Lest we forget, again

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!