Psychosomatic Medicine 8:258-270 (1946)
© 1946 American Psychosomatic Society

Analysis of Neuroses Developing After Combat in Four Individuals with Outstanding Combat Records

¹ U.S. Naval Hospital, San Leandro, California

The relation of the combat breakdown to the pre-existing personality was in part demonstrated in this report of four patients who developed combat neuroses. Mechanisms involved and some theoretical considerations were discussed. It was shown that intravenous sodium pentothal, when employed relatively soon after the traumatic experience, is at times useful in uncovering subjective material otherwise difficult to find in a brief period. As to the therapeutic benefits of such techniques of therapy, return of the patient to combat duty after treatment is not in itself a safe criterion of success since he may immediately be killed or hurt or readmitted to another hospital with a second breakdown. Careful comparative studies with long follow-up by energetic and well-trained psychiatric teams working near the front might provide the answer to this important question. It is most regrettable that the military services have not sufficiently encouraged competent and aggressive organized research in the field of war psychiatry.

It has been this writer's experience that the psychiatric breakdowns of this war, like other neuroses, have to do with problems of infantile anxiety, hostility and guilt which are aroused by the traumatic situation. Guilt at killing the enemy is rare, but when it does occur it is seen to express a remorse concerning hostility which the patient has long harbored. Mourning and anxiety in connection with the loss of an unconscious homosexual love-object can be demonstrated in many cases. Anxiety at the sight of mutilating wounds through identification is often seen. Enemy assault, such as shelling, is especially disturbing to patients, who have unconscious passive feminine identification. "Blast concussion" is a very common precipitating agent of war neuroses. While little evidence of a resulting neurological lesion can be proven in the great majority of such cases, careful exploration of the meaning of the event to the patient will usually bring out that the blast was immediately interpreted as a confirmation of a specific neurotic fear, as, for example, that it is the long-expected punishment for an infantile "criminal" wish. Although a very large percentage of patients studied in the combat zone are not aware of psychosexual disturbances, in the author's material such disturbances appear to be basid in the production of their neurosis.

The research value of the study of the combat neurosis does not now lie in preparing for the next war, since, should there be one, it is doubtful that the medical department would have much opportunity to operate at all. It lies rather in the opportunity for studies as to the nature of repression and defense, as to the value of brief therapies with the aid of drugs and hypnosis, and of the mechanisms of development of neurotic symptoms, as to the effect of anxiety upon the body, and as to whether a catastrophic event in an adult is alone sufficient to precipitate a chronic neurosis without a background of anxiety.

There is considerable reason to believe that battle nightmares and the repetitive reminiscences of combat experience which harass most patients may indeed be symbolic, although it has been written to the contrary that the dreams and many of the symptoms are uninterpretable. The combat scene is certainly a very satisfactory representation of the bloody and violent fantasies, often motivated by unconscious, guilt, evidently mobilized in neurotic personalities by war experience. The most persistent sign of the combat reaction is usually irritability and other expressions of hostility, and the nightmares. In many case this hostility may be a substitute for or defense against depression or other form of current anxiety. In others, factors in the past history can be found which indicate the presence of a large amount of unconscious hostility with which the dreams then deal. The violence against the dreamer of the manifest contents seems at times to be in proportion to the dreamer's unconscious guilt. Combat nightmares are probably anxiety dreams with the same significance as those of any other neurosis. In cases sufficiently studied it has been found that the psychological connection between the traumatic event and the patient's pre-existing unconscious problems is made immediately at the time of the trauma rather than later, even though the clinical symptoms may not be apparent for some weeks or even months.

Although the symptoms of these four patients were colored by the war setting, they represent in each case the exacerbation of an old neurosis, and their illness does not deserve a special name. In the writer's experience, such is the case with all persistent combat reactions.

Note:
The opinions or assertions contained herein are the views of the writer and are not to be construed as official or as reflecting the views of the Navy Department or the Naval Service at large.

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