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Combat stress reaction

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Combat stress reaction is a term used in medicine. It describes a psychological reaction to the trauma of war. It was previously called battle shock, war neurosis, or battle fatigue. It causes both mental and physical damage. It is like acute combat stress, which is the civilian term. Combat stress reaction can often become post-traumatic stress disorder. It is related to acute stress disorder, used in civilian psychiatry.

Combat stress reaction can become severe. It ranges in level of impact. Sometimes it causes soldiers to be very unhappy. Sometimes it causes soldiers severe disability. The acute stage of combat stress reaction is seen as the window to prevent further damage. Since World War I, front-line treatment has been the preferred method of treatment during this stage.[1]


Symptoms for combat stress reaction include physical, emotional, and behavioral reactions. These reactions are labeled from mild to severe.[2]

Physical: Mild physical symptoms include fatigue, jumpiness, sweating, difficulty sleeping, rapid heartbeat, dizziness, nausea, vomiting, diarrhea, frequent urination, slow reaction times, dry mouth, and muscular tension. These symptoms may not create safety concerns, or prevent work but can become severe symptoms. These severe symptoms include constant movement, severe startle response, shaking/trembling, weakness, paralysis, difficulty hearing, loss of touch sensation, total exhaustion, immobility, stares vacantly, acute abdominal pain, inability to speak, staggering/swaying, heart palpitations, hyper ventilation, loss of sleep.

Emotional: Emotional symptoms include anxiety grief, difficulty concentrating, nightmares, self doubt, anger, stressed over minor issues, and loss of confidence in self.

Behavioral: Behavioral symptoms include doubt in decisions, lack of attention, carelessness, hyper-alertness, lack of motivation, aggressive behavior, lack of drive, crying, and unable to relax.


Sigmund Freud studied the effects of war neurosis. His concluded that under ideal conditions the tension between impulses and prohibitions are kept at a minimum. Life experiences create impulses or reflexes, and these impulses create drive. Prohibitions are developed over time and come from parents or other adults. An infant cries when he/she is hungry, but it later learns to resist this impulse. Traumatic stress can cause powerful impulses that a person can no longer repress. For combat situations this could cause service-members to flee, or to blindly attack. The attempt to repress these impulses eventually leads to the psychoneurosis symptoms and even loss of physical functions.[3]

World War I: By early 1916 the British "shell shock" causalities were catastrophic, with few returning to battle. Hospitals in France achieved a return rate of 30-40% while hospitals in the UK were as low as 4-5%. These numbers helped to create a new units called "Not Yet Diagnosed, Nervous Centers." These centers avoided the use of terms like war neurosis and shell shock. These units used the "PIE" principles to treat casualties. The PIE principles stand for proximity, immediacy, and expectancy. Proximity means treat the casualties close to the front line. Immediacy means treat them without delay and do not wait until the physically wounded are treated. Expectancy means ensure every casualty expects to return to combat. These principles were developed by Thomas W. Salmon and an estimated 80% of causalities treated at these centers returned to combat. These numbers do not include numbers of causalities that were ineffective when returned to combat. [4] [5]

World War II: The PIE principles were not adopted by British forces in WWII, casualties were instead treated at psychiatric wards. The United States military found themselves unprepared when entering the war. The belief was that screening during enlistment would reject any psychologically weak recruits before deployment. Captain Frederick Hanson began to use the PIE principles again, reporting that 70% of the 494 patients returned to duty after 48 hours of treatment. General Omar Bradley demanded a 7 day rest period for all casualties fitting this description and provided a term for the disorder, exhaustion. The main objective of PIE was returning causalities to combat, not treating the underlying disorder. Many of the soldiers who returned to duty, possibly as many as 70%, returned in non-combat positions. [6]

Korean War: During the Korean War, the United states started using the PIE principles within the first 8 weeks of the war. Reports show 65-75% of causualties returned to duty, but only 44% were assessed as performing at an average or better level. [7]

Vietnam War: At the start of the Vietnam war, the United States military had effective psychiatric services in place withing 8 weeks of the outbreak of the war. Treatments were based on the PIE fundamentals. Treatment was given by mobile psychiatric detachments. During the war, cases of combat stress reaction were relatively few. Fewer than 5% of cases were placed under this category. These statistics lead to the belief that psychiatric causalities would no longer play a large part in warfare. Combat stress reaction did present itself in a untypical way when the service-members returned home. Alienation lead to substance abuse that concealed untreated psychiatric causalities. If the rates of post traumatic stress disorder are accurate, the PIE principles did not prevent an epidemic of psychiatric disorders.

Persian Gulf War: The United States military went into this war expecting high numbers of psychological causalities. The treatment included traditional forward psychiatry, with attention on family issues as well. The fast moving campaign made diagnosis difficult. This eventually added to the stigma attached to mental health problems in the military. [8] Commanders used the diagnosis as grounds to block the return or to discharge the service-member.

Present-day treatment and diagnosis

The United States Army currently uses the acronym BICEPS; brevity, immediacy, contact, expectancy, proximity, and simplicity. Brevity is the initial rest period. Many soldiers return to duty after this brief rest. More seriously affected patients are referred to the next level. Immediacy is essential for treatment. Intervention should occur as soon as symptoms appear. Contact with the service-member's unit can help the soldier feel like a war fighter rather than a patient. Expectancy, the soldier should be told his reaction to stress is normal and is he is expected back with his unit. Proximity (closeness) of treatment is important. Service-members should be moved to a facility close to their unit but away from medical or surgical patients unless no other option is possible. Simplicity, keep it simple and use straightforward methods to improve physical well-being and self confidence. The treatment also includes the "5 R's", reassure normality, rest, replenish bodily needs, restore confidence with purposeful activities and talk, and retain contact with fellow service-members and unit. Service-members are treated for their response to combat stress, not as having emotional problems.


  1. Solomon Z; Shklar R; Mikulincer, M. (n.d). Frontline treatment of combat stress reaction: a 20-year longitudinal evaluation study. 162(12), 2309-14.
  3. Charles R. Figley and William P. Nash. Dec. 4th 2006. Combat Stress Injury: Theory, Research, and Management
  4. Manon Perry. "Thomas W. Salmon: Advocate of Mental Hygiene". Retrieved 2013-11-17.
  5. Edgar Jones and Simon Wessely. Apr 1, 2005. Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War.
  6. 16.Jones E, Wessely S: “Forward psychiatry” in the military: its origins and effectiveness. J Trauma Stress 2003; 16:411–419
  7. Hausman, W., & Rioch, D. McK. (1967). Military Psychiatry, A protoype of social and preventative psychiatry in the United States.Archives of General Psychiatry, 16, 727–739.
  8. Greene-Shortridge TM, Britt TW, Castro CA: The stigma of mental health problems in the military. Military Medicine 172:157–161, 2007