagnosed.  
After 1914, physicians began to acknowledge that shell shock was an essential factor for recognizing the development of a psychological or an emotional disorder among soldiers (Marlowe, 2001).   Social and cultural conditions started to be examined as a part of the physicians diagnosis and disposition. Officers and enlisted men both did not escape the risk of breaking down, while the former took periods of time to do so, enlisted men were more likely to do so in their early experiences of battle.  Thus, during the World War I, officers and enlisted men had differential diagnosis for CSR.  Officers were more likely to develop symptoms of neurasthenia and enlisted men developed symptoms of hysteria.

There were significant lessons that were learned from World War I, which influenced the way psychological injury was viewed in the wars that followed it.  One of the most common symptoms for the effects of war was termed to be shell shock, hysteria, war neurosis or gas neurosis was still considered to be physical (Marlowe, 2001).

In the Second World War, servicemen found the gastro-intestinal symptoms to be important due to the fear for peptic ulcer (Jones  Wessely, 2005).  Thus, dyspepsia and stomach pain carried a sense of seriousness.  They would also merit the attention of regimental officers who were tasked to invalid men that had the possibility of breaking down in combat.  Understandable, doctors look for symptoms that were considered significant during that time.

The effort syndrome started as an unexplained heart disease into becoming a functional disorder that carried psychological features.  Paul Wood discussed the status of this disorder in the British Medical Journal in 1941, which discussed about the effort syndrome during World War II.   He described the effort syndrome to be an emotional reactive pattern peculiar to psychopathic personalities and to subjects of almost any form of psychoneurosis (Jones  Wessely, 2005).   Thus, the aftermath of the World War II did not provide for an epidemic of pensions for those with effort syndrome.  It was not because this syndrome was less common but it was because it as a disfavored diagnostic.

Psychiatrists wanted to categorize their patients according to the psychiatric disability by which they suffered, instead of their intolerance for effort.

It was significant to note that in the World War II, the conception that men were either courageous or cowardice was already being broken down.  No matter how brave a soldier was, it was already accepted that all men well vulnerable to develop psychological symptoms and syndromes (Marlowe, 2001).  World War II began with the dependence on psychological screening.   It concluded in the denial of the efficacy of screening and accepted the fact that every person could reach a psychological breaking point.

World War IIs perception of soldier breakdown and symptom formation experienced the shift from biological perception to the acceptance of battlefield and war zone, as stressors that interact with soldiers and their social environment to change psychological and physiological behavior (Malrowe, 2001).  It was already an established fact that soldiers experienced internal consequences from external events.  This included post-event experiences that could bring about significant consequences.

It was also during the World War II that soldier selection was the solution into avoiding any psychological breakdown during their service (Marlowe, 2001).  Thus, selective service was implemented.  They were mostly recognizing the cost of neuropsychiatric load in terms of the cost and the impact patients had among their troops.  Furthermore, there was also a concern for the soldiers who could end up with long-term psychoses.

While more than a million men were rejected because of mental, emotional disorders and educational deficiencies, there were still over 500,000 men that were separated from the Army based on psychiatric or behavioral grounds (Marlowe, 2001).  Therefore, despite the consistent weeding out process for enlisted men for combat units, it seemed that it was impossible to know the actual numbers of soldiers that could be vulnerable.

Despite the selection process during the World War II, an average of one every four were reported to develop psychological casualty.  Despite using screenings, the US forces continued to experience psychiatric casualties during the war (Marlowe, 2001).  Battle or combat fatigue was also a major issue during the World War II.  In acceptance of the belief that every man was universally vulnerable, the US Army soon took on the principle that every man has his breaking point.  It remained difficult to grasp expressions of illness according to culturally and socially acceptable metaphors.

However, the Nazi government rejected the concept of psychological breakdown, in the forms of shell shock, war neurosis and battle fatigue (Marlowe, 2001).  They still held on to cultural beliefs that insanity was a mark of cowardice and treachery.  They had punishment for this because it was manifested in carrying out ones duty in the face of the enemy.  The penalty for this was death or punishment.

The Influence of these Psychological Dilemmas
There had been significant influences by which psychological dilemmas occur in the face of war.   There were several factors that could be considered in order to understand where these dilemmas manifested. Education

Psychosocial Behavioral Backgrounds
Hendin and Haas (1984) described combat to be intrinsically traumatic, however there was no telling the level by which it could affect different individuals.  There were different perspectives as to how the individuals pre-existing character and personality, and psychosocial background affected the development of mental disorders as a product of life-threatening trauma.

Most of the psychoanalysts observed stress disorders immediately following World War II and agreed that childhood precursors had a significant role in the development of such conditions (Hendin  Haas, 1984). In fact, infantile and childhood conflicts that were centered on hostility played a major role in the development of stress symptoms.  

Veterans that experienced the stress of battle in World War II that had stress reactions were described to have been exposed to neurotic conflicts that were repressed while they were growing up (Hendin  Haas, 1984).   Theodore Lidz revealed that the history of dysfunctional family ties with excessive hostility and withdrawal of affection caused World War II veterans to have repeated postwar nightmares regarding their combat experiences.  These nightmares were marked to have expressions of suicidal wish because death could bring an end to anxiety and also feared because it could separate them from their loved ones.

However, Abram Kardiner argued that traumatic experiences did not need to have a symbolic relationship with the persons past (Hendin  Haas, 1984).  Although, it was true that pre-existing psychosis or neurosis could be worsened by war traumas, he did not agree that it should be a pre-existing basis for symptom development.  According to this view, sufficient stress could bring about war neurosis.  Work during World War II based on the experiences of trauma stress victims showed that the personality of the person had little significance to the development of traumatic stress.
Observers of civilian trauma victims also revealed that if stress was great enough everyone will develop extremely related stress responses.  Hendin and Haas (1984) further discussed that most scholars discounted the relationship between stress symptoms and preexisting personality or other factors in the patients earlier life.  Exposure to stress in a fixed duration or degree could be a more relevant measurement for understanding the development of stress.  Even PTSD studies in Vietnam war veterans were focused primarily on the war experience and less on the personality and previous background of the servicemen.  Most studies about CSR and PTSD were widely focused on the extent of combat stimulus and the veterans response to it was just a personal and subjective quality of the experience, which could not be generalized for military men (Hendin  Haas, 1984).

Contributory factors of combat environments
The nature of warfare was viewed to be changing dramatically over different periods of time (Doyle, 2000).  For example, troops who fought in the Boer War needed to march extreme distances just to engage with the enemy, thus it was a war of movement without mechanization.  Aside from actual combat stress, physical exertion was also involved in producing combat stress. The Gulf War syndrome was surrounded by the technical nature of modern warfare.  There were already threats of chemical and biological weaponry.  It manifested in headaches, poor concentration and memory impairment.

According to Doyles (2000) analysis of military records of servicemen, as well as war diaries, the percentage that was involved in actual fighting decreased over time, as the combat support roles in the troops had risen.  It was also observed that war syndromes also arose, not only in servicemen, but also those who faced the prospect of combat.

 Murray (1992) described the experiences of Vietnam veterans to be different from other wars because of the differential culture towards the concept of war.  They were often not welcomed when they come back home from battle and even criticized for their involvement in the war.  This was the kind of stress that exacerbated the problem of adjusting to post-war experiences.  These veterans were described to have unresolved guilt for taking part in killing civilians in the Vietnam war.  Moreover, soldiers from lower ranks were also said to be the most vulnerable to developing CSR and Post-Traumatic Stress Disorder (PTSD).  There was also the new element of the speed by which soldiers arrived home from the battlefield.  They were able to return home from combat in a few days, instead of the slower return by ship that provided them time to digest their stressful experiences, which in a way served as their debriefing.

The Psychological Signs and Symptoms
Grossman  Siddle (2000) described the psychological effect of combat to include a broad variety of processes and negative impacts that needed to be considered in the context of assessment for the immediate, as well as the long-term costs of the war.  The wide-spectrum of the psychological effects of combat included psychiatric casualties suffered during combat, fear, the physiology of close combat, and the cost of killing, as well as PTSD.  The psychological cost of war was something that could easily be determined on the individual level.  Even if an individual survived combat, he or she might still end up suffering from deep psychological costs that could last for a lifetime (Grossman  Siddle, 2000).

Prevalence of Physical and Psychological Symptoms
The violent conflicts that had occurred in the world, and those currently occurring now were bound to have long-term impact for millions and even for subsequent generations.  In a study that was conducted about the Norwegian survivors of the Nazi concentration camps in the early 1970s, the subjects were found to have more tuberculosis, neurosis, alcohol and drug abuse, and less successful work lives, more sick leaves and longer, as well as more frequent hospital admissions (Williams  Wilkins, 1996).  There were also growing literatures about the problems of World War II veterans, such as anxiety, depression and alcohol abuse, which were often related to war memories and nightmares from traumatic experiences that were left unresolved for years.

After World War I, when the symptoms such as nightmares, insomnia, excessive startle reaction to loud noise and even outbursts of anger were initially recognized to be relatively rare (Hendin  Haas, 1984).  However, as other wars went by, more soldiers had been experiencing the same symptoms.

Societys need to see soldiers as heroes in the war and disregard them in times of peace, in terms of considering their post-war struggles as weaknesses interfered with their ideal image and disregarded the fact that these heroes paid a high price for their wartime glories (Hendin  Haas, 1984).   Joshi and ODonnell (2003) pointed out that throughout history, the violence of war and terrorism resulted in negative life events, such as loss of loved ones, displacement, lack of educational structure and drastic life changes.  The impact of war does not only affect the soldiers but the children that witnessed war and the children of those who were traumatized by it.

The prevalence of psychological disorders as a result of the war was prevalent in the US general population with 2.6, as identified by the Epidemiologic Catchment Area Study and 7.8 by the National Comorbidity Survey, both for PTSD (Gaylord, 2006).  Furthermore, it was predicted that the increase in deployment of Reserve and National Guard service members could increase the prevalence of this psychological disorder from stress.  Furthermore, depression, generalized anxiety and PTSD were discovered to be higher after duty in Iraq with 16.6-17.1 than after Afghanistan with 11.2 (Gaylord, 2006).  Despite this, only 38-45 were subjected to mental health concerns and only 23 to 40 reported to have received professional help.  This revealed that there was still a stigma about having mental health disorder, which remained a hindrance for receiving proper and timely mental health care for military service members (Gaylord, 2006).  Furthermore, service members with PTSD needed a large proportion of healthcare resources in the military, government and civilian healthcare facilities.

Lew et al. (2009) described the prevalence and coprevalence of chronic pain, PTSD, and persistent post-concussive symptoms (PPCS) in servicemen returning from the Operation Iraqi Freedom or Operation Enduring Freedom. The study of their medical records revealed that there was a high prevalence for the three conditions of 340 veterans from the said group.  There were only 12 veterans or 3.5 that did not experience chronic pain, PTSD or PPCS. The frequency of these conditions was presented in isolation and was lower than those with combination of each other.   Data showed that there was an increasing prevalence in physical and psychological symptoms from combat stress. In 2009, more veterans were coming home with either a physical and psychological condition as a result of combat stress.

Degree of physical and psychological symptoms
Psychological symptoms secondary to physical trauma
Social Side-Effects During Post-Deployments
Family matters
Destructive behaviors
History of Psychological and Psychiatric Interventions in Combat Environments

Before troops were deployed to Europe, the US Army sent a medical team in order to analyze the lessons from the British and French troops.  They learned simple and established principles for psychiatric casualty management, which called for simple and immediate treatment, that were as close to the front as possible (Doyle, 2000).

Training
Pre-deployment Health Risk Assessment
Treatments for Combat Stress
Echelons of care
Psychiatric teams
Post Deployment Health Risk Assessment
Coping with Post Traumatic Stress disorder
Assorted techniques
Wounded Warrior programs
Conclusion and Summary