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It has been two decades since American troops were withdrawn from Vietnam, yet there has been little interest in resolving challenges that arose during the war regarding the ethical justification for military psychiatry's principles and field techniques for treating combat-generated casualties. Recently, thousands of American service persons were sent to fight in the Middle East accompanied by psychiatrists trained to use the same military treatment doctrine. In the wars before Vietnam, this doctrine had proved to be highly effective for treating individuals with combat stress casualties and returning them to duty. Furthermore, it was uncontroversial and later successfully adapted for use with civilian populations. During the Vietnam war, however, many psychiatrists intensely opposed a treatment regimen designed to induce symptomatic soldiers to believe that facing further combat risks would be in their best interest or that of the nation. As this review of the doctrine's rationale and ethical quandaries suggests, combat psychiatrists are influenced by powerful, potentially competing values systems but cannot realistically assess some of the most important factors that affect the balance of harm and benefit associated with their treatment decisions. This latest armed conflict reminds us of critical moral and ethical questions regarding the divided loyalties of combat psychiatrists--questions that should be addressed through future research and formalized professional guidelines.

Objective: Studies indicate that chronic combat-related posttraumatic stress disorder (PTSD) is frequently associated with other psychiatric disorders. Questions regarding the nature and interrelationships of these conditions require clarification. The purpose of this study was to address primary and secondary illness relationships by focusing on the specific phenomenology and course of illness onset of PTSD comorbidity. Method: In order to minimize confounding factors, only outpatients without recent substance use disorders were included. Sixty subjects who had been exposed to severe combat stress, including veterans of Vietnam and veterans of World War II or Korea, 1 5 of whom were former prisoners of war, received structured assessments over serial evaluations. Results: PTSD was the most prevalent lifetime disorder followed by major depression, panic disorder, generalized anxiety disorder, and phobic disorder or symptoms. Endogenous-appearing features overlapping other clinical populations were common; however, some specific symptom patterns also were suggestive of traumatic influence. Unlike generalized anxiety disorder and past substance use, the mean onset of phobias, major depression, and panic disorder, respectively, occurred later than PTSD. Conclusions: These observations suggest that persistent conditions related to PTSD progress toward symptoms that are increasingly autonomous in their pattern of occurrence. (Am J Psychiatry 1992; 149:1568-1574)

The authors examined the effectiveness of the prevailing treatment doctrine stressing the principles of proximity, immediacy, and expectancy for combat stress reaction among Israeli soldiers in the Lebanon War. Two treatment outcomes were measured: return to military unit and presence of posttraumatic stress disorder. All three treatment principles were associated with a higher rate of return to the military unit. The beneficial effect of frontline treatment was also evidenced by lower rates of posttraumatic stress disorder. The authors suggest that these principles can also be effective in treating other forms of posttraumatic stress disorder.

The authors assessed the impact of the Nazi Holocaust on the course and symptoms of posttraumatic stress disorder (PTSD) among Israeli combat stress reaction casualties. They examined a sample of 96 such casualties of the 1982 Lebanon War whose parents had gone through the Nazi Holocaust and compared them to casualties who did not have such family history for 3 consecutive years beginning 1 year after their participation in the war. Results showed that 2 and 3 years after their participation in the 1982 Lebanon War, the children of Holocaust survivors, i.e., "second-generation" casualties, had higher rates of PTSD than did the control subjects, as well as a somewhat different clinical picture. Clinical and methodological implications of the findings are discussed.

One year after the 1982 Lebanon War, the authors assessed the prevalence, type, and severity of posttraumatic stress disorder in a large representative sample of Israeli soldiers who had been treated for combat stress reactions. Comparisons were made with a group of soldiers who had fought in the same battles but had not been treated for this reaction. A dramatically higher percentage of soldiers with combat stress reaction (59%) than of soldiers without combat stress reaction (16%) developed posttraumatic stress disorder. Age was significantly associated with posttraumatic stress disorder. The authors discuss the differential quality of posttraumatic stress disorder among both groups as well as the factors facilitating recovery.

A series of 58 war neurotic enlisted Air Force returnees from overseas theaters routinely admitted to a United States convalescent hospital were observed for one month without specific psychotherapy. The primary purpose was to determine which patients could be handled without specific psychotherapy and be confidently returned to duty status in an improved condition at the end of hospitalization. The results were as follows: 1. Of the series, 26 percent fell into the markedly improved group. 2. The principal factors having practical prognostic value in the determination of candidates for this group were: a. Mild anxiety, in the absence of anxiety-binding mechanisms. b. Mild predisposition. c. Combat stress rather than non-combat. It is therefore suggested that in convalescent hospitals treating overseas returnees with neurotic symptoms, a preliminary psychiatric screening be made by psychiatrists experienced in the diagnosis and therapy of war neuroses. By so doing a quarter or thereabouts of the patients ...

1. A series of 325 neuropsychiatric disorders studied at an Aleutian post is presented and discussed from the standpoint of etiology, incidence, reaction types and treatment. 2. Though combat was not a factor in precipitating or reactivating neurotic syndromes in this particular locality, other less tangible external factors played a decisive role in the production of neuropsychiatric disability. 3. Of the psychoneurotic patients, 80% gave a history of clear-cut symptoms before entering the service. 4. Psychoneuroses made up over 50% of the cases. 5. Some of the psychoneurotic reactions in these men who were not in combat were similar to cases reported in the literature as "battle neurosis" and "combat fatigue." 6. Psychoneurosis, dementia precox and miscellaneous disorders are illustrated by case histories. Certain problems in dealing with these disorders are discussed. 7. The general problem of disposition and treatment is presented, emphasis being laid on mental hygiene. Roughly 75% of the psychoneurot...

In this brief comment upon the insistent problems of the neuroses of war, I shall dwell chiefly upon the entity of combat fatigue-a condition so aptly named, now so well defined by others, and daily better understood by psychiatrists, medical men in general and the military personnel as a whole. The current emphasis upon this most prevalent of all psychiatric war disabilities is well deserved, in view of the tremendous toll from the standpoint of casualties that can be attributed to this single illness alone. On the combat front, it is important to arrive at an early diagnosis and there is a growing unanimity of opinion that treatment instituted early is the sine qua non of recovery and the instrument to a favorable ultimate outcome. For all practical purposes, it is well to bear in mind as the diagnostic criteria of combat fatigue (previously labeled psychoneurosis, war or traumatic neurosis) that we are dealing with a neurosis developing acutely under experiences of extreme threat to ego-security in individuals previously well integrated. Objectively, startle reaction is to some degree universal in the acute stage. Anxiety, tremors, sleeplessness, battle dreams and some degree of confusion or temporary amnesia are usually all presentat least in the early stages of the condition. The conditioning factors which predispose to this profound personality disintegration may vary in intensity and duration. Usually, physical and emotional exhaustion are present to a degree sufficient to prepare a fertile field for a neurotic catastrophe. Then comes some terrifying life-threatening episode, unendurable to the psyche, which allows for only one response: an acute psychoneurosis.

A simple accessory method is described for the desensitization of startle reaction and, to some degree, of anxiety, in cases of combat fatigue, by the use of moving pictures of battle scenes. Each showing takes only about 15 minutes and on the average 12 showings have produced marked improvement in all but one of 14 cases. The simplicity of the method; its relative speed and the favorable results achieved without taxing the physician's time, indicate a more extensive trial of this supplementary procedure.