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. appel believed that british soldiers were able to continue to fight almost twice as long as their american counterparts because the british had better rotation schedules and because they, unlike the americans, "fight for survival" – for the british soldiers, the threat from the axis powers was much more real, given britain's proximity to mainland europe, and the fact that germany was concurrently conducting air raids and bombarding british industrial cities. like the americans, british doctors believed that letters from home often needlessly damaged soldiers' morale. canadian the canadian army recognized combat stress reaction as "battle exhaustion" during the second world war and classified it as a separate type of combat wound. historian terry copp has written extensively on the subject. 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: ... he believed that there were no important problems due to stress breakdown since it was prevented by the high quality of leadership. but, he added, that if a soldier did break down and could not continue fighting, it was a leadership problem, not one for medical personnel or psychiatrists. breakdown (he said) usually took the form of unwillingness to fight or cowardice. 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 sns activation a u.s. long range reconnaissance patrol leader in vietnam, 1968. many of the symptoms initially experienced by people with csr are effects of an extended activation of the human body's fight-or-flight response. the fight-or-flight response involves a general sympathetic nervous system discharge in reaction to a perceived stressor and prepares the body to fight or run from the threat causing the stress. catecholamine hormones, such as adrenaline or noradrenaline, facilitate immediate physical reactions associated with a preparation for violent muscular action. although the flight-or-fight-response normally ends with the removal of the threat, the constant mortal danger in combat zones likewise constantly and acutely stresses soldiers. general adaptation syndrome the process whereby the human body responds to extended stress is known as general adaptation syndrome (gas). after the initial fight-or-flight response, the body becomes more resistant to stress in an attempt to dampen the sympathetic nervous response and return to homeostasis. during this period of resistance, physical and mental symptoms of csr may be drastically reduced as the body attempts to cope with the stress. long combat involvement, however, may keep the body from homeostasis and thereby deplete its resources and render it unable to normally function, sending it into the third stage of gas: exhaustion. sympathetic nervous activation remains in the exhaustion phase and reactions to stress are markedly sensitized as fight-or-flight symptoms return. if the body remains in a state of stress, then such more severe symptoms of csr as cardiovascular and digestive involvement may present themselves. extended exhaustion can permanently damage the body. treatment 7 rs the british army treated operational stress reaction according to the 7 r's: recognition – identify that the individual has an operational stress reaction respite – provide a short period of relief from the front line rest – allow rest and recovery recall – give the individual the chance to recall and discuss the experiences that have led to the reaction reassurance – inform them that their reaction is normal and they will recover rehabilitation – improve the physical and mental health of the patient until they no longer show symptoms return – allow the soldier to return to their unit biceps modern front-line combat stress treatment techniques are designed to mimic the historically used pie techniques with some modification. biceps is the current treatment route employed by the u.s. military and stresses differential treatment by the severity of csr symptoms present in the service member. biceps is employed as a means to treat csr symptoms and return soldiers quickly to combat. the following subsections on the biceps program are adapted from the usmc combat stress handbook: brevity critical event debriefing should take 2 to 3 hours. initial rest and replenishment at medical csc (combat stress control) facilities should last no more than 3 or 4 days. those requiring further treatment are moved to the next level of care. since many require no further treatment, military commanders expect their service members to return to duty rapidly. immediacy csc should be done as soon as possible when operations permit. intervention is provided as soon as symptoms appear. centrality/contact service members requiring observation or care beyond the unit level are evacuated to facilities in close proximity to, but separate from the medical or surgical patients at the bas, surgical support company in a central location (marines) or forward support/division support or area support medical companies (army) nearest the service members' unit. it is best to send service members who cannot continue their mission and require more extensive respite to a central facility other than a hospital, unless no other alternative is possible. the service member must be encouraged to continue to think of themselves as a war fighter, rather than a patient or a sick person. the chain of command remains directly involved in the service member's recovery and return to duty. the csc team coordinates with the unit's leaders to learn whether the over-stressed individual was a good performer prior to the combat stress reaction, or whether they were always a marginal or problem performer whom the team would rather see replaced than returned. whenever possible, representatives of the unit, or messages from the unit, tell the casualty that they are needed and wanted back. the csc team coordinates with the unit leaders, through unit medical personnel or chaplains, any special advice on how to assure quick reintegration when the service member returns to their unit. expectancy the individual is explicitly told that he is reacting normally to extreme stress and is expected to recover and return to full duty in a few hours or days. a military leader is extremely effective in this area of treatment. of all the things said to a service member experiencing combat stress, the words of his small-unit leader have the greatest impact due to the positive bonding process that occurs during combat. simple statements from the small-unit leader to the service member that he is reacting normally to combat stress and is expected back soon have positive impact. small-unit leaders should tell service members that their comrades need and expect them to return. when they do return, the unit treats them as every other service member and expects them to perform well. service members experiencing and recovering from combat stress disorder are no more likely to become overloaded again than are those who have not yet been overloaded. in fact, they are less likely to become overloaded than inexperienced replacements. proximity in mobile war requiring rapid and frequent movement, treatment of many combat stress cases takes place at various battalion or regimental headquarters or logistical units, on light duty, rather than in medical units, whenever possible. this is a key factor and another area where the small-unit leader helps in the treatment. csc and follow-up care for combat stress casualties are held as close as possible to and maintain close association with the member's unit, and are an integral part of the entire healing process. a visit from a member of the individual's unit during restoration is effective in keeping a bond with the organization. a service member experiencing combat stress reaction is having a crisis, and there are two basic elements to that crisis working in opposite directions. on the one hand, the service member is driven by a strong desire to seek safety and to get out of an intolerable environment. on the other hand, the service member does not want to let their comrades down. they want to return to their unit. if a service member starts to lose contact with their unit when he enters treatment, the impulse to get out of the war and return to safety takes over. they feel that they've failed their comrades who have already rejected them as unworthy. the potential is for the service member to become more and more emotionally invested in keeping their symptoms so they can stay in a safe environment. much of this is done outside the service member's conscious awareness, but the result is the same. the more out of touch the service member is with their unit, the less likely they will recover. they are more likely to develop a chronic psychiatric illness and get evacuated from the war. simplicity treatment is kept simple. csc is not therapy. psychotherapy is not done. the goal is to rapidly restore the service member's coping skills so that he functions and returns to duty again. sleep, food, water, hygiene, encouragement, work details, and confidence-restoring talk are often all that is needed to restore a service member to full operational readiness. this can be done