Combat Stress Reaction (CSR)
Combat Stress Reaction (CSR) is a psychological response that can affect soldiers after experiencing combat, characterized by a range of behaviors that hinder their ability to perform effectively. Historically referred to as "shell shock" or "combat fatigue," CSR manifests through symptoms such as fatigue, slowed reactions, decision-making difficulties, anxiety, and an overwhelming sense of confusion. While CSR is a short-term reaction, it is often confused with Post-Traumatic Stress Disorder (PTSD), although they are distinct; CSR may lead to later PTSD if not addressed. The concept of CSR has evolved over time, gaining recognition especially during World War I and II, when it was noted that soldiers exhibited significant distress following combat experiences.
Modern approaches to manage CSR include the BICEPS intervention, which emphasizes a quick return to duty while providing support and debriefing to affected soldiers. This method helps mitigate feelings of loneliness and psychiatric symptoms in the long term. However, the push to reintegrate soldiers into combat quickly remains a topic of debate among mental health professionals. As awareness grows about the implications of CSR, particularly its potential link to psychological issues in civilian life, it underscores the need for understanding and addressing the mental health challenges faced by service members.
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Combat Stress Reaction (CSR)
Combat Stress Reaction (CSR) describes an array of behaviors that impact a soldier’s ability to effectively fulfill the role for which he or she was trained. Other phrases have been used synonymously to explain the experience of a soldier who has endured and witnessed combat losses and death. "Shell shock," and "combat fatigue" were once commonly used to describe CSR. The observable traits of CSR include but are not limited to fatigue, slowed response, difficulty making decisions, an inability to order decisions in terms of importance, and a seeming lack of presence in the current surroundings. CSR is not Post-Traumatic Stress Disorder (PTSD), but is often confused with PTSD. CSR is a short-term reaction whereas PTSD and other chronic psychological disorders are chronic. Though the two mental health challenges are erroneously conflated, CSR often predicts the later development of PTSD.
Brief History
Writings about battle from ancient Greece reveal that mental health matters after combat were predominantly disregarded. Soldier response to battle was recorded during the Civil War as a "nervous heart." By World War I, trench warfare in the European theater indexed the phenomenon now called CSR. In 1917, it was termed "war neurosis," and soldiers with fatigue and sickness after battle were described as "malingerers." By World War II, the diffuse impact of violent battle deaths made the frequency of short-term combat fatigue and stress more notable than in previous military conflicts. This phenomenon was described as a "nerve sickness" or injury, and was most often called shell shock. W. H. Rivers developed the very first intervention to return soldiers quickly to their units and battle. A version of Rivers’s intervention is still used, though CSR is now understood as a complex reaction and likely precursor to other mental health complications.
Noted signs and symptoms of CSR include an array of acute distress such as: headache, pain, nausea, dizziness, sleep problems, anxiety, confusion, mistrust, and substance abuse. More subtle signs and symptoms reveal a loss of personal initiative, exhaustion/fatigue, and a fixation with mundane tasks of daily functioning such as folding clothing, organizing personal effects, or making a bed. Substance abuse is a common coping behavior for CSR soldiers as well.
CSR is also experienced by soldiers engaged in peacekeeping missions that can include stressors leading to identical symptoms to those of combat soldiers. An awareness of potential conflict and violence, which is complicated by an absence from home, can intensify mission challenges such that stress reactions meet the same intensity of a post-combat context.
Psychologists understand CSR to be an outgrowth of the fight or flight response. In the context of battle, the natural response to fight or flight is complicated. The natural urge to flee is suppressed, just as the response to fight might not always be possible—as in instances of waiting for battle. If CSR is poorly addressed or ignored, it can develop quickly into General Adaptive Syndrome (GAS). GAS sufferers have highly compromised long-term coping abilities. The body is trapped in a state of deep exhaustion, abdominal complications, and sleep disturbance, all leading to multiple comorbidities.
Impact
The armed services have dealt with the recognized reality of CSR for a century. The risk CSR presents for combat units is the soldier’s abandonment of the site of danger and the unit. The first plan for triaging soldiers facing CSR was the practice of PIE in World War II, which stands for Proximity, Immediacy, and Expectancy. In short, PIE trained units to control CSR by keeping soldiers close to their own units and bonded to their organization and debriefing their combat experiencing as soon as possible. Finally, soldiers were assured that their reaction was typical of anyone in that situation and that they could expect a good recovery.
Adjustments and extensions made on the original PIE model resulted in the creation of the BICEPS intervention. This more recent approach to control CSR includes the following treatment steps: Brevity, Immediacy, Centrality, Expectancy, Proximity, and Simplicity. Many who study the subject see this approach as controversial. BICEPS, at its core, retains the broader goals of the PIE approach. However, it adds components that emphasize the expedient return of a soldier to combat. In 1999, the US Department of Defense mandated the use of the term combat stress reaction, and the Department of the Army issued the manual for administering BICEPS (Army).
The soldier receiving BICEPS is debriefed for 2–3 hours by the Combat Stress Control Team (i.e., nurses, counselors, psychiatric clinicians), and depending on the soldier’s response he or she may receive additional days of rest. Soldiers are not identified as sick or mentally ill and are not cared for near medical patients. In order to emphasize the short-term effort to resume duty, uniforms, practices, and weapons are maintained by the soldier during treatment. Soldiers treated with BICEPS had lower rates of loneliness, psychiatric symptoms, and had higher social functioning twenty years after treatment than those without treatment.
CSR is not PTSD, nor any other stress induced diagnosis. Differences among health care professionals exist over the intent to return CSR soldiers to combat in fairly short order. Evidence from 2015 proves a correlation between combat experience, PTSD, and insomnia for veterans 15 months post-deployment. Other findings demonstrate that PTSD is an indicator of early death. CSR soldiers who have returned to civilian life and their spouses, experience marriages with more conflict, less cohesion, and less intimacy than do those non-CSR couples. Parental attachment and functioning is also lower for those service members previously diagnosed with CSR.
Bibliography
Army, Department of the. Combat Stress; Field Manual 6-22-5. Washington, DC: US Army, 2000. Print.
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Horesh, Danny, et al. "Stressful Life Events across the Life Span and Insecure Attachment Following Combat Trauma." Clinical Social Work Journal 42.4 (2014): 375–384. SocINDEX with Full Text. Web. 2 Aug. 2015.
Quartana, Phillip, et al. "Indirect Associations of Combat Exposure with the Post-Deployment Physical Symptoms in US Soldiers: Roles of Post Traumatic Disorder, Depression, and Insomnia." Journal of Psychosomatic Research 78.5 (2015): 478–83. Print.
Soloman, Zahara, Rami Shklar, and Mario Mikulincer. "Frontline Treatment of CSR: A 20-Year Longitudinal Study." American Journal of Psychiatry (2005): 2309–14. Print.
Ustinova, Yulia, and Cardena Atzel. "Combat Stress Disorders and Their Treatment in Ancient Greece." Psychological Trauma: Theory, Research, Practice, and Policy 6.6 (2014): 739–48. Print.
Zahawa, Soloman, et al. "Marital Relations and Combat Stress Reaction: The Wives' Perspective." Journal of Marriage and Family 54.2 (1991): 316–26. Print.