THE PSYCHIATRIC CASUALTY OF WARt
A. L E V IN , M .B., Ch.B.*

sEpTEMBER 1977 F I S I O T E R A P I E  9

'n Oorsig van psigiatriese ongevolle ten tye van oorlog 
<ord geSee- D is reeds in 1904 beskryf. Oorsake en die 

lliniese beeld (in tw ee fases) word om skryf. Daar word 
a die situasie in Israel, waar v y f oorloe in 25 jaar onder- 

".'nd is, verwys. O nder behandeling word keuring van 
'oldatel voorkom ing, akute en chroniese toestande, asook 
u ru ifke er na die slagveld bespreek. D ie skryw er raak o o k 
jje kwessie van burgerlike ongevalle en die invloed op die 
fainitte van soldate aan.

Battle fatigue or w ar neurosis was first described in 
Ihe R u s s o - J a p a n e s e  W ar of 1904, when com batants were 
found to suffer from  psychiatric states th at could not be 
ttrib u te d  to any know n m ental disease.

(  Observers could not grasp the concept o f a situation 
a|]v induced m ental disorder. Instead they attributed the 
high incidence of psychiatric disorders am ongst com ­
batants to exposure to shells and high explosives, the 
concept of “ shell sh o ck ” w hich was fu rth e r reinforced 
during W orld W ar I when w ar neurosis was so 
common in  the trenches and appeared to be related 
to enemy shelling.

We have subsequently learnt:

1. that shells them selves are not the cause of battle 
fatigue and th at situational stress can produce 
anxiety reaction;

2. that this can occur in so-called norm al personnel 
as well as in those who are particularly vulnerable, 
e.g., the neurotic;

3. that prom pt intervention w ith the aim o f assisting 
adjustm ent o f the com batant to his situation is far 
better than total w ithdraw al to the rear. (Once the 
com batant with battle fatigue was w ithdraw n, he 
rarely came back to the fro n t w ithout even more 
heightened anxiety);

4. that the th erapeutic com m unity w ith the m ental 
\  health team  is a valuable fo rm  speeding up treat- 
u ment.

Causation
Battle fatigue o r w ar neurosis is the resu lt of both 

high intensity te rro r and long-term  u nbroken stress. F o r 
the average com batant in W orld W ar II the preceding 
period of u nbroken exposure to stress of enem y attack 
was found to average 42 days. It did not m atter w hether 
the sufferer was in a trench which was being shelled, or 
under enem y attack while being pinned down- in a 
foxhole, or in a bush dugout, o r simply being pinned 
down and cut off fro m  the rear.

Where the relationship of the com bat group was poor 
and military training and discipline inadequate, battle 
fatigue arose earlier.

tfaper presented at Post-registration course preceding 
the 12th N ational C ouncil M eeting of the South A frican 
Society of Physiotherapy, M ay 1977.

'Principal Psychiatrist, A ddington H ospital, D urban.

B attle fatigue is prevented by the following:
1. G ood group identification w ith its “ b uddy” system 

w ith a strong leadership hierarchy and good disci­
pline. T hese are vital in m aintaining the psychiatric 
health of the com batant. C haos leads to battle 
fatigue. O rder mitigates against it. H ighly m otivated 
troops w ith good m orale allow fo r superhum an 
effort.

2. Physical well-being, adequate sleep, freedom  from  
fear (including the fear of dying o r being m aimed 
w hich excessive casualties tend to reinforce).

3. H ope of success and victory. These are the key 
factors.

Symptom atology
Battle fatigue presents in its initial phase w ith heigh­

tened anxiety, restlessness, agitation, initial and middle 
insom nia, tachycardia, butterflies in the stom ach, red u c­
tion o f appetite, moist palm s, irritability, etc. This phase 
may last for hours, days o r months. T h e m ore vulnerable 
person may experience a hysterical conversion reaction 
w ith inability to walk, talk, or move, or m ay dissociate 
colloquially (bosbedonderd or bush bush). If in addition 
the person is drinking excessively, the problem  becomes 
even greater.

P hase two: C h ro n ic fatigue or w ithdraw al phase. 
D uring this period the p atien t starts developing features 
o f fatigue and o f endogenous depression. T h e person be­
comes w ithdraw n, quiet and asocial, is losing weight, eats 
poorly, has im paired concentration, im paired mem ory, 
and sluggish reflexes, is anxious yet dem onstrates little 
anxiety physically, is vaguely depressed and m ay becom e 
m orbidly so with feelings o f im pending doom  and death, 
has reduced self control and inhibition level and generally 
invites death by enem y fire. This is the “ zom bie” type 
figure of the Bridge at R em agen.

Battle fatigue need not only occur under conditions of 
death o r disaster. T his syndrom e may occur in th e most 
vulnerable group w ithout even com ing into contact with 
the enem y; one can have battle fatigue w ithout ever 
having seen a shot fired in anger. Purely anticipating 
com bat is enough to cause sym ptom s in a very frightened 
person..
T he victim  o f w a r disaster

Sudden overw helm ing unexpected disaster endangering 
life o r the lives o f loved ones causes people to act ra th e r 
differently from  th e n orm al controlled m an n er of 
ordinary circum stances.

One of the problem s w ith sudden disaster is th a t th ere 
is no w arning; lack o f w arning com pounds the disorgani­
sation and confusion th a t follow. W hen people do not 
expect w ar or disaster, they tend to freeze or panic m ore 
easily. W h eth e r they freeze, w hether they are im mobilized 
o r w hether they panic and act o u t depends to som e extent 
on personality. T hose who under stressful circum stances 
becom e w ithdraw n or depressed w ould un d er the im pact 
of disaster become m ore prone to be im mobilized and 
freeze, while those th a t tend to act out and yell and 
shout at the best of times will only yell, shriek and shout 
louder under the im pact of stress. T h e m ore overw helm ­
ing the disaster, the m ore vulnerable the person is to 
inappropriate response. T his is why gradual disaster with 
one crisis sparking off an o th er tends to be beneficial to 
the person’s ability to cope w ith crisis; anticipation of 
crisis is healthy. It is the sudden loss, the sudden bereave­
m ent, th e sudden fear o f death for which th e person is 
not prepared th a t is dangerous.

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T h e reason fo r Isra e l’s trem endous ability to cope with 
5 w ars in 25 years was the experience of the previous 
w ar th a t helped the person cope better with the next 
one. O n th e  o th er hand, th e  fact th a t th ere w ere far 
m ore psychiatric casualties during the O ctober (Yom 
K ip p u r) W a r was the result of lack of anticipation and 
prep aratio n  for the w ar w hich caught Israel to  a large 
extent off guard. T o be lulled into a state o f false 
security is m ore dangerous than some rattling and p re ­
paring for w ar and disaster.

C risis/disaster plans have the additional advantage of 
attuning a person to a very different type of behaviour — 
they offer a form  o f desensitization to th e h o rror, a 
m ethod o f teaching the person to act autom atically and 
efficiently in a crisis. W ithout this conditioning, the in ­
dividual is f a r  m ore vulenrable. P rep arin g  fo r disaster 
prevents disaster.

TREATM ENT

Selection
I t is advisable to weed out before re ferral fo r m ilitary 

train in g  persons who have a low threshold to  anxiety 
o r who are  afraid. In  this m an n er one is following the 
advice o f th e  Bible to G ideon’s band to thin o u t their 
ran k s o f the lovers, the hom esick, the poorly motivated, 
etc.

P revention
F re q u e n t ro tatio n  o f front-line troops fo r sh o rt periods 

of rest and recreation in the com m unication zone or 
area just behind the fro n t line is advisable. In  very acute 
circum stances "this should be done every few  days. 
M orale, leadership, housing and feeding are im portant 
preventives.

T re a tm e n t o f the early case
W ithdraw al from  th e fro n t line to the com m unication 

zone w ith rest and recreation and sleep fo r 12 hours is 
indicated; when the anxiety has lifted, re tu rn  the patient 
directly to the com bat unit.

T re a tm e n t o f established battle fatigue
W ithdraw al to a specialised psychiatric unit, p refer­

ably close to  the fro n t line is advised. S argant and Slater 
recom m ended abreaction, reliving o f the experience th at 
helped to precipitate the state o f battle fatigue catharsis. 
T his state of abreaction is best obtained thro u g h  the 
injection o f either a benzodiazepine such as diazepam , 
R ohypnol o r o th er sim ilar sedative o r hypnotic o r even 
old-fashioned sodium thiop entone in very small titrated  
doses.

A n o th e r m ethod is the K au fm an n  m ethod of hypnosis 
in the field.

Follow ing on the catharsis, a portion of w hich takes 
place on a subconscious level and is not fully rem em ­
bered in the conscious state, the m aterial elicited in th e 
sem i-conscious abreacting state is discussed repeatedly in 
the w aking state. In  addition, som e authorities believe 
in periods o f sleep therapy and others insist on regarding 
the state as at least in p a rt a depressive reaction o f 
psychotic proportions and m ay give A nafranil infusions 
o r o th e r antidepressants in heavy dosage.

A t tim es the abreaction m ay be so severe th a t it has 
to be broken and fo r this purpose m ajo r tranquillizers 
such as T rilafo n  injection o r Serenace injection are used 
in doses of 5-15 mg.

R e tu rn  to com bat
If th e person responds well and is highly m otivated, 

he should be allowed to re tu rn  to com bat. If an u n d er­
lying psychotic process o r a severe anxiety rem ains, the

person should be rem oved to a re a r hospital for m 0re 
intensive treatm ent. T he m ore acute and m ore intensive 
the treatm ent, the better the prognosis.

T he civilian, non-com batant casualty
Few  things are m ore disrupting o r m ore terrifying than 

a life endangering situation in which one finds o n ese lf 
caught in cross-fire. T h e civilian victim who has no 
control over his environm ent and can n o t defend himself 
is caught in the most im mobilising of psychiatric states’ 
referred to as an avoidance conflict. H e cannot run 
because th ere is now here to ru n  to, and he can n o t fight 
because he has not the weapons to fight with. This 
results in a very sim ilar state to battle fatigue with 
civilians having the highest casualty rates and the poorest 
medical and psychiatric services. F o r civilians, the best 
and only treatm en t is to w ithdraw  them  from  the battle 
zone and to allow group interaction to give support and 
consolation.

SEPTEMBER, 197}

T h e  co m b atan t’s family
T h e disorganisation of w ar results in the breadwinners 

fathers, m others, brothers, husbands and wives being 
rem oved from  th eir usual role, w ith loss of fam ily co­
hesiveness. W hile peer group influences might protect the 
child, both husband and wife are the prey of their 
em otions; infidelity, m aking hay w hile the sun shines, 
causes a gross disorganisation in previously adjusted 
families. A fam ily is never the sam e afte r a w ar, and 
generally not altered for the better.

In  closing, we must say th a t just as w ar produces 
physical cripples, invalids, am putees, and deaths, so also 
does w ar produce psychiatric casualties. A m ongst com­
batants th e greatest risk is th at the person with battle 
fatigue will become vulnerable as a soldier wih a grossly 
heightened m ortality rate; he becom es a mortality 
statistic.

F o r those th a t are treated and recover, scars tend to 
rem ain  in th e form  of heightened anxiety levels.

A large proportion o f casualties are left with both 
physical and psychological problem s, e.g., the amputees 
and paraplegics. T h e  psychiatric approach is to allow for 
strong em otionally laden grief. T h e person must be 
allowed to face and accept reality and com e to terms 
w ith it. In addition, the support of a group of fellow 
sufferers who share the sam e disability is m ore valuable 
th an  individual psychotherapy.

T h e key person is the m atter-of-fact, encouraging yell 
realistic physiotherapist who acts as a group leader f o r  
w hat is a group therapy session in action for 18 hours 
a day.

T he fam ily should also be consulted about how to 
handle the am putee and they can do no b etter th an  watch 
and participate in the activities o f the am putee rehabili­
tation physiotherapy unit in action and apply the same 
methods.

O n the o th er hand, let it be unequivocally stated that 
w ar does not produce psychopaths o r m ake people 
violent; the opposite has been proved, th a t m en who 
have experienced w ar tend to become less violent.

On the o th er hand, w ar provides th e opportunity for 
the psychopath and fo r the anti-social to com m it anti­
social acts w ithout the sam e sanction th a t apply in peace 
time.

T h e  w orst casualties o f w ar are civilians and families. 
A disorganisation occurs in their lives from  w hich they 
m ay never recover; w ithout on-going and intensive sup­
p o rt by the society in which they live and by its medical 
services, th eir lives m ay bear th e scars fo r the rest of 
th e ir days. T h e one message th a t comes thro u g h  is that 
countries m ust be strong enough to rem ain at peace.

P H Y S I O T H E R A P Y

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