Technical Report 791

C Factors Influencing Combat Stress Reactionsand Post-Traumatic Stress Disorder:00 O1 A Literature Review

Suelen F. Weaver and Nora Kinzer StewartArmy ResearQh Institute

Leadership and ,Management Technical Area

Manpower and Personnel Research Laboratory

DTICELECTEK

AUG 2' 98

H

U. S. Army

Research Institute for the Behavioral and Social Sciences

d April 1988

Approved for public release; distribution unlimited.

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Deputy Chief of Staff for Personnel

WM. DARRYL HENDERSON

EDGAR M. JOHNSON COL, INTechnical Director Commanding

Techniical review by

Robert F. HolzLaurel W. Oliver

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Factors Influencing Combat Stress Reactions and Post-Traumatic Stress Disorder;A Literature Review

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Suellen F. Weaver and Nora Kinzer Stewart13a. TYPE OF REPORT 13b. TIME COVERED 14. DATE OF REPORT (Year. Month, Day) IS. PAGE COUNTFinal FROM 06/87 TO_12/187 1988, April 8

16. SUPPLEMENTARY NOTATIONThis report is an overview of current research findings on combat stress and post-traumatic stress disorder (PTSD).

17. COSATI CODES 18. SUBJECT TERMS (Continue on reverse if necessary and identify by block number)FIELD GROUP SUB-GROUP Psychological factors during the war

05/,08 06/10 06/05 Physical factors of the warDemographic factors (Continued)

19, ABSTRACT (Continue on reverse if necessary a.nd identify by block number)I -- This study reviews 91 articles dealing with Post-traumatic Stress Disorder (PTSD)or Combat Stress Reactions (CSR). The articles were classified into these four cate-gories: psychological factors during the war, physical factors of the war, demographicvariables, and post-war adjustment iactors. A lengthy appendix analyzes each study asdpresents its conclusions. Relying on an extensive survey of the literature, this paperexamines those specific variables thought to be causes of PTSD or CSR. Unfortunately,the research does not indicate strong support for most of these variables. Such diver-gent results indicate the need for more precise future research in the area. (N -)

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ARI Technical Report 791

18. Subject Terms (Continued)

Post-war adjustment factorsPost-traumatic Stress Disorder (PTSD)Combat stress reactions

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Tech~nical Report 791

Factors Influencing Combat Stress Reactionsand Post-Traumatic Stress Disorder:

A Literature Review

Suellen F. Weaver and Nor& Kinzer StewartArmy Research Institute

Leadership and Managemen~t Technical AreaRobert F. Holz, ChiefI

Manpower and Personnel Research LaboratoryNewell K. Eaton, Director

U.S. ARMY RESEARCH INSTITUTE FOR THE BEHAVIORAL AND SOCIAL SCIENCES

5001 Eisenhower Avenue, Alexandria. Virginia 22333-5600

Office, Deputy Chief of Staff for Personnel

Department of the Army

April 1988

Army Project Number Manpower, Personnel, and Training20162722A7B1

Approved for public release: distribution unlimited.

FOREWORD

Military unit cohesion is an ongoing and importantconcern of the United States Army. A critical but somewhatforgutten element affecting cohesion is stress, specificallycombat stress reactions (CSR) and post-traumatic stress dis-order (PTSD). Knowledge of the causes and effects of stresswill help us control its negative effects, especially itseffect on cohesion.

As a first approach to understanding the relationship ofstress to cohesion, this technical report summarizes pastresearch results and offers research comparisons with sug-gestions for future study. This review should provide back-ground information on which to build future study, provideconfirmed results that can be incorporated in current cohe-sion research, and point out specific problem areas thatRhould be addressed.

EDGAR M. JOHIiSONTechnical Director

Iv,

FACTORS INFLUENCING COMBAT STRESS REACTIONS AND

POST-TRAUMATIC STRESS DISORDERS: A LITERATURE REVIEW

EXECUTIVE SUMMARY

Requirement:

Research on the factors thought -to cause stress rear.-tions during and after 7>attle experience was conducted inconjunction with the "South Atlantic Conflict of 1982: ACase Study in Military Cohesion" (Army Research InstituteResearch Report 1469, Stewart, 1988). In reviewing the lit-erature on cohesion, the authors found that sound studiesdealing with the topic of stress and its relationship tocohesion within troops were noticeably lacking. Further re-search led to the conclusion that the stress literature hadmany methodological shortcomings and that it addressed onlyperipherally the problem of the relationship of stress to-cohes ion.

This report presents a review of the findings of manystudies on stress to pro,-ide the reader with a summary ofwhat has been done and, more important, with some areas need-ing research. The res'ults are combined into several catego-ries of causal factors related to stress reactions, includingpsychological factors during the war, physical factors of thewar, demographic factors, and post-war adjustment factors.

Procedure:

Studies were identified via several computer data basesand bibliographies supplied by the Veterans AdministrationVietnam Outreach Office. Revietw articles were organized bytopic area, and their findings were compared within theseorganized groups. overall conclusions could then be drawnregarding the factors contributing to stress. Conflictingresults led to recommendations for future study.

Findings:

The results of this review showed that there are manyareas in which the data on stress reactions are not conclu-sive. Most factors thought to cause stress reactions are notsupported as such by the literatu: u. Further, many methodo-logical problems ma.-e it impossible to draw any definitive

vii

answers regarding the relationship between streas reactionsand their causes.

Utilization of Findings:

Recommendations for future research are made and includeinstructions for researchers interested in strect problems.The study recommendations also suggest ideas f or militaryplanners interested in increasing training effectiveness andsoldier adaptability.

viii

FACTORS INFLUENCSG COMBAT STRESS REACTIONS ANDPOST-TRAUMATIC STRESS DISORDER: A LITERATURE REVIEW

CONTENTS

Page

INTRODUCTION

M4ETHOD .. 3

PSYCHOLOGICAL FACTORS DURING THE WAR. .. .. .. . . . 3

Anger/Hostility/Agg.ession . . . . . . . . . . . . . 3Anxiety/Stress . . .. . . . . . . . . . . . . . . . 3Confidence in Commanders/Leadership . . . . . . . . . 4Confidence in Weapons . . . . ............ 4Early Childhood/Parental Neglect or Abuse/

Preexisting Personality/Coping Style . . . . . . . 5Experience of Adverse Life Events in Adulthood . . . 6Fear/Threat to Physical Existence . . . . . . . . . . 6Gr!lef/Loss of Comrades . . . . ...... *.... 7Group Cohesiveness/Mora.e/Esprit/Motivation .. . 7Social Support . . . . . ............Estrangement/Newcomer to a Clique/Interpersonal

Adjustment . .. .. .. .. .. .. .. .. ... 9Guilt for Surviving or Killing .. .. .. .. ... 9History of Impulsive Acts/Poor Attitudes/Arrests . . 10Meanings of Combat to the Individual . . . . . . 10Self-Concept/Self-Esteem/Self-Confidence . . . . . . 10Sense of Helplessness . . . .. .. . .. . . .. . . 11

PHYSICAL FACTORS OF THE WAR . .. .. . .. . ..... 11

Alcohol/Drug Use and Abuse ............. 11Boredom . . . . . . . . . . . . . . . . . . . . . . . 12Combat Exposure/Severity/Intensity . . . . . . . . . 12Exhaustion/Fatigue . . . . . . ......... 13Familiarity with Mission and Terrain/Training . . 13Forward Treatment of CSR . . ... .. . ..a.. 13Hostile and Deprived Environment/Jungle/Weather . 14Inadequate Diet .... ........ ....... 14Indirect Fire . . . . . . . . . . . . . . . . . . . . 14Inability to Return Fire ......... . . . . 15Physical Isolation/Loneliness/Detachment in

Combat . . . . . . . . . . . . . . . . . . .. . . 5Legitimacy of the War . ............ 16Offensive/Defensive Posture of the War . . . . . . . 16

ix

Page

Physical Disconfort/Pain/Physiologioal State . . . . 16Rotation Schedule . . 16

Aqe of the Soldier s ....... .. 17Cultural Factors . . . . . . . .... . . . . . . 17Education Levels . . . . . . ... 18Intelligence . . . . . . . .. . . . . . . .. . 18Marital Status/1? Aily Environment . . . . . . . . . . 18Rac e . . . . . . . . . . . . . . 18Rank . * .. . .. . 4b 19

POST-WAR ADJSTMENT FACTORS .• . . . 19

CONCLUSION a. . . . . . 20

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . 21

APPENDIX A ...... . ...... 34

IX

FACTORS INFLUENCING COMIAT STRERS REACTIONS ANDPOST-TRAUMATIC STRESS DISORDER: A LITERATURE REVIEW

S~ ~~Introuto

Post-traumatic stress disorder (PTSD) is currently ahighly visible research topic, especially due to theincreased recognition afforded the veterans of Vietnam. TheAmerican Psychiatric Association's Diagnostic andStatistical Manual (DSN-III) defines PTSD as *thedevelopment of characteristic symptoms following apsychologically traumatic event that is usually outside therange of human experience.* Silverman (1986) stated thatPTSD is a psychiatric syndrome that occurs in someindividuals after a stressful experience or trauma. Severestress usually contains some harm, threat or challenge tothe individual. The individlial must deul with the stressorin order to prevent the loss of his/her well-being(Silverman, 1986).

PTSD and combat stress reactions, though very similarin symptomotology, are separate and distinct syndromes.Combat stress reaction (CSR) occurs when the soldier is ina combat situation. While both PTSD and CSR result fromcombat experience, CSR has immediate onset and PTSD isdelayed in onset.

historically, combat stress has many different labels.Prcbcaly people have always suffered from tnis disorder,but the disorder was not conceptualized formally until the19th century (Silverman, 1986). Ellis (1984) reportedfindings related to war neuroses an early as the Battle ofMarathon between the Greeks and the Persians in 490 D.C.During the 17th century, European troops experienced manycases of "nostalgia," characterised by melancholy,insomnia, weakness, loss of appetite, anxiety, cardiacpalpitations, stupor, and fever (Ellis, 1984). The AmericanCivil War of 1861-1865 had the most significant psychiatricca-ualties of the later 19th century, with 5,213 diagnosedcases of "nostalgia" in the white Northern troops duringthe first year of war (Ellis, 1984).

Shortly after the American Civil War, the functionalaspect or the disorder was recognised, and Oppenheim andThompson coined the term "traumatic neuroses" (Ellis,1984). Finally, in 1885, H. Page described "neurastheniafollowing trauma" (Ellis, 1984). A biological and

nedrological perspective of the disorder persisted untilfroud identified several underlying psychological factors.freud's students later used the term "shell-shock" todescribe the phonomenon during World War I (Ellis, 1904).As the connection between stress and psychophysiologicalfunctioning became of interest, psychiatrists during WorldWar 1I diagnosed soldiers with "battle stress" and *combatfatigue" (allis, 1984).

Although history Is replete with anecdotal incidenceof battlefield breakdown, the Vietnam var has provided theimpetus for extensive, albeit methodologically imprecise,studies of PTSD. Tiffany (1967) stated that the rate ofneuropsychiatric illness during Vietnam was lower than inany other conflicts. He attributed the lover rate ofneuropsychiatric illness to the new one-year rotationpolicy, less combat exhaustion, better morale, bettertraining of troops and sufficient mental hygiene personnelwith proper psychiatric polices. Although neuropsychiatriccasualty rates were lower during the Vietnam war, VanPuttenand Yager (1984) now estimate that more than 500,090Vietnam veterans are in need of treatment for emotionaldisturbances.

PTSD is a relatively common diagnosis among warveterans. Yet, it is difficult to estimate the prevalenceof PTSD due to its delayed onset. Factors important to theonset of PTSD range from individual psychological to groupor sociological and the physical ronditions of combat.Experimenters attribute causal roles in the onset of PTSDto many factors, such as the intensity of combat,personality factors and physical conditions of the war.Researchers attempt to measure these factors in order topredict and alleviate the onset of PTSD.

Although there is a body of literature focusing oncivilians, the purpose of this paper is to review thepossible causal factors relevant to war and the military.This paper presents recent research findings on PTSD.Although the studies reviewed have severe methodologicalproblems, they do present many possible causal factors forPTSD. Stewart and Weaver (1987) analyze these problems indepth in another paper and provide a few guidelines forfuture research, including the need for better and moreextensive subject groups, the replication of past researchfor the support of their findings, and the use of extensivestatistical analysis to determine cause and effectrelationships among variables. Because of faulty researchand lack of conclusive evidence in support of most of the

2

variables investigated, more research is needed.This article is an overview of current research

findings pertaining to combat stress and PTSD. Individual.factors will be discussed in four general categorics:psychological factors during the war, physical factors •.fthe war, demographic factors of the soldiers, and post-waradjustment factors. Each section begins with a summary andevaluation of the relevant literature on the topic andconcludes with an assessment of future research needs inthe area. The relevant research includes studies on the US,British and Israeli Armies.

MethodNinety-one studies dealing with PTSD or CSR were

reviewed. Studies were chosen through literature searchesvia several computer data bases (MEDLINE, DROLS, AerospaceData Base, PTS Aerospace Data Base, PSYCHINFO, NTIS, andnewspaper, magazine, and book indexes). Variousbibliographies from the Veterans Administration VietnamOutreach Office were also used. Requirements for inclusionwere that the study dealt with possible causal factors ofPTSD or CSR and that it was fairly recent (1970+). Thestudies chosen included review articles and originalresearch. While the majority of the studies were conductedon United States soldiers, Israel and Britain are alsorepresented. Most studies conducted prior to 1970 wereconsidered inappropriate due to the later influence andchange of the stress literature caused by the Vietnam War.

Psychological Factors During the WarPsychological factors thought to contribute to the

onset of stress reactions, include: anger, anxiety,confidence in commanders, confidence in weapons, earlychildhood and preexisting personality, experience ofadverse life events, fear, grief, co'esion, social support,estrangement, guilt, history of impulsiveness, meanings ofcombat, self-concept, and sense of helplessness.

Anger/ Hostility/ AggressionAnger and rage stemming from the combat situation

contribute to greater instances of PTSD (Dewane, 1984;Jelinek & Williams, 1984). Hostility and aggression playimportant roles in the onset of battle stress reactions(Bourne, Coli, & Datel, 1968; Weil, 1985; Yager, 1984;Brende, 1983). Participation in aggressive acts duringbattle led to more emotional problems, especially among

3

blacks. Hostility and external aggression (aggressiondirected outward toward others) contribute consistently toPTSD, but there is little research on the subject of angerand its relationship to PTSD. Thus, further replication ofthe studies is needed to compensate for the small number ofstudies on this topic.

Anxiety/ StressStress and anxiety contribute to CSR and PTSD,

although the extent of such contribution is unclear(Dasberg, 1975; Donnelly, 1982; Ingraham & Manning, 1980;Cohen & Hoberman, 1983; Bey, 1972; Bey & Zecchinelli,1974). While researchers generally agree that stresscontributes to the onset of CSR and PTSD, there isdisagreement on the extent of its role. Some researchersconcluded that stress is one factor among many which leadto stress reactions (Dasberg, 1975; Cohen & Hoberman, 1983;Bey, 1972; Bey & Zecchinelli, 1974). Others (Ingraham &Manning, 1980) found that stressis the single mostinfluential factor in the onset of stress disorders sinceanyone can break down physically and emotionally if exposedto enough stress.

However, Saigh (1984) found that stress levelsdecreased when the stressful event was reduced or resolved.This finding contradicts the premise of the previouslymentioned articles that stress will lead to PTSD. If stressdoes indeed decrease after the trauma, then stress would bean unlikely contributing factor to PTSD, since PTSD is, byits own nature, delayed. We need to focus on stress as apotential causal variable in order to resolve thiscontradiction.

Confidence in Commanders/ LeadershipLeadership and confidence in commanders are associated

with a lower rate of psychiatric casualties. Studies (Gal,1986; Noy, Nardi, & Solomon, 1986; Steiner & Neumann, 1978)indicate that an absence of leadership, or lack ofconfidence in leaders, leads to increased numbers ofpsychiatric casualties and poorer organizational climate.Thus, research generally supports confidence in leadershipas a preventative factor for stress reactions although thenumber of studies dealing with leadership and stressreactions is less than prolific.

Confidence in WeaponsGal (1986) proposed confidence in one's weapons as one

4

I of eight factors found to influence company morale andcohesion. Soldiers more confident with their weapons hadhigher levels of unit and personal morale. He postulatedthat increased morale leads to fewer incidences of stressreactions. Since it is generally not sound to accept theresults of only one study as law, researchers need toinvestigate further to determine the relationship betweenconfidence in weapons and stress reactions.

Early Childhood/ Parental Neglect or Abuse/ PreexistingPersonality/ Coping Style

Early childhood experiences, including parentalneglect, arrests and school history, was found tocontribute to violent acts in combat and to the onset ofPTSD (Sudak, Martin, Corradi, & Gold, 1984; Yager, 1975).There is a decided controversy regarding the effect ofearly childhood experiences and preexisting personality(personality present prior to entering the military) onPTSD. Some researchers proposed that the meaning given tothe combat experience depended on the preexistingpersonality of the individual (Hendin, Pollinger-Haas,Singer, Gold, & Trigos, 1983). Preexisting personality

-provides an individual with a coping style and creates apredisposition to neuroses or a neurotic coping style insome people (Andrews, Tennant, Hewson, & Valliant, 1978;Hendin, Pollinger-Haas, Singer, Gold, & Trigos, 1983; Lund,Foy, Sipprelle, & Strachan, 1984; Smith, 1985; Weil, 1985;Helzer, 1984; Davidson, Schwartz, Storck, Krishnanf&Hammett, 1985). Other authors questioned the role ofpreexisting personality and found that proexistingpersonality has no relationship to the onset of PTSD (Gal,1986; Glover, 1984; Cavenar & Nash, 1976; Hocking, 1970;Ingraham & Manning, 1980; Silverman, 1986).

Clearly there is evidence for an effect of preexistingpersonality on the onset of PTSD. However, severalquestions remain unanswered. We do not know if preexistingpersonality has a causal role in the onset of PTSD or if itis simply a predisposing factor that will cause breakdownearlier and in response to less stress than with theaverage person. We do not know the extent of the influenceof preexisting personality. If evidence becomes availablethat proves personality has a direct causal role in theonset of PTSD, how will the military branches screen forit? Is it possible to screen out those people with thesepredispositions who serve in the military? How many of theexisting veterans with PTSD had some sort of predisposing

5

Ineuroses? How do we know that the personality we call"preexisting" did nct develop as a result of battlefieldconditions?

We ca. it sake any definitive conclusions regardingthe role of eyisting personality factors without answeringthese important questions. Research needs to focus onsamples with n>100 to promote better generalization.Replication of results will help to support the currentfindings. The use of control subjects (those from withincombat situations without any known PTSD symptoms) willdetermine if the factors considered are present only inPTSD patients or in the population as a whole. Researchersmust continue their efforts, using better research methodssuch as matched experimental groups, to determine therelationship and its extent that the family and pastchildhood experiences contribute to PTSD.

Experience of Adverse Life Events in AdulthoodMeasures of individual stress fluctuate with the

number and nature of adverse events axperienced throughoutthe individual's lifetime (Andrews, Tennant, Hewson, &Vailiant, 1978; Brende, 1983). Adverse events areprecipitating factors to the onset of PTSD, as indicated bythe American Psychological Association's (APA) definitionof PTSD ("the development of characteristic symptomsfollowing a psychologically traumatic event that is usuallyoutside the range of human experience"). Researchers cantest this assumption by searching for ways to measure theamount of trauma necessary for PTSD to occur and how thiswill interact with other relevant personal and individualfactors.

Fear/Threat to Physical ExistenceFear of losing one's life or of experiencing bodily

harm is an important factor in the onset of PTSD andespecially CSR ( Donnelly, 1982; Hendin, 1984; Hendin,Pollinger-Haas, Singer, Houghton, Schwartz, & Wallen, 1984;Weil, 1985; Shatan, 1982; Kolb, 1983; Gal, 1986; Glover,1984; Ingraham & Manning, 1980). The experience of severepsychic trauma under terrifying and tiring conditionsproduces certain reaction behaviors. These reactions, suchas passivity, freezing behavior, withdrawal, impairedcommunication and regression, provide the basis for theonset of a stress reaction. Fear or threat of dyingincreases the incidence of these symptoms in theindividual.

6

____________

There seems to be overall agreement on the role thatfear or threat play in PTSD. Yet, several questions remainunanswered. How much fear is necessary to produce a stressreaction? Can this fear be measured? Who is moresusceptible to fear--are there individual factors involved?We need more precise research to understand the role offear in stress reactions.

Grief/ Lose of ComradesThe loss of a comrade and the resulting grief is also

a precipitating factor in the onset of PTSD and CSR(Dasberg, 1975; Hocking, 19701 Dewane, 1984). Grief,, andthe prevalent consequence of survivor guilt (see "Guilt forSurviving or Killing"), can lead to feelings ofhelplessness and mourning. A soldier not only might mournthe loss of his "buddy," but also feels remorse (guilt ofthe survivor) for not being killed instead of his friend.while research shows that grief plays a role in PTSD, westill do not know the extent of that role. Since fewstudies of PTSD deal with grief specifically, we cannotassess the actual incidence of grief reactions. Thus,further research along these lines is needed.

Group Cohesiveness/ Morale/ Esprit/ MotivationMilitary researchers evince an understandable interest

in the relationship between cohesion, morale, and PTSD.Specifically, military researchers seek to find a way topromote cohesion and because they believe that increasedcohesion will decrease the occurrences of stress reactions.most research has shows that strong group cohesion Is afactor in the reduction of psychiatric casualties (Bourne,1970; Price, 1984; Shaw, 1983; Gal, 1986; Gal, 1983; Gal,1986; Solomon, Noy, & Bar-On, 1986; Noy, Nardi, & Solomon,1986; Tiffany, 1967; Yager, 1975; Milgram & Hobfall, 1986;Steiner & Neumann., 1978).

Gal (1986) states that, during wartime, groupcohesiveness is a "primary and powerful source of personaland group morale." His research indicates that relationshipvariables are important in predicting the overall climateof the organization. This conclusion is used to promotecohesion among troops, even though it is unclear exactlyhow "cohesion" and "unit climate" are related.

Research findings agree that cohesion is important toefforts to decrease the rates of psychiatric casualties,both during and after war. Morale of the group and measuresof cohesion influence rates of psychiatric casualties.

7

I1

Higher morale will lessen the number of mental breakdownswithin military units. Current research supports the theorythat higher levels of morale promotes decreased rates ofcombat stress reactions. The structure of socialrelationships within the primary unit, including morale,cohesion and mutual responsibility, are the dominantmotivating factors in combat behavior (Gal, 1983). Mostevidence points to the importance of morale in loweringpsychiatric casualty rates. Thus, military leaders andpolicy planners need to search for ways to promote moraleand cohesion in units and troops. The armed forces austemphasize-t-raini-ng--and leadership In- order to creat-e andsustain morale and cohesion among troops in stressfulcircumstances. Further evidence of the psychiatriccasualties related to the lack of group cohesiveness is therotation schedule (as discussed under "Physieal Factors ofthe War") and the resulting estrangement (as mentioned inthe following section).

Social SupportSocial support is closely linked to cohesion, since

social support is often the outcome of a highly cohesivegroup. Social support has been investigated as a bufferingvariable on stress and as having a direct effect all itsown. Some authors have found that social support has adirect effect on stress (Solomon, Mikulincr, & Kobfall,1986). Other researchers found varying results dependingupon the variables being measured or assessed (Cohen aHoberman, 1983; Hobfall, 1985; Cohen & Wills, 1985). Stillother scientists view a reduction in social support asoccurring gradually and lessening immediately followingreturn from combat (Keane, Scott, Chavoya, Lamparski, &Fairbank, 1985). This view thus indicates that PTSD has nodelay, but becomes more acute with time until it isrecognized as the full-blown syndrome.

There are significant theoretical and methodologicalproblems in this research (Stewart & Weaver, 1987). Wilcoxand Vernberg (1985) pointed out that there are manydifferent definitions of social support which is not aunitary construct. Empirical literature does indicate thatobjective and perceived characteristics of supportiverelationships exert influence on health and well-being.However, we do not know how these variables influenceindividual physical and mental functioning. Therefore, weneed to research `Lhe relationship between well-being andsocial support more thoroughly.

8\

Estrangement/Newcomer to a Clique/Znterpersonal AdjustmentProblams in interpersonal adjustment (adjusting within

a group) have also beezs studied in relation to CSR andPTSD, Researchers have found that a significant factor inthe psychiatric problems of veterans was the isolation andestrangement from their homes, family, friends, and combatunits they felt during and after their combat experiences'Dewane, 1984; Figley, 1978; Brende, 1983; Bey, 1972). Dueto a policy of one-year rotation (individual rather thangroup replacement), individuals joined an alreadyestablished unit in Vietnam. Abandonment and helplessnesswere significant factors in the onset of PTSD. A loss ofego supports in the form of leadership and groupidentification was a major contributor to rtress reactions.While these few studies agree that estrangement (beingoutside a group or not included in the group) increasespsychiatric casualtiest we need more research to explicaterelationships between this factor and variables such as therotation schedule, leadership, and cohesion.

Guilt for Surviving or KillingSurvival guilt, and guilt as the result of killing

other humans, contributes to mental breaklown during combatand PTSD (Dasberg, 1975; Hendin, Pollinger-Haas, Singer,Gold, & Trigos, 1983; Thienes-Hontos, Watson, & Kucala,19E2; Dewane, 1984; Glover, 1984; Laufer, Brett, & Gallops,1985; Smith, 1982; Brende, 1983; Jelinek & Williams, 1984).Soldiers who are the sole survivors from their units after

a combat incident are highly vulnerible to mentalbreakdown. Other soldiers feel guilt about having killedwomen, children, and civilians during combat. Even if suchdeaths were unavoidable, guilt seems to be a common factoramong the PTSD patients from the Vietnam and Korean wars.Veterans often have ideas of omnipotence (belief that theyare all-powerful and ultimately responsible for everythingand everyone) (Glover, 1984), which cause them to feelresponsible for the-deaths of soldiers in their own ranks.They feel their decis~ons are extremely important, anddirectly influence the war outcomes. The guilt theseveterans feel requires psychictric treatment. Thus,feelings of personal responsibility, or guilt, plays animportant role in the development of traumatic stressreactions.

Research supports the theory that guilt plays a rolein PTSD. However, we do not understand the extent of that

9

role, nor do we know whether guilt is a component or acause of the syndrome. We need further research andreplication, while using in-depth statistical analysis andmore appropriate research methodology. For instance, sincemost of the studies are done with only PTSD patients, wecannot be sure that guilt is a factor in PTSD. It ispossible that all veterans feel guilt, and only somedevelop PTSD from other causes.

History of Impulsive Acts/ Poor Attitudes/ ArrestsSoldiers who experienced stress reactions had

histories of impulsive acts and difficulty in adaptingwithin society prior to their entry into the military (Boy& Zecchinellit 1974; Bourne, 1970; Sudak, Martin, Corradi,& Gold, 1984; Yager, 1975; Helzer, 1984).

Researchers conclude that soldiers with histories ofimpulsive acts, poor attitudes and arrests among theirfamily or themselves are more likely to suffer from theeffects of combat stress, commit violent acts againstincorrect.. targets (such as their own units members), andexperience depression. Replication of the studies on largersamples (n>100) might determine the extent of this effect

- and the reliability of prediction.

Meanings of Combat to the IndividualThe development of stress reactions is integrally

related to the individual's perception of the traumaticexperience (Hendin, Pollinger, Singer, & Ulmen, 1981;Hendin, Pollinger-Haas, Singer, Gold, & Trigos, 1983). Anindividual's response to a combat situation depends on itsmeaning to that individual. Those meanings, orphilosophical judgments of the war (i.e. Is killingjustified? Is it wrong to take a life in defense of acountry? Is the war legitimate?) are reflected inindividual adaptation within society before and aftercombat. We may be able to increase our understanding ofPTSD by acknowledging and identifying these meanings, thusenabling the development of intervention strategies.

Self-Concept/ Self-Esteem/ Self-ConfidenceSelf-concept, esteem or confidence, are possible

etiological factors in PTSD. Some authors found that a lackof self-esteem led to greater incidences of psychiatricillness (Bourne, 1972; Cohen & McKay, 1984; Hirsch, 1980;Sudak, Martin, Corradi, & Gold, 1984; Gal, 1986; Steiner &Neumann, 1978; Brende, 1983). Higher self-confidence was

10

L!_

related to better overall organizational climate andincreased fighting ability. Lower self-esteem was relatedto lower satisfaction with socialization, depressed moods,and increased sysptomotology. Soldiers witn high levels ofself-confidence were less likely to have clinical evidenceof combat reaction than were those soldiers with lessself-confidence. However, we do not know if the lowself-confidence is a result or cause of PTSD. Futureresearch should focus on the cause-effect aspect of theself-concept variable.

Sense of HelplessnessResearchers have found that a sense of helplessness

will contribute to combat exhaustion and the symptoms ofcombat stress reactions (Shaw, 1983; Dewane, 1984). Assoldiers are continually exposed to the battle situation,they have a diminishing chance of survival and an increasedsense of helplessness. Other authors also mention a senseor state of helplessness as a common finding among PTSDsufferers (Brende, (1983); Jelinek, 1984). We do not knowif sense of helplessness is a result or a cause of thestress reaction. Most of the research is retrospective,

- thus there is no way to determine if helplessness is causeor effect (Stewart and Weaver, 1987).

Physical Factors of the WarIn addition to psychological factors, a second major

set of elements influencing CSR and PTSD include physicalfactors such as: alcohol and drug abuse, boredom, exposureto combat, fatigue, training, treatment techniques, the warenvironment, diet, indirect fire, inability to return fire,isolation and loneliness, legitimacy of the war, theposture of the war, physiological states of the soldiers,and the one-year rotation schedule.

Alcohol/ Drug Use and AbuseThe use of alcohol and drugs was widespread in the

Vietnam war and is associated, as a possible causal factcror as a symptom, with the onset of PTSD and CSR. Measuresof PTSD were highly cu..related with heavy alcohol andmarijuana use (Bey & Zecchinelli, 1974; Branchey, Davis, &Lieber, 1984; Sierles, Chen, McFarland, & Taylor, 1984;Behr, 1984; Helzer, 1984; Laufer, Brett, & Gallops, 1985;Jelinek & Williams, 1984). Alcohol abuse and depressionwere the most common diagnoses among patients with PTSD.Thus, there is evidence for a link between PTSD and

11

substance abuse. However, we do not know if abuse is acausal factor in PTSD or a symptom of PTSD.

BoredomMenninger (as mentioned in Bourne, 1970) proposed that

boredom may be a factor in the onset of CSR. Lack of mentalstimulation has been known to cause stress in somesituations. Although there are few studies dealingspecifically with boredom, research might use boredom as avariable for future analysis.

Combat Exposure/ Severity/ Intensity"Exposure to combat is one of the most widely

researched variables in relation to combat stress and PTSD.Many authors found that participation in combat was relatedto the diagnosis of PTSD (Branchey, Davis, a Lieber, 1984;Hendin, Pollinger-Haas, Singer, Gold, Trigos, & Ulman,1983; Hendin, Pollinger-Haas, Singer, Houghton, Schwartz, &Wallen, 1984; Keane, Scott, Chavoya, Lauiparski, & Fairbank,1985; Lund, Foy,-Sipprelle, & Strachan, 1984; Bourne, 1970;Price, 1984; Shaw, 1983; Solomon, Mikulincer, & Hobfall:1986; Yager, Laufer, & Gallops; 1984; Gal, 1986; Smith,

- 1982; Ingraham & Manning, 1981; Noy, Nardi, & Solomon,1986; Levac, Greenfeld, & Baruch, 1979; Silverman, 1986).This relationship was a direct one: soldiers with morecombat exposure were more likely to be diagnosed as havingCSR or PTSD. Corbat exposure (being in a combat unit) wasdirectly related to increased post-war convictions andarrests, and increased emotional problems. Thus, theseauthors conclude that time or length of exposure to combatand its intensity are factors contributing to PTSD.

Contrary to these findings, other authors haveprovided evidiaice against the r'le of combat exposure ascontributing to CSR and PTSD (Bourne & DuySan, 1967; Boman,1986; Toubiana, Milgram, a Noy, 1986; Steiner & Neuman- I1970). These studies have shown that PTSD can occur withequal frequency in all groups regardless of the length ofcombat experience or combat intensity. Soldiers whoexperienced nvore hardships (under heavy fire, short insupplies, experiencing exhaustion) did not have higherrates of psychological breakdown than others with fewerhardships.

There is obvious controversy in regard to combatexposure since there is research both pro and con for itsrole in the orset of CSR or PTSD. There is a need for

replication of studies, changes in methodology to promote

12

I

accuracy and universality, end better statisticalevaluation (see Stewart & Weaver, 1987).

Ixhaustion/ FatigueMenninger (as quoted in Bourne, 1970) proposed that

exhaustion was a contributing factor to CSR. Soviet armedforces doctrine states that exhaustion contriLutes tostress (Donnelly, 1982). Hendin, Pollinger-Haas, Singer,Houghton, Schwarts and Wallen (1984) found that Vietnamveterans suffering from PTSD had experienced psychic traumaunder conditions of terror and fatigue. Shaw (1983) alsopostulated that the length of rest periods and amount ofphysical exertion and sleep contributed to stress reactionsduring combat. While there is a wealth of research on sleepdeprivation and fatigue, there are few studies that relatethese variables to stress reactions. The military hasofficial quidelines concerning work/sleep cycles duringcombat operations, which may decrease the effects offatiyue in future operations.

The general conclusion indicates that faticue andS~exhaustion will contribute to stress reactions, but we do

not know the extent of that contribution. Future researchshould concentrate on the incidence of fatigue and stressreactions to determine if there is a constant link betweenthe two.

ramiliarity with Mission and Terrain/ TrainingFamiliarity with the mission and terrain promoted a

better unit climate, which, in turn. is a factor in thedecrease of psychiatric casualties (Gal, 19861 Nilgran andHobfall, 1986; Bourne & DuySan, 19671 Donnelly, 1982).Training and leadership, combined with fightinq on nativesoil or familiar terrain, led to lower rates of stressreactions among the Israelis in the Yca Kippur wat (Milgran& Hobfall, 1986). Similarly, poor leadership and trainingmay have contributed to the high rates of psychiatricbreakdown in the US Army during WWII (Milgram & Hobfall,1986). Concentration on training techniques, especiallythose on varying types of terrain, may help to increasesoldier familiarity with maneuvers and decrease the ratesof psychiatric breakdown.

Forward Treatment of CSRMany authors advocate immediate front line (or

forward) treatment of CSR in order to avoid chronic illnessand PTSD (Levy & Neumann, 1984; Gal, l186; Ingraham &

13

I

Manning, 1980; Toublina, Hilgram, & moy, 1986; Prices1984). According to this viewpoint, the goals of treatmentare to return the soldier to active duty and, at the veryleast, keep him/her in optimal physical and mental health.Longer therapy in rest houses had tho effect of promotingslow and minimal recover.es with chronic symptomaticrecurrence.

While the literature promotes quick and temporarytreatment principles in an attempt to eliminate chronic andlong-term illness, we can not be sure that these principlesao decrease psychiatric casualty rates. Longitudinalcomparative studies are necessary to detervine the effectsof forward treatment.

Hostile and Deprived anvironuent/ Jungle/ WeatherOungle warfare placed extreme physical demands on the

soldiers in Vietnam, which may have led to the onset ofstress reactions (Dey & Zecchinelli, 1974; Bouru*e, 19701Shaw, 1983; Thienes-Mfontos, Watson, a Kucala, 1982; Brend*,1983; Tiffany, 1967; Shatan, 1982). The unpredictability ofdanger in guerrilla warfare is a related factor that maylead to the onset of CSR. Although these artiles mention

" the jungle environment and extreme climates as possiblefactors, there is little comparative empirical evidenceavailable from which to draw more definitive conclusionsabout the influence of these conditions on PTSD and CSR.

Inadequate DietLack of food and supplies and malnutrition are also

proposed as factort in the onset of stress reactions incombat. Henninger (as stated in Bourne, 1970) stated thatsoldiers suffered from inadequate diets in Vietnam, whichmay have caused more physical stress. Inadequacy ofsupplies and scant food quantities may cause an increase inphysical exhaustion and the symptoms associated with combatstress reactions (Shaw, 1983). Diet is obviously related toother variables such as physiological discomfort, fatigue,morale and stress. Future research should concentrate onthe effects of diet on other variables leading to PTSD andCSR.

Indirect FireIn his study of the British in the Falklands War,

Price (1984) found that indirect fire was more stressful tothe soldiers than dArect fire. He also found thatneuropsychiatric casualty rates increased in the presence

14

of indirect fire in American wars. Belger (1984), ot hother hand, found that personal injury or direct ex osureto combat, rather than indirect fire, is most stres ful.Thus, there is a controversy over the roles of direct andindirect fire in relation to stress. The controversy may bedue to differing measures of stress or definitions.Clearly, the resolution of this controversy (through soundresearch with operational definitions) may shed some lighton the effect of combat in general on stress reactions.

inability to Return FireBey and secchinelli (1974) reported that there were

many instances in Vietnam in which soldiers were unable toreturn fire when fired upon. This situation cevated extremestress. Bourne (1970) mentioned also that soldiersexperienced artillery and other bombardment without methodsof retaliation. Medical personnel were unable to carryweapons at some times, and were thus helpless against theenemy (Dewane, 1984). While it is likely that thesesituations caused high levels of stress, there is noempirical evidence linking that stress to the onset ofsubsequent stress reactions. The Bey and Zecchinelli study

- was based on psychiatric patients under care. Clearly, itwould be beneficial to research the effects of an inabilityto return fire with a random sample of combatants, not justthose undergoing treatment In a psychiatric facility. Thelack of empirical proof should not be considered conclusivesince so few studies are available on the subject.

Physical Isolation/ Loneliness/ Detachment in CombatMany soldiers reported being physically isolated

during their combat experience. Loneliness and abandonmentwere related to mental breakdown during battle (Dasberg,197S; Bourne, 1970; Dewane, 1984). Mental breakdown duringbattle was more likely to occur when the soldier was in anisolated position and physically detached from the rest ofthe unit.

Isolation is also directly related to PTSD (Jelinekand Williams, 1984; Steiner and Neumann, 1978). Soldierswith lower rates of psychiatric breakdown had higher moraleand trust and were most often fighting with friends withinfamiliar units. Bey and Zecchinelli (1974) posed analternative view of isolation. They stid that the physicaland social closeness demanded by certain war situations mayprovide few opportunities for the acquisition of distancefrom one's peers. While isolation is stressful, being too

15II

closely confined with others in one's unit Is also stressinducing.

The general consensus seems to be that isolation andabandonment peoduce combat stress reactions, yet there arefew empirical studies to support this notion. We do notknow if there is an optimal level nf social detachmentduring war, or if all detachment has negative effects. isisolation a cause of the PTSD or a result of it? We do notknow.

Legitimacy of the War

Soldiers fighting in a war that was legitimate andmorally correct in their eyes had lower rates ofpsychiatric breakdowns (Gal, 19861 Brenda, 19831 Glover,1984). These initial findings infer that the politicalnature of the war being fought, and society's commitment orlack of commitment to the war, seem to be important factorsin the rates of psychiatric breakdown during combat. Again,a large body of empirical research in this area is lacking.

Offensive/ Defensive Posture of the WarUnits in an offensive posture during combat were less

likely to have high rates of psychiatric casualties thanwere units fighting defensively (Price, 1984; Nay, Nardi &Solomon, 19865 Levac, Greenfeld, & Bsaruch, 1979). Defeatresulted in high psychiatric casualty rates. Few otherstudies deal with this aspect of combat and itsrelationship to stress.

Physical Discomfort/ Pain/ Physiological StateDiscomfort and illness are possible contributing

factors to the mental breakdown suffered by many duringcombat (Bourne, 1970; Donnelly, 1982; Shaw, 1983; Weil,1984). Pain, surprise, fear and fatigue will producestress, yet they are nearly unavoidable in combatsituations. Physical discomfort is often the result offatigue and exhaustion (cf., pp. 1-19 and 1-20). We do notknow how extensive the influence of physical discomfort ison stress reactions. While we can recommend that discomfortbe minimized, this is often impossible. Thus, the best wayto reduce the stress caused by discomfort may be bytraining those in the military how to deal with their owndiscomfort and to aid their fellow unit members.

Rotation ScheduleThe one-year rotation schedule is an individual

16

replacement procedure (as opposed to a whole unitreplacement) which was developed after WWII, when Armyleaders and research found that soldiers were experiencingbattle stress due to the length of combat exposure.However, researchers generally agree that the rotation

F schedule disturbs the formation of small group cohesion.(Bourne, 1972; Steiner, 1978; Bourne, 1970). The gain inindividual adaptation (both mental and physical) to acombat environment resulted in a loss of group cohesion. Wedo not know if cohesion or a soldier's ability to adapt ismore important to the soldier's well-being.

Demographic FactorsA third major set of factors potentially influencing

CSR and PTSD are demographic variables. The followingdemographic variables will be discussed in this section:age, cultural factors, education, intelligence, maritalstatus, race, and rank.

Age of the SoldiersThe ar~e of a soldier will determine, in part, his/her

vulnerability to stress during combat (Bey & Zecchinelli,-1974; Bourne, 1970; Gal, 1986; Solomon, Noy, & Bar-On,1986; Silverman, 1986; Levac, Greenfeld, & Baruch, 1979).Most soldiers are adolescents and young adults who aregreatly affected by stress. older soldiers, too, are moresusceptible to breakdown during combat. While age is animportant, the lack of empirically sound evidence prohibitsus from reaching any definite conclusions about age of thesoldier as a variable in producing PTSD.

Cultural FactorsBourne and DuySan (1967) are two of very few authors

who dealt with cultural factors in relation to combatstress. They studied a group of us soldiers and a group ofsoldiers from the Army of the Republic of Vietnam (ARVI4).They found that the two groups had low rates of psychiatriccasualties, but exhibited strikingly different behaviordisorders. The US group had character behavior disordersani the ARVN had anxiety reactions. The authors concludedthat the groups may have been equivalent in that both wereusing the most effective way to escape from an undesirablesituation. They stated that the major differences betweenthe groups were due to cultural aspects. Thus, we may wantto study the relationship of culture to stress reactions.Cultural differences may help explain why some people break

17

down during combat while others do not.

Education Levelsindividuals with less than an eighth-grade education

were at higher risk for combat exhaustion than individualswith higher education levels (Helzer, 1984; Shaw, 1983;Gal, 1986; Solomon, Noy, & Bar-On, 1986). Although thesestudies concluded that education has a role in the onset ofstress reactions, we do not know why or how. we needresearch with empirical and statistical data to reach moresound conclusions.

IntelligenceResearch most often links intelligence and education

level. However, Gal (1986) stressed that intelligence,separate from educational level, played an important rolein the onset of stress reactions. while there may be arelationship between intelligence and stress reactions,there is not enough research available to estimate thenature of that relationship.

Marital Status/ Family EnvironmentIngraham and manning (1980) found that married Israeli

soldiers are more susceptible to the stress of combat thantheir unmarried counterparts. Births and deaths in thesoldier's family will also increase their susceptibility tostress. It is possible that married US soldiers experiencemore stress, as is the case with Israeli soldiers, yet thestudies reviewedt do not examine this possibility.

Psychiatrists have studied family pathology as apredisposing factors in PTSD (Helzer, 1984; Davidson,Schwartz, Storck, Krishnan, & Hammett, 1985). There may bea genetic or biological factor involved in combat stressreactions and PTSD. Further research on the area of familypathology is needed.

RaceThere is little research linking racial differences

and stress. Yager, Laufer and Gallops (1984) found thatparticipation in abusive violence or torturous acts had a

greater emotional impact on blacks compared to whites. Thisfinding suggests that there are racial differences inresponse to certain events. VanPutten and Yager (1984) alsofound that blacks experienced more symptoms of stress andpsychological distress than whites when both groups hadparticipated in combat. There are several reasons why this

18

may have been found. Assignment in military positions isnot random, but based on ability and rank. Blacks oftenhold lower ranks and have less education than whites.Another possibility, is that studies did not control forbackground. Therefore, the findings of racial differencesmay in fact be reflecting socioeconomic or educationaldifferences, rather than racial differences.

RankA soldier's rank is a factor in susceptibility to

combat stress (Gal, 1986; Solomon, Noy, & Bar-On, 1986;Levac, Greenfeld, & Baruch, 1979; Bourne, 1970). Rank, witheducation level and combat suitability, provides the basisfor selection and expectation of military performance andfactors into the susceptibility to stress. All of the aboveresearch studies have all been conducted on Israeli forces,thus making it difficult to generalize to the U.S. Army.

While factors during the war (both psychological andphysical) are important to the study of PTSD and CSR,factors occurring post-war are also considered to have someinfluence on the onset of the stress reactions. Thesepost-war factors, including the job market, familyenvironments, political controversy, and reentry shock, arediscussed below in the final section of this paper.

Port-war Adjustment FactorsThere are several factors relating to PTSD which

occur after the combat experience. These are mentionedbriefly below since they are all extensions of categoriesdiscussed in previous sections. Veterans of Vietnam weremet with a limited job market upon return to the UnitedStates (Thienes-Hontos, Watson, & Kuchala , 1982). Theirfamily environments had changed drastically, since theirwives and children had no contact with them for a longperiod of time (Nice, McDonald, & McMillan, 1981; McCubbin,Hunter & Dahl, 1975; Glover, 1984). The politicalcontroversy over the Vietnam war made the veterans feelunwelcomed when they returned. Society blamed the soldiersfor an unpopular war (Bourne, 1972; Bourne,1970;Thienes-Hontos, Watson & Kuchala, 1982; Brende, 1983).Finally, veterans experienced culture shock, or reentryshock, upon reentering the US. They were absent from an eracharacterized by overwhelming and drastic change (Bourne,1972; Cavenar & Nash, 1976; Dasberg, 1975; McDaniel &McClelland, 1986; Kleiger, 1984). Kleiger (1984) found thatmen who had remained in the military after returning home

19

A

may have fared better in terms of psychological problemsbecause they remained identified with the group that would Aprovide support. However, the soldiers in any war have toadapt to a new lifestyle during military srrvice, and theyare forced to readjust to the host society when they returnfrom war. These post-war factors, while not always presentto the same extent, play important roles in the onset ofstress-induced reactions. Reintegration into a changedsociety, especially an unwelcoming one, increases stressinstead of alleviating it and may subsequently produce morepsychiatric casualties.

ConclusionMany of the variables andfiactors discussed in this

paper are interrelated. Currently, it is nearly impossibleto make any general overall conclusions about factorsrelating to PTSD and CSR based on this body of research.The major reason for this inability to generate conclusionsis that, for the most part, the research ismethodologically unsound (see Stewart & Weaver, 1987, for acomplete review of the methodology). There are a fewinstances in which there are conflicting findinge; but, onthe whole, there are just not enough empirical studies toprovide conclusive answers. Therefore, we present thispaper as a description of what has been found, whether itis supported or not, and directions for further research..Although the lack of sound research is disappointing,, thisdoes not mean that there are not sany intriguing andperhaps important idias presented in the literature. Theproblem does not lie in the concepts pee se, but rather inthe absence of design, hypothesis testing and confirmingresults in the research studies (see Stewart & Weaver,1987).

We hope this paper will provide researchers withresearch ideas that will help to increase our understandingof PTSD and CSR. Such an understanding could assist policyplanners and military strategists in developing methods forgreater combat effectiveness and fewer incidences ofpost-war trauma.

20

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