ACADEMY OF HEALTH SCIENCES, U.S.

ARMY AMEDD NONCOMMISSIONED OFFICERS ACADEMY BASIC NONCOMMISSIONED OFFICERS COURSE

TASK: Identify the Symptoms of Battle Stress.

IDENTIFY THE SYMPTOMS OF STRESS

Section I: TYPES of BATTLE FATIGUE

1-1. WITHSTANDING STRESSORS ON AND OFF THE BATTLEFIELD
a. Pushing Yourself to the Limit in Combat. To accomplish your team's mission in combat, in either low or high intensity, you must help yourself and your buddies to withstand the extreme stresses of war. Tough, realistic training will help a lot, but in war, real enemies will be trying to kill you or stress you until you break. Winning may require your team to push continuously, under terrible conditions, to limits far beyond those you've ever reached before. At other times you may face only tension, waiting, loneliness, and boredom. All of you may have to do or see things that make you feel badly. need to teach these signs and how to cope.

stressor: Any stimulus that provokes a stress reaction.

stress: Any stimulus, such as fear or pain, that disturbs or interferes with the normal physiological equilibrium of an organism; physical, mental, or emotional strain or tension.

b. When Not Under Direct Attack. Whether your unit has a combat, combat support, or combat service support mission you and your buddies may still experience battle fatigue. This can conditions." happen even when you are not under direct attack. Mental and physical fitness will help you to endure that stress, but you will still have to confront fear and 1-2. TYPES OF other unpleasant feelings before, during, and after combat. These symptoms of battle fatigue are a BATTLE FATIGUE natural result of the hard work of facing danger under tough conditions. As a soldier you need to know the a. Duty and Rest Battle Fatigue. Duty and rest physical and mental signs of normal, common battle battle fatigue, previously referred to respectively as fatigue and how to live with them. As a leader, you mild and moderate battle fatigue, are nondisabling

c. Combat Stress Leads to Battle Fatigue. A combination of physical and mental stressors in the combat zone can produce symptoms in any soldier which temporarily interfere with military performance. While control of "Battle fatigue is a stress is a command responsibility, each soldier must natural result of the do his or her part to manage hard work of facing their own stress, to the extent danger under tough possible.

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stress reactions. Most stressed soldiers can be treated for their symptoms, reassured, and restored to effectiveness by leaders and medical personnel within the unit. If the affected soldier(s) can be treated within their own unit, the condition is categorized as duty battle fatigue.

evaluation by an MD, PA, or Mental Health Officer. It should be noted that some cases of heavy battle fatigue may also be due to dangerous medical/ surgical conditions. Whether heavy battle fatigue is due to job stressors or a medical/surgical condition (medical stressors), evacuation for evaluation is the course of action.

duty battle fatigue: nondisabling stress reaction treated within the unit by a day or two of light duty.
If the symptoms or situation requires a day or two of light duty in a supporting (non-medical) unit, the condition is considered rest battle fatigue.

heavy battle fatigue: stress situation requiring evacuation for further evaluation; produces a nonfunctional soldier who presents an unacceptable burden to the unit.
c. Heavy Battle Fatigue Not Necessarily a Casualty. In heavy battle fatigue cases, no attempt should be made to apply diagnostic labels to the specific condition. Rather, all such cases should initially be carded as battle fatigue, heavy with brief factual notes describing symptoms and any known contributing factors. At the nearby medical unit (usually an aid station or divisional or corps clearing company), they may be treated and released to either duty or rest. (Only if retriaged as hold or refer do they become battle fatigue casualties.)

rest battle fatigue: a nondisabling condition treated with a day or two of light duty in a supporting (nonmedical) unit.
b. Heavy Battle Fatigue. Heavy battle fatigue, formerly referred to as severe battle fatigue, cannot be handled within the unit. Stressed soldiers who are nonfunctional and who represent an unacceptable burden to their unit should be evacuated to nearby medical elements for immediate

Section II: SIGNS AND SYMPTOMS

2-1. IMPORTANCE OF RECOGNIZING SIGNS AND SYMPTOMS OF BATTLE FATIGUE
a. Self-Awareness Paramount. It is important for you to be able to recognize the signs and symptoms of battle fatigue. Self-awareness and a certain awareness regarding the condition of your buddies is the key to effectively managing the physical and mental stresses that are inevitable in a combat zone. If you know what to look for and react promptly, you will have a better chance of effectively managing your battle fatigue within the unit. b. Self-Awareness Enhances Likelihood of Effective Coping. As stated earlier, battle fatigue is an inevitable and temporary product of the stressors in the combat zone. Most of you will have some of the signs now and then. All of you can still be effective soldiers. You can make the extra effort and win, if you learn some practical ways to pace yourself and your buddies so as to withstand the physical, mental, and emotional strains of themission. If you accept that you can expect to experience some level of battle fatigue and you know what to look for, you will be more likely to be in a position to effectively cope with it, if and when it happens.

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2-2. COMMON AND LESS COMMON SIGNS/SYMPTOMS (DUTY & REST BF)
a. Most Common Signs/Symptoms. Anxiety, shakiness, feelings of inadequacy, grief, and simple exhaustion predominate. These are not, of course, the only symptoms. (See figures 2-3 and 2-4 for a more comprehensive summary of the full range of possible physical, mental, and emotional signs and symptoms.)

"Anxiety, shakiness, feelings of inadequacy, grief, and simple exhaustion predominate."

PHYSICAL SIGNS/SYMPTOMS
Exhausted: Tired, drained, takes effort to move, haunted 1000yard stare.

b. Less Common Signs/Symptoms. A loss of motor, sensory, speech, or memory functions resulting from an emotional response to combat stress is less common, but possible. Bizarre, impulsive behavior, total withdrawal or persistent hallucinations, on the other hand, are uncommon. Wrapped up with physical symptoms, there may be hidden forms of battle fatigue, resulting from stress: excessive pain and disability from minor or healed wounds, negligent injury and illness, and alcohol/drug misuse. c. Battle Fatigue vs. Misconduct Combat Stress Behaviors (MCSB). To put battle fatigue in perspective, it may be helpful to understand what battle fatigue is not. Indiscipline, the commission of atrocities, desertion, and deliberate self-inflicted wounds may fall under the category of misconduct combat stress behaviors (MCSB). These are not signs of battle fatigue. The difference is that MCSB necessitates disciplinary action, whereas battle fatigue requires reassurance and rest.

Shaky/jumpy: Startled at sudden sounds or movements. Tense: Head and backache, trembling, fumbling. Cold sweat: Dry mouth, pale skin, difficulty focusing eyes. Heart pounds: Possibly dizzy or light-headed. Out of breath, Breathless: hyperventilating to the point that fingers and toes tingle, cramp, and go numb. Stomach upset: Maybe vomiting, diarrhea, or constipation, frequent urination; bowels and bladder emptied at instant of danger.

2-3. MORE SERIOUS SIGNS OF DUTY/REST BATTLE FATIGUE

a. When Routine Signs and Symptoms Signal a More Serious Problem. You must constantly monitor yourself and your buddies to determine whether or not the situation is under control or

Figure 2-1. The physical signs and symptoms of duty and rest battle fatigue.

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MENTAL & EMOTIONAL SIGNS & SYMPTOMS

Feeling inadequate: Losing confidence in self and unit. Anxious: Worried, irritable, keyed up, expecting the worst. Grief-stricken: Tearful, crying for dead or wounded buddies. Angry: Feeling let down by leaders or others in the unit. Irritable: Swearing, complaining, easily bothered. Difficulty Concentrating and Communicating: hard time paying attention, remembering details, thinking, speaking, communicating. Sleepless: Troubled sleep, awakened by bad dreams. Confidence (in Self/Unit) Shaken: Feeling badly about past mistakes and ability to do what has to be done.
Figure 2-2. The mental and emotional signs and symptoms of duty and rest battle fatigue.
escalating into a more serious case of battle fatigue. If you see the more serious signs and symptoms, it does not necessarily mean that you have a case of heavy battle fatigue on your hands. (Remember that heavy battle fatigue, cannot be effectively managed with light duty and/or rest and represents an unacceptable burden on the unit.) Even the normal, common signs and symptoms outlined earlier, however, can become evidence of a more serious case of battle fatigue. (See figure 2-3.) b. More Serious Signs and Symptoms. The problem may be more serious if normal signs don't subside or if new ones appear. (See figures 2-4 and 2-5.)

COMMON SIGNS SUGGEST MORE SERIOUS PROBLEM IF SOLDIER:

Continues to disrupt mission after you have taken corrective action. Doesn't improve somewhat after a good rest. Acts very differently from customary behavior.

Figure 2-3. When normal signs of battle fatigue MORE SERIOUS suggest a more serious PHYSICAL problem.

SIGNS AND SYMPTOMS

RESTLESSNESS: Can't keep still, constantly moving around. FLINCHING: Flinching or ducking at most sudden sounds and movement. SHAKING/COWERING: Shaking arms or whole body, cowering in terror. INEXPLICABLE MOTOR/SENSORY IMPAIRMENT: Body part (hand, arm, legs) won't work, though there is no physical impairment. Seeing, hearing, feeling, partially or totally impaired. FREEZING UP: Freezing up under fire or prolonged, total immobility. PHYSICAL EXHAUSTION: Slowed down or just stands or sits. VACANT STARE: Spaced out, staggers, sways when standing.
Figure 2-4. The more serious physical signs and symptoms of battle fatigue.

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2-4. REFERENCES MORE SERIOUS MENTAL AND EMOTIONAL SIGNS AND SYMPTOMS
RAPID SPEECH: Talks fast, constantly makes suggestions. INCREASED AGGRESSION: Argumentative, starts fights, takes deliberately reckless action. MEMORY LOSS: Forgets--orders, military skills, traumatic events, time, place, what is going on, or even everything. SEVERE DIFFICULTY IN COMMUNICATING: Severe stuttering, mumbling, total loss of speech. EXTREME FEAR OF SLEEP: Afraid to fall asleep for fear of terrifying dreams, danger; unable to fall asleep even in a safe area. DELUSIONS: Sees or hears things that aren't really there. MOOD SWINGS: Rapid emotional swings; crying spells, wishing to be dead. SOCIAL WITHDRAWAL: Silent or sulking, prolonged sadness. APATHY: No interest in food or anything else. HYSTERIA: Hysterical outbursts, frantic or strange behavior. PANIC: Running under fire.
Figure 2-5. The more serious mental and emotional signs and symptoms of battle fatigue. 1. GTA 21-3-4, Jun 86--Battle Fatigue: Normal Common Signs What to Do For Self & Buddy. 2. GTA 21-3-5, Jun 86--Battle Fatigue: More Serious Signs; Leader Actions. 3. Information paper, 5 Nov 90--Management of Combat Stress and Battle Fatigue, COL J. Stokes, MC.

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b. Stressors.

WHAT HAVE YOU LEARNED?

MULTIPLE-CHOICE. For exercises 1 through 10, select the ONE word or phrase (a,b,c, or d) that correctly completes the statement or answers the question. When you have completed the exercises, check your answers against the solutions that immediately follow.

c. Disturbances. d. Games played by soldiers.

4. The nondisabling stress reaction that can be treated within the unit by a day or two of light duty is referred to as: a. Heavy battle fatigue. b. Rest battle fatigue. c. Misconduct combat stress behavior (MCSB). d. Duty battle fatigue.

5. The nondisabling condition that requires a day or two of light duty in a supporting (nonmedical) unit is referred to as: a. MCSB.

1. Which of the following statements accurately describes battle fatigue? a. It is a natural and temporary condition. b. It is rare among fit soldiers who practice active comradeship. c. It is a permanent affliction, in most cases. d. It is totally avoidable and unnatural.

b. Rest battle fatigue. c. Heavy battle fatigue. d. Duty battle fatigue.

6. In heavy battle fatigue cases, the soldier must be as he or she is nonfunctional and presents an unacceptable burden to the unit. a. Dishonorably discharged.

2. Battle fatigue is caused by: b. Transferred to another unit. a. Weakness of character. c. Evacuated for further evaluation. b. Excessive cowardice. c. The hard work of facing danger under tough circumstances. d. An inability to handle even minimal stress. 3. The factor most directly responsible for combat stress in the combat zone is the combination of physical and mental . a. Imagery. 7. The most common of the many signs and symptoms that may present with battle fatigue are: a. Anxiety, shakiness (easily startled), feelings of inadequacy, grief, and simple exhaustion. b. Loss of motor, sensory, speech, or memory functions. c. Tenseness, cold sweat, pounding heart, breathlessness, upset stomach.

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d. Anger, irritability, difficulty concentrating/communicating, sleeplessness, and shaken confidence.

10. Which of the following are mental and emotional signs and symptoms of a more serious case of battle fatigue? a. Confidence in self and unit diminished, worried, irritable, keyed up, expecting the worst.

8. A soldier who is indisciplined, commits atrocities, deserts the unit, or deliberately inflicts wounds to him- or herself is subject to disciplinary action for: a. Heavy battle fatigue. b. Rest battle fatigue. c. The fight-or-flight response. d. Misconduct combat stress behavior.

b. Grief-stricken (tearful, crying for dead or wounded), feels let down by leaders or buddies in the unit, irritable (swearing, complaining, easily bothered). c. Rapid speech, increased aggression, memory loss, severe difficulty communicating, extreme fear of sleep, delusions, mood swings, social withdrawal, apathy, hysteria, and panic. d. Some difficulty concentrating and communicating, troubled sleep, awakened by bad dreams, feeling badly about past mistakes and ability to accomplish the mission.
- THE END -

9. Which of the following are physical signs and symptoms of a more serious case of battle fatigue? a. Restlessness, flinching, shaky body parts, cowering, inexplicable motor/sensory impairment, freezing up, totally slowed down pace (sitting/standing still), spaced out, staggering, swaying. b. The 100-yard stare, being startled at sudden sound or movements, head and backache, trembling, and fumbling. c. Dry mouth, pale skin, difficulty focusing eyes, pounding heart, (dizziness and light-headedness.) d. Hyperventilating (fingers and toes tingle, cramp, and go numb); vomiting, diarrhea, or constipation; frequent urination; bowels/bladder emptied at instant of danger.

Courage is resistance to fear, mastery of fear--not the absence of fear.

Mark Twain

Courage is grace under pressure.

Ernest Hemingway

The only thing we have to fear is fear itself.

Franklin Delano Roosevelt

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Worry is interest paid on trouble before it is due.

William Ralph Inge

SOLUTIONS
Be sure to re-read and study the paragraph(s) pertaining to any exercises you might have answered incorrectly. The relevant paragraph(s) is (are) listed after each answer in parentheses.
1. a 2. c 3. b 4. d 5. b 6. c 7. a 8. d 9. a 10. c (1-1b) (1-1b) (1-1c) (1-2a) (1-2a) (1-2b) (2-2a) (2-2c) (Figure 2-4) (Figure 2-5)

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