Department of Psychiatry, Royal Defence Medical College, Fort Blockhouse, Gosport, Hampshire P012 2AB, UK
May I comment upon and add to the recent paper by Jones & Wessely (2001).
The deployment of psychiatrists in both World Wars was a constant battle waged against ignorance and prejudice (Shephard, 2000), even when as well prepared and aware as the Americans prior to the First World War (Salmon, 1917). It appears that each generation is doomed to relearn the lessons of combat psychiatry.
Although the authors describe its effects, they make no mention of combat psychiatry's touchstone, evacuation syndromes. Described by the Russians in 1904-1905 they revealed what happened when a soldier's social role is replaced by that of a patient, i.e. the fixation of symptoms (Awtokratow, 1907). A similar type of problem may be seen in civil practice (Hadler, 1996).
Combat-related military diagnostic practice has been, and remains, problematic (especially in research) as the aim is to minimise stigma, normalise the experience where possible and positively emphasise recovery (McCarroll et al, 1993). During combat, military medical officers have the moral and ethical dilemma that their patient is the organisation rather than the individual and is affected by whether they relate predominantly to the majority (civilian) or minority (military) culture. While doctors may feel compassion towards those who break down, evacuation may mean the lives of those who remain behind are made more uncomfortable and dangerous hardly surprising therefore that peers or commanders may not view breakdown sympathetically.
Acute or post-combat psychological reactions are multi-factorial in aetiology. Their genesis is the product of an interaction between the individual, the event, the environment (before, during and after) and the culture from which individuals hail and to which they return. Hence, rates may range from 0 to 100% in the same theatre of operations (Noy et al, 1987). Although there is a direct relationship between physical and psychological casualty rates, this relationship may be stated more bluntly: winners get fewer psychological casualties.
The word fatigue is used loosely by Jones & Wessely. During the discussion of the Normandy offensive they state that "high percentages were also a function of widespread battle fatigue in soldiers who had already fought in North Africa..."; this should read war-weariness. In 1939, unlike 1914, there was no euphoria about the impending war and throughout the Second World War there was a feeling that "I've done my bit, now it's time for someone else to do their's" this certainly seemed true in experienced veterans recalled to duty in Normandy and Korea.
Although often forgotten, the lessons of military psychiatry are as true today as in 1904-1905. Military psychiatrists cannot escape the social consequences of their labelling behaviours perhaps this is the current combat psychiatry lesson to be forgotten!
REFERENCES
Awtokratow, P.M. (1907) Die Geisteskranken im russischen Heere während des Japanischen Krieges. Allgemeine Zeitschrift für Psychiatrie, 64, 286-319.
Hadler, N. M. (1996) If you have to prove you are ill, you can't get well: the object lesson of fibromyalgia. Spine, 21, 2397-2400.[CrossRef][Medline]
Jones, E. & Wessely, S. (2001) Psychiatric
battle casualties: an intra- and interwar comparison. British
Journal of Psychiatry, 178,
242-247.
McCarroll, J. E., Orman, D. T. & Lundy, A. C. (1993) Differences in self- and supervisor-referrals to a military health clinic. Military Medicine, 158, 705-708.[Medline]
Noy, S., Belenky, G. & Solomon, Z. (1987) Battle stress, morale, cohesion, combat effectiveness, heroism and psychiatric casualties: the Israeli experience. In Contemporary Studies in Combat Psychiatry (ed. G. Belenky), pp. 11-20. New York: Greenwood Press.
Salmon, T.W. (1917) The care and treatment of mental diseases and war neuroses ("shell shock") in the British Army. Mental Hygiene, 1, 509-547.
Shephard, B. (2000) A War of Nerves. Soldiers and Psychiatrists 1914-1994. London: Jonathan Cape.
GKT School of Medicine, Department of Psychological Medicine, 103 Denmark Hill, London SE5 8AZ, UK
Constructive criticism from a collaborator is always welcome. Palmer is right to point out the importance of evacuation syndromes, although sadly no psychiatric casualty statistics are readily available from the Russo-Japanese war. He also properly points out the broader cultural environment in which psychological casualties are framed. However, the purpose of our paper was to suggest that these factors shape the expression of these disorders rather than their incidence, which is largely determined by battle intensity irrespective of place or period. This explains why rates may vary considerably in the same theatre of operations as we demonstrated (Jones & Wessely, 2001, Table 4). Although it is generally true that "winners get fewer psychological casualties", this does not apply to Pyrrhic victories. Ultimately, the French defeated the Germans at Verdun in December 1916 but suffered greater casualties, many of which were treated in their newly established neurological centres set up close to the front line (Roudebush, 1995).
We cannot accept that the term fatigue was misused. In fact, the War Office report (1951) from which we quoted used both "exhaustion" and "fatigue" to describe servicemen suffering from acute combat stress (War Office, 1951: 7). It is not true to say that all of these men were simply war-weary as Palmer claims. A detailed analysis of 153 cases admitted to 30 corps's Exhaustion Centre in the week ending 18 June 1944 showed that 47 (30.7%) were recently enlisted replacements (Wishart, 1944). It is likely that these men had not been given adequate time to become fully assimilated in their units and, without the protection of group cohesion, rapidly broke down. Equally, UK reservists recalled to fight in Korea, who might be presumed to have been war weary, often recorded lower rates of cold injury (an index of morale) than their younger and less experienced counterparts (Watts, 1952).
REFERENCES
Jones, E. & Wessely, S. (2001) Psychiatric
battle casualties: an intra- and interwar comparison. British
Journal of Psychiatry, 178,
242-247.
Roudebush, M. O. (1995) A battle of nerves: hysteria and its treatment in France during World War I, pp. 88-90. PhD thesis, University of California at Berkeley.
War Office (1951) Psychiatric Disorders of Battle. London: War Office.
Watts, J. C. (1952) Cold injury in Korea. Journal of the Royal Army Medical Corps, 98, 1-7.
Wishart, J. W. (1944) Psychiatric reports, Normandy. London: Wellcome Institute for the History of Medicine archive RAMC 408/3/3.
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