Identify characteristics of combat stress reaction (CSR) and how to refer to appropriate care.

Given written items pertaining to the identification and treatment of combat stress.

Score 70 or more points on the 100-point written examination.

FM 8-51, Combat Stress Control in a Theater of Operations: Tactics, Techniques, and Procedures.

STP 21-1-SMCT, Soldier's Manual of Common Tasks: Skill Level 1.

FM 21-11, First Aid for Soldiers.

FM 22-51, Leader's Manual for Combat Stress Control.

A soldier can suffer a wound from an enemy bullet, be burned by an explosion, or fracture a leg by jumping from a building. In all of these injuries, physical injury to the casualty can be seen (blood from a wound, burned flesh, abnormal position of a limb, etc.). A casualty with combat stress reaction (CSR), however, does not present such an obvious injury. In World War II, CSR was called battle fatigue. In this subcourse, battle fatigue and CSR will be considered to be the same. Such soldiers are as much a casualty as a soldier who has been wounded by a bullet. Like any other injury, the more rapidly CSR is identified, the better the chances for a quick recovery.

A combat soldier’s routine has always been characterized by stress. This stress may result from physical exhaustion, constant alertness, the trauma of seeing fellow soldiers wounded or killed, the fear of being killed or maimed, the fear of killing other people, worry about family problems back home, fear of failure or disgrace, or a combination of these or other fears. CSR is a psychological reaction to these stresses. Loss of sleep, physical fatigue, and illness can also be contributing factors. CSR is usually temporary and does not require a soldier to be removed from combat conditions. Sometimes, however, the CSR is severe and the soldier cannot function effectively. He may become a threat to his own safety and to the safety of his fellow soldiers.

Expect CSR to occur. Mild CSR does not seriously interfere with the soldier's effectiveness. It is the natural result of the heavy mental and emotional work of facing danger under difficult conditions. Almost all combat soldiers will suffer mild CSR now and then. Some of the physical, mental, and emotional signs and symptoms of mild CSR are listed below. Do not confuse CSR with fear, fear is a normal response to danger. The symptoms are like CSR but fear can be positive. Fear can make a soldier more alert and increase concentration.

Tense, jumpy, startled at sudden sounds or movement.

Headache, backache, pain in old wounds.

Fidgeting, fine trembling of the hands, fumbling.

Cold sweat, dry mouth, pale skin.

"Tired" eyes, blurred vision.

Pounding heart, feeling dizzy.

Feeling "out of breath," breathing too rapidly.

Fingers and toes tingle, cramp, and go numb.

Upset stomach, "dry heaves," or actual vomiting.

Diarrhea or constipation.

Frequent urination.

Uncontrollable emptying of bowels and bladder when danger suddenly appears.

Fatigue, feeling drained of energy.

Blank, haunted "1000-yard stare."

Anxiety, keyed up, worrying.

Irritability, swearing, complaining, bothered by little things.

Difficulty in paying attention or remembering details.

Difficulty in thinking, speaking, and communicating.

Sleeping difficulties, such as being awakened by bad dreams.

Grieving, tearfulness, crying for a dead or wounded buddy.

Feeling guilty about mistakes made or at things that had to be done.

Anger, resentment, or feeling let down by leaders or fellow soldiers.

Decrease in confidence in self and his unit.

An easier way to recognize CSR is to observe the soldier and ask these questions. If you can answer "NO" to one or more, you should suspect CSR.

Is he being himself?

Can he respond to commands?

Can he protect himself?

Will he engage the enemy?

Is he demonstrating appropriate behavior?

Remember CSR is real. It is not cowardice or insanity. Affected soldiers are not weak they are not failures. They are temporarily disabled.

The following techniques can be used to help a soldier suffering from mild CSR. If these techniques do not work, have a medic evaluate the casualty. The techniques can also be used to help prevent combat stress.

Appear to be calm and in control of the situation.

Keep the combat stressed soldier focused on the unit's immediate mission. Get everyone to think of succeeding and to talk about ways the team can handle the current situation.

Expect the soldier to continue his duties. Have him to perform a simple, well-learned task or drill according to the local standing operating procedure (SOP).

Have the soldier use relaxation techniques (take a deep breath and let it out slowly, shrug shoulders to release tension, etc.).

Remind the soldier, and others as needed, that CSR is not a sickness or cowardice. It is a reaction to an abnormal, uncomfortable and dangerous situation.

Encourage the soldier to relax, drink water (not alcohol), take nourishment, bathe, and sleep (four hours or more if possible, "catnaps" if not) as the tactical mission and safety permit.

Allow and encourage the soldier to ventilate his feelings.

Keep the soldier busy when he is not resting.

Report on the casualty to the leader or to the medic/health care provider available.

A soldier suffering from moderate or severe CSR is ineffective and usually requires evacuation. Since a major difference between moderate and severe CSR is the casualty's reaction to treatment, both conditions are usually combined under the term "more serious" CSR. It can occur at a slow or fast rate, depending on the person and the situation. The following are some of the physical, mental, and emotional signs and symptoms of more serious CSR.

Cannot keep still, constantly moving around.

Shaking of arms or whole body

Cowering in terror.

Flinching or ducking at almost any sudden sound or movement.

Paralysis of a body part (hand, arm, leg, etc.) with no obvious physical explanation.

Sudden blindness or deafness (partial or complete) with no obvious physical explanation.

Total immobility (freezing) under fire.

Total physical exhaustion (just stands or sits).

Staggering or swaying when standing.

Vacant stare.

Rapid talking, constantly making suggestions.

Argumentative behavior, starting fights, deliberate recklessness, "vicious" within his own squad or group, uncontrollable anger.

Social withdrawal (silence, sulking, prolonged sadness).

Inattentiveness to self-care and hygiene.

Indifference to danger.

Apathetic (no interest in food or anything else).

Loss of memory (cannot remember orders, how to perform duties, or where he is).

Inability to concentrate or make decisions.

Severe speech problems, including stuttering and inability to talk.

Fear of sleeping, even in a relatively safe area.

Seeing or hearing things which are not there (usually after severe sleep loss).

Rapid emotional swings, crying spells, wishing to be dead, hysteria, frantic activity, strange behavior.

Panic running under fire.

A soldier suffering from moderate or severe CSR should be evaluated by a medic or other health care provider as soon as possible. Early on, CSR casualties need to talk, ventilate to any medical person. All combat stress patients should be treated with the expectation of their going back to duty. Usually CSR casualties recover completely after resting in a safe area, being able to clean up, and receiving hot, nutritious meals.

A casualty with moderate or severe CSR can be a danger to himself and to other soldiers. The techniques used with a casualty with mild CSR can also be used with a casualty with moderate combat stress. The following procedures are used with a soldier suffering from more serious combat stress.

Calmly try to talk the casualty into cooperating if he is responsive.

If the casualty's actions endanger the mission, himself, or other soldiers, do whatever is necessary to bring him under control.

If the soldier appears to be unreliable, unload his weapon. If he is dangerous, take his weapon away from him.

Physically restrain the casualty if he is a danger to himself or to others.

Have a medic evaluate and evacuate the casualty.

Evacuate the casualty to a medical treatment facility if the casualty's condition does not improve or if the casualty is a clear danger. Restrain the casualty during transportation, if needed.

When a CSR casualty returns to the unit, welcome him back. Be willing to talk about what happened and express your confidence in him.