Acute War Neuroses
By William Sargant and Eliot Slater
The Lancet, July 6 1940
After the German onslaught on Flanders and the evacuation of the B.E.F. from Dunkirk there began to arrive in this hospital a type of case that had not been previously seen by us, either during the war or in years of previous peace‑time experience. These were cases of acute "shell‑shock." The patients admitted between the outbreak of the war and that time had been men who had broken down with neurotic disorders under the comparatively trivial stresses of life abroad under army conditions, without any of the severe strains entailed in actual fighting. It was obvious that personality deviations, constitutional instability, and lack of stamina played the preponderant role in these cases. This could easily be established from their past history. The acute cases of war neurosis, on the other hand, demonstrated that men of reasonably sound personality may break down if the strain is severe enough.
This is not to deny the importance of constitutional factors, even in this latter group of cases. Compared to an average population, they would almost certainly show an excessive proportion of men who had suffered from nervous troubles in earlier life, and an excessive frequency of psychiatric disorder in the nearer blood relatives. Nevertheless these acute cases had shown a satisfactory adaptation to army life; and the previous history showed in most cases a man of normal intelligence, personality and work record. The stress required to produce a breakdown of such personalitis was of an altogether different order from any to which they could expect to be subjected in ordinary life. The stress in question was, of course, the period of fighting leading to the withdrawal to and evacuation from Dunkirk, and witness to its severity is borne by official records, newspaper accounts, and the stories told by the patients. It was an accumulation of strains, both physical and mental, of great intensity‑bodily danger, continuous physical exertion, loss of sleep, insufficiency and irregularity of meals, intermittent but perpetually recurrent bombardment, and the sight of comrades and civilian refugees being killed round them. Another disturbing factor was the necessity of continual withdrawal from the enemy; the impossibility of striking back produced a sense of frustration that contributed to the disastrous effect on the mind.
These cases were admitted to hospital very shortly after their evacuation from Flanders, but few before several days had elapsed from the time of their original breakdown. A certain number were admitted to this hospital direct ; a larger number were transferred after being in other hospitals a few days. The clinical picture was surprisingly uniform. There were first the signs of physical exhaustion‑thin, fallen‑in faces, pallid or sallow complexions. The expression and the whole attitude of the body was one either of tension and anxiety, or of a listless apathy. Neurological signs of a functional nature were usually present. A coarse irregular tremor of the hands was exceedingly common; in some cases it resembled the tremor of extrapyramidal lesions, and in one it presented the typical pill‑rolling form seen in chronic encephalitis, differing from it in that it could not be voluntarily controlled for a few seconds. The resemblance to a parkinsonian picture was often increased by an immobile facies, and the superficial resemblance was so great that a number of cases had been sent here under a diagnosis of parkinsonism‑i.e., they had been thought to be organic. In a few cases a true nystagmus was seen. Reflexes were usually exaggerated, occasionally sluggish. Mentally the patients complained of the usual symptoms of the acute anxiety state: sleeplessness, terrifying bad dreams, a feeling of inner unrest; and a tendency to be startled at the least noise but particularly at the sound of an aeroplane going overhead or any sound resembling it. The noise of a train going past outside would make the patient jump perceptibly. In many cases there was an amnesia, more or less extensive, for the worst part of the past experiences. Individual cases showed other signs of a hysterical nature. One man had a series of hysterical fits, repeated at short intervals during the day, in which he would suddenly shoot up in bed, throw his hands over his head and give a series of loud groans. As these gradually diminished in frequency, their place was taken by persistent air‑swallowing and eructation. Another, a merchant seaman who had been torpedoed, complained that even in the day‑time he could see his ship going down and his mates drowning beside him. Another patient had a hysterical twilight state lasting for days, with complete disorientation and subsequent amnesia.
The course taken by these patients under treatment, even with a minimum of treatment, was uniformly towards improvement. The change in appearance in the first few days with adequate sleep and rest and food was striking. Tremors rapidly diminished in intensity, as did also the general attitude of tension. The ease of being startled diminished more slowly, and persisted subjectively when it was no longer to be observed from without. Some in a few days, some in a week or more, could be allowed up all day and be put on the regular routine of occupational treatment and rehabilitation. The degree to which recovery is complete is more doubtful. It seems that these patients have gone through a process for which the term conditioning may be used, for lack of a better expression. After the few weeks during which they have been observed they remain easily upset by slight stimuli, especially noises, they continue to sleep uneaxiiy arni suffer‑from bad dreams,‑and they are sun some distance from regaining their old self‑confidence.
Treatment can be divided into immediate and remote. The first essential is to secure rest. This may be done in the milder cases simply by confinement to bed for a few days and the administration of an effective hypnotic. This must be combined with a full diet and ample fluids. The best method of securing the essential sleep varies in different patients. Some go to sleep with great difficulty, but once asleep sleep well; for them a quickly acting drug with an effect that lasts only a few hours may be all that is necessary. But the majority find difficulty not so much in getting off to sleep as in remaining asleep. Their sleep is disturbed by nightmares, and they are liable to wake in the early hours and be unable to sleep again. For these a drug with a longer effective action will be required. The patient's own statement about his sleep is by no means always reliable, and in cases resistant to treatment it should be checked by sleep charts. With such treatment the milder cases begin to improve rapidly, and they may be allowed up in a few days and encouraged, indeed directed, to engage in some simple, interesting and sedative form of occupation. A considerable number of the severer cases, however, will require more energetic treatment. For them a course of continuous narcosis can be recommended. It will get them through the worst period of their convalescence without their being aware of the severity of their symptoms, and it helps to minimise the process of conditioning already mentioned. It seems probable that the longer symptoms are allowed to last, with the knowledge of the patient, the more deeply they will be ingrained, and the more likely they will be to recur as future behaviour patterns. The striking subjective improvement experienced on coming round from the narcosis is itself an encouragement to getting more completely well.
What is true of hypnotics is true of narcosis. Any of the standard methods may be employed - Somnifaine helped out with paraldehyde, sodium amytal, the combination of Luminal and Medinal by mouth, and the like. At this hospital a trial has been made of the Mira method employed in the Spanish civil war - i.e., hyoscine gr. 1/150 and luminal gr. 1 ½ four‑hourly intramuscularly. This treatment has been found rather disappointing in some cases, since the narcosis obtained was not always complete (after the first day or two it was difficult to get more than twelve to sixteen hours sleep a day) ; and delirious symptoms, confusion, an increased tendency to illusion formation, even hallucinations, were sometimes seen, especially if the treatment used continued for more than two or three days.
Continuous narcosis has not been given here as a rule for much longer than a week. This time should be used to improve the patient's general physical condition. The most important measure in this direction is the giving of large quantities of fluids, up to 100 oz. a day. The physical exhaustion seen in these cases produces a state approaching the clinical picture of dehydration and collapse. A full diet should also be given, and the narcosis should be so arranged that the patient can be fed at meal times and given the necessary fluids. Careful nursing and attention to details are of course of greatest importance, and the secret of success in continuous narcosis. A quiet ward with the least possible disturbance and interruption is desirable, but complete darkness is not necessary.
It seems to us that the physical problem was the most urgent, and that psychotherapy could not be usefully employed until the general health of the patient had been restored. The first essential is to obtain an account from the patient of his experiences. Both for patient and doctor it is necessary to know what was the proximate cause of the breakdown. In this exploration the hysterical amnesia shows up. There is a blankness of recollection between a certain point after the beginning of active hostilities and a point on the journey to the hospital‑both anterograde and retrograde amnesia. It is necessary to abolish this amnesia, and the simple process of doing so may sometimes with profit be undertaken very early, even before a proposed course of narcosis. In milder cases these lost memories may return spontaneously over the course of days without outside interference; but they can be quickly brought back by hypnosis, with or without medical adjuvants, or, less kindly, by taking the man over the same ground again and again. In our experience the quickest and most convenient method is the giving of up to gr. 7 of sodium amytal by graduated intravenous injection; the easily controlled hypnoid state so obtained may be used for the recovery of amnesia, for the reinforcement of suggestion and the relief of hysterical symptoms.
The experiences remembered by the patients under these circumstances have shown, of course, numerous similarities, but have differed in detail. Surprise has not infrequently been caused by the extent to which there have been additional horrifying features, not directly attributable to the war. From one man it was elicited that he had found his badly injured brother near him, and had taken him into a field and shot him to put him out of his misery. The torpedoed merchant seaman remembered under hypnosis that in the water at his side had been his particular friend, the second engineer on board the ship of which he was third engineer, but who had subsequently been washed away and drowned. Between these two there had existed a peculiar emotional relationship, and the patient was filled with an unreasonable sense of guilt, that somehow he might have done more to save him. Recollections so obtained cannot always be regarded as entirely trustworthy. One patient in an amytal hypnoid state produced a nightmare fantasy that at the time of the worst bombardment he had been accompanied by his little son, and that he had then somehow lost him and had to go searching for him. This nightmare operated for a time to the exclusion of the genuine memories.
The recollection of these forgotten incidents is accompanied by an exhibition of intense emotion; the recalled incidents are profoundly painful to the patient and difficult to elicit on that account. It is here that the intravenous sedative is particularly helpful, as it may be given gradually to damp down waves of emotion as they appear, and so save the patient some unnecessary misery. Furthermore, with skilled use, the whole of the amnesic gap can be filled at one interview. Of course every type of simple psychotherapeutic measure may be employed to get the patient to adopt a reasonable and objective attitude to his experiences and to help him to deal with the attendant emotion. Other conversion symptoms, which have not been frequent in the material treated at this hospital so far, may be dealt with by the same methods. The important thing in treatment is to abolish the abnormal behaviour pattern as soon as possible, as it will be the harder to remove the longer it is allowed to persist. This is the justification for carrying out at once a hypnotic exploration, even before a longer period of narcotic or rest treatment is begun.
The experience so far gained with these patients is still too recent for any firm statement to be made about the prognosis. As a rule we have not thought it advisable in the early stages to say anything at all to the patient about his returning to an active army life ; we have thought it better to shelve that subject completely in the apparent confident expectation that he is going to make a complete recovery and be as well as ever. But many of those with whom the matter has been broached have expressed a conviction that they could never go through such an experience again without breaking down at once. Such a conviction, if it persists, is tantamount to a fact; if a man firmly believes that he will break down in a particular way in particular circumstances, and has already done so once, then he will again. The conviction has to be shaken and destroyed. It is here that the fragment of truth is based in the quoted opinion of a high military authority that shell‑shock is nothing but insufficient training. Even if this morbid belief is abolished it still may be true that a recurrence of the circumstances will bring about a recurrence of the breakdown. On the other hand, it seems probable that the number of soldiers subjected to such an intensity of trial on a foreign shore will not be nearly so large in the future as it has been in the recent past. A man who has broken down under a severe strain will not necessarily break down under strains less severe or prolonged. The prognosis will to some extent depend on the severity of the strain; if it was not very severe it is probable that the patient is constitutionally not entirely stable, and is therefore unfitted for the most arduous military duties. Environmental stress has to be balanced against personality make‑up. A history of previous neurotic illnesses or symptoms in civil life should exclude the patient as a rule from duties that will be the equivalent of front‑line service.
Cases of acute war neuroses, such as arose in the Flanders retreat, showed the physical signs of exhaustion and mixed anxiety and hysterical symptoms.
For mild cases immediate treatment by rest, fluid, full diet, and sedative drugs was found effective.
For more severe cases continuous narcosis proved beneficial. It was found desirable to relieve acute hysterical symptoms, including amnesias, at the earliest moment by persuasion under hypnosis, prcduced directly or with the aid of intravenous barbiturate.