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FM 22-51



10-1. Introduction

War with sustained operations has the potential to generate numerous KIA, WIA, and battle
fatigue casualties. To counter this, all units must be well-trained and well-led, and all soldiers
made aware of the factors that cause battle fatigue (see Table 10-1). Active prevention programs
can reduce the incidence of battle fatigue casualties. Attrited units with exhausted leaders can
become incapable of self-help. These units must be permitted to reconstitute psychologically as
well as physically. Only then can they be a combat effective force prepared for return to the
battle. Battle in the rear area will increase stress and stress casualties in all units.

Table 10-1. Likely Stress-Producing Aspects of War on the High-Tech Battlefield

Table 10-1

Table 10-1. Likely Stress-Producing Aspects of War on the High-Tech Battlefield (continued)

Table 10-1 continued

At the end of the conflict, after-action debriefings should be conducted. These debriefings, in
small groups if possible, are conducted to help prevent PTSD. Post-traumatic stress disorder can
occur even in soldiers who showed no disability during combat.

10-2. The Battlefields of War

During war the battlefields are, by definition, chaotic, intense, and highly destructive. They may
extend across wider geographical areas. While each of these features can be understood
separately, their combined effects constitute the actual setting of operations.

a. Employment of Soviet-Type Offensive Doctrine. A characteristic of the offensive
doctrine developed by the former Soviet Union is continuous attack by echelons of fresh
units. Supported by massed artillery, these units reinforce success, bypass resistance, and
break through. All available means are employed, perhaps including NBC, to destroy and
disrupt rear area command, control, and logistics. Electronic warfare is another tactic;
this blocks communication and spreads misinformation. These tactics maximize
confusion, uncertainty, shock, and fatigue. They are intended to make the defender
unable to function -- to put him in a state of physiologic and mental helplessness. This
state was called battle paralysis or shock by the former Soviet Union.

b. Employment of Battlefield Tactics. United States Army operations doctrine intends to
minimize the effectiveness of potential enemy tactics and turn the tables on an aggressor.
Instead of waiting passively to be overrun or isolated, US units must take the initiative
and carry the attack to the enemy rear. They must disrupt the enemy's timetable and
damage some of his reserve echelons. They must deprive his remaining force of sleep and
confidence so they develop battle paralysis or desert their unit. Even with our
technological advantage, we must expect to fight around the clock, whether on defense or
offense. We must rest and resupply in a highly mobile environment. To succeed, our
leaders and troops at all levels must retain the mental agility to detect windows of
opportunity in the midst of confusion and stress. Leaders must act spontaneously and
synchronously in accordance with their commanders' intent, even though the situation has
changed and communications are disrupted. Exhausted and attrited units, even those
which have suffered mass casualties, must be returned quickly to the battle. The demands
on CSS units, as well as the combat arms, may be extreme. If NBC weapons are
employed, the stressors on the integrated battlefield will be incalculably greater.

c. Lines of Operation. In modern war, Army forces must prepare to fight campaigns of
considerable movement, not only to reduce vulnerability but also to obtain decisive
points. The speed with which today's forces can concentrate and the high volumes of
supporting fires they can bring to bear will make the intermingling of opposing forces
nearly inevitable. Telling friend from foe in darkness, smoke, and dust will be difficult.

With the rapid pace and the urgency of firing first, tragic episodes of accidentally killing
friendly forces ("brother" killing "brother" or fratricide) may happen. Prevention requires
emphasis on vehicle and other identification training, awareness of the tactical situation,
and continual risk analysis by leaders at all echelons.

(1) From the first of battle, deep reconnaissance, air mobility, long-range fires,
and SOF will blur the distinction between front and rear. This will impose a
requirement for allaround defense and self-sufficiency on all units. Throughout
the battle area, attack and defense will often take place simultaneously as each
combatant attempts to mass, economize locally, and maneuver against his
opponent. This creates a state of uncertainty that calls for continued vigilance.
Constant vigilance is impossible for individuals to maintain. Only a well-trained,
highly-cohesive unit can maintain constant vigilance for a prolonged period of

(2) Fluidity will also characterize operations in the rear of forward-deployed
committed forces. Guerrillas, enemy SOF, and terrorists will seek to avoid setpiece
battles and to strike at scattered points of vulnerability. Defending forces
will try to preempt such attacks wherever they occur.

d. Lethal Systems. With the end of the cold war, sales of high-tech weapons (by the
successors to the former Soviet Union and by western countries) may increase rather than
decrease. The US intends to maintain our technologic advantage. Potential enemies,
however, may field high-quality weapons systems whose range and lethality equal or
exceed those of our lead elements. The following examples indicate a concentration of
enormous combat power, especially at decisive points. These may be used by potential
enemies, as well as by ourselves and our allies.

(1) Potent ground and air systems with missiles (air-to-surface, surface-to-surface,
and surface-to-air).

(2) Armored vehicles with reactive armor and all-weather, day-night target
acquisition systems.

(3) Multiple-launched rocket systems and tube artillery capable of saturating large
areas with fire at really long ranges.

(4) Fixed-wing aircraft and attack helicopters firing multiple bomblet munitions.

(5) Scatterable mines with delayed or smart fuses.

(6) Fuel-in-air explosives which approach the blast effects of low-yield nuclear

(7) Precision-guided or smart fire and forget munitions.

(8) Nonpersistent or persistent chemical or biological agents, or nuclear warheads.

e. Sensors and Communications. Wide-ranging surveillance, target acquisition sensors,
and communications will provide information almost immediately. These will increase
the range and scope of battle. Sensors offer the commander more than just timely
information on deep enemy locations and activity. They also serve as the basis for
attacking enemy follow-on forces or units resting or reconstituting in reserve. Since these
attacks can be of vital importance in battle, the sensors and communications means which
make them possible are particularly valuable and subject to counterattack. They will also
be subjected to electronic countermeasures and deceptive simulation devices which
decrease the validity of their input.

When functioning, battlefield sensors may contribute to information overload. If too
much reliance is placed in them, confusion, stupor, and even panic may occur when they
malfunction or are deceived, as they surely will be at times.

Caution should be taken with global position locating devices. These provide tremendous
technologic advantage, but troops must not become so dependent on them that they
cannot navigate by map and compass when the device is damaged.

f. Command and Control. The more fluid the battlefield, the more important and difficult
it will be to identify decisive points and focus combat power. Under such conditions, it is
imperative that the commander's intent and concept of operations be understood
throughout the force. Communications will be interrupted by enemy action at critical
times. Units will have to fight while out of contact with higher headquarters and adjacent
units. Subordinate leaders must be expected to act on their own initiative within the
framework of the commander's intent. If soldiers at all levels are trained to be active
rather than passive, that in itself will substantially counteract the tendency to become
battle fatigue casualties. However, the necessary mental functions are also the functions
more likely to deteriorate with sleep loss, fatigue, and stress.

g. Air Dimension. The airspace of a theater is as important a dimension of ground
operations as the terrain itself. Airspace is used for maneuver, delivery of fires,
reconnaissance and surveillance, transportation, resupply, insertion of forces, patient
evacuation, and command and control. The control and use of the air will always affect
operations and can decide the outcome of campaigns and battles. Commanders must
distribute proportionally air power in planning and supporting their operations. They
must protect their own forces from observation, attack, and interdiction by the enemy and
must expect the enemy to contest the use of the airspace.

· Having air superiority decreases battle fatigue casualties.
· Being subject to air attack increases battle fatigue casualties.
· Being hit by friendly air attack greatly increases battle fatigue casualties.

On the rapidly changing, integrated battlefield, fast-moving friendly aircraft (who are
themselves at great risk from air defenses) will have only a split second to distinguish
friendly units from enemy targets.

10-3. The Integrated (Nuclear, Biological, and Chemical) Battlefield

a. The Nuclear, Biological, arid Chemical Warfare Threat. The future battlefield may
have a high threat of NBC. Until recently, the former Soviet Union continued to test,
produce, and stockpile NBC weapons. Soviet doctrine, organization, training, and
equipment supported NBC weapons' use, especially chemical, in order to obtain a
military advantage. Former Soviet weapons or design experts may be acquired by Third
World countries. Other countries, notably Iraq, have recently used chemical weapons in
combat. Use of NBC weapons in rear areas may severely degrade CSS capabilities. Its
use would increase casualties and patient work loads, slow operations, and rapidly fatigue
personnel because they are forced to operate at the various MOPP levels for extended
periods of time. Evacuation and triage will be complicated by contaminated casualties.
Vehicles and aircraft will require decontamination at the completion of all missions that
encountered contamination from a NBC agent.

b. Nuclear Warfare. Even though the primary purpose of nuclear weapons is to deter their
use by others, the threat of nuclear escalation hangs over any military operation involving
the armies of nuclear powers. It imposes limitations on the scope and objectives even of
conventional operations. United States nuclear weapons may be used only by following
specific directives from the NCA after appropriate consultation with allies. Even if such
authority is granted, however, the employment of nuclear weapons would be guided more
by political and strategic objectives than by the tactical effect. A particular authorized
employment of nuclear weapons would certainly magnify the destructiveness of
operations and could sharply alter their tempo. Besides the effects of physical damage,
the psychological stress on soldiers would be severe, especially if they have not been
prepared by their leaders. As a consequence, battles and campaigns may last only hours
instead of days or weeks, crippling friendly and enemy combatants.

(1) During the Cold War, a full scale global exchange of all available
thermonuclear weapons was widely believed to be capable of making the earth's
environment temporarily unsuited to human civilization. This doom was
attributed to persistent radiation and to the dust particles which would be lifted
into the upper atmosphere, causing temporary climatic changes and cooling of the
earth ("nuclear winter"). More accurate computer models suggest only a partial
"nuclear autumn" is likely, but disruption of crops, distribution means, and
technologic infrastructure would still cause extreme global suffering.

(2) During the Cold War, many people were convinced that first use of any
nuclear weapon in war would inevitably bring on an uncontrollable rapid
escalation. The "nuclear winter scenario," however, clearly is not triggered by a
small number of low-yield tactical nuclear weapons. Climatic changes were not
encountered following the fire-bombing of cities in WWII or the occasional
atmospheric testing of large thermonuclear weapons by several of the nuclear
powers. The breakup of the Soviet Union and the continued progress in strategic
arms limitations makes massive global strikes unlikely now, but the future
remains uncertain. Fear of radioactive fallout spreading to other regions of the
globe could be created even by a regional nuclear conflict.

(3) Given this background, if US troops know a nuclear weapon has been used but
are not being kept adequately briefed by their leaders, some may still think we are
on the brink of total world catastrophe and perhaps already over the edge. The
spread of rumor will be compounded by the usual problems of communication in
the presence of electronic jamming, deliberate misinformation by the enemy, and
conventional countermeasures. It may be further disrupted by the electromagnetic
pulse of high-altitude nuclear bursts.

(4) Measures must be taken in advance to structure and prepare the soldiers'
perceptions of the situation. If this is not done, there is potential for hopelessness.
In the common Cold War perception of nuclear war, there was no winner, and
even if you survived the initial blast, there is no hope of meaningful survival. It is
unknown what such a level of hopelessness for the future of humankind would do
to inadequately-trained soldiers. Some soldiers have been exposed to movies,
books, and TV shows which have created myths and gross exaggerations about
the effects of radiation.

(5) We must prepare soldiers mentally and emotionally for the shock of seeing or
hearing a first nuclear attack. An important step is to provide realistic, clearly
presented information on the risk of various levels of radiation exposure.
Information about true risks, especially low-levels of radiation, should be
compared to those risks associated with other commonly accepted hazards. These
hazards may include cigarette smoking, therapeutic x-rays, and high altitude
flying or residence.

(6) Nuclear weapons use usually implies high-intensity conflict. The possibility of
terrorist use (or of attacks on civilian reactors or damage to nuclear-armed
weapons in conventional war) must also be considered. United States' forces
might be called in as part of a peacekeeping force following use of nuclear
weapons. This could be in a conflict between Third World countries or between
factions in a civil war within a nuclear power. They might also be called in to
support civil authorities following a major nuclear reactor accident. Actions to
prepare soldiers for the special stressors of nuclear war are discussed in Appendix

c. Biological Warfare. The US has renounced the use of biological weapons. However,
this unilateral renunciation does not free our own forces from the threat of enemy
biological warfare. Army forces must continue to train to fight an enemy who could use
biological weapons. New genetic technology may put this capability into the hands of
unstable Third World countries (or terrorists) as they develop a pharmaceutical industry.
Biological warfare is, therefore, a threat in war and operations other than war (conflicts).

(1) An added stress feature is that it may be difficult to prove that the presence of
biological agents is an act of war rather than a natural or accidental occurrence.
Reputable biologists still argue that the mycotoxins ("yellow rain") which killed
Laotians and Cambodians were not a Soviet (North Vietnamese) weapon but only
naturally fermented bee feces (although interestingly, the deaths apparently
ceased after the allegations reached the world press coverage). Such weapons
could also be used as agents of economic/agricultural sabotage without war being
declared. Some of those agents cause long-term contamination of ground and

(2) Biological toxins pose a threat similar to chemicals but perhaps harder to
defend against. Some toxins, such as the ergot derivatives, produce organic
psychotic states. Others, like the mycotoxins, are terror weapons which produce a
rapid, horrible death by uncontrollable bleeding.

(3) Infectious organisms create the added hazard (and psychological threat) of
contagion and uncontrolled spread. The success of medical science in controlling
the rapidly lethal epidemics of history may make the populace less familiar with
how to face this risk. Hence, this unfamiliarity makes the populace more
susceptible to panic or maladaptive reactions if newly created threat agents spread
more rapidly than defenses can be fielded,

d. Chemical Warfare. Chemical warfare was employed in KIWI and sporadically since
throughout this century. Use of chemical weapons is most likely at the high and low ends
of the combat continuum -- in high-tech war, or against insurgents or minority groups in
remote areas. United States' forces maintain a capability in this area only for deterrence.
Chemical warfare presents some of the same complications as nuclear operations,
although chemical agents are easier to defend against.

(1) Because chemical weapons are more widespread and the inhibition against
their use is lower for some nations, US forces are more likely to face a chemical
than a nuclear threat, Chemical weapons are inexpensive and can be produced by
Third World countries which have factories that produce fertilizers, insecticides,
or pharmaceuticals.

(2) Chemical agents can be lethal and devastating against those who lack adequate
protection or training. Nerve agents in sufficient concentration kill within minutes
with convulsive seizures. Blister agents rarely kill; rather they are employed as
casualty-producing agents. Blister agents like lewisite and mustard can cause
either immediate or delayed eye and skin pain, blister formation, and with severe
exposure, lung and bone marrow damage. Choking agents cause the lungs to fill
with fluid -- "drowning on dry land." The potential for mass casualties is great
among unprotected troops and civilians. The nature of their deaths, while not
more horrible than that from flame, blast, or projectile weapons, has an element of
mystery. This may be especially unnerving to those who witness it or come on the
scene later.

(3) For troops with adequate protective equipment, chemical agents serve
primarily as a harassment which makes other combat and CSS operations much
more difficult and time consuming. They also produce high rates of battle fatigue
casualties (most of whom return to duty if properly treated) and sublethal
chemical injuries (many of which may have longterm disability).

e. Stress Reaction to the Nuclear, Biological, and Chemical Warfare Threat. The threat
of chemical-biological use will require frequent high levels of MOPP. Using protective
clothing and other defensive measures against NBC warfare adds to physical fatigue?
primarily because of heat, visual and auditory restriction, and impeded movement, The
necessity for precautions will further reduce the time available for rest and sleep,
increasing exhaustion. The threat of NBC warfare is a major source of stress whether or
not NBC agents are actually used. The associated fear of the unknown, the high degree of
ambiguity in detecting the threat, and the uncertain short- and long-term effects of NBC
weapons add significant psychological stress to the physical/physiologic stress of MOPP.
Stress itself contributes greatly to fatigue.

(1) Overreactions. Many soldiers may overreact to an NBC threat -- that is, do
more than the situation calls for. The reactions listed below were seen in WWI
(when chemical weapons were used) and sometimes in WWII (although chemical
weapons were not used). They have been seen in peacetime civilian populations,
in response to the news about the Three-Mile Island and Chernobyl nuclear
reactor accidents, chemical spills, dioxin and toxic chemical waste dumps, and
AIDS. Overreactions to NBC are discussed in the following paragraphs.

(a) Increased sick call (hypochondriasis). People will overattend to
physical sensations, looking for warning signs. They will find things that
worry them and will bring them to the doctor or medic for reassurance or
in hope of being sent to safety.

(b) Increased "conventional" battle fatigue. Uncertainty, lack of
confidence in equipment and leaders, assuming a passive defensive
posture, and new or surprise weapons all tend to increase battle fatigue
symptoms of anxiety, depression, or simple exhaustion.

(c) Nuclear, biological, and chemical battle fatigue. This is battle fatigue
with physical symptoms that mimic real NBC injury. The early US Army
WWI ratio (in supposedly well-trained but inexperienced troops) was two
"gas mania" cases for every one true exposure case (a 2:1 ratio). Epidemic
hysteria can occur as the first anxious person hyperventilates (breathes too
fast, gets light-headed, and has "pins and needles" sensations and muscle
tenseness in face, fingers, and toes). Others, seeing this and believing him
to be a true gas casualty, become anxious and hyperventilate, too.

(d) Malingering. Nuclear, biological, and chemical battle fatigue is, by
definition, not a voluntary behavior. Soldiers who deliberately fake NBC
injury, or who self-inflict minor chemical injuries to gain evacuation are
malingering, a misconduct stress behavior. Exposing one's radiation
counter to radiation artificially in order to raise the count and be relieved
of duty also is malingering.

(e) Panic flight. This may also be epidemic. It occurs when a group feels
threatened, unprepared, and believes that the only defense is immediate
flight. Some event causes one soldier to run, after which the others in the
group panic and run wildly.

(f) Rumor. The former Soviet Union, through their military literature,
recognized and valued the threat of NBC warfare to "demoralize through
rumor." These rumors were concerned with family and home, as well as
with self and unit, in any perceived NBC war. Commanders must counsel
the spreaders of rumor and ensure that the best available information
passes through the chain of command and reaches every soldier. Covering
up or withholding information can permanently destroy the leadership's
credibility. Utilization of unit or attached public affairs personnel and a
solid Command Information Program (CIP) can prevent rumors or stop
them from spreading. A wide range of CIP products are available through
public affairs channels. Commanders should avail themselves of these.

(g) Excessive anxiety and "phobic" avoidance. Soldiers may refuse to go
into places or to use equipment which is wrongly believed to be
contaminated. Even when they go, they may be too anxious and cautious
to perform well. They may shun people who are believed to be contagious
or contaminated.

(h) Excessive decontamination ("obsessive-compulsive" cleaning). This
wastes time and scarce supplies. This can even cause dermatologic
problems if soldiers use caustic decontamination chemicals on their skin.

(i) Congregating in safe areas. People will naturally find excuses to stay
in collective protection or safe areas. Headquarters personnel in such
protection areas may get out of touch with the troops in the field. Medical
teams which must work in collective protection areas may find many
nonpatients giving reasons to join those who are working inside and being
difficult to move out. The misconduct stress behavior version of this is
desertion to hide in safe areas.

(j) Stealing protective equipment. If there is not enough protective
equipment or collective protection to go around, another potential
misconduct stress behavior is stealing from or killing others to take over
their protection.

(k) Suspiciousness. Vision and hearing are impaired in MOPP and
everyone looks alike. Even friends may not be readily identified. People
tend to develop a "paranoid" suspicion of the strange, monster-like
figures; they may become jumpy and shoot at shapes or sounds without
checking first. This requires emphasis on vehicle and other target
identification training, challenge procedures, and passwords. Identifying
labels may have to be added to personalize the MOPP gear.

(l) Risks to leaders. Mission-oriented protective posture requires much
more active leadership. It hides the usual nonverbal cues of alertness,
understanding, and readiness to act which leaders normally rely on.
Leaders must move around, touch to get attention, and insist on
information and confirmation. This movement increases the leader's risk
of heat exhaustion, carelessness, and being accidentally shot by a jumpy
soldiers. Accidental fratricide (killing of leaders and other friendly
personnel) has been alarmingly high in MOPP field exercises which use
the multiple integrated laser engagement simulation devices. The same
problem occurs in jungle and night fighting where vision and hearing are
also reduced. Fratricide must be prevented by careful adherence to the
TSOP, coordination between units, target identification, and the use of
challenge procedures.

(m) Isolation and loss of cohesion. Mission-oriented protective postures
interfere with normal friendly support, such as conversation, sharing
snacks, or simply smiling. As a result of the sensory and social isolation
and encapsulation, soldiers tend to feel alone. They may feel surrounded
by a totally hostile world in which even the air they breathe is against
them. This isolation tends to make people become passive, insecure, and at
high risk for battle fatigue unless it is actively counteracted. It requires a
more active, verbal, and deliberate effort to maintain a sense of
comradeship and unit cohesion.

(2) Underreactions. Underreactions may be more likely than overreactions in
some situations.

(a) Denial. Things are too horrible for a soldier to think about, so he just
thinks about something else.

(b) Rationalization. "No one would be so crazy as to use such terrible
weapons, so why should we waste our time preparing and training for

(c) Fatalism. "If anyone is so crazy as to use these weapons, they are so
terrible that I can't protect myself anyway, so why bother to prepare, and

(d) False alarm. If there is a threat situation with frequent false alarms,
troops may neglect alerts and fail to react, believing it "just another false
alarm" when, in fact, it is the real thing.

(e) Overconfidence. "We have this one defense (or detector, or higher
headquarters, or whatever) that's going to warn and protect us. We can
forget about everything else."

(f) "Pie in the sky." "The Strategic Defense Initiative, or immunization, or
something will solve all these problems within the next year, so why train

(g) Intellectualization. "This is so serious that we have to study it and do
more research before we take any action to correct the problem."

(3) Consequences of the maladaptive responses. Any of these maladaptive
responses lowers the maximum advantage that protective equipment and training
can provide during accomplishment of the mission. Underreactions may lead to
discarding equipment and failure to follow the TSOP. Overreactions tend to
disrupt a unit's overall ability to perform its mission. Appendix A presents
recommendations for how leaders can prevent or correct these maladaptive
reactions to the NBC threat.


Go to Chapter 11 - Prevention of Battle Fatigue Casualties and Misconduct Stress Behaviors


FM 22-51
Table of Contents
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

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


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