The following PIE principles were in place for the "not yet diagnosed nervous" (NYDN) cases: • Proximity – treat the casualties close to the front and within sound of the fighting. • Immediacy – treat them without delay and not wait until the wounded were all dealt with. • Expectancy – ensure that everyone had the expectation of their return to the front after a rest and replenishment. United States medical officer Thomas W. Salmon is often quoted as the originator of these PIE principles. However, his real strength came from going to Europe and learning from the Allies and then instituting the lessons. By the end of the war, Salmon had set up a complete system of units and procedures that was then the "world's best practice". After the war, he maintained his efforts in educating society and the military. He was awarded the
Distinguished Service Medal for his contributions. Effectiveness of the PIE approach has not been confirmed by studies of CSR, and there is some evidence that it is not effective in preventing PTSD. US services now use the more recently developed BICEPS principles: • Brevity • Immediacy • Centrality or contact • Expectancy • Proximity • Simplicity
Between the wars The British government produced a
Report of the War Office Committee of Inquiry into "Shell-Shock", which was published in 1922. Recommendations from this included: Part of the concern was that many British veterans were receiving pensions and had long-term disabilities. By 1939, some 120,000 British ex-servicemen had received final awards for primary psychiatric disability or were still drawing pensions – about 15% of all pensioned disabilities – and another 44,000 or so were getting pensions for 'soldier's heart' or
effort syndrome. There is, though, much that statistics do not show, because in terms of psychiatric effects, pensioners were just the tip of a huge iceberg." War correspondent Philip Gibbs wrote: One British writer between the wars wrote:
World War II American At the outbreak of
World War II, most in the United States military had forgotten the treatment lessons of World War I. Screening of applicants was initially rigorous, but experience eventually showed it to lack great predictive power. The US entered the war in December 1941. Only in November 1943 was a
psychiatrist added to the table of organization of each division, and this policy was not implemented in the
Mediterranean Theater of Operations until March 1944. By 1943, the US Army was using the term "exhaustion" as the initial diagnosis of psychiatric cases, and the general principles of
military psychiatry were being used.
General Patton's slapping incident was in part the spur to institute forward treatment for the
Italian invasion of September 1943. The importance of
unit cohesion and membership of a group as a protective factor emerged. John Appel found that the average American infantryman in Italy was "worn out" in 200 to 240 days and concluded that the American soldier "fights for his buddies or because his self respect won't let him quit". After several months in combat, the soldier lacked reasons to continue to fight because he had proven his bravery in battle and was no longer with most of the fellow soldiers he trained with. Appel helped implement a 180-day limit for soldiers in active combat and suggested that the war be made more meaningful, emphasizing their enemies' plans to conquer the United States, encouraging soldiers to fight to prevent what they had seen happen in other countries happen to their families. Other psychiatrists believed that letters from home discouraged soldiers by increasing nostalgia and needlessly mentioning problems soldiers could not solve.
William Menninger said after the war, "It might have been wise to have had a nation-wide educational course in letter writing to soldiers", and
Edward Strecker criticized "moms" (as opposed to mothers) who, after failing to "wean" their sons, damaged morale through letters. Airmen flew far more often in the Southwest Pacific than in Europe, and although rest time in Australia was scheduled, there was no fixed number of missions that would produce transfer out of combat, as was the case in Europe. Coupled with the monotonous, hot, sickly environment, the result was bad morale that jaded veterans quickly passed along to newcomers. After a few months, epidemics of combat fatigue would drastically reduce the efficiency of units.
Flight surgeons reported that the men who had been at jungle airfields longest were in bad shape: ::Many have chronic dysentery or other disease, and almost all show chronic fatigue states. ... They appear listless, unkempt, careless, and apathetic with almost mask-like facial expression. Speech is slow, thought content is poor, they complain of chronic headaches, insomnia, memory defect, feel forgotten, worry about themselves, are afraid of new assignments, have no sense of responsibility, and are hopeless about the future.
British Unlike the Americans, the British leaders firmly held the lessons of World War I. It was estimated that aerial bombardment would kill up to 35,000 a day, but
the Blitz killed only 40,000 in total. The expected torrent of civilian mental breakdown did not occur. The Government turned to World War I doctors for advice on those who did have problems. The PIE principles were generally used. However, in the
British Army, since most of the World War I doctors were too old for the job, young, analytically trained psychiatrists were employed. Army doctors "appeared to have no conception of breakdown in war and its treatment, though many of them had served in the 1914–1918 war." The first Middle East Force psychiatric hospital was set up in 1942. With
D-Day for the first month there was a policy of holding casualties for only 48 hours before they were sent back over
the Channel. This went firmly against the expectancy principle of PIE. In Normandy, "The infantry units engaged in the battle also experienced a rapid rise in the number of battle exhaustion cases with several hundred men evacuated due to the stress of combat. Regimental Medical Officers were learning that neither elaborate selection methods nor extensive training could prevent a considerable number of combat soldiers from breaking down."
Germans In his history of the pre-Nazi
Freikorps paramilitary organizations,
Vanguard of Nazism, historian
Robert G. L. Waite describes some of the emotional effects of World War I on German troops, and refers to a phrase he attributes to
Göring: men who could not become "de-brutalized". In an interview, Dr Rudolf Brickenstein stated that: However, as World War II progressed there was a profound rise in stress casualties from 1% of hospitalizations in 1935 to 6% in 1942. Another German psychiatrist reported after the war that during the last two years, about a third of all hospitalizations at Ensen were due to war neurosis. It is probable that there was both less of a true problem and less perception of a problem.
Finns The Finnish attitudes to "war neurosis" were especially tough. Psychiatrist Harry Federley, who was the head of the Military Medicine, considered shell shock as a sign of weak character and lack of moral fibre. His treatment for war neurosis was simple: the patients were to be bullied and harassed until they returned to front line service. Earlier, during the
Winter War, several Finnish machine gun operators on the Karelian Isthmus theatre became mentally unstable after repelling several unsuccessful Soviet
human wave assaults on fortified Finnish positions.
Post-World War II developments Simplicity was added to the PIE principles by the
Israelis: in their view, treatment should be brief, supportive, and could be provided by those without sophisticated training.
Peacekeeping stresses Peacekeeping provides its own stresses because its emphasis on
rules of engagement contains the roles for which soldiers are trained. Causes include witnessing or experiencing the following: • Constant tension and threat of conflict. • Threat of
land mines and
booby traps. • Close contact with severely injured and dead people. • Deliberate maltreatment and atrocities, possibly involving civilians. • Cultural issues. • Separation and home issues. • Risk of disease including
HIV. • Threat of exposure to toxic agents. • Mission problems. • Return to service. ==Pathophysiology==