Treatment of War Neurosis
by Gilbert Debenham, William Sargant, Denis Hill, Eliot Slater
The Lancet, Jan. 25, 1941, p. 107
Since the beginning of the war over 1500 cases of neurosis or psychosis in members of the armed forces have been treated in this hospital and the more important conclusions drawn from this experience may be of use to those dealing with similar problems. 
The cases have ranged from the extremely chronic to the most acute. In the early months of the war they consisted largely of men who, had all the facts been known, would never have been regarded as fit for military service‑mental defectives, epileptics and the chronically anxious or hysterical‑who had broken down at once under the stress of active‑service conditions and removal from home. They included a large number of the constitutionally abnormal, but most of them were not openly concerned to make the most of their symptoms. With the onset of violent fighting and at the evacuation from Dunkirk different types of case began to appearacute anxiety or exhaustion syndromes in men of comparatively normal personality, who had not broken down until placed under considerable strain. In these the prospects of treatment were good, and most of them could be returned to the Army in capacities where the strain was not likely to reach the same level again. Since then cases of a third type have appeared in men who have broken down under aerial bombardment in this country. The strain experienced has never reached the intensity endured in the Dunkirk episode, and it is not surprising to find that these patients are of feebler stamina, and that the constitutional element was once again well to the fore. What has been surprising, however, is that hysterical mechanisms have been much more superficial in many of them, and in a few have almost reached the level of open malingering; to others even the most cautious psychiatrist might be tempted to apply the term " scrimshanker." It may be that these men, breaking down at a later stage in the war, and being less obviously unfit for service, feel that they must bolster up their illness with adventitious aid; or rather, perhaps, evade further unpleasant necessity by refusing to consider the possibility of natural recovery.
THE AIM OF TREATMENT
With the neurotic war casualty, to a much greater extent than with the private patient of peace‑time, treatment has to be limited by practical possibilities. We hold, contrary to some, that it is impossible by psychotherapy to reconstitute the make‑up of the personality; that the neurotic cannot be freed of his neurotic tendencies. In any case, radical psychotherapy is out of the question in war conditions, if only because of the time required. Treatment has three practical goals to deal with the symptoms and to bring about a return to the condition before the breakdown; to re‑adapt the patient to a socially valuable life; and so to arrange his future that strains that are for him intolerable will not have to be endured again. If this can be done within the framework of Army life, so much the better; if not there must be an effective re‑adaptation for civilian life. The Army is not organised to provide a shelter for neurotics, and neurotic casualties throw more grit into the machinery than a corresponding number of organic casualties. It is no good sending back into the Army, merely because he is symptom‑free, a man who is liable to break down under small strain. It is necessary, by accurate history‑taking and a quantitative as well as qualitative diagnosis, to make an assessment of the personality and of the strains that it is and is not able to support. Judgment is more likely to err towards optimism than in the opposite direction, for there is a natural bias against invaliding any man unless it is absolutely necessary. Each one of us has seen return cases of men who had been sent out fit for home service and had unexpectedly proved unfit even for that. They had gone to their units, had spent weeks on light duty or no duty at all, no‑one knowing what to do with them, and had caused great trouble and difficulty before they were finally returned to hospital, disgruntled and resentful. The longer a neurotic reaction is allowed to persist, the more difficult it is to deal with; among the neurotically predisposed, emotional attitudes such as disgruntlement, panic, or scrimshanking are highly infectious. Every consideration urges, therefore, that if treatment is to be effective it must be quick, and limited to an aim that is quickly obtainable.
Psychotherapists will agree that the most important factor for the success of treatment is a real desire on the patient's part to get well, even when that involves a degree of sacrifice and a painful self‑realisation. The reward is a greater freedom from hampering difficulties, a greater capacity for enjoyment, and a knowledge and acceptance of those fundamental circumstances which are incapable of change. The military case, however, differs from that of peace‑time in that treatment encounters the same difficulties but does not offer the same reward; and that illness can secure a fundamental change in life, which is not otherwise to be obtained. The soldier is uprooted from an environment to which after years of painful endeavour he has made some sort of adjustment, even if a neurotic one; he is forced through a military mill and subjected to previously unimagined strains. Then, when illness comes, it may be weeks or months before even the possibility of treatment is reached. By the time he reaches the psychiatrist he is a man with a grievance, sullen or apathetic. And all the reward that is offered for cure is, to his mind, the privilege of returning to the scene of his failure in the knowledge that he has failed.
Treatment, then, is faced with unusual difficulties, and must be pragmatic. In late and less favourable cases it is wise to limit its aim to getting the patient well enough to return to his job as a civilian. The patient is best told that he will be recommended for discharge; and an attempt is made to show him that his grievances are understood, and to remedy any sense of failure or worthlessness he may have acquired. He needs to be assured that he can serve his country equally well as a civilian; and there are few who are not eager to accept this point of view. Most of those who have broken down after little or no strictly military stress have to be so treated ; and so have veterans of the last war, of whom significantly many have a history of previous shell‑shock." There is more hope for those whose breakdown has been precipitated by promotion or by the conflict over putting in for it; but care must be exercised here, as a seemingly situational neurosis may be firmly rooted in the personality.
In the acute war neuroses there is a considerable tendency to spontaneous recovery. But even if acute symptoms abate, an effort should be made to clear up amnesias and to let the patient re‑experience the violent emotions that battle scenes have aroused. This process ‑abreaction‑‑has a prophylactic as well as an immediate therapeutic effect. It may be induced by various means, according to taste and experience. The slow intravenous administration of a suitable narcotic (such as sodium amytal gr. 5‑7 ½ ) is quick, effective, and of particular use to those unversed in hypnotic and analytic techniques. Before it is begun a good rapport must be established and cooperation gained. The patient should be told that certain painful memories are buried in his mind and are responsible for his symptoms, and that he will get better when they are dealt with. The anamnesis under the drug maybe sudden and violent; in which case it is essential to give the patient time to weather the emotional storm, and to help him by an attitude of understanding and detachment. At other times it may be necessary to use firm and persistent questioning to overcome resistance. Sometimes actual memories are falsified by or mixed with fantasies; this may be made use of in subsequent interviews, in giving the patient insight into the deeper causes of his anxiety. Other varieties of behaviour under narcosis have been observed. Tremors, stammers and other conversion symptoms usually disappear under the drug; and an attempt should be made by suitable suggestion, and by continuing the interview until the patient is fully conscious, to prolong the improvement into the waking state. Though much may be done in one session, it is nearly always necessary to cover the ground again, exploring deeper into obscure episodes, laying bare amnesias previously unsuspected, relating specific anxieties to the forgotten events, and familiarising the patient with the emotions he has suppressed.
The psychopathology of war neuroses is more complex than has been described by some writers who gained their experience in the last war. Apart from the nature of the precipitating agent, the structure of the cases seen so far, especially late cases with much anxiety and depression, has resembled that of the occupation and post‑traumatic neuroses of peace. Differences are shown in the striking regressions that often follow being oneself, or seeing others, blown up, and in the temporary disturbance to the sense of reality caused by the bizarre effects of high explosive. The most fantastic dreams are suddenly realised, as though by magic, in actual life; and the mind regresses to primitive mechanisms appropriate to the time of life when such fantasies seemed real. The experiences of war provide a stimulus to aggressive and sadistic impulses, with the consequence that guilt and its associated depressive effect are very common; or projection mechanisms may come into play, the man believing that every 'plane is coming specially to punish him. The therapentic aim is then to make him aware of latent hostilities, to give him an opportunity of expressing them in a reasonable way, and to increase his confidence in his powers of control.
Special problems are offered by the patients who show a marked hostility during treatment in hospital. The aggressive reaction may be that of a constitutionally unstable personality to an unfamiliar environment. These men have been social misfits all their lives, and their neurosis is the expression of failure to adapt to the Army; their asocial activities in hospital are usually childish ; they defy discipline, or break bounds without reasonable gain‑behaviour which is difficult to deal with, and has a bad effect on others of better personality. As the prospect of a useful Army career is usually minimal, it is well to secure their discharge at the earliest possible moment, and to give them priority when it comes to boarding. Aggressive reactions with a paranoid tendency are also seen in men of comparatively good personality with acute anxiety states, usually during recovery from the acute stage of the illness. The phenomenon is part of the illness, and is to be treated as such. In many of our cases it could be regarded as an over‑compensation for loss of self‑esteem, as the meaning of the illness became clear.
Cases complicated by an organic factor offer special problems. Neurosis commonly follows a post‑concussive state, and it is important to decide how far the influence of the injury extends. It is harmful to keep patients in bed for more than two or three weeks in an attempt to prevent post‑concussive headaches ; the subsequent illness is more prolonged. It is well to acknowledge that headaches do occur after concussion, but to make little of them; anxiety symptoms, however, should not be shelved. The chief danger is that the patient will sidestep his problems and use an organically determined symptom to evade further responsibility. Where hysterical mechanisms come into play and replace anxiety, the illness is likely to become progressively more difficult to treat.
Drug therapy of the acute neuroses has been dealt with in a previous communication. Since that report we have had to treat a considerable number of cases which had been acute and have now become chronic. Treatment of an acute neurosis is almost as urgent as that of the acute abdomen. Whether treated in hospital or not, these chronic cases had received no adequate sedation in the acute phase and they had been returned to duty too soon. Conversion symptoms had been allowed to persist, and large periods of amnesia had been left untouched. By the time they arrived for treatment here the neurotic reaction had become fixed and prospects of return to full duty were almost hopeless. It is of the utmost importance that the acute neurotic should receive effective first‑aid as soon as he is seen.
Apart from the treatment of acute panic reactions, physical and biochemical methods have their place in speeding up recovery in the later stages. As always, the success to be expected depends on the previous personality, and good results cannot be expected from poor material. In addition to sleep therapy, a modified form of insulin treatment is useful in some cases for breaking down the vicious circle of anxiety and loss of weight. Increasing doses of insulin are given in the mornings, up to a maximum insufficient to produce coma or hypoglycaemic excitement, followed three hours later by 12 oz. of potatoes or 7 oz. of sugar. The treatment is without any of the risks associated with insulin coma, and generally produces a rapid gain in weight and improvement in physical condition. Furthermore, the insulin often exercises a sedative effect, which may last for the whole period between administration and interruption.
Full psychological recovery is rare without the restoration of good physical health. The mere appearance of physical fitness is often deceptive, and on inquiry remarkable changes in physique will often be found, including loss of weight up to 2 or 3 stone. In all forms of drug therapy the aim should be, by a large intake of fluid and food, not only to at»iilish the anxiety but also to remedy the metabolic distnrbances due to, and conducing to, its continuation. Only when his normal physique is restored is the patient fully accessible to psychotherapy and rehabilitation.
The occupational technique worked out at this hospital has been described by Cameron. Occupation is even more valuable for the sub‑chronic than for the aeut neurotic, and for a stabilised return to a normal workinn civil life it is almost indispensable. Its value as a distraction from neurotic preoccupations can be used even during the operation of stress. Our patients were much better when kept at work during air‑raids than when allowed to congregate in cover‑points and place of greater security. When allowed to seek the greatest available security the men became preoccupied solely with the desire of finding a Utopia where they would feel safe, and from spending nights in open trenches the mom panicky took to breaking bounds in order to sleep ii public shelters. Such breakdown of control has itpenalty in heightened anxiety; and the remedy is to deal by sedation with the subjective fears which, rather than the real dangers, are the effective noxus.
The problems of necessity for boarding and propu boarding category should be faced as early as possible, foi they inevitably influence the line that treatment itself will take. If invaliding is indicated, the desire of the patient to evade further military service can be used to aid recovery rather than to perpetuate illness; he can be told, for instance, that he will be recommended for discharge, but only when he has recovered from his symptoms. A healthy civilian is of more value to the country than a sick soldier. Problems of boarding have been more difficult of late for now the position of the man boarded "C" is not much easier than that of one still marked "A."  We have found that men passed suitable for service not involving strain have been sent to guard points subjected to heavy bombing, which has promptly precipitated a new breakdown. Suitable employment within the Army framework is difficult to find, even for the neurotic of fairly good personality; and mistakes are costly. These tragedies would be fewer if the vocational recommendations of the psychiatrist had any force.
We do not believe that invaliding out, if done carefully, will greatly add to the number of neurotic casualties, or that there is any risk of an epidemic of neuroses. Certainly the prompt removal of the constitutionally unfit from the Army aids its efficiency and obviates much chronic invalidism. Since there are at present no pensions for war neurosis, it is important that the neurotic should be re‑adapted to a working life before the question of pension arises ; and, owing to conditions in the labour market, this is much easier now than it will be when peace comes. After this war the country must not be burdened with the large numbers of pensioners that crowded psychiatric clinics and Government hospitals for many years after the last war, who are, indeed, still with us. A proper settling of the questions of attributability is still awaited; but when the time for this arrives it is to be hoped that the authorities will not lose sight of the malignant influence that the award of a premium for illness exercises on the neurotically predisposed.
The principal conclusions derived from the investigation of a large number of military neurotic casualties are:
1. The nature of the material admitted to hospital varies with the progress of the war, and with the different types of strain that war from time to time imposes. Similar variations can be expected in the future.
2. At times, large numbers of cases will be seen in which there is a semi‑deliberate magnification of symptoms.
3. Treatment has to be adapted to what is possible in a short space of time. It should not be aimed too high.
4. Psychotherapy is faced with unusual difficulties in war‑service cases. Both from the structural and therapeutic points of view they closely resemble, with specific differences, unsettled compensation cases of peace‑time. Quick abreactive techniques have a special value. Special problems are offered by cases with aggressive tendencies, and those arising after head injury.
5. Medical first‑aid is of the utmost importance. Physical methods of treatment are very useful, and should have as a principal aim restoration of normal metabolism.
6. Occupational therapy is also valuable, even more for chronic than for acute cases.
7. Over‑optimism is to be avoided, and too much resistance should not be offered to invaliding the patient. The constitutionally unfit must be weeded out of the Army; and for his own sake the unfit soldier should be returned to civilian life fit for work as early as possible.
 Apart from a proportion of very acute eases, our material closely resembles both diagnostically and prognosticaily the Naval material analysed by Desmond Curran and W. P. Mallinson (Leant, 1940, 2, 738).
 Sargant, IV. and Slater, H. Lancet, 194 e, 2, 1.
 Cameron, K. Ibid, p. 659.
 Roughly speaking, categorisation as "A" signifies that the soldier is fit for all duties, as "B" that he is fit for all duties within limits (e.g., that he should not be submitted to great strain and exposure), and as "C" that he is fit for home service only.