PROCEEDINGS OF THE NEUROPSVCHIATRIC CONFERENCE of iho SIXTH SERVICE COMMAND John B. Murphy Memorial Auditorium AMERICAN COLLEGE OF SURGEONS 50 East Erie Street Chicago. Illinois 16 - 17 NOVEMBER 1945 Major General David McCoacb, Jr. Commanding Colonel William J. Bleckwenn Consultant in Neuropsychiatry Colonel Don G. Hiildrup Surgeon AHL FORM _ 1 NOV 49 1 O Colonel minara i. Bleckwenn Consultant in Neuropsychiatry Colonel Don G. Hilldrup Surgeon CONTENTS Address of VTolcomo* ..•••••••• 1 Introduction •••••.•.••.••••••••••••*• 2 Greetings and Opening of Sessions • ••••••••••••* 3 X Psychiatric Roactions on Bataan « Corrogidor . ./5 The Division Neuropsychiatrist •*••••••».•••••• 10 The Combat Syndrome • •.•••••••••••••••••• 20 Neurosis, hour otic Reaction 38", was another factor in the fixation of the combat syndrome. To the psychiatric casualty it was a conno- tation of a combat syndrome with ineffectiveness for further combat duty. When available, capsules of sodiun pentothal or other barbiturates were administered with no material decrease in therapeutic efficiency. A daily dose of 10 units of insulin resulted in gratifying improvement in those of complete anorexia associated with negativism, of a catatonic-like typo. Continued improvement at the end of AS hours was manifested by interest in Surroundings, insight, and satisfactory motiva- tion. 'Than conditions permitted, three tents wore sot up, or throe wards in n building during the winter months. One was used for completely sedated eases, one for post sedated cases who manifested satisfactory progress, and the third for the "ready to go back t' duty cases". The latter typo of cases wore assigned to the "refitting company", located at the Administrative Center, the r.ar element of the division. This company had a line officer as co-randor. There wore facilities for showers, cleaning of laundry, and replacement of lost clothing. Daily lectures wore given on the progress of the division in the campaign, A ;u/’icr.l 'fficor present for sick call and reassurance in regard to minor ailments. The ••• t losphcre was deliberately more military than medical. It ■ • • ... noted that no mention has been made relative to a careful history, I- the division • u did not foci that it x/as our purpose to unearth too much of the past history of the soldier. v. ' ash to r-w-a’.v.ken old conflicts either by direct questions or deep and. prolonged narcosynthesis. Abrc.ac- tion for the more recent subconscious conflict serves the functior of first aid therapy within the division. Psychotherapy, or any of thj detailed methods of analytical treatment, is mentioned only in passing. Obviously, they have no place in the therapeutic regimen in a division during com- bat. However, there is-a form of psychotherapy which, un- questionably, produced gratifying therapeutic results, if conscientiously applied, from*the divisional level throughout the- channels of medical evacuation. It has been referred to as indirect psychotherapy, and includes a kindly attitude and a personal interact in the patient, physical comforts and proper nourishment, F.wd Dress assistance in the daily distribu- tion of toilet articles, individual soap and towels, cigar- ettes, Hershey bars and literature, to these patients in the division during combat. An affable salutation by the admitting officer, and a hand-clasp, has frequently been more effective therapy than any other at our command. The material items enumerated arc usually attainable, but the abstract phase of indirect psychotherapy has been found-wanting. It is a critical indictment that indirect psychotherapy is frequently and unin- tentionally, omitted in our nodical installations. The importance of these simple and obvious measures in the therapy of psychiatric casualties should not be underestimated. Brig, Gen. r*illian C. Menninger,* aptly refers to statis- tics in the following -ords; ”2ven though wo know statistics lie, v:e invariably place irrational credence in then. The goal for us in tn nodical department is the efficiency of the unit, not how it looks on paper". The psychiatric casualty statistics of any *;Lvcn division can be evaluated only by a consideration of the nun. reus variable military situations encountered by that division during a given period. Divisional statistics nay bo likened to a portion of a picture puzzle. Alone it has no final significance. However, when properly inserted in the total picture, the combined result will prove to bo a monumental con- tribution t: military psychiatry. SUMMARY 1, A •pell integrated personality, which is a more or loss constant factor, combined with a high degree of morale, an inconstant factor, makes for the ideal combat soldier. 2. A few of the many factors which tend toward fixation of symptoms, in the combat syndrome, are enumerated. 3. Immediate sedation, as far forward as possible, begin- ning at the battalion aid station, Is the therapeutic manage- ment of choice. A. The opinions and set forth in this paper arc not tc be construed as official or reflecting the views of the medical department of the arm^y, but rather, the im- pressions of an individual division ncMiropsychiatrist, *Thc Military Surgeon,Vol. 96,No. 2, Fob. 1945. DISCUSSION of MAJOR A. J. BONER'S PAPER Nathaniel J, Berkvatz, Major, M.C. Gardiner General Hospital, Chicago, Illinois. Major Boner is to be commended for his clear and compre- hensive presentation. The several Division Neuropsychiatrists v;hon I met in the European Theater have held essentially the sane opinions and conclusions as Major Boner has just expressed. Since I have little to odd or detract from his paper, I will give you a few nerds of ny ovm experiences as an Infantry Division Neuropsychiatrist. Since I entered the service, I have had the good fortune of serving as a neuropsychintrist in station, regional, and general hospitals, as well as in Neuropsychiatric Consultation Services and as a Division Neuropsychiatrist in the European Theatre. As a Division Neuropsychintrist as well as in a Neuropsychiatric Consultation Service, the primary function of the neuropsychiatrists is to practice preventive psychiatry rather than to treat and to dispose of cases as generally practiced in Army Hospitals. I consider the establishment of Neuropsychiatric Consultation Services in the various Training Centers and the assignment of ncuropsychiotrlsts to combat divisions as two of the most out- standing contributions to military psychiatry of this war. In both of these assignments the psychiatrist is offered the greatest civ 11 eng e and opportunity to help our beys adjust to the service and. to hoop down the psychiatric casualty rate. To practice preventive psychiatry successfully, it is man- datory that the -utmost support and. cooperation of the Commanding General of the unit is obtained. If this is attained better cooperation from the classification, personnel, and plans and training sections is then also procured. Another important function of the Division Meuropsychiatriat is salvage as nary men as is possible and to recommend evacuation for only those who cannot be used in the division. Early or unnecessary evac- uation of non to hospitals is fraught v/ith danger. Unless hospital treatment is definitely indicated the soldier often suffers additional psychic trauma when evacuated to hospitals in the pear. There ho is placed in close association v/ith other emotionally upset individuals and he invariably finds the morale of the patients considerably lower than that of the non of his original outfit. Our clearing station v/as generally situated in school houses, private residences, or in tents from 5 to 15 miles behind the front lines. Here it was not difficult to distinguish those admitted for nontal conditions from those admitted for physical injuries, Ever those who suffered severe injuries talked freely, joked, and were grateful that they wore still alive, whereas the former appeared dejected, depressed, confused, and spoke very little. The}- seamed to have a guilt feeling for not being able -17- to take it any further, leaving their buddies behind, and won- dering ’.;hat others ’.’ill think of then. They generally appeared stunned, blank, or bewildered and their symptoms were of the free floating anxiety type. Those admitted to the clearing station with mental dis- turbances v.'cr.Q.placed in our wards. After taking a brief his- tory and making a cursory examination, the patient was immod- iatcly given 6 to 9 grains of sodium amytal with hot drinks. He •ms then undressed and put to bod. Twelve to fifteen hours later, he v-c awakened f~r mealtime. Unless he still remained disturbed, lie as iad.o t? get up, trash,, and shave, and one of our men - vld give hi”1 a haircut, "fe then transferred him to another ward where wo had a radio (donated by the American Rod Cross), magazines, St'\rs& Stripes papers, and some large orien- tation maps or the walls. r.’o saw that ho got plenty of nour- ishment, An attendant vms present at all times to see that the conv n the patients carried on was not harmful to their well-being and he did not allow them to sit -alone and worry, Re encouraged thwse who had improved to help their buddies keep occupied by playing checkers or leading healthy discussions, I had t- trained psychologists and 4- or 5 ward men wh'-1 were carefully 1 etructed not to be too firm, not too solicitous, but friendly t • the soldiers, Vo posted a daily war bulletin on the v:rll one. I passed all information I could get in re- gards to our .army positions, who were on mir flanks, and how promising the future appeared. I assured them that our casualty list was net nearly as bod as many often surmised when they got excited and panicky. Intravenous sodium amytal vr s given to of the more severe cases. If this failed I gave them faradic non-convulsive therapy with intravenous sodium amytal. Very favorable results ’.-ere obtain.: ! ■ dth this treatment and I am now preparing a paper of ny results with this typo of treatment for publica- tion. I node a practice of not keeping any patient in our unit for nre than four days, ’’non no •/ere unable to dispose of our patients ith.ln four days an increase of psychosomatic exo- plaints usually became quite cannon. They found life away frx'i the fr 't linos too cxifortable and pleasant. Not infrequently on t!n. thirl ’ay such remarks as "By the ray, 'Doe', what is wr ng ’-1th -r-r elbow," "Why does my heart pound so fast," or "I got severe headaches often," were made, I would promptly re- examine the soldier and then explain to him her psychosomatic conditions arise -an*1 the danger of rorry about symptoms when no underlying organic basis could be found. This early reassurance had proved very beneficial in our experience. *.7e designated all of our cases as C.E. eases (abbreviated for C-nbat Exhaustion) for of a better nano, I believe that la jar Dan.-r’a method using letters to designate different reaction typos was an excellent idea. In nest Divisions 6 per cent of all admissions to clearing stations were C.TS. eases. In three months of continuous active combat duty in cur Division only 4- per cent of all admissions were admitted for this condi- tion. Mo returned 65 per cent to duty, but this percentage would be higher if me did not evacuate 12 per cent of our ad- missions for trench foot or other physical conditions found in conjunction -.1th their rental disorder. Only 20 per cent of our patients mere sent on to evacuation hospitals for mental con- ditions alone for further observation and treatment. Only 8 per cent of our first admissions were returned to us for a second admission. Ten percent of our admissions -.’ere found to be un- qualified for front lino combat duty, but they showed sufficient skill or other qualifications to be retained in the Division for Limited assignments, Svory one of these had made excellent adjustments in their new assignments. The assigment of a Division Psychiatrist was not an easy one. Our original table of equipnont was very United, Although we were assigned to the Office of the Division Surgeon we drew our supplies fr-an the Nodical Battalion Surgeon and we often got only the supplies the Medical Battalion do without and we often got the least desirable quarters to house our patients. Any recommendations to inprove conditions in the Division which wo offered had to go through channels. To obtain action through channels is a matter which I io not intend to discuss today. Before I close I would like to make one suggestion: I believe that the Division Neurnpsychiatrist could function much more effectively if ho were made a junior staff member of the Division rather than have him assigned to the Office of the Division Surgeon, THE CO'SAT SYNDROME Nila 3. Hersloff, ha jar, M,C, * Abraham Brodsky, Captain, MC. * This term, Combat Syndrome, refers to the battle reaction as seen at the front lines. This may bo an acute state precip- itated by a shell concussion, or induced by prolonged arduous combat stress, or further, it nay develop a day or two subse- quent to hosp'talization for shell fragment or other typo wound. Personal experience ■•ith this entity, gained in the European Thea.trc of Operation and Southwest Pacific, relative to the psych-'neurotic effects of combat experience, have led us to cer- tain conclusions regarding this syndrome. In contrast to the circumstances usually found in the de- velopment of what we might term the "civilian" psychoncurosis, it appe-ars that, in very many cases of combat syndrome, there is a complete absence or very minimum presence of pre-disposing factors. The environmental and personal factors generally recog- nized as initiating or influencing the groa-th )f a neurotic character are absent in many cf the patients suffering combat syndrome. Neuropathic traits are not necessarily related to the syndrome. To the contrary, these same traits may propel the in- dividual to extend hinsolf, committing the most adequate service in a xlit-ry sense %o a p-int of exhaustion without dev.loping the. c il.r'.t syndrome. G'-riV'-t reactions are only occasionally the result of a single orperience as compared with the oti'logy and devclopnont of the civilian psychcncurosis. The syndrome is determined by sue'., factors as persistent threatening situations, oppressive physical activity, intolerable living conditions and most trauma- tizing, in many instances, is the casualty of a "buddy” with the concomitant overwhelming loss of security and confidence derived from grmip psychology. In C'-r.b'vt syndrome, precipitating factors .arc sudden, less accunulrtiv o, lacking in chronicity and arc unrelated to previous experience. It ie recognized that long periods of combat service can croat.. persisting cumulative reactions, but it is felt that these do not compare with the contributing factors to the civilian neurosis which nay have been of years duration. It is rise recognized that the fearful contemplations of prc-conbat nay influence the thinking and behavior of the individual although this factor does net appear in the- syndrome of combat exhaustion. rJhilo the Ar y has recognized the need for establishing some semblance of combat experience through the battle conditioning Pha sc of its basic training program, it cannot necessarily fully simulate the utter realism of battle. This element—the realism of battle—dismisses the. possibility of fantasy in the develop- ment of the combat syndrome. Shellings, bombings and strafings ♦Percy J-'-nos Convalescent Hospital, Ft. Custer, Michigan, produce no dronn states comparable to the rich fantasy life of the civilian psychoneurotic. Jinny mild civilian neuroses are held in chock through rational escape mechanisms. In the precipitation of the combat syndrome escape is not a factor. The hell of combat can neither be rationalized nor escaped. The most severe reactions seem to havo come from combat situations where there have bocn considerable holding actions or reversals such as occurred at Anzio, Cassino and the Belgian Bulge, To reiterate for the purpose of emphasis, the clinical picture of the combat syndrome does not suggest previous neuropathy . nor does it scorn allied to the civilian types of psychonoiorosis. At first glance, the patient appears enervated, lacking in in- terest except for displaying varying degrees of apprehension. Objectively the picture reveals apprehension, bewilderment, psychomotor retardation, poverty of affect, memory impairment, restlessness and irritability,to mention only a few, but nonethe- less consistent elements of the syndrome. Those cases have been followed through from th-. clearing station to the evacuation hospital, the station hospital, the general hospital and, finally, t~> the convalescent hospital, and generally the symptomatology differs little from that just described. It is interesting to note that after evacuation and remov- al fr:m the acute areas of precipitation, the patient very often develops a fixation of symptoms in order to assuage the super- ego and his consequent guilt feelings. The prognosis of the combat syn’r'.io reveals a growing tendency on the part of the patient tovrard rationalization and utilization cf defense mechan- isms, all aiming at the alleviation or displacement of his guilt feelings. The need for self-Justification becomes more evident. It is felt that the clement of guilt becomes markedly present at the HZI” stage of the combat syndrome and it nay bo well to suggest, at this point, that civilian agencies charged with the treatment of the discharged combat syndrome recognize that worth- while endeavor, particularly that related to the war effort, will help the patient in satisfying his need.for self-justifica- tion, his desire to bo of service although removed from actual fighting. Another impediment to satisfactory prognosis is the feel- ing of personal defeatism found in many patients. In others the desire, for discharge is so strongly folt that he unconsciously retains his symptoms until ,medical discharge is assured. This attitude is not to be regarded as malingering, but should bo viewed ns synptomic. Return to the Zone of Interior also brings about ,tho incep- tion of other factors which impede favorable prognosis .and confuse, to some extent, the patient’s clinical situation. Having been returned to a place* near home And having- frequent opportunities of renewing home ties, the patient absorbs all of the economic aid social problems involved in his homo environ- nent, These problems have arisen, in the main, from his ab- sence from the hone and, recognizing this, he feels a definite responsibility. The alleviation of those problems becomes uppermost in his thinking and sooner or later his family anxiety becomes super-imposed upon those which have arisen from his military experience. In an effort to deal with patients suffering from the combat syndrome for rehabilitation to duty or civilian life, various methods have been utilized. At the level of the con- valescent hospital the therapy program consists of orientation, group and individual psychotherapy, vocational guidance, physical reconditioning and trials on a civilian level. The therapy utilized is both general and specific varying largely as to the individual needs of the patient. It is felt that the c hospital is a definite aid in stabilizing the combat soldier and experience shows that the majority of patients are symptomatically improved and feel they have benefited by convalescent hospital care. An interesting reaction in about ten per cent of the cases of combat syndrome become manifest at an early date in the patients' convalescence. This group was noted to have shown gradual, but progressive improvement for from three to four weeks subsequent to their return from furlough. Following this period, however, their condition was observed to regress ap- proximating the level cf the clinical picture on admission. Study of th-.se cases demonstrated a sense of insecurity and lack of confidence pertaining to adjustment to civilian life. this problem aggravated, accentuated, and perpetuated the anxiety condition. Psychotherapy in both large and small groups failed to check or alleviate this process. Individual attention, however, elicited the fact that firstly they had misgivings as to their immediate future in civilian life and secondly they were not only ashamed of this feeling of insecurity, but also were dubious as to their abilities, to compete on a civilian plane. From, a practical standpoint it was decided to inform the patient regarding his ultimate disposition, namely, separation from the service and then to give him a trial furlough of from five to ten days. This enabled the soldier to straighten out familial or domestic problems ho was unable to cope with on his convalescent furlough as well as permit an opportunity to gain employment, and .lastly to accustom himself to the routines of civilian living, TIhcn indicated these trial furloughs are often times repeated. In this manner the patient still retains the advantage of his rapport with his nodical officer who has indiv- idually handled his case since the day of admission. If further psychotherapy i? indicated, it is administered. Other problems of the patient also may be discussed acre fully. When the patient is ready,and with the approvals of his medical officer, he is separated from the service and Is confident regarding his civilian adjustment. Approximately ten per cent of those boarded by myself have required and requested such handling and benefited by this policy as shown by the amelioration of the remnants of the combat syndrome. To summarize, wo find that in the combat syndrome precipi- tating factors are sudden, lacking in chronicity and unrelated to previous experience. Civilian predisposing factors play a negligible port in the original picture and neuropathic traits arc not per sc related to the syndrome. Following evacuation to safe areas, symptoms tend to become fixed and guilt feelings become predominant, associated with feelings of personal defeat- ism, Return to the 21, renewing faraily ties and responsibilities, frequently initiates new anxieties which are superimposed on the combat syndrome and hence alters the clinical picture. It is felt that a stay at the convalescent hospital prior to return to duty or civilian life materially aids the patient in resolving new anxieties and gives a better insight into his overseas exper- ience. DISCUSSION of C0?1BAT SYNDR0?!E Chester L. Reynolds, Commander, (HC) USNR, U. S, Naval Hospital, Great Lakes, Illinois. "hjor Horsloff and Captain Brodsky have presented a clin- ical oroblcn which, though exhaustively xTitncssed. and investi- gated during the recent years loaves nuch variance of opinion as to ncchanisn, dynanics, and exact nosological place among disturbances of nentation. In our sincerely motivated desire to save foclin-'s and serve up a paJLatablo label for those per- sonality disruptions storming from the horrors of World War II uc have seised* upon this dramatic and sympathy-provoking tag of "Combat Fatigue", Lot us not be blind, as wc wore so long when t;c errployod the term "Shell Shock", to the true nature and gen- uine understanding of this entity for the broad, sociological and preventive psychiatric implications involved in the problem, We, in our experience are cognizant of the fatigue factor in those men vh., pounded and pounded again with repetitious, dogging fear, lose their resiliency and can n? longer assimilate their fearful experiences: There is reasonable evidence to show, however, that nn man can panic or break dorm as a result of a. contemporary fear alone. Wo believe those patients have been saving up their fear and carrying large volumes of inexperienced fear bo lev; the level of consciousness. This has been occasioned fcy very early psychological happenings which heretofore have not given rise to neurotic expression because no trauma with the impact of that experienced in combat threatened the organism, Were I ashed x.trt single psychological factor operates most prom- inent V1, in producing combat fatigue, I rruld answer, "Insecurity"j tremendous, overwhelming, inescapable, acute insecurity from which there is no solace except through the development ;f a mcnt-l illness. Wo have fund that great numbers of our patients cone frm broken hones, family relationships disrupted by death or divorce; that they mere boys still conscious of their having boon rejected as children; boys who lacked parent ideals, and boys who never had the sense of belonging to a family. Those lads, then, ere face to face xvith the most critical test of stability, the most threatening situation they have ever experienced. Here they moot xmeertainty and insecurity and meet it consciously, unmasked in its bare, stark naked reality. By virtue of their early deficiencies in emotional development, insecurity has al- ways been prominent—for the most part, unconsciously, prior to this—but now it cones as a gross terrible experience crash- ing dox/n upon them. When the factor of insecurity is thus understood in the total picture of the Combat Fatigue, it becomes even more readily understandable why these boys who have seemingly na.de good progress toward recovery, regress when subjected to situations fraught with the sane threat while on furlough or on convales- cent leave. Wo have found such occurrences therapeutically advantageous in working through with the patient the realization that he needed something more than just food and rest to return to a state of efficient, comfortable functioning. One cannot pre- dict v/hether these patients would or would not have broken down later on in life. It night be assunod that being repet- itious ly subjected to traumatic life experiences, which would activate the insecurity principle lying dormant and waiting for expression, that they would. The challenge which this problem brings to the Social Sciences is tremendous for if wo arc to execute a dynamic pre- ventive program for this and allied neuroses, it will not bo enough to afford concentrated vitamin foods and adequate rest for our soldiers and sailors, but more important—adequate oppor- tunities for hoalthy growth and development from childhood on, 17ith the success of such a program wo may hopefully move toward the day when thoro is no longer not only "Combat Fatigue", but the mass neuroticisns which contribute to the making of war itself. NEUROSIS, NEUROTIC REACTION AMD MOTIVATION I.> L. Turow • ■ Major/ Medical Corps Percy Jones General Hospital, Battle Creek, Mich. Few of us, before ,the conflict, have had tho opportunity to observe, so•closely, how the personality functions under stress. The intimate contact-.which the military psy- chiatrist has had with non under tho varied conditions of military life, the. observations of the, effects of separation, group thinking, motivations,.interpersonal 'relationships,• regimentation, splf-nrotective behavior jdriyqs/.jSdbial* and cultural standards, indqed. the whole gamut of - physicalenvironmental and psycho- logical, onslaughts against thfr{total personality have provided the psychiatrist with an upusutel opportunity to widen his scope and to cause reorientation-in his- -.thinking regarding emotional reactkn and illness. The war,' situation with its over present throat against individual security in bembat, yes against tho very existence of the individual in his battle for survival, has frequently fully exposed the innermost part of his emotions and "crudely removed or cor.nl < tely stripped its veneer." At the beginning of tho war the. military psychiatrist had to usi. as his measuring stick in diagnosis the experience and diagnostic criteria which he acquired in civilian practice. Civilian and army diagnostic standards were in the main closely akin. As tin*, went on our a my experiences began to rake us more acutely aware of th< part played by sociologic, cultural, and physical influences to Individual tolerance to stress, and we then began to note that our nomenclature and standards of differentiation between normal emotional reaction and abnormal emotional reaction, to the army str< ss factor with all its com- ponent influences was not as clear cut as we had previously imagined. Furthermore, experience quickly taught us that to use such a common tom as psychunourosis and apply it to individuals who were temporarily incapacitated by reaching their limit of tolerance, to physical and mental stress was not specifically applicable in all situations, and often presented tho soldier with a stigmatizing handicap which would greatly interfere with his later civilian adjustments and relationships. The lack of clear understanding both by tho laity and some nrofossional people, oftinos further co.ifused by so-callod scientific double talk explanation, brought Us to the stago wherein we w..re challenged to evolve from experience gained, a bettor set of concepts for diagnosis and, what obviously follows, a more concrete method of treatment principles. In this naper an effort is being nado to evaluate tho difference between neurotic illness and reaction. It is ad- mitted that differentiation is frequently difficult. II' we are to attempt to separate tho two it beeorea necessary to attempt a definition of terms. It is unfortunately not possible to give a precise definition of the tom "psychoneurosisMany writers only attempt to describe the s-’mptons, divide thorn into symptomatic categories, but fail to point out the lino of cleavage between the end point of norm- 1 reactions and nourvtic Illness. It is a '-onoral working orincipl- that when symptoms iron d- the fficioncy f ar Inaivi iual and or ••/-•nt him from 1 mdinp •>. s. - cell d Iv.r.py, adjust-, d existence, neurotic illness is to bo assured. The nur:-t ion and extent of th-.; a;,•motors, and tv specially tin. ufi-.cte. of r-.roval or a.It- ration of th-. onus s which or - due- th symptoms, ere important in dotormininf th. existence of oen—aio tuac-' of a n- urefcic illness. Kaur< sis * Tie n uros ,s -..re disorders of behavior and somatic function arlsiay out u th. difficulties which individuals moot in gaining satlefac si on of th-'ir n-:ods 1;. th* cultural milieu of which they ar- e. : art. Th s., needs ar ; of thru- primary categories; 1) th- bi L.-vlc nt-.d;: of nutri' ion, sex and prut- ction during a.lol- ee e-.riods of lif-:, 2) th • cultur: lly inculcated needs of -r. st.i ;• or status in tin ra cial preup, and 3) th ru.-ni to dls- cn-ar ■ h stll . • ryrossiv- tensions resulting from th f rust rat ion a f t’n Of 1..oic and cultural :ee- ic. The; factors -.1. t.rnininp the •ccurrerv ,-f e arc tic s'-mptons in an individual tires 1) the depr-.e or iat ' -r ti-.-n of the- s- If or personality, and, 2) the curr it -‘ruatr 'lens .f his needs. At tin s vc hav ■ boor all t'-nc, but rath, r symptoms a* aouto maladjustment to Into lor- bl< g i.tua‘; Lrric. I am in . -r -. pvnt with Past->* and others that it tr., rat* ate nr- tr-a*- d, nr-nptly, r /classified, and placed in nca-c-inbatan': unit:; irvru-lint ly eft. r th<* onset their synutons, tho majority o£ th-. i will c*-ntinu*• to function in the army. They rill then ro.tur.a t< civilian lif>v at the on.; •-£ th Ir t.rn of r rvicu n t • a invalids, but ns h • Jthy individuals who hav actually ..cnt their share to th-; best of their ability. tl\" ti • ns Much has be* a written ana ccais idcrabl- er.ohasis has he on : 1 * f■ ; a the ,v,rt motivation plays in th- mental health • f tho g I i-,*r. The intl.na . re..ticnohip bot'/e.r v.ur; psychiatric isabiliti g and with its feun . .tions of r-cd leadership, lisciplitte# rc-o-l i.-ntal h- .alth, yrour spirit, indoctrirr. t .l . n, ri-.nt--.tion, ana r 1-at d -.ff >rt: arc well known by this tine, - I do not int oei t discuss then h- r . The unci-no«al us Gtru *f*l- b tr --a th-. a■ rands of th:; instinct of self-nr .s-. '-vat' on ir, att ;; ,otin,-* t rcr.o 7 tiie ir Ivldunl fr.-m. the r- th .if ''an • r and th- rrnvsia.* ■ lor t of r.opair-non4- t; fif.ht, fear of r c. •••; itier. !>y ;v mr 3 of this far, the indoctrination ana r r tat lea h 1*1 ait, certainly nr me , a nr n ..ud -us conflict in " any a ... la th* in-a*T--ctiv c and in those who have succumb..- . i ”c ribv.t fatiruo", ;v a •in- could net b*- broken until the viren. -J"i ctr-.ss st rv/h.-lp d then, this Conflict with'ub . . ubt has or euo- . rsyclu-l. ;ic repercussions. I:, th yr mu >-i' n-ur psychi M.ric lisabi lltios r turn' d Mr -* rs. as th*' r. hiw.tl.jn fact - *r are; attitude t.'wnr 3 furth r an,.y G'.rvi" . revs In nany instances oc.en ensure al tc b«. at a 1 .' lev ?. All to -I* to a h .0 the psychiatrist ha* -n ihc*d "ri th eh- mi sti. ... "lin/ is it pussibl ; t; pr .;tv\* ir.nro wmnrt in tr: T ati- .it, wh n hi S P.etl Vatie-Ii tcv rd Sorvic*. IS it S 1. V/ a~- Mb?" The. e Mae-cat P y-ii.a by r«. -ression into lustiny illness as a a a.as I* - r..tec tiro- th in iviaunl frar. furth r ar-:.y thr .at is :• t ir.fr uj '.tly a najor r>pv blen to contau-'i v/ith. I an sur-v that fr- ru.ntly peer . tivation is a barrier tc resolution of syrsptc r.s. S y'aration in r. th* .-*r..-ui. and 1 ,-ss c>f unit identification oy h . s-vitaliz-.ti-,,.a an i ovacnation tc, th* zoru* of the inte-ri-r is a fact; r, anon" nany etrv. rs, which soru-tines changes the attittJ.dc ani f.r service fror. . to poor. This is ■articularly n tic able in the iruat, the psychopath, nnn for proving nodical disability. The ’War Department in its circular Ul, dated 13 March, Ibio, clearly recognizes the effect of poor motivation and attitude, stating, "There has been a tendency to attribute non- - I factivenose tc coexistent nodical delects such as flat feet, 1umbo-sacrai strain, or nil’ psychonourosis, when actually these cel\.cts v/«re not in th..mselvos significantly disabling and tile primary caus , of the nonvffoc -*iv«noss v/r.s nonn.niical, -.g., inaptnoss, inadaptability, defective attitudes." Defective motivation and attitudes in the absence cf incapacitating psychi:-trie illness, if allowed to bo considered a part of illness and considered a nodical disability, will net only prove detrimental to unit morale, but is plainly a sign cf haphazard psychiatric thinking, ’he have all too often soon what remarkable adaptations are mc.de by non with valid neurotic illness.;s to army assignments for which they are psychologically fitted. Poor motivation and attitudes are not primarily com- ponents of illness. Psychiatry has received excellent recognition during this war and has gained a greater place cf prominence in nodical practice than ever before. It behooves all of us to utilize the experience which we gained in the understanding of emotional problems that in our fu -urc civilian practice this knowledge can be made more useful to the welfare of the individual, communitv and nation as a whole. 30 NEUROSES, HEUROTIC REA.CTIOII AtiP IIOTIV/.TION Discussion by Francis J. Gerty, H.D•, Professor and. Chairman of Department of Psychiatry, University of Illinois In civilian life the succes of on individual is measured In terns of ’nis ability to bear Ills own special responsibilities and his fair share of the group burdens. To fail--to fall be- low a somewhat indefinite acceptable minimum in these things, Lc looked upon either as justifying blame because of a lack of moral fiber, n ’*badness11 of some sort or degree, or else is excused as being due to misfortune or illness. Tho stresses of civilian life are commonly less dis- cernible, less definable, and usually loss dramatic tlian those of military life during v/ar. Further, in a military service, his portion of the group burden is directly and uncompromisingly thrust upon the individual. His responsibility to and for himself becomes of secondary importance. Kis choice, his pleasure, his profit, his safety are mutters about which he can determine only what military rc,dilations permit, which is much loss than he is accustomed to deton.inn. hevorthoiess, all men in the military service grow up as civilians and expect to be civilians again, a matter of some importance for tho future. The funda- mental Mechanisms acting in them an those- of the civilian, but these mechanisms are put Into operation under unusual and severe test conditions of a somewhat more uniform nature than the tests of non-military life* The special tests and stresses act selectively to bring out a greater percentage of some ? ?cc:al sets of reactions than vrould appear in civil life. Taken altogether, it is to be* expected that tlv. general effect of stress will approxinat . that ,d in tho sane material under non-military stresses. Good motivation, i.o., good • ttitud„ or good moral fib; r, a thing of some complexity as to >rigin, will product- the good citizen and tho good soldier. Lack of this quality is thought of as a defect of material rath-r ban as an indication of illness. How this defect comes about rid how it may be distinguished from neurotic illness are viestions not easy to answer. /is to neurotic reactions, I think that is my bo granted that in loss striking forms they are of common occurrence in everyday lif- , but w#? have become so accustomed to thorn that we pay no great attention to them especially since they aro usually mild in manifestation. Combat, fatigue', and danger should pro- duce the: in more dramatic form, even in persons who arc ordinarily quite stable. The lesson I draw from Dr. Turov;* s paper is that a method 01' adequate examination of the patient and of the facts in his whole life history gathered from reliable sources is of para- mount importance if wo are to distinguish between the ones who will bear burdens and tho ones who will bo burdens under the’ . conditions of military service. Ilotivation, with tho reservation i have suggested, is tho touchstone which in actual tost will separate the fit from tho unfit. It will also be connected*with some differences between two types of tho unfit, those who will , not bear fyll burdens, the psychopaths, and those who cannot, the definitely psychoneurotio. bUS I DUALS OF COJIB'.T TEDVCSD AUXIUTY Charles 0. Sturdovant, Captain, HC Gardiner General Hospital, Chicago, 111. It is inevitable that demobilization will release from . Hi-/ ry sorvic . a number of veterans still experiencing residuals of combat induced anxiety. Veterans' clinics, civilian psychiatrists od physicians generally are seeing these men now. Some may need v rolonged card; many, possessing a nor-; stable personality structure, will need little more than an opportunity for insight and logical reorientation in peacetime i.nd civilian pur- suits. In th. neuropsychi-.tri'* section of a general hospital s rving a large n> tropolitan area v'o have had an opportunity to obsf.-rv- and ’■ret a r.ur.ber of rati ants n ar to separation from the servic- whom v/u belie/a- ■resent problems common in veterans» clinics today. Some ’/are admitted from i.tss or furlough because *f acute emotional disturbances while oth« rs wore referred from the medical and surgical Services within the hospital. A signi- ficant number of tnase patients gave no history of neurotic deter- minants be for-. tiic-y were overwhelmed by ..-xcessivu and harrowing combat exp rience. A grx-.ter number u».-.to i th i onset of symptoms to days or months following or cu tion from the battle zone altl.ouyi th ir disorder was similar, though less intense, to that usually designated as combat exhaustion in the forward areas. It is this group of relatively stable, nature and well adjusted individuals vrjiom we ha,ro design-..ted as suffering from residual • nxioty r. actions for the purpose of emphasizing their specific - •a.rareutl-- needs and good prognosis as contrasted to the more -lassie- * s of usvehon. urosic. In gtr.-ral, the residual anxiety reactions showed many /imilarities tc the usual types of neurotic illness but they difft red, s Goldstein pointed out, la that no fixation of symptoms or funda- i ■ vital personality change had taken oluco at this hospital level. ;>.cy s-, iied .ic non. ■ tael i she.u than "combat exhaustion" which * t. commission of civilian psychiatrists, reviewing tho psychiatric clicy in id J3urop an theatre, reported did not correspond to any r- cognized or established psychiatric syndrome. The differences • .re apparent in a comparative study of thirty-six residual anxiety states ; nd an. equal number of individuals presentin': symptoms y j sychon ;uros s whos--- histories won- indicative of neurotic ad- iustnent in the past. One. t of Symptoms All of the r;Siduvl anxiety group had exp- rienced combat or vary :.nf s verity and duration. The established nsychonturotic group h.id bvt.n ov-..roen s but only twenty had had actual battle experience. Their exposure to buttle conditions had. been much less Sever.j ;..nd prolonged for they Sj 10**0d an approximate average of thirty-si:: days in cornuat coryerc; to seventy-eight and nine tenthsfor the former. Study of individual cases revealed many differ nt factors responsible for the final psychoneurotic disablement in thoso predisposed. Thirteen developed symptoms while stationed in non-combatant bases — three while in isolated outposts in the Aleutians and one in Labrador. Symptoms of equal severity had ncen present before or sinco the day of induction in four in- dividuals. One patient claimed that his symptoms had not developed until ho entered the hospital for a second wound which appeared to be self-inflicted; another developed multiple complaints while recovering from an injury incurred in the rear echelons of supply. A r,larked increase in tremulousnass while aboard ship returning to the United States was noticed by a medical aid man. One medical officer and a tail gunner, who had been a prisoner of war after bailing out over Germany, developed acute depressive reactions after returning hone and learning of the infidelity of their wives. The twelve patients whoSu symptoms wore pre- cipitated by combat differed from the residual anxiety group in the character and fixity of their complaints. Four of them obviously exaggerated disability resulting from wounds or in- juries. One dental officer became extremely depressed after three busy months in a battalion aid station. One soldier ran to the rear as soon as he was placed undoP artillery fire; an officer cowered in his fox hole and was totally useless as a leader of troops from the outset of battle; one dfrrelopod an hysterical amnesia and a multiplicity of persistent gastro- intestinal complaints; and a schizoid gunner developed many paranoid ideas before he was relieved of duty because of a flak wound. The ten patients in the residual anxiety group who developed symptoms in combat did so only after prolonged or harrowing ex- periences. Severe stuttering occurred in one patient after a prolonged advance through the hedgerows of France. Ho recovered after five days in a rest camp only to break again when next ex- posed to the sound cf rrtillery fire. An enlisted man who had been through four major battles and a total of one hundred days of combat in the Pacific did not develop symptoms until he was subjected to bombing of the hospital where* ho was confined be- cause of a severe am wound. One patient was blown out of his plane and fell 14,000 feet before he could open his damaged para- chute; another could not continue after losing three pianos to enemy firo in five days. An officer in a holding position subject to nightly Japanese infiltration attacks and daylight bombing raids developed symptoms which persisted after ho was returned to the United States on rotation. A lieutenant who had served successfully throughout the African and Sicilian campaigns broke down after he had led five attacks into Cussino in three days. A near burst of an artillery shell caused unconsciousness and bleeding from his ears and, whon he tried to carry on, ho was unable to coxxtrol his weeping and tromulousncss. Latent N symptoms developing in twenty-throe patients after removal from battle zones were similar to those developed in combat. Six of this group we re accompanied to the hospital by frightened relative* who had witnessed a terrifying nightmare or had become concerned about the patient’s behavior. Symptom Analysis It is difficult to show clearly the difference observed in tho psychiatric examination of tho two groups although here the tense, hesitant, somewhat defensive individual who is suffering residual anxiety is most unlike tho established psychonourotic. Patients were encouraged to list their complaints with as little guidance from tho therapist as possible. The psyohonuurotic usually gave a good account of his symptoms with little prompting while patients in the residual anxiety group were more often reluctant to of thoff experiences and frequently showed embarrassment during the initial interview. The loading in the two groups were summarized for comparison. Tenseness and other symptoms typical in "combat exhaustion" were more prominent in tho residual anxiety states v/hilo phobic reactions, hysterical conversion symptoms, somatic complaints ana depression v/«r<‘ itore often encountered in tho psychonourosos. Somatic complaints wore common in both groups but there was little evidence of fixation of anxiety in tho former. Headache was as frequent in one group as the other, although only two of the psychoneurotics had a definite history cf exposure to blast as compared with twenty-three in the anxiety group. Tiu blast >/r.s of sufficient force to produce unconsciousness in five and tinnitus was present in six. A sense of "dizziness" was not mentioned in any of this number although it occurred six tines in tho psychoneurotio group. Little is known concerning tho role of blast concussion in tho development of "combat exhaustion." Most non who have seen tho amount; of combat encountered in our group must have boon oxoosod to some blast. In at least four patients blast concussion may have been partially responsible for their removal from combat although throe had other wounds, In several removed because of combit exhaustion, exposure to nour burst of artillery shells seemed to serve as tho final precipitating blow in their breakdown. Treatment The good response tc briof psychotherapeutic procedures and ;vn activity program designed to permit a gradual strengthening of the patients sense of personal security through contact with civilian life first led us to distinguish tho residual anxiety states from the more fixed psyohonourotic reactions. Treatment was conducted on an individual basis. Tho patient was uncouragsd to relate his symptoms and an attempt was mao to reconstruct associated events on a conscious level. V/hen this could not be accomplished easily hypnosis techniques wore employed. In our experience hypnosis accomplished the same results obtained with sodium am;'til or pen tot ha 1 sodium interviews. Uo are in agreement with Hurt and his associates who believe those drugs merely fa- cilitate hypnotic therapy. The same violent reactions on re- collection of traumatic scones of battle, often with mancod expression of guilt, wore obtained with all methods. The intensity of the response seemed dirootly related to the horror of tho * combat experiences. All patients reported subjective relief from tension after undergoing one of those "abroactive" sessions. Tt was necessary to repeat the procedure in some although con- tinued improvement was most dependent upon additional psycho- therapy, The material gained in various interviews was recon- structed in consciousnoss and was gradually related to past and current experiences as treatment progressed. In addition to participation in the recreational and occupational therapy pro- gram within the hospital, patients were urged to take advantage of free pass privileges in order to increase their contact with civilian activities. Thus, attitudes toward friends and relatives, hopes and ambitions for tho future as well as attitudes toward symptoms and military experience became tho basis for further ex- planation and reassurance. Dependent attitudes v/e re discouraged. The fact that symptoms often subsided after admission to tho hospital from furlough or pass stimulated discussions of de- pendency upon a known military regime in more than one ease. The mode of onset and duration of symptoms had little effect upon accessibility for treatment, iVo have ssen ono ease in which nightmares developing after tho last war were relieved twenty years later. A heightened suggestibility is apparent in some cases. This may lead to apprehension concerning the significance of symptoms if not actual displacement of anxiety. At least one case in this series first become fearful of heart disease after a medical officer had casually ashed him if he know he had heart trouble. The fact that ho had been able tc vrith stand the rigorous physical demands of prolonged combat was overlooked by both tho patient and his doctor# There does appear to be a real possibility that free anxiety noted in this group of patients may become trans- lated into functional disturbances. The neurotic fixation of anxiety apparent in the psychoncurotio group followed pattern?; established before combat experience. Treatment of phobias, conversion mechanisms and somatizations rem ining after the acute reactions induced by battle situations had subsided was not very satisfactory. In the residual anxiety group whom we have segregated, treatment usually resulted in the establishment of a healthy orientation and return to a level stability vrith little evidence of neurotic displacement or fixa- tion, This difference points toward the specific traumatic ex- periences of war as the significant otiologic factor in the develop- ment of symptoms in this group. Discussion Much has been written concerning the dynamics of the "war neuroses" since the evacuation of Dunkirk and the bombing of London, Brief, direct methods of treatment have afforded an opportunity to explore and relieve the acute reactions. Two generalizations have cone out of this approach which appear particularly applicable to this group whoso residual anxieties wo believe to be a specific product of thoir war experiences; namely, anxiety is the basic problem in tho war neuroses, and; oven the most stable individual will show* "neurotic" breakdown if subjected to stress beyond his individual level of tolerance. This breakdown appears to be a final mastery by more instinctual patterns in the struggle against the idealism and group loyalties which have controlled behavior as a respected member of a combat team. The acquisition through military training and discipline of ego strengthening devices which prepare the in- individual for the combat situation has been discussed by Grinker and others who speak of "combat exhaustion" as resulting from a final disintegration of the weakened ego in the face of overwhelming anxiety. Several different factors seem to be responsible for the continuation of symptoms or their latent development.- Identified as a member of a group the soldier exerts strong suppressive forces to hold anxiety in check. These are no longer so necessary when he finds himself removed through wounds or other illness to a hospital in the rear. The outlet for aggression which has been focused unon a common enemy is no longer available to him and ho finds behavior acceptable and unnoticed in the battle zone in conflict with wiiat is now expected. Gillespie in commenting or the latent period, mentioned the role of suggestioii either from within or without in the development of symptoms. He noted that so long as individuals wer-. kept busy thoy were loss likely to develop symptoms, but that given an opportunity, rumination over events experienced rather than perceived often led to additional meanings. One of our patients expressed this when he said that his symptoms did not develop until he arrived in a hospital in Paris and began thinking of his narrow escapes. Guilt feeling often expressed as a sense of failure in responsibility to the group and depressive fractions growing out of reflection over participation in some noxious act of aggression were soon us an elaboration of this mechanism. Some symptoms we iiavo observed are best explained as con- ditioned responses. The seasoned soldier soon learns the moaning of sounds and responds to them automatically. The startle* response often persisted after many other symptoms had been relieved. The slight scraping of a chair behind him caused one of our patients to suddenly freeze. He had been engaged in sabotage behind enemy lines and had become adept at evading the enemy. Lightning, the back fire of an automobile exhaust and other unexpected noises often caused sudden increase in muscular tension, palpitation and visceral sensations which as quickly disappeared when the situation was perceived. Generally, such reactions became less bothersome with relief from tension, elapse of time and reorientation. Most soldiers show an increase in anxiety on return homo— some of them admit apprehension. Host of them have a fanciful concept of the home to which thoy have yearned to return, still, after the first joyous reunion, their own strangeness becomes apparent to them. The realities of the challenge in future ad- justment where they must again assume responsibility for them- selves and others when thoy have had little tim** to recover from the isolation of functioning near to primitive levels S3i*ves as a further source of tension which may bring to the fore the re- sidual unresolved anxieties induced by combat. Undoubtedly, the majority of returning veterans will find security in old civilian patterns with a minimum of emotional disturbance. How many will encounter insurmontable frustrations loading to dependent neurotic attitudes in the future must still remain a matter of conjecture. SLIDE I ONSET OF SYMPTOMS Psyoho- ncurosis Residual Anxiety State Before military service 2 0 Since day of induction 2 0 In overseas base (no combat) 13 0 In combat 12 10 '.foile prisoner of war (German) 2 3 In evacuation or U.S. Hospitals 2 10 On ship enrouto to U.S. 1 1 Upon return to U.S. 2 7 On furlough from overseas 0 ST 5 SLIDE II SYMPTOMS Psycho- neurosis ' R'e's'i'dual Anxiety State Tenseness 24 36 Tremulousness 7 19 Battle Dreams 1 16 Startle reactions 2 15 Sleeplessness 2 14 Disturbed by noise and confusion; poor adjustment to civilians 2 14 • Restlessness 4 12 Irritability 2 11 Somatic symptoms 19 11 -cardiac 3 T -gastrointestinal 14 3 -respiratory 0 1 -urinary 2 1 IIoadacHcs ib 10 Dizziness 6 0 Tinnitus 0 6 Depression 13 7 Morbid fears, doubts, compulsions 11 0 Hysterical conversion symptoms 7 1 RESIDUALS OF COMBAT INDUCED ANXIETY Discussion by Hugh T. Carmichael, Ji.D., Associate Professor of Psychiatry, University of Illinois. Captain Sturdevant has called to our attention again the need for differentiation between two types of individuals who, when exposed to combat during military service, may mani- fest clinical symptoms usually regarded as indicative of neurosis. One of those types is that of the individual whose past history shows no evidence of so-called neurotic trends, but who under the stress and strain of combat experiences finally roaches a point where he can no longer tolerate the demands made upon him and develops reactions which overtly resemble the picture usually called neurotic or psychotic behavior in civilian practice—the so-called state of "combat exhaustion." The other typo is the individual who may also break down in comoat but in whom there is a past history of * so-called neurotic behavior or trends. This typo of individual tends to succumb to the stresses of combat at an earlier period than the fi~st type and tends to have more fixation of symptoms and co bo more- resistive to treatment than the first typo. I believe it is most important to bo aware of the differences between those two typos and to be on the alert to recognize them. The hypothesis that there is a difference in the two groups of patients is supported strongly by Captain Sturdevant1s convincing demonstration of the symptom picture and better response to a therapeutic approach conducted primarily at the conscious level in the ’■residual anxiety group," and the need for "deeper*- and more intensive methods of psychotherapy in the "psychoneurotic group." Tho question of the affects of exposure to blast is an interesting one. It nay be that in addition to acting as one of the immediate precipitating factors in the production of symptoms during combat, blast my woll have occasioned in many of the individuals exposed-to it some bodily injury which is difficult to recognize with tho usual clinical tools, I think in this regard, especially of damage to tho brain. In some of these patients, it may well bo that the residual anxiety is more directly related to tho attempts of tho in- dividual to meet the usual demands made upon him cither in tho hospital environment or in civilian life-demands which he has great difficulty in meeting adequately due to the defects caused by the brain damage, with the resultant appearance of symptoms w'hich seem to be neurotic. Why was tho first appearance of symptoms delayed in twenty tnreo of tho residual anxiety group until after their removal from the battle zone? And why in tho other members of that group, did tho symptoms which began during combat continue for such a long period? I believe that Captain Sturdevant is correct in his assumptions that removal from the combat group of which he has been a mem- ber deprives tho individual of the support he had as a member of the group, and thus makes hiajnpre_•vulnerable to his own individual anxieties, fears and guilt feelings; and that it also deprives him of acceptable outlets for diroot expression of his aggressive trends, and subjects him too much opportunity for self-examination and rumination over his battle experiences and self-recrimination about his failure (as he sees it) to carry his full share of responsibility with the rest of the group. With tho removal of such supports as were afforded by the group, the weakened ego succumbs to tho anxiety which it had previously been able to master and resorts to on at- tempt at mastery by the use of more primitive patterns of behavior. I believe it is possible too that tho increase of anxiotv on return home might well bo occasioned by losing tho support of tho military environment and having to face tho lack of understanding on tho part of civilian friends and relatives, as well as the quite different demands made on tho individual as an individual in civilian life as contrasted with those made on him as a group member in tho services. I heartily concur in Captain Sturdovant’s concluding remarks that the majority of veterans will bo able to find security in civilian life with a minimum of emotional disturbance. They will need to accomplish this smoothly with assistance of the sort given by Captain Sturdevant to his group of patients with residuals of combat induood anxiety; that is a gradual rointro- duction to civilian status with support and guidance during that period. DEEP AMYTAL NARCOSIS IN THE DIAGNOSIS 6F iftSTfifTK Franklin 0. Moisten, Uaj«, ilC♦ Stanley ',7• Conrad, Cant., 1,1C* During tho present war, u good deal of attention has been given to the diagnosis and treatment of the emotional disorders. This emphasis has not bean limited to any one zone of operations nor to any one ’type of medical installation, or to any special group. The surgeons, tho internists, and particularly tho medical officers, in tho aid stations of the forward areas, became "neurosis conscious". This awareness of emotional dis- orders played a major part in tho early diagnosis and the prompt treatment which, as you know, obviated tho necessity for evacu- ation in a high percentage of such casualties. One would expect that the passage through the successive units in the chain of evacuation would quickly reduce the number of undiagnosed nourc- . . Cu arrival at the final unit in this chain, the named gen ral hospital, only the rare case should be a problem in diagnosis. Our experience in the consultation service of such a general hospital would indicate that this is generally true. However, wo did com*, unon a number of such undiagnosed cases. In most of those the diagnosis was difficult and in all, the initial therapeutic efforts were tedious, time-consuming and iiscouraging. A r view of our own difficulties with this group of patients would indicate that any imnlied or expressed criticism of th<; nodical officers who hud previously cured for them would certainly be unjust. The primary re-.son for hospitalization in this group was surgical, and all of them had been evacuated to the Zone of the Interior as surgical patients. The injuries in all instances had been severe ana the immediate therapeutic indications had bfcr.n surgical during the major portion of tho previous neriod of hospitalization. The problem, us it presented itself to tho ward surgeon when the patient arrived in the general hospital, was, on superficial examination, no different from that found in tho majority of his patients. The record would show a number of severe ar.d mutilating wounds v/hich had required a series of operations and usually souk, surgical manipulation as well as the use of some forn of traction or splinting. Preliminary examination would reveal a number of contracted and perhaps adherent scars; the <-vid- nets of loss of muscle tissue from atrophy and from th. mutilating nature of tho original wound; and a disability that might bo explained on the basis of these injuries and their r siduals. *d, sod Inn umytal, on** gram to 20 cc of v.r.t* r was given intrav ,ncusly, at' tm rate of one cc per minute, until the patient reached the lev-,'1 of corneal anes- thesia. During this induction p-riou, no attempt was made to question or examine the patient, though any spontaneous comments or questions wi.ro discussed briefly as they cumo up. ’.«hon corneal .nesthesi:. had boe-n attained, the patient wxs pomittod to remain at this Icv'.-l for about 15 minutes. Ho was next given plototoxin ir. a solution of on ; milligram per cc. This was given intra- venously at approximately mi cc per minute until the patient coulu b arcus a v.'ithout much difficulty. At this time tho urological examination was repeated and after the disability had been evaluated, th • interview wis conducted in the usual fashion. !?y this method It mo possible to evaluate tho. disability with considerably 1-ss difficulty than wo had experienced unaor the ordinary r. urc psychiatric approach. The residuals of the injury ecu! 1 be differentiated .from the conversion symptoms and from th- conscious distortions. uopeatod neurologic exami- nations wor- no longer necessary and the examiner usually did not convi-v to the patient any of his enm doubts concerning the origin of th'. disability, v/ith thin prompt clnrification of the diagnostic confusion, ns ye ho therapy ooul i b*. instituted at once. The lessening of the rosontnont r.nd hostility so frequently encountered in these patients is c rtainly not one of the minor advantage of this type of aopr • oh. With repetition of the lu.-ytnl Li it orvi or, it \r s posalbl* tc facilitlato the therapy and a co?-.s:l derabli savins in tine consumed >v.s effected. This Is •, factor not tc tv. ov rloohod in an Amy General Hospital. SUIL ARY It das boon our experience on an II,p. consultation service in a named general hospital, that the cause ol a manifest disability is oft latinos difficult t<> evaluate by ordinary clinical exami- nation. I/ith the aid of d- ep narcosis we have been able to determine that the disabling symptoms in some of these cases are functional in origin rather than the r siduul of the original injury. Having na \c the diagnosis of hysteria by this method, psychotherapy can be initiate-, at once, fly tv.tins of deep narcosis the- initial hostility not infrequently encountered,in cases of this tyru. by the usual psychiatric approach, can bj eliminated or materially reduced. The use of intravenous sodium araytal is r ooi.cnmded boo*.use the* deeper levels of narcosis required in thosi eases ct.n oa safely produced and easily controlled. DEEP AmYTAL NARCOSIS IN TdE DIAGNOSIS ctf UYST-RIA Discussion by Clarence A. Foymnn, H.D., associate professor of Psychiatry, Northwestern University. The paper by Major mcistor and Capt. Conrad is very timely. It is patout that wo nay expect to onocuntor numerous special psychogenic conflicts and tensions in the injured and convalescent v t- ran. Usually thos« do not occur in civilian life. In a way we might state that almost any veteran, who has boon injured, e-sreoially If the injury is .extensive end looks as if it wore german ntly disabling, lias a tendency towards invalidism. In the first place, the veteran questions whether he will net be seriously disabled in later years after he has boon dis- charge d. Secondly, he has become accustomed to army life and to all the fine <* ,n..rouc car*., which is heaped on him. Thirdly, i- considers himself a hero and wishes everybody to realize that ho h..s fought and suffered for his country. Fourthly, he may b . scaping fr u. difficult family situations, which do not trouble- i r frustrate him while h* is in the hospital. Fifthly, h, knows full well that th greater the disability trio nrro extensive will bo the reward in the form of c. n ns ion. Finally, he- nay sir.ply have bacon-; lazy during his life e f luxurious oaso. It is, thor. fere, cl-.nr why any veteran should bo antagonistic to a psychiatrist, who is nt best a kind ef witch-doctor, likely to upset his comfortable and complacent flight fron reality and at worst a man folio'/, who my call hi.; insane or peculiar and bizarre. Ko ono is i.dr us of having his mental aptitudes questioned. F'ir these reasons, which ‘ire really nothing more than an int«.rr-:acti:m between ego, id .• nd superego, deep therapeutic narcosis would s-.-r. to be indicated in all cases whore the diagnosis is In doubt. Curin' rcosis the higher integrative judgment of the* ego is t ,-rmererily 1 st or in abeyances. Therefore, the ’Vitiont will be nuoh nor easily persu*. dod to cooperate with the examination; especially when In- is asked to novo muscle groups that an functionally paralyzed. In a way, deop narcosis is quivalunt t. the lad: of fin. r judgment coon in acute alcoholism. Temporarily th* patient becomes therapeutically accessible. Only a very deep narcosis can be expected 1-. influoneo such patients. They will disgt rg , their tans ions only when their ego Judgment is in aboy .nco. However, we must remember that the final cur* will depend on an oxplf.nt-.ticn at a conscious level. The whole preblftien pressure t6 perform duty is enforced on these individuals, various typos of reactions become evident. The greater percentage become resentful, resistive, and refractory to discipline. Morale becomes low, sense of responsibility, pride, patriotism and effic- iency of the soldier* is lost. More important than his loss to the arqy is the pattern of behavior whieh becomes well ingrained in the individual and the effect it will have upon his adjustment emotionally, socially, and economically in the future. One.could well argue the point as to whether or not these individuals could be looked upon as malingerers or basically emotionally .immature, unstable, inadaptable individuals. The Russian literature is meagre regarding these individuals, with frank statements that one does not see malingering. Again we must remember, the Russians had a different philosophy in life, a differerit political ideology, and strong hatred for the enemy, as only those individuals could develop their homes, families and country ravaged by the enemies. It is the general consensus of opinion that the majority of guardhouse prisoners, i.e, the psychopaths, alcoholioa> and other mentally ill persons, should never have been inducted into the military service. On the other hand, rejecting these individuals or returning them to civilian life would obviously create resentment and poor morale in the soldier who was con- scientious and willing to make sacrifices. The mentally and physically adequate youth of the nation became invalids by the hundreds of thousands, whereas remaining behind were the psychopaths, alcoholics, eto«, who will continue to display their asocial and antisocial behavior, and become economic burdens to society and financial drains on the government. Mira, former Psychiatrist in Chief of the Spanish Republican Amy, claimed that he achieved good results by transferring most of the delinquents to the disciplinary and labor brigades, which were called upon to either perform heavy work or asked to provide volunteers for especially dangerous tasks, I wonder what he considered, "good results”, In my own personal opinion, I feel we have erred in judgment by not considering a fundamental proverbial saying, “Survival of the fittest”. Our groat problem, post war is now the same old question, - only ever increased, - "Vfoat to do with the Psychopath?” DISCUSSION Dr, John J, Madden# Dr, Kaplan is to be congratulated on his forceful exposition of a serious psychiatric •and social problem. To those of us who are connected with institutions which admit large numbers of individuals exhibiting behavior deviations, the high incidence of constitutional psychopathy has always caused deep concern. Since these individuals are usually of good intelligence and shrewdly sophisticate in demeanor, their serious personality disorder may remain undiscovered for long periods. Acutely aware of the ease with which maudlin sympathy nay be aroused they impose upon well intentioned but naive lay people, and occasionally psychiatrists, and as a result they go on their merry antisocial way leaving turmoil and choas in their wake. One hears endless discussions concerning plans for the better care of the neurotic and psychotic but seldom is mention made concerning plans for iaore adequate and efficient care of the psychopath. Currently and for several years past much investigation goes »n and much is written regardim alcoholism, but #nly occasionally is it recognized that in the goodly percentage of so-called chronic alcoholics the basic disorder is constitu- tional psychopathy. Treatment is as we all know, eminently unsatisfactory. However, there is at least a possibility that a more general and forthright recog- nition of the problem and its social implications may lead to more efficient methods of care. and Chairman, Dept, of.Neuropsychiatry Loyola University PSYCHIATRIC PREV|EffS Lt. Col. Paul A. Petree, MC* Capt. Lawrence K, Taylor, MC* Capt, Leonard R, Straub, VC* The progress of psychiatry has been somewhat cyclic, almost seasonal, coincident to the regularity with which waoccur. In peacetime the progress has been at pedestrian pace compared with the tempo set by war; for war works fast and kicks hard and opens the gates to many ideas that may be today's psychiatric previews of tomorrow's procedures. The mass of clinical material made available by the war per- mits statisticians to card-index disorders, symptoms, etiologic- al factors and personality types, so that by a punch system, or a code system, similar in manner to matching fingerprints, almost any information is made immediately available to the investigator. The high incidence of nouropsychiatric disorders that has occurred in the military forces has resulted in much criticism from both lay and professional sources of the screening pro- cesses ct our induction centers. While thousands of the emotion- ally and physically unfit were weeded out, other thousands v- slipped through the.net, . Much of this criticism has been un- warranted, It has been revealed that not only the individual with inherent physical and mental weakness becomes a psychiatric casualty, any of us—you and you and I—has his breaking point under a given chain of circumstances: disease, exhaustion, pro- longed caibat, economic distress or domestic discord, Many of the nouropsychiatric casualties admitted to Army general hospitals have as good a background from a physical, educational, social and economic standpoint, as can be elicited from any of us who have not yet succumbed. It is likely that the inductee screened for the next war will be given a probationary training period during f which tho psychiatrist, psychologist, psychiatric social worker and chaplain will work along with the line officers in an effort to further eliminate potential psychiatric casualties. This procedure has had on experimental try-out in the Women's Marine Reserve Corpsi Tho war has stimulated ideas and much knowledge has been gained in both tho field of mental hygiene and in the management of psychiatric problems. For instance, it is believed that intra-psychic phenomena and unconscious childhood conflicts have been over-stressed in the development of neuropsychiatric dis- orders, Rigid Army regulations, separation from home and tho hazards of war breed insecurity and permit minor personal prob- lems to assume tremendous importance. More emphasis should bo (fcven to tho conscious conflicts, physical defects, and to ob- vious environmental and situational determinants. Evidence that there is very close relationship between those precipitating causes and nervous disorders is convincing ♦Vaughan General Hospital, Hines, Illinois when it is observed that many soldiers recover from their battle reactions when removed from combat. ;iany recover on board ship returning home, while others recover in the hospital after two or three reassuring visits from their family. Those soldiers who develop disorders as a result of economic, social or physic- al conditions recover when bad assignments are corrected or the soldier is permitted a furlough to straighten out some financial or domestic difficulty, or when the physical defect is cured. The writers do not believe that every soldier who exhibits introspection, moodiness, irritability, or even violence toward his superiors because of some of these problems, is necessarily showing evidence of a psychoneurosis, In certain instances this reaction is normal to the situation and wo boliovo that in the Army, even as in civilian life, most soldiers should be allowed to express righteous anger toward their superiors. In view of this knowledge it.is certain that university professors, teachers and investigators will, of necessity, give less space in their text books to tho major psychoses, and more time, attention and energy to tho cause, prevention and management of the psychoneuroses and psychosomatic disorders which constitute the major factor in tho loss of manpower. In this war ’ c have seen relatively fewer cases of schizo- phrenia and r-ianic d.pr.jssivc psychoses, and more eases of un- classified psychoses than is seen in the civilian population, but by large odds the majority of the eases have been psychor- neurotics of one type or another. The severe typo nay resemble an acute psychotic episode. In the civilian the causes are subtle and diverse; in the soldier they are objective or situa- tional, and his conflicts are more immediate and more con- scious, There is closer relationship between cause and effect. The soldier’s reaction is abrupt in onset, severe in degree and shorter in duration, and becomes similar to the civilian’s illness only when his war reaction merges with pre-existing ncuropsychiatric components and with recovery he tends to re- tain only those pre-existing abnormalities ho harbored as a civilian. There is yet to be developed an a.ccepted diagnostic labora- tory test for functional mental disorders. Some advancement has been made in psychology, in personality studies, psychonetry and aptitude testing. The Rorschach and other tests have been popularized, but tho final diagnosis is still a clinical one. This war has made the public acutely conscious of nervous end mental diseases. The profession must be to cope with the problems that industry, labor and the individual will pre- sent, Our industries will require tho services of trained pern sonnel who will see that tho employee is placed in tho job ho’ . likes .and is competent to perform, and that he is properly com- pensated. This will safeguard the morale factor, as essential to the civilian as to the soldier, and promote emotional security necessary to maintain a high level of efficiency in his work. The demand for ncuropsychinfric personnel is going to bo very great. Tho Army has had to take a positive stand to oope vrith this shortage and has had to introduce a large number of young nodical officers into the field of neuropsychiatry. While the Amy recognizes that those men are not trained psy- chiatrists, nevertheless, wo feel it has been beneficial in stimulating interest and in making a large number, of men con- scious of tho importance of neuropsychlatric disorders. This has been reflected by more nouropaychietrio referrals and consulta- tion requests. To compensate for the shortage of personnel, the Array general hospital has developed a psychiatrist-psychologist- social worker fcoan rhich has proved highly efficient and most useful in producing the fullest possible clinical picture and in carrying out group psychotherapy and other treatment procedures. Such a team is strongly recommended for after war needs. Centers devoted to the rehabilitation of veterans have already seized upon this team iidoa. Since in this war there has bean no outstanding development in management and treatment, the blueprint to be followed is the continued use of those procedures of tha past which are thought to bo worthwhile. This calls for well-trainod and understanding personnel with proper attitude and technique. The psychiatrist and nodical officer will collaborate to obtain a sound physiolog- ically functioning body. Our veterans and state hospitals should freely utilise the services of a consulting staff. Individual and group psychotherapy, occupational and recreational programs, and hydro- and physiotherapy; all play an important part. It is essential that not only the soldier, but any mental patient, should bo hospitalized according to his social, economic and intellectual level; that is, the intellectual should not bo hospitalised with a defective, nor should the man vrith a high moral sense be placed with a moral degenerate. Each patient should bo seen promptly on admission and oriented as to tho reason for his admission and it is wise to discuss briefly with him the inter- relationship between physiological and psychological processes so that ho will have a bettor concept and be able to interpret body sensations, such as palpitation, sweating and tremors occurring in anxiety states, that might otherwise frighten him and result in introspection, self-criticism, or withdrawal manifestations. Ho should bo told vrhat his privileges and restrictions will bo. It has been found that soldiers received in convoys tend to bond to- gether, which aids thorn in adjusting to their new situation. This morale factor is followed up, and wherever possible in trans- ferring patients from one ward to another the group idea is main- tained. The management should provide*for progressive steps. If a disturbed patient quiets down, he should be moved from a closed to an open ward, and if there is further improvement, additional privileges should be extended. We often observe pronounced im- provement simply in moving a patient from a locked to an open ward. Later, passes and furloughs should be added. This re- stores his confidence and provides him with an incentive to get well. In doubtful cases, the patient should be allowed to go home on visits several times before he is discharged. Many have to be re-inoculated or desensitized to thejr homes or civilian life. The idea of sending patients to the country to be “close to nature” has not been sufficient. What the patient really needs is a good job to restore confidence and self-respect. There should be close working relationship between our mental hygiene clinics and industry. It is our opinion that these clinics could carry along many veterans and other persons in groups on an out-patient basis with weekly interviews and thus avoid hospitalization with a consequent loss of manpower. In this manner, many illnesses would receive early treatment which other- wise would progress to the stage of ohronicity. Along with the procedures outlined above, special treatments will bo given. There has been a revival of interest in the use of insulin. At Vaughan General Hospital we provide music during the insulin treatments. Many patients, such as the anxiety cases, to whom one would hesitate to give insulin on a deep coma level have been carried on a sub-shock level and many stubborn cases have received insulin coma alternating with electric convulsive therapy. The insulin is given once a day intravenously, gradually bringing up the dose to the desired effect and then gradually de- creasing it. Electric shock is limited to a small group of patients, Soup psychotherapy has proved valuable and helped to solve the shortage of personnel. Hypnosis and. narcosis have boon popularized. We have used hypnosis to suggest away symptoms or attitudes under- lying symptoms, to obtain repressed material, and for abreaction. We have used pcntothal and amytal as a sedative, to establish better rapport, to obtain information, and to facilitate the handling of resistive patients. After its use many patients will participate in ward activities or go for walks, while others who had to be tubed or force fed, will oat. The effectiveness of those various procedures in an Array general hospital, taking only the psychotics and severe psychoneur- otics, can bo somewhat evaluated from tho following figures: From 14,00 admissions there have been 1125 dispositions. Of these 700 received insulin and 100 electric shock. Only 14,5 have been sent to veterans1 facilities for further care. In another general hospital treating all classes of neuropsychiatric disorders, from 1800 dispos- itions, only 85 were sent to a Veterans' Administration Facility, In other words, out of approximately 3000 dispositions only 230 have been sent to veterans' facilities. The management of nouropsychiatric patients may also include a planned passive or negative approach. The policy is not one of "watchful waiting" or just “sitting tight and doing nothing", but is patterned somewhat after the thought expressed by a mental patient who raised canaries as a hobby. Ho had several trick birds that would perch on his fingers and clip his fingernails or light on his bald head and peck at his stubby hair or dandruff. One day a visitor asked him, “Oh, how did you train tho bird so well?" to which tho patient replied: "I did not train it - it trained no, I just watched and found out what it wanted to do and let it do it,” nay apply the snno philosophy. Patients think their own thought's and live their own lived and wo can often assist than nost by watching and finding out what they wont to do and help then to do it, , It has been observed among tho nurses and attendants, that individuals who arc a bit conical or inclined to Indulge in witti- cisms are often able to handle or manage Certain patients with whom no one olso could establish "such good rapportt The possi- bility of combating one amotion with another appears to be worthy of investigation. Humor is a very powerful and therapeutic emo- tion. It is studied and less is known about it. laughter is tho physiological expression of honor, and anyone with a sense of humor who can lau&h or make his patients laugh will bo an asset to his organisation. Wo have node many diagnostic examinations and tests before, during and after treatments, and have arrived at the conclusion that there are a host of factors that should bo emphasised - that each method and treatment plays its own port.* It is not insulin or electric shock, it is not individual or group psycho- therapy, it is not tho individual doctor or his particular method - it is the prompt application of all factors favoring im- provement, Getting tho patient started promptly on the right foot, down the right road -. and it is just as difficult to sep- arate one method from the whole as it is to separate one battle from tho war. DISCUSSIOil OF i PSYCHIATRIC PREVISES Discussed by* Slight, HD, Professor of Psychiatry, University of Chicag* The authors rightly say that events in vmr wove fast and that the gates have been opened to i:any ideas which nay lead to the development of now procedures for tomorrow, Alse, they speak cf the mass of clinical data that has been collected during the war which should be available to the psychiatric investigator, * The various battalion programs wore then assessed at staff conferences so that eventually the following prdtrr_V was adopted-as being most suitable from the point of view of pers onnel ahd chse load, • Administration; All patients took part in group psychotherapy which was conducted by the psychiatrists, the clinical psychologists, the psychiatric social workers and through the media of selected movies. Groups were conducted on two levels; large group therapy and snail group therapy. Large group therapy was part of the regularly planned program and four one hour periods per week wore scheduled, Ihe tine was divided by all the members of the clinical team. The large groups were company size (maximum 100 patients) and all patients attended large group sessions. Due to the difficulty of handling large groups and because some patients needed nore personalized therapy, small group therapy was given to selected individuals. It was found that the best therapy could be accomplished when the group consisted of 5 - 1C men, sometimes slightly larger. Patients were selected for snail group therapy which was con- ducted by the clinical psychologist or psychiatrist in different ways, (1) Patients were referred for snail group therapy by the psychiatrists and the social workers. (2) Patients were selected by the psychologist and psychiatrist on the basis of the clinical picture which nade for a homogeneous group, (3) In one battalion all new patients were handled in small groups. The length of the group sessions usually varied between 45 minutes and one hour. No rigid time limit could be set. The meeting was concluded when interest lagged or restlessness was noted. Ihe atmosphere of the group meetings was informal. Everything possible was done to break down the traditional barrier that existed between officer and enlisted men, T.Vhile the therapist had a pre-arranged plan there was no pre-arranged text for the meeting, A pre-arranged text invariably resulted in a health talk which had to be avoided. Occasional straying from the subject caused no great concern. An opportunity for release of aggression r was valuable and had to be encouraged. Later in the day. Captain Hirschfeld will present to you his experiences with the technique while a member of the convalescent hospital staff. Educational Reconditioning; Educational reconditioning was considered adjunct therapy. In order to place this activity on a doctor-patient relationship it was coordinated in our battalions through the clinical psychological sections which were under the supervision of the medical officers. As a result, our patients were given assignments by individ- uals who had understanding of the emotional problems involved and whose progress in the particular studio, shop or class room was followed from a psychological point of view. Ihe school and shop program aided mater- ially in stimulating a reawakening of interest and combating apathy which was initially present in many of our patients. It helped restore con- fidence in our anxietous patients, particularly those showing preoccupation- restlessness, impaired concentration and inability to sustain attention over long periods of time by proving to them, through personal performance, that they could cope with their deficiencies. For those exhibiting startle reaction the more noisy shops permitted them to make adjustments to occupa- tional noises. Occupational Therapy: This was utilized for our nore severe anxietous patients and those with poor intellectual endowment who were on psychiatric grounds not ready for the more formal school and shop program. Physical Reconditioning; It was found that maximal therapeutic benefit was derived from competitive games and athletics at inter and intra eompany, battalion and regimental levels. This approach made for spontaneous participation and in addition to restoring physical fitness, aroused enthusiasm and a feeling of "belonging” on the part of the patient for the first time since he was lost to his unit overseas and remained lost in the hospital evacuation chain, Ihis rebirth of enthusiasm and feeling of "belonging” made for good patient morale which was essential for effective, more formal psychotherapy. SPECIAL PROJECTS: C- mpany for jsychopaths: Due tx the large number of psychopaths beirv admitted despite directives, it was imperative that something be done to.prevent the unaernining of•morale of the other patients and sabotaging .f the program by these military delinquents. At the suggestion :.f Major Nils P, Kersloff, M.C. a special company was activated* This typo if patient was processed rapidly and returned to duty to oc handled ao/iinistratively by the line, ‘In tine, the company became known as the special treatment platoon to which were sent, in addition to the aggressive psychopaths, those patients wha wore awaiting courts .martial principally f r AWOL nn those who were sentenced t > restrictions oy courts' martial. Trial Furloughs: dhon it became apparent that the symptonatelegy of a snail number :f. patients was aggravated and accentuated by amdeties relative t.> civilian adjust-.ents and rehabilitation, Major Nils B, Hersloff instituted the policy 'f trial furl ughs, After nnxinun hospital benefit head been attained art. pri r t. final disposition, this group of patients were given furloughs of from five to ten uays.* inasmuch as they were definitely aware of their ultimate disposition they were enabled to estab- lish their families, bt-ain employaent and accus’tom themselves to the routine of civilian living. In some instances it was necessary to repeat these furloughs in order to dissipate the accumulated anxiety. Approxi- mately eight percent f the patients dispssitioned by Major Hersloff»s board have required and requested such proceeure and as a result benefited immeasurably. Duty Company; The auty company was establishes "t the suggestion of Captain Willard E, Keman after on exhaustive study in order to effect a physical separation between patients who v/ore likely candidates f„,r duty =and those who warranted separation from the service. Mingling of duty prospects witn those wh. sn ;.ul< be separated Tram the service blocKed adequate thera- peutic endeav rs, All e.uty prospects in the reg iment were transferred t. this duty company, as soon after return from convalescent furlough as possible, r.t this level i rientmti r: and psyche therapy programs were conducted with a return to duty as -a key n'-te as opposed t adjustment to civilian life. 'This c mpany was I necessity created since the a licy of higher :-utii rity prevented the medic 1 officers from ipfc rrln*, the patient of his ultimate dispositi on. However, shortly after its establishment this policy was relaxed, and the company clisornded. In a staff evaluation of the program we are unanimously of the opinion that the majority of o' tients whom we have returned to civilian life have boon ac. justed to the p int where once again they can take their places in the community as useful citizens. There is no single factor responsible f'-r this. The professional approach used, utilizing the psychiatrist, psych 1 gist and psych!•trie social worker as a team was in no small way responsible f r the results achievec, ’.rhile everything for the oati nt c nstituted treatment inducing company .management, the contri- butions of the professional team in terms cf group and individual psycho- therapy wore the backbone c f the treatment program. The therapeutic contributions mace in the f.-r-; of educational and physical reconditioning by the reconditioning service wore very important adjuncts, 'He were very f rtunate in having at our cisposal an unusually fine educational system. The shops, classrooms and studios were well equipped and excellently staffed. The agricultural school and its fam was an outstanding project. For the physical reconditioning program we had nore than our share of playfields and recreational areas. With the coning of winter there are bowling alleys, new gynnasiuns and an indoor swimming pool. The atuosphore of the convalescent hospital provided an effective framework for the treataent program. The usual hospital ward routine was lacking and in its place was substituted a modified type of garrison living, T;/hile it is true that discipline was maintained yet our patients were given considerable freedon. The patient was free to do as he wished after five o'clock and could get week-end passes for the asking providing there had been no breach of discipline. They were in a sense on their own again; and for nany of the patients this was so for the first tine in many nonths. The self Imagined stigma of an N.P. ward, even though an open one, had been ronoved. This sinplc fact was of untold therapeutic value in that it gave support to danaged egos and restored self esteen and self confidence. Most of our patients lived within a distance of 200 - 300 nilos jf the hospital, and consequently nost of then, spent their week-ends at hone, i'-.s a result nany civilian problens surfaced during this period, F rtunately, since the patient was still under nilitary control, he had available- the help of his doctor, psychologist and social worker, who as a tean helped hin resolve his newly acquired anxieties, Ihis benefited not only the soldier returning to duty, but also the one to be discharged. The later in essence was .being prepared for a return to civilian life. His exposure tc it was gradual and controlled rather than abruptly fron hospital ward to civilian status. With this approach we felt that a majority of the patients discharged needed no particular follow-up in the community. Host of the patients in this group had made plans for the future and many had already secured em- ployment by the tine they were ready to bo discharged, A snail percentage were found however, who although they had received maximum hospital benefit, could profit from further psychiatric follow-up. Upon discharge those were referred directly by their doctor or through the Red Cross follow-up service to psychiatric clinics in or near their comunities. Vte of the Convalescent Hospital staff have always been extremely enthusiastic about the program and its effect on our patients. Since we have no follow-ups, our assesment of the program is based entirely on prognostication by the staff and may for that reason be biased. Be that as it may, we are convinced that the approach used was psychiatrically sound. We shall one step further and state that for the milder neuro- psychiatric casualty, the management )f choice is at a convalescent hospital level. DISCUSSION ''NEUROPSYCHIATRIC TREATMENT AT A CONVALESCENT HOSPITAL" by Dr, Raymond ?. Waggoner* That there would bo a psychiatric problen of consequence in military service was recognized before Selective Service was established. Early attempts were nr.de by Selective Service to screen registrants for actual r potential neuropsychiatric disease. First at Local Board Level and later at the Inauction Station, the examiners were handicapped by lack f information about the registrant. This situation was improved in 19A3 with the development >.f the Radical Survey Plan by Selective Service and by the use of questionnaires at the Induction Station, It is believed that each development was a step forward. In spite of all screening an unf ortunately largo number of men were inciucted who carried in themselves tne potentiality cf seme type of neuropsychiatric disorder. Many men in service were subjected to a degree »f stress which would result in neuro- psychiatric symptoms in even those with high threshold values of resis- tance to the development of such manifestations. It is common knowledge that large numbers of neuropsychiatric casualties have developed in service, Many have* been adequately treated before discharge and, of course, there have been some recurrences. Others unfortunately have been uis- charged too soon before the maximum degree of recovery has occurred. Those non are in the communities and are the responsibility of the Veterans Administr; tion r civilian agencies, Thq problem they present is not f-'r discussion at this time except that the problem thus presented is in ru re or less direct ratio to the quality and thoroughness of the treatment these men receive before discharge from the service. Any plan which mnilizes to the fullest extent the individual's capacity for adjust:lent is destined to be the m st successful. Such a plan appears to be the f, al toward which Colonel Senerchia and his co- workers r.rv striving'. They have made an important contribution toward the optimum in treat ment values. In ehc first pi:ce the rgynizational plan has resulted in a teamwork v.'hich is ■ pleasure t observe. There appears to bo excellent cooperation between the administrative level, the professional staff and the ancillary workers, The treat)mnt program utilizing as it oocs both group and inaiv- idual psychotherapy as well ns important correlated activities serves not only to aid in the res lution of the oatlent's problem but also to keep him sufficiently occupied to prevent tine lag. D'ict r ’Jeisonburr who had a so; lewhat sii.iilr.r program at Plattsburg f -Hewing '.I rib ’fr.r I .lade a paint of keeping; a few patients in each ward about tw be discharged, who had recovered, This kept alive a tradition f recovery which served as excellent suggestive therapy for the new arrivals. In this c nncction it would seen unwise to keep a patient in one installation for t no lent, a period of tine since this nay result in a 1 wering of norale. Exceptions nay be necessary but provision for such exceptions can easily be jv.de. psychiatric Inst., Ann Arbor, Michigan 64 Of particular importance in the convalescent program is the opportunity for the patient to return hone for one or two.trial periods of a few days each, thus giving bin a chance to make his civilian adjust- ment slowly and with a sensp of security, since ho knows he can depend upon those with v;hom he has established rapport until he can completely accept the responsibility of the civilian environment. As Colpnol Senerchia points out, civilian problems my surface during such trial periods while the patient is still under military control and he may thus receive the additional help he needs before final discharge. The psychopath always presents a serious problem in any treatment pr.'gro/i. The sooner he is olirdnated from a group such as this, the loss damage he vail do, I must confess that I an very pessimistic about treatment benefit in such cases. The plan of a special company would seem to bo an admirable solution for this problem. Colonel Senerchia and his co-workers are to be congratulated upon the program which they have developed. It is hoped that similar treat- ment procedures will be established throughout the country. COMBAT NEUROSES IN FLYING PERSONNEL (Abstrsct) BY HOY R. DRINKER, M. D. * There is little difference between neuroses in flying and ground personnel except that in the former the syndromes are milder and are colored by the special characteristics of the com- bat groan. We have learned a great deal about the human person- ality and its reactions to stress by our war experiences. This knowledge is invaluable for the field of psychiatry since there is no essential difference between neuroses of civilian life and the war neuros s, Otferseas the external stress loons large as th*.:ain cause of the psychological difficulties and the en- tire symptomatology is often referred to the stress of battle. Some psychiatrists attribut'd all difficulties in adjustment to pre-comoat neurotic weakness and hence nad a pessimistic atti- tude toward oossiole therapy. Actually there occured an inter- action oetween the basic personality anci a particular type of stimulus so that anyone co*ild develop a neurosis. The important factors were the severity and meaninffulness of the stress. In the Air the closely knit groups provided a repetition of the family situation and stimulated old unsolved ambivalences toward sibling rivals and father figures. As a result Air *orce casualities showed greater numbers-of guilt-pervaded clinical syndromes. We have seen neuroses originating after return from overseas, not as delayed reactions, but as new frustrations were encountered by psychologically regressed personalities. Some were nsychotio-ltke, others were dependent to extreme, manifested by alcoholism, childish behavior and psychosomatic gastrointestinal disturbances, some showed evidences of overt aggressiveness while others were depressed. Each man's problems are individual and are not understandaole except by individual investigation. The severity of the illness is not a handicap to complete recovery. Active therapy to be successful must un- cover the basic conflict but eoually important is the preven- tion of new neuroses in regressed individuals during their attempts at restitution by sensible measures to insure opportuni- ties for new economic, social and political independence. * Chicago, Illinois (Formerly\#5.c«£enant Colonel, Army Air Forces, Chief of Profess!one. 1 Services end Fsych:atry, Den ce Sr.r C.-r vales cent Center Hospital, Florida*) FUNCTIONAL OVERLAY IN PHYSICAL DISEASE Willard Z. Kerman, Captain, Modical Corps* discussing functional overlay before an audience of neuropsychicatristsentails the misapplication of a preacher’s belaboring his faithful congregation for the sins of those who are absent, because functional overlay is primarily the concern of those who deal with physical disease, and only by heritage, that of the psychiatrist. We’ve defined fun- ctional overlay as 'Vion-organio exaggeration, prolongation, or embellishment of physical symptoms." This paper summarises impressions of a "psychiatrist without a psychiatric service" in a 2000-bed Army general hospital, specializing in neurology, neurosurgery, and vascular medicine and surgery, with a heavy sprinkling of general medical, dermatologic, and orthopedic problems. In approximately a thousand consultations, most cases were typical medical and surgical problems which might have been, and, in parrallol oases, often were managed sons benefit of psychiatric opinion. Thus, this represents a psychiatric evaluation of primarily non-psychiatric problems, in a totally non-psyohiatrio setting. Functional disability is usually first suspected when the symptom to logy fails quantitatively or qualitatively to match objective findings or the diagnostic requisites of an organic disorder. Though this is "diagnosis by exclusion," and hmee, generally deplored, it is pragmatic and deserves mention. We have noted several characteristics, common to patients with functional disabilities, whioh have helped in their identifi- cation. They aroi(l) A patient's lack of explanation for, or curiosity about his illness; (2) l«*anipulating a complaint as an argumentative foil rather than as an expession of distress; (3) An inferred challenge whioh says, in effect, "What are you going to do about ray complaint?" instead of "How. much oan I dio for, or in spite of ray symptoms?"; (4) Failure of overt distress to measures alleged discomfort; (5) Passive indifference to prolonged hospitalisation and leveling of progress; (6) Suggestibility. Any symptom mentioned is grasped by the patient. (For example, almost no patient with any functional disorder will deny headaches, if asked.) (7) Invalid leanings—spending much time in bed, though ambulatory, and wearing pajamas and bathrobe when convalescent suits are available. (8) Little socialisation, or inclination to spend leisure gainfully or pleasurably, (u) Little or no planning for the future, regardless of family responsibilities. The diagnosis of functional disability is clinched, rsychodynamically, when it can bo shown that suspect somatic symptoms compensate or neutralize existent emotional cravings and/or frustrations. In functional overlay involving loss of motor power, sensation, or memory, examination under hypnosis or amytal narcosis proved an invaluable aid for diagnosis and. ♦Mayo General Hospital, Galesburg, Illinois treatment, as well us an effective weapon for proselytising the skeptical organicist. Discussion of the prevention of functional overlay in- volves a somewhat philosophic digression. It was demonstrated in case after case that much ftmctional overlay was iatrogenic in origin, i.o. the product of medical management. *rtiis strongly indicated the need for u now therapeutic orientation based on mora than lip service to the proposition that is-is the patient, and not the illness, who must be treated. Many busy clinicians admit that half their practice is comprised of functional disorders, and yet, because it’s mumbled "no one ever dies of psychouourosis", treatment is conducted with the functional problem, a last consideration. I submit that this perspective is conp.l->t-ly erroneous. The total of humn beings needlessly functioning below thoir intrinsic potential, with emotionally induced incapacities blighting thoir own happiness and casting a pall on the rest of society, comprises far greater tragedy than any surmation of misfortunes resulting from the mis- identification of physical illn;ss, I am reminded of a patho- logist who delights in retelling about four men who died of hepatitis when earlier labled "psyehonourotio".. Ho never could gain that more* valid perspective that emphasized the thousands of individuals whofd been permitted, yos, encouraged, to jell into half-oripples by the injudicious management of functional headaches, backaches, taohycardlns, „to. Grunting the immensity of this problem, wherein does the physician stand indicted for contributing to tho development of functional overlay? In our experience tho following were important* (1) Excruciatingly netrioulous, diagnostic probing, beyond reasonable need. To the patient, every additional technical procedure further crystallizes his conviction of serious illness. (Particularly in patients suspected of manifesting functional overlay, or exhibiting suggestibility and denondent traits, all necessary diagnostic procedures should be prefaced by explanation and reassurance, designed to neu- tralize the subtle toxin implicit in their administration.) (2) "Hemming and Viewing" before the patient. (Clinical indecision should be confined to the privacy of oners own mental processes. Tho patient may know nothing of.medicine, but he instantly recognises lack of conviction in the physician, and is harmed by the discovery.) (3) Slyly "aoloiowledging1* the presence of a "touch” of this or that, when nothing was found. Tho patient remembers the diagnosis, forgets the word "touch". The utilization of diagnostic terms that "sound" like labels of physical disease, such as "cardiac neurosis" and "neuro- circulatory aosthonia" when the condition is regarded as functional is a sin of the sane genus, (4) Heat lamps, in-' jections, backstrappings, and braces, naively proffered as "psychotherapy". Tho physician must sometime use placebos as a measure of expediency, but should not forgot their true ’ ♦ purpose. Suoh therapeutic gestures nay fixate somatic complaints --hardly the goal of real psychotherapy. (5) Exaggeration and dramatization of the illness and tho cure by self-aggrandizing physicians, recollections of "similar cases", and recitations of morbidity and mortality figures in front of the patient. (It goes without saying that. tlvs. only discussion, bearing prognostic implications'; pejriifaablo-within oar-shot'of the patient is that which is .convincingly-reassuring.)-' " must be er.nhusiz jd a^uin and again that-, the .treatment of functional overlay in physical* disease begins, prophyldqtically, th-s-* moment the: patient submits, to nodical -caro. ; 'I?hose who aro Ambulatory should be k pt p,ut of ,bed. An extra week of bed rest can hurt. Patients with pcooasari'ly' prolonged disability must prodded to'maximal utilization of their intellectual faculties, m.*chanioal; skills, social affinities.'-.The ortho- pedist has learned through sad- experience, in cases of pro-'. •lorfgod' imnqbifisatibh, that it is necessary to. bivalve casts and apply physiotherapy in. order to nrescrv - muscle and joint function, but ho and physicians often neglect the "tone of the psyche", which must.be guarded even more jealously - against the ubiquitous throat's of. tho sidk rpbn,./ It i-s not Just the “eight ball" who slumps into prolongation and exaggeration of his'illness. Tho mdst productive individuals have latent dependent cravings which crystallize into, invalidism, if encouraged. by unwarranted coddling and undue procrastination. If this, occurs / eviin though by default, tho physician has done the patient, as .wo 11 as nooioty, »jji irrouarable dajnage. . Lot ii*e phrase this metaphorically, " u good therapist encourages with a tug on the nos . us well as a pat bn the back” •’> : 5 * 3vcn.the active treutaaont of functional overlay must remain chiefly the. responsibility of the. physioinn v’ho mjihgos the physical illness. This is nee- ssitatnd by tho nature qf the disorder, the nut lent- being unable to distinguish what is functional from what is organic in hie symptoms. Since he has beun treated for physical illness, all prodding toward maximum activity must come from tho rthQalor“ in whom he hu.s already placed, trust* In. oases whore emotional conflicts roquiro the, . attention of. thu psychiatrist, managondnt had best be a-‘ * . "combined• operation*, exercising meticulous care that avoids precipitous, relegation (in the pationf.S eyes') to the role of “psycho". Expeditious mnugewont„ dogmatic reassurance, and prodding are keystones in both, the prevention and treatment of functional overlay ,and are psychotboutio measures just as truly as the nor* classic ,! techniques of ventilation, orientation, and neutralization. . The puccoss of those- hon-spociffc measures', negates neither t|io a 'psyuhqdynami.o substratum ' nor the probability that*'some ’psyche-logic "adjustment ;has taken '' plL.ce; it simply infers £hdt the psychogenic factors were them- selves relatively,non-Specific'hind superficial. -vV.-.r ” *’ i * * ; • *’ •* / .V t ' '• Before mentioning*hypnosis. and. narco therapy, it should' bo emphasized that many furtctional losses respond to patient, r dogmatically insistent reassurance. Particularly is. this 5 _* true in#the highly patient. Hypnotherapy should be an ideal therapeutic agent,'especially because’qf the sus- tained effect possible in tl\o post-hypnotic phenomenon, but its efficiency is. dependent upon tho skill-of the hypnotist and hence, we can attest, wasn't universally successful. Narootherapy suffersTror/ the arm ;sla attendant t.o its administration and thus makes difficult, postnardotlo suggestion, but it proved excellent Tor diagnostic purposes. To enhance its therapeutic poosibilitiou wo ddod picrotoxin to the procedure and aro intruding a detailed descrituion of the toc’mique employed; F' ti nts wem narcotised with intravenous sodium amytal. Wr used twice the dilution recommended, i.o. 16 grains in 20 c.c. of water, and administered this solution at tho rate of I c.c. per Minute. *ho stage of narcosis sought was ono just short of corneal an- s the sir. in which tho patient lost orientation and often exhibited purposeless movements as though in delirium. "Lost” motor functions wore first incited us defensive gestures, i.e. as a response to a painful stimulus. This was repeated several times, first supplementing, an lat r substituting for tue stimulus u verbal command; by this tine orientation, though nebulous, vtus partially restored. Wo found it expedient tc continue repetitious performance of the function, against resistance, und in automatic whence to counting. Meanwhile, picrotoxin was slowly introduced until appreciable analenuis was effected, a stage characterised by clarification of orientation and re-establishmcnt of good contact. Though tho patient might subsequently lapse into sleep, t!i to was no .ormosin for this period and restored motor functions w re prosorvud. The stock solution of picrotoxin cones 3 milligrams to tho c.o.j m diluted this to half-strength and administered it .1 c.c. per minute. We found that it generally required about 1 •nilligr-.jn of pi ore toxin for each grain of sodium uMytal nr viously administered to effect adequate anulopsis. In our exp ;rienco 12 grains of sodium amytal sufficed for the av .rage adult rial..., varying generally, though not aIways , v/ith size. We can subscribe to the recognised principle that appli- cation o:' this ’’bind: magic” is not good treatment unices a coincidental psychedynamic readjustment takes place. This usually r* quires that th<; patient be carefully prepared for th«. procedure- by explanation of the nature of the dis- ability and the plan for treatment, and, that tho ’'restoration” cf function be followed by similar discussion, the ain being to neutralise aggressions projected from self-condemning guilt feelings which arise from tho condition, the explanation, und the ”cure”. (Since. the well-motivated individual is unable to differ ntiaa . b. tween era ling .*ring uni functional disability in his owr. synptons, ho May, won thou t real psychotherapy, be- come worse for the "euro”,) Functional overlay in physical disease, its incidence, its responsibility for loss of productive capacity and blighted happiness, and its prevalent iatrogenesis, demands the un- relenting effort of all phyt.iclans toward its prevention, or early recognition and cure. This cannot bo accomplished a~ an afterthought, but must be integrated with all therapy, from the inception of medical care in every patient. DISCUSSION OF: FUNCTIONAL OVERLAY IN PHYSICAL DISEASE Discussed byj Reginald S. Lourie Commander (ilC) US HR U* S. Naval Hospital Great lakes, Illinois Gapt ain Kerman is to bo congratulated on tho use ho has made of ais opportunity to bo a psychiatric missionary, loading tho organicists in military medicine to see thoir own part in creating tho gold-brick", "o has tir.de a sound mental hygiene approach tov'ard orienting the -orthopedist, and others in provontivo measures ai>d dynamic understanding, oven hand!copped as ho was' by the uso of tho so often misinterpreted term "functional" which emphasizes to then r. body-mind dichotomy# The attitude of tho organicists toward tho psychiatrist is too often in any case, off the functional layers in the patient for mo, and then I can euro him • However, if tho; can be brought to .realise that a conversion symptom for example, involves tho use of established pathways and physiological mechanisms in such a manner as to cause an individual to respond pathologically, its prevention becomes as real and nocossary to thorn as procedures to avoid a contracture when a patient is in a cast, ,4o could very w'dl use a now ten.:, in reaching common ground with the internist an.’ surgeon, that would indicate a predominantly vegotativoly dot cm j. nod reaction and avoid tho too prevalent vise of the diagnosis of psychenourocie. In at least one Naval Conval.v»e*»t hospital, by the use of a questionnaire 'which was ('iron to each medical, surgical and ortho- pedic admission, the staff-was brought to an awareness of the ex- istence of potentially or actively disturbing psychogenic elements which could, or already had, prolonged roc every. Approximately 30/'° of all the questionnaires, and more than 50/® of thoso answered by patients returning from overseas, indicated the existence of such elements • Ac anticipated, a ixipority of tho staff members began to notify their concepts concerning, sand handling of, thoso patients, and wore encouraged in the handling of tho so-called "functional overlay by themselves# Group therapy, using tho*ward atmosphere as a background, v/as found to 1. c a valuable tool* 1 agree heartily on the iatrogenic origin of many of tho so- called functional manifestions but I disagree that tho psychogonic factors involved are "relatively non-specific and suporficir.l" or derived predominantly from 'latent dependent cravings", as inferred by Dr. Kerman. as a driving force in developing and perpetuating symptoms, has boon discussed hero today, but I should lima to bring up fern and insecurity again as an example of the specific and powerful drivlng factors in the development of "functional overlay", screening and Coast Cuard personnel r turning from overseas, it appears that most of then arc no longer afraid of dying, but they aro still a.fraid. 1he majority of them aro afraid of being crippled or mangled, much as described by Cchildcr in his concept of threat to , . * I! II body image. 'mbatant troops. In many eases a mixture of anxiety, hysteric 1, an! reactive depressive symptoms ..'ore noted, but in -11 eases, the outstanding symptom was that of anxiety and fear. fETHOr All patients treated had benefit of thorough psychiatric and psychometric cxami.-ati'n, a. complete physic-1 and neurological cxar.iinr.ti n, white blood cell count, hemoglobin determination, complete urinalysis, a Kahn serological test, and x-ray of the chest. In ■’ 'ition, general medic*'1 and surgical consultations as ".’ell as ad 'iti yia! laboratory and x-ray studios wore carried •ut when these measures seemed nec^ss-ry. Thu p-ticnt was started on 20 units of regular insulin, given intramurcularlv -1 0700 hours on the first fry rf treatment, The treatment * os terminat; 1 ot 1000 hours by the adnir.i strut ion of glucose and orange juice in sufficient quantity to neutralize the insulin riven, Th dosage of the insulin was increased daily by increments -f ten until,the desired level of response was reached. This level was preferably somewhere between Stage 1 and Stage TI -s ’escribed by The course of treatment at this point -was individualized, therapy being continue! until, in the impress!-a* -f the therapist, a desirable result had boon ob- tained. Th-. sa e of j, nsulin was then decreased gradually until the ori. inal lev.,1 was reached. Therapy w s given on five days of each week, bonday through Friday inclusive, and where prac- tical, the patients were one uraged to utilise pass privileges on week-on’s. In the series an .average maximum dosage of 71,6 units of insulin was utilized, the range extending from 50 to 140 units. The average duration of treatment was 19 days, with a range from 8 to 42 days. All treatments were riven on n ward utilized for this purpose alone. Cases receiving higher or those showing greater degrees of reaction were placed in avail- able private rooms to avoid alarming the other patients should untoward reactions occur. In this series three cases had convuls- ive seizures on one occasion during the course of their therapy. No complications or sequelao resulted. It was of interest that in each of these cases the convulsion occurred in the downward course of the treatment program and the patients admitted to ex- cessive drinking the previous week-end. These cases were the only ones in which the treatment period had to be terminated by intravenous injection of 50% glucose.' There were, however, a few cases in which the treatment period was shortened by early administration of oral glucose when the patient was experiencing moderately severe myoclonic twitching. Precautions were taken to meet any emergency which m4ght arise as a result of therapy. These were set forth in a list of instructions conveniently placed in the nurseTs office on the ward. Nurses and other ward personnel were instructed in the nature of reactions and the care of such in patients on insulin therapy. Careful notes descriptive of each patient's reactions during therapy wore recorded by the nurse in a book provided for this purpose, A medical officer was available on the ward at all times throughout the treatment period. As previously stated, all cases treated had one common denominator, namely, the presence of anxiety symptomatology. However, a wide variety of psychopathology was represented in the group. The following cases have been selected for presenta- tion to demonstrate some of the more common types seen: CASE I The patient was a 30-yoar-old white T/5 with 2-10/12 years of service who was admitted to the hospital on 8 Juno 194.5. He hai been an emotionally immature, unstable individual in civ- ilian life who was strongly attached to his family. His work adjustment had been fair, but he had always been unable to oper- ate under pressure or in competition with others. Ho went overseas in May 1944'and was in combat area four months in the ETO, during which time he “tagged along with the rest of the crowd", but never fired his rifle. He was wounded in his right leg in March 1945 and while being evacuated, was riding on a truck which ran over a nine, causing him to be thrown from the truck. Subsequent to this he developed a severe combat reaction for which he was evacuated to the Zone of the Interior, On arrival at this hospital he was confused, tense, emotionally labile, and demonstrated narked tremors and a startle pattern. At the completion of therapy he was relieved entirely of the anxiety features seen on admission. He gained only 3“l/2 pounds during the treatment. Psychometric retesting indicated he was perform- ing at the sane level as ho had been at the time of his induc- tion. CASE II The patient was a 26-year-old T/3 with 3-1/2 years of ser- vice at the tine of his admission to tihe hospital on 23 April 1945. Ho was a college graduate with a degree in pharmacy whose preinduction history was essentially negative,,. In the service he served as an instructor in the technicians1 school and later on as a. technician with an evacuation hospit- al in a non-combatant area. He tried for a commission on numerous occasions, but failed, each time. After each failure ho became increasingly tense until he finally began to exper- ience anorexia, nausea, vomiting, insomnia, marked tremors, diaphoresis, startle pattern, ideas of reference, and mild paranoid trends. Those symptoms were predominant on admission. After treatment his anxiety symptoms subsided completely. A defeatist o.ttitudo present on admission no longer existed. He. gained 6 pounds during treatment. Psychometric retesting in- dicated ho v;as' performing at the sane level as he had at the time of his induction. . CASE III The patient was a 29-year-old S/Sgt. with 4 years of service rt the tine of his admission to the hospital on 18 July 1945. His past history was essentially negative. In the service ho functioned very effectively overseas in the Pacific theater with a supply unit. About two years before his hospit- alization he began to experience anorexia, nausea, weight loss, and burnin : sensations in his abdomen. He continued at duty and return©1 to the Zone of the Interior on rotation. After a furlough he was assigned to the Personnel Section at the hos- pital-, Here, his symptoms became ag'dravated and he complained as well of tenseness, tremors, diaphoresis, and reduction in potency. At the completion of his therapy he felt very much improved. Ho gained 15 pounds, his anxiety symptoms disappeared, and he was returned to duty status at his own request. Psychometric retesting indicated he was functioning at a level higher than he had at the tine of his induction. CASE IV The patient was a 27-year-old white Pfe, with 3-6/12 yoars of service at the tine of his admission to the hospital on 31 Au 'ust 194-5. His preinduction history was replete with neurotic stigmata in an inadequate, schizoid individual raised in a poor environment. After four months of service in the Amy he was sent overseas where he participated in the North African, Tunisian, and Italian campaigns,, during which time he was wounded ■->a two occasions and returned t' duty each tine. He had a penile lesion in March 1944 for which he received anti- luctic therapy. In January 1945 he began to worry about the possible effects that the luetic disease night have on him. Ho developed a severe syphilophobia with a concomitant severe chronic anxiety state which was subject to frequent acute panic states. Serologic tests for syphilis were all negative. On therapy his anxiety symptoms subsided entirely. His syphilophobia resp ndod to’intensive psychotherapy. Ho gained 6 pounds. Psychomet-ic retesting indicated a moderate improve- ment in intellectual function. RESULTS From the observations made cn the cases treated on this service we were impressed with the following’ as clinical evi- dence of therapeutic response to sub-coma doses of insulin in anxiety states; (a) There was evidence of autonomic stabilization as was manifested by decrease in diaphoresis, disappearance of flushing, lowering of elevated blood pressure, slowing of the pulse rate, and a subsidence of multiple gastro-intestinal complaints, including anorexia, nausea, and vomiting. (b) Tremors, startle patterns, insomnia, restlessness, and other evidences of increased psychonotor activity dis- appeared . (c) Irrita. ility and aggressiveness disappeared, and the establishment of rapport between the therapist and the patient was very much facilitated, rendering the concomitant psycho- therapy much mere effective. (d) Patients entered more readily into the ward and. occu- pational therapy program prescribed for them, and the ability of the patient to socialize while in the hospital and on pass progressively im.:roved. (c) There was an increase in appetite in alnost every case.. However, re rsre unable tn correlate our clinical results with the r; to or degree of weight gained, as had been previous- ly describee by :thwr authors.12 Some of our best responses were seen in patients in whom there was little weight gaine'3, and in light of this re did not feel it advisable to terminate treat- ment should the patient fail to gain weight by the end of the first ton days. Although weight gain rf as much as 15 pounds was observed, the average gain for the series was 4-*26 pounds. Objective efforts to correlate the degree f improvement with our appraisal of clinical response were undertaken in a small group of the total series who were psychometric retests. The following trends were soon: (a) An average gain in the full weighted score on the Bellevue-7echslcr examination of 16,2 points was observed, with a range of from 2 to AO, (b) On the Shiplcy-Hartford Retreat examination there was an average gain of ,1 points in the vo-cabulary score, with a range of -3 to c /3, while on the abstraction score the aver- age gain was 5.6 points with a range of 2 tso 16. In no case was there a decrease in the abstraction secure on the Shipley- Hartford Retreat examination. After completion of the treatment program 22 of the 65 patients, or 34/5, wore considered recovered, 28 patients, or 43%, were considered much improved, and 15, or 23%, were con- sidered as improved. In our opinion the 77% considered recov- ered or much improved were able to return t" a general or limited duty status at the completion of hospitalization. CONCLUSION Sixty-five cases in which the outstanding pattern was that of severe anxiety were treated by means of sub-cona insulin. In evaluating the inprovoment noted in those patients we have duly considered the direct psychcpathologic and physiol- ogic effects of insulin therapy, but at the same time wc have not overlooked the effect of the therapeutic enthusiasm of the staff, the morale on the ward, and the drama associated with the treatment program. Whereas most of the patients had been evacuated progressively with barbiturate sedation as the chief therapeutic approach, the insulin ward a systematic program was Instituted producing tangible results that the patient ccui • ofca rvc both in himself and in others. Combined with active individual maychothcrapy, sub-coma insulin therapy has proved a great value in the treatment of a variety of patients manifesting severe anxiety. REFERENCES 1, Dcbonham, G,, iiill, D,, Sargant, b,, find Slater, E,; Treat- ment f v.Tr neuroses, Lancdt 1:107-109, 25 Jan, 1941. 2, Ronnie, T,A.C., Use nf insulin as sedation therapy: control of baric anxiety in psychosis. Archives of Neurology and Psychiatry 50:697-705, Dec. 1943. 3. Fox, Henry M,, Insulin for rehabilitation. Bulletin of the U.S. Army Med. Dept., Vol. IV, No.4: 447-452, Oct.1945. 4. Bychowski, G,: Psychoanalyse in hypoglyktfnischen Zustand ,Intornat, Ztschr. f. Psychoanal. 23:540-547, 1937, 5. Ecrze, J,: Dio Insulin-Chok-Behandlung der Schizophrenic,Wien. ned, VJchnschr, 49:1365-1369,1933. 6, Boss,’!.; Die Grundprinzipicn der Schizophreniebohandlung in historischen RUckblick, Ztschr. f, f. ges. Neurol, u, Psychiat. 157:358-392,1937. 7, Piers,G.: Prognostic observations in insulin treatment of schizophrenia, Elgin State Hos;p. Papers,4;34-45,1941* 8. Hinv/ich, Harold E,: The physiolo.gy of the "shock” therapies. Psychiatric Quarterly, 18:357—373, July 1944. 9. Harris, M.M., Boelock, J.H., and Horwitz, W.A.: Metabolic studies during insulin hypoglycemia therapy of psychoses. Arch. Neurol, and Psychiat,, 4.0:116-124., 1938. 10. Katzenelbogen, S,: A critical appraisal of the "shock therapies" in the major psychoses. II. Insulin, Psychiatry, 3:211-228, 1940, 11. Gold, Leonard; Autonomic balance in patients treated with insulin, shock as measured by mecholyl chloride: A preliminary reoort. Arch. Neurol, and Psychiat., 50:311-317, Sept. 1943. 12. Sands, Dalton E,: Insulin treatment in neurosis. J. Ment. Sc., 90:767-771, July 1944. croup PoYgiiothekapy e: ut y hospital RELATING TO CIVILIAN READJUSTMENT Capt. Maurice R, Friend* T/4 Walter F. Sullivan A group psychotherapy project was initiated at Vaughan General Hospital in October, 1944. The neuropsychiatric facilities of this hospital comprised a "center" for the nsre severe neurotics and psychotics. The bulk of the patients were men originally from Illinois, Wisconsin, and Michigan, who had broken down in overseas theatres. During the process of evacuation to the United States, there was a marked recession of acute reaction to war stress, either through definitive treatment or through spontaneous remission. Thus it was that even in this severe group of war reactions, a large number wore sufficiently integrated txJ participate in group therapy. The hospital facilities possessed superior educational, physical and occupational resources to meet the requirement of this type of patient. Trained enlisted psychiatric social v-'orkers as well as qualified psychologists familiar with Rorschach technique and Red Cross psychiatric social workers comprised part of the special features of the center. In addition, it was conveniently located a short distance from Chicago where transportation facilities enabled the patient to take frequent weekend and furlough trips to his home or for visits from the family. At this hospital the individual patient was treated for an average period of three nonths. Because the patient had been previously carefully screened, the general therapeutic ain was to restore nost of the individuals for civilian life rather than further military needs. In such an atmosphere, where patients were continually returning to civilian life, increased individual security was developed and associated with a diminution of hostility to the army and particularly to treatment within the military structure. An unusual opportunity was afforded the therapist to share, understand and help resolve the patient's first contact with family and community associations. Accord- ingly our group psychotherapeutic goals more nearly approximated civilian needs than most reports of therapy by military authors. Our goals were: 1. To diminish guilt feelings engendered bj' traumatic war situations 2. To enhance self confluence as a result of group membership. 3. To assist the individual through his first steps of civilian adjustment on a. group level. It is felt that these superficial goals wore accomplished in the group by: 1, Positive transference relationships to the group leader, 2, Group acceptance of the individual, 3, Partial and incomplete abreacti#n of emotions, 4, Individual repressions and suppression to obtain group acceptance, 5, Partial acceptance of emotional conflicts in their relationship to somatic expression. *Vaughan General Hospital, Hines, Illinois Thirteen groups, comprising about 250 patients were treated. Approx- imately 75$ were neurotics, 13% psychotic reactions and 10$ psychotics. Forty-five percent of the men's aisorders were precipitated by combat, 35$ occurred overseas, but not in combat, and 20$ originated within the contin- ental limits of the United States. ’Thilo these figures arc by no means accurate, it is to be noted that most of the patients were neurotics and had combat experience. In the group were both officers and enlisted men. It is noted that a number of psychotics attended, but none of these should be con- sidered as such in the civilian sense of the word; they wore all in a good clinical remission and had well-developed ego strength and probably would not develop a recurrence unless faced v.ith strong external stress. The great majority of neurotics were by no means chronic and did not have well-established defense mechanism. It was our experience that the severe and chronic neurotics operating under the repetitive compulsive principle did not profit nor could contribute to other members of the group. The greatest number of men had either free floating anxiety or various psychosomatic complaints. They approached their dilemma from an organic base. They either did not have the background or the wish to appreciate the causative emotional factors, A number of men in each group gained partial insight and the desire to continue treatment in civilian life. The following is an extract from written comments about the group by an intelligent, dependent, passive individual with severe anxiety who had not been particularly outstanding in the group: "These group discussions were a revelation (can't think of a stronger word) to me. I believed my stomach, bladder, etc., were actually on uhe oum,.,showed no that it was a mental condition. For the first time since hospitalization, I became aware of the nature of my sickness.,,my mind like my little toe, was something I just tolerated, not knowing its rami- fications. .. .it made me aware of something I never realized existed, namely: the motor that makes me tick. It's new to me, and I want to know more about it," The staff initially was comprised of one psychiatrist, two enlisted social workers ane a Red Cross recreational worker. The psychiatrist had previous experience with proup psychotherapy of adults, under Dr. Paul Schildcr and experience with children anc, adolescent f-.roups in conjunction with S. R. Slavson. The staff, as a eroup, carefully selected nenbers after review of the history/ and present behavior status of the individual. Special attention was pfid to possibility for leadership and the ability to socialize. An a.ttej ;;>t was node in each croup to select a c'iven nenber of loaders, a certain number of passive dependent individuals and a few individuals who wore hostile ana not anonablo to the usual ward therapy. It was not found necessary to differentiate the non by virtue of conbat experience. Officers were selected on the sane basis, but with the provisions that there be nore than one in the Croup. Diagnostic classification wa.s not of najor inportance. After several preliminary conferences, group meetings were scheduled and there wore staff group conferences immediately following each session to evaluate the interplay amongst the group and to assay the role of the leader. Later, the social workers became group leaders and employed a psychologist and a Rod Cross recreational worker as their team maintaining the same technique. They had weekly conferences with the psychiatrist to further control their technique. The Red Cross workers, always women, had a passive role in early group sessions ana later participated in skits taking various female roles. As the social workers progressed in their ability to lead groups, psychologists came in for training and participated. In this manner, an accumulative body of trained group personnel was developed* Meetings were held in a comfortable recreation room which included a seni-raised platform, which was at times used for impromptu situations under discussion. It was gradually learned that a circular seating arrange- ment eliminated the pre-conceivcd ideas of formal lectures. Smoking was permitted to ease the situation. It was found that a series of 12 to 15 consecutive daily sessions was of greater value than a longer time period with interval gaps. It was the considered policy that the group loader accept differences in opinions to his own statements or that of other members of the group and to offer these to the group for discussion. Near the end of each period, the group leader invariably paraphrased the main of thought and tried to keep continuity by referring to an unfinished discussion at the beginning of each session. At the first meeting the group leader discussed the purpose of the group, namely: that it was felt all members wished an understanding of emotional problems and conflicts which had landed them in a psychiatric ward and understanding of the term "psychonourosis " and what other people would think about them and problems of the future after .their army career. They were told that the hospital was a logical place for them tc openly face their problems and that it was a practice ground for their future adjustment. It was stressed that all members had been particularly selected as those individuals who would profit from such a discussion. It was recognized that certain individuals would be more free than others. The men were told that if after three meetings, they did not wish to partic- ipate, they could discuss this with the group leader individually, and that then they would be free to leave the group. The group meetings would in no way comprise, a part of their hospital record, and furthermore, participation would not delay or interfere with passes, furlough or separation. They were informed that army rank was to play no part and this was quickly evidenced in groups when staff -members represented in themselves a tremendous dis- parity in rank. Each staff uenber introduced himself, giving his none, hone town, arny experience, professional background and sonc personal information. Questions were encouraged from the group and frequently included "What is a social worker?*' In the next three sessions, the topics of indiviaual development and background before military service, the presentation of anxiety and fear with physiological expression, the methods and mechanisms of controlling anxiety, the persistance of neurotic anxiety following their evacuation from overseas, and finally the difference between psychosis and psycho- neurosis, was presented in as clear and understandable language as possible. This material was presented with the aid of the group's participation, and not in the formal manner outlined above, Ibc film "Introduction to Combat Fatigue" and transcribed battle sounds were used to concretize discussion. It was found that the material was stimulating to the group and offered material to test the group leader and at the sane time, to familiarize themselves with other group members, Characteristic individual nodes of behavior, such as intellectuality, masked hostility, withdrawal trends, guilt reactions and depressive tendencies, as well as individual acceptance, were noted. At this stage, members were asked to relate their particular difficul- ties that led to hospit-lization. This response varied with the individual, was filled with omissions and was open for discussion by other members. Severe emotional abreaction was never found in our groups. It is felt that [roup acceptance would not tolerate this on the’one part, and that our patients through their previous series of hospitalizations, had bound up their free floating anxiety. Rather than a goal of abreaction by personal narration, our aim was to enable the group to see the similarity of anxiety reactions, the universality of psychosomatic complaints and the basic conflicts in all members. This served to clarify the common mis- conception in the army, MIt‘s all in your head”. The following is a sample of a group introduction. Brief histories of the individuals are given to allow understanding of what transpired in the group; W, a 2U year .Jewish private, suffered an hysterical paralysis of his right lei in his first day of conbat. Ho was reclassified, and he felt racially discriminated against in his new outfit, and was ash-tuned that he, a college graduate, never advanced beyond the err.de of private. He was particularly conscious of the fact other non housed and fed Italian girls, He openly projected his foolin; s in an incident whore he infuriated his ness sergeant by conplaining about food and feeding it to a do, . There then ensued depression, resentment and excessive feelings of inferiority. The patient was an only child of an over-protective mother. His father hat. a severe depression while the soldier was overseas. The p-' tient had always been seclusivo and h: d marked feelings of sexual inadequacy, and attempted to compensate in civilian life by studying sociology. One tine while in college, he had a [love anaesthesia which cleared up by osteopathic treatments. On the ward, the patient was a smug, self-satisfied individual with passive negativism. He was always attempting to take advantage of ward personnel because of his feelings of superior intellect. In addition, ho projected his difficulty onto others and had no insight into his own disturbances. Group therapy helped this individual see his own role in provoking counter aggression. It did not give him insi, ht into his fundamental problems. S, is a 25 year staff ser ;oant of Hun. arian-Jewish decent. He performed valuable service overseas in the Intelligence Division of Army Head- quarters end underwent much enemy strafing. One evening, while standing on a plank platform of a house, he suddenly became tremulous and dizzy and fell two stories to the [ round. Marked anxiety and tremor of the lower extremities developed and persisted. The patient was evacuated to the United States, ho developed a recurrence of his initial syr.iptor.-is while on furlough shortly before return to duty. The patient was a severely traumatized individual who had sepn severe hardships in the first war, as well as in Nazi-occupied Hunt-ary, He was neurotically attached to a nasochistic mother, who suffered con- tinual physical abuse from a paranoid and borderline psychotic father, ’Thile overseas, and at the time of his fall, he had received news that his father was again maltreating his mother, and he worried excessively about this. The story of his family experiences had never been revealed in all his previous hospitalizations, and it was readily apparent to the patient that his marked tremulousness and excitability was a re-dupli- cation of his emotional state during the many violent quarrels witnessed at home between his parents. His narked dependent feelings wore neurot- ically sublimated by a fixed desire to placate the father by inordinate work and attention. His main desire for years was to keep his parents together and provide for the comfort of his mother. On the ward, he Initially showed marked anxiety which was heightened following a home visit. It soon became impossible for him to withhold his family concerns, and he f ained a great relief in discussion with the ward officer. He later brought his mother to the hospital and she confirmed the distressing family situation and finally made plans to leave her husband and make her home with her son. This man had partially neurotically solved his present family difficulties by the time he started roup psychotherapy and gained increasing ego satisfaction by positive leadership in the group. G is a 26 year platoon sergeant who was hospitalized because of acute anxiety reactions and an exacerbated speech defect after severe combat for 57 days on Okinawa. While engaged in active combat, he received wore that his brother had been killed in Europe. Shortly thereafter, his lieutenant and several men in his outfit were killed in front of him. Still later, while in combat, the hatch cover of his tank fell on his head and he developed acute anxiety reaction plus a severe speech disturbance following his return to safety. The patient cane from a'very underprivileged family, and had numerous siblings. He was extremely close to his mother, who had tola him that, he was the only one in the family who might accomplish something in life. He had repressed hostility towards his father, who was shiftless and at one tine was placed on probation for incostual relationships with the patient's sister. His childhood speech defect was explained to him as caused by a fall on the stairs in which ho struck his head. Following his mother's death, when ho was 10, he was placed with a number of other siblings. One' of these has been hospitalized for many years because of dementia praecox. The patient blamed himself because he had influenced his deed brother to join the’army, and had seen him before his death at a time when they both had a furlough. Ho was extremely conscientious, driving and always trying to be the opposite of his shiftless, boasting father. Ho was always a very insecure'and deprived individual who had done well in the amy until the combined influence of prolonged combat, a blow on the head, loss of his brother and his own lieutenant, removed all ego support• On the ward, he was a sensitive, dependent patient, who at first needed a great deal of support. The goal of therapy both individual and was to enable him to again attain his compensation by group acceptance and solf-confidencc. His speech defect, as one night suspect, proved to be the nost refractory of all his symptoms. The following is their own account of their self introduction in a group meeting with contributions from other members: S stated, "I am 26, and I was born overseas and came to this country when I was 20. I an different from most of you fellows, because I know my trouble started before I was in combat, I got into the hospital, because curing an air raid, I was on a roof and fell, I was unconscious, and when I came to, I was tremulous and tense, (He rationalizes his feelings of estrangement by his foreign birth, ' His family problems which he had already discussed with the ward officer, are omitted. Note also how the other patients pick up the basic omission). W asked •What was there that went on before, that caused you to be tense, if it wasn't the air raid?* S then told of having been in a concentration camp in Hungary and having, no home land. His entire family had been placed there. He was finally freed cand the major part of his youth from 1936 until 1940 was spent in supporting his nrents and sister, "I intend to write a book concerning the relationships of men in a democracy”. His basic desire was acceptance as an adult stoning from his original hostility toward his father, V said he could see why S said the causes of his difficulty preceded his combat experiences, but he didn't believe that combat would not also leave its effects, (This member was one who was exceedingly fearful of combat, had never seen any, and had projected all of his insecurities onto family tribulations during his absence). He thought S was as much afraid as anyone else, S said that he didn't feel that he was as much afraid as some of the others, who said they were. The members of the group refused to believe this. W was next. "You will be here for the duration and six months before I get my story told". A group leader said *Take all the time you want*. "I am an only child, and I usually have my own way, I went through college and received a B.S. degree, majoring in sociology, I had some nervous trouble when I was in school, but got over it, I got in the army like the rest of you and went into the Infantry, I was placed in the cadre as a Chaplain's assistant, and was sent to another camp in Florida. I got into an argument with the Chaplain and went overseas as a replacement to Italy. I went into the lines and then got shipped back on limited service, I was assigned to a railroad outfit and was sent on a detail away from the outfit. I got into a couple of arguments with the mess sergeant. He finally told me that he wouldn't feed me," (The manner in which this was stated was typical of the frustrated hostile child), "I called the Criminal Investigation Bureau on the telephone and told them that the mess fed civilians (Note the omission concerning the fact that it was Italian girls who were fed. The whole situation was reminiscent of a small child invoking additional strength to defend against expected retaliation by a father figure), "I was over heard by some cf the fellows, and they beat me up, I was sent to the hospital, and after I got in, 'blew my top*", G asked if the people were hungry. He was Answered evasively* M stated that people were fed everywhere out of the army mess and W agreed that this was true. Before anyone else made any comment, G said "I am going to toll my story. I was section sergeant in a tank outfit. Everything went OK until we got a new lieutenant on Okinawa. He didn't know anything about tanks. Vie were going down a road, when the soconu tank in line hit a mine. It blocked my tank*,.and I pulled back out of the lino of fire. I signalled the lieutenant to halt, and I got out of my tank and wont to see what the damage was. The assistant driver had been woundod.r.-r.t'vm' badly in the back. I gave him first aid, and didn’t let anyone touch him because I thought his back was broken. The other fello.0: had w?vvoud to move him, but I had been told to leave it for the Mu a: o, ho/ '-re dropping mortar shells around us and the lieutenant coulda t b-rj. \t nis tank back on. the road, I went up and told him to pull o v** th .u, h -- rice paddy, but he was afraid to do this. So I got in t. ’c f uil: ;.nh directed hi: bank out of there. The Medics finally got up t but tip officer didn't want them to go in because it was too dan n. a a. '.her they finally got in, the assistant driver was dead, I always vr a. It T a ad done right, A few days later, I got hit on the head cy the' In t«.h cover, I couldn’t stand on my feet, and I stutter*. >. (tins recital, the men were very interested, despite a marked Interr- if uvti.-p of the proient's speech defect. In this recital is 3-.ee z>m pah-?ant’s extreme effort to compensate for feeling of loss co.yc.iu 01 -ed 'ey uhe death of his old leader. This theme ran throughout hi: previrv.a life in relationship to his parents. His typical ar.br "lease in * I woausred whether I did right’, is a constant problem of his present life situation. The actual traumatic incident of being struck by a natch cover wps definitely related to the onset of his speech difficulty•at the ago of 5, when he was told by his family that his speech difficulty followed a fall on.his head.) N asked if he had ever stuttered before, "Yes, when I was a kid, but I got over it". M said ’You had a tough job to make up your mind what to do there. You had to take care of those fellows who were not hurt,’ (This member was exceedingly loyal and responsible, and was in the same combat area). S said ’You might have killed the wounded fellow tryiniv* to get him out. That is a job for the Medics', S said "That is what '>■> they told ne." M was next. He looked at the floor with his hands tightly clasped and said, "I don’t want to talk about myself, Jty problem can’t be helped in the arqy”. His group leader said ’That is your right. You can either talk or not, as you see fit’, (This individual throughout his hospital course was a stolid phlegmatic individual who showed no wish to accept aid .for his own problems,’ He persisted in fixed somatic complaints). Sometimes an individual who cannot relate in a group will bo stimu- lated by the discussion to give an account to the ward doctor or some staff member in an individual interview. R,.a 35 year warrant officer, had been referred from the surgical service because of persistent rectal pain and itching. He had never been able to fully appreciate the affect of his combat experiences because he had spent most of* his hospital time with excessive concern with his physical symptoms. He had had three previous hemorroidectomies and had secured no relief, but had instead become sensitive to the fact that others had felt that he had "goldbricked". He forced himself to go with his outfit overseas and persisted through' severe combat. He came into his ward officer’s presence, without appointment, under great tension and related the following: "I have to tell you about my experiences overseas, I think that this might have something to do with my tenseness, I was with ray enlisted men in a truck proceeding down a hillside road under enemy fire. We were mopping up around Brest, I could see a shell coming and gave the order to ’Stop and get out’, A few seconds later, a shell landed between the two front seats, destroying the-vehicle”. He told in another session of further combat experiences, and for the first time developed an understanding of how his somatic fixations were aggravated by stress. An example of how-group interaction influences one’s attitude is portrayed in the following excerpt; W said that he always get started into an argument and always felt that the other follow was at fault. V said openly that that was how V,T always seemed to act in the group, by being angry against the army and people, V said- that he was fed up with the army too, ”7 said ”Yeah, but I always picked the guy that was the boss”, G (a sergeant) said "That’s the hell of- a thing to do because that’s the surest way to get into trouble.” W said ”1 will more than likely have to get over that”. It is seen that V is accepting criticism within the group and is already free enough to recognize openly that he provokes aggression. By the sixth meeting, groups had gained some understanding of their condition and generally brought up the point "Now that we know something about ourselves, what do others think of us and what can we tell then?” Members found that they had much in common when they returned hone on pass or furlough. That lonv anticipated furlough was- sometimes fraught with depression and anxiety. ’ Many members found that what they had first dis- cussed in groups actually was lived through when they left the hospital. Reaction to city noises was universal and sometimes provided situations of humur. The question ,m,hat can we tell others?” was brought up in a very modified spontaneous dramatic session with the job situation and family situation generally forming the background. For example; D, who had a difficult problem in discussing his reasons for discharge because his com- plaint was flat feet, depended on his sex appeal and his generosity. The leader suggested a scene in a bar, Red Cross worker was a pickup. (D) "Can I buy you a drink, honey?" (Girl) "Sure". They drink. (Girl) did you get back, Mac?" (D) "Just recently". (Girl) "Out of the amy?" (D) "You bet". (Girl) "How did you got out?" (D) '’Lot’s not talk about those small details. I’m flush, and have boon looking: forwaro to drinking and having; as good looking, a girl as you across the table from me. You know I spotted you when I came in anc s4id to myself ’That's the one I have been droamio, of’, ”How about another-drink?” Another patient, De, who had shame reactions returning to his home community from where eight comrades were never to be seen by their families, was markedly hostile and tense. He projected this onto civilians until he actually was able to go home and bo accepted. He said: "If an employer asked me too many questions) I would pop him in the nose.” The scone was the Personnel Manager’s office in an iron mine. The s cial worker plays the part of a very- strict personnel man who is wary of "neurotic war veterans”, A knock is heard on the door. The office boy escorts Do, seeking employment, into the office and introduces him to employment manager. (Employment Manager) "So you’re a veteran, Ity son is fighting in the Southwest Pacific, I haven’t heard from him for a long time, ’.There did you servo?" (De) ”In the sane area as your son.” (Employment Manager) ’’You'lock fine* That brought you back?” De blocked and the skit hac to end. This was .reenacted by other members ana it was brought out by the leader that the civilian reactions were more natural than, the soldier’s. Later events proved this patient was the hero in his community and had the choice of five jobs. The following is a -.roup eiscussicn about civilians H told about a fight he had with a civilian. The civilian had said "I hope that war won’t end for another year". Other members said that! they would kill the person who said that to then. The group leader v threw out the statement "Is this true of the majority of civilians?” P responded that some fellows in the service were forgotten by their families. Ho told h ;w his mother knocked down’another woman who said she was getting more money than over before because her sons were in the service. Z told about a civilian who expressed the opinion that his son should develop an ailment whereby he could secure a discharge. The group leader in a discussion like this brings out the common feeling of the group and at the same time always strives to present an understanding of the safe, secure, selfish civilian of which the-very same soldier was once a member and to which he will again return after the war. At the last group session, which was always announced well in advance, there was a ..eneral mood of ambivalence. The leader with little effort would invariably bring forth the reaction fmm the men that they would never again repeat their army experiences, but at the same time they wqre glad to have been in the service. They compared experiences with their separate outfits ana showed, positive pride in their outfits. Most of them were intent on maintaining membership in Veterans* organizations* Positive transference reactions to the leader and other members of the Lroup continued throughout the patients* hospital stay. Patients always greeted the enlisted social worker affectionately with a pat on the back. They would comment as one did "You have more on the ball than some of the officers around here," They would mention their individual problems assum- ing the L roup leader knew all about them. Their closeness and familiarity with the Red Cross worker was maintained in an entirely different area of activity. Members of particular groups tended to continue friendships made within a ; iven group. CONCLUSION: 1, An account of group psychotherapy with 13 groups, totalling approx- imately 250 soldiers in a military nouropsychiatric center has been presented. 2. The group sessions were particularly oriented to readjustment of •the s >ldicr to civilian life. The environment offered unique opportunities to tost transitional adjustments through family contacts and visits on the part of soldier and his family. 3. Selection of men for these groups rested principally on the basis of need for help and ability to socially participate. Most of the men had :pod backgrounds and broke only under severe stress. It was found that many psychotic reactions responded well to group therapy. U. Long standing neuroses did not profit from group experience except on a most superficial basis. 5. It is felt that the primary” psycho logical mechanisms operating vdthin the group were: A. Positive transference and identification with the leader, B. Need for group acceptance, C. Repression of basic conflicts, D. Possibility of environmental change; ie, release from the army. 6. Definite sequential , mup trends were noted: A. Initial hostility and resistance to authority; ie, loader, hospital and army. B. General intellectual acceptance and understanding of emotional conflicts as related to their symptomatology. C. Guilt feelings about their condition associated with methods of social sublimation in family relationships, employment and ‘ civilian contacts. D. Fearfe of recurrence. E. Feelings of positive satisfaction regarding arn\y experience, coupled with a gratified sense of survival from danger. 7. It is felt that these group psychotherapy experiences are particularly pertinent tu adjustment difficulties of the war veteran in the future. The great majority of men should make a satisfactory civilian adjustment. Group psychotherapy on a military level has served to help concretize their problems and lessen their anticipatory anxieties4 DISCUSSION Maxwell Gitelson, II.D.* In discussing; this paper I regret .that I bring to the task important ueficicncies: First I have never conducted any experiment in group psycho- therapy myself* Second, I have had no Army experience on which- to base ray views of the particular work reported today by Captain Friend and his associates, ' IJhat I have to say is based upon some familiarity with the literature of the subject and upon impressions which the present report evoked. Besides this, in the course of previous efforts to comprehend vhat was going on in the treatment of patients in groups, I have of necessity had recourse to experience gained with spontaneous groupings which, during the course of work with individual p tionts,’have shown themselves to have had a therapeutic effect, , I think th.at it can he stateu from the beginnijv. that Individuals can and do spontaneously use group affiliation.for.self-integrating pur- poses ana that in a measure such individuals are successful in these attempts at auto-therapy* Outstanding examples of this are to. bfe found particularly amom: adolescents. These present us with the following types of spontaneous group formations which in the long run are’ of integrating value: * ' ' . ... - First, there is the adolescent g&ng, fully delinquent or operating just within the boundaries of tolerable behavior. Here, under the influence of a leader who carries the major .burden of the’guilt, and, by virtue of sharing the rest of thoburden with companions, the individual lives out his emancipation conflicts. In some instances there is ultimate stabilizaf- tion and socialization of the individual. I have in mind particularly the cose of an ex-soldier whom I have recently treated, who* joined a delinquent group during his teens, while in the midst of an emotional conflict involving his relationship to a kindly and admired but strict father. He was fortun- ate enough to escape the possible social consequences of this affiliation and in the upshot spontaneously gave up his delinquent associations and lived an integrated life as a worker and a married man for more than ten years. He cracked only, after eight months of frontline service when his relationship to his superior recapitulated‘the old father conflict. It is interesting that his army reaction again took the fPrim of group delinquency. ♦Michael Reese Hospital, Chicago, Illinois Second, there are groups of intellectualizing adolescents, who in the course of their mutually inflicted ponderin' and philosophizing succeed in abreacting and rosynthesyzing their several and separate conflicts. Third, there is the - roup phenomenon of adolescent conversion which occurs even amonf. normal individuals at these age levels. One sees attitudes of self-purifiertion and self-dodicrtion emerging and giving direction and stability to a previously shaky personality organization. Fourth, we are all aware of the fact that the adolescent social ,.roup is a spontaneous self-educational experiment in which -the adolescent learns the external limitations and possibilities of normal interpersonal relations. ’re are all familiar with the ebb and flow of activity and custn am'a: teen-agers on. a,-,oo in finding out where they fit in the scheme of thirds. Finally, there are the indiviuUt'ds who spontaneously, •-'ften it seems by /icrc chance, chan, e in the direction of more interra ted living, after finain themselves in a rifferent school, a different job, or in a different nei hborh i.-d. This duos not mean that the new .3roup affiliations are simply ’'better" in terms of eur external and abstract evaluation of thorn. Quite the c; ntra.ry nay bo true. The sig nificant thin for the purpose of our discussion is that somehow these .roups prove to cc better for the iven individual. They somehow complement him and his neeos in some specific if obscure way. Somehow in the particular croup he has found his into,, rative level. All of this seems to sum itself up to the following propositions: The problems ?f roup treatment boloa* among the problems of ego psychology, Neuroses anc psychoses, as a part df their symptonatolo/gy, present us with the fact of the ego’s failure to integrate the impulses of the individual with the externally imposed necessities of group living-. In the given individual this shows up, often quite consciously, as a deep sense of difference, of loneliness, and of helplessness. ’’That we seem to sec in the therapeutic group is the creation of opportunities for mitigating these feelings with consequent liberation of the individuals capacities fer inter- personal relations. These opportunities may be enumerated as follows: 1. By way of the transference to a suitable leader personality the indivi ual neurotic may t,ain an f lly in his struggle against his excessively severe self-critical attitudes. The leader orovides the patient with an auxiliary conscience which is more benign than his own. 2. In his association with other patients the individual may discover that there are others like himself who harbor omnipotent fantasies and destructive impulses. These are the chief barriers to the wish of every individual for positively-toned contact with his fellows. It might be immensely relieving to find oneself and others alive and well despite the prevalence of these fantasies and impulses. To discover that one is only human anu not a pariah among men mi,, ht be a really effective bit of reality testing . 3, A certain amount of abreaction through actinp-out may be possible. 4. A certain amount of peripheral working through of specific individ- ual conflicts may occur. I do not think that it would make much difference whether or not the individual were able actually to verbalize those specific conflicts. The empathy of the members of a therapeutic troup with each other coulc. enable each person in the g roup to sweat it out with each of the others in terms of his own specific conflicts. As in the case of young children who under- o psychotherapy, the development of intellectual or conscious insi ht is not a therapeutic necessity though it mirht occur as a byproduct. 5, It is known that in an equilibrated . roup the participating individuals assume certain balancing and complementary relationships which, in the individual case, means the gratification of particular needs and tendencies, with consequent relief of tensions. 6. Finally, the individuals in a therapeutic rroup, like those in a proup of adolescents, may actually pass through a learning experience repardinp the possibilities and limitations of interpersonal concuct and relationships. In closing, it seems necessary to state that the present stage of group psychotherapy is one of empiricism based on borrowings from our scanty knowledge of the forces that have been identified as operating in spontaneous groups. To a great extent the prevalent ideas also stem from our more precise knowledge of the nature of limited interpersonal relations. This is inevitable, T.Te can move only from the known towards the unknown. However, caution is necessary. There is still- a great lack of precisely reported material ana a greater lack of meticulous study of that material. Too many of the clinical reports in the literature seem to reveal psycho- therapeutic intentions rather than an identifiable process or verifiable results. The workers who jparticipated in the experiment reported today are to be complimented on the fact that they have re*otnizod the empirical nature of their work and have limited their intentions and their efforts to the practical requirement of doing possible towards easing the way of their patients into civilian life. The deductions which they have drawn from their work scorn warranted in the present state of our knowledge. GROUP PSYCHOTHERAPY FOR IEUROTICS Alexander H, Hirschfold, Captain, bl, C,* Yho Units of tho torn psychotherapy aro not woll-establishod des ito years of practice. Croup psychotherapy is a phrase which is even noro ephemeral and there is no agreement in tho literature on its scopo, constituent parts, or even the goals, a largo number of neurotics at Percy Jones Convalescent Hospital offered an oppor- tunity to clrrify sono aspects of tho problem. Before reporting our experiences, the limited nature of the clinic.-1 material must bo emphasized. All of our patients wore returnees from overseas theaters of war and the majority wore com- bat casualties, Because of several circumstances, there is possibly a different prognosis in those eases fra; that of similar states observed in civilian practice, the first place there was a favorable factor since a high percentage of these men had experienced minimal psychological difficulty previous to their breaks. Con- versely a second factor augored for reduced success, all of the non standing to 0ain by extrication from an untenable military situation if they remained ill, A lifelong pension was also considorod in the o fing by most of the patients. Finally, .those men. wore the most recalcitrant therapeutic risks of the neurotic group since 90>° of the original number of such casualties l)ad been screened out before reaching our hospital. uur first step in attempting group therapy was the use of didactic presentations. *n these lectures, both, tho content and the physician giving the material wore varied, Unfortunately, when the men were quizzed on this material it was discovered that they had absorbed little or nothing. Since several workers in the armed forces have reported success rath this method, our failure was diffi- cult to explain unless ono seldom-discussed factor is considered, i.n.service the physician pronounces his patient improved or well and the soldier returns to duty. Since the doctor, in this position, has command function, his success depends upon what tho physician believes about the patient rather than on how tho patient himself fools, therefore, it is possible that reports based on tho opinions of other therapists could vary widely with results determined by quizzing our patients, a procedure which may not have been utilized elsewhere. Th.j second procedure attempted was almost immediately appreciated as the method of choico. Discussion groups were inaugurated and in those, patients carried nearly all of the responsibility for picking material and guiding tho course, remainder of this paper is a description of our effort to nako this procedure more useful. *Pjrcy Jones Convalescent Hospital, Fort Custcr, Michigan, Paradoxically,the first significant variant in the success of those free discussion groups was discovered to bo tho physician# A statistical study of several hundred eases so treated confirmed this observation. Results varied more sharply with recognized capabilities of a therapist than they \fculd with any other factor. The influence of particular personalities over a group was again emphasized in an early mistake, In order to accelerate the pro gran and to olimins.tc red tape the soldiers wore interviewed both on admission and on return from initial furlough by the first physician available to then rather than by the man who would bo their th rapist, f.’us procedure was almost destructive in its results becaus • the sessions therupon deteriorated into got- acquainted procodur . Ilio apparent conclusion was that it was necessary f rth. _a':i.nts tc know their therapist and for the therapist to • them, at the onset of group treatment. It will be seen that r. wider concept of group psychotherapy '..*as beginning to emerge from our early experience, work had bopun with the frequently enunciated thesis that an hour or so of group discussion was, in itself, group psychotherapy. At least in the case of soldiers, v.’ho arc neurotic, this was emphatically no' the ease, wo discovered that the choice of therapists * was very significant, Next, wo discovered that previous contact between the therapist and his patients was important, finally, it was appreciated tliat wider contact between physician and patient during treatment resulted in much bettor discussions, free though thev were. An example of tho useful, broader contacts was ward rounds, This procedure was not originally scheduled as part of tho con- valescent hospital program in the army, but we found that sending our physicians through the barracks as frequently as possible was efficacious. *t must be emphasized that this advantage was not appreciated in tho ward rounds themselves, but in tho group sessions which seemed to improve because of the ward rounds. This was especially true if the doctors wore very careful with tho normal amenities of physician-prtient relationship, such as greeting each pa.ticnt by none and briefly discussing some little problem of his illness. A second type of additional contact which proved necessary was individual interviewing, This was indispensable, a vital con- tributing factor tc the success of the discussion groups, It is fully described below. As a result of our widening contacts in utilizing the other methods discovered, tho phenomenon soon developed which was recog- nized as tho essence of tho method. This was group transference, and it scorned a different factor from individual transference. The vital significance of being en rapport with a group can be appreci- ated after even a cursory examination of literature about this problem in the service, "ithout the use of some such method at this, the psychiatrist, an officer, is a symbol of hated authority, furthermore, both ho and tho patient recognise that therapeutic success will ro-procipitato the soldier into what, for him, is a horrible environment. As a result of those factors very fgw patients in service ordinarily seek out the type of psychiatric help they would in civilian life. °n tho other hand, when this point of group transference is reached in the present method, the physician suddenly emerges as tho kind father and is capable of treatment which is truly efficacious, It is bocauso of the development of this situation, in contrast to tho ordinary military ncuronsycljiatric procedures, that tho development of tho group transference is regarded as the essence of this method. At this point, the relation botv;con tho group and individual interviews defines itself, “ith tho dovolopnont of transference, contain men bcJLn to want and oven demand individual treatment. Ihoso non develop insight which is taken into the group and acta as a pump-priming factor in causing tho entire group to precipitate significant psychodynamic material. unly a small portion of men require many real individual interviews under these circumstances, so that tho amount of tine consumed is negligible, real treat- ment for tho 1 rgc majority proceeds entirely in tho group dis- cussion. c-n be deduced from those facts that the frequently-put question, *»hat is the best subject natter for discussion• is superfluous. I ho patients have a large steel: of appropriate material tc discuss, and the problem is not how to have a doctor explain those problems to the : on, but rather how the therapist can cause th-. group to precipitate thou for discussion. The sizo and tho compostion of the groups wo• o tho last questions to bo settled. It was felt that a fairly largo group, perhaps 40 men was entirely satisfactory in tho early stages, Dator, after the development of group transference, smaller groups wore mere efficacious and tho division was nr. do on a basis of synptomology, he sym; tom groups could number from 10 to 15 men. • seemed best to completely eliminate non in two classifications, Deficients rnd borderline mentalities -wore not particularly harmful to tho group, but were unable to extract enough gain to make tho group sessions worth while to themselves. Aggressive psychopaths, on tho other hand, were net difficult to handle, as is reported elsewhere. In fact, if tho aggressive individual proved amenable to treatment he helped the group greatly. If ho did not improve, but, on the other hand continued unreasonable antagonistic behavior ho made a significant impression on tho non .round him, By comparison others would shortly recognize hov; unreasonable or perverted sons ©f their own attitudes wrere. The second particularly unfortunate group was the asocial psychopath# *