FM 22-51
LEADERS' MANUAL FOR COMBAT STRESS CONTROL
CHAPTER 2
STRESS AND COMBAT PERFORMANCE
Section I. STRESS TERMINOLOGY AND THE STRESS CONCEPT
2-1. Introduction
The understanding of the stress process has been refined over time by research and experience,
leaving some terms obsolete. This chapter establishes how the Army's combat stress control
concept currently defines and interprets stress terminology.
2-2. Understanding of Interactions
a. Stressors. A stressor is any event or situation which requires a nonroutine change in
adaptation or behavior. Often it is unfamiliar or creates conflict among motives within the
individual. It may pose a challenge or a threat to the individual's well-being or selfesteem.
Stressors may be positive or negative (for example, promotion to new
responsibilities or threat of imminent death).
b. Combat Stressors. Combat stressors are any stressors occurring during the course of
combat-related duties, whether due to enemy action or other sources. Combat duties do
not necessarily involve being shot at and may be carried on even in "safe" areas far from
the enemy. Many Stressors in combat duties come from the soldier's own unit, leaders,
and mission demands. They may also come from the conflict between mission demands
and the soldier's home life.
c. Stress. Stress is the internal process of preparing to deal with a stressor. Stress involves
the physiological reflexes which ready the body for fight or flight. Examples of those
reflexes are increased nervous system arousal, release of adrenaline into the bloodstream,
changes in blood flow to different parts of the body, and so forth. However, stress is not
synonymous with arousal or anxiety. Stress involves physical and mental processes
which, at times, suppress arousal and anxiety. Stress also involves the accompanying
emotional responses and the automatic perceptual and cognitive processes for evaluating
the uncertainty or threat. These automatic processes may be instinctive or learned.
d. Stress Appraisal. Stress may or may not involve conscious awareness of the threat, but
the stressor must be perceived at some level to cause stress. The amount of stress
experienced depends much on the individual's appraisal of the stressor and its context,
even if that appraisal is wrong. The stress process includes psychological defenses which
may filter the perception and appraisal to shield the individual from perceiving more
threat than he is ready to tolerate.
e. Physical Stressors Versus Mental Stressors. A distinction can be made between those
Stressors which are physical and those which are mental.
- A physical stressor is one which has a direct effect on the body. This may be
an external environmental condition or the internal physical/physiologic demands
of the human body.
- A mental stressor is one in which only information reaches the brain with no
direct physical impact on the body. This information may place demands on either
the cognitive systems (thought processes) or the emotional system (feeling
responses, such as anger or fear) in the brain. Often, reactions are evoked from
both the cognitive and the emotional systems.
f. Stress Behaviors. These are stress related actions that can be observed by others; for
example, moving or keeping still, speaking or not speaking. The behaviors may be
intended to overcome and turn off a stressor, to escape it, or to adapt to it. They may
simply reflect or relieve the tension generated by the internal stress process. Any of these
different types of stress behavior may be successful, unsuccessful, or not influence the
stressful situation at all. They may make the stressor worse. They may resolve one
stressor but create new stressors.
g. Combat Stress. This is the complex and constantly changing result of all the stressors
and stress processes inside the soldier as he performs the combat-related mission. At any
given time in each soldier, stress is the result of the complex interaction of many mental
and physical stressors.
2-3. Discussion of Physical Versus Mental Stressors
a. Table 2-1 gives examples of the two types of physical stressors (environmental and
physiological) and the two types of mental stressors (cognitive and emotional).
Table 2-1. Types of Physical and Mental Stressors
b. The physical stressors evoke specific stress reflexes. For example, cold causes
shivering and decreased blood flow to skin and extremities; heat causes sweating and
increased blood flow to skin. These stress reflexes can maintain internal balance and
comfort up to a point but then may be exceeded.
c. The distinction, however, between physical and mental stressors is rarely clear cut.
(1) Mental stressors can also produce the same stress reflexes as do some physical
stressors; for example, decreased blood flow to skin, increased sweating,
adrenaline release, and pupil size. These reflexes can markedly increase or
decrease the individual's vulnerability to specific physical stressors. The mental
stressors also presumably cause changes in brain chemistry (involving the
neurotransmitter chemicals in the brain).
(2) Physical stressors are also mental stressors when they provide information to
the brain which creates a mental demand or poses a threat to well-being. Even if a
physical stressor is not a threat to life and health, the discomfort, distraction, and
performance degradation it causes may be emotionally upsetting. Therefore,
physical stressors, too, can produce the nonspecific arousal reflexes. Heat, cold,
dehydration, toxic chemicals, and other physical stressors can also interfere
directly with brain functioning; they can impair perceptual and cognitive mental
abilities, thus increasing the stresses. Light, noise, discomfort, and anxiety
provoking information may interfere with sleep, which is essential to maintain
brain efficiency and mental performance over time.
d. Because of this intermeshing of physical and mental stressors and stress reflexes, no
great effort needs to be invested in distinguishing them in military contexts until the
physical stressors and stress reflexes become so severe that they warrant specific (and
perhaps emergency) protective measures and treatment. Prior to that stage, unit leaders
and medical and mental health personnel should assume that both physical and mental
stresses are usually present and interacting within all unit personnel. Guidelines for
controlling both physical and mental stressors at the same time should be contained in the
tactical standing operating procedure (TSOP), if possible.
2-4. Positive Stress
a. Stress is not necessarily bad or harmful. Positive stress (or eustress) is that degree of
stress which is necessary to sustain and improve tolerance to stress without overdoing the
stress experience. Some level of stress is helpful and even necessary to health. This is
especially clear for some physical stressors to which the body can acclimatize. To
achieve greater tolerance or acclimatization to a physical stressor, a progressively greater
exposure is required. This exposure should be sufficient to produce more than the routine
stress reflexes. Well-known examples of acclimatization are heat acclimatization,
cardiovascular (aerobic) fitness, and muscle strength. These examples are so important to
combat stress control that they are worth reviewing. The process of improving tolerance
to stressors through progressive exposure to those stressors will also be true of cognitive
emotional stressors.
(1) Heat acclimatization. You cannot become fully acclimatized to heat by just
lying around in hot conditions. You have to perform physical exercise in the heat
to stress the body's temperature regulation system. At first, the body may
overreact with excessive sweating and heart rate. As acclimatization occurs, the
body becomes more efficient at cooling itself. However, acclimation has a
maximum level. If you stop exercising in the heat, you will gradually lose the
acclimatization you have gained. Mission-oriented protective posture (MOPP)
training should be considered as a part of the acclimatization program.
(2) Aerobic fitness. It is well known that you can become aerobically fit only by
exerting yourself to progressively greater degrees of physical effort. One way is to
enter into 20-minute (or more) exercise programs of jogging, running, bicycling,
swimming, or special aerobic exercises each day. Any physical effort which
sufficiently raises heart rate and respiratory rate and works up a sweat for 20
minutes or more will increase your tolerance. In other words, you must stress the
system. After doing that for several days, the same effort raises heart rate and
sweating only a little. You become less short of breath, and the effort seems much
easier. To become more aerobically fit, you have to increase the work stressor
even more until the body again shows the stress of increased heart rate, shortness
of breath, and sweating. If you stop exercising aerobically for weeks or months,
your improved aerobic fitness will gradually be lost.
(3) Muscle strength. Body builders increase their muscle mass by lifting
progressively heavier weights or working against progressively greater resistance
on exercise machines. In order to increase muscle strength, you have to increase
the stressor (the weight lifted) and the stress (the physiological increased effort
within the muscle cells). After the muscle has become accustomed to lifting a
given weight, it no longer seems like a great effort. There is little stress taking
place in the muscle. The muscle will merely maintain its strength and not get any
stronger with repeated exposure. If you stop doing even that amount of lifting,
your muscles will get flabby again over time. A good maxim is, "If you do not use
it, you will lose it."
b. It is important to understand that stressors which overstrain the adaptive capability of
the body (whether or not they cause pain) do not hasten acclimatization or increase
tolerance to the stressor. They often retard it and may even permanently impair future
acclimatization. Consider the examples of the physical stressors discussed above.
(1) Heat acclimatization is not speeded by getting heat cramps or heat exhaustion.
Neither is it significantly slowed, although the person's self-confidence and
motivation to try again may be impaired. However, people who are driven to the
stage of heatstroke and survive will forever be physically less tolerant to heat.
They will be more likely to develop heatstroke in the future if exposed to heat.
(2) Runners or body builders who push too hard early in training may not feel
severe pain at the time. Hours later, however, they may develop muscle swelling,
ache, and stiffness. At best, this will take days to recover to the point where the
athlete can even continue with the exercise regimen. At worst, the damaged
muscles may break down and release the substance myoglobin into the
bloodstream which can permanently damage or destroy the kidneys. Excessive
painful stress on bones, joints, and ligaments does not make them grow stronger
but instead causes stress fractures, sprains, tears, and other damage that may
require months of reduced activity to heal.
(3) The issue for the master fitness trainers is how to keep the physical work
stressors and stress in the positive or eustress range which increases strength and
fitness. They must control the stressors and stress so they are not extreme-too
little or too much.
WARNING
Unconditioned, unacclimatized troops should not be overextended in training
as this could cause severe injury or even death. A special physical training
program will be required.
c. Positive stress also applies to mental stressors (cognitive and emotional), as well as to
physical stressors (environmental and physiological). Appropriate exposure to mental/
emotional stressors is necessary to increase tolerance to them.
(1) Armies have known for centuries about the positive effects of stress in
preparing soldiers for combat. In old-style basic training (prior to 1970), the drill
sergeant deliberately made himself more fearsome than death itself so that the
trainee would learn to respond automatically, even in a state of terror. That
technique is not useful today because modern war requires more small unit
cohesion, trust between leaders and those led, and initiative even on the part of the
junior enlisted soldier. The modern drill sergeant must, instead, require the
trainees to meet difficult (stressful) standards and work with the trainees to assure
that they master them. The result is a well-earned sense of confidence in self,
comrades, and leaders that can be applied to future demands.
(2) The Army knows that airborne and air assault training are not just intended to
teach the skills needed to arrive on a battlefield after jumping from a low-flying
aircraft or repelling from a helicopter. Their greater value comes from requiring
soldiers to confront and master their extremely strong, instinctive fear of heights
under circumstances which are deliberately stressful at the time. During training,
this fear builds self-confidence and a sense of special identity on completion. (In
fact, the training itself is not exceedingly dangerous, statistically speaking.
However, the possibility of death does exist if you are extremely unlucky or fail
to do the task correctly. This can contribute to additional stress.)
(3) Ranger school is a clear example of the Army's recognition of the benefits of
positive stress. A generic ranger course objective would read: Perform complex
and difficult physical and mental task under great pressure, sleep loss, water and
food deprivation, and physical fatigue. No one coasts through ranger school. If
anyone seems to be coasting through, the trained ranger cadre will increase the
demand on that person until he, too, reaches the stage of stress where he realizes
he cannot get through it all alone. Ranger school teaches small teams and their
rotating leaders how to control stress in all the team members so the team
accomplishes the mission. The training gives the individual soldier confidence,
but even more, an awareness of how stress works in oneself and others. It teaches
stress control, not stress reduction. Often the need for the team and its individual
members is to play different mental and physical stressors against each other. This
is done by increasing some stressors while decreasing others to keep the team on
its mission and to keep individual soldiers from giving up.
d. To some degree, acclimatization to mental (cognitive/emotional) stressors also shares
that "use it or lose it" feature which is true for adaptation to physical stressors. The
airborne qualified trooper may experience more unpleasant stress symptoms when
jumping after not having jumped for many months. The physician may find the stress
unexpectedly higher when performing a potentially risky patient-care procedure that was
once so frequently practiced that it had seemed to involve no stress at all but which has
not been performed for some time. However, the memory of successfully mastering the
stressor in the past usually speeds up the return of adaptation.
e. Tolerance to mental stressors is increased by successfully facing and mastering similar
stressors (just as tolerance to physical stressors is). However, being overwhelmed by
emotional or mental stress may temporarily or permanently impair future tolerance (just
as exceeding the ability to cope with physical stressors may). Up to a point, mental stress
(even uncomfortable mental stress) may increase tolerance to future stress without any
current impairment. A higher level may cause temporary overstrain but may heal as
strong or stronger than ever with rest and restorative processing. More severe overstrain,
however, may permanently weaken tolerance to future mental stress. As with some cases
of damage from physical stress, the harm done by mental stress may not be apparent at
the time. It may only be apparent later. There is reason to believe that immediate
preventive measures or treatment can greatly reduce the potential for chronic disability,
even in cases of extreme emotional overstrain.
2-5. Relationship of Stress to Task Performance
Stress is an internal process which presumably evolves because it helps the individual to function
better, stay alive, and cope successfully with stressors. However, there is an optimal range of
arousal (or motivation or stress) for any given task.
a. If there is too little arousal, the job is done haphazardly or not at all because the
individual is easily distracted, makes errors of omission, or falls asleep. If arousal
becomes too intense, the individual may be too distractible or too focused on one aspect
of the task. He may have difficulty with fine motor coordination and with discriminating
when and how to act. If the individual is unfamiliar with his own stress reflexes and
perceives them as dangerous (or incapacitating, or as a threat to self-esteem), the stress
itself can become a stressor and magnify itself.
b. With extreme arousal, the individual may freeze (become immobile or petrified by
fear). Alternately, he may become agitated and flee in disoriented panic. If stress persists
too long, it can cause physical and mental illnesses. Extreme stress with hopelessness can
even result in rapid death, either due to sympathetic nervous system overstimulation
(such as stroke or heart attack) or due to sympathetic nervous system shutdown (not
simply exhaustion). An individual giving up can literally stop the heart from beating.
c. The original purpose of the stress reaction was to keep the person alive. The military
requirement for the stress process is different. It is to keep the soldier in that range of
physiological, emotional, and cognitive mobilization which best enables him to
accomplish the military mission, whether that contributes to individual survival or not.
This optimal range of stress differs from task to task. Tasks which require heavy but
gross muscular exertion are performed best at high levels of arousal (Figure 2-1). Tasks
that require fine muscle coordination and clear thinking (such as walking point on a
booby-trapped jungle trail, or distinguishing subtle differences between friendly and
enemy targets in a night-vision gun sight) or that require inhibiting action (such as
waiting alertly in ambush) will be disrupted unless the stress process is kept finely tuned.
If the stress process allows too much or too little arousal or if arousal does not lessen
when it is no longer needed, stress has become harmful.
2-6. Fatigue
Fatigue means weariness and/or decreased performance capability due to hard or prolonged work
or effort. It reflects the stage where the energy mobilized by the stress process is beginning to run
down. If the effort continues, the fatigue can build to the point of exhaustion.
a. Fatigue can be produced by both physical and mental tasks. A well-known example of
physical fatigue is muscle tiredness. This can be limited to specific muscles which have
been overworked. Another example is aerobic fatigue (where the whole body is short of
oxygen and perhaps blood sugar, is probably overheated, and is wanting to rest).
Figure 2-1. Change in performance with increasing arousal (stress) for two types of tasks.
b. Sleep loss produces a different kind of fatigue which is primarily mental. The sleepdeprived
person has trouble keeping his mind focused although he has no decrease in
muscular or aerobic work capacity. People with sleep-loss fatigue usually appear tired
and slowed down, or they may also be speeded up, hyperactive, and irritable.
c. Continued mental effort on a specific task, whether it is a task requiring much thinking
or constant attention, produces mental fatigue. That is, performance gets progressively
worse with time, and the person wishes he could stop to do something else. Even a few
minutes of break, while the mind does some quite different mental tasks, substantially
relieves the mental fatigue and improves the performance.
d. Physical illness can also bring on fatigue. People who have ever had the flu or even
just a cold know how quickly one tires. They only want to rest or sleep.
e. Intense emotions also produce fatigue. This is especially true of anxiety and fear
because they arouse the fight or flight reflexes of the physical stress process. This will be
discussed later in justifying the use of the term battle fatigue.
f. The level of fatigue experienced may be influenced by --
- Work intensity.
- Task difficulty.
- Duration of sustained effort.
- General well-being of the individual.
Fatigue can also be influenced by the level of preparedness to perform the specific task.
(1) For physical fatigue: A marathon runner may have strong legs, superb aerobic
fitness, great health, and self-confidence, but too little arm and shoulder strength
to be able to chin himself even once before being stopped by fatigue.
(2) For emotional fatigue: A healthy, confident soldier may have learned to carry
his Dragon missile and guide it to its target easily in peacetime training. But if he
has never learned to control his own fear, he may find himself too quickly
fatigued to even carry the weight, let alone keep the missile on target for 10
seconds while under real, lethal enemy fire. He may, however, still be able to
perform simple tasks. In WWII, the following observations and conclusion were
made:
(a) In the fighting for Kwajalein Atoll, troops were halted three times by
enemy fire. Their energy was exhausted even though they suffered no
casualties and had moved fewer than two miles. In the Normandy
invasion, a strong infantry company with many vigorous young men hit
the beach still fresh. Under intense fire, they found they had to drag their
heavy machine guns across the beach a few feet at a time; when in
training, they had been able to carry the same loads on the run.
(b) The Army reached the following conclusion from those observations:
Fear and fatigue effect the body in similar ways. Fear, like physical work,
drains the body of energy. This creates a self-perpetuating cycle. The
overloaded soldier, feeling tired, becomes more susceptible to fear. The
more fearful he becomes, the weaker he feels, and the more quickly he
becomes fatigued.
2-7. Stages of Adaptation to a Threatening Situation
a. The stage of alarm (usually brief) is when the fight or flight response is extremely
active. Performance is likely to be impaired unless the soldiers' responses are simple and
instinctive (like running or freezing) or well drilled.
b. The stage of resistance is achieved if the subject successfully copes with the threat.
The overarousal moderates and the sufferer begins to actively try to overcome or escape
the stressor or to adapt to it. Performance is often enhanced in the stage of resistance. If
the stressor is mastered or adapted to, the person either returns to the baseline level of
stress or may have some residual stress while working through the unpleasant memories
and their long term implications.
c. The stages of exhaustion may occur if the victim of stress is unable to escape,
overcome, or tolerate a severe stressor. Performance deteriorates and may cease
altogether. The victim may develop a stress-related illness and can even die of stress.
Section II. COMBAT PERFORMANCE AND COMBAT STRESS BEHAVIORS
2-8. Phases of Adaptation to Combat
During the first time in battle for soldiers, their combat performance is usually lower than it was
in precombat training. The novice soldiers are also at relatively high risk of being killed or
wounded. This is partly because they have not yet learned to identify and respond automatically
to the true dangers (such as the specific sounds of incoming artillery or mortar rounds). Under
extreme stress, they may experience difficulty with focusing their attention and remembering
what they were taught in training. Their ineffectiveness may also be caused by fearinduced
fatigue. First-battle soldiers are at high risk of becoming battle fatigue casualties. Soldiers in
their first time under fire are likely to experience high anxiety (the stages of alarm) (see Figure 2-
2[A]). Poor showing on first exposure to real battle can be reduced by providing tough, realistic
training (especially battle drills under high stress), but it cannot be totally prevented.
a. The Experienced Veteran. If the soldier does not become a casualty in the first battle,
his combat skills will improve quickly over the next few days. His skills continue to
improve gradually over the next weeks until he is as good as he can get. An experienced
soldier gains confidence in his skill, comrades, and leaders (see Figure 2-2[B]). For him,
the stage of alarm is mostly in anticipation. He responds selectively and automatically to
the truly dangerous sounds and cues of the battlefield. When the action starts, he
immediately achieves the stage of resistance and is remarkably calm as he focuses on his
job. However, the veteran is likely to have a considerable rebound of arousal and anxiety
when the fight is over. Not all veteran soldiers ever achieve the state of really low fear in
action. Some drop to mid levels, yet still perform their duties effectively.
b. Sustainment of Optimal Combat Skills. Combat skills and high stress tolerance are
maintained when frequent successful combat actions occur. If losses in the unit remain
low, the veteran can maintain his optimal combat skills for many months. If there is a
prolonged cease-fire or if the skilled soldier leaves the combat zone on individual R&R,
there may be a brief drop in performance on his return to battle. That drop would be
accompanied by a return of the anxiety pattern shown by new soldiers (Figure 2-2[A])
but the anxiety is much briefer. This would be like the anxiety felt by the airborne
qualified soldier who is making a jump after not having done so for many months.
Predictably, the experienced veteran will regain his combat edge quickly upon returning
to battle.
c. The Overstressed Veteran. If the unit suffers many casualties, however, and the chance
of surviving a long war seems poor, the experienced soldier's combat performance begins
to decline. It can occur after 14 to 21 days of cumulative combat or even after only a few
days of extremely heavy losses. The overstressed veteran becomes more careful, loses
initiative, and may be indecisive when he needs to act quickly. Figure 2-2(C) shows the
anxiety pattern of an overstressed soldier who is doubting his chances of survival. There
were too many close calls in the last battle; too many of his friends were killed (slowly
over time or quickly). Under such stress, he feels his own skills are slipping, and it is just
a matter of time before he, too, will surely be killed or maimed. Unless he is given the
opportunity and help to reduce arousal level and regain some hope, he will soon fail.
Figure 2-2. Anxiety, fear and arousal at different stages in combat tour.
d. Decline of Combat Skills. How quickly performance declines will usually be related to
how many casualties have occurred and how close the soldier was to them (both
physically and emotionally). The decline may be hastened or slowed by leadership, unit,
scenario, and home front factors such as those discussed in later chapters and in
Appendix A.
e. Restoration of Combat Skills. Rest and recuperation, preferably with other soldiers in
the unit, can substantially restore combat proficiency. Rest would also substantially
return the anxiety pattern to that of the experienced veteran (Figure 2-2[B]). This
recuperation can be accomplished with the help of the medical and combat stress
control/mental health personnel at a medical restoration or reconditioning facility.
2-9. Combat Stress Behaviors
a. Combat Stress Behaviors. Combat stress behavior is the generic term which covers the
full range of behaviors in combat, from behaviors that are highly positive to those that are
totally negative. Table 2-2 provides a listing of positive stress responses and behaviors,
plus two types of dysfunctional combat stress behaviors-those which are labeled
misconduct stress behaviors and those which are labeled battle fatigue.
b. Positive Combat Stress Behaviors. Positive combat stress behaviors include the
heightened alertness, strength, endurance, and tolerance to discomfort which the fight or
flight stress response and the stage of resistance can produce when properly in tune.
Examples of positive combat stress behaviors include the strong personal bonding
between combat soldiers and the pride and self-identification which they develop with the
combat unit's history and mission (unit esprit). These together form unit cohesion-the
binding force that keeps soldiers together and performing the mission in spite of danger
and death. The ultimate positive combat stress behaviors are acts of extreme courage and
action involving almost unbelievable strength. They may even involve deliberate selfsacrifice.
Positive combat stress behaviors can be brought forth by sound military training
(drill), wise personnel policies, and good leadership. The results are behaviors which are
rewarded with praise and perhaps with medals for individual valor and/or unit citations.
The positive combat stress behaviors are discussed further in Chapter 3.
c. Misconduct Stress Behaviors. Examples of misconduct stress behaviors are listed in the
center column of Table 2-2. These range from minor breaches of unit orders or
regulations to serious violations of the Uniform Code of Military Justice (UCMJ) and
perhaps the Law of Land Warfare. As misconduct stress behaviors, they are most likely
to occur in poorly trained, undisciplined soldiers. However, they can also be committed
by good, even heroic, soldiers under extreme combat stress. Misconduct stress behavior
can be prevented by stress control measures, but once serious misconduct has occurred, it
must be punished to prevent further erosion of discipline. Combat stress, even with heroic
combat performance, cannot justify criminal misconduct. See Chapter 4 for a discussion
of misconduct stress behaviors.
d. Battle Fatigue. Battle fatigue is also called combat stress reaction or combat fatigue.
See Table 2-2 for examples of battle fatigue. Those battle fatigue behaviors which are
listed near the top may accompany excellent combat performance and are often found in
heroes, too. These are normal, common signs of battle fatigue. Those that follow are
listed in descending order to indicate progressively more serious or warning signs.
Warning signs deserve immediate attention by the leader, medic, or buddy to prevent
potential harm to the soldier, others, or the mission. Warning signs do not necessarily
mean the soldier must be relieved of duty or evacuated if they respond quickly to helping
actions. However, soldiers may need evaluation at medical treatment facilities to rule out
other physical or mental illness. If the symptoms of battle fatigue persist and make the
soldier unable to perform duties reliably, then medical treatment facilities, such as
clearing station and specialized combat stress control teams, can provide restorative
treatment. At this point, the soldier is a battle fatigue casualty. For those cases, prompt
treatment close to the soldier's unit provides the best potential for returning the soldier to
duty. See Chapter 5 for a detailed discussion of battle fatigue.
Table 2-2. Combat Stress Behaviors
2-10. Overlapping of Combat Stress Behaviors
The distinction between positive combat stress behaviors, misconduct stress behaviors, and battle
fatigue is not always clear. Indeed, the three categories of combat stress behaviors may overlap,
as diagrammed in Figure 2-3. Soldiers with battle fatigue may show misconduct stress behaviors
and vice versa. Heroes who exemplify the positive combat stress behaviors may suffer symptoms
of battle fatigue and may even be battle fatigue casualties before or after their heroic deeds.
Excellent combat soldiers may commit misconduct stress behaviors in reaction to the stressors of
combat before, during, or after their otherwise exemplary performance. Combat stress, even with
good combat behavior, does not excuse criminal acts. However, it could be taken into account as
an extenuating circumstance for minor (noncriminal) infractions or in determining nonjudicial
punishment under Article 16, UCMJ, for minor offenses.
Figure 2-3. Overlapping of combat stress behaviors.
2-11. Post-Traumatic Stress Disorder
Post-traumatic stress symptoms are normal responses after extremely abnormal and distressing
events.
a. Post-Traumatic Stress Disorder Signs and Symptoms. As with battle fatigue, posttraumatic
stress symptoms come in normal/ common and warning signs. These signs and
symptoms do not necessarily make the sufferer a casualty or deserve the label of disorder.
It is normal for the survivor of one or more horrible events to have painful memories; to
have anxiety (perhaps with jumpiness or being on guard); to feel guilt (over surviving or
for real acts of omission or commission); and to dream unpleasant dreams about it. This
becomes PTSD only when either the pain of the memories or the actions the person takes
to escape the memories (such as substance abuse, avoidance of reminders, social
estrangement, and withdrawal) interfere with occupational or personal life goals.
b. Post-Traumatic Stress Disorder Preventive Measures. As with battle fatigue, there is
no virtue in suffering, ignoring, neglecting, or hiding post-traumatic stress symptoms.
The normal/common signs deserve routine preventive measures, such as talking out and
working through the painful memories. The warning signs certainly deserve this
attention, as self-aid, buddy aid, and leader aid. Good preventive measures can head off
true PTSD which might not show up until years after the incident.
c. Relationship Between Post-Traumatic Stress Disorder and Battle Fatigue. While
PTSD and battle fatigue obviously share much in common, by definition, symptoms are
not PTSD until the trauma is over (post). Therefore, this diagnosis should not be made
while the soldier continues in, or is expected to return quickly to, the combat mission. As
the dotted lines (Table 2-2) show, PTSD can follow battle fatigue (especially if
inadequately or incorrectly treated). Israeli studies confirm earlier observations that
immediate, far-forward treatment and return to duty protect battle fatigue casualties
against subsequent PTSD. Premature evacuation of battle fatigue casualties often results
in chronic PTSD. However, most cases of acute, chronic, and delayed PTSD after a war
were not battle fatigue casualties during the battles.
d. Relationship Between Post-Traumatic Stress Disorder and Misconduct Stress
Behavior. Post-traumatic stress disorder often follows misconduct stress behaviors. It
may occur in --
- The victims of others' misconduct.
- Those who committed misconduct under stress and are haunted by guilt later.
- Those who were passive or reluctant participants.
- Those who simply observed severe misconduct and its human consequences.
- Those who were involved as rescuers or care givers.
e. Post-Traumatic Stress Disorder and Positive Combat Stress Behavior. Post-traumatic
stress disorder can also occur in soldiers (or veterans and civilians) who showed no
maladaptive stress behaviors at the time of the trauma and who showed positive, even
heroic, combat stress behaviors. Even heroes can feel delayed grief and survivor guilt for
lost buddies or be haunted by the memory of the enemy soldiers they killed in battle.
f. Leader Responsibilities to Prevent Post-Traumatic Stress Disorder. During the
conflict, commanders and NCOs have the additional responsibility of preventing or
minimizing subsequent PTSD. The most important preventive measure is routine afteraction
debriefing by small teams after any difficult operation (see Chapter 6 for
additional discussion). Critical event debriefings led by trained debriefing teams should
be scheduled following exceptionally traumatic events. Recommended leader actions are
provided in Appendix A. When units or individual soldiers redeploy home from combat,
leaders should debrief them and help prepare them for the transition. As Figure 2-4
illustrates, painful memories do not have to become clinical PTSD or misconduct stress
behaviors. They can be accepted and diverted into positive growth. Chapter 6 gives more
information on PTSD and its prevention and treatment.
Figure 2-4. Relation between combat stress behaviors and PTSD.
Go to Chapter 3 - Postive Combat Stress Behaviors
FM 22-51
LEADERS' MANUAL FOR COMBAT STRESS CONTROL
Table of Contents
Preface
Chapter 1 - Overview of Combat Stress Control
Chapter 2 - Stress and Combat Performance
Chapter 3 - Postive Combat Stress Behaviors
Chapter 4 - Combat Misconduct Stress Behaviors
Chapter 5 - Battle Fatigue
Chapter 6 - Post-Traumatic Stress Disorder
Chapter 7 - Stress Issues in Army Operations
Chapter 8 - Stress and Stressors Associated with Offensive/Defensive Operations
Chapter 9 - Combat Stress Control in Operations other than War
Chapter 10 - War and the Integrated (Nuclear, Biological and Chemical) Battlefield
Chapter 11 - Prevention of Battle Fatigue Casualties and Misconduct Stress Behaviors
Appendices
Appendix A - Leader Actions to Offset Battle Fatigue Risk Factors
Appendix B - Organization and Functions of Army Medical Department Combat Stress Control Units
Appendix C - United States Army Bands
Appendix D -The Unit Ministry Team's Role in Combat Stress Control and Battle Fatigue Ministry
Appendix E - Example Lesson Plan
Glossary - Abreviations and Acronyms
References - Sources Used
|
Home