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Pseudopsychotic and Psychotic States Arising in Combat
Lieutenant Colonel Benjamin Boshes (ref 27)
Lieutenant Colonel Clifford O. Erickson (ref 28)
Soldiers evacuated from the battle scene showed many types of emotional disturbances. At the forward treatment centers it was often difficult to determine which of these disturbances would be transient and which would be prolonged. Most patients, even those severely affected, went into a rapid remission after a few days of treatment at a forward psychiatric installation. In one group, however, symptoms persisted despite removal from the battle scene and care and treatment with rest, food, adequate sedation, barbiturate analysis, and psychotherapy. This group had to be evacuated to the rear echelon, usually to a general hospital, for further care. Some of these soldiers suffered from psychoses of the kinds seen in civil practice. Others, who manifested a clear-cut reaction to the battle situation, under proper management underwent rapid remission, and ultimately their symptoms resembled those of the ordinary case of battle neurosis, as described elsewhere in this symposium. The latter group presented so many distinctive features that the two groups are discussed separately, under the headings, respectively, of "true psychotic reactions" and "pseudopsychotic reactions."
The term "pseudopsychotic," though not commonly used, is useful in denoting that (1) the presenting symptom complex is that of a psychosis; (2) the process is rapidly reversible by proper treatment; and (3) the symptoms remaining are those of a severe psychoneurosis, with anxiety, tension, and fears. These soldiers greatly feared return to combat, whereas those who were genuinely psychotic, some of whom may also have had transitory episodes, were almost
(ref 27) Formerly chief of neuropsychiatric service, 12th General
uniformly desirous of returning, even after the psychosis disappeared. Further, the pseudopsychotic soldiers commonly broke down under the first heavy stress of battle, while those who were truly psychotic in some cases saw a good deal of combat before they succumbed. Despite the wealth of literature on emotional reactions to battle, this particular group has received little attention. References to such reactions appear in Grinker and Spiegel, (ref 14) in Miller, (ref 29) and elsewhere. It would appear that the various authors present the same syndromes under such different names as "acute regressions," "panic reactions," "acute schizophrenia," and "psychosis unclassified." Whatever the term applied, the symptoms first presented by the patient are those of a psychotic reaction, and if the series is large enough all the syndromes described by the various authors will be seen. These patients have one characteristic in common; they are so acutely disturbed that they require closed ward care and quantitatively must be considered psychotic
There are no "pure" cases. The symptoms overlap from one group to another and the state is dynamic; patients change from one type to another. For the sake of convenience, however, these patients must be classified into six groups, each of which has some dominant characteristics. Representative cases of each type are described, with case histories to clarify and illustrate the several classifications. The factor of overlap of symptoms must be kept in mind. From a psychopathologic point of view these patients belong in the category of the psychoneuroses. Hargreaves believes that much the same mental mechanisms are found in the psychoneuroses as in the psychoses. (ref 30) He writes: "--- as to whether the difference lies in some more serious emotional disturbance with more profound regression or in some deeply seated biologic deviation in the psychotic, we must confess to complete uncertainty - - -. We can only say that we can recognize the difference between these two groups if we cannot explain it."
Despite the violence of early symptoms, these states are essentially benign and yield in some patients to withdrawal from the battle scene or narcoanalysis, usually in forward psychiatric installations. Such patients arrive at the base section hospitals already diagnosed as psychoneurotic. Certain of them, however, who are resistant to these regimens remain psychotic and require evacuation to a general hospital where special treatment is available. It is with these patients
(ref 14) Grinker, R. R. and Spiegel, J. P.: War Neuroses in North Africa: The Tunisian Campaign. New York: Josiah Macy, Jr. Foundation, 1943.
(ref 29) Miller, Emanuel (ed): The Neuroses in War. New York: The Macmillan Company, 1943.
(ref 30) Hargreaves, G. Ronald: Chap. IV in Miller, op. cit.
that we are concerned in this section. It is important to stress that not all patients with severe psychoneurotic states are included, but only those whose behavior was psychotic on admission. We were careful, for example, to evaluate a rather common "auditory hallucination" that appeared at bedtime even in nonpsychotic, young dependent soldiers with severe anxiety states. These soldiers heard the voice of the mother, grandmother, aunt, or whoever had reared them, in reassurance: "You are a good boy. You have done your duty. You can always come back to me at home." This voice would return night after night during the acute state, but only to patients suffering from neuroses, never to those who were psychotic, and the ego remained well in contact with reality despite this manifestation. It was interpreted as a defense against, or an answer to, the hostile superego, which was threatening or punishing the ego for its failure. Since our earlier records were not available, we cannot say exactly how many pseudopsychotic patients we saw, but there were about 100. The following six groups include all the pseudopsychotic reactions seen in the two campaigns. Among them the reactions of schizoid personalities, which begin to shade into the spectrum of the true psychosis, were the most difficult to treat.
Acute Delusional Type
Some of these soldiers appeared to be chronically "stuck in the battle" and had difficulty in recovering from their dissociated state. Sedation in forward installations had been of no benefit to these men. Under intravenous pentothal or amytal some had given a coherent account of their experiences, but then had lapsed back into the same state. No rapport at all had been obtained with others, who were merely temporarily quieted by the drugs without being able to tell their stories. These soldiers were actively deluded. Their delusional experiences were vivid and connected with battle sights and sounds. They kept hearing planes or shells, or they saw the enemy or their comrades, the latter often as dead or severely wounded. They were as a rule violently apprehensive and noise sensitive and overreacted strongly to all stimuli. This group responded readily to therapy. Case 29 is illustrative.
CASE 29. A 26-year-old rifleman, with an 11th grade education, had been a construction laborer in civil life. He had had 37 months of service and 1 month of combat. He had been treated for 1 day at a psychiatric clearing company with heavy narcotherapy prior to entering the general hospital. He had shown no response to treatment but had been totally inaccessible, confused, and at times incontinent. He lived in the battle scene and kept yelling for his bazooka. At the general hospital, where all sedation was omitted for 24 hours after admission, he continued to exist in combat. He was totally careless of his personal appearance, displayed marked noise sensitivity, ducked at the sound of
planes or even trivial noises, was restless, and tried to waken other patients, in the belief that they were in his squad. Once he indicated that he thought ward officer was the commanding officer of his unit, an repeatedly attempted to set out on a patrol. Attempts to convince him that he was in a hospital and repeated firm reassurance failed to bring him back to reality.
After 24 hours of this behavior he was given one electric shock treatment, after which he came into good contact, became accessible, and conversed readily and coherently. He appeared moderately tense, anxious, and noise sensitive, and for a time suffered from insomnia. He stated that he had been in combat in a defensive position for nearly a month, but lasted only 2 days in the big offensive of May 1944. During these 2 days he became progressively more tense, tremulous, apprehensive, and unable to stand the sight of blood or the wounded. He contemplated suicide and finally "got so I couldnt control myself and didnt know what I was doing." His history revealed that he came from a closely knit family group in which the mother, who was "always nervous" and on whom he was markedly dependent, had died 5 years before. He had two older sisters. He was a nail biter as a child. Like his mother, he was afraid of water and thunder, and during thunderstorms he hid with her in a closet. He was enuretic until 14 years of age, and occasionally again in the past year. He had always been "high-strung" and "nervous." It was discovered that since 18 years of age he had occasionally used marijuana. His father's discovery of this habit and urging him to enter the Army to get away from his companions led to his enlistment in April 1941. He still resorted to the drug occasionally, though he had not used it for 2 months prior to his hospitalization. Tension and anxiety cleared under psychotherapy and a balanced program of activity, and he had apparently reached his usual status at the time he was discharged to limited service duty.
Type Characterized by Prolonged Panic Reactions
There is a certain amount of overlap between this group and the preceding one, in that some soldiers in this group appeared still to experience battle sounds. In general, however, the delusions in this group were of a minor nature and the outstanding feature was violent overactivity, with severe danger of injury to self or others. In some there was apparently a continuation of the panic that arose in combat, in which the soldier might suddenly leave the comparative safety of shelter under fire and run out blindly into gunfire, dashing against trees or other objects. Most of these patients cleared fairly rapidly when brought back out of danger, but others did not and required evacuation to the rear. An occasional patient, despite severe anxiety, tension, tremor, and fear, had kept a tenuous grasp on awareness until he was back out of danger; then a little stimulus had severed his thin hold on reality and a wildly disturbed panic state ensued. Case 30 typifies this group.
CASE 30. A 33-year-old rifleman, single, with a 7th grade education, a truck driver in civil life, had 2 years of service, with 4 months overseas and 2 weeks of combat. He was treated for 2 days at a psychiatric clearing company, where he was overactive, confused, uncooperative, and noise sensitive and showed multiple muscle spasms. He was totally out of contact, even during intravenous
amytal and pentothal. At the general hospital he thrashed about wildly, attempted to run at times, and had severe generalized muscle spasms in reaction to noise. He made no response when attempts were made to talk to him. After two electroshock treatments he regained clear contact with the environment, but for a few days still had mild muscle spasms. He also for a time was noise sensitive and tense and awakened in fright at night. His history revealed that he had never known his parents. He had been adopted as an infant by foster parents who died when he was 12 and 13. He then lived with an older foster sister. As a child he was "nervous and jittery." At 11 he injured his lower back in skating and spent 4 months in it body cast. At 17 he had a "nervous breakdown" and spent 1 month in bed at home. After that he avoided crowds, noise, and excitement, which upset him. He had been in defensive positions in combat for about 12 days and was in a big offensive for 2 days, during which he remembered trembling all over and men falling about him, but he could not give a clear account of his experience and had a total amnesia for the period from then until after the electroshock treatment. His tension and anxiety gradually cleared, and he was returned to his usual meek, passive, quiet personality status. He was ready for reclassification and discharge to noncombat duty 30 days after admission, when sudden orders to empty the hospital necessitated transferring him to another hospital instead.
Type Characterized by Epileptoid States
Occasionally the battle situation releases violent, unpredictable, explosive behavior that resembles an epileptic furor. At times there are repeated convulsive seizures, which are atypical and follow the hysterical pattern, rather than the epileptic. The epileptoid type of reaction was the least common of all. These patients remain in a dissociated state and out of contact with reality between seizures. In one such patient electroshock treatment was successful after prolonged treatment by sedation, wet packs, intravenous amytal explorations, hypnosis, and a brief attempt at Dauerschlaf had failed at several hospitals. Three electroshock treatments were required in the following case.
Case 31. A 21-year-old infantryman, with 13 months of service, had been in a severe battle in Africa that lasted for several days. His group was forced to engage in hand-to-hand fighting with the Germans. He knew nothing of what had happened until a citation was read to him by his commanding officer. Apparently in the amnestic period he had bayoneted several Germans. On hearing the citation he fainted. Since then he had had dizzy spells and slight disturbances produced unpredictable "moods to kill." He suddenly developed a resistance to authority and expressed a desire to die, but only after accomplishing his impulse to kill. This impulse was directed toward officers. Several hospitals had found him too difficult to handle. After he had beaten up a medical officer on a closed ward in a station hospital, he was transferred to a general hospital, with his chart marked "homicidal." At this hospital he developed the same episodes of tension. They were so dangerously violent, despite psychotherapy and sedation, that electroshock treatment was resorted to. This treatment quieted him so that he was evacuated without difficulty. He could anticipate the attacks and would warn the ward officer to "get out because even
though youve never done nothin' to me, I'd kill you because I'm getting a mood to kill." Once he made an attempt to hang himself. The mechanism of his hostility toward officers was interesting. He had been a passive child, despite a "bull-like" build, and closely attached to his mother. He had been put out of the home by his father at 15, and became resentful of all father figures, i.e., all figures of authority, civil or military. Yet he had no desire to fight or make trouble and had "bummed around the country" peacefully until he entered the Army. In service he was submissive until the bayoneting experience into which he was "forced by his officers." Apparently he was "unconscious" during this period and regained consciousness at the reading of the citation. All the hostility against his father, released as the repressed "need to kill," was now turned on the officers. The growing tension was the aura, the actual outburst the fit. Afterward he knew little of what he had done and was easily managed until the next episode. Between episodes he was quiet and cooperative, but kindness from an officer seemed to disturb him, probably because it aroused so much reactive guilt against his own hostile feelings.
Type Characterization by Depressive States
Reactive depressions were common among soldiers with battle reactions, particularly among commissioned and noncommissioned officers who had developed an idea that they had let their comrades down. Most of these cases were mild, yielded easily to psychotherapy or simple sedation, and could be managed on an open ward. Obviously benign, these cases do not belong in the present category. Sometimes, however, the depressive state was very deep and progressed after the soldier had been removed from the battle scene. These patients became suicidal and their condition resembled an endogenous depression. Their self-incrimination was usually based on some alleged or real act that brought injury or death to a comrade. Sometimes the findings were those of an agitated depression, usually in a compulsive character setting. All patients in this group differed from those having true psychotic reactions in responding readily to brief treatment, showing a typical neurotic make-up, and having a definite precipitating cause for their depression, to which, however, they overreacted. Case 32 is typical of the group.
CASE 32. A 19-year-old infantryman, with 10 months of service, had seen 1 month of combat. He was brought in because he was suicidal. He was distraught and wrung his hands. His only verbalizations were: "Buddy, buddy, talk to me, buddy! Forgive me, buddy!" Tears rolled down his cheeks as he said these words. He was entirely uncommunicative and refused to eat. Under intravenous amytal he revealed that one night while on guard up front he heard a noise and fired in the direction it came from. The next morning he investigated and found the dead body of his best friend where he had shot. He became depressed, and the condition progressed to it point where he required closed ward care in a general hospital. Considerable abreaction was obtained under intravenous amytal, but it was of no therapeutic value. Finally, electroshock treatment was resorted to. After three treatments he became bright and cooperative. He was still sad over the death of his friend, but he could handle his emotion with progressive ease. He was an immature boy of 19, attached to his family and his "buddies."
Acute Regressive or Catatonic Type
This group included the largest number of patients. They were quite abstracted from reality, inaccessible, retarded, mute, withdrawn, confused, perplexed, and resistant. They assumed various postures indicative of regression toward the intrauterine position. The majority showed less reaction to noise and stimuli within the immediate environment than other groups. The syndrome simulated the catatonic state, as shown in case 33.
CASE 33. A rifleman with 10 months of service, 2 months overseas, had seen 40 days of combat, all in a holding position until the day of his breakdown, when the unit entered a big offensive. He was brought into the division clearing station in a confused state with repetitive speech and movements. He was sent to a psychiatric clearing company, where he sat or reclined without moving, staring blankly directly ahead. His face was devoid of expression. Occasionally he mumbled inaudibly to himself. Nothing beyond irrelevant and incoherent responses was obtained under intravenous pentothal. After 2 days without improvement he was transferred to a general hospital, where he lay motionless in bed, mute, apathetic, and bewildered, taking no cognizance of his surroundings. On the second day he was given an electroshock treatment with a grand mal convulsion, after which he regained contact with his environment. He still appeared somewhat retarded and depressed. He was tense, apprehensive, and easily agitated, and often expressed marked fear of return to combat. He had had a complete amnesia from the time of a forced withdrawal of his unit under heavy shellfire, in which he saw many killed. As his symptoms gradually lifted, he revealed himself as basically a timid, passive, dependent person. He was the older of two siblings, of whom the younger was a girl. He had always been quiet, shy, and very close to his family, with little interest in the opposite sex. He was kept in the hospital 32 days because of a wounded finger. At the time of his discharge to limited service he was getting along well except for occasional battle dreams.
Type Characterized by Schizoid Reactions
This group was differentiated from the preceding one by the slower development of schizophrenic reactions. In these soldiers the battle reaction developed gradually, but tended to be reversible. Most of these soldiers revealed evidence of a previously schizoid personality. While some showed a simple persistent withdrawal, others developed an organized system of delusions. Overt anxiety identified their disorder with other battle neuroses and separated it from the true schizophrenic reactions. The anxiety of all patients was related to their own experiences in battle. The ego retained its hold on reality despite the schizophrenic fašade. This type bridges the gap between the pseudopsychotic and the true psychotic reaction. Case 34 illustrates the reactions of this group.
Case 34. A 24-year-old lieutenant, with 2 years of service, had been overseas 5 months and had experienced 4 weeks of combat. He became greatly disturbed when 41 men under his command were killed and he was covered with dirt in his slit trench. He was evacuated. At the general hospital he was at first tense, anxious, and depressed, and stuttered badly. Later he expressed ideas of reference, heard voices, and had delusions of electric currents being shot into him and of being poisoned. Although he showed marked improvement after 4 electroshock treatments, he had to be evacuated to the zone of the interior because of the pressure of' new patients. Several weeks later a series of letters from him indicated that he had gone into complete remission. During his stay with us his anxiety regarding the battle scene persisted.
The aim of therapy in these acute episodes is to bring the patient into contact with reality so that he will become accessible to psychotherapy and readjustment in the Army scheme. The longer the delay in bringing about this contact, the more protracted the illness is likely to be. The danger of chronicity is the bugbear of every psychiatrist. Most of the acutely disturbed states incident to battle are transient and if properly treated clear up when the soldier is removed from the battle scene. Some of the stupors, confusions, panics, and even regressions clear up on treatment with intravenous pentothal or amytal or after 2 or 3 days of moderate narcotherapy. A few of these patients these patients are ready for return to limited service. The majority, however, must be returned to the United States for further treatment. Any soldier whose behavior is even briefly at a psychotic level is potentially too much of a hazard to his comrades to be returned to combat. The patients with whom we were concerned in the general hospital did not yield to these measures. Either the personality was too fragmented or the process had become fixed. At any rate, the symptoms did not yield to the therapeutic armamentarium of forward installations, nor were further waiting, psychotherapy, and attempts at release by intravenous amytal, pentothal, or the comparative safety of the general hospital of avail. For the most part the pattern persisted.
If such reactions continued narcotherapy was harmful. Working in different overseas hospitals we each tried Dauerschlaf in a few patients of this type. They were not benefited by this procedure; in fact, the illness often increased in severity. Occasionally a psychotic episode was produced by prolonged use of barbiturates, especially when the patient went through several installations in a long course of evacuation. This episode was either a true toxic psychosis or a drug-released reaction, in which repressed symptoms and tension were released so rapidly that the patient could not handle the flood, and a psychotic state ensued. The usual order of treatment was
psychotherapy followed by manipulative therapy. If psychotherapy failed, intravenous pentothal or amytal was tried if it had not previously been given. Sometimes this procedure was used even when previous attempts had failed. If the patient did not regain contact with reality after the administration of intravenous barbiturates with exploration and attempted synthesis, electroshock therapy was instituted. This procedure caused reversal to the neurotic level, and the usual psychotherapeutic measures were then adequate to restore the patient to such a condition that he might do well on limited service. In acute types, when there were acute delusions, severe prolonged panic, or acute regression, one to three treatments were needed, usually two. In these types of illness electroshock was needed only to bring the patient back into good contact with reality. In the more chronic illnesses, with depression and schizoid reactions, three to six treatments were needed, the larger number for patients with schizoid reactions.
True Psychotic Reactions
There has been much argument concerning whether battle experience precipitates true psychotic reactions of the types seen in civil life, particularly the most common psychosis, namely, schizophrenia. We cannot answer this question because of the brevity of our records and the absence of collateral data. We can state only that in battle some soldiers develop mental disorders that mirror the psychoses of civilians. Since all psychotic soldiers were directed to certain base section hospitals equipped to treat them, our statistics give a false impression of the proportion of psychiatric battle casualties that were psychotic. Our figure of 12.4 percent in one hospital (107 of a total 865 psychiatric casualties) is unquestionably too high. While we have no actual figures to prove it, it is our impression that the incidence of genuine psychoses was no greater in combat periods than in noncombat periods, and that we have seen more psychotic soldiers in noncombat periods and in base section troops. (Ref 31) Most soldiers with a tendency toward psychosis break down under the stress of military life and training before they reach combat duty.
On the other hand, some soldiers with schizoid, paranoid, or cyclothymic personality traits tolerated much front-line action before they became psychotic. Occasionally the battle scene precipitated a recurrent schizophrenia in a soldier who had recovered from a previous breakdown. Some soldiers were seen who had apparently had an active schizophrenia before entering service, but escaped detection
(ref 31) Editorial note: Theater statistics indicate that the incidence of psychoses was lower in combat troops than in noncombat troops.
and proceeded to combat duty. One such soldier, who evidently had been psychotic for about 8 years, was sent in only after his paranoid ideas had led him to shoot and kill another soldier. He had seen several weeks of combat. The incidence of psychoses arising under combat conditions varies greatly from the civilian rates in that schizophrenia is relatively much more common, accounting for 71.9 percent of our 107 patients. The paranoid type was by far the most common. In the occasional mixed psychosis in which manic or grandiose features were prominent, there were feats of valor on the field of battle, undertaken usually not as part of group action but as solitary acts that frequently did greater harm than good to the other soldiers.
Pure manic states or depressions were relatively uncommon. Occasionally paranoid states other than schizophrenia and, rarely, psychoses with mental deficiency, constitutional psychopathic state, or epilepsy were seen. Toxic psychoses, especially those associated with alcohol or infections, also occurred infrequently, as did posttraumatic psychotic states. No case of general paresis was seen. The major symptomatology of all these reactions was similar to that of civilian psychoses of the same type. The onset, however, was more often abrupt, and more acute catatonic and paranoid excitements were seen. The reactions were often transitory and thus less malignant than in civil life, perhaps because the process was precipitated by more environmental stress than a civilian ordinarily encounters. Thus even the more stable personalities were temporarily overthrown, and were then capable of more rapid reintegration.
The kind of treatment given to psychotic patients was often determined as much by the need for beds, the utilization of an available hospital ship or train, or the press of new patients from the front as by the needs of the patients. Ideal individual psychiatry was practically unavailable in the theater of operations, hence the need for rapidly effective therapies. In difficult cases, therefore, electroshock therapy proved a boon. It was safely, easily, and rapidly administered. Many patients could be treated; and, most important, it worked. Often in 24 to 48 hours the inaccessible and mute patient and the acutely disturbed and unmanageable patient were in good contact, especially if treatment was given twice daily at the beginning. After the first 2 days electroshock treatment was given daily; later, every other day. The frequency of treatment varied with the patient and his response to treatment, as well as with the pressure of the situation. Additional treatments were given after remission to ensure continued improvement, provided the situation permitted retaining the patient long enough. Just how much treatment could be given in a particular
case depended at times on the need for beds. The patient was treated if his condition could be cleared up rapidly or if he was difficult to manage. If, however, he was quiet and easily managed, or appeared to need protracted care, as in the few cases of chronic schizophrenia, he was sent to the zone of the interior. Owing to the pressure of work and the paucity of closed ward beds, this was the policy regularly followed.
When the severe battle reactions of the Tunisian campaign proved to be particularly difficult to manage, electroshock therapy was introduced as a last resort when all other methods of treatment had failed. It was recognized that shock therapy was not without dangers, that it was a short-cut technique with popular appeal and might, therefore, be used too generally; yet there was the danger of chronicity of symptoms that might make the reversal of the illness difficult if treatment were deferred. There was also the problem of bringing the patient to a state in which he could be shipped home easily. Later in the war there were sufficient facilities for treating severe cases on the hospital ships. Earlier, however, transfer of these patients to the United States on transports or freighters depended on the willingness of the shipmaster to accept them, and acutely disturbed patients were often rejected. In using electroshock therapy over a period of 22 months, in which thousands of treatments were given, only one fracture was detected. This was a mild compression of a thoracic vertebra in a schizophrenic patient. There were no other accidents, an outcome in which good fortune no doubt played a part, but one in keeping with the safety records established for electroshock therapy in the United States.
Though the pressure of the military situation often allowed holding a patient for only a brief time, an attempt at "total push" in therapy was made and found valuable. Various forms of supervised activity, including occupational therapy, entertainment, and games, opportunity for self-expression along various artistic lines, outdoor and indoor athletics, and assisting in caring for and improving the ward were all part of this program. It was one of the chief duties of the nurses and ward attendants to encourage the patients in these activities and to join with them. It was found best to omit sedation and restraint and to substitute packs for quieting the patients. Dauerschlaf was found disappointing as a therapeutic measure. It was used only for extremely disturbed patients who were destroying themselves by overactivity, and then only when an electric shock unit was not available. Even so, after 12 to 15 days at a deep level of sleep, such patients soon manifested all their former disturbance. Individual psychotherapeutic treatment was given as far as time permitted, though necessarily at a superficial level. Even so, it undoubtedly benefited certain patients.
Acute psychotic reactions occur incident to battle. Most of these reactions are transient and rapidly reversible, but some persist longer. While quantitatively psychotic, nosologically they belong among the psychoneuroses. The term "pseudopsychotic reactions" is used to describe them. Anxiety related to the battle scene, present even after the psychotic symptoms are gone, distinguishes these reactions from the true psychoses. These reactions yield readily to special. therapies, such as electroshock treatment, available in general hospitals. This treatment causes resolution to a psychoneurosis, most often all anxiety state which is then treated. Most of the soldiers suffering from pseudopsychotic reactions could be returned to limited service and adjusted satisfactorily. Genuine psychoses, while infrequent, did appear in battle. The psychosis was usually schizophrenia with paranoid features predominating. The genuine psychoses that occurred were also often more transitory than those occurring in civil life, or even than the reactions arising under noncombat conditions. Electroshock therapy was also found valuable in the true psychoses, especially in treating depressions or acute schizophrenias, or quieting disturbed patients so that they could be evacuated.