Like every war, World War One (WW1) produced heavy physical and psychological casualties. However, 1914-1918 became known as a watershed period during which, surprisingly ‘vast numbers of psychiatric casualties were observed’, and the number of men needing medical treatment for such problems rose significantly. Medical records reveal that, ‘in the crisis year of 1916, neurasthenia accounted for 40% of causalities in combat zones’, and by 1917 it was recognised that sufferers of combat neuroses comprised one seventh of all personnel discharged from the British Army. By armistice this figure had risen to encompass one third of all dismissals, and the army had dealt with 80,000 cases of shell shock alone.
The British Armed Forces experienced many forms of psychiatric disorder, but some were unique to particular Services. This paper will primarily focus on symptoms experienced by army combat soldiers, although reference will be made to several syndromes peculiar to the Royal Air Force (RAF).
The nature of combat and environment of WW1 were major factors as to why war reports consistently showed elevated levels of psychiatric casualty amongst soldiers. Due to the conditions of theatre, incidents of trauma and reactionary syndromes increased greatly. The trench warfare that characterised WW1 was extremely dangerous and physically testing for soldiers, while the nature of combat, (notably aerial bombardment and constant shelling), was an ideal setting for psychiatric issues to flourish. The intensity of the warfare fought along the front lines, most notably in France and Flanders, also caused seemingly stable soldiers to break down. Medical reports also reveal that rates of admission for psychological symptoms, especially shell shock, rose significantly during offensives when the intensity of fighting increased and physical causalities escalated: ‘The high casualties of the Somme battle brought the issue of shell shock to the fore’. These high-intensity battles were combined with long periods of static tedium and the constant stress of threat of bombardment, which created an epidemic of psychological issues, relating particularly to anxiety, fear and trauma.
Contrary to earlier hypotheses, it became clear that psychological symptoms were not confined to weak-hearted or feeble-minded soldiers, and ‘the same symptoms were apparent in both seasoned soldiers and raw conscripts’. However, the rate of breakdown did differ between ranks in the British Army. In 1917 the ratio of Officers to men at the front line was 1:30, yet according to one survey, the rate of Officers to men in hospitals specialising in war neuroses was 1:6. Symptoms also differed between them due to the differing stressors of their roles. ‘Regular’ soldiers were more prone to hysteria, paralysis, blindness, deafness, and contracture of limbs, (amongst others), while Officers mainly experienced nightmares, insomnia, depression and mutism.
Brown ‘distinguished three forms of combat neuroses: hysteria, neurasthenia, and transient psychosis’. Hysterical symptoms were the most frequently found, and included both somatic disassociations and more completely mental dissociations. Obsessions, compulsions, anxiety and depression were classic features of neurasthenia, while transient psychosis found expression in mental instability, characterised by irregular mental states and widespread affective symptoms. Hurst subsequently defined four primary categories that produced hysterical symptoms. He claimed fear was responsible for shell shock; gas hysteria was rooted in gas attacks; minor injuries were precursors for hysterical symptoms; and major wounds amplified any psychological symptom, often long after the physical injuries had healed.
The majority of symptoms were common and somewhat unremarkable, and could be experienced by both soldiers and civilians in times of peace or war. However, during WW1 they were reported as combined symptoms, and in such high numbers that physicians and reporters struggled to understand and explain the widespread and unusual groupings of symptoms:
The soldier...may become blind or deaf or lose the sense of smell or taste. He is cut off from his normal self and the associations that go to make up that self...At night insomnia troubles him, and such sleep as he gets is full of visions; past experiences on the battlefield are recalled vividly; the will that can brace a man against fear is lacking.
The need for specific diagnoses and categorisation of disorders became ever more necessary as the war progressed and the number of afflicted soldiers increased. Symptoms were thus amalgamated into named syndromes and categorised into short-term (acute), long-term (chronic), or delayed-onset cases (where the individual does not begin to suffer until a period of around six months has elapsed since the end of their deployment). Front line troops were highly susceptible to acute psychological symptoms, and most likely to break down as they were the faction most frequently exposed to stressful and traumatic experience. 'Operational stress, or acute stress disorder, encompasses an array of effects caused by the strain of operations; the term refers to a usually temporary psychological upset, which causes a marked reduction in an individual’s ability to function effectively.'
Anxiety, fear, and traumatic experience were the root causes of the majority of psychiatric symptoms. Pilots were particularly susceptible to acute disorders, and data reveals the Royal Air Force (RAF) suffered from unique syndromes. Aeroneurosis was one such condition that afflicted pilots, and was largely attributed to stress and nervous exhaustion whilst flying. During high altitude flights, inadequate levels of oxygen also contributed to the condition, which was physically exhibited through gastrointestinal symptoms including digestive problems and stomach upset or pain. Flying stress was a similar complaint, again caused by the highly pressurised and dangerous working conditions experienced by pilots. This stress was also manifested in gastrointestinal symptoms and hysterical reactions.
Nightmares were another short-term symptom of warfare, experienced by all Service branches. Sources reveal how soldiers would be tormented by re-living their traumatic combat experiences in their sleep, while even during waking hours they may have disturbing visions. ‘The dreams might occur “right in the middle of an ordinary conversation” when “the face of a Boche that I had bayoneted, with its horrible gurgle and grimace, comes sharply into view', an infantry captain complained.’
Such nightmarish visions regularly developed into long-term syndromes and were often accompanied by inability to eat and sleep. They could recur nightly (or daily) and would often deplete a patient’s self-confidence, leaving him with no enthusiasm for life. One reason why nightmares were so common, was the fact that a large percentage of men in combat roles were not career soldiers, but were volunteers who had been drafted into the army and deployed with minimal training. Due to the haste of the recruitment and training processes, new soldiers had not yet fully developed coping mechanisms for dealing with the experiences and trauma of warfare by their date of deployment.
The First World War also produced a plethora of long-term, or chronic symptoms, many of which had the potential to last for years and be completely debilitating. Most disorders arose from the general stresses and trauma of warfare, although Gas Hysteria had a specific origin; namely the fear of gas attacks. Gas hysteria was originally believed to be an organically-rooted disorder, although it was soon understood to be psychological, for although the use of gas had a debilitating physical effect on soldiers, the threat of an attack added a psychological element, which rendered it doubly devastating. For example, during a conventional artillery bombardment, soldiers felt they could shelter in the trenches and gain comfort from each other, but during a gas attack they felt isolated and unprotected, with the exception of a mask. Gas attacks also occurred in the quieter regions of the Front, and at irregular intervals, which meant soldiers posted there to rest, instead had to remain constantly alert. These factors greatly contributed to war weariness, stress, and depression.
Shell Shock was another widespread war neurosis that doctors originally believed to be an organic disorder, sustained as a result of concussion, forces created by the explosion of a shell, inhalation of a toxin, or a combination of the above. However, it was later reclassified as being psychologically-rooted as a result of further studies in combat psychiatry. British physicians thus divided shell shocked soldiers needing medical attention into two categories: the ‘shell shock wounded’, for those who had been exposed to direct physical trauma; and the ‘shell shock sick’, for those who had not.
The War Office used the term ‘Shell-Shock’ (and later ‘War Neuroses’), to describe the psychological upset experienced by soldiers, which rendered them so traumatised they were unable to carry out their duties on the battlefield. It was considered by many to be the ‘signature injury of WW1’, and it became the cornerstone for medical understanding of trauma-related stress disorders, as it ‘irrevocably blurred the rigid distinction between the body and the mind.’ It also challenged the perceptions that war neuroses had organic roots, and soldiers displaying symptoms were simply malingering. Previous to 1914, there had been no medical dialogue between physicality and psychology, but the emergence of shell shock revealed a clear link between the two.
Although it had previously been in existence, cases of shell shock reached epidemic proportions in 1915. It could exist in several forms: it was ‘either acute in men with a neuropathic predisposition, or [it developed] slowly as a result of prolonged strain and terrifying experience’. A wide range of physical and psychological symptoms were attributed to shell shock, which varied widely in intensity, and ranged from moderate panic attacks to effective mental and physical paralysis. ‘While often referred to as a unitary phenomenon, shell shock was actually a diverse congeries of symptom complexes,’ and commonly reported indicators included: poor concentration; fatigue; irritability; tics; and depression. ‘Some [soldiers] cursed and raved and had to be tied to their litters; some shook violently…some trembled and slunk away in apparent abject fear of every incoming shell, while other simply stood speechless, oblivious to all surroundings.’
Bourke outlined further symptoms ranging from unrelenting anxiety and hysteria to stomach cramps, while Jones revealed that soldiers’ senses could also be affected: ‘[Soldiers] sometimes experienced strange smells and their sight and hearing was often impaired.
….some were deaf, and some were dumb, others were blind or paralysed.’ Such examples of somatoform dissociation are major consequences of psychological trauma, and especially common when an individual’s life has been directly threatened. The most prominent symptoms however, were known as conversion disorders or reactions. They were also characteristic of hysterical disorders, and consisted primarily of, ‘blindness, paralyses, contractures, aphonia, anaesthesias, and profound amnesias.
Several psychological disorders were characterised by chest pain or cardiac-related symptoms. Disordered Action of the Heart (DAH), or Effort Syndrome, was once such disorder. Its name implies an organic affliction, related purely to heart problems, but DAH was actually a result of psychiatric upset. It was characterised by symptoms including: exhaustion; dizziness; sleep difficulties; joint pain; breathlessness; and heart palpitations.
Neurocirculatory asthenia (NCA) was another condition very similar in characteristic to DAH. It was so alike that the two were often amalgamated into one syndrome (Oppenheimer, 1942). NCA is also referred to as Da Costa’s Syndrome, or Soldier’s Heart, and was characterised by: ‘dyspnea, palpitations, chest pain, exhaustibility, dizziness, headache, nervousness, and a great variety of associated symptoms’. NCA was not a disorder new to WW1, and neither was it restricted to military personnel. Civilians were susceptible to it, although it was much more commonly found in soldiers, and the symptoms were far more intense in a military setting. When NCA first emerged in 1847 it was understood to be an organic condition relating to strain or ‘over action of the heart’,although during WW1 physicians realised it was in fact psychologically rooted. It was still recognised as a valid cardiac disorder, but it became understood that the cause lay in the traumatic experiences of theatre. Wood stated that: ‘the symptoms and signs of Da Costa’s Syndrome more closely resemble those of emotion, especially fear, than those of effort in the normal subject’.
The majority of combat neuroses were experienced during soldiers’ deployment periods, (although there were occurrences where soldiers reported symptoms much earlier during their training). However, one grouping of symptoms came to the fore after a soldier’s deployment had ended, or even once armistice had been reached. For some, the return to ‘normal’ civilian life after the realities of war, was one cause of extreme psychological trauma. Post-traumatic amnesia (PTA) was one such disorder that was relatively common, and often accompanied other symptoms. As with many other issues, ‘Myers recognized the cause as ‘massive emotional shock, equivalent to present day DSM-IV acute stress disorder.’ Dissociative memory loss was symptomatic of PTA, and Rivers noted that the gaps in soldiers’ memories usually began from the moment preceding the shock impact to when they had been admitted to hospital, or even weeks later. Interestingly, during such periods of amnesia, soldiers usually continued functioning militarily and socially in a normal fashion, albeit in a rather dazed state. This was often accompanied by an inability to remember personal information: ‘many subjects were unable to recall their name, regiment, family background or marital status. In short, they had lost their identity.’
In medical terms, the Great War is synonymous with the outbreak of psychological symptoms in epidemic proportions. Despite the obvious negativity of psychiatric symptoms, some positive developments did occur as a result of the outbreak. The number of psychiatric casualties was so high that they demanded immediate and thorough consideration, so medics could attempt to protect the soldiers’ psychological welfare and return as many as possible to fighting positions. The effects of combat stressors began to be quickly recognised as precursors for psychological symptoms, and ‘the lessons learnt during [WW1] were certainly instrumental in the growth of psychiatry as a discipline.’ Young agreed, stating that the carnage of the warfare of WW1 aided the development of medical science in certain fields. ‘In the case of the psychogenic traumas, there was no accumulation of knowledge, development of new treatments, or revision of established theories to parallel the changes that occurred in biological medicine.’
The lessons learnt during WW1 changed the face of medicine forever, and allowed psychiatry (and particularly military psychiatry) to develop with less public scepticism. The perception of soldiers displaying psychological symptoms also improved vastly, as did the treatment they received. For example, ‘in 1900, the idea that soldiers could suffer psychological damage in action was barely acknowledged, and yet forty years later psychiatrists were routinely deployed to fighting units’,(although it should be mentioned that this was normally during the latter stages of war when the number of psychiatric casualties was increasing rapidly).
Before 1916 the lack of understanding of 'war neuroses' was demonstrated through the treatments prescribed to patients. Some were extremely detrimental to their conditions, and included electric shocks, solitary confinement, and harsh emotional and physical re-education. Fortunately by 1917, the approaches taken by the medical profession were generally more humane. The role of emotional disturbance in producing shell shock was recognised by a number of psychologists, including Myers and Rivers, and this psychological approach increasingly held sway. Special units were set aside for neurasthenic patients at institutions including the Maghull and Craiglockhart. Here, treatment regimes were based around cognitive therapy, and gentle rehabilitation methods involving light work, rest and reintegration. ‘Shepherd argued that the Maghull Institute was the “first school of clinical psychopathology in Britain” and as such represented a “landmark in psychiatric history”’. It appears that war neuroses, and especially shell shock, helped undermine the traditional distinction between the hereditary fit and unfit, and propelled military psychiatry to the forefront of public consciousness.
 Evans & Ryan (2000), p. 8
 Showalter (1987), p.63
 Bourke (1996), p. 109
 Due to the stigma attached to psychological symptoms, many cases were covered up by sending psychiatric cases to ordinary hospitals and the true figure could be approximately
200 000 cases.
 Feudtner (1993), History of Science, 31: 377
 Jones, Fear & Wessely (2007), American Journal of Psychiatry, 164 (11), 1644
 Bourke (1996), p.111
 Van der Hart, Brown & Graafland, (1999), Australian and New Zealand Journal of Psychiatry,33:38
 Hurst (1919), The Journal of Laryngology & Otology. pp.189-200
 Feudtner (1993), History of Science, 31: 379
 Babington (1997)
 Jones, Fear & Wessely (2007), American Journal of Psychiatry, 164:1641
 Bourke (1996), p.108
 Jones & Wessely (2005), Medical History, 49:67
 Coffman (1986), p. 224
 Van der Hart, Brown & Graafland, (1999), Australian and New Zealand Journal of Psychiatry,33:38
 Wood (1941), British Medical Journal, 1(4194): 767–772
 Oppenheimer (1942), Bulletin of New York Academy of Medicine, p.368
 Oglesby (1987), British Heart Journal, 58; 312
 Van der Hart, Brown & Graafland, (1999), Australian and New Zealand Journal of Psychiatry,33:40
 Ibid, p.39
 Bourke (1996), p.120
 Young (1995), p.85
 Jones & Wessely (2001), p.242
 Jones (2010), Journal of the History of Medicine and Allied Sciences, 65:3; 380