Military & Disaster Psychiatry

8/14/2019 Military & Disaster Psychiatry

1/8

See also : Demographic Techniques: Data Adjustmentand Correction

BibliographyBo $ hme H W 1996 Kontinuita $ t und Traditionen bei Wander-

ungsbewegungen im fru $ hmittelalterlichen Europa vom 16Jahrhundert. Archa W ologische Informationen 19: 89103

Dixon J 1999 Late Pleistocene maritime adaptations andcolonisation in the Americas. Pre - prints of the World Archae -ological Congress 4: 1014

Garanger J 1987 Le peuplement de lOce !

anie insulaire.LAnthropologie 91(3): 80316

Keeley L H 1996 War Before Ci ilization . Oxford UniversityPress, Oxford

Klein R 1989 The Human Career . The University of Chicago

Press, ChicagoKo !

c )

ka-Krenz H 1996 Die Westwanderung der Slawen.Archa W ologische Informationen 19: 12534

Mohen J-P (ed.) 1996 La ie preT

historique . Faton, Dijon, FranceOtte M 1995 Traditions bifaces. In: Les industries a

Z

pointes foliace

T

es dEurope centrale. PaleT

o supplement no. 1 195200Otte M 1996 Aires culturelles au Pale

!

olithique supe !

rieurdEurope. In: Mohen J-P (ed.) La ie pre

T

historique . Faton,Dijon, France, pp. 2869

Otte M 1997a Contacts trans-me !

diterrane !

ens au Pale !

olithique.In: Fullola J M, Soler N (eds.) El mo

T

n mediterrani despreT

s del Pleniglacial (18.00012.000BP) . Museu dArqueologia deCatalunya, Girona, pp. 2939

Otte M 1997b Pale !

olithique nal du nord-ouest, migrations etsaisons. In: Fagnart J-P, The

!

venin A (eds.) Le Tardiglaciairedu Nord-Ouest de lEurope . CTHS, Paris, pp. 35366

Otte M in press. Le Me !

solithique du Bassin Pannonien et laformation du Rubane

!

. In: Proceedings of the ConferenceFrom the Mesolithic to the Neolithic , Szolnok, 996

Roe D A 1981 The Lower and Middle Palaeolithic in Britain .Routledge, London

WolpoffM 1998 Paleoanthopology . McGraw-Hill, Maidenhead,UK

M. Otte

Military and Disaster Psychiatry

1. Introduction

Whether by force of humans or nature, massivedestruction creates an atmosphere of chaos andcompels individuals to face the terror of unexpectedinjury, loss and death. In times of disaster or war,psychological injury may occur as a consequenceof exposure to physical injury, disruption of theenvironment, or the terror or helplessness producedby these events. To address such injury in a timelymanner, mental health care must be provided inenvironments near chaos and destruction, as well as in

the hospital. The disciplines of military and disasterpsychiatry address care demands in nontraditionalenvironments and in mass casualty situations, whereresources are overwhelmed. Care in these environ-ments relies on contributions not only from psy-chiatrists, but also from other physicians, socialscientists, epidemiologists, psychologists, nurses andemergency responders such as police and remen.

This overview of military and disaster psychiatrybegins with an examination of the consequences of disasters and wars for communities, and the evolutionof medical responses to these traumatic experiences. Adiscussion of the phenomenology of trauma-relatedpsychiatric morbidity and principles of prevention,mitigation of consequences, and management follows.Finally, transnational economic, ethical and legaltrends are presented as issues requiring further study.

2. Practice En ironments in Military Operationsand Disasters

Disaster has numerous denitions. The word isderived from the Latin dis (against) and astrum(stars)the stars are evil. A disaster such as anearthquake or a ood overwhelms a communityscapacity to respond. The distinction between naturaldisasters (e.g., earthquakes) and human-made ortechnological ones such as explosions, or trainderailments is increasingly difficult to make. Forexample, much of the death and destruction from anearthquake may be due to poorly constructedhousingthus, there is a human-made element to theconsequences of even natural disaster. From apsychological standpoint, a more critical distinctionconcerns whether the disaster was inicted inten-tionally, as is the case with acts of war or terrorism.

War may be dened as a political act (generallyinvolving violence) to achieve national objectives orprotect national interests. During the last 30 years,militaries around the world have increasingly becomeinvolved in peacekeeping and humanitarian relief missions. The use of military forces in these endeavorsalso maintains a countrys inuence and minimizespolitical instability in the affected nation.

The potential stressors in all disaster environmentsinclude exposure to the dead and grotesque, threat tolife, loss of loved ones, loss of property, and physicalinjury. Although the military brings supplies anda portable living environment to protect soldiers,civilians (frequently exposed to combat environmentsin modern times)maybe subject to large-scale devasta-tion, become refugees, and experience shortages thatthreaten life. Frequently, such victims do not receivetreatment for psychiatric symptoms that emerge frombombings, battle, rape, torture and unrestrainedmurder. Although an earthquake may be concludedin seconds, the consequent traumatic experience may

9850

Migrations, Colonizations, and Diasporas in Archaeology


2/8

continue for weeks, months and possibly years. Forboth soldiers and civilians in combat environments,exposure over time may include anticipated or entirelyunexpected life-threatening experiences followed bydaily life in an austere and disrupted environment.

The emotional and behavioral responses followinga disaster occur in four phases. The rst immediatelyfollowing a disaster generally consists of strongemotions including feelings of disbelief, numbness,fear and confusionnormal emotional responses toan abnormal event. The second phase usually lastsfrom a week to several months and is accompanied bythe appearance of assistance from outside agenciesand communities. Adaptation to the austere environ-ment as well as intrusive symptoms (unbiddenthoughts and feelings accompanied by hyper-arousal)occur during this phase. Somatic symptoms such asfatigue, dizziness, headaches and nausea may develop.Anger, irritability, apathy, and social withdrawal areoften present. The third phase is marked by feelings of disappointment and resentment when hopes for aidand restoration are not met. Here, often, the sense of community is weakened as individuals focus on theirpersonal needs. The nal phase, reconstruction, maylast for years. During this period, survivors rebuildtheir lives, make homes and nd work using availablesocial supports. Individuals may progress throughthese phases at various rates. Many persons may beunable to reconstruct their lives fully and insteaddevelop persistent symptoms.

Thecauses of disaster andwar have been historicallyattributed to sources ranging from the gods, to thewind of a passing cannonball, and various natural,unnatural or supernatural sources of contagion.Emotional consequences of disaster are described inthe Iliad , and references to the terror induced by theattack of this hero are diverse. Ancient Greeksattributed epidemic illness to Apollos wrath after thedesecration of his temple. TheFrenchmilitary surgeonLarrey commented clearly on the ill effects of warupon the health of Napoleons soldiers. Otherscommented on combat-related pathological behaviorsduring the US Civil War, and recent studies havenoted the descriptions of veterans of that warhospitalized for symptoms very similar to those of todays Post Traumatic Stress Disorder (PTSD).

The science of neurology entered military medicinewith Weir Mitchells work during and after the CivilWar. Over the remainder of the nineteenth andtwentieth centuries studies increasingly distinguishedbetween diseases of the nervous system for whichtraumatic lesions could be demonstrated and thosefor which no such lesion could be identied. Theconcepts of neurasthenia, dissociation, hysteria andpsychological suggestion were developed to denepsychoneurological states without demonstrableanatomic abnormality.

Military physicians in the RussoJapanese Warmade similar diagnostic distinctions. Recognition of

the nontraumatic injuries that followed railwayaccidents and other technological disasters occurredat the same time. Military psychiatric experience inWorld Wars I and II led to the development of specictreatment principles. During World War I, physiciansfrom various armies addressed the problem of soldierswith emotional or behavioral disturbances with avariety of diagnostic labels such as shell shock,gas neurosis and conversion paralysis. Treatmentranged from prolonged psychiatric hospitalization, topunishing electric shock and various talk therapies.Gradually, US, Canadian and British forces incor-porated into their treatments the expectation thatthese soldiers return to battle after brief evaluations.German military scientists recognized the importanceof unit cohesion in mitigating psychological injury.Elsewhere, efforts were made to screen out soldiers feltto be at risk for psychological disturbances on theassumption that these soldiers were genetically weak.Although the terms proximity (treatment near thecombat zone), immediacy (early identication of stress-related disorders), simplicity (treatment withrest, food and brief support) and expectancy (ex-pectation of prompt recovery and return to duty)were dened in later conicts, these practices evolvedto varying degrees during World War II. Theseprinciples, along with the development of psycho-tropic medications, the failures of screening programs,and the recognition of the problems of drug abusein operational environments greatly inuenced themanagement practices of subsequent military anddisaster responders.

Civilian physicians have also long recognized thetrauma of war as a cause of human suffering. In 1859,Jean Henri Dunant arranged for civilian medicalservices for the injured after observing soldiers diefrom lack of medical attention during the Battle of Solferino. His efforts led to the establishment of theInternational Red Cross, and to international guide-lines for humane care to the sick and wounded intimes of war. During the later part of the twentiethcentury the Red Cross, and other internationalmedical and relief agencies such as Doctors WithoutBorders increasingly provided mental health-relatedconsultation, education and direct care in the after-math of war, natural and human-made disasters. The

World Health Organization and the PacicAsianHealth Organization have also supported inter-national disaster relief efforts.

3. Phenomenology

3.1 Symptoms ersus Functioning

Military and disaster psychiatry must address theclinical concerns of identied patients, but must alsostrive to prevent potentially incapacitating morbidity

9851



3/8

in entire populations. Distress-related symptomsare universal during disasters and combat. Initialpsychiatric response in the aftermath of war anddisaster must focus on mobilizing effective function-ing. Symptoms occurring in persons who are notimpairedarea secondaryconcern.Such symptoms canbecome medicalized if clinicians cause impairedfunctioning by unjustiably reinforcing a view thatsymptoms are due to a disease. While the ultimatelabel given to clusters of symptoms has political,economic and research-related signicance, the self-perception that one is ill can become a powerfuldeterminant of impaired functioning both during andafter combat and disasters.

3.2 Military Operations, Disasters and Psychiatric

SyndromesMuch of military and disaster psychiatry focuses onthe myriad behavioral reactions to stressful eventsstressors. Well-dened psychiatric syndromes de-scribe many of these responses. The precipitatingstressor for PTSD involves a threat to the physicalintegrity of self or others, so immediate that theexposed individual suffers a potent sense of helpless-ness, horror or fear. A characteristic distress responsemay follow such trauma. This response consists of symptoms that involve: (a) reliving the original event(e.g., nightmares, distressing vivid recollections orfear when exposed to events resembling the originaltrauma); (b) numbing of responsiveness or behavioralavoidance of events or situations that somehowresemble or symbolize the original trauma; and (c)symptoms of increased vigilance, such as exaggeratedstartle, outbursts of anger or other evidence of hyper-arousal. If these symptoms of severe distresspersist for over a month, then a diagnosis of PTSDis appropriate. Symptoms may rst occur monthsor even years after the triggering event, but thisis not the norm. If symptoms occur within the rstmonth after the trauma and have not lasted longerthan a month, then Acute Stress Disorder (ASD) isdiagnosed. Controversy persists regarding the diag-nostic validity PTSD, probably because it was denedin the aftermath of the Vietnam War in the wake of political and antiwar pressures. Nonetheless, PTSD

and ASD are conceptualized as modal distressresponses to severe or catastrophic stressors, and havebeen as carefully dened and delineated as otherpsychiatric disorders.

Disabling distress reactions occur in response to lesssignicant trauma and present in patterns not de-scribed by PTSD or ASD. Adjustment Disorder, forexample, is a maladaptive behavioral and \ or emotion-al response to a diverse array of stressors. ConversionDisorder may be diagnosed when one develops un-explained symptoms or decits affecting voluntarymotor or sensory function (e.g., sudden paralysis of the trigger nger) without demonstrable neuro

anatomical injury. Bereavement, a normal grief re-action after the death of someone who is valued orloved, may also occur in response to losses incurredduring war or disaster. Other distress responses to waror disaster include anxiety and depressive syndromes,and antisocial behavior (involving acts of violence,criminalbehavior, militarymisconduct, or war-relatedatrocities). Alterations in health-related behaviors(e.g., misuse of tobacco, drugs or alcohol, poor eatinghabits) may also develop after exposure to disaster orwar.

3.3 Battle Fatigue

The term battle fatigue provides a framework toencompass the variety of responses to operational

stress, but does not dene a specic constellation of symptoms, as in Major Depressive Disorder or PTSD.A wide range of physical and emotional symptomsand signs can occur among individuals with battlefatigue including gastrointestinal distress, tremulous-ness, anxiety, perceptual disturbance, a sense of unreality, and a dazed look (i.e., thousand-yardstare). The diversity and non-specic nature of presentation distinguish this entity from ASD. Battlefatigue occurs in combatants who have exhaustedphysiological and psychosocial coping mechanismswith the intense combat experience. Minor injury,parasitic infection, starvation, heat exhaustion, andcold injury may decrease the coping resources of acombatant.

3.4 Medically Unexplained Physical Symptoms

War historians have observed that unexplained physi-cal symptom syndromes are common sequelae of combat since at least the US Civil War. Syndromessuch as soldiers heart and illnesses characterized byphysical symptoms attributed (by sufferers) to war-related exposure to Agent Orange are examples.Contentious debates between scientists, clinicians,veterans and their advocates, and journalists persistaround putative etiology. Some argue that the con-sistent appearance of thesesyndromesafterwarspeaksto the likelihood that psychosocial factors contribute

to their etiology.

3.5 Other Psychiatric Illnesses

Depression, anxiety disorders and personality changeshave all been associated with exposure to the traumaof disaster and war. These psychiatric disorders maybe accompanied by somatic complaints. Such illnesseshave been described in large numbers of personsexposed neither to war nor other disasters. Therefore,biological, genetic and environmental risk factors areall likelyinvolved in the development of these illnesses.

9852



4/8

4. Etiology and Epidemiology

4.1 Predisposing Factors

PTSD, other anxiety and depressive disorders, andphysical symptom syndromes are more frequentlydiagnosed among women than men in associationwith any given stressor. Explanations for this involveneurobiological and psychosocial factors includingthe greater rate at which women seek treatment forstress-related symptoms and that duration of illness(e.g., PTSD) may be longer for women and thereforemore likely reach clinical attention. Men are at higherrisk for post-war problems with alcohol and substanceuse, and antisocial and violent behavior. Gender-specic neurophysiological factors as well as culturalfactors are again implicated in these differences.

Level of functioning after combat and disasters alsorelates to pre-trauma functioning. Individuals whofunction marginally in various roles (e.g., occupationaland social) prior to disaster or combat exposure are atincreased risk for poor functioning after traumacompared with individuals who were previouslyhigh functioning. Individuals who have successfullynegotiated past traumatic experiences may be resilient(hardened) in similar future situations. However, if past traumatic events resulted in PTSD or psychiatricdistress syndromes, subsequent traumatic exposuresmay make future episodes of these disorders morelikely.

4.2 Protecti e Factors

Protective factors may be present to varying degrees ingroups such as military units, police, or reghtersexposed to trauma. Strong leadership can createpowerful loyalty and interpersonal cohesion withpopulations. Potent leaders can create a unit dynamicwherein leaders are so valued and trusted by membersof the unit as to enable voluntary participation inextremely high-risk combat or rescuerecovery situa-tions. A common symptom of poor leadership is theoccurrence of destructive inter-group conicts andorganizational splits.

An axiom of professional soldiers is we will ght as

we have trained, therefore we must train as we expectto ght. If the level of training is high, individuals inthe unit (military or civilian) more frequently trustingrained basic principles aimed at supporting oneanother in a quest for mission success. Recently,nonmilitary disaster responders (remen, police,physicians and civic leaders) in developed countrieshave assembled to train for response to terrorist attackor natural disaster. Government emergency pre-paredness agencies such as the US Federal EmergencyManagement Agency are increasingly coordinatingsuch training. The quality and extent of t betweenpersons, equipment (e.g., comfort and mobility of

chemicalprotective suits, familiarity with operation of remotely controlled bomb or mine detectors or per-sonnel recovery devices), and the environment maymodify stress responses of individuals or communities.Theextent to which the livingor working environmentmay modify response is evident in studies of thoseforced to exist in close quarters for extended periods of time with only limited contact with the outside world,such as those aboard ships or submarines. The tbetween pilot and aircraft as well as between aircrewmembers may be improved through specic training.Finally, the effectiveness (or perceived effectiveness) of leadership response to crisis is a factor that maymodify community response.

4.3 Precipitating FactorsPrecipitating factors are the proximate circumstancesthat initiate the various sequelae of trauma. Fordisaster responders and military populations, deploy-ments and peacekeeping missions disrupt familiesand are often poorly timed with regard to other lifeevents. High intensity and duration of disaster orcombat exposure relate directly to the likelihood of psychiatric casualties. Specic experiences, such asphysical injury, witnessing grotesque deaths, tortureor other atrocities place individuals at increased riskfor adverse mental health consequences. Victimizationin the form of rape, harassment, or assault canprecipitate distress reactions in those victimized. Sex-ual assault is a potent precipitant of adverse neuro-behavioral changes.

4.4 Mitigating and Perpetuating Factors

Ongoing factors, including the security and safety of recovery environments, extent of secondary trauma-tization andin military populationsrotationschedules, extent of recognition or compensation forefforts and belief in the mission effect the rate andseverity of distress symptoms. Symptoms in civilianvictims of war or in the aftermath of disaster may bemitigated or exacerbated by perceptions of communityleaderships preparedness for disaster, response to

crisis, recognition of heroes, and provision of medi-cal,nancialor emotionalassistanceboth immediatelyafter crisis, and over time.

Nonmilitary, nongovernmental organizations suchas the American Red Cross and the Salvation Armyhelp to minimize the stress following a disaster. Byattending to basic human needs such as food, clothingand shelter, they reduce both the psychological andthe physiological effects of the event. In recent yearsthe Red Cross has developed training for volunteerhealth care workers to recognize, minimize and treatstress responses in disaster workers and victims of disaster.

9853



5/8

5. Management and Care Deli ery

5.1 General Principles

Often disasters or military conicts shatter the ex-pectation of a just and safe world within populationswhere notions of basic justice and safety are culturalnorms. In such populations, establishing the sense of safetyandexpectation of justice is an important aspectof recovery. Other interventions vary with the stage of the disaster. Initially, establishing a safe environment,and managing life-threatening injury and diseasepossibilities, such as those resulting from infection orabsence of potable water, can be the most importantpsychiatric interventions. Subsequently, identifyinghigh-risk populations such as disaster workers, re-ghters, police, persons at impact zones and childrencan focus intervention strategies. Outreach programsare critical, since disaster victims rarely seek mentalhealth care. Those who are physically injured are alsoat great risk for psychiatric disturbance. Educatingmedical and community groups about normal re-sponses to abnormal events as well as when mentalhealth referral is indicated is an important part of outreach programs. Advising community leaders onexpected behavioral problems and needs is required toensure availability of resources to care for victims.This work must involve planning for expected naturalor human-made disasters, and allocating funds for thecare of anticipated victims before disasters actuallyoccur.

Responsibility for preventive measures, and recog-nition and treatment of the psychological con-sequences of such wars and disaster cannot be limitedto the few (if any) available psychiatrists. Generalphysicians, psychologists and other social scientistsmust use their diverse skills to care fordisaster andwarvictims. They must diagnose and treat disordersassociated with trauma, (e.g., PTSD, depression andanxiety disorders), provide consultation to medicaland surgical colleagues and other rst responders, andeducate community leaders about predictable re-sponses to abnormal events.

5.2 Military Mental Health Care

The US military has attempted to decrease theincidence and severity of combat and operationallyinduced psychiatric disorders. Mental health teamsare now routinely assigned to US forces in combat anddeployed operations other than war. Each branchof the US military service has specialized rapidintervention teams to provide consultation and acutetreatment to units that have experienced traumaticevents. These teams instruct commanders on likelybehavioral responses to stress and recommend lead-ership actions that may reduce negative responses tostressful situations. Post-incident debriengs assess

the effect on the unit, and attempt to reduce long-termconsequences of traumatic events. Open discussion of an incident is believed to fosterunit cohesion, facilitateaccurate individual and group understanding, andreduce the development of psychiatric disorders.However, in the few groups actually studied, there isno convincing evidence that acute incident debrienghas any effect on the later development of psychiatricillness. Debriengs may be useful in identifying indi-viduals who require further mental health attentionand decreasing individual isolation and stigma.

Despite the absence of consensus data supportingtheir effectiveness, there is increasing interest inexpanding the use of rapid intervention teams. The USmilitary currently proposes to establish a unied,multi-service policy on the composition and use of these teams. This effort follows the widely publicizedGulf War Illness complaints of veterans from thatcampaign. Some believe that since these symptoms arelargely tied to psychological problems, increasedattention to stress during military operations couldhave reduced their incidence or severity.

Different missions, patterns of deployment, andmedical support systems among US military servicespose major problems to the development of a uniedapproach to managing operational stress. Armiestypically deploy large units for extensive periods of time and allocate large amounts of medical assets tosupport these units. This medical support includesspecialty services. The US Navy and Marine Corpsdeploy smaller units both at sea and ashore. Generalmedical officers and nonphysician providers furnishmedical support, and specialty care is not routinelyavailable in the operational theater. The US Air Forcehas both short- and long-range missions. Operationalstress management doctrine must consider thesedifferences. Military physicians also provide medicaland psychiatric assistance to civilian populations intimes of natural and human-made disasters. In ad-dition to direct patient care, military psychiatristsconsult with community leaders and with civilianphysicians not accustomed to responding to large-scale physical and emotional traumas.

In the USA, denitive treatment of psychiatricillness is often provided in the militarys system of hospitals. Medical care is provided to active duty

personnel and to their families. Other mental healthspecialists, nurses, social workers and psychologistsaugment this care. Military members who developpsychiatric disorders while on active duty are eligiblefor medical retirement disability pay, and continuedtreatment through a system of Veterans Administra-tion hospitals. Individuals may be separated fromservice due to personality problems without disabilitypayment or ongoing medical care from the military.

Other nations with recent wartime experience, suchas Israel and Croatia, have developed programs toevaluate and treat soldiers and civilians exposed tocombat. Their experiences are somewhat different

9854



6/8

from the US, since they rely much more heavily onreserve forces. These nations have a more inclusivesocial medical infrastructure therefore treatment pro-grams are less reliant on the military medical system.Other nations are increasingly confronted with man-agement of operational stress in peacekeeping andhumanitarian missions. Asian nations that have re-cently experienced natural disasters and terroristevents are also studying approaches to evaluating andtreating individuals exposed to trauma.

5.3 Medical Education

Several nations provide medical education specicallyfor members of their armed forces. The US Congressin 1975 authorized The Uniformed ServicesUniversityof the Health Sciences (USUHS) to provide medicaleducation and produce physicians for military service.USUHS provides a four-year medical degree programand a number of graduate degree programs in thebasic and clinical sciences. The USUHS Center for theStudy of Traumatic Stress conducts research, andconsults to communities, and federal and internationalagencies on matters surrounding individual and com-munity responses to trauma, disaster and war. Japan,the UK and Russia are among nations with institu-tions that teach military specic curriculum to militarymedical care providers. As in other nations, thesecountries also call to national duty physicians notspecically trained in militaryinstitutions during timesof war or crisis.

6. Future Challenges and E ol ing Issues

As political, social, scientic,and technologicalfactorsevolve, societies will change their responses to theconsequences of disasters and wars. Psychiatric prac-tice associated with wars and disaster has changedwith the evolution of scientic understanding of illness. In the future, the resources to deal with theconsequences of disaster or war and the relativeimportance assigned to dealing with the resultantinjuries and disabilities are likely to be inuenced bypolitical and sociocultural values.

6.1 Ethical Challenges

The hyper-suggestibility of recently traumatizedindividuals has provided an occasion for exercisingpolitical inuence and manipulating loyalties. Pro-viding care in the mass casualty situation raises ethicalquestions about the equitable distribution of resourcesand the moral values to consider in determiningtheir apportionment. Governments in trouble havewithheld treatment to minority racial or politicalgroupsclearly an ethical breach. Since govern-

mental terrorism is a common form of terrorism, careproviders and leaders must be sensitive to the possi-bility that disasters will afford tyrants an opportunityto manipulate citizens for their own purposes.

To facilitate command assessment of troop healthstatus, militaries have denied members condentialityin medical communication. Mental healthcare pro-viders must strike a balance between a promise of privacy that encourages persons to seek care, andresponsible reporting to higher command regardingsituations that pose dangerto largergroups. Thus dualallegiance to both individuals and to the largercommunity presents an ethical challenge that must benegotiated by the military care provider. Persons inextreme circumstances may behave in ways that theylater view as shameful. Shame may contribute toposttraumatic symptoms and disturb ones capacity touse social supports. Disaster triage is frequentlycarried out in large open areas that allow everyonepresent to hear what patients say to caregivers. Giventhe social stigma assigned to the manifestations of psychiatric illness it is easy to understand bothpatients reluctance to communicate and doctorsreluctance to inquire. Perhaps re-educating the popu-lation can reduce ethical and therapeutic problemsassociated with stigma. However, altering deeplyingrained cultural expectations is just as challenging asproviding privacy in chaotic triage environments.

6.2 Technological Ad ances

New technologies in combat will modify the means of sorting and treating persons with medical and psy-chiatric injury. Future militaries in technologicallyadvanced nations are likely to become much smaller,move rapidly across the battleeld, use advancedsensors, and direct intense re across a considerabledistance. These capabilities, coupled with the possibleuse of weapons of mass destruction, will likely makethebattleeld more chaotic andinhospitable to humanlife. Emergency care and evacuation of those withdisease and injury may become increasingly difficult.The inability to maintain contact with rapidly movingunits may preclude returning individuals to theiroriginal units. Future military casualties may increas-

ingly rely on care by unit buddies, medicsand frontlineleaders rather than specialized medical units orspecialists at hospitals in the rear.

Underdeveloped nations may have limited access toadvanced technologies, so more traditional ways of organizing medical and psychiatric practice may con-tinue to be relevant.

The evolution of highly mobile units on widelydisbursed battleelds will decrease the opportunity forexchanging rested troops from the rear area for thoseexhausted by frontline combat. Provision of brief respite for exhausted troopsa hallmark of man-agement of battle fatiguemay become impossible

9855



7/8

as each individual may be performing a criticalspecialized task. Small medical units operating withinthe area of combat are likely to be eliminated fromthis technology-intensive battleeld. While treatmentmay by necessity move to the battlefront, medicalspecialists at the rear may render triage decisions anddiagnoses through the use of telemedicine communi-cation technology. Experience has shown that front-line mental health providers take a pragmatic view of acute psychiatric symptoms, and tend not to makehasty formal diagnoses on overstressed troops. Rear-echelon providers, by contrast, tend to assign formalpsychiatric labels that may be inaccurate and maystigmatize troops without contributing to treatment.Rear-echelon mental health specialists in futurebattlesmust address the challenge of providing useful thera-peutic advice from afar while avoiding meaninglessdiagnostic stigmatization.

Advanced technology will have similar implicationsfor those responding to human-made disasters such asterrorist attacks especially as terrorists gain increasedaccess to so called weapons of mass destruction(chemical and biological agents). Clarifying the rolesof military and civilian responders in terms of triage,treatment, consultation and education in any jointresponse to crisis is another challenge for military anddisaster psychiatrists.

6.3 Cultural Issues

Social scientists note that responses to trauma may beconsidered either normal or pathological, dependingon the interested party. Many have expressed fear thatmental health practitioners, motivated by prot, willtry to convince individuals experiencing normal un-comfortable responses that they need treatment.Overcoming this fear or the belief that acceptingassistance signals weakness is a challenge in circum-stances where necessary and available external as-sistance is rejected by a nation in crisis.

Most individuals exposed to traumatic events de-serve to be reassured that with return to work,community and family, they will recover. However,some individuals (and perhaps some cultures) willexperience greater psychopathologic responses and

more prolonged symptoms following trauma. Thenature of the behaviors and symptoms associated withtrauma response across cultures is still uncertain. Theextent to which social supports, biologicalgeneticpredisposition,concurrent illnesses,andotherpoliticaleconomic parameters contribute to variability acrosscultures is not known. While it appears clear that theseverity of the trauma is important, reliable measuresof severity remain to be determined. Trauma may,under some conditions, create the opportunity forpersonal growth as well, and further understandingof this potential must also be exploited to reducemorbidity.

7. Conclusion

Natural and human-made disasters result in traumaticdisruption of societal function. Wars and acts of terrorismwith their attendant large-scale death, injuryand destruction affect populations in much the sameway as massive natural disasters. Whatever the cause,disasters and military operations leave in their wakepopulations experiencing psychological disturbancesthat have been described by social scientists, civilleaders, physicians and other care providers through-out the ages.

The consequences of exposure to disaster and warmay take the form of psychological disorders such asPTSD or may manifest as various (and sometimesmore subtle) forms of behavioral change, anxiety ordepression. Symptoms may present at different times

during and after traumatic exposure. Many factorscomplicate the evaluation and treatment of neuro-psychological syndromes in the aftermath of war ordisaster. Resources are overwhelmed, life-threateningillnesses require immediate treatment, and psycho-logical casualties areoften reluctant to seek assistance.

Progress has been made in identifying the nature of trauma-related psychological responses. Predisposing,exacerbating and mitigating factors have been identi-ed. The value of multidisciplinary preparation andtraining for disaster management and the need foroutreach programs have also been demonstrated.Further study will focus and clarify the roles of psychotropic medications and various forms of psychosocial support and psychotherapy in the treat-ment of war and disaster-related morbidity. Withtechnological advances and global economic shifts,the nature of war and other human-made disasters willchange. Military and disaster mental health caredelivery must anticipate such changes to developimproved methods of prevention, evaluation, and carefor individuals and groups devastated by war ordisaster.

See also : Disasters, Coping with; Disasters, Sociologyof;MilitaryPsychology:United States; Post-traumaticStress Disorder; Reconstruction \ Disaster Planning:Germany; Reconstruction \ Disaster Planning: Japan;Reconstruction \ Disaster Planning: United States

BibliographyGeiger H J, Cooke-Deegan R M 1993 The role of physicians in

conicts and humanitarian crises: Case studies from the eldmissions of physicians forhuman rights, 1988 to 1993. Journal of the American Medical Association 270: 61620

Glass A J (ed.) Neuropsychiatry in World War II: II. O erseas.US Government Printing Office, Washington, DC

Jones F D, Sparacino L R, Wilcox V L, Rothberg J M (eds.)1995 War psychiatry. In: Textbook of Military Medicine. PartI, Warfare, Weaponry, and the Casualty . Office of the SurgeonGeneral, Washington, DC

9856



8/8

Jones J C, BarlowD H 1990 Theetiology of posttraumatic stressdisorder. Clinical Psychology Re iew 10: 299328

Holloway H C, Benedek D M 1999 The changing face of terrorism and military psychiatry. Psychiatric Annals 29:36375

Iacopino V, Waldman R J 1999 Warand health: From Solferinoto Kosovothe evolving role of physicians. Journal of theAmerican Medical Association 282: 47981

Mollica R F, McInnes K, Sarajlic !

N, Lavelle J, Sarajlic !

I,Massagli M P 1999 Disability associated with psychiatriccomorbidity and health status in Bosnian refugees living inCroatia. Journal of the American Medical Association 282 :43339

Shalev A Y, Solomon Z S 1996 The threat and fear of missileattack on Israelis in the Gulf War. In: Ursano R J, NorwoodA E (eds.) Emotional Aftermath of the Persian Gulf War:Veterans, Families, Communities and Nations , 1st edn. Ameri-can Psychiatric Press, Washington DC, pp. 14362

Ursano R J, HollowayH C 1985Military psychiatry. In:KaplanH I, Sadock B J (eds.) Comprehensi e Textbook of Psychiatry,4th edn. William and Wilkins, Baltimore, pp. 19009

Ursano R J, McCaughey B G, Fullerton C S (eds.) 1994 Indi-idual and Community Responses to Trauma and Disaster: The

Structure of Human Chaos . Cambridge University Press, NewYork

Weisaeth L 1994 Psychological and psychiatric aspects of technological disasters. In: Ursano R J, McCaughey B G,Fullerton C S (eds.) Indi idual and Community Responsesto Trauma and Disaster . Cambridge University Press, NewYork, pp. 72102

D. M. Benedek and R. J. Ursano

Military and Politics

Virtually all nations have some form of military forcefor protection against external foes, for internationalprestige, and often to maintain internal order. Therelationship between a nations political life and itsmilitary is a fundamental andenduring problem whichmay be understood as a matter of managing theboundary between them. Civil authorities desire tocontrol the military; but, militaries are more effectivewhen they are professionalized, which requires sub-stantial autonomy and minimal civilian penetrationinto their internal operations (Wilensky 1964).

1. Ci ilian Control of the Military

The scale of the problem of relations between militaryand politics differs between modern democracies andless well developed and differentiated societies (seeModernization, Political: De elopment of theConcept ).In stable democratic regimes, widely accepted politicalnorms and formal institutional mechanisms serve tomaintain the boundary (see Political Culture ). Hist-orically, standing militaries have been viewed as

contributing to tyranny because of the expense of theirmaintenance. In modern times they gain politicalinuence through symbiotic relationships with theprivate enterprises that produce their weapons syst-emsthe militaryindustrial complex that formerUnited States President Eisenhower warned against in1961.

Within democracies, institutions of civilian controlinclude constitutional, legal, and administrative mech-anisms such as military budgets and establishments,civilian conrmation of officer commissions, appoint-ment of top military officials by civilian authorities,and prohibitions on militaryemployment for domesticproblems. Even powerful and popular military officerswho exceed existing boundaries may be removed fromtheir positions by their civilian superiors, as when, inApril 1951, US President Harry Truman summarilyrelieved General Douglas MacArthur.

Professional, full-time military, consists of memberswho devote all of their time to their duties, minimizingconicts of interest. In some regimes, civilian author-ities worry about militaries with a capacity to competewith their authority. In both communist and fascistregimes, specialized political officers have been em-ployed within military units with lines of authorityparallel to military commanders as a means of en-suring the latters compliance with regime dictates.

However, such institutions are not effective absentan underlying foundation of well-developed andwidely accepted norms in the broader political culture,which may take centuries to develop (Landau 1971).Political norms include general acceptance of militarysubordination to civilian authorities and specic pro-hibitions on serving officers engaging in politicalactivities such as legislative lobbying or standing forelected or appointed office. These norms constituteessentially a social contract about the roles andfunctions of civil and militaryauthorities, respectively.The exact character of this contract tends to berenegotiated over time.

In democratic regimes, such as Britain, a pattern of norms developed over centuries in which both civilianand military bureaucracies were subordinated to thecontrol of Parliament. In the United States, rep-resentative political institutions were constitutionallyestablished before any other, with the result that

control of the military by civilian authority has neverbeen at issue, nor has the legitimacy of representativeinstitutions relative to the military (see Public Bureau -cracies ). In developing nations, representative poli-tical institutions may still have to compete with themilitary for legitimacy (Stepan 1971).

Development of separate and effective institutionsfor domestic law enforcement and state militias,combined with rmly established political normsallowing employment of militias internally only inextreme circumstances of natural disaster or civilunrest, have reduced pressures to use military forcesinternally.

9857

Military and Politics

International Encyclopedia of the Social & Behavioral Sciences ISBN: 0-08-043076-7

Copyright # 2001 Elsevier Science Ltd.All rights reserved.

Documents

Military & Disaster Psychiatry