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Chapter 9, Part 2

Medical Science Publication No. 4, Volume II

SOME COMMENTS ON THE DIFFERENTIAL DIAGNOSIS AND TREATMENT OF PSYCHIATRIC BREAKDOWNS IN KOREA*

MAJOR F. GENTRY HARRIS, MC

I. Introduction

In the limited time I have today I will confine my remarks to only a few aspects of studies conducted by a psychiatric team which operated in Korea at division level between 17 May and 23 October 1953. The members of this team were myself, a psychiatric social worker, and a psychology technician. Dr. David McK. Rioch and Dr. Frederick C. Redlich also acted as consultants, both present part of the time with the team in Korea. Our intention was to gather data which might be indicative of psychological stress in a combat zone, to check the performance and adjustment of psychiatric patients returned to duty, and to determine the correspondence between psychiatric diagnosis, personality "structures," name-calling, etc., and the actual functioning of men in combat.

Before speaking of these matters, however, I would like to make some remarks about the combat zone in Korea, where our studies were confined. From the psychological point of view the combat zone is two things: On the one hand actual fighting (hand-to-hand combat, artillery and mortar shelling), and on the other, life in the combat zone, irrespective of fighting. This suggests that there are also two broad psychiatric problems. The combat zone also differs markedly in the types and degrees of stress depending on whether one is in the rear or the forward areas. Table 1 gives some of these levels of difference as extremes.

With this brief preface I will move on to consider psychiatric patients themselves. We will not be particularly concerned with the previously psychotic or neurotic individuals who happen to land in the combat zone. They are relatively few in numbers and present no major problems. As a matter of fact, it is generally conceded that many of the neurotics-in-civil-life actually do well in the combat zone-only to revert to their neuroses upon return home. The major


*Presented 30 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington,
D. C. This paper is an abstract of a complete report of the studies conducted by the Psychiatric Research Team under the Army Medical Service Graduate School.


391

Table 1. Differences in Stress in Forward and Rear Areas

Forward

Rearward

Extreme danger, more or less constant and often sudden.

Little or no danger; at most intermittent and rarely sudden.

Comrades being mutilated and killed.

Rarely being mutilated or killed.

Little mobility of individuals, and extreme closeness between them.

Much mobility of individuals, and less extreme closeness.

But great isolation otherwise.

Less isolation.

Instability of interpersonal relations (through turnover, rotation, death, injury).

More stability even if not more prolonged.

Direct concern with destruction and killing.

No direct concern with destruction or killing.

Consistent youthfulness.

Mixture of many age-groups.

Rank divergencies less marked (captains to privates).

Rank divergencies greater (generals to privates).

Discomfort of living conditions (foxholes, bunkers, trenches, tents).

Relative comfort of living conditions (prefabs, quonsets, janeways, clubs).

Absence of women.

Presence of women.

Material poverty.

Relative material richness.

Contraction of sense of time.

Less contraction of sense of time.

Dependency.

Independency.

Quick, important decisions.

Deliberation.

Stability and identity of units as teams, with definite demarcation of territory.

Less identity of units as teams, with more indefinite demarcation of territory.

problems of combat psychiatry lie with the more or less severely disturbed patients (dissociative reactions) from actual combat situations, and on the other hand with the less disturbed patients from the combat zone but not from a situation of actual combat.

The dissociative reaction under actual combat appears to be a fairly distinct entity. In our series of cases it always occurred in association with intensive artillery and mortar shelling, never on patrols beyond the front lines or while performing ordinary duty on the front lines during relatively quiet periods. It did occur in rearward areas when these areas were undergoing heavy shelling. The dissociative reaction usually occurred in men who had been some time with their units, were effective and well-liked soldiers, to whom the reaction apparently occurred suddenly and came as a surprise both to themselves and their comrades. There is evidence that in some cases this reaction was contagious to small groups of men. On the other hand, most of them occurred as single, isolated cases. The reaction was more or less severe, with considerable effacement of reality and of learned abilities. It was, however, usually transient.


392

The other category of psychiatric patients are the men who get to the psychiatrist during periods of relative quiescence, and are usually diagnosed as "character and behavior disorders" (including the "immaturity reactions") or simply as "no disease." It was in this category that psychiatric diagnosis most often failed to encompass the actual circumstances under which an individual becomes a psychiatric patient.

II. One Battle

Only one battle occurred during our stay which lent itself to study. Thirteen rifle companies from two regiments were directly involved. This action lasted 6 days. Furthermore, one small hill, an outpost in front of the main line of resistance, took the brunt of the fight throughout. There was, however, during this period greatly increased shelling of the rearward elements of the division concerned-and this produced casualties of all sorts. Officers had good indications for several days in advance that this battle was impending, but evidence is that the men did not.

But confining ourselves for the moment to the immediate battle area, the outpost hill, we note some striking phenomena. Approximately 2,000 men were committed to this fight at overlapping intervals of time ranging from approximately 15 to 50 hours. Of these 2,000 men, 52 were killed, 846 were wounded, 164 were missing, and 25 became psychiatric casualties. None of those who became psychiatric casualties in this battle had ever for any reason been to a psychiatrist before. And of 39 men who had seen the division psychiatrist prior to this battle, who were still present in Korea, and about whom information could be obtained, 10 were on the outpost hill and 1 in the vicinity during the battle, 14 were in company rear areas, 9 had been transferred, and the location of 5 could not be determined. These 39 men were classified as 8 neurotics and 31 psychiatric administrative problems. Also of the 10 who were on the outpost hill, 1 was killed, 3 were wounded, and 1 was missing. None of these 39 men, however, became psychiatric casualties during the battle. Although this material is scanty, it does have the double element of exclusiveness, such that in this one instance the following statement can be made: Noncombat psychiatric cases do not become combat psychiatric cases and combat psychiatric cases have not been noncombat psychiatric cases.

I hardly think there was anything special in this battle or in the command or logistical situation which would account for this phenomenon. It could conceivably be a result of a really superior system of psychiatric disposition-e. g., where the 10 psychiatric patients who were retained for combat and the 14 who were disposed


393

in rear areas were all correctly evaluated and assigned. I feel that is highly improbable. It could be an entirely spurious phenomenon, though even in view of the small number of examples, I do not believe it is a chance occurrence. Other observers have reported similar phenomena. At any rate, the fact that those men who had previously seen the division psychiatrist did not break down, and that those who did break down in the battle had not seen the psychiatrist goes counter to most of our prognostic notions, and is worthy of very careful investigation. Furthermore, the men who did break down in this battle were evaluated by their NCO's as "normal," average, or above-average soldiers before their breakdown-whereas the reverse evaluation was given of men who had seen the division psychiatrist in periods of relative quiescence. On the other hand, many of those with previous noncombat psychiatric history were said to have performed well in actual combat. This of course by no means excludes the possibility of evaluation biased according to circumstances, i. e., whether a man breaks in a combat or a noncombat situation.

It is clear that more examples are needed to test the generality of such a phenomenon. Moreover, whether this is found to be general or particular, it should point to the need to know by what processes it is produced.

To me there is one outstanding thing about this battle, which lasted 6 days and in which 13 rifle companies directly participated for periods of 15 to 50 hours each. About half of the men were killed, wounded, or missing and talk of ending the war was hot. Furthermore, the area to be held was only an outpost-though I had heard one battalion commander remark long before the battle: ". . . Hill is tactically not a critical feature, but it is psychologically." At any rate, from my point of view I would consider this a pretty "demoralizing" situation. Yet it produced only 25 psychiatric casualties in the 13 companies directly involved.

This particular battle, however, produced psychiatric casualties in other than the 13 rifle companies involved. In all there were 40 additional cases from engineer, artillery, medical, and other units. They were apparently a result of either the heavy enemy shelling of rearward units or the presence of individuals from these other units on the outpost hill. That is, engineers and aid men from the regimental collecting companies were brought into the battle to assist in the operations. Casualties from these other units, however, did not appear to be any different essentially from the ones who came from the rifle companies.


394

Characteristic of psychiatric battle casualties at the time they arrived at the Division Clearing Company were the following phenomena:

They presented a dazed, apathetic, absent, or drawn appearance. (Some were under the influence of sedatives.)

Physical fatigue was present but not marked.

They appeared to have little interest in their surroundings or in food or drink, moved slowly, indulged in no spontaneous conversation.

A few mumbled incoherently, and some talked spontaneous nonsense.

There was usually a definite startle response to noises or sudden movement. Most were otherwise passive to stimuli, but a few ineffectually "fought" stimulation.

Some made no response to questions; some would give short, apparently irrelevant or hazy answers; and others would begin complaining that they remembered nothing after a certain event or else began to ask (out of context) what happened to so-and-so. When attempts were made to relate events, they were in negative terms: "I feel empty; we couldn't move; we called for artillery 2 days and didn't get it; so-and-so was blown up; if I'd only knocked him out he'd still be living; I don't remember what happened; I never expected it to be like that," etc.

With all this there was slight to marked disorientation for time and place. Time sense was blunted.

Some of the outstanding symptoms were muteness, waxy flexibility, and complaints of stomachache, backache, and headache.

Example of a dream: "Last night I was dreaming he (a sergeant) was calling me-'Help me!' I was saying 'I can't, I just can't.' I said, 'Medic, what you gonna do?' I said it over and over again, 'I can't, I can't.'" Someone said, "You're next"-at which the patient wakes up.

Example of an expressed attitude: "Now know what it is to live-want to live at all costs. Maybe it wouldn't have been so bad if I had died during the first part of the fight. I would like to go home."

A description of the same men approximately 11/2 months after the battle:

All the above had apparently passed-in fact, most of it only a few days after these men became patients. In other words, there were no overt symptoms. There were no spontaneous comments about their battle reactions or about continuing traumatic dreams.

There were references, however, to feelings that their experiences had affected them. Some of the comments in reference to these experiences were: "Feel funny-can't describe it; everything was crazy


395

up there; lost my head; thought I couldn't make it; get most 'nervous' after a fight when you begin to think what a close call it was; thinking about dying; the shells and/or the dead bother you; makes a man even nervous to talk about it."

The comment was frequently made that smoking or talking to someone helped to keep the nervousness down.

There was actually little else clinically observed that marked these men off from the majority in the non-patient category. The results of our psychometric tests on these patients and their controls have not been completed, so I can give no data on them at present.

III. The Noncombat Psychiatric Patient

In the preceding section we dealt mainly with the dissociative reaction occurring during a hot battle-a reaction which is characteristically designated as "combat exhaustion."1 Now I will attempt to delineate the other broad category of psychiatric patients, i. e., those who break down in the combat zone, but not as a result of actual combat. I have mentioned that these are the patients who get one of the "character and behavior disorder" diagnoses.2 The "character and behavior disorders" officially include two main groups: The pathological personality types and the immaturity reactions. I am not concerned, however, with defining and pigeon-holing these different types, for this will not serve my purpose here. Some observations on the circumstances under which they become patients are more to the point.

These patients generally come trickling one by one to the division psychiatrist. They are either themselves "fed-up" or else somebody is "fed-up" with them. They are usually sent in by their immediate commanding officers. They may even have various symptoms of a sort, but what strikes the psychiatrist is their inability to relate, in explicit terms, what their trouble is-this, even when there is no reason for us to suspect a disabling inarticulateness. It might lead us, however, to suspect that perhaps all the trouble is not theirs. If we are kind, they seem to be victims of chronic misfortune of one sort or another; if we are not so kind, they may simply be classified as "bastards" or "sons of bitches."


1The term "combat exhaustion" was meant originally, however, to cover all kinds of fluid reactions within the divisional area. After evacuation to the rear of the divisional area a definitive diagnosis is in order. It thus serves a limited purpose. This policy, however, does not take into consideration the apparently very important matter of wide fluctuations in actual combat stress on the front lines, e. g., as measured in number of artillery and mortar rounds per unit sector per unit of time.
2See the "Joint Armed Forces Nomenclature and Method of Recording Psychiatric Conditions," Washington, D. C., 1949.


396

In any case, what frequently happens in such situations is that the psychiatrist, having no more to go on than the patient can tell him, goes off on the tangent of examining the patient for present and past evidences of various immature or deviant personality features. And certainly I believe he can find them in abundance whenever he looks or whomever he looks at-his only trouble being a lack of quantitative measures.

Now, I think there are two aspects we should examine here. In the first place, our present classification system recognizes these reactions as results of individual, idiosyncratic psychopathology. With this I have no objections as far as it goes. But it does not take into sufficient consideration what has happened, what may actually be going on, say, back in a particular patient's rifle company. As an example, several patients from one rifle company were sent to a division clearing company sporadically and as individuals over a period of several weeks. They had various complaints, none of which seemed very clear. On a visit to three of the squads in this company it was found that the men were in a serious uproar about their company commander, who had twice failed them in a battle by sitting down and burying his head in his hands, unable to talk to his men. Furthermore, the regimental commander had removed this company commander on the occasion of his first breakdown-but later had sent him back for a 2-week tour so that he could get his promotion! The men openly feared and hated the company commander. There seemed little doubt that this situation had produced a number of unnecessary psychiatric problems.

The second aspect is that the patient apparently has little or no realization of significant connections between his stimuli and his responses, more particularly when he comes alone to the psychiatrist. And because he comes alone and because the psychiatrist knows neither how many more in the parent unit may be disturbed nor for what reasons, there is really very little chance of getting together in a meaningful way.

The result is that these patients are sent back to duty with one recommendation or another, the sum total of their psychiatric benefits at most a brief respite from their troubles. But no understanding has been reached and no course of action has been clarified. The patient goes back to the situation where he feels that he does not matter, that it makes no difference to the others whether he stays or goes, or that he is not worth reclaiming. The same clique that excluded him may still be in operation, the same seductiveness, intolerance, or punitiveness of his commanding officer or sergeant toward him may still be present, or there may be even more subtle causative factors in operation. Such predicaments are difficult to verbalize in


397

isolation, even given a prolonged period in which to do so. Also, because of his own inability to communicate, the patient may get the feeling that the psychiatrist is not on his side or "doesn't give a damn"-and this creates further difficulties.

Now, it is with this type of patient that I feel a more direct approach could be made, such as a frank statement by the psychiatrist to the patient that it is not clear what is going on, followed by a proposal that the psychiatrist visit him at an appointed time along with his squad. In a few instances in which I tried this, there seemed to be three factors of possible significance in favor of good results. In the first place the psychiatrist's visit will partly restore the patient's sense of importance and he will shed any ideas he might have about the psychiatrist's lack of interest. Secondly, the psychiatrist can get an incomparably better idea of what the difficulties are. And thirdly, the psychiatrist will undoubtedly have placed himself in a better position to strike on effective measures that can be taken to restore a reasonable balance. Also, I believe this method could be developed into a reliable research technic.

IV. The Psychiatrist and the Handling of Psychiatric Patients

It is probably by now clear that combat psychiatry presents unique features when compared to civil psychiatry. One of the problems that faces us is that we have to draw upon civilian psychiatrists and also upon military psychiatrists without combat experience, to supply the needs of fighting forces. And I am inclined to say that the major problem here is the orientation of the psychiatrists called upon to fill these jobs. In turn, the orientation of other medical personnel in more immediate contact with fighting men is also very important.

In this section I will discuss some of these points of orientation in relation to the combat psychiatric casualty, where, I believe, it is most easily observed. In the last section I spoke of a possible method for handling (and also for observing) the noncombat psychiatric patient-but this has not been developed and we do not as yet have any well-formulated policy for it.

So far the most distinctive task of the combat psychiatrist is the handling of the sometimes large numbers of cases of "combat exhaustion" (mild to severe dissociative reactions), which occur during periods of active fighting. This task would be at times overwhelming if the psychiatrist did not possess assistance, in the form of more or less oriented aid men and battalion surgeons out ahead of him.

Ordinarily the company aid men are the first links in the chain of evacuation. They, in fact, decide who will or will not be evacuated. And they have their own particular nomenclature for the psychiatric


398

problems they encounter. For example, they recognize what is called the "Gung-Ho" reaction, which occurs in the more experienced men, and is characterized by a glassy-eyed stare, a fearsome (not a fearful) expression and a tendency to momentary reckless, but often nevertheless purposeful, exposure. The aid men may temporarily remove men with this reaction from areas of greatest danger, but they do not evacuate them. Aid men apparently learn early in their experience who is a poor and who is a good risk, psychiatrically speaking. It is, in fact, rather remarkable how many things do occur that we would ordinarily think needed psychiatric attention, that do not ever get to the psychiatrist. This means to me that there is a good deal of innate or developed understanding that aid men working under the same conditions as the riflemen use in the support of these riflemen. It may also mean that becoming a psychiatric casualty is distinctly second choice. Such areas are almost totally unexplored.

The battalion surgeons at their posts very near the battle area are in a position similar to but not as favorable as that of the aid men. Their contact with the immediate situation, however, is superior to that of the psychiatrist rearward in the division clearing company. Apparently the battalion surgeon handles many psychiatric problems quite well but evacuates to the division clearing the overflow or those men he feels he cannot handle. Here, at division clearing, patients can be held longer, observed more carefully, and presumably treated more definitively. I sometimes think, however, that the division psychiatrist is at a distinct disadvantage as compared to the aid man or the battalion surgeon. For already, at the clearing company, time and distance may be becoming effective as obstacles to the recovery of the patient. Probably a more important way of putting this is that the psychiatrist, situated at the division clearing company, will not know or understand the circumstances of the patient as well as the aid man or the battalion surgeon-and hence has difficulty in effectively communicating with him. To the psychiatrist at this distance an isolated, evacuated psychiatric casualty is likely to be viewed in terms of his motivation to go back to duty. But this may well be an end result of two people (patient and psychiatrist) reacting to the results of a prior experience of the patient on the battlefield. The patient, for one thing, has been removed from the battlefield, from the context of his experience. Meanings may have changed altogether. At least the nearer the front we get the less we hear about motivation, and the further rearward we go the more we hear about it. Rearward it is "motivation to escape" from combat; forward it seems to be "motivation to stick it out."


399

What can considerably ameliorate the psychiatrist's position, however, is his expectation that most of his patients after a few days will return to duty with their parent units. If he once lets go his expectation of returning a patient to duty, he might as well give up on that particular case.

The psychiatrist gets his expectations from his orientation-from others' and his own experience he rather quickly learns what the "score" is. I doubt if many patients could ever be returned to duty if the division psychiatrist did not expect it. I think this matter is extremely important, all considerations of combat psychotherapy notwithstanding.3 Else why is it, in such difficult circumstances, that the majority of psychiatric casualties seem themselves to initiate the idea of their returning to their parent units? There are, of course, within the patient certain attitudes derived from his parent unit that support this tendency to return to duty. But certainly, as a last word on this, neither the patient nor the psychiatrist has time to get involved in any official, elaborate psychotherapy. It is, practically speaking, a problem of the psychiatrist's own orientation and the means he finds for handling (in contradistinction to what is usually called treating) patients. Most of the rest must be left to the remarkable powers of the individual for adjustment anyway. This is not to say, I remind you, that one best "let things ride." No, there are good and effective ways of handling patients, and very poor ways indeed.

One well-established policy, the soundness of which, I think, is unchallenged, is the keeping of psychiatric patients as near the front as possible, not far from their parent units. This probably means several things: It leaves their loyalties undisturbed; it prevents the idea of serious psychiatric and/or physical disability getting established in the patients' minds and so fixing for future trouble what is a temporary experience; it allows primary gain but it offsets most of the problem of secondary gain and self-justification; and it saves manpower. By far the majority of the combat psychiatric casualties can be returned within a few days to duty, functioning perhaps not supremely well, but at least near their former degree of efficiency. This practice does not apparently have deleterious effects on the patients, even if it is repeated. I am not certain about this, however. We ourselves had no opportunity to study men who had more than once become combat psychiatric casualties. Nor did we have an opportunity to check on the long-term adjustment of those who had once broken down in combat. These are studies sorely needed.


3This same phenomenon of expectation is also evident in what is referred to as the "testing" of a doctor-a new battalion surgeon or division psychiatrist. People have a need to know what they can expect.


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V. The Performance of Psychiatric Patients Returned to Duty

Psychiatric patients returned to duty were followed up indirectly by means of interviews with noncommissioned officers who were personally acquainted with them. The object was to obtain some estimate of their performance on duty. Several control groups were treated in the same way. All groups were then rated on a 5-point scale: + +, +, 0, -, =. Superior is
+ +, distinctly inferior is = and average is 0. Agreement among three scorers was 73 percent. The principal difficulty encountered in this study was the evaluation of such comments as, "He's excellent in combat, but poor in the rear," or vice versa. In all such cases we gave the rating as 0 or - , whichever seemed fitting.

Psychiatric patients and controls fell roughly into three groups, as follows:

    1. Men returned from R & R in Japan, men with their units continuously for 5 months or longer, and medical and surgical casualties returned to duty. This was the most effective group.

    2. Court-martial (stockade) cases sent over from the United States, and venereal disease cases. This group fell between groups 1 and 3 in performance.

    3. Psychiatric patients (combat and noncombat). This was the least effective group.

Table 2, giving both numbers and percentages, shows the relations between the three groups on the 5-point scale.

Table 2. Follow-Up Classification of Psychiatric Patients and Controls

Numbers

Percent

 

Control

CMVD

NP

 

Control

CMVD

NP

++

25

10

2

++

9.2

3.2

2.7

+

73

59

11

+

26.9

19.0

14.5

0

160

173

31

0

59.1

55.8

40.8

-

11

43

25

-

4.0

13.9

32.8

=

2

25

7

=

0.8

8.1

9.2

Total

271

310

76=657

Total

100

100

100

Legend

    Control=1. Continuously with company since January 1953.
    2. Medical, surgical, and wounded in action.
    3. Rest and rehabilitation in Japan.

    CMVD=1. Court-martial cases (before Korean tour).
    2. Venereal disease.

    NP=Neuropsychiatric casualties (combat and noncombat).


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VI. Psychiatric Research in a Combat Zone

I will close these remarks with a few comments on psychiatric research in a combat zone. To begin with, it is important to get an overall picture of the phenomena that take place in a combat zone. This must be done in the field. For on the basis of the overall picture the details to come later can be interpreted in their proper perspectives. Getting the overall picture, however, presents special difficulties. It requires patience and restraint, which over long periods will seem to be without results; it requires a great deal of moving around in unfamiliar territory and among unfamiliar people; and it demands the sacrifice of one's usually comfortably authoritarian position in a hospital setting.

In the discussion of the noncombat psychiatric case I have indicated one advantage of getting a broader picture. This applies equally to the combat psychiatric casualty. That is, we notice that the combat psychiatric patient at division clearing company talks and dreams (example on page 394) about the real or assumed loss of a buddy. If this detail is studied in isolation, I don't think it means very much. It will make more sense, however, if from general observations of rifle squads on the front lines we know about the following facts:

    1. That men are intensely preoccupied with problems of personal invulnerability and of assuming that if anyone "gets it," it will be the "other guy." It was not difficult to elicit this sense of invulnerability-and marked uneasiness if the reality of it was questioned. And even in talking about the "other guy getting it" the self would always be implicated, e. g., "I'd be sorry if another man got it, but I'd be glad it wasn't me."

    2. That an extensive system of "buddying" operates among riflemen and others who must maintain themselves on the front lines. This is much more than an official policy or a swimming-partner-like arrangement. It is intimate and quite exclusive and does not occur in the rear areas. And for the vast majority of riflemen it is disturbing to be without a buddy.

    3. That there is a strange and frequent comment that men make about their buddies. It surprises you because it seems to come "out of nowhere." It is that one's buddy can be forgiven for almost any transgression, even for "bugging out." Now such "strange" things that seem to come "out of nowhere" nearly always represent significant unconscious processes.


402

    4. With 1, 2, and 3 we must contrast the fact that riflemen rarely communicate with buddies who have rotated home or who have been evacuated. Absent buddies cease to be useful.

With these additional facts we can at least produce a hypothesis, namely, that a buddy assures one's invulnerability as long as the buddy is okay, but that as soon as something happens to the buddy the conviction, "You're next," may occur with disrupting force.

The next steps will be the "testing" of the hypothesis we have made. In the example I have given above the "testing" can consist of, say, a search for information on the following points:

    1. How invariably is the loss of a buddy connected with dissociative reactions in combat? It is at least very frequently so connected.

    2. Does it ever happen that both of a pair of buddies become psychiatric casualties in combat at the same time? I have never encountered such an example.

    3. What exactly goes on between buddies at the time of a break?

    4. What varieties of buddy systems are there?

    5. Do phenomena other than disruptions of buddy relationships seem to be necessary for the production of psychiatric breakdowns in combat? Intensive artillery and mortar shelling appears to be an important factor.

    6. Are lost buddies replaced, and if so, how soon after they are lost?

This list could be expanded but at least these questions give some idea of the scope of the problem.