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.
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.
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."
War correspondent Philip Gibbs wrote: