Wilderness Medicine, First Aid, and Outdoor Skills
Specific Psychological Reactions

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US Army First Aid Manual
Fundamental Criteria for First Aid
Basic Measures for First Aid
First Aid for Special Wounds
First Aid for Fractures
First Aid for Climatic Injuries
First Aid for Bites and Stings
First Aid in Toxic Environments
First Aid for Psychological Reactions
Appendix A: First Aid Case and Kits, Dressings, and Bandages
Appendix B: Rescue and Transportation Procedures
Appendix C: Common Problems/Conditions
Appendix D: Digital Pressure
Appendix E: Decontamination Procedures
Appendix F: Glossary

Specific Psychological Reactions

8-8. Emotional Reaction to Injury

Every physically injured person has some emotional reaction to the fact that he is injured.

a. A minor injury such as a cut finger causes an emotional reaction in most people. It is normal for an injured person to feel upset. The more severe the injury, the more insecure and fearful he becomes, especially if the injury is to a body part which is highly valued. For example, an injury to the eyes or the genitals, even though relatively minor, is likely to be extremely upsetting. An injury to some other part of the body may be especially disturbing to an individual for his own particular reason. For example, an injury of the hand may be a terrifying blow to a baseball pitcher or a pianist. A facial disfigurement may be especially threatening to an actor.

b. An injured person always feels less secure, more anxious, and more afraid not only because of what has happened to him but because of what he imagines may happen as a result of his injury. This fear and insecurity may cause him to be irritable, stubborn, or unreasonable. He also may seem uncooperative, unnecessarily difficult, or even emotionally irrational. As you help him, always keep in mind that such behavior has little or nothing to do with you personally. He needs your patience, reassurance, encouragement and support. Even though he seems disagreeable and ungrateful at first, ensure that he understands you want to help him.

8-9. Emotional Reserve Strength of Distressed Soldiers

Realize that distressed soldiers have far more strength than appears at first glance. An injured or sick person may not put his best foot forward. The strong points of his personality are likely to be hidden beneath his fear, anguish, and pain. It is easy to see only his failures even though he worked efficiently beside you only a short time ago. With your aid he will again become helpful. Whatever made him a good soldier, rifleman, or buddy is still there; he is needed.

8-10. Battle Fatigue (and Other Combat Stress Reactions [CSR])

Battle Fatigue is a temporary emotional disorder or inability to function, experienced by a previously normal soldier as a reaction to the overwhelming or cumulative stress of combat. By definition, battle fatigue gets better with reassurance, rest, physical replenishment and activities which restore confidence. Physical fatigue, or sleep loss, although commonly present, is not necessary. All combat and combat support troops are likely to feel battle fatigue under conditions of intense and/or prolonged stress. They may even become battle fatigue casualties, unable to perform their mission roles for hours or days. Other negative behaviors may be CSRs, but are not called battle fatigue because they need other treatment than simple rest, replenishment and restoration of confidence. These negative CSRs include drug and alcohol abuse, committing atrocities against enemy prisoners and noncombatants, looting, desertion, and self-inflicted wounds. These harmful CSRs can often be prevented by good psychological first aid; however, if these negative actions occur, these persons may require disciplinary action instead of reassurance and rest.

8-11. Reactions to Stress

Most people react to misfortune or disasters (military or civilian, threatened or actual) after the situation has passed. All people feel some fear. This fear may be greater than they have experienced at any other time or they may be more aware of their fear. In such a situation, they should not be surprised if they feel shaky, become sweaty, nauseated or confused. These reactions are normal and are not a cause for concern. However, some reactions, either short or long term, will cause problems if left unchecked. The following are consequences of too much stress:

a. Emotional Reactions.

    (1) The most common stress reactions are simply inefficient performances, such as:

    • Slow thinking (or reaction time).

    • Difficulty sorting out the important from all the noise and seeing what needs to be done.

    • Difficulty getting started.

    • Indecisiveness, trouble focusing attention.

    • A tendency to do familiar tasks and be preoccupied with familiar details. This can reach the point where the person is very passive, such as just sitting or wandering about not knowing what to do.

    (2) Much less common reactions to a disaster or accident may be uncontrolled emotional outbursts, such as crying, screaming, or laughing. Some soldiers will react in the opposite way. They will be very withdrawn and silent and try to isolate themselves from everyone. These soldiers should be encouraged to remain with their assigned unit. Uncontrolled reactions may appear by themselves or in any combination (the person may be crying uncontrollably one minute and then laughing the next or he may lie down and babble like a child). In this state, the person is restless and cannot keep still. He may run about, apparently without purpose. Inside, he feels great rage or fear and his physical acts may show this. In his anger he may indiscriminately strike out at others.

b. Loss of Adaptability.

    (1) In a desperate attempt to get away from the danger which has overwhelmed him, a person may panic and become confused. In the midst of a mortar attack, he may suddenly lose the ability to hear or see. His mental ability may be so impaired he cannot think clearly or even follow simple commands. He may stand up in the midst of enemy fire or rush into a burning building because his judgment is clouded and he cannot understand the likely consequences of his behavior. He may lose his ability to move (freezes) and may seem paralyzed. He may faint.

    (2) In other cases, overwhelming stress may produce symptoms which are often associated with head injuries. For example, the person may appear dazed or be found wandering around aimlessly. He may appear confused and disoriented and may seem to have a complete or partial loss of memory. In such cases, especially when no eye witnesses can provide evidence that the person has NOT suffered a head injury, it is necessary for medical personnel to provide rapid evaluation for that possibility. DO NOT ALLOW THE SOLDIER TO EXPOSE HIMSELF TO FURTHER PERSONAL DANGER UNTIL THE CAUSE OF THE PROBLEM HAS BEEN DETERMINED.

c. Sleep Disturbance and Repetitions. A person who has been overwhelmed by disaster or some other stress often has difficulty sleeping. The soldier may experience nightmares related to the disaster such as dreaming that his wife, father, or other important person in his life was killed in the disaster. Remember that nightmares, in themselves, are not considered abnormal when they occur soon after a period of intensive combat or disaster. As time passes, the nightmares usually become less frequent and less intense. In extreme cases, a soldier, even when awake, may think repeatedly of the disaster, feel as though it is happening again, and act out parts of his stress over and over again. For some persons, this repetitious reexperiencing of the stressful event may be necessary for eventual recovery; therefore, it should not be discouraged or viewed as abnormal. For the person reexperiencing the event, such reaction may be disruptive and disturbing regardless of the reassurance given him that it is perfectly normal. In such a situation, a short cut that is often possible involves getting the person to talk extensively, even repetitiously, about the experience or his feelings. This should not be forced; rather, the person should be given repeated opportunities and supportive encouragement to talk in private, preferably to one person. This process is known as ventilation.

d. Other Factors. In studies of sudden civilian disasters, a rule of thumb is that 70 to 80 percent of people will fall into the first category (a above). Ten to 15 percent will show the more severe disturbances (b and c above). Another 10 to 15 percent will work effectively and coolly. The latter usually have had prior experience in disasters or have jobs that can be applied effectively in the disaster situation. Military training, like the training of police, fire, and emergency medical specialists in civilian jobs, is designed to shift that so that 99 to 100 percent of the unit works effectively. But sudden, unexpected horrors, combined with physical fatigue, exhaustion, and distracting worries about the home front can sometimes throw even well-trained individuals for a temporary loss.

e. Psychiatric Complications. Although the behaviors described (a through c above) usually diminish with time, some do not. A person who has not improved somewhat within a day, even though he has been given warm food, time for sleep, and opportunity to ventilate, or who becomes worse, deserves specialized medical/psychiatric care. Do not wait to see if what he is experiencing will get better with time.

8-12. Severe Stress or Battle Fatigue Reactions

You do not need specialized training to recognize severe stress or battle fatigue reactions that will cause problems to the soldier, the unit, or the mission. Reactions that are less severe, however, are more difficult to detect. To determine whether a person needs help you must observe him to see whether he is doing something meaningful performing his duties, taking care of himself, or behaving in an unusual fashion or acting out of character.

8-13. Application of Psychological First Aid

The emotionally disturbed soldier has built a barrier against fear. He does this for his own protection, although he is probably not aware that he is doing it. If he finds that he does not have to be afraid and that there are normal, understandable things about him, he will feel safer in dropping this barrier. Persistent efforts to make him realize that you want to understand him will be reassuring, especially if you remain calm. Nothing can cause an emotionally disturbed person to become even more fearful than feeling that others are afraid of him. Try to remain calm. Familiar things, such as a cup of coffee, the use of his name, attention to a minor wound, being given a simple job to do, or the sight of familiar people and activities will add to his ability to overcome his fear. He may not respond well if you get excited, angry, or abrupt.

a. Ventilation. After the soldier becomes calmer, he is likely to have dreams about the stressful event. He also may think about it when he is awake or even repeat his personal reaction to the event. One benefit of this natural pattern is that it helps him master the stress by going over it just as one masters the initial fear of jumping from a diving board by doing it over and over again. Eventually, it is difficult to remember how frightening the event was initially. In giving first aid to the emotionally disturbed soldier, you should let him follow this natural pattern. Encourage him to talk. Be a good listener. Let him tell, in his own words what actually happened (or what he thinks happened). If home front problems or worries have contributed to the stress, it will help him to talk about them. Your patient listening will prove to him that you are interested in him, and by describing his personal catastrophe, he can work at mastering his fear. If he becomes overwhelmed in the telling, suggest a cup of coffee or a break. Whatever you do, assure him that you will listen again as soon as he is ready. Do try to help put the soldier's perception of what happened back into realistic perspective; but, DO NOT argue about it. For example, if the soldier feels guilty that he survived while his teammates were all killed, reassure him that they would be glad he is still alive and that others in the unit need him now. If he feels he was responsible for their deaths because of some oversight or mistake (which may be true), a nonpunishing, nonaccusing attitude may help him realize that accidents and mistakes do happen in the confusion of war, but that life, the unit, and the mission must go on. (These same principles apply in civilian disaster settings as well.) With this psychological first aid measure, most soldiers start toward recovery quickly.

b. Activity.

    (1) A person who is emotionally disturbed as the result of combat action or a catastrophe is basically a casualty of anxiety and fear. He is disabled because he has become temporarily overwhelmed by anxiety. A good way to control fear is through activity. Almost all soldiers, for example, experience a considerable sense of anxiety and fear while they are poised, awaiting the opening of a big offensive; but this is normally relieved, and they actually feel better once they begin to move into action. They take pride in effective performance and pleasure in knowing that they are good soldiers, perhaps being completely unaware that overcoming their initial fear was their first major accomplishment

    (2) Useful activity is very beneficial to the emotionally disturbed soldier who is not physically incapacitated. After you help a soldier get over his initial fear, help him to regain some self-confidence. Make him realize his job is continuing by finding him something useful to do. Encourage him to be active. Get him to carry litters, (but not the severely injured), help load trucks, clean up debris, dig foxholes, or assist with refugees. If possible, get him back to his usual duty. Seek out his strong points and help him apply them. Avoid having him just sit around. You may have to provide direction by telling him what to do and where to do it. The instructions should be clear and simple; they should be repeated; they should be reasonable and obviously possible. A person who has panicked is likely to argue. Respect his feelings, but point out more immediate, obtainable, and demanding needs. Channel his excessive energy and, above all, DO NOT argue. If you cannot get him interested in doing more profitable work, it may be necessary to enlist aid in controlling his overactivity before it spreads to the group and results in more panic. Prevent the spread of such infectious feelings by restraining and segregating if necessary.

    (3) Involvement in activity helps a soldier in three ways:

    • He forgets himself.

    • He has an outlet for his excessive tensions.

    • He proves to himself he can do something useful. It is amazing how effective this is in helping a person overcome feelings of fear, ineffectiveness, and uselessness.

c. Rest. There are times, particularly in combat, when physical exhaustion is a principal cause for emotional reactions. For the weary, dirty soldier, adequate rest, good water to drink, warm food, and a change of clothes, with an opportunity to bathe or shave may provide spectacular results.

d. Group Activity. You have probably already noticed that a person works, faces danger, and handles serious problems better if he is a member of a closely-knit group. Each individual in such a group supports the other members of the group. For example, you see group spirit in the football team and in the school fraternity. Because the individuals share the same interests, goals, and problems, they do more and better work; furthermore, they are less worried because everyone is helping. It is this group spirit that wins games or takes a strategic hill in battle. It is so powerful that it is one of the most effective tools you have in your "psychological first aid bag." Getting the soldier back into the group and letting him see its orderly and effective activity will reestablish his sense of belonging and security and will go far toward making him a useful member of the unit.

8-14. Reactions and Limitations

a. Up to this point the discussion has been primarily about the feelings of the emotionally distressed soldier. What about your feelings toward him? Whatever the situation, you will have emotional reactions (conscious or unconscious) toward this soldier. Your reactions can either help or hinder your ability to help him. When you are tired or worried, you may very easily become impatient with the person who is unusually slow or who exaggerates. You may even feel resentful toward him. At times when many physically wounded lie about you, it will be especially natural for you to resent disabilities that you cannot see. Physical wounds can be seen and easily accepted. Emotional reactions are more difficult to accept as injuries. On the other hand, will you tend to be overly sympathetic? Excessive sympathy for an incapacitated person can be as harmful as negative feelings in your relationship with him. He needs strong help, but not your sorrow. To overwhelm him with pity will make him feel even more inadequate. You must expect your buddy to recover, to be able to return to duty, and to become a useful soldier. This expectation should be displayed in your behavior and attitude as well as in what you say. If he can see your calmness, confidence, and competence, he will be reassured and will feel a sense of greater security.

b. You may feel guilty at encouraging this soldier to recover and return to an extremely dangerous situation, especially if you are to stay in a safer, more comfortable place. Remember though, that if he returns to duty and does well, he will feel strong and whole. On the other hand, if he is sent home as a psycho, he may have self-doubt and often disabling symptoms the rest of his life.

c. Another thing to remind yourself is that in combat someone must fight in this soldier's place. This temporarily battle fatigued soldier, if he returns to his unit and comrades, will be less likely to overload again (or be wounded or killed) than will a new replacement.

d. Above all, you must guard against becoming impatient, intolerant, and resentful, on one hand, and overly solicitous on the other. Remember that such emotion will rarely help the soldier and can never increase your ability to make clear decisions.

e. As with the physically injured soldier, the medical personnel will take over the care of the emotionally distressed soldier who needs this specific care as soon as possible. The first aid which he has received from you will be of great value to his recovery.

f. Remember that every soldier (even you) has a potential emotional overload point which varies from individual to individual, from time to time, and from situation to situation. Because a soldier has reacted abnormally to stress in the past does not necessarily mean he will react the same way to the next stressful situation. Remember, any soldier, as tough as he may seem, is capable of showing signs of anxiety and stress. No one is absolutely immune.

8-15. Tables. See Tables 8-1, 8-2, and 8-3 for more information.

Table 8-1. Mild Battle Fatigue
1. Trembling, tearful
2. Jumpiness, nervous
3. Cold sweat, dry mouth
4. Pounding heart, dizziness
5. Nausea, vomiting, diarrhea
6. Fatigue
7. "Thousand-yard stare"
1. Anxiety, indecisive
2. Irritable, complaining
3. Forgetful, unable to concentrate
4. Insomnia, nightmares
5. Easily startled by noises, movement
6. Grief, tearful
7. Anger, beginning to lose confidence in self and unit
8. Difficulty thinking, speaking, and communicating
1. Continue mission performance, focus on immediate mission.
2. Expect soldier to perform assigned duties.
3. Remain calm at all times; be directive and in control.
4. Let soldier know his reaction is normal, and that there is nothing seriously wrong with him.
5. Keep soldier informed of the situation, objectives, expectations, and support. Control rumors.
6. Build soldier's confidence, talk about succeeding.
7. Keep soldier productive (when not resting) through recreational activities, equipment maintenance.
8. Ensure soldier maintains good personal hygiene.
9. Ensure soldier eats, drinks, and sleeps as soon as possible.
10. Let soldier talk about his feelings. DO NOT "put down" his feelings of grief or worry. Give practical advice and put emotions into perspective.
*Most or all of these signs are present in mild battle fatigue. They can be present in any normal soldier in combat yet he can still do his job.

Table 8-2. More Serious Battle Fatigue
1. Constantly moves around
2. Flinching or ducking at sudden sounds and movement
3. Shaking, trembling (whole body or arms)
4. Cannot use part of body, no physical reason (hand, arm, legs)
5. Cannot see, hear, or feel (partial or complete loss)
6. Physical exhaustion, crying
7. Freezing under fire, or total immobility
8. Vacant stares, staggers, sways when stands
9. Panic running under fire
1. Rapid and/or inappropriate talking
2. Argumentative, reckless actions
3. Inattentive to personal hygiene
4. Indifferent to danger
5. Memory loss
6. Severe stuttering, mumbling, or cannot speak at all
7. Insomnia, nightmares
8. Seeing or hearing things that do not exist
9. Rapid emotional shifts
10. Social withdrawal
11. Apathetic
12. Hysterical outbursts
13. Frantic or strange behavior
1. If soldier's behavior endangers the mission, self or others, do whatever necessary to control soldier.
2. If soldier is upset, calmly talk him into cooperating.
3. If concerned about soldier's reliability:
  • Unload soldier's weapon.
  • Take weapon if seriously concerned.
  • Physically restrain soldier only when necessary for safety or transportation.
4. Reassure everyone that the signs are probably just battle fatigue and will quickly improve.
5. If battle fatigue signs continue:
  • Get soldier to a safer place.
  • DO NOT leave soldier alone, keep someone he knows with him.
  • Notify senior NCO or officer.
  • Have soldier examined by medical personnel.
6. Give soldier tasks to do when not sleeping, eating or resting.
7. Assure soldier he will return to full duty in 24 hours; and, return soldier to normal duties as soon as he is ready.
*These signs are present in addition to the signs of mild battle fatigue reaction.
**Do these procedures in addition to the self and buddy aid care.

Table 8-3. Preventive Measures to Combat Battle Fatigue
1. Welcome new members into your team, get to know them quickly. If you are new, be active in making friends.
2. Be physically fit (strength, endurance, and agility).
3. Know and practice life-saving self and buddy aid.
4. Practice rapid relaxation techniques (FM 26-2).
5. Help each other out when things are tough at home or in the unit.
6. Keep informed; ask your leader questions, ignore rumors.
7. Work together to give everyone food, water, shelter, hygiene, and sanitation.
8. Sleep when mission and safety permit, let everyone get time to sleep.
  • Sleep only in safe places and by SOP.
  • If possible, sleep 6 to 9 hours per day.
  • Try to get at least 4 hours sleep per day.
  • Get good sleep before going on sustained operations.
  • Catnap when you can, but allow time to wake up fully.
  • Catch up on sleep after going without.

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