Combat stress reactions

24 World Health • 47th Year, No.2, Morch-Aprill994 Combat stress reactions Lars Weisaeth I n conventional warfare, about 20% of all soldiers who need medical attention are not physically wounded, but have combat stress reactions (CSRs) as their primary problem. In addition, many of the physically wounded also suffer from psychological problems. As the term implies, a CSR - also called battle shock - is caused mainly by the massive physiological and psychological stresses of combat. Soldiers with CSR suffer a significant loss of combat efficiency or are totally incapacitated. When fighting is extremely intense, up to 80% of medical losses have been of a psychiatric nature. Fear of death as well as any uncontrollable and unpredictable dangers are likely to lead to this condition. CSR is more likely when there are very heavy casualties, surprise attacks, exposure to unknown weapons or to air or gas attacks, continuous heavy artillery, heavily mined areas, lack of sleep, poor food and hygiene, inadequate communications, isolation and lack of trust in the leadership. A soldier who feels in control during battle does not develop CSR. The most important protective factors are strong group cohesion, trust in the commanders, high motivation, being well armed and protected, a high quality of combat training, and a reliable medical corps. Most cases will be consistent with the diagnosis of acute stress reactions listed in the latest International Classification of Diseases. This monument in o pork in Montreal, Canada, depicts the stress that soldiers experience in combat. Treatment A breakthrough occurred during the First World War in 1917, when C.S. Myers, a pioneer British Army psychiatrist, developed "forward psychiatry" and treated "shellshock" as a disorder of a psychological, and not organic, nature. The treatment emphasized reducing the stress exposure without evacuation from the front (to avoid inflicting personal failure and to protect the soldier' s group identity), as well as sleep, rest, food and an optimistic approach that this was a passing condition, soon to be over. It proved possible for 90% of CSR sufferers to return to duty within 72 hours. These lessons were forgotten and had to be rediscovered during both the Second World War and the Korean war. Today the attitude to CSR is that it should be seen as a temporary and reversible reaction which causes a reduction of functional capacity in a previously normal person who is overwhelmed by severe stress. The realization that the relationship to a group was of fundamental importance inspired social psychiatry, and it was no coincidence that such forms of treatment as group therapy, group stress debriefing and the therapeutic community were all created or received powerful impetus during the Second World War. Many post-war psychiatric problems start as CSRs, and post- traumatic stress disorder (PTSD) is by far the most frequent psychiatric war-related illness. For instance, fifteen years after the Vietnam War, 15.2% of all United States male veterans were still suffering from a PTSD.• Professor Lars Weisoeth is with the Division of Disaster Psychiatry (KPP} at the University of Oslo, P 0 Box 39, Gaustad, N-0320 Oslo, Norway.