FOR OFFICIAL USE ONLY 
PHYSICAL AND PSYCHOBIO LOGICAL 
STANDARDS AND EXAMINATIONS 
TITLE VIII 
MILITARY —MEDICAL COURSES 
PREPARED BY 
BUREAU OF MEDICINE AND SURGERY 
BUREAU OF NAVAL PERSONNEL 
NAVPERS 10818 
MARCH 1949 FOR OFFICIAL USE ONLY 
PHYSICAL AND PSYCHOBIOLOCICAL 
STANDARDS AND EXAMI NATIONS 
TITLE VIM 
MILITARY-MEDICAL COURSES 
PREPARED BY 
BUREAU OF MEDICINE AND SURGERY 
BUREAU OF NAVAL PERSONNEL 
NAVPERS 10818 
MARCH 1949 PREFACE 
The following material consists of a compendium of articles by well informed persons 
working and writing in this field, and is intended as a more or less "case presentation” or 
discussion of common and special features met with in handling personnel both for induc- 
tion and subsequent services. It is further intended to give the reader an over-all picture of 
the problem rather than to offer established opinions or facts. The articles are arranged in a 
relative sequence with the view to one subject area blending into that following. Credit is 
given each author in a foot note. References indicated within a chapter by numbers in 
parentheses are listed at the end of the chapter. 
Note.—Italic figures in parenthesis used throughout* this book refer to references at the end of 
chapters. CONTENTS 
Section I. - BASIC CONCEPTS AND FACTORS 
Chapter Page 
1. Biological Concepts in Psychiatry 1 
2. Constitutional Factors in the Selection of Re- 
cruits 13 
3. The Value of the Social Service History in the 
Detection of Those Psychlatrically Unsuited for 
Military Service 13 
4. Psychiatric Selection at the Precommissioning 
Level 22 
5. The Mental Defective and the Under-Age Man in 
the Navy 26 
6. Subnormal Intelligence in the Maladjusted Naval 
Trainee 29 
7. Psychoses in Navy Inductees with Less Than Fif- 
teen Days Active Duty 33 
8. Neuropsychiatric Clinic at a Naval Construction 
Training Center 40 
9. Functions of a Psychiatrist in a Navy Yard 44 
Section II. - EXAMINING PROCEDURES 
10. A Rapid Determination of Intellectual Adequacy 
for the Naval Service 49 
11. Neuropsychiatric Screening of a Million Men.. . 51 
12. A Psychometric Procedure for Screening Mental 
Defectives 56 
13. A Neuropsychiatric Questionnaire for Group Ex- 
amining 59 
14. Psychiatric Screening Tests at a Precommissioning 
Center 63 
15. Mental Mechanisms and Morale Factors of Naval 
Recruits in Training 67 
Section III. - CONDITIONS IN ACTIVE SERVICE 
Chapter - Page 
16. Neuropsychiatric Problems on a Battleship 71 
17. Neuropsychiatric Experiences in Advance Base 
Unit 77 
18. Psychiatric Preparations for Combat in a Marine 
Division 81 
19. Fatigue 84 
20. Treatment of Combat Fatigue in a Forward-Area 
Hospital 89 
21. Psychoneuroses Precipitated by Combat 94 
22. Combat Fatigue and War Neurosis 99 
23. Analysis of Psychiatric Patients Transferred to the 
United States from an Overseas Base 112 
24. Psychiatric Data Compiled at a United States 
Naval Personnel Separation Center 115 
25. Method of Practicing Preventive Psychiatry in a 
Naval Personnel Separation Center 118 
26. Mental Health of Men Discharged Under the 
Point System 123 
Section IV 
DELINQUENTS AND DISCIPLINARY INFLUENCES 
27. The Role of the Psychiatrist in the Naval Dis- 
ciplinary Barracks 129 
28. The Naval Offender 134 
29- The Naval Personal Inventory and the Naval 
Offender 138 
30. Psychiatric Evaluation of the Naval Delinquent. 144 
31. Study of 1,063 Naval Offenders 152 
32. A Psychologic Study of Desertion and Overleave 
in the Navy 160 
33. The Psychotic Naval Prisoner 166 
34. A Study of 200 Violators of General Court- 
Martial Probation 171 SECTION I 
BASIC CONCEPTS AND FACTORS CHAPTER 1 
BIOLOGICAL CONCEPTS IN PSYCHIATRY* 
THEIR MEANING AND SIGNIFICANCE 
INTRODUCTION 
Science is continually evoking a series of inventions 
that effect every phase of our daily lives. Time and dis- 
tance alike diminish, and the very planets shrink to the 
measure of human hands. In addition to an increased 
knowledge of the physical world, which science has be- 
stowed upon us, it has given us accurate information con- 
cerning the processes of life itself. Through the medium 
of biology, we have learned what sort of people we are, 
and how we may best exist in our novel surroundings. 
After all, this is what matters. Had we been presented with 
a new environment, without being told how to adjust our- 
selves to it, we should have known nothing of the perils 
that beset our path, and we should have gone rattling back 
into barbarism long ago. Biology represents, therefore, 
the magic wand that permitted us to escape the crushing 
power of dogma and superstition, and become a ration- 
alistic race. 
While biology has been of extreme benefit and value 
to mankind in general, we must investigate, through in- 
trospections, the mind of the individual, and study his 
mental conflicts, if we wish to penetrate into the real 
causes of the difficulties of life, for here are encountered 
numerous stumbling blocks to efficient adjustment. This 
is the field and province of psychology, a scientific dis- 
cipline that gives us insight into how men know and think, 
how they reason and feel, and how they react under stress 
and strain. Supplementing the work of biology, the new 
genetic psychology has taught us the way in which we 
might all the more accurately deal with the many per- 
plexing obstacles that confront us at every turn. It has 
accomplished this by emphasizing the driving power of 
the instincts, by tracing the genesis of impulses, by point- 
ing out the forces that shape human character, and by pay- 
ing specific attention to the biological needs of the organ- 
ism at the psychological level. 
The subjects of biology and psychology are coming 
nearer and nearer to occupy a common ground. These two 
sciences overlap to the extent that in the study of many 
problems it is almost impossible to determine where the 
one begins and the other ends. Each lends its support to 
the facts that serve to elucidate the phenomena of the other 
order, and they are really the same science viewed from 
different aspects. In its broadest meaning, biology is in- 
clusive of psycho’ogy, the .humanities, and the social 
sciences, and it is in this sense that we shall use the term. 
Biology concerns itself with all of the mechanisms that 
the individual uses to bring about an adjustment with his 
surroundings. Hence, it is likewise interested in any nocu- 
ous agent or element, either exogenous or endogenous, 
which may set up a reaction within the organism and dis- 
turb the state of physical equilibrium in which it is ac- 
customed to dwell. 
In order to dominate their environment, and to live in 
perfect harmony with the external world, organisms must 
be able to conquer constantly arising new problems and 
situations. In the lowest forms of animals, this adaptation 
is accomplished by physical and chemical reactions. In the 
higher types, the same physiological functions are at work 
in the process of adjustment, but in addition, the aid of a 
nervous system is brought into play. In the human organ- 
ism, psychological and social attributes are added. View- 
ing the psyche as the means by which the individual as a 
whole is adjusted to his surroundings, it follows that dis- 
eases of the mind, or the neuroses and the psychoses, inas- 
much as they throw his adaptive responses out of gear, so 
to speak, will prevent him from reacting in an efficient 
manner to environmental conditions. This constitutes a 
problem that is thoroughly biological. It is also the subject 
matter of psychiatry. This specialty becomes, therefore, a 
*By Commander F. M. Harrison, Medical Corps, United States Navy. 
1 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
medical branch of applied biology, and it should be 
studied as such. 
The practicing physician has too often looked upon the 
new biological psychiatry as a subject, unattractive and 
obscure, difficult and abstruse, and as one with which he 
need have no immediate concern. If the surgeon and the 
internist, however, will but take the trouble to analyze 
the problems confronting them in the surgical and medical 
wards of hospitals, and in their own private offices and 
consulting rooms, they will find psychological factors of 
importance in a large proportion of their patients. Al- 
though it is cultivated as a separate discipline, psychiatry 
stands in close and intimate relation with internal medi- 
cine, and it must always represent an important chapter 
to the clinician. The internist will certainly fail in his work 
unless he is acquainted with the aims and methods of this 
specialty, and unless he is familiar with the various reac- 
tion types as exhibited in different individuals. At the 
same time, the psychiatrist can have become really expert 
only after a thorough training in internal medicine. 
Many of the newer discoveries in medicine have been 
brought to light through the channels of biology. This 
latter science has also been a potent factor in changing 
our conception of mental disease, and it has been responsi- 
ble for many of the revolutionary advances in psychiatric 
thought in recent years. Indeed, a biological approach is 
fundamental to all of the clinical branches of medicine 
because it furnishes us with a standard of normal physical 
and mental activity. As a result of the emphasis now being 
placed on the study of man in biology, a more comprehen- 
sive survey and a more intelligent understanding of the 
human organism have been made possible. This is a fact 
of momentous importance to psychiatry, in particular, and 
to the practice of medicine in general. It occurred to me, 
therefore, that it might be of some interest and value at 
this time to very briefly review a few of the more basic 
concepts in biology which may be said to underlie an ade- 
quate grasp of the problems of psychiatry, and to point 
out, wherever possible, their significance to medicine. 
STRUCTURE VERSUS FUNCTION 
The morphologists, or structuralists, on the one hand, 
maintain that structure is the cause of function. They in- 
sist that the essential thing in development is the transfor- 
mation of one structure into another, the functions occur- 
ring in the course of evolution being regarded as merely 
incidental phenomena. To them, all disorders that affect 
the body have a meaning only when they can be logically 
explained by a detectable alteration in structure. One rea- 
son for such an attitude, perhaps, is that the principal 
stages in the growth and differentiation of structures are 
better known, and they have been described in far greater 
detail, than in the case of functions. Then, too, the theory 
of organic evolution, introduced by Darwin in the nine- 
teenth century, and an increased knowledge of the physics 
and chemistry of the body, achieved by a series of brilliant 
physiologists, as well as the discovery of the microbes and 
their relation to infection, tended very strongly to establish 
and reenforce this strictly mechanistic view of the indi- 
vidual organism. 
The vitalists, or functionalists, on the other hand, claim 
that function determines structure. They teach that the 
various habits and activities of the organism produce cor- 
responding changes in structure, this being the chief prob- 
lem in evolution. They cite as justification for their posi- 
tion the fact that a great many functional distinctions are 
recognizable between organisms that are morphologically 
indistinguishable. It has also been noted that the autopsy 
table, and the highest powered microscopes, as well as 
other instruments of precision, have often failed to reveal 
structural changes where during life there was every rea- 
son to suspect their presence. In addition, the physiologists 
and chemists, the biologists and physicists, by applying 
the methods of their respective sciences to the study of 
organ activity in man, have been able to demonstrate 
changes in function in many diseases where no alteration 
of structure has been visible. The formulation of a purely 
psychological conception of the neuroses by Freud, and 
the inevitable increase in the number of severe cases of 
psychogenic disorders with no organic basis during the 
last World War, helped still further to substantiate the 
claims of the vitalists for the primacy of function. 
The only way in which this controversy can be settled is 
to trace the structures and functions of the mature organ- 
ism, in all their bewildering complexities, back to their 
simpler beginnings, and study them in the process of be- 
coming. This involves a knowledge of differentiation, 
which may be defined as the progressive change from the 
general to the special, or the setting aside of certain cells 
for specific work and duties, or the accumulation of func- 
tion as structure. It will be impossible to give a detailed 
account of all of the phenomena of development here, be- 
cause it is too extensive a subject. Nor can we even indi- 
cate the principal stages and phases in which the evolu- 
tion of the more important groups or organs manifests 
itself, despite the fact that therein lies the answer to our 
problem. 
Suffice it to say, according to more recent trends in 
biology, neither structure nor function precedes the other 
as cause precedes effect, but their growth, development, 
and evolution are contemporaneous, and they go hand in 
hand. In other words, as the organism is confronted with 
more intricate problems of adjustment, and as it comes into 
more intimate contact with its surroundings, new and 
2 Chapter 1 .—BIOLOGICAL CONCEPTS IN PSYCHIATRY 
more highly specialized structures are formed, with a 
progressively more complex differentiation of functions. 
In biology, therefore, structures and functions are never 
investigated separately, but the one is considered just as 
essential as the other in the study of any problem that af- 
fects the individual, especially disease. There is a growing 
tendency, however, to emphasize function, and very rightly 
so. New functions arise whenever the organism is faced 
with the need of more efficient means of conquering its 
environment. In order for the functions, thus developed, 
to be of maximum benefit to the individual, they must be 
stable and definite, fixed and stereotyped, and they must 
be structuralized, or laid down in permanent pathways. 
It is this necessity that brings about the formation of struc- 
tures, which are the physical substrata of functions. In an 
ultimate analysis, structure in nothing but organized func- 
tion. The elaboration of these biological principles in 
recent years has resulted in the building up of a concept of 
disease, particularly in psychiatry, that stresses function in- 
stead of structure. This new point of view has already sup- 
plemented, and it will eventually supplant, the old ideas 
of the structuralists. 
The significance of this subject to medicine becomes 
apparent at once. It is simply that the internist and the 
surgeon must not permit themselves to think exclusively in 
terms of either structure or function. They should give 
equal consideration to both. This has not been done pre- 
viously as structures have been emphasized and functions 
neglected. The school of pathology founded by Virchow 
has left such an impression upon medicine that the modern 
physician continues to be obsessed with the feeling that 
he must discover a defect in structure in order to account 
for disease in human beings. All of his efforts at treatment 
are dominated by this point of view, and he is often 
amazed to find that certain forms of therapy, which he 
regards as being unsound and as having no relation to the 
case whatsoever, very frequently accomplish the desired 
results. Such an attitude needs to be corrected. The search 
for organic lesions is important, but it will never bring 
about a complete understanding of disease. A knowledge 
of the behavior activities and the reactions of the organ- 
ism that follow an initial stimulus or fault is also neces- 
sary. This means that internal medicine, following the lead 
of psychiatry, must recognize frankly and completely the 
claim of function to a place of equal importance and 
reality with structure. 
Functional disorders are spread thickly throughout each 
department of medicine and surgery, but they are partic- 
ularly prevalent in the endocrine, gastro-intestinal, cardiac, 
gynecological, urological, and metabolic clinics. It has been 
conservatively estimated by numerous authorities, notably 
Strecker and Ebaugh (1), that functional disease consti- 
tutes from 60 to 70 percent of medical practice. In other 
words, a large majority of the patients seen in the dispen- 
saries of our large hospitals, and in the consulting rooms 
of private practitioners, present symptoms and complaints 
for which no adequate organic basis can be found. 
In spite of their frequency, however, these functional 
disturbances are commonly neglected, misunderstood, and 
improperly treated. They command interest only as long 
as they are considered to be diagnostic problems. As soon 
as it is discovered that the patient has "nothing the matter 
with him,” as we have often heard it expressed, he is 
passed over lightly, no further attention is paid to him, 
and he is referred to the psychiatrist. From a technical 
standpoint, most of these cases come under the broad 
heading of the psycho-neuroses, but a great many of them 
do not. For practical purposes, as suggested by Peabody 
(2), the patient who has a functional disorder may merely 
be suffering from severe subjective sensations due to alter- 
ations in the physiological activities of one or more of the 
organs in the body. His symptoms may depend upon an 
increase or a decrease of a perfectly normal function, or 
simply upon his suddenly becoming aware or conscious 
of a wholly normal function that is usually not noticed. Or 
as McDougall (3) would have it, functional disorders rep- 
resent nothing but an ill-adjusted timing of the reactions 
of the various organs and an imbalance of their relations 
to one another. The ultimate causes of these disturbances 
of functions are to be found, not in any gross structural 
changes in the organs involved, but rather in the influences 
emanating from the intellectual and emotional life of the 
patient, which may effect in one way or another any por- 
tion of the body. To say that an individual has a neurosis, 
therefore, because no demonstrable pathology can be 
pinned on him, so to speak, is wrong and not even logical. 
Functional disorders really belong to the field of gen- 
eral medicine. It is often extremely difficult to determine 
whether we are dealing with an organic disease or with a 
pure disturbance of function, and the differential diagnosis 
requires the broad training in the use of clinical and lab- 
oratory methods which forms the equipment of the in- 
ternist. Then, too, the patients themselves very often fear 
the stigmata of any professional contact with a psychia- 
trist, and they prefer to go to their family physician. As a 
matter of fact, many of these cases can be helped by the 
general practitioner without the aid of highly specialized 
psychological technic, if he will but appreciate the sig- 
nificance of functional disturbances and interest himself 
in their treatment. 
It should be borne in mind, of course, from what has 
already been said, that we are really not justified in draw- 
3 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
ing a hard and fast line between organic and functional 
disorders. The opposition between them does not rest on 
a sound basis. Organic diseases are invariably accompanied 
by altered functions, while it is probable that an unlim- 
ited microscopist could always discover corresponding 
changes in structure in purely functional disturbances. 
Function is, in a large measure, dependent upon structure, 
and vice versa, and disease will continue to be an enigma 
until a definite correlation between them is made. The 
internist will certainly expand his horizon and broaden 
his outlook if he concerns himself with the vital capacities 
of organs instead of with mere changes in structure, and 
if he adopts a functional concept of disease, as suggested 
by biology and psychiatry. Such an approach will do away 
with therapeutic nihilism, because treatment will then be 
directed towards improving function rather than to elimi- 
nating the anatomical changes produced by disease, which 
usually are permanent. 
BODY AND MIND 
The origin of the mind is a topic upon which there has 
been much speculation by philosophers and theologians. 
One of the very earliest hypotheses was that which is 
known as transmigration. This doctrine probably reached 
its greatest development in India, where it formed an im- 
portant part of the Buddhistic belief. It was also a part of 
the religion of ancient Egypt, and it was embodied in the 
writings of Pythagoras and Plato. According to this theory, 
the number of souls is a constant one; souls are neither 
made nor are they destroyed; but at birth a soul which 
had once tenanted another body enters the new body. The 
view was adopted later on that God creates a new soul 
for each body that is generated, and that every soul is thus 
a special divine creation. This has become the prevailing 
concept of the Christian Church, and is spoken of as crea- 
tionism. Still another doctrine, which has been given the 
name of traducianism, taught that the souls of children are 
generated from the souls of parents as bodies are from 
bodies. This theory has been defended by certain modern 
theologians, but it has been formally condemned by others. 
Traducianism came much nearer to the present-day scien- 
tific ideas concerning the development of the mind than 
did any of the other doctrines. In all of these theories, the 
psyche, or the soul, or the mind, was regarded as an en- 
tirely separate entity, which inhabited the body during life, 
and which departed at the moment of death. They were 
all based on erroneous beliefs as to biological phenomena, 
and hence they did not hold. 
In addition to the various theoretical ideas as to the 
origin of the mind, numerous conceptions of the relation 
between the higher mental functions and the physical proc- 
esses underlying them have been introduced. A brief defi- 
nition of each will suffice. The theory of epiphenomenal- 
ism holds that mental reactions are due to physical changes 
taking places in the neurones in much the same manner 
that machinery gives rise to noise when in motion. Ac- 
cording to another view, mind and body are merely two 
aspects of a third reality, the nature of which has not yet 
been revealed to us. In the hypothesis known as psycho- 
physical parallelism, the physic and physical processes 
occur as contemporaneous accompaniments of one another 
without any direct casual relation. The two series, physical 
and mental, run parallel, but there never was, nor can be, 
any transition from the one to the other. The school of 
psychic monism regards the mind as the only reality, and 
believes that matter has no existence outside of conscious- 
ness. The animistic theory teaches that there is a non- 
material agency in all living things that exerts an influence 
over their actions. These various conceptions amount to 
nothing more nor less than pure metaphysical speculation. 
They have no practical value, and they are of interest only 
from an academic point of view. 
The only way in which we can gain any real insight into 
the nature of the mind, its relation to the body, and its 
development, is to study the psychical processes of all 
organisms from the lowest to the highest, as revealed by 
their activities, their reactions to stimuli, and their general 
behavior under normal and experimental conditions. 
When this is done, the fact that the mind, as well as the 
body, develops out of the germ stands out in bold relief. 
The essential oneness of life holds true here as elsewhere. 
A very excellent description of the evolution of the mind 
from its germinal bases has been given us by Conklin (4), 
and we can do no better than to briefly summarize his 
views on the subject. 
One of the fundamental properties of all protoplasm is 
general irritability, or sensitivity, which is the capacity of 
responding to stimuli. In the course of development, gen- 
eral sensitivity becomes differential sensitivity, or the 
ability to respond differently to stimuli that differ in kind, 
quality, and degree. This in turn gives rise to various spe- 
cial senses and sensations. Such sensitivity is the basis of 
all psychic processes. All of the reactions of germ cells 
and of the lowest organisms are in the nature of reflexes 
and tropisms. From these simple mechanical responses 
develop the complex automatic movements involving 
nerve centers, the inherited instincts, and the acquired 
habits of the mature forms of higher animals. Protoplasm 
has the capacity of registering and storing up the effects of 
stimuli for a short time. This is termed organic memory. 
Out of this function arises the faculty of associative mem- 
ory, or the power of nerve cells to preserve the effects of 
former stimuli, or experience, for much longer periods 
4 Chapter 1.-BIOLOGICAL CONCEPTS IN PSYCHIATRY 
and in more varied combinations. By the gradual elimina- 
tion of useless responses, and the preservation of the use- 
ful ones, the behavior of organisms comes to be purpose- 
ful and intelligent. All of the evidence points to the fact 
that human beings arrive at reason and intelligence by the 
same process of many trials and errors mixed in with a 
few successes, a remembering of these past experiences, 
and an application of them to entirely new conditions. 
Where several responses to a stimuli are possible, and 
where it has been learned that one response is more satis- 
factory than another, action may be limited to this par- 
ticular response, not only by external compulsion, but also 
by the internal impulse of experience and intelligence. 
This is what is known as conscious choice or will. In spite 
of the frequent changes of the materials of which we are 
composed, our sense of identity remains undisturbed 
throughout life, it being dependent upon the continuity 
of individual organization, especially of the nervous sys- 
tem. Associated with this continuing sense of identity and 
developing out of it is the most complex of all psychic 
phenomena, or consciousness. The elements out of which 
it is formed are found in the germ cells, and by a long 
series of various combinations and transformations due to 
interactions with one another and with the environment, 
the fully developed condition arises. At the particular time 
the individual becomes aware of the effects of stimuli, he 
experiences subjective phenomena, such as emotions, per- 
ceptions, judgment, imagination, and other psychological 
processes, which are usually included under the term 
"mental.” 
As a result of numerous investigations in biology, we 
now know that there is nowhere in the entire course of de- 
velopment a sudden appearance of psychical processes, but 
there is a gradual evolution of them from simpler and 
simpler beginnings. From the very start, every organism, 
no matter how far down the scale it may be, shows a dif- 
ferentiation into a head end and tail. In an elongated 
prone animal moving forwards, the head end of necessity 
comes first, most intimately, and most intensively into re- 
lationship with any change in the environment. The head 
end is naturally exposed to the operation of forces that 
differ a great deal from those to which the other portions 
are exposed, and hence it becomes decidedly different. The 
earlier acquisition of information concerning the outside 
world necessarily gives the head end exceptional oppor- 
tunities for influencing the rest of the body. This predom- 
inance is still further accentuated by the development of 
the organs of special sense in the head region. In some 
very primitive and remote ancestor of the vast majority of 
animals and man, the front or head end develops out of 
all proportion to the other parts of the body, becomes en- 
hanced in importance, and forms the great centralizing 
and coordinating organ, or brain. This latter constitutes a 
dynamic locus wherein are concentrated those activities 
to which later in the course of evolution the name of 
"mind” is given. 
Utilizing the above biological principles, psychiatry 
teaches that the psyche is just as old as the soma, and that 
there is no more reason for supposing that the mind is 
supernaturally created than that the body is. In other 
words, just as the structures and functions of the body 
may be traced back to the simple and fundamental prop- 
erties of the germ cells, so the characteristics of the mind 
may be found to exist in germinal protoplasm. The devel- 
opment of mental faculties runs parallel with the develop- 
ment of bodily structures. No fact in the realm of science is 
more certain or more significant than this, from both a 
practical and a philosophical point of view, and yet no 
fact is more generally disregarded. Body and mind belong 
to the same order of phenomena, and the old distinction 
that existed between them has disappeared entirely in the 
light of newly acquired knowledge in biology and psychi- 
atry. This means that physicians must no longer think of 
the mind as something very mysterious and incomprehens- 
ible, and they must not regard it as being closed to anyone 
except the expert and special student, as most of them are 
inclined to do now. 
A definition of mind is impossible. Mind is known 
only through its operations. We are conscious of our own 
minds from subjective evidence within us. We realize that 
mind exists in other persons because they act in obedience 
to outward circumstances as we do ourselves under similar 
conditions. Mind is the medium through which the indi- 
vidual becomes aware of the many things that constitute 
his surroundings, and of the laws that govern them. It is 
that subtle something through which our feelings are 
stirred, and by means of which we act and think intel- 
ligently. Mind is an adaptive mechanism which coordi- 
nates and directs all of our reactions as a whole in an en- 
deavor to push us along in such a manner that our own 
interests, as well as those of society, are served to the best 
advantage. The human psyche is the highest form of 
structural and functional integration that has so far been 
developed, and it represents the final answer of the organ- 
ism to the increasing demands placed upon it by the com- 
plex environment. 
As far as the realtionship between body and mind is 
concerned, they are so closely interlinked that it is impos- 
sible to conceive of the one apart from the other. The na- 
tural operations and processes of the mind depend upon 
the relative integrity of the body, and vice versa. Mind is 
related to body, as function is to structure. Mind is not 
5 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
the cause of body, nor body the cause of mind, but both are 
inherent in one common individuality and organization. 
The problems that confront the psychologist are exactly 
the same as those with which the physiologist is concerned. 
In other words, body and mind must ultimately be de- 
scribed in similar terms. 
UNITY OF THE ORGANISM 
A great many opinions have been put forward as to just 
what is responsible for the unity of the organism and what 
accounts for the uniformity of its behavior. The so-called 
corpuscular theories postulate a multitude of specific ma- 
terial entities in one form or another, each of which is 
supposed to represent some characteristic of the organism, 
the latter presumably being the product of their combined 
and harmonious activity. These theories fail to take into 
consideration, however, the basis of the individuality of 
the hypothetical physiological units, and their orderly in- 
tegration. They merely translate the problem into terms of 
the meta-microscopic anatomy of the organism, and they 
are fundamentally teleological and anthropomorphic in 
their implications. The vitalistic theories assume the ex- 
istence of a non-mechanistic principle which controls and 
orders the physiochemical factors to a definite end or 
purpose. This vital force, which has been called entelechy 
by a number of authorities, is entirely independent of 
physiochemical laws and is superior to them. It constructs 
the organism as a man would build a machine. These 
theories recognize and state more or less clearly the essen- 
tial problem instead of ignoring it completely, but they 
are frankly speculative and involve assumptions which 
are unwarranted. The organism has often been compared 
to a crystal. This has led to hypotheses which state that the 
laws underlying unity and order in the organic individual 
are the same as those governing the aggregation and ar- 
rangement of molecules. There is no optical or other evi- 
dence, however, for the crystalline character of protoplasm 
in general, and so these theories may be dismissed as being 
unsatisfactory. 
Recent investigations have demonstrated that certain 
parts of the organism produce substances which are es- 
sential to the normal activity or structure of other parts. 
Many observers state that every organ in the body is an 
organ of chemical correlation, which means merely that it 
produces something which plays a role in making other 
parts what they are. The hypothesis has been advanced, on 
the basis of these facts, that these chemical correlations are 
primarily responsible for unity and order in the organism. 
It is quite likely that chemical correlation is a factor of 
very great importance in determining the character of 
events in the organic individual, but it does not give us 
the solution of the real problem of unity. Chemical cor- 
relations depend upon the production and transportation 
of specific substances within the organism. It is evident, 
therefore, that parts decidedly different, or an organiza- 
tion of some sort, must be already present in order to pro- 
duce such substances. In other words, the individual must 
exist as such before chemical correlation is possible. 
In this connection, the work of Child (.5) is of monu- 
mental importance. He conducted a series of experiments, 
extending over a period of fifteen years, in which he 
studied and analyzed the processes of individuation in 
lower animals. As a result of his investigations, he reached 
the conclusion that the physiological individual comes 
into being because of the relationship that exists between 
protoplasm and its environment, and not because of any 
self-determined or inherent organization in the former. 
In other words, he has given us a dynamic conception of 
the foundation of unity and order in the organism. Let us 
summarize his views very briefly. 
To begin with, he assumes a mass of protoplasm, which 
is morphologically and physiologically homogeneous and 
undifferentiated. If a stimulus in the environment is per- 
mitted to act upon some point of the surface of such an 
aggregate, the first result is an increase in metabolic rate 
in the region immediately affected. This is followed by an 
irradiation of a dynamic change throughout the protoplasm 
from the point of original contact. As the wave of activity 
spreads, it successively acts as an exciting factor. This 
process is fundamentally a transmission, for it consists in 
the passage of energy, and not in the bodily transportation 
of substance. The transmitted excitation gradually de- 
creases in degree and intensity, and in its ability to produce 
further changes, until finally it becomes inappreciable and 
dies out altogether. In other words, a decrement in effec- 
tiveness occurs in transmission. The metabolic rate is high- 
est at the point of original excitation and slows down in 
direct proportion to the distance from the spot where the 
stimulus was first applied. 
If the external factor acts only momentarily, the changes 
in the protoplasmic substratum are slight and last only a 
short time. If the stimulus, however, is long continued, or 
repeated often enough, or if its strength is increased, the 
irritability or reactive capacity of the protoplasm is quick- 
ened, and permanent changes in its structure occur. These 
changes are greatest at the point of origin, where the ex- 
citation is most intense, and decrease with increasing dis- 
tance from this region. In other words, there is established 
what Child has termed a dynamic or metabolic gradient, 
which becomes the starting point of a permanent quanti- 
tative order in the living protoplasm. Such an order repre- 
sents a physiological axis or the physiological individual in 
its simplest form. This first order to arise is the chief, or 
6 Chapter 1.-BIOLOGICAL CONCEPTS IN PSYCHIATRY 
polar, or major axis, or the main gradient. Similar orders 
which are developed later determine minor axes or 
gradients, and on the basis of these the symmetry of the 
individual is perfected. 
In a metabolic gradient a relation of dominance and 
subordination exists between the levels of the highest and 
the levels of lowest rate. This is a simple and necessary 
result of the differences in rate of reaction. The region of 
highest irritability, or rate of reaction, must control all re- 
gions of lower rate, because it reacts more rapidly and 
more intensely than other regions. Its greater irritability 
also determines that it shall react to some conditions 
which are not effective in other regions. Consequently, the 
excitations transmitted from the region of highest rate are 
more effective in determining the metabolic rate at other 
levels of the gradient than the changes transmitted from 
any other region. The region of highest irritability, or rate 
of reaction, is then a physiologically dominant region be- 
cause it is the chief factor in maintaining the gradient after 
it is established. This dominant region of the gradient is 
relatively independent of other regions, while the latter 
are relatively subordinate to the former. In general, each 
level of the gradient dominates lower levels, and is in turn 
controlled by higher levels. 
As a result of the constant interaction between the 
organism and its environment, certain substances begin 
to collect along the pathway of the main gradient. The 
nature and accumulation of these substances is dependent 
upon their relative stability in relation to the metabolic rate 
of the particular part of the gradient where they are found. 
The substances which gather at each plane of the gradient 
must of necessity be of the same osmotic tension as the 
energy transmission at that level. In other words, the dy- 
namic gradient is in a state of physiochemical equilib- 
rium. As a rule, only the most stable substances can ac- 
cumulate in regions of higher metabolic rate, whole sub- 
stances of less stability may exist where the rate is Jower. 
It will thus be seen that qualitative differences in the dif- 
ferent parts of the gradient arise, and that each level of 
the gradient is characterized by specific substances. This is 
the beginning of differentiation, which now proceeds in 
an orderly fashion very much as if there were underlying 
it a plan or scheme specific for each kind of individual. 
The region of highest metabolic rate becomes the apical 
area of the main gradient or the head end of the organism, 
while the region of least activity is the basal portion and 
develops organs of attachment. The localization of parts 
with respect to the minor gradients is also definite and 
characteristic. An individual has many gradients, and each 
organ has a dominant gradient of its own and probably 
numerous subordinate ones. All of the dynamic forces of 
growth and development in the organism can be visualized 
as operating along the axes of these multitudinous gradi- 
ents, the latter being held in precise and orderly organiza- 
tion because of mutual relations of dominance and depend- 
ence, and all of them in the last analysis being under the 
direct control of the region of highest metabolic rate in the 
main gradient, or the head end. Such are the theories of 
Child, which are based on scientific experimental data, and 
which account in an adequate way for the processes of in- 
tegration in the individual. 
We begin now to get some idea of just what we mean 
by unity of the organism, and what it stands for. We can 
best define this concept perhaps by stating that in biology 
structures and functions, body and mind, are considered to 
be inseparable. Each depends upon the other for exist- 
ence, and anything that modifies the one must of neces- 
sity modify the ether also. They all develop together from 
the germ in a manner that is normal and specific by pro- 
gressive differentiation, and they are but different aspects 
of one and the same thing, namely, organization. The 
component elements of the organism are not thrown into 
place in a helter-skelter fashion, but they are slowly 
evolved under the dominance of a head end, which con- 
trols all of the subordinate axes and gradients of the body. 
The entire individual is a sharply defined biological unit, 
which cannot be divided into parts without altering their 
character and significance. The only justification for deal- 
ing with these different constituents of the organism as if 
they were separate entities lies in the increased effective- 
ness of such treatment from an academic point of view. 
The lesson to be derived from this principle of the unity 
of the organism, as far as medicine is concerned, is that the 
mind cannot be kept out of any problem that affects the 
individual, especially disease. This is obviously funda- 
mental in psychiatry, it is of equal importance in thera- 
peutics, and it is often of the most profound significance 
to the surgeon and to the internist. Every sick person, no 
matter what the nature of the malady may be, shows some 
variation from his normal mental state. Scarcely a single 
patient who is critically ill, as in typhoid fever, pneu- 
monia, erysipelas, influenza, or after a surgical operation, 
thinks and acts as he does in health. To put it differently, 
there is in every pathological condition, over and above the 
physical derangement present, a certain nervous and 
mental element, which varies in degree in different indi- 
viduals, and which constitutes a more or less conspicuous 
part of the disease entity. In other words, there is a mental 
aspect to every illness, whether medical or surgical. In 
mild disorders, this amounts to little more than a group 
of disagreeable feelings, which call for no special attention 
directed to their relief. In more serious diseases, however, 
the nervous and mental element may, and often does, be- 
7 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
come a very important factor in that it lowers the resist- 
ance of the patient, aggravates the organic pathology al- 
ready present, and hinders recovery. In the language of 
White (6), "the psyche is the central station, the clearing 
house, so to speak, for all the activities of the body, and 
hence, every physical symptom must have its reverberation 
in the mind of the patient.’’ Every morbid process, there- 
fore, with which we deal, is in reality a psychophysical 
problem. The psychical reacts on the physical, and the 
physical on the psychical. In diseases of the psychical life, 
the psychiatrist never dares to lose sight of the physical 
organism, because he knows that if he dwells too long 
upon the mysteries of a psychical unconscious he may 
forget that the body is ill. On the other hand, the internist 
must always take into consideration the psychological, as 
well as the somatic symptomatology, in the study and treat- 
ment of disease, if the latter is to be fully encompassed, 
and if our methods of total diagnosis are to be improved. 
The fact that every organism, from the lowest to the 
highest, represents what might be termed a psychosomatic 
unity, as we have just seen, indicates that we have no right 
to separate body and mental disorders, and to say either 
internist or psychiatrist, which is commonly done in med- 
ical practice today. Always it should be somatic and psychic 
treatment at the same time, and in the proper dosage and 
relationship. This is what modern psychiatry insists upon. 
Such an approach involves a complete study of every case, 
and requires not only a detailed physical examination, in- 
cluding all the necessary laboratory tests and special pro- 
cedures, but also an estimate of the personality make-up 
of the patient. If no organic basis can be found for the 
symptoms which he presents, inquiry should then be made 
into marital conflicts, financial failures, religious difficul- 
ties, sorrows, disappointments, anxieties, and thwarted 
ambitions and ideals in social life. This can be done diplo- 
matically without seeming to pry into his private affairs, 
and without attempting to delve into the unconscious, or 
to unearth buried sexual complexes. Having gained the 
confidence of his patient, the physician is then in a posi- 
tion to use drugs and diets at the same time with psycho- 
therapy in the form of convincing reassurance and gen- 
eral reeducation. It is necessary, therefore, for all internists 
and surgeons to possess at least a working knowledge of 
the mechanisms at the psychological level, and to recog- 
nize that they are just as reasonable, and just as definitely 
determined, as the physical, chemical, and physiological 
reactions with which medicine has so long been familiar 
in its other departments. 
ORGANISM AS A WHOLE 
When the discovery of the cellular structure of plants 
and animals was announced to the world, it was heralded 
as an epoch-making event. And so it was. The cell was 
the smallest morphological unit exhibiting vital activities 
that science had so far been able to find. The tissues of the 
more highly developed creatures were simply regarded as 
an aggregation of cells. The organism was explained by 
the sum of the substances of which it was supposed to be 
composed and their products. The human individual was 
considered to be nothing more nor less than a constellation 
of different elements. It soon became evident, however, 
that the cellular theory did not adequately account for life 
phenomena. Consequently, the concept that the cause of 
the existence of every part of the living organism is con- 
tained in the whole was put forward, or we should say re- 
vived, inasmuch as it had already been made the subject 
matter of an extensive literature, even dating back to the 
ancients. This idea ffom biology, because it is essential to 
its purpose, has been particularly elaborated in the realm 
of psychiatry. In this specialty, therefore, the dynamic 
organism, moving about as it does in its environment, and 
bringing all of its machinery to the task of effecting its 
various complex adjustments, is looked upon as something 
more than, and different from, the mathematical sum of 
its cellular constituents. In other words, the organism is 
more than a being that is merely physical, concrete, and 
tangible. It is an integrated whole, which exhibits many 
functions and reactions that are in addition to those that 
have so far been discovered in any of its component parts. 
t 
The important lesson to be derived from this principle 
of the organism as a whole is that we have no right to 
regard the body as being composed of a group or system 
of organs, each with a special function to perform, and 
each being a mere collection of cells, nothing more, noth- 
ing less. The anatomical elements of the body are not in- 
dependent and autonomous, but they are related to the 
whole organism. In order to gain any knowledge of an 
organ and its functions, therefore, we must think of it, not 
as an isolated entity, but as an ensemble of relations. The 
various organs of the body function by virtue of their de- 
pendence upon one another, and upon the whole organism 
of which they are a part. Their activity is not due to any 
power inherent within their structure. 
The failure to recognize the tremendous significance of 
the concept organism as a whole, together with the ad- 
vances in scientific morphology, led rapidly to the parti- 
tioning of the body into various organs and systems. In- 
tensive research around each of these anatomical subdivi- 
sions has opened up whole fields of professional endeavor. 
We have grown to look upon the diseases of the different 
organs as entities in themselves. Specialization in medical 
practice has been harmful in many respects, and it is es- 
sential to get away from too much of it. We need also to 
8 Chapter 1.-BIOLOGICAL CONCEPTS IN PSYCHIATRY 
eliminate the gradually increasing tendency to consider 
diseased hearts and livers, and so forth, as organs for 
which the body provides a sort of test tube, and in the 
treatment of which the personality of the patient is irrele- 
vant. A change in this attitude will eventually come about 
as a result of the newer emphasis on the importance of the 
whole to an understanding of the parts in all phases of 
biological research. 
The cardiologist, the urologist, the gastro-enterologist, 
and other medical specialists, are certainly no longer justi- 
fied in considering the organs and the diseases thereof in 
which they are primarily interested to the exclusion of the 
rest of the body. One need only to refer to disorders of 
the thyroid gland, for instance, to appreciate that dis- 
turbances in this organ are reflected in the circulatory 
system and other remote parts of the body. The effects of 
cardiac pathology are often manifested in the liver, kid- 
neys, and lungs. The secretory processes of the various 
glands, the work of the heart, the rhythmical nature of the 
respiratory movements, the activation of the ureters and 
the bladder, the propulsion of the food through the gastro- 
intestinal tract, and the nutrition of the body as a whole, 
are all profoundly influenced by diseases of the cerebro- 
spinal nervous system. Acute infection often leads to 
febrile delirium arterial hypertension and arteriosclerosis 
may produce certain forms of encephalopathy, and uremic 
poisoning frequently causes disturbances of consciousness. 
Examples of this sort could be multiplied, but even these 
few illustrate in a rough way the interdependence of all 
parts of the body. Internal medicine, following the teach- 
ings of psychiatry, must stress and emphasize the role 
which the anatomical and physiological units of structure, 
whatever they are, play in the whole economy, if it is to 
maintain its proper perspective, and not drift into too 
narrow a point of view concerning the human organism. 
To know an organ and its diseases is the apparent aim 
of most medical specialists. The ultimate goal of the psy- 
chiatrist, however, who appreciates the full meaning of 
the concept organism as a whole, is deeper and more far- 
reaching than this. He attempts to understand the patient 
as a total human being, with conflicts as well as a heart, 
with emotions as well as tonsils, and with thwarted pur- 
poses as well as a gastro-intestinal tract. In other words, 
instead of being interested in the pathological changes in 
some particular portion of the body, he surveys the entire 
individual. This enables him to treat the patient from many 
angles instead of from the standpoint of his chief qr major 
disease alone. The real secret of the success of many phy- 
sicians is the thoroughness with which they grasp and 
apply the principle of the organism as a whole to the baf- 
fling problems which they are called upon to solve. 
In order to fully comprehend and understand the na- 
ture of disease in our patients, we must take into considera- 
tion the complex whole which the interacting parts create. 
Disease is a manifestation of the physiological reaction of 
the organism to various nocuous elements in its environ- 
ment. In other words, disease is a modality of organic 
activity, and like all organic activity, it is a reaction of the 
organism as a whole. From a biological point of view, 
therefore, disease represents, not the responses of sepa- 
rate organs, or partial reactions, but total reactions to the 
causative agent, whatever it might be. Strictly speaking, 
there is really no such thing as a local disease. All diseases 
are general in nature and affect the entire organism, but 
their principal manifestations may be more or less local- 
ized. The meaning and significance of these facts to in- 
ternal medicine is that many chronic conditions of un- 
known etiology and pathogenesis may possibly be ex- 
plained as reactions of the organism as a whole, or total 
reactions to long-continued stresses and strains, both from 
within and from without, the organic compensations and 
defenses of the tissues breaking down in certain directions, 
so that different organs become involved to a greater ex- 
tent than others. 
PSYCHOGENESIS 
In all human beings there’ may be observed certair 
types of responses that are more or less closely allied tc 
instinctive acts. These are the emotional reactions, which 
result from special kinds of stimuli affecting the entire 
organism. An emotional reaction on the part of a person, 
however, is not merely a physiological response to a stim- 
ulus. It is the reaction of an individual to a situation which 
impedes, facilitates, or stimulates some instinctive tend- 
ency. We recognize emotion in others by a characteristic 
behavior, and we are cognizant of physical changes occur- 
ring in ourselves when we are experiencing an affective 
state. The emotions, whether mild or strong, are always de- 
pendent upon, and accompanied by, alterations in the 
physiology of the body. There is a considerable mass of 
evidence, based on pathological and experimental lesions, 
that the thalamus is the great subcortical center for certain 
primitive forms of the emotions, as well as visceral sen- 
sations, and the feeling tones of pleasure and pain. These 
are given expression in muscular movement through the 
rubrospinal tract. The emotions serve to aid the body in 
undergoing the necessary changes for driving the organism 
into a state of activity. In other words, by means of the 
emotions, the attention of the organism becomes focused 
upon some particular point in its environment, so that its 
energies may be coordinated for a specific reaction. More- 
over, the emotions intensify the marks made by experience, 
9 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
with the result that upon the repetition of a stimulus, a 
more perfect response will be evoked in the future. It will 
be seen, therefore, that the emotions are related to a phase 
of behavior, as well as to feeling, and that they are adap- 
tive reactions. In this sense, they are of tremendous bio- 
logical significance and importance. 
At the beginning of this century, there was a deeply 
rooted opposition to the idea that the emotions could in- 
duce illness, either physical or mental. Such a thing was 
generally repugnant to the then current medical thought. 
It did not harmonize with the prevailing physiochemical 
theory of disease as it had been crystallized by the brilliant 
achievements of the clinicians of that period. This was in 
striking contrast to the readiness with which the discovery 
of etiology of general paresis was accepted by the medical 
profession. Due to the lessons derived from biology and 
psychology, however, and to the emphasis placed upon it 
by psychiatry, it is now being appreciated that a large pro- 
portion of all of the patients encountered by physicians 
in their practice present psychic factors and emotional con- 
flicts of importance. These are capable of producing a 
great variety of functional disorders, as well as organic or 
structural changes in the different organs of the body. This 
is the problem of psychogenesis, a fundamental psycho- 
biological concept which demands scientific testing be- 
cause of its far-reaching implications. 
We are all more or less familiar with the role played 
by emotional states and conflicts in causing somatic dis- 
orders, and we see evidences of it almost daily in our 
routine ward rounds. Increased flow of saliva and gastric 
juice, vomiting, and all kinds of dyspeptic symptoms, 
may be excited by the sight of some revolting agent. Fright 
and anxiety often produce acute diarrhea. The influence of 
the emotions in the etiology of peptic ulcer has been em- 
phasized over and over again. Many cases of ulcerative 
and mucous colitis may be regarded simply as physio- 
logical expressions of some deepseated emotional disorder. 
The occurrence of attacks of bronchial asthma and biliary 
lithiasis is more or less conditioned by the emotional state 
acting through the autonomic nervous system. The flush- 
ing of embarrassment, and the blanching of fear, is proof 
of the effect of these states upon the walls of the arteries. 
Clinical and pathological studies and observations have 
brought to light the fact that the morbid manifestations 
of such an organic disease par excellence as angina pec- 
toris appear to be controlled, to a certain extent at least, 
by the emotions. Violent anger may sometimes play a part 
in seriously aggravating an already damaged heart, and 
in producing tachycardia, palpitation, premature beats, pre- 
cordial distress, and other signs of disordered cardiac 
function. Emotional shock, especially fear, quite often 
brings on a frank exophthalmic goitre. We note also the 
apparent effect of the emotions in the genesis and course 
of diabetes mellitus and arterial hypertension. These ex- 
amples and many others, too numerous to mention, furnish 
abundant proof that psychic factors must have a very 
definite effect on the physiology of the body. If these 
emotional conflicts occur repeatedly, and if they dominate 
the life of the individual, it is logical to suppose that they 
might leave an imprint upon the tissues, and produce or- 
ganic or structural changes. 
It will be seen from the above, therefore, that it is 
highly important for all physicians to make, as a routine 
procedure, a definite inquiry into disturbing emotional 
factors in all individual histories, with the possible excep- 
tion of the acute infections, as Favill (7) has suggested. 
If this is done, it will frequently be found that the diges- 
tive disorders in a particular patient began at a time when 
he lost a huge sum of money, due to a bank failure, and 
that they have recurred whenever he has been in financial 
straits, or when there has been a marked fluctuation in the 
stock market. Or it may be learned that a few years ago, 
upon arriving home from a business trip, a patient was 
informed of the death of a near relative from chronic 
myocarditis. He was overcome by the shock of the news, 
developed an attack of precordial pain, dyspnea, palpita- 
tion, and tachycardia, and then promptly fainted. Con- 
sulting his physician, he was told that he probably had 
heart disease, but he was cautioned not to worry about it. 
For over a decade he has not even so much as mentioned 
it, but his symptoms have continued, he has greatly re- 
stricted all of his activities, and he has lived constantly 
with the fear that he might pass away suddenly. Or again, 
we may discover that the headaches, and the pains in the 
back, of which this man complains, made their appear- 
ance at a time when he first felt the pangs of domestic 
incompatibility, and they become pronounced and more 
acute whenever he has a dispute with his wife. These hid- 
den emotions must be recognized if the proper rapport 
between the doctor and the patient is to be assumed. In 
this connection, Stevenson (8) states that neglect of the 
emotional problems that are involved in the numerous 
complaints of the patient by ethical practitioners is today 
lending aid and comfort to the cultist, and is wasting a 
powerful instrument of treatment. 
The average clinician very commonly approaches the 
consideration of pathological condition with far too little 
knowledge of their psychic antecedents. The successful 
physician, however, with a broad experience in the prac- 
tice of medicine, knows that the varied emotional factors, 
which may affect the personal or domestic life of the 
patient, exert a tremendous influence on the etiology of 
disease. The causes of many conditions, seemingly due to 
10 Chapter 1.-BIOLOGICAL CONCEPTS IN PSYCHIATRY 
organic visceral disease, may be found in psychic or en- 
vironmental backgrounds. A properly cultivated apprecia- 
tion of these facts, according to Stengel (9), is as neces- 
sary to the trained internist as is a knowledge of the 
biochemical or physiologic changes which accompany 
certain diseases. He feels that it is a part of the routine 
duty of the clinician to recognize and determine by appro- 
priate tests these latter factors in disease without calling 
upon the chemists and physiologists to point them out. 
In the same sense, he believes that it is essential to the 
efficiency of the practicing physician that he should be 
alive to the emotional and psychic factors in disease with- 
out seeking the aid of the psychiatrist. To overlook psycho- 
logical causes at an early stage is just as grave an error as 
to fail to recognize and diagnose an infective process or a 
surgical anomaly, a constitutional disorder, or a frank 
pneumonia. 
INDIVIDUATION 
Each organism has a personal quality which causes it to 
vary its action indefinitely, to change its form, to try end- 
less adaptations to external conditions, to produce young 
which differ from each other and from the common an- 
cestor, and to alter its shape so as to secure the best possible 
adjustment to its surroundings. The traits and the char- 
acteristics, as well as all of the other variations, which 
living creatures take on, must always be in the direction 
of increased fitness, and those that hinder or incapacitate 
must be discarded. Those favorable peculiarities in in- 
dividual specimens which enable them to better meet the 
struggle for existence will be developed from constant 
use. The eminently significant feature, however, is that in 
some way these changes are accumulated in the succession 
of generations, and new species, which are in a state of 
continuous alteration, appear on the earth. This is the 
biological process of individuation, which makes for in- 
creasing differentiation, not only in the race, but in the 
separate members thereof, and which renders each and 
every organism entirely distinct from all others. 
People of the same age, sex, race, family, and social 
status, vary in every trait which so far has been measured 
or estimated. Individual differences, for instance, in sta- 
ture, weight, strength of grip, endurance, pigment in skin 
and hair and eyes, and in resistance to disease, are com- 
mon. We all vary greatly in our ability to concentrate 
attention. Even a superficial observation of human be- 
havior reveals significant differences in the degree of 
initiative, originality, and emotional stability, which in- 
dividuals manifest in a critical situation. Everywhere we 
turn we discover that a given stimulus fails to elicit exactly 
the same response from any two people. There is a differ- 
ence in the kinds of moods which we allow to persist over 
long periods of time. People vary widely in the traits that 
go to make up the different temperaments, which appear 
in varying degrees, and in bewildering complexities and 
combinations, in each person. Two equally important 
factors unite to produce this infinite variety in the human 
race, namely, heredity and environment. These are inter- 
acting and interdependent, and it is impossible to deter- 
mine where the influence of the one begins and the other 
ends. 
Because of these individual differences and peculiarities, 
it follows that the reactions of each organism, especially 
to disease, will be extremely variable, and that the symp- 
toms of the same pathological condition will be different 
in each individual. These facts have long been recognized 
in psychiatry. In this branch of medical science, therefore, 
we try to seek out the individual factors in disease, par- 
ticularly as they express themselves at the psychological 
level, and by an understanding of them, we endeavor to 
work out something constructive in the life of the patient 
under our care. In other words, each person who seeks 
help is individualized. This is the very essence of psychi- 
atry, and may be termed its point of view, inasmuch as it 
is the only specialty in medicine that stresses this attitude. 
For a long time the internist has been studying disease, 
and treating it, without a sufficient appreciation of just 
how the individual who had the disease was reacting to 
it. This tendency needs to be corrected. The general aphor- 
ism in psychiatry, treat the patient, not the disease, may 
be applied with equal advantage to all branches of medi- 
cine. One or two examples of this principle will suffice. 
A patient who has heart disease may be disturbed much 
more by worry over his wife and children than he is by 
the dyspnea from which he suffers, and as a result of his 
brooding, he may develop a long train of neurotic symp- 
toms. In such a case, a talk with an understanding physi- 
cian, who tries to make the situation clear to him, and who 
then has the social service department investigate and take 
care of his home conditions, does more to help him and 
straighten him out than a book full of drugs or diets. Or 
as Ruggles {10) shows, the patient who is to undergo a 
radical operation for cancer of the breast, or for some other 
surgical condition, may be very much concerned over the 
probability of success, and she may be thinking of the 
subsequent deformity that may be produced. From the 
standpoint of the surgeon, the problem is the same as in 
many other cases he has had, but the whole procedure to 
the patient is most profound. Attention to her peculiarities 
and personal reactions may prevent considerable shock, 
and bring about a favorable outcome. This is only an in- 
dication of what can be accomplished by treating the in- 
dividual factors in disease. Neglect of them may result in 
the unsuccessful handling of the case. 
11 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
CONCLUSION 
is the principal theme, to which disease is but a corollary, 
and establishes a philosophy upon which the practice of 
medicine will ultimately depend. 
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chiatry for students and practitioners. 4th ed., p. 484, 
1935, P. Blakiston’s Son & Co. 
2. Peabody, F. W.; Care of the patient. Pp. 24-25, 1927, Har- 
vard University press. 
3. McDougall, William: Outline of abnormal psychology. 
P. 37, 1926, Charles Scribner’s Sons. 
4. Conklin, E. G.; Heredity and environment in the develop- 
ment of men. 5th ed. Pp. 32-56, Princeton University press. 
5. Child, C. M.: Individuality in organisms. 1915. University 
of Chicago press. 
6. White, Wm. A.: Foundations of psychiatry. P. 7, 1921. 
Nervous and Mental Disease Publishing Co. 
7. Favill, J.: Need for emotional data in the medical history. 
Ann. Inter. Med. 3: 462-466, Nov. 1929. 
8. Stevenson, G. S.: Why patients consult the gastro-enterolo- 
gist. Jr. Amer. Med. Assoc. 94: 333-337, Feb. 1, 1930. 
9. Stengel, A.: The internist as his own psychiatrist. Ann. Inter. 
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10. Ruggles, A. H.; Psychiatry’s part in preventive medicine. 
Ann. Inter. Med. 3; 368, Oct. 1929. 
In conclusion, let me reiterate that whatever fields we 
touch in medicine, persistently and inescapably, we find 
ourselves in the presence of problems that can only be 
approached in an intelligent manner from a psychobio- 
logical point of view. Exclusive somatic medicine, as we 
have already indicated, is fast disappearing from the scene, 
and there is a distinct drift noticeable to a conception of 
disease in which the sick person, as well as his individual 
organs, receives attenion. The consideration of the patient 
himself should always dominate and surround the investi- 
gation of his affliction. When this is done, it is amazing 
how frequently the particular pathological disturbance 
with which he is suffering is found to belong irresistibly 
in the whole fabric of his personality. The medicine of 
the future, in addition to being concerned with the ana- 
tomical structures of the patient, must interest itself and 
include in its survey the important problems of human 
distress, social relationships, emotional maladjustments, 
and personality disorders of all types. This will come about 
as a result of considering each individual as a psychosom- 
atic unit. Such an approach involves a knowledge of the 
salient factors of life, and its significance, which after all 
12 CHAPTER 2 
CONSTITUTIONAL FACTORS IN THE SELECTION 
OF RECRUITS* 
Recruit selection has always operated on the principle 
that any young man of sound body and reasonable in- 
telligence could be made, with the proper amount and 
kind of training, into a good sailor. In peacetime the fal- 
lacy of this principle was not obvious because there was 
plenty of time for variants in constitutional make-up and 
temperamental capacities to find their own levels as to 
duties that they could perform with satisfaction or as to 
assignments to the various naval environments to which 
they could adjust themselves with contentment. If they 
could not reach their levels, they could ultimately be dis- 
charged and the loss of time and the wasted training and 
the nuisance value of the misfits were not counted as 
anything very serious. 
The present necessity of enlisting large numbers of men, 
cutting short their training, and sending them out to situa- 
tions requiring considerable responsibility and technical 
skill has resulted in the assignment of large numbers of 
men to duties for which they are obviously unsuited. These 
men are failing not because they are physically defective 
or because they lack the intellectual equipment with which 
to cope with their problems, but because they are tempera- 
mentally and emotionally inadequate to the situation. 
This fact of large numbers of failures in the service 
does not necessarily mean that these men should not have 
been enlisted but that, during the period of training, a 
greater effort should have been made to determine their 
temperamental qualities or their behavior capacities in 
order that duties could be selected for them in which they 
had some possibility of succeeding, and that those who 
were not at the moment adequate to a duty could be given 
sufficient time and further training, in preparation for it. 
If we should eliminate from the service all those who 
show so-called neurotic traits or who at the moment do not 
seem entirely adequate, a large group of potentially good 
recruits would be lost from the service. 
Two obvious criticisms of attempts to select on the basis 
of temperamental characteristics present themselves. The 
first is that there is insufficient time to make any estima- 
tion of temperament; and the second, that we have an 
insufficient knowledge of the factors making up tempera- 
ment to form any valid judgments. 
An attempt has been made at the Portsmouth Naval 
Hospital to study this problem. Two groups were studied, 
the first composed of those who had obviously been suc- 
cessful in their adjustment to naval life, and the second, 
those who had been obvious failures. The material for the 
successful group was derived from a submarine crew who 
had been together for some time, and who, the command- 
ing officer felt, formed a fairly representative group; and 
from a group of hospital corpsmen from the Portsmouth 
Naval Hospital. The corpsmen had ratings and positions 
of responsibility indicating their successful adjustment. 
The men were all interviewed individually, and, in addi- 
tion to a history of their background, they were all asked 
what qualities they would look for in choosing men for 
their branch of the service. The qualities they enumer- 
ated reflected to a considerable degree their estimation 
of themselves and could not be considered entirely objec- 
tive, but, because of their own success and the diversity 
of the individuals interviewed, it was felt that the qualities 
listed were sufficiently significant. 
Below is a list of qualities given by the men who were 
successful in submarine work and hospital corps work: 
SUBMARINE MAN 
1. Maturity: Must be able to take care of himself; must be able 
to take responsibility. 
2. Intelligence: High school level. 
3. Must know how to mix; must be able to get along with 
people; must not be forward. 
* By Lieutenant Commander R. G. Freeman, Medical Corps, U.S.N.R. 
13 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
4. Must be physically rugged; must be able to stand changes 
in temperature, irregular diet, irregular and long hours 
of work, conditions of poor ventilation, 
5. Must not be nervous, anxious. 
6. Must be patient, not need a lot of exercise; must not be rest- 
less. 
7. Must understand discipline; must understand his place with- 
out being told and must not take advantage of the in- 
formality of the life. 
8. Must be aggressive, eager, and anxious to get ahead. 
9. Must be quick. 
10. Must be clean. 
11. Must be a worker. 
12. Must be honest. 
13. Must have regard for the feelings of others. 
14. Must not be too moral. 
HOSPITAL CORPSMAN 
1. Intelligence; High school level. 
2. Must have personal pride, be neat and clean. 
3. Must be obedient. 
4. Must be interested in hospital work. 
5. Should have had past experience with similar work. 
6. Must be honest, exact. 
7. Must be eager, curious, alert, ambitious. 
8. Must be quiet, not restless. 
The group which had failed to adjust were drawn from 
apprentice hospital corpsmen and from prisoners in the 
Portsmouth Naval Prison who were 20 years old or under. 
List 1 gives the summaries of interviews with 10 corps- 
men who had either been repeatedly on report or who had 
been found inadequate to their duties and shows the 
temperamental qualities and personality traits found in 
these poorly adjusted individuals. 
LIST 1 
1. Seems a simple, likeable individual, who at his own level 
will do fairly satisfactory work. Recommend transfer to seaman 
or fireman rating. 
2. Not very good material, but considering probable early 
over-protection and low intelligence, he is not doing badly. 
3. Cyclothymic make-up. Capable of both excitement and de- 
pression. Insecure, anxious. Instincts and ideals poorly integrated 
with poor ego formation. 
4. Excitable, stubborn boy, with poorly developed affect and 
not constitutionally well endowed in this capacity. Will need a 
great deal of supervision and personal interest. Recommend out- 
side detail for a while and then return to ward. 
5. Well-developed, powerful individual with great energy and 
very strong, deep emotions. Many of his attitudes result from a 
not too happy childhood. Many of his attitudes are quite mature 
but good emotional control has not yet been established. Wants 
hard work, challenges to his self-responsibility, and firm, inter- 
ested, patient leadership. Wants submarine duty and has con- 
sidered the physical and emotional hazards. Boy seems to have 
great potential value. Would recommend transfer out of hos- 
pital to active duty at sea. 
6. Poor material for Navy. 
7. Poorly adjusted, withdrawn, irritable, with considerable 
depth of mood. Unable to project emotions. Preschizophrenic. 
8. Poor somatic material. Poorly developed. Probably inade- 
quate to duty. Feels nervous, cries easily. Homesick and lonely. 
Has no friends. 
9. Simple, childish, dependent, restless, and diffuse. Will 
probably never make a good corpsman. 
10. Simple, poorly balanced, unstable, insecure individual. 
Certainly not hospital corps material. Might possibly get by in 
a protected situation. Boy is not good naval material. 
List 2 gives the summaries of the interviews with 10 
prisoners and again shows the traits and qualities found 
in. these individuals. It is interesting to note the similarity 
of traits and qualities in the 2 groups showing that there 
is a common denominator of inadequacy and there is a 
large element of chance and circumstance in whether the 
individual continues to get by on a low level, becomes a 
hospital patient or ends up in prison. 
LIST 2 
1. Outstanding features are strong drives to aggression and 
sexual satisfaction together with poor affect, so that no sublima- 
tion in socially acceptable patterns is possible. Intelligence has 
never been used beyond immediate satisfaction of drives. Said 
he thought there must be something the matter with him be- 
cause he always had such hard luck. 
2. Constitutionally poor material and his environment has 
made him operate at his minimum rather than at his maximum. 
3. Underdynamic, sensitive, introspective boy who is essen- 
tially poor service material. With more maturity and guidance 
might make fair corpsman. Was too immature to carry the load 
of emotional responsibility with which he saddled himself. Inr 
terview with wife by some member of staff might help his 
future. 
4. Hyperirritable, sensitive, sensory individual, with very 
little control over his instinctual reactions. Dependent, affec- 
tionate, will need plenty of activity, friendliness and stimulation. 
Efforts should be made to stimulate his intellectual processes 
and allow him to sublimate some of his instinctual desires. Must 
learn emotional control. 
5. Underdynamic individual with poorly controlled instincts. 
Poor psychological control. Enuresis. Poor social relations. Poor 
standards and convictions which are readily soluble in alcohol. 
6. Boy is blocked, repressed, withdrawn. Affect is inappro- 
priate and inadequate to thoughts expressed. Irritable, frequent- 
ly smiles in silly way. Impresses as preschizo'phrenic and worthy 
of close watching. 
7. Underdynamic, weak, immature boy without drive, ambi- 
tion or intellectual interest. Soft, dependent, sensitive. Work 
should be towards an emotional goal, admiration for some adult 
person with development of ideals and conviction. Has good 
social sense which should be utilized. 
8. This boy is definitely preschizophrenic and needs careful 
watching and guidance. Needs occupation and guidance with it. 
9. Large, soft, characterless individual who is emotionally un- 
stable. Needs development of more hardness, conviction and 
ability to sustain his convictions. Would think facing fairly hard 
physical tasks from which he could not withdraw or put the 
burden on others might help. 
10. Slow sensitive boy who has been through many emotion- 
ally traumatic situations. Strong instinctual desires, with con- 
14 Chapter 2.-CONSTITUTIONAL FACTORS IN THE SELECTION OF RECRUITS 
siderable autonomic instability making their control difficult. 
Little opportunity for development of ideals but boy has sur- 
prising feeling for the physical world and has been not too much 
spoiled by his contact with the human being. 
It is obvious that these qualities represent a combination 
of inherent constitutional characteristics and the results 
of environment and training. It is equally true that it is 
the inherent characteristics that condition an individual’s 
reaction to his environment and that he can only react to 
this environment within the limits of his constitutional 
make-up, and that if he is to possess these qualities, he 
must have certain inherent characteristics to serve as a 
basis of the desirable qualities. Conversely, if he does not 
possess them but has the fundamental qualities, then train- 
ing and reeducation will enable him to develop them. 
There will never be time in recruit selection to make a 
complete analysis of the background, but if we can get at 
the inherent capacities, we can at least know whether the 
material is sufficiently good to work with and whether 
there are present characteristics which will make certain 
phases of naval life difficult or impossible for the indi- 
vidual. 
The six characteristics listed below are regarded as 
being necessary to survival and reproduction, as being 
transmitted by inheritance, as varying in the degree to 
which they are possessed by any individual, and as being 
subject to modification by disease and other environmental 
conditions. 
1. Physical make-up. 
2. Irritability—the speed of reaction to stimulation of reflex 
patterns or instincts and the intensity of the feelings accompany- 
ing the stimulation of these patterns. 
3. Energy or drive—the capacity to sustain and carry to a 
successful conclusion the reflex patterns or instincts which have 
been stimulated. 
4. Affect—the ability to enjoy and understand human rela- 
tionships, to feel affection, sympathy and loyalty, to be able to 
modify one's own feelings for the sake of better relationships. 
5. Mental activity—curiosity, alertness, interest. 
6. Intelligence—capacity to learn, to remember. 
It is possible in a 15-minute interview to make a fair 
estimate of the degree to which these characteristics are 
possessed by any given individual. They are character- 
istics recognized by every trainer or breeder of dogs and 
horses. The persistence of accentuation or diminution of 
these temperamental characteristics in certain blood lines 
is made a basis of breeding, and plans of training take 
place around these characteristics as fixed points. 
In the determination of physical efficiency, functional 
examination must be added. In the determination of the 
first item of physical make-up, the ordinary static examina- 
tion, as done in the recruit station, does not actually re- 
veal or answer the questions that must be known to de- 
termine the individual’s ability to handle situations requir- 
ing hard work, persistent effort, exposure to temperature 
changes, and severe muscular activity, so that functional 
tests of cardiac function under effort, pulmonary capacity, 
a short gastro-intestinal history, and any other questions 
designed to reveal the functional capacities of the various 
organ systems are important. 
In studying speed of reaction, whether to a simple single 
reflex or a complex pattern belonging to the group of in- 
stincts, we want to know, beside the speed with which it 
is set off, whether its function is accompanied by feelings 
of excitement, fear, anger, somatic symptoms of head- 
ache, dizziness, palpitation, flushing, sweating, tachycar- 
dia, nausea, hyperperistalsis, vomiting, diarrhea; whether 
stimuli to the reproductive patterns reveal stability or 
instability, are well controlled or poorly controlled. His- 
tory will reveal a good deal of it. The recruit’s behavior 
during the psychiatric interview, his behavior with his 
fellows in the barracks, his reactions under restriction, 
criticism, pressure of one kind or another, the speed with 
which he obeys orders, his ability to get along on a ship, 
his sleep, his reaction to diet, the number of times he comes 
to sick call, all will have a bearing on the factor of irrita- 
bility. Test situations can be set up which might produce 
anger, fear, excitement, or resentment and the recruit can 
be deliberately placed in these situations. 
Energy and drive again can be determined by a short 
history of the recruit’s interests, the persistence with 
which he has held a course of behavior, his athletic activ- 
ities, the kind of jobs he has looked for, his endurance 
during recruit training; and there again test situations for 
the individual’s ability to sustain effort can be easily 
devised. 
Affect can be easily brought out by the recruit’s story 
of his family relationships, his friends, both boy and girl, 
social activities, attitudes toward the war, reasons why he 
came into the service, etc.; and confirmation of this may 
be obtained by observation of his relationships with the 
other recruits, whether he becomes dependent on the 
approval of other people, whether he is able to handle him- 
self independently, make his own decisions, whether he 
is a leader or a follower, whether he appears considerate 
of others and gives way to the desires of others or whether 
he is continually trying to put himself in front and to 
protect himself. 
Mental activity can be determined through a short his- 
tory of the recruit’s interests, his school progress, his 
views on and knowledge of current topics, and again, the 
interest and curiosity which he displays in learning during 
his training period, the intelligence of his questions, and 
his ability to learn new technics. 
15 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Intelligence can be readily and fairly accurately de- 
termined by well standardized tests. 
The first three of these six capacities controlling and 
forming the basis for the instinctual level of behavior, are 
the strongest motivating forces in behavior, and are pos- 
sessed by all members of the animal world. The social, 
cultured, intelligent human being is produced by the in- 
tegration and control of these capacities by the other three 
of affect, mental activity and intelligence. These capacities 
do not operate in an isolated way but by virtue of their 
integration with other capacities to form total behavior, so 
that a wide degree of compensation is possible, and, where 
an individual is high in irritability and excitability, a high 
intelligence and a desire for good human relationships 
will help him to control this. An individual of relatively 
low intelligence who is alert, not excitable, and has ade- 
quate energy can become an extremely useful citizen. And 
so there are all possible combinations of these six capac- 
ities which produce the tremendous range of human 
variants, and it is a matter of estimating the degree to 
which an individual possesses them, the way in which he 
has integrated one quality with another, in order to deter- 
mine the probable degree to which he is subject to modi- 
fication and thereby his ability to make a better adjustment 
to service conditions. 
What, then, is the relationship of these fundamental 
capacities to the desirable qualities of submarine men and 
hospital corpsmen listed above? What qualities go into 
developing maturity? It is obvious that the hyperirritable, 
sensitive, easily stimulated individual is going to have a 
more difficult time in emancipating himself from the pro- 
tection of his family, friends and community than the 
more phlegmatic recruit who takes things as they come 
and is not easily disturbed. Again, the individual with 
high affect, who has been dependent on the relationships 
with the people about him, his family and friends, may 
find himself lonely and unhappy in the recruit situation. 
The most mature men are those who are not above aver- 
age in the capacity of irritability, are physically adequate, 
have average energy or drive, are not too dependent on 
human relationships, and have had some experience in 
taking care of themselves in an independent situation. 
The ability to understand and accept discipline is really 
related to maturity, but the highly energetic, restless, driv- 
ing individual has a much greater problem in restraining 
himself and accepting routine discipline than those who 
are less energetic. Also, the hyperirritable individual is 
more likely to resent discipline and criticism. 
Aggressiveness is in direct relationship to the individ- 
ual’s ability to be aggressive. Aggression is a normal 
attribute of the human being and is a part of his instinctive 
make-up. The physically well-endowed, energetic, reactive 
individual, with not too much affect, will prove the most 
aggressive, whereas the person who is continually thinking 
of the feelings of others, who does not like to hurt other 
people, who is easily hurt himself because of sensitiveness 
or hyperirritability, who is not too well endowed with 
energy, will not show aggressive characteristics. 
What are the factors in producing honesty? Again, 
honesty is the result of the courage to be honest; and dis- 
honesty will be found in the nervous type individual, the 
individual who is fearful, afraid of his ability to maintain 
his convictions or to do the hard work necessary to an 
honest effort. 
It becomes apparent that for the good sailor under 
combat conditions, physical fitness, good energy, drive, 
determination, not above average excitability, not above 
average affective capacity, somewhat better than average 
curiosity and alertness, and intelligence of the high school 
level are desirable in anybody who expects to rise above 
the seaman level, with the highly technical problems 
confronting him. For the hospital corpsman, he must 
be an individual who is sufficiently excitable and reactive 
to feel situations and move quickly in them, but one who 
is not going to react with too intense feelings. He must 
have adequate energy, but it need not be of the highly 
aggressive variety; rather it should be a type that can be 
expended in somewhat smaller amounts over a prolonged 
period. He is never called on for sudden, intense effort, 
but must keep up a persistent effort over long periods. He 
must have better than average affective capacity or he will 
not have the necessary interest in the patients under his 
care. He must be above average in mental activity or he 
will not be able to learn the many and various technics 
necessary to a hospital corpsman, or to devise ways of 
meeting situations when short of the necessary materials. 
He cannot master the knowledge necessary without at 
least a high school level of intelligence. 
Let us now examine some of the failures in the light 
of the necessary qualities to make for success: 
ANALYSIS OF SOME OF THE FAILURES FOR SUCCESS 
Corpsmen 
1. (a) Low irritability, slow, phlegmatic. 
(b) Low intelligence—10 years. 
2. (a) Low intelligence—10 years. 
3. (a) High irritability. 
(b) High affect—immature, poorly developed, fear of evil, 
repressed and inhibited. 
(c) Cyclothymic—periods of depression and periods of in- 
creased activity. 
4. (a) High irritability. Poor reflex and instinctive control. 
(b) Low affect. 
(c) High intelligence. 
16 Chapter 2.—CONSTITUTIONAL FACTORS IN THE SELECTION OF RECRUITS 
5. (a) Exceptional physical development. 
(b) Hyperirritable. Strong instinctive drives. 
(c) Excessive energy and drive. 
(d) High affect. 
(e) High intelligence. 
(/) Capacities poorly integrated and poorly controlled. 
6. (a) Poor physical development. 
(b) High irritability. Seasickness. 
(c) High affect but immature and repressed. 
(d) Low intelligence. 
7. (a) Poor physical development. Bad acne. 
(b) High irritability, anxious, sensitive, enuresis, fainting. 
(c) Low energy or drive. 
(d) High affect but poorly developed with withdrawn be- 
havior. 
8. (a) Poor physical development. 
(b) Hyperirritable. 
(c) Low energy or drive. 
(d) High affect but immature, dependent, insecure. 
9. (a) High energy. 
(b) Affect poorly developed. 
(c) Low intelligence. 
10. (a) Hyperirritability. 
(b) Low intelligence—10 years. 
Prisoners 
1. (a) Strong instinctual drives, aggressive, hostile. 
(b) Low affect. 
(c) Average intelligence. 
2. (a) Poorly controlled reflex and instinctive behavior. Enu- 
resis up to 15. 
(b) Low energy. 
(c) Dependent on mother. 
(d) Low intelligence. 
3. (a) Poor physical development. 
(b) High irritability, autonomic instability, angio-edema. 
(c) Low energy. 
(d) High intelligence. 
4. (a) Hyperirritability. Has enuresis. Anxiety, tension. Poor 
instinctual control. 
(b) High affect—dependent, insecure, immature. 
(c) Low mental activity. 
5. (a) Poor reflex control. Enuresis up to 10 years. 
(b) Low affect—inability to make relationships or be 
guided by them. 
6. (a) Schizoid make-up, withdrawn, fantasy, preoccupied. 
(b) Low intelligence. 
7. (a) High irritability—enuresis up to 10 years, anxiety, ten- 
sion. 
(b) Low energy and drive. 
(c) High affect but dependent and immature. 
8. (a) Poor physical development. 
(b) Poor energy or drive. 
(c) Affect poorly developed, immature, dependent. 
(d) Mental activity—no reasoning or judgment. 
(e) Preschizophrenic. 
9. (a) High irritability. 
(b) High affect—poorly developed, immature. 
(c) Low intelligence. 
10. (a) High irritability. 
(b) High affect. 
(c) Low intelligence. 
CONCLUSIONS 
1. All psychiatric examinations of recruits should be 
made at the training stations. At the recruiting stations 
only the obviously incompetent can be weeded out, and 
examination is not necessary. 
2. At the training station there should be an increased 
time for psychiatric examination, so that certain definite 
questions concerning the individual’s behavior in relation- 
ship to his previous environment, his attitudes toward his 
family, his social activities, athletics and school work can 
be asked, and an initial estimate of his capacities and 
present temperamental status can be made, noted, and sent 
to his company commander. 
3. If the time at the training station is to be reduced, 
then the larger part of the training must take place after 
the recruit is sent to duty, so that the major emphasis at 
the training station should be on getting to know the man 
and his capacities in order that a wise selection can be 
made. 
4. The company commander should immediately start 
checking on the observations made by the psychiatrist at 
the time of induction and should be aided in setting up 
test situations to demonstrate physical ability, excitability, 
energy and drive. Every week he should check on his 
observations and, at the end of the training period, make 
definite recommendations for the type of duty to which 
that recruit is to be sent. This should be detailed as to the 
kind of ship, whether submarine, destroyer, cruiser, or 
battleship; whether the recruit is fit for combat conditions 
on the ship or should be at sea in a situation where emer- 
gencies are unlikely to arise; whether the recruit would do 
better in some type of shore duty. 
5. The company commander, at the end of the training 
period, should meet with the psychiatrist and they together 
should make the final selection for-the type of duty. 
6. In order that no human material shall be wasted, 
there should be formed labor battalions and work details 
connected with hospitals where closer observation is pos- 
sible, where men of doubtful capacities can be sent for 
further training and observation, with the idea that ulti- 
mately they will be able to undertake more active duty. 
7. A system should be worked out so that duties can be 
shifted and, where a man is found unfit for destroyer duty 
or some other special duty, he will not have to be surveyed 
from the Navy, but can be transferred, at least temporarily, 
to some other duty for which he is more capable. 
8. It should also be possible, where men are showing 
signs of nervous exhaustion either through anxiety, 
apathy, or through various somatic symptoms, that they 
can be sent ashore for periods of three weeks or a month 
and then again returned to duty. 
17 CHAPTER 3 
THE VALUE OF THE SOCIAL SERVICE HISTORY IN THE 
DETECTION OF THOSE PSYCHIATRICALLY UNSUITED 
FOR MILITARY SERVICE* 
A STUDY OF 500 ENLISTED MEN 
During World War II much attention was devoted 
to the development of methods for facilitating the early 
elimination of the potential neuropsychiatric casualty 
from the military service. Although the need for a careful 
psychiatric interview at time of induction was recog- 
nized, such interviews were in reality very brief and often 
quite inadequate. Thus it was suggested (Billings, E. G., 
Ebaugh, F. G., et al., War Med. 4:283-298, September 
1943) that social-service histories for each inductee be 
made available to the examining physician as confidential 
information, with the hope that such material would be 
helpful in detecting the psychiatrically unfit. In a previous 
study (U. S. Nav. M. Bull. 43:909-921, November 1944) 
it was thought advisable to have such histories include the 
following data: (1) Character of the man’s family rela- 
tionship; (2) history of mental illness in the family; 
(3) persistence of infantile traits, such as enuresis, marked 
fears, temper tantrums, nightmares, etc.; (4) history of 
previous mental illness afflicting the man himself; (5) 
educational history, adaptability, truancy, scholastic record, 
etc.; (6) social adjustment in the community, participa- 
tion in group activities, any peculiarities of personality, 
etc.; (7) criminal record; (8) employment record; 
(9) use of alcohol and other drugs; and (10) degree of 
emancipation from the home. There was little informa- 
tion concerning the effectiveness of such histories in 
actually identifying those who might develop mental ill- 
ness under the strain of service life. 
The purpose of this study is to test the usefulness of 
social-service histories as a supplement to the neuropsychi- 
atric examination of inductees for military service. Five 
hundred enlisted men (U. S. N., U. S. M. C, U. S. C. G., 
regular and reserve) were chosen at random from among 
the patients admitted to St. Elizabeth’s Hospital, Washing- 
ton, D. C, from January 1942 to May 1944. It was as- 
sumed that each man presented a normal enough appear- 
ance at the induction center to be accepted for military 
service, and that any rejections from this group would 
have been made entirely on the basis of findings revealed 
in the social-service histories. In reviewing these cases we 
attempted to base our decision for acceptance or rejection 
on the data in such histories. Certain defects of this 
method of study are apparent. The social-service history 
taken after a man has been hospitalized (as in these cases) 
may be more complete than such a history prepared for 
use at the induction center, many facts being more will- 
ingly revealed after the illness is manifest than before. 
In some cases the history may not in itself afford enough 
information to warrant rejection, but may be suggestive 
and justify a request for further material. In the cases re- 
viewed here we have attempted to keep in mind the prac- 
tical considerations faced by the hurried physician in the 
induction line, the urgent need for men in the armed 
services, the brief time allotted for examination, the pres- 
sure exerted by the community that often resents the 
rejection of the man who may seem fit for duty to the eye 
of the layman, and the still persistent attitude in some 
places that the ne’er-do-well, the chronic behavior problem 
should be sent into the military camp as a corrective or 
disciplinary measure. Hence, we have not rejected cases 
lightly and have passed some with considerable reluctance, 
doubting their ability to make a satisfactory military ad- 
justment, but realizing that in actual practice some doubt- 
ful candidates would still justify a trial of duty. 
♦By Otto A. Will, Jr., Lieutenant (MC) U. S. N. 
18 Chapter 3.-THE VALUE OF THE SOCIAL SERVICE HISTORY 
Table 1.—Diagnoses of 300 unselected enlisted men hospital- 
ized at St. Elizabeth's Hospital (January 1942 to May 1944) 
On the basis of the social-service history, an attempt 
having been made to carefully evaluate the 10 factors 
previously noted, 178 (35.6 percent) of the 500 men 
would have been rejected. In table 3 is shown the dis- 
tribution of these men according to length of active mili- 
tary duty. In this group, as would be expected, is noted an 
increase in those with only brief periods of service (com- 
pare with table 2). Thirty-three and seven-tenths percent 
had less than 1 month of duty before hospitalization. 69-1 
percent less than 6 months, and 84.8 percent less than 1 
year. Those with the more obvious mental defects, revealed 
by the short social histories available, seemed to have a 
greater chance of becoming mentally ill in a shorter period 
of time than those whose abnormalities had not been so 
grossly manifest. 
Diagnosis 
Percent 
Schizophrenia (dementia praecox) 
72.0 
Manic depressive psychosis (manic) 
8.3 
Manic depressive psychosis (depressed) 
3.4 
Involutional melancholia 
.6 
Paranoia 
.6 
Unclassified psychosis 
10.3 
Psychopathic personality with psychosis 
1.0 
Psychosis with alcoholism 
1.0 
Psychosis with epilepsy 
0.4 
Psychosis with mental deficiency 
1.0 
Paresis 
.4 
Psychosis associated with trauma 
.6 
Psychoneurosis 
.4 
Total 
100.0 
Table 3.—Length of active military service prior to hospitaliza- 
tion for a mental illness of 178 enlisted men who would have 
been rejected for military service on the evidence revealed in 
their social-service histories 
The diagnosis of the 500 cases studied are shown in 
table 1. The striking feature of this grouping is the large 
number diagnosed as schizophrenic. A similar distribution 
of diagnoses was found in the group of men that would 
have been rejected as the result of findings in their social- 
service histories. In this study there is no evidence that 
it is easier to eliminate (by social study) one prepsychotic 
type than another. It should be noted that almost all of 
the cases studied here are psychotic, and thus any con- 
clusions may not necessarily be applicable to the psycho- 
neuroses. 
Length of service 
Number 
of men 
Percent 
Less than 10 days 
31 
17.4 
10 to 30 days 
29 
16.3 
1 to 3 months 
33 
18.5 
3 to 6 months 
30 
16.8 
6 to 12 months 
28 
15.7 
1 to 2,years 
21 
11.8 
2 to 4 years 
5 
2.8 
More than 4 years 
1 
.6 
Total 
178 
100.0 
Table 2.—Length of active military service of 300 unselected 
enlisted men prior to hospitalization at St. Elizabeth's Hospital 
(January 1942 to May 1944) 
The major reasons for the rejection of the 178 men are 
shown in table 4. Those who had been previously hospital- 
ized because of a mental illness or who showed definite 
evidence of a pre-existing psychosis or severe neurosis 
were rejected on that evidence alone. Other rejections were 
made, not because of a single behavior abnormality or per- 
sonality defect, but only when an individual had displayed 
a number of such abnormalities, suggesting a grossly un- 
stable personality which had never been able to effect an 
adequate social adjustment. The same individual, there- 
fore, may be listed under several categories in table 4. 
It is of interest to note that of the 178 rejected, 100 
(56.2 percent) were considered to have had definite psy- 
chotic episodes prior to induction. Of these, 6 had had 
more than one previous mental hospitalization (2 men 
had each been committed to mental hospitals on three 
previous occasions , 2 had been treated with insulin shock, 
1 with electric shock, and 1 had received insulin shock 
followed by a prefrontal lobotomy. At the time of their 
previous hospitalizations, 22 were diagnosed as schizo- 
phrenic, 6 as manic-depressive, 1 as paretic, 3 as alcoholic, 
Length of service 
Number 
of men 
Percent 
Less than 10 days 
56 
11.2 
10 to 30 days 
46 
9.2 
1 to 3 months 
73 
14.6 
3 to 6 months 
73 
14.6 
6 to 12 months 
98 
19.6 
1 to 2 years 
87 
17.4 
2 to 4 years 
44 
8.8 
More than 4 years 
23 
4.6 
Total 
500 
100.0 
The distribution of the 500 men as to length of service 
is shown in table 2. As in previous reports by various 
authors, the short length of service of the majority of those 
who become mentally ill is emphasized. Thus 20.4 percent 
were hospitalized with service of less than 1 month, 49.6 
percent with less than 6 months, and 69.2 percent with 
less than 1 year. 
19 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 4.—Major reasons for the rejection for military service of the 178 men under study 
Reason for rejection 
Number 
rejected 
Percent 
rejected 
Previous hospitalization for mental illness 
38 
21.3 
Previous psychotic episodes (not hospitalized but under physician’s care) 
16 
9.0 
Previous psychotic episodes (no medical care received) 
46 
25.8 
Convulsive states 
7 
3.9 
Chronic alcoholism 
19 
10.7 
Severe psychoneurotic traits 
31 
17.4 
Mental deficiency 
22 
12.3 
Markedly peculiar personality 
22 
12.3 
Enuretic at time of induction 
14 
7.9 
Previous criminal record 
15 
8.4 
Inability to adjust in school 
50 
28.0 
Chronic behavior problem in community 
10 
5.6 
Illiterate 
3 
1.7 
Previous suicidal attempts 
7 
3.9 
Previously discharged from military service (bad conduct, inaptitude, and for neuropsychiatric defects) 
8 
4.5 
Previously rejected as unfit for military service 
3 
1.7 
Miscellaneous (recent pulmonary tuberculosis, severe birth injury with residual defects) 
2 
1.1 
while 6 were either unclassified or the diagnosis was not 
available. Of those hospitalized previously, 81 percent be- 
came ill again before they had served a year on active mili- 
tary duty. At the present time it is our opinion that the his- 
tory of a previous hospitalization for a mental illness, or 
the existence of any such illness of great enough severity 
to require prolonged psychiatric care or discontinuance of 
normal activities for any length of time, are adequate rea- 
sons for rejection for military service. 
It seems clear on the basis of other observations as well 
as this small study, that even with adequate social-service 
histories only some of those men who will develop a severe 
mental illness soon after their entry into military life can 
be detected and eliminated at the induction centers. We 
must acknowledge that as yet we have no very accurate 
means for complete evaluation of the potentials of the 
human personality. We cannot hope to identify all those 
who will at some time suffer a mental disability, any more 
than we can predict accurately which man will distinguish 
himself under the strain of some military emergency. 
There may be a ' breaking point” for every man, a point 
at which the personality retreats before the attacks made 
upon it and seeks refuge in the cloak of a psychosis or 
other mental disturbance. With our present skills and 
means of measurement such a "breaking point” can be 
foreseen in only a comparatively few men. Yet we should 
devote every energy to the elimination of those who will 
become incapacitated after only a short period of service. 
If one-third of these can be detected (35.6 percent in this 
study), the use of the social-service history would seem 
quite justified. 
Much of our emphasis during the early months of the 
war was on the problems of induction, and the psychiatrist 
worked to identify and eliminate the potential psychiatric 
casualty, and to facilitate his service discharge. These are 
important functions, but as the list of neuropsychiatric 
casualties increased and greater numbers of such men 
returned to civil life, we became increasingly aware of 
the problems incident to that return. Such problems are 
by no means solved by discharge alone, as the psychiatric 
patient is notorious for his tendency to require prolonged 
hospitalization, to suffer a recurrence of his illness, and 
in many cases to become a public charge. It is becoming 
increasingly important to turn our attention to the prob- 
lems of treatment and rehabilitation, hoping to aid him 
who has been mentally ill in making a satisfactory social 
adjustment that will enable him to maintain himself with- 
out constant resort to public aid. 
SUMMARY 
1. A study was made of 500 unselected psychotic Navy, 
Marine, and Coast Guard enlisted men admitted to St. 
Elizabeth’s Hospital, Washington, D. C., from January 
1942 to May 1944. 
2. Social-service data in each case were reviewed to de- 
termine how many of these men would have been rejected 
at the time of induction had such data been available then. 
3. On the basis of findings in the social-service histories 
178 (35.6 percent) of the 500 men would have been re- 
jected for military service. 
4. Of these 178 men, 100 (56.2 percent) were found 
to have had previous psychotic episodes prior to induc- 
tion, 21 percent having been previously hospitalized be- 
cause of a severe mental illness. 
20 Chapter 3.-THE VALUE OF THE SOCIAL SERVICE HISTORY 
5. It is believed that a social-service history would be 
a valuable adjunct to the psychiatric examination made at 
the induction center. 
6. The need for the early elimination of the potential 
psychiatric casualty is emphasized by the short period of 
service such patients have before their entry to a hospital 
(69.2 percent less than 1 year), the length of hospitaliza- 
tion required, and the great difficulties encountered in 
rehabilitation. CHAPTER 4 
PSYCHIATRIC SELECTION AT THE 
PRECOMMISSIONINC LEVEL' 
The problem of assembling and training ships’ crews 
for new naval construction resulted in the conversion of 
one of the naval training stations into a precommission- 
ing ship. Here were gathered ships’ crews for advanced 
training while waiting the completion and commissioning 
of their ships, the men coming from various naval sources, 
such as from training stations, from service schools, and 
from previous duty either ashore or in the fleet. 
With the change in function from that of training sta- 
tion a question arose concerning the need for continuing 
a psychiatric unit. There were good grounds for assuming 
that such a unit would be necessary, and that re-examina- 
tion of the precommissioning men would reveal many who 
were unfit because of neuropsychiatric defects. It is in- 
evitable that the screening procedure at the training sta- 
tions should make mistakes and pass on some unfit men 
to the fleet. Thus, of the recruits discharged for inaptitude 
when the station was a recruit training camp, about 15 
percent represented cases which were missed during the 
original screening examination and were referred to the 
psychiatrist later. 
In addition to the persons who are missed at the train- 
ing station level, there are some disorders which require 
a period of incubation before they are noticeable. This is 
particularly true owing to the increase of intrapsychic ten- 
sions in the green recruit when sea duty becomes imminent, 
as occurs when he is finally assigned to a ship’s crew. 
Finally, with many men coming from the fleet there in- 
evitably will be cases of service-connected disability such 
as combat fatigue, posttraumatic personality disorder, and 
traumatic epilepsy. 
In previous writings the authors2 discussed the need 
for such periodic re-examination. Experience demon- 
strated amply the pressing need for psychiatric selection 
at this level. 
The psychiatric program as finally evolved resembles 
that in practice at the recruit level with the exception of 
certain changes in standards, and in the procedures for 
separation from the service. It soon became evident that 
many of the cases of neuropsychiatric unfitness were fairly 
obvious ones which could be detected immediately upon 
the arrival of the men at the station, and it was decided 
after some experimentation to institute a psychiatric screen- 
ing procedure to which every man entering the station 
would be subjected. The shortage of personnel made it 
impossible to give each man a special psychiatric inter- 
view, so the men were tested by a paper and pencil test 
with only the high scorers on this test receiving a personal 
interview. 
An experimental run on over 1,000 cases showed that 
screening in this fashion would result in the detection of 
80 percent of the eventual casualties during the training 
period, while necessitating the interview of only a quarter 
of the incoming population. Only about 25 percent of the 
men tested score high on this test, and it is the function of 
the psychiatrist in a brief personal interview to separate 
among this 25 percent those who are true neuropsychiatric 
problems from those men who have been mistakenly iden- 
tified as such by the test. 
As a result of this interview men suspected of neuro- 
psychiatric defects are either sent to the observation ward 
for study preliminary to receiving a straight medical survey 
or a survey to limited shore duty, or they are sent on to 
duty for a trial period and reinterviewed later. Since most 
of these men have had some length of service in the Navy 
and represent quite an investment in terms of training, 
every effort is made to salvage as many for further service 
1 By Cecil L, Wittson, Commander (MC) U.S.N.R., and William A. 
Hunt, Commander H(S) U.S.N.R. 
JWittson, C. L. ; Harris, H. I. ; and Hunt, W. A. ; Evaluation of brief 
psychiatric interview. J. Psychol. 16:107-114, July 1943. 
22 Chapter 4.—PSYCHIATRIC SELECTION AT THE PRECOMMISSIONING LEVEL 
as possible. The granting of a medical survey for neuro- 
psychiatric disability is a serious matter and not to be 
taken lightly, and it has been the policy of this station to 
survey only those men who are obviously unfit and whose 
unfitness is clearly demonstrated by their social histories 
and by their record in the naval service. The procedure 
of investigation and observation are largely those which 
were in use when the training station was a recruit station, 
and which have been described elsewhere.3 The main dif- 
ference comes in the greater time and attention that must 
be given to the survey cases, and in the different method of 
disposition, because these cases now go through a regular 
board of medical survey rather than through the Aptitude 
Board. 
As only the most severe cases are admitted to the psy- 
chiatric ward directly from the screening examination, a 
heavier burden is thrown on trial duty, referrals, and con- 
sultations than was typical of the recruit program. This 
increases the necessity for giving ships’ officers general 
indoctrination into the necessity and operation of psychia- 
tric selection. Fortunately all officers arriving on the sta- 
tion spend the first week after their arrival in indoctrina- 
tion school where they are made familiar with the pre- 
commissioning program. As a regular part of the indoc- 
trination a member of the psychiatric staff delivers a lec- 
ture to the officers on the necessity for psychiatric screen- 
ing, recognition of common psychiatric cases, and the 
mechanics of referring such cases to the observation ward. 
This has resulted in excellent cooperation from the line 
and medical officers of the various ships’ details. 
As was typical of the procedure under the recruit train- 
ing program all patients in need of immediate hospitaliza- 
tion ate transferred to a naval hospital. Transfer to a 
hospital is also utilized for those who need medical treat- 
ment not available under present facilities, and when 
there is every indication that the administration of therapy 
would produce beneficial results, as likewise where the 
man’s difficulties are thought to have been aggravated by 
his naval service. This results in a relatively greater num- 
ber of hospital transfers than was necessary in the han- 
dling of recruits. Analysis of the cases handled demon- 
strates three sources from which they come and may be il- 
lustrated by case reports. 
CASE REPORTS 
Mistakes of Training Station Selection 
Case I.—A youth with a mental age of only 10 years, whose 
mental deficiency was further complicated by his illiteracy, could 
read only at a first-grade level. School and work records were 
poor. At the training station he was transferred to a school for 
illiterates. When he showed no progress after 5 weeks at this 
school, he was transferred here for assignment to a combat ship. 
Here he was unable to perform his duties as a crew member and 
was referred to the psychiatric ward by his ship’s medical officer. 
He was surveyed as a mental deficient. 
Case 2.—This man was unstable with a long history of mal- 
adjustment previous to enlistment. He once had gastric ulcers, 
and had been under treatment by his local physician for his 
"nervous condition.” A few days after his arrival at the training 
station he became very nervous and was sent to sickbay by his 
company commander. Here he was placed under sodium bromide 
sedation for the remainder of his recruit training, after which 
he was transferred to a precommissioning crew, where he was 
detected during the screening examination. He showed obvious 
signs of a severe anxiety state and was admitted to the ward for 
survey. 
Case 3.—A youth who had a history of occasional grand mal 
seizures previous to enlistment had been under treatment by his 
family physician. He concealed his condition at the induction 
center and later when he arrived at the training station. He had 
two mild seizures during his boot training and was referred 
each time to the sickbay for treatment. The epileptic symptoms, 
however, were not recognized and he was treated for syncope. 
He was detected during screening examination and was sur- 
veyed when the diagnosis of epilepsy was confirmed by the social 
history and by an abnormal electroencephalogram. 
Conditions in Which a Period of Incubation It Necessary 
Case 1.—This man was unstable with a history of mild 
anxiety before his enlistment. During his recruit training he was 
very anxious and depressed but did not seek medical attention. 
During the screening examination upon his arrival at the station 
his condition was detected, but it was thought to be simple 
nostalgia and he was given superficial therapy and sent to duty. 
By the end of 2 weeks a situational depression of considerable 
depth had developed accompanied by severe headaches and 
vomiting of a functional nature. He was surveyed. 
Case 2.—This man had a history of a suicidal attempt 5 years 
previously. He concealed his history when he was inducted. 
During his recruit training he became anxious and apprehensive 
but did not seek medical attention. Following recruit training 
he was sent to service school where it was necessary for him to 
seek medical attention for his condition. He was given sedatives 
for several days. His condition became aggravated and upon his 
transfer here he was immediately detected during the screening 
examination. He was exceedingly tense, anxious, and apprehen- 
sive, and confessed to a return of suicidal thoughts. He was 
transferred immediately to a naval hospital. 
Case 3.—This person was unstable with a history of extreme 
nervousness and maladjustment before enlistment. He had never 
sought medical attention in civilian life. He was detected dur- 
ing the screening examination at his recruit training camp and 
was admitted to its psychiatric observation ward. There his con- 
dition improved somewhat and he requested a chance to serve. 
As a result he was sent to duty. His condition became aggra- 
vated during a period at service school and upon his transfer 
here he was detected immediately during the screening exam- 
ination and referred to the psychiatric ward for survey. 
Service-connected Disabilities 
Case 1.—This man had received a fractured skull when tossed 
to the deck by the concussion of a shell explosion. He was hos- 
*Wittson, C. L.; Harris, H. I.; and Hunt, W. A.: Detection of neuro- 
psychiatrically unfit. U. S. Nav. M. Bull. 40;}40-}46, April 1942. 
23 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
pitalized for 1 month and then returned to duty. For a while he 
had headaches but these were infrequent and less severe with 
time. Six months later while at a shore station his headaches 
began to occur more frequently and with greater severity. Shortly 
after this he had two convulsive episodes. He was allowed to 
continue on duty but was under outpatient observation at a 
naval hospital when he was suddenly transferred here. He was 
detected at the screening examination, but until his health record 
could be checked and an electroencephalogram obtained he was 
sent to duty. Before this could be done, however, he had another 
seizure. He was transferred to a naval hospital. 
Case 2.—This young man’s ship had been torpedoed. While 
in the water he received severe internal injuries attributable to 
exploding depth charges. These necessitated his hospitalization 
for 6 months. He received attention for his physical injuries but 
no psychiatric examination was made. When he was physically 
sound again, he was returned to duty and sent here. He was de- 
tected in the receiving examination as tense, anxious and appre- 
hensive. Further observation showed him to be suffering from 
severe combat fatigue and he was transferred to a naval hos- 
pital. 
Case 3-—This youth’s ship was torpedoed while he was in his 
bunk. He escaped but spent 12 hours in the water before he 
was rescued. He was shipped back to the States and given a 
30-day leave. During the leave, insomnia, restlessness, anorexia, 
and terror nightmares developed, despite which he did not seek 
medical attention. At the end of his leave he was assigned to a 
new cruiser but during the shakedown cruise he found that his 
anxiety symptoms were aggravated, and that he was unable to 
sleep below decks. He asked for transfer from the ship and was 
sent here. His obvious anxiety was immediately noticeable dur- 
ing the screening examination. He was diagnosed as having 
severe combat fatigue and was surveyed to shore duty. 
Tables 5, 6, and 7 analyze the men separated from the 
service, surveyed to limited shore duty, or transferred to 
a naval hospital from this activity during the month of 
July 1944. Table 5 shows the relative percentages referred 
for disposition from various sources. It will be seen that 
the original screening examination is the largest source. 
The large numbers referred from other sources in part 
reflect our liberal trial duty policy. Table 6 lists the diag- 
noses established in the order of their frequency. Table 7 
gives the length of service of the men. It is significant that 
one-third of these patients had less than 4 months’ service 
in the Navy. 
The opportunity for the indoctrination of line officers 
in the principles of neuropsychiatric selection is one of 
the most important aspects of the selection work at this 
precommissioning station. The original neuropsychiatric 
selection program was instituted by a joint directive from 
the Bureau of Naval Personnel and the Bureau of Medi- 
cine and Surgery to the commanding officers of the vari- 
ous naval training stations. Unfortunately it was not pos- 
sible to instruct the line personnel of the Navy in the 
philosophy and practice of military selection at the time 
the program was instituted, and since the program was 
Table 5.—Sources of referral for cases separated from service, 
surveyed to shore duty or transferred to hospital July 1944 
Sources 
Percentage of 
total cases 
Screening 
32.0 
31.0 
22.0 
Main sickbay 
Detail sickbay 
Captain’s mast 
9.0 
4.0 
Self referral 
Chaplain 
1.0 
Classification officer 
.3 
Battalion commander 
.3 
Dental department 
.3 
Table 6.—Diagnoses established for cases separated from service, 
surveyed to shore duty or transferred to hospital July 1944 
Diagnosis 
Order of 
frequency 
Constitutional psychopathic state 
1 
Emotional instability. 
Inadequate personality. 
Schizoid personality. 
Paranoid personality. 
Psychoneurosis 
2 
Mixed. 
Anxiety. 
Hysteria. 
Situational. 
Psychasthenia. 
Unclassified. 
Traumatic. 
Fatigue 
3 
Combat. 
Operational. 
Mental observation 
4 
Posttraumatic cerebral syndrome 
5 
Epilepsy 
6 
Constitutional psychopathic inferiority 
7 
Without psychosis. 
Dementia praecox 
8 
Mental deficiency 
9 
Moron. 
Psychosis 
10 
Unclassified. 
Manic depressive. 
With psychopathic personality. 
Posttraumatic personality disorder 
11 
Left ear deafness, infection 
12 
Keratitis 
13 
Paralysis 
14 
Right facial nerve. 
Enuresis 
15 
Nystagmus 
16 
begun in naval training stations there was little under- 
standing of it among those in command at sea. The vari- 
ous ships’ officers’ impressions were formed largely 
24 Chapter 4.-PSYCHIATRIC SELECTION AT THE PRECOMMISSIONING LEVEL 
through whatever discussion appeared in public print, 
and this unfortunately often gave a distorted picture. Here 
at the precommissioning station where officers and men 
are gathered prior to their being assigned to new construc- 
tion it is possible for the ships’ officers to see neuropsy- 
chiatric selection functioning in relation to their own 
personnel problems. It is no longer an abstract question, 
but becomes a concrete matter of handling the disposition 
of men whose unfitness for sea duty becomes apparent to 
their officers during this final training program. Under 
these circumstances the line officer is getting new insight 
into the meaning of psychiatric selection through his di- 
rect participation in the functioning of the program. The 
response has been enthusiastic. 
There exist, however, many borderline cases of persons 
who are temperamentally unfit for military service and 
who are unable to adjust adequately to the demands of an 
efficient naval organization but nevertheless do not fall 
clearly into any medically diagnostic category. A man may 
be discharged by reason of medical survey only when a 
clear medical condition exists and a diagnosis can be es- 
tablished. Despite the fact that many of these borderline 
cases are not medical problems in the usual sense, they 
remain unfit for service and their unfitness becomes ap- 
parent the minute they undertake duty at sea. As a result 
once their unfitness is discovered, they are disposed of by 
transfer to another ship. In this way a floating population 
is set up which is transferred from ship to ship, finding 
no welcome anywhere. This has been observed here at this 
station where men have been on the psychiatric ward and 
sent back to duty because it was impossible to handle them 
by medical survey despite the psychiatrist’s personal opin- 
ion that they were unsuited for service. Regularly a few 
months later these men were seen once more at the pre- 
commissioning station in a draft from sea for assignment 
to another vessel. There is one group of approximately 6 
men; these are now in their third crew within 6 months. 
No one wants these men because of their unsuitability; 
yet it is impossible up to the present date to eliminate them 
through the channels of medical survey as they are not a 
medical problem. 
SUMMARY 
Nine months of neuropsychiatric selection at a precom- 
missioning level has shown the value of such a program. 
Many unfit men are found at this level and their elimina- 
tion is essential to an efficient fighting organization. No 
ship is better than the crew that fights it and a neuropsy- 
chiatric problem among her personnel strikes directly at 
her efficiency and morale. The importance of the men’s 
physical condition is recognized in the principle of phys- 
ical re-examination at regular intervals. Experience at this 
station would suggest that a regular psychiatric re-examina- 
tion would be of equal value and importance. 
Table 7.—Length of service of cases separated from service, sur- 
veyed to shore duty or transferred to hospital July 1944 
Length of service 
Percentage of 
total cases 
More than 1 year 
32.0 
10.0 
More than 6 months 
6 months or less 
7.0 
5 months or less 
4.0 
4 months or less 
11.0 
3 months or less 
25.0 
2 months or less 
10.0 
Less than 1 month 
.3 
Unknown 
.6 
25 CHAPTER 5 
THE MENTAL DEFECTIVE AND THE UNDER-AGE MAN 
IN THE NAVY* 
Probably one of the most difficult groups of individuals 
to be understood by the layman, and the most often mis- 
handled through such misunderstanding, is the mental 
defective group. Because their severe limitations are so 
frequently obscured by their age, and by their often aver- 
age and pleasing appearance, these individuals are com- 
monly considered merely "delinquents.” 
The world of the mental defectives is a simple world, 
due to the limitations of their abilities to learn new things, 
to comprehend what takes place about them, to retain and 
assimilate cultural stimulations, and above all to be able to 
be self-directive in a new setting. An attempt to force such 
an adaptation upon these individuals is made when they 
enter the service. The degree of difficulty resulting from 
the strangeness or unfamiliarity of this new setting, as well 
as the understanding of the officers or men in charge of 
them, determines to a great extent how they will adjust 
themselves to this new life and its demands. Because of 
the wide contrast between their simple civilian cultures 
and the complexity of a mechanized war, their adaptation 
to productivity for the armed forces is more or less a fail- 
ure. The amount of supervision and direction required by 
them is not commensurate with their output for service. 
Often the mental defective who has escaped recognition 
during the early part of his Navy career eventually be- 
comes a disciplinary case. He probably will respond to the 
mild discipline administered for his petty offense, both 
the offense and the purpose of the discipline being under- 
stood by him. Many times, however, other offenses com- 
mitted have childlike motivations, and since his own child- 
like reactions to the thwartings are stronger than any sense 
of duty that he could comprehend, he easily becomes a 
serious naval offender, chiefly AOL (Absence Over 
Leave) or AWOL (Absence Without Leave). His mis- 
fitness becomes an ever-present administrative problem, 
when he is retained in the service. The few who have not 
become involved in discipline might well be those whose 
assignments are yet quite simple and in line with their 
aptitudes. Acceptable efficiency on a low routine job must 
not presuppose a universal and versatile efficiency. 
The aim of this chapter is to present briefly some im- 
portant factors peculiar to the mental defective with the 
implications of these factors in the disciplinary handling 
of the individual. The almost parallel problem of the 
under-age offender in the Navy will also be considered. 
Mental deficiency is considered as a state of (1) social 
incompetence resulting from a state of (2) mental growth 
arrestment which has been (3) developmental in nature. 
When these criteria have been satisfied, a diagnosis of 
mental deficiency can be advanced. 
Psychometric test scores have tended to supplant the 
above criteria for mental deficiency. These scores must be 
handled and interpreted very carefully to be of any value. 
Among the many psychologic tools devised for the pur- 
pose of measuring the attributes of human beings, the 
tools that measure personality are gradually proving to be 
helpful. Similarly tools for evaluating individual social 
competence or social maturity have been developed which 
are useful in establishing the state of incompetence among 
the mentally deficient, mentally ill and delinquent. The 
Vineland Social Maturity Scale developed at the Depart- 
ment of Research, The Training School, Vineland, New 
Jersey, has been and is probably the most successful to 
date. This scale permits the measurement of social devel- 
opment from birth up to maturity, a 25-year range. The 
degree and kind of incompetence is measurable and ex- 
pressable in Social Age (SA) and Social Quotient (SQ) 
units. This tool offers a means of establishing the initial 
criteria of mental deficiency as well as a point of depar- 
ture for any psychologic problem of adjustment. 
•By H. Robert Otness, Lieutenant H(S) U.S.N.R. 
26 Chapter 5.—THE MENTAL DEFECTIVE AND THE UNDER-AGE MAN IN THE NAVY 
A detailed item analysis was made of the social com- 
petence (Vineland Social Maturity Scale) and of the 
mental competence (Wechsler-Bellevue Scale of Intelli- 
gence) of 35 mentally-defective enlisted men, many of 
whom were naval offenders. The ages of the men in this 
group ranged from 16.5 to 38.8 years. The diagnosis were 
not made on the fallacious "I. Q.,” but were based on the 
criteria involved in the total definition of mental de- 
ficiency. 
SOCIAL COMPETENCE 
Social competence refers to the capacity of the indi- 
vidual to carry on the minimum essentials of everyday liv- 
ing without supervision or direction of others. This inde- 
pendence develops with and is measured according to 
progressive age levels, as is the development of intelli- 
gence. On the Vineland Social Maturity Scale this briefly 
includes: (1) Self-help items (general, eating, and dress- 
ing); (2) self-direction; (3) occupation; (4) communi- 
cation; (5) locomotion; and (6) socialization—all com- 
mon elements and minimum essentials to any individual’s 
development to complete adult maturity or independence. 
The analysis of the social maturity of the 35 mental 
defectives revealed that there were 8, or 23 percent, who 
did not carry out the bathing routine (not just showers) 
without the aid of supervision of wife or some member 
of the family; 2, or 6 percent, who could not comb and 
part their own hair; and 28, or 80 percent, who required 
assistance in completing the self-dressing routine ( several 
were unable to tie their own neckties and neckerchiefs). 
All of these minimum essentials are perfected by normal 
children in from the 8th to 13th year. 
Of this group 12, or 35 percent, were not trusted to go 
about their own home towns unaccompanied by parents, 
wife, or other trustworthy member of the family; and 
there were only 9, or 26 percent who were capable of 
going outside the limits of their home town to relatively 
unfamiliar places and of being responsible for their own 
arrangements. None of the 35 have traveled alone to re- 
mote towns or places. None was permitted to go out un- 
restrictedly at night and 29, or 82 percent, required su- 
pervision during the daytime. 
Eight, or 23 percent, were unable to tell time to a 
quarter-hour accuracy. Thirty-four, or 97 percent, were 
able to perform routine household tasks under their own 
responsibility, while only 19, or 54 percent, reported work 
done about the neighborhood that merited payment, such 
as gardening, household tasks, or simple farm jobs. Twen- 
ty-two, or 62 percent, were performing some simple crea- 
tive work on their own initiative such as making simple 
useful articles, doing simple repairs, gardening, raising 
pets, or sewing. Only 3, or 9 percent, were performing 
responsible routine chores such as family chores, assisting 
in housework, or gardening. Thirty-four, or 97 percent, 
had not been gainfully employed at such occupations as 
servants, farmhands, laborers, or factory help, usually ex- 
pected of boys and girls of 18 years of age. 
Thirty-two, or 91 percent, of these individuals were 
able to write or print legibly their first name or full name 
without using copy, while 23, or 65 percent, were unable 
to write simple words from dictation, and 33, or 94 per- 
cent, were unable to write well enough to prepare brief 
notes to friends or relatives. Only one was capable of 
making a phone call without help. 
Only 20, or 57 percent, were capable of handling money 
and making simple change in the purchase of useful arti- 
cles, and had had experience in doing so; 31, or 88 per- 
cent, did not select or purchase minor articles of clothing 
such as socks, underwear, shoes or shirts, but had this 
done for them by mother or wife. 
Thirty-one, or 88 percent, did not have their own 
spending money, amounting to a dollar or so per week, 
to spend on their own initiative or discretion. Inability to 
make simple change in small amounts is a not uncommon 
finding. 
Five, or 15 percent, were unable to participate in simple 
table games observing rules; and 10, or 29 percent, did not 
engage in cooperative play such as baseball. 
Sixteen, or 46 percent, still held to the belief in Santa 
Claus, and spoke enthusiastically about his reality. 
These men are still small children in their capabilities, 
and their adjustment to the naval service has resulted in 
numerous administrative problems. 
The social age and social quotient were calculated on 
each of these individuals. The range of Social ages was 
from 6.3 years to 14.4 years, with social quotients from 
31 to 69. These individuals, despite their real-life ages 
(range 16.5 to 38.8 years), are children ranging from 
childhood to preadolescence in degree of social maturity 
or independence, even with due consideration given to 
any influence a subcultural background may have had. 
MENTAL COMPETENCE 
A detailed item analysis was made of the quantity and 
quality of mental capacities measured by an individual in- 
telligence test, but the findings are not reported here in 
detail. Mental incompetence also was revealed in all the 
cases on the Weschler-Bellevue Scale of Intelligence. 
Another group causing numerous administrative prob- 
lems is the under-age enlistment group. These youths have 
falsified their ages, and sometimes their names, but be- 
cause of some physical precociousncss have been believed 
and have been taken into the Navy. 
27 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 8.—Social maturity and mental competence of 33 mental defectives 
LA (Life 
age) 
SA (Social 
age) 
SQ (Social 
quotient) 
MA* 
(Mental age) 
IQ (Intelligence 
quotient) 
Range 
Mean 
Mode 
16.5-38.8 
22.68 
18.0 
6.3-14.4 
9.93 
10.5 
31-69 
47.79 
52 
6.0-10.0 
8.59 
9.5 
35-69 
56.43 
55 
* Weschler, D.: The Measurement of Intelligence. The Williams & Wilkins Company, Baltimore, Md., 1939, p. 122. 
The study of the development of intelligence from 
birth to its maturity shows that intelligence reaches its 
growth at about 14 to 16 years of age, as measured by the 
best standardized tests, although there may be improve- 
ment in the quality as maturation goes ahead. Hence for 
the normal under-age enlisted man it is highly probable 
that he reached his normal peak of mental development 
at 16 and will change but little in development when of 
adult age. Although he is poorly experienced for adult 
responsibility because of his youth, he might well be re- 
sponsible for most of his actions as a naval offender from 
the intelligence angle, providing there are no other psy- 
chologic anomalies of behavior and development present. 
In the normal well-adjusted 16-year-old lad, social ma- 
turity or social competence is quite apt to be at his nor- 
mal life-age expectancy level, or even slightly above, pro- 
viding there are no other complicating factors or circum- 
stances. 
With the mental defective, and especially with the 
group in whom the causation is endogenous (since few 
exogenous types enter the Navy), the picture is quite dif- 
ferent. Intelligence here develops more slowly and reaches 
its low peak of maturity at different life-age periods. The 
peak of intelligence growth often hovers between the 
mental ages of from 9 to 12 years, and often below these 
age levels. Even with adult-life ages the mental ability 
has remained that of a child of the preadolescent level of 
development. Despite his real-life age, this level of intelli- 
gence and comprehension limits his ability to benefit or 
assimilate new experiences thrust upon him, when these 
experiences are at an adult level of expectation. It is not 
surprising that this is difficult for the layman to under- 
stand, because these mental defectives appear so mature 
physically, strong and often good looking, and yet are 
children of from 6 to 10 years mentally and in experience. 
Similarly the social maturity or social competence of these 
individuals reveals that they are living and adjusting as 
children in an adult situation. With the conflict that re- 
sults when demands of the adult or preadult levels are 
thrust upon children, the reactions are usually failure, dis- 
interest and escape to a simpler level of adjustment. This, 
also, often is interpreted by the layman as planned de- 
linquent behavior and severe discipline is given. 
From this brief description the following questions 
might be raised: 
1. As the Navy does not desire to take into the service 
normal boys under the age of 17 years, is it justified in 
retaining in the service mental defectives whose abilities 
are those of children much below that age? 
2. The mental defective who enters the Navy offers to 
the service the best that he has. Since this "best” is too 
little to be useful to the Navy and of a quality which the 
Navy neither needs nor wants, should he be disciplined 
for this shortcoming over which he has no control? 
3. Since mental deficiency and the resulting incompe- 
tence are inherent in the mental defective, long confine- 
ment as part of a disciplinary measure will not change the 
abilities to the extent of making him useful in the Navy. 
Should this not be considered in dealing with mental de- 
fectives who are given courts-martial with confinement 
and possible restoration to duty? 
4. The normal under-age enlisted man who becomes a 
naval offender may possibly be granted clemency on ac- 
count of his age, but being of normal intelligence and 
competence at his age level, might not discipline 
strengthen him and improve his maturity for the service? 
5. Since age, intelligence, personality and physique 
are so often misleading in evaluating men, does not social 
maturity become a very important psychologic considera- 
tion? 
28 CHAPTER 6 
SUBNORMAL INTELLIGENCE IN THE MALADJUSTED 
NAVAL TRAINEE’ 
PROBLEMS IN RECOGNIZING LOW INTELLIGENCE 
One of the chief functions of the neuropsychiatric units 
at naval training centers is to separate the inapt and mal- 
adjusted individual from service as expeditiously as possi- 
ble. Several articles have been written outlining the 
programs, problems, and procedures of these units (2) 
(6) (9). One of the duties of the psychologist at these 
units is the supervision and administration of psycho- 
metric examinations. He thereby becomes acquainted with 
the situations where low intelligence is associated with 
maladjustment. 
The purpose of this chapter is to demonstrate the extent 
to which subnormal intelligence occurs in the cases con- 
sidered unsuited for service, and further, to point out the 
tendency to overlook this factor in populations where it 
is presumably important. 
The most apparent cases where maladjustment is due 
to intellectual limitations are those of the mental defec- 
tives. Although all who are obviously defective are re- 
jected at naval recruiting or induction centers, a certain 
percentage of less obvious defectives reaches the naval 
training centers. Of all the recruits discharged from the 
centers as neuropsychiatrically unfit, the proportion that 
is definitely feebleminded is small. The monthly average 
of mental defectives at the U. S. Naval Training Center, 
Sampson, N. Y., has ranged from 3 to 7 percent of those 
discharged for psychiatric reasons. A comparison of these 
figures with those obtained earlier in the war suggests 
that the screening at induction centers and recruiting sta- 
tions improved. In the early months of 1942 twenty-seven 
percent of the men discharged from the U. S. Naval 
Training Station at Newport, R. I., were classed as mental 
defectives (9). Though these figures are not directly 
comparable,2 the trend is apparent. 
Now, let the much larger group of cases that are not 
definitely defective but are of subnormal intelligence be 
considered. In the writer’s experience as a psychologist at 
naval training centers several thousand discharged cases 
have been reviewed. Certain facts emerging from this ex- 
perience are: (1) There is an unduly high proportion of 
cases of subnormal intelligence; (2) there is a widespread 
failure to recognize the extent to which the factor of low 
intelligence may be operative in maladjustment; and 
(3) low intelligence is not readily detected during recruit 
training. Data supporting these statements is given in the 
following discussion. 
In confirmation of the first point the intelligence levels 
of 2 groups of dischargees have been ascertained, using 
2 separate measures of intelligence. The subjects in the 
first group numbered 101 and represented the complete 
run of unfit recruits discharged during 6 consecutive ses- 
sions of the aptitude board. For this group the Kent Bat- 
tery was used. This is a brief, individual intelligence test 
which has had wide use at naval training centers. Its use 
has been described by Hunt, Lewinski, and others (3) 
(4) (3). Median mental age on the battery was used as 
a measure of intelligence level. The results are shown 
graphically in figure 1. In this figure the distribution of 
intelligence of the experimental group is contrasted with 
that expected in the normal population. For distribution 
of intelligence in the normal population, interpolation 
from the figure given by Wechsler ((7), figure 1, page 
30) has been made. The validity of this comparison is 
supported by the study of Lewinski, in which he found a 
correlation of -|-0.727 between the Kent and Wechsler 
Bellevue scales (3). Examination of the figure shows that 
differences at any mental age level are gross. The neuro- 
JBy Minter M. Jackson, Lieutenant Commander, H (S) U.S.N.R. 
2 There were slightly different standards in that the Newport figure in 
eluded some cases with mental ages between 10i/2 and 11 years. The Samp 
son figure includes only those with mental ages of loy2 and below. 
29 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
psychiatric group has a strikingly high proportion of cases 
in all of the subnormal groups. 
One might assume that if all obvious cases of low in- 
telligence were excluded, neuropsychiatric cases would not 
show disproportionate weighting in the subnormal levels. 
To show that even this is not the case, another group was 
chosen. In this group the General Classification Test 
scores of 98 unfit recruits who also were given discharges 
were examined. Only those who had been referred to the 
neuropsychiatric unit after they had first completed a pe- 
riod of recruit training were considered. It is important 
to note that all of those who had appeared definitely de- 
fective or obviously unfit had previously been eliminated 
in the receiving-line examination. The General Classifica- 
tion Test is a written intelligence test given to all naval 
recruits for purposes of classification. The test is scored so 
that the average score in the normal recruit population is 
50. The standard deviation is 10. The average score for 
this second group of dischargees was 46. While the dif- 
ference between this and the average recruit score is not 
as marked as differences shown by the first group, yet 
nevertheless the difference is statistically significant. The 
critical ratio of the difference between the scores of the 
selected group and the scores expected from the normal 
recruit population is 3.78. In examining the distribution 
of scores it was found that over 50 percent of the group 
made scores of 45 or below. This group comparison would 
show that even after the brief psychiatric screening had 
eliminated the most obviously unfit, the group of neuro- 
psychiatric dischargees scores lower on intelligence tests 
than the normal recruit population. 
Additional evidence of low intelligence as a factor in 
maladjustment can be cited from other sources. Some re- 
sults obtained by the Special Tests Division of the Classi- 
fication Department at one training center (1) are briefly 
summarized next. This office set up a psychological clinic 
to improve the placement of men in service. Individuals 
failing to adjust were referred to this clinic from various 
activities at the center and the most severely maladjusted 
cases in turn were referred to the neuropsychiatric unit for 
examination. Of those referred to that unit and subse- 
quently discharged, two-thirds had made marks of 32 or 
below on the General Classification Test. In all, 95 per- 
cent of this low General Classification Test group were of 
subnormal intelligence. 
Interviewing the recruits making low marks on the 
General Classification Test has been found to be a valu- 
able supplement to the psychiatric screening procedures. 
In recent months at this center the Classification Depart- 
ment has administered a written personality inventory to 
the lowest scoring group on the General Classification 
Test. Cases indicating either a number of somatic com- 
plaints or a single symptom (such as enuresis) considered 
significant by naval criteria are referred to the neuro- 
psychiatric unit. Approximately two-thirds of those re- 
ferred are found to be definitely unsuited for service. It 
is of interest to compare this figure with that obtained from 
the group of men placed on trial duty following the initial 
psychiatric interview. At the screening interview individ- 
uals having complaints of a psychosomatic nature are 
placed on trial duty and are subsequently interviewed. In 
comparing this group with the low General Classification 
Test group over a period of several months a higher pro- 
portion of the low General Classification Test group was 
found to be unfit. One of the principal differences in the 
two groups was that the low General Classification Test 
group contained for the most part subjects of subnormal 
intelligence. 
These results show that the neuropsychiatric dischargees 
as a group are of lower intelligence than the normal pop- 
ulation, but further analysis is needed to demonstrate the 
type of cases that is responsible for this difference. As 
stated elsewhere, the purpose of the examination at the 
psychiatric unit is to determine whether or not the indi- 
viduals concerned are suitable for naval service. In some 
instances, cases may be discharged where unsuitability is 
demonstrated, yet a psychiatric diagnosis is not established. 
LNORMAL 
r POPULATION 
|*N.P. DISCHARGEES 
MENTAL AGE CEV££ 
Figure 1. 
30 Chapter 6.-SUBNORMAL INTELLIGENCE IN THE MALADJUSTED NAVAL TRAINEE 
Analysis of these cases is nevertheless fruitful as the rea- 
sons given for discharge represent the cumulative opinion 
of two or three psychiatrists, along with supportive mate- 
rial such as psychologic tests, social history, and company 
commanders’ reports. Of all neuropsychiatric discharges 
the largest group by far is that termed personality disorder, 
in which the primary feature is inadequate personality. 
Psychiatrists most frequently term such cases as generally 
inadequate. Frequently allied to this descriptive term are 
those of emotional instability and emotional immaturity, 
dullness, little drive, nostalgia, and poor integration. In 
the majority of such cases there were a number of somatic 
complaints for which no organic basis has been found. 
These complaints may be of recent origin and may have 
been precipitated by separation from the home environ- 
ment. The part of the body to which these complaints are 
referable is usually one in which the subject had experi- 
enced minor distress previously. Concomitant with the 
other spheres of inadequacy exhibited, there is often poor 
motivation for the service. 
If the groups which were tested are considered and 
analyzed in terms of diagnosis or reason for referral, cer 
tain relationships between intelligence and diagnosis are 
readily apparent. Of the group that had been termed in- 
adequate personality practically all had subnormal intelli- 
gence. In the majority of cases the diagnosis was estab- 
lished independently without knowledge of psychometric 
results. Of the cases diagnosed psychoneurotic, the major- 
ity had normal or superior intelligence. To illustrate this 
relationship the diagnoses in portions of the General Clas- 
sification Test group previously mentioned might be 
analyzed and those that made scores of 60 or above com- 
pared with those making marks of 40 or below. (To clarify 
the comparison cases of neurological disorder, epilepsy, 
migraine, and schizoid individuals, as well as one mental 
defective, were eliminated.) In the high group, 80 per- 
cent of the cases was considered neurotic or reported to 
have anxiety states. One was discharged because of a per- 
sonality disorder, emotional instability. None in the group 
was labeled as an inadequate personality. In the group 
making marks of 40 or below, 21 of 24 cases were termed 
personality disorders and 3 were classed as psychoneurotic. 
Of the 21 personality disorders, 17 (or 81 percent) were 
considered as inadequate, 3 as emotionally unstable, and 
in one case it was not certain whether schizoid features or 
those of inadequacy were more important. Of the 3 neu- 
rotics in the low group, 2 were cases of conversion hysteria. 
The foregoing discussion might be summarized by stat- 
ing that two separate measures of intelligence show a 
heavy weighting of neuropsychiatric discharges in the dull 
intelligence group. The majority of such cases fit into a 
category described as inadequate personality. 
If low intelligence is an attribute of such a large num- 
ber of cases unsuited for service, then one might assume 
that it is a factor which could easily be recognized by 
those without special training. This is not so. 
The question of whether or not a recruit is making a 
good adjustment in training is frequently referred to his 
company commander. The company commander supervises 
and observes the recruit from the beginning of training 
through graduation. He observes him in all phases of his 
training activities. Replies to questionnaires about indi- 
viduals on trial duty status from the neuropsychiatric units 
are given by the company commander. Most training cen- 
ters have made extensive use of such questionnaires. The 
questionnaire used at this center refers to two aspects of 
behavior which were considered to serve as indicators of 
subnormal intelligence. One question is: "Does he learn 
easily?” The answer to this question for men who had 
made below 32 on the General Classification Test has been 
analyzed. In a group of 547 cases making below 32 in the 
General Classification Test, only 121 or 22 percent were 
noted as not learning easily. Yet a separate study (i) has 
shown that 95 percent of those making such scores were 
below the range of normal intelligence. As regards the 
second aspect of behavior in the same group only 22 per- 
cent was noted as being awkward in drill. 
Learning ability generally has been found to correlate 
highly with intelligence test scores. Many studies upon this 
relationship have been made and, indeed, in defining the 
concept of intelligence many use learning as one basic part 
of their concept. However, it was observed here that there 
was little relationship between the judgments of learning 
in recruit training and intelligence test scores. Company 
commanders’ reports were analyzed for a group of 888 
cases which were referred to the psychologist for psycho- 
metric study. The Kent median mental age was obtained. 
The group was composed of men making below 32 on 
the General Classification Test so that practically all of 
the distribution falls below the average intelligence range. 
(The mental-age range was from 9 years to 14 years, and 
the mean mental age for the distribution was 10.7. The 
correlation (bis. r) between reports of learning and intel- 
ligence was .020±.030. Statistically there was no signi- 
ficant relationship between reports of learning and intelli- 
gence. This corresponds closely to the findings of Wheeler 
et al. (8) in which a bis. r of .09±.04 was obtained for 
a similar group. 
It might also be expected that reports of awkwardness 
in drill in a group of subnormal intelligence would show 
some relationship to intelligence test scores. However, in 
a similar group of 918, the correlation (bis. r) between 
Kent mental age and the report of "not awkward in drill” 
was .067±.030. (Mental age range 9 to 14 years and 
31 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
mean mental age 10.7). Once again there was no signi- 
ficant correlation between intelligence test scores and re- 
ports of awkwardness. 
In an effort to determine more exactly the conditions 
under which a recruit w 1 observed, all company com- 
manders in one regiment were interviewed. In the inter- 
view the following questions concerning the replies made 
to the questionnaire were presented; (1) Whether or not 
the reports were based upon first-hand observation of the 
men in question; (2) in what situations were their obser- 
vations most frequently made; and (3) what aspects of a 
recruit’s behavior determined their decisions as to his 
learning ability? 
In regard to the first question the majority stated their 
reports were based upon first-hand impressions or else 
these impressions were supported by those of the assistant 
company commander. As to the second question, the ma- 
jority stated that the principal situation in which observa- 
tions were made was on the drill field. Other situations 
frequently named were conduct on work details, in the 
classrooms, and while on guard duty. Answers to the third 
question are related closely to the second. Since most ob- 
servations were made upon behavior on the drill field, the 
most frequent signs of learning difficulties were slowness 
or failures to properly carry out the orders given. Other 
characteristics of a recruit’s behavior frequently cited as 
determiners in judgments were the type of questions 
asked, whether or not he kept his gear in an orderly man- 
ner, and his personal neatness and military bearing. 
Certain conclusions may be made in regard to judg- 
ments of a recruit’s learning ability: (1) Most reports are 
based on observation of the recruit on the drill field; (2) 
observed slowness and failures in executing commands 
given on the drill field were not related to intelligence in 
the group studied; and (3) if an individual of subnormal 
intelligence is alert, of neat appearance, and if he does not 
expose his intellectual limitations by asking questions, his 
low intelligence will most probably not be detected while 
in training. 
A general failure to note deficiencies in intelligence is 
also shown by various staff officers who refer recruits for 
examination. Aside from those recruits noted in the psy- 
chiatric screening interview, the second most common 
source of referral is from the medical dispensaries. Analy- 
sis of the examining psychiatrist’s reports on referral sheets 
shows that the majority of inadequate individuals of sub- 
normal intelligence are referred because of persistent 
somatic complaints for which no organic basis has been 
found. In the group that is of subnormal intelligence it is 
relatively rare that deficiencies in this part of the indi- 
vidual’s personality are noted. The same statement holds 
true in regard to those referred by chaplains and other 
officers. 
SUMMARY 
An unduly high proportion of subnormal intelligence 
is found among the maladjusted recruits who are subse- 
quently discharged from service for neuropsychiatric rea- 
sons. This is true even when mental defectives are ex- 
cluded. Two group studies are reported in which the 
greater incidence of low intelligence among dischargees 
is shown. Other evidence corroborating these studies is 
also given. Cases accounting for the increased weighting 
at subnormal levels are most frequently termed inadequate 
personalities and low intelligence therefore appeal's to be 
one of the more constant attributes of such cases. 
Even though low intelligence would seem to be an im- 
portant factor in adjustment failures, it is seldom recog- 
nized. When inadequates of subnormal intelligence are 
referred to the neuropsychiatric unit, the factor of low in- 
telligence is not often noted. Also, in a group of cases 
where 95 percent was of subnormal intelligence, only 22 
percent was noted as learning slowly by the company com- 
manders. If low intelligence could be recognized with any 
degree of accuracy one might expect some correlation be- 
tween reports of recruits’ learning and intelligence. How- 
ever, analysis of a large number of cases shows that there 
is no significant relationship between reports made of 
learning in recruit training and intelligence. 
REFERENCES 
1. Bernard, M. W.: One thousand inadequate'personalities. 
(Unpublished study.) 
2. Gerstle, M., Jr., Wagner, R. L., and Lodge, T.: Inapt 
naval recruit. U. S. Nav. M. Bull. 41: 480-491, Mar. 1943. 
3. Hunt, W. A., Wittson, C. L., Harris, H. I., Solomon, 
P., and Jackson, M. M.: Psychometric procedures in de- 
tection of neuropsychiatrically unfit. U. S. Nav. M. Bull. 
41: 471-480, Mar. 1943. 
4. Hunt, W. A., Wittson, C. L., and Jackson, M. M.: Selec- 
tion of naval personnel with special reference to mental 
deficiency. Am. J. Ment. Deficiency 48: 245-252, Jan. 1944. 
5. Lewinski, R. J.: Performances of naval recruits on Kent oral 
emergency test and verbal battery of the Bellevue Wechsler 
adult intelligence scale. Am. J. Orthopsychiat. 13: 138-140, 
Jan. 1943. 
6. Southworth, F. C, Jr., Boshes, L. D., and Lewinski, 
R. J.: Neuropsychiatry at Great Lakes Naval Training 
Center. Dis. Nerv. System 6: 5-17, Jan. 1945. 
7. Wechsler, D.: Measurement of Adult Intelligence. 2d edi- 
tion. William Wood & Company, Baltimore, Md., 1941. 
8. Wheeler, J. A., Jr., Williams, S. B., Drummond, W. A., 
Jr., and Harris, J. D.; Experiences in use of Kent battery. 
U. S. Nav. M. Bull. 43: 44-45, July 1944. 
9. Wittson, C. L., Harris, H. L, Hunt, W. A., Solmon, 
P. S., and Jackson, M. M.: Neuropsychiatric selection of 
recruits. Am. J. Psychiat. 99: 639-650, Mar. 1943. 
32 CHAPTER 7 
PSYCHOSES IN NAVY INDUCTEES WITH LESS 
THAN FIFTEEN DAYS ACTIVE DUTY* 
NEED FOR EARLY ELIMINATION OF 
POTENTIALLY PSYCHOTIC 
Only a comparatively small number of psychiatric casu- 
alties were treated near battle areas and returned to full 
duty status. who treated such casualties in the 
North African theatre were able to send fairly large 
numbers of neurotic individuals to limited duty, but rec- 
ommended only a very small number for further participa- 
tion in actual combat activities. Psychotic cases were all 
returned home for hospitalization and eventual discharge. 
As has been pointed out many times the man who must 
be hospitalized because of a mental illness is not only one 
of the most difficult of medical problems, but is in addi- 
tion a military and social responsibility of no little degree. 
The man aboard ship or on land who succumbs to a ner- 
vous ailment becomes at once an element destructive of 
group morale, as in him his companions see an intensified 
reflection of their own fears and insecurity. The psychiatric 
casualty, therefore, must be quickly evacuated, and in most 
instances, must travel far into the interior before adequate 
facilities for his care can be provided. 
Complete rehabilitation for military service is as yet the 
exception rather than the rule, and the majority of neuro- 
psychiatric patients receive medical discharges after pe- 
riods of hospital care usually exceeding in duration those 
given to any other type of patient because of the tendency 
toward chronicity and recurrence of mental illnesses. Dur- 
ing the years since 1918 there has come an increasing reali- 
zation of the financial cost, to say nothing of the personal 
tragedy of neuropsychiatric casualties. We have learned 
that a mental illness is sixteen times more likely to result 
in permanent disability than are other diseases (i) and 
that each such case from World War I has cost the country 
about $30,000 to the present time. In June 1940 there 
were 33,016 neuropsychiatric patients in 27 Veterans’ 
hospitals in the United States, forming over 50 percent of 
all beneficiaries under treatment in all of the 179 Vet- 
erans’ hospitals then operating (2). 
Such facts assume greater significance when we realize 
that a man suffering from a neuropsychiatric disorder tends 
to break down comparatively early in his military career, 
and hence has in many cases contributed relatively little as 
a member of his service group. An analysis of patients 
discharged from an Army camp for neuropsychiatric rea- 
sons showed that 50 percent were disabled in the first 
month of service, 75 percent in the first 2 months, and 97 
percent within 6 months (3) . In such cases the expense of 
the man’s training and maintenance is completely wasted, 
while his disability interferes with the training of others, 
is destructive of morale to a considerable degree, and be- 
cause of its slow recovery rate, prolongs the use of hospi- 
tal beds that are greatly needed for other casualties. 
Finally it is well known that the individual who is men- 
tally ill tends to remain a liability after his discharge from 
the service. As yet we have no satisfactory methods of 
treatment whereby the psychiatric casualty may be re- 
turned to arduous duty without the greatest likelihood that 
his illness will recur; he is therefore generally looked upon 
as an irreparable liability, an attitude unfortunate for phy- 
sician, patient, and all others concerned. 
The answer to this problem would seem to be the elim- 
ination of the potentially misfit from the induction line. 
Although this is easily said and has been emphasized by 
numerous writers, the importance of the problem is not so 
well recognized in lay and civilan groups as in medical or 
military centers. As a war progresses greater numbers of 
men are called to service, and at the same time men are 
reclassified and many previously rejected may be calldd to 
•By Otto Allen Will, Jr., Lieutenant (MC) U.S.N. 
33 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
duty as induction standards are lowered. It then becomes 
necessary to learn more efficient methods of eliminating 
the potential psychiatric casualty, and to make clear to the 
public the need for such elimination. 
There are few objective tests that may be applied to de- 
termine the stability of a personality, and selection must be 
made largely on the basis of the examiner’s rather sub- 
jective impression of the candidate for military service, 
usually the result of an interview lasting only a very few 
minutes. The examiner’s difficulties are further com- 
plicated by the fact that the inductee may very well wish 
to conceal evidence of past social maladjustments or of 
mental illness, because of feelings of shame. Such selection 
could be facilitated greatly if social service data were 
available on the inducted men (7). However even with 
adequate social studies there would still be considerable 
divergence of opinion concerning which factors or com- 
bination of factors should be considered of sufficient sig- 
nificance to justify rejection from military service. 
In reviewing the histories of men who have suffered 
mental breakdowns while on duty one is impressed by 
the frequency of various evidences of past inability to ad- 
just socially and of emotional instability and immaturity. 
Such men could be rejected by examining boards if more 
adequate histories were available and more careful studies 
made. An objection commonly raised is that we do not 
have an adequate control group as we do not know how 
many men making a satisfactory military adjustment have 
in their backgrounds many of the same undesirable traits. 
An interesting study considering this point has been made 
recently of Army patients (4). 
The Navy in the past has followed the policy of sur- 
veying men disabled at any time by nervous ailments, and 
that policy is still pursued, with the exception of the ef- 
forts that are being made to rehabilitate for military duty 
men who have suffered temporarily and minor nervous 
disabilities as the result of prolonged military operations. 
All cases of psychoses were surveyed from the service, 
such casualties eventually being sent to the U. S. Public 
Health Service Hospital at Fort Worth, Texas, or to St. 
Elizabeth’s Hospital, Washington, D. C. 
During the 10 months from 1 January to 1 November 
1943, 1,022 service cases were admitted to St. Elizabeth’s 
Hospital, the majority having been diagnosed as psychotic. 
All of these men had been treated previously at one or 
more Navy hospitals. These 1,022 patients were analyzed 
to determine the length of active duty each man had be- 
fore his first admission to the sick list with the illness that 
caused his eventual transfer to St. Elizabeths. The results 
are shown in table 9. 
Of this group 53.3 percent broke down during the first 
Table 9.—1,022 patients (Navy, Marine, Coast Guard, few 
Army) admitted at St. Elizabeth’s Hospital 1 January, 1943 to 
1 November, 1943 
Number 
of cases 
Percent 
Time of active service before first admission 
to sick list because of present disability 
150 
14.6 
Less than 15 days 
223 
21.8 
More than 15 days, but less than 3 months 
173 
16.9 
From 3 to 6 months 
215 
21.1 
" 6 " 12 ” 
138 
13.5 
1 " 2 years 
123 
12.1 
Over 2 years 
1,022 
100.0 
6 months of military service, while 74.4 percent were hos- 
pitalized within the first year. 
It was decided to study in some detail the group having 
less than 15 days of active duty, as it was believed that in 
this brief period of service, the most important factors 
operative in causing the individual’s illness are the es- 
sential weaknesses of his own personality structure, re- 
vealed by exposure to the aggressive life of a training 
camp. Within the 15-day period any unusual traumatic 
factors (such as great fatigue) can scarcely be operative, 
except the influence of homesickness and the difficulties 
incident to a necessarily rapid adjustment to military life. 
It would seem that men breaking down within such a 
short period of time must have had well established per- 
sonality defects, which, had they been known, would have 
led to their rejection by the induction board. 
In order that the group might be as nearly homogeneous 
as possible, only noncommissioned white males were 
chosen. This left for study 100 white noncommissioned 
men having had less than 16 days of active duty prior to 
their admission to the sick list and admitted to St. Eliza- 
beth’s Hospital over a 10-month period. As a control 
group, 100 hospital corpsmen were studied. These men 
had been in the Navy varying lengths of time (average 
I2y2 months), but all had successfully completed their 
training, and made a satisfactory service adjustment. Study 
of the patients was made by means of the usual rather ex- 
tensive psychiatric history, supplemented by data obtained 
by social workers. A condensation of this form was used 
in studying the control group; however no social service in- 
vestigation was made of the controls. The purpose of the 
questioning was carefully explained to the control group; 
they were not individually interviewed, and their names 
were not attached to the questions. 
An attempt was made to include only those items which 
might readily be determined by social workers or by a 
physician in a hasty interview. The following outline in- 
cludes certain elements which are of interest in comparing 
34 Chapter 7.—PSYCHOSES IN NAVY INDUCTEES 
the two groups under discussion, but would not neces- 
sarily be included in a questionnaire prepared for in- 
ductees. The points considered are listed below under sep- 
arate headings. 
Hospitalization.—Of the 100 men under study, 5 dis- 
played such abnormal actions that they were placed under 
observation while on their way to training camp, 11 were 
taken from the recruit line at the camp, and 84 were de- 
tected during the following few days. 
These men were admitted to local hospitals at the vari- 
ous training centers, and then sent to other naval facili- 
ties, eventually arriving at St. Elizabeth’s Hospital for final 
disposition. (The serviceman is eligible for care at this 
hospital as long as he may need it, even after his discharge 
from the service, although he may be transferred to a Vet- 
erans’ hospital should he so desire). The average total 
length of time spent in naval hospitals before being ad- 
mitted here was 28 days. At this writing 81 of the 100 
patients had been discharged, their average length of stay 
in'this hospital being 95 days. This group therefore had 
a total hospitalization period of about 4 months (average 
123 days) before being returned to civil life. The greater 
number of servicemen now passing through this hospital 
conform rather closely to these figures. The condition on 
discharge of these 81 men is shown in table 10 . 
days prior to arrival here; to this must be added the pay 
received by each patient. Yet this is insignificant when we 
consider the fact that each of these men by virtue of even 
. few days’ sendee is eligible for lifetime care in a Veter- 
ans’ hospital and may well become a claimant on the state 
under future bonus plans. In addition such men are com- 
pletely nonproductive during their hospitalization; where- 
as if they had remained in civilan life they might have 
been able to avoid an actual breakdown and have been of 
value to their respective communities. 
Type of illness.—As these men moved from one hos- 
pital to another their appearance from a psychiatric point 
of view often underwent considerable change. In the 
majority of cases the noteworthy characteristics of the ill- 
nesses were the sudden, violent onset of symptoms, the 
rather rapid subsidence without specific treatment soon 
after hospitalization, and the apparent significance of sit- 
uational factors. These have been noted previously by 
Duval and Hoffman (8). The prognosis, even without 
specific therapy, is good, hospitalization itself playing an 
important role, as many situational elments are thus 
eliminated and the patient’s feelings of insecurity some- 
what relieved. 
Table 11 shows the final diagnoses made in the 100 
cases under consideration. These diagnoses were applied 
after approximately 2 months of hospital observation. 
Table 10.—Condition on discharge from St. Elizabeth’s Hospital 
No. of cases 
Percent 
Recovered 
18 
22 
Social recovery 
27 
33 
Improved 
32 
40 
Unimproved 
4 
5 
81 
100 
Table 11.—Final diagnoses of cases 
Diagnosis 
Number 
of cases 
I. Manic depressive psychosis: 
A. Manic phase 
5 
B. Depressed phase 
3 
Total 
8 
II. Dementia praecox (schizophrenia); 
A. Catatonic type 
47 
B. Paranoid type 
9 
C. Hebephrenic type 
4 
D. Mixed type 
4 
E. Undetermined typo 
15 
Total 
79 
III. Undiagnosed psychosis 
6 
IV. Evolutional melancholia 
1 
V. Psychosis, alcoholic 
2 
VI. Psychosis with mental deficiency 
3 
VII. Psychoneurosis (hysteria) 
1 
13 
Of this total 76 or 93 percent were discharged within 
4 months, the remaining 5 being discharged after periods 
of from 5 to 10 months. Treatment consisted of that which 
is usually available in large institutions—hydrotherapy, 
occupational therapy, superficial psychotherapy, and elec- 
tric shock (used in 9 cases of this series). Extensive psy- 
chotherapy is not possible because of the heavy case load 
and the relatively small number of physicians available. 
Of the 19 cases not discharged at this writing 11 had 
been hospitalized at St. Elizabeth’s less than 6 months, 
while 8 had been there from 6 to 11 months and were 
showing only very slow improvement. It is anticipated that 
within the next 6 months the greater number of these 19 
patients will be discharged. 
The economic aspect of this problem cannot be ignored. 
There is first the cost of hospital care for each of the 28 
The large majority of schizophrenic reaction types is 
the most striking feature noted. It will be interesting to 
35 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
compare this percentage at some later date with psychotic 
casualties evacuated from combat areas. 
Of the 100 patients, 6 had made serious suicidal at- 
tempts, an illustration of the rapid breakdown of the de- 
fenses of an already unstable individual when there was 
a sudden increase in his feelings of insecurity by virtue 
of his rapid transfer to a military environment. Faced by 
an apparently intolerable situation the man seemed to 
rush to the very definite protection afforded by his illness. 
In these men the psychosis seemed to be a more functional 
and obviously protective device than is usually seen in 
peacetime in civilian life. 
In none of these men was there any question of malin- 
gering, but each buried himself in a psychotic maelstrom, 
being quite incapable of effecting an adjustment to the 
actualities of the situation. Improvement in most instances 
followed rather quickly upon removal from the traumatic 
environment, and the assurance that further military duty 
would not be required. 
Age.—An outstanding feature of both groups was their 
youth. The ages of the patients ranged from 17 to 49 
years. Of this number, 54 were under 20 years, while 90 
were less than 30 years of age, the remaining 10 ranging 
from 31 to 49 years. With one exception (the man aged 
49) all were subject to draft, and the great majority were 
inducted. 
Twenty-two of the patients had shown a marked fear 
or resentment of induction. Forty-four definitely stated 
that they had no desire to enter the service. Twenty-nine 
had been eager to enter for patriotic reasons. In one in- 
stance the man had been retarded and hallucinated, but 
was urged to go into the service by his parents who be- 
lieved that camp life might effect a cure. The remaining 
four joined "to get away from it all.” 
The control group ranged from 18 to 36 years, with 
26 being less than 20 years, while 85 were less than 30 
years. Of the controls, 40 entered the service for patriotic 
reasons, 55 were inducted, 3 wished to make the Navy a 
career, and 2 joined to escape an unhappy marital life. All 
were subject to induction. 
Family relationship.—Some difference was noted in the 
two groups when an attempt was made to evaluate the 
degree of happiness found in the home life. In the control 
group 90 individuals considered their home life happy 
and looked back with pleasure upon their formative years. 
Ten stated that the home had been disturbed by conflict 
between parents. In 6 instances the father had died when 
the child was less than 10 years of age, and in 5 the 
mother had died during this period, but in only one in- 
stance had both parents died before the child had reached 
maturity. None of these children were cared for in insti- 
tutions or foster homes, but were supported by the survi- 
ving parent or by relatives. Divorce of the parents was 
noted in only two instances. Sixteen of these men said that 
they were very closely attached to the mother, while three 
were devoted to the father. 
In the patient group the family life was disrupted by 
divorce of the parents in 9 instances, this occurring when 
the patient was under 10 years of age in 6 instances, the 
remaining 3 taking place when the patient was between 
the ages of 10 and 20 years. In 21 cases the family was 
broken by the death of the father, and in 9 by the mother’s 
death, all of these deaths occurring before the patient was 
15 years of age. Two of the children were cared for in 
orphan homes, and 9 were cared for by relatives. Only 49 
of the homes were listed as happy, while 11 were marred 
by parental discord, 11 by alcoholism of the father, 1 by 
an alcoholic mother, and 3 by the criminality of one or 
both parents. In 3 cases the parents were listed as being 
cruel to their children. Twenty-eight of the patients mani- 
fested an extremely close attachment to the mother, and 
two showed a similar attachment to the father. 
Although these findings are not conclusive, it is empha- 
sized again that a stable home, which offers the child 
security and aids him in developing self-confidence, plays 
an important role in forming an intact personality pattern. 
For this reason information concerning the home en- 
vironment of the prospective servicemen should be avail- 
able to the examining physicians. 
Mental illness in the family.—In the particular groups 
under consideration physical illness in the family as a 
factor in disrupting the home seemed to be of minor im- 
portance. Table 12 summarizes the findings regarding 
mental illness in the family. 
Fourteen of the patients’ families reported two or more 
members mentally ill in addition to the patient. Fifty per- 
cent of the families reported no history of mental illness. 
The conclusion to be drawn of course is not that a man 
should be eliminated from service because of a familial 
history of mental illness, but that when such a history is 
presented the case should be investigated more thoroughly 
to determine if other characteristics of an unstable person- 
ality are present. 
Infantile traits.—The persistence of certain infantile 
traits into adolescence and adult life is looked upon as evi- 
dence of inadequate maturation and is suggestive of per- 
sonality instability. Certain of these traits may assume 
greater importance in military than in civil life, as they 
may be the cause of unfavorable comment by others, and 
thus increase the individual’s feelings of insecurity. Enu- 
resis for example cannot be tolerated aboard ship because 
of hygienic reasons, in addition to the fact that the fault 
cannot be concealed and will be subject to much public 
comment. Table 13 outlines a number of these traits, list- 
36 Chapter 7.-PSYCHOSES IN NAVY INDUCTEES 
Table 12.—Mental illness in the family 
Relative mentally ill 
Emotional instability 
not hospitalized 
Definite mental illness 
not hospitalized 
Mental illness requiring 
hospital care 
Patients 
Controls 
Patients 
Controls 
Patients 
Controls 
Father 
3 
1 
2 (epileptics) 
0 
7 
1 
Mother 
8 
2 
2 
1 
4 
2 
Both 
1 
0 
0 
0 
0 
0 
Siblings 
5 
0 
11 
0 
8 
2 
Uncle 
0 
2 
0 
2 
0 
0 
Aunt 
0 
I 
0 
2 
6 
0 
Other 
Q 
2 
8 
0 
6 
3 
Total 
17 
8 
23 
5 
31 
8 
ing only those that were persistent into adolescence or 
later. 
Of the patient group, 13 were enuretic beyond the age 
of 11 years, whereas in the control group none displayed 
this trait into the twelfth year. Fifty-seven of the patients 
reported some of the characteristics noted in table 13, 
whereas 72 of the controls had none of them. 
It is interesting to note that five of the controls mani- 
fested a fear of water, three a fear of heights, and one fear 
of crowded places—definitely undesirable traits in men 
who may be called upon to serve at a variety of stations 
during their naval careers. These characteristics noted in 
the controls are of course more typical of the psychoneu- 
rotic, and their absence in the psychotic patients is not al- 
together surprising. 
Previous mental illness.—It is contended that a man 
should be rejected by the military service if he has pre- 
viously suffered from a mental disorder. The man who has 
made a satisfactory adjustment to civil Life after recovery 
from a mental disease may break again under the strains 
incident to military existence. 
Of the control group, 94 reported negative histories. 
Five members of this group had at some time in their lives 
had their work or schooling disrupted for brief periods 
because of emotional disturbances not requiring hospital 
care. One man had been hospitalized for a few weeks be- 
cause of mental illness. 
Of the patient group, 7 had been previously hospital- 
ized in mental institutions, and 10 had been cared for at 
home during periods of mental illness. Of those treated 
at home, 4 had suffered from recurrent episodes of the 
disorder. In addition 4 had been under psychiatric care at 
intervals before their entry into the service. It is interest- 
ing to note that 13 of these men displayed obvious evi- 
dence of mental disorder for some months prior to induc- 
tion, 6 being actively hallucinated, 1 having made a sui- 
cidal attempt, and 1 being hampered by a profound ob- 
sessive-compulsive pattern. Only 69 of the patients gave 
negative histories. 
Although a few individuals who have undergone a 
mental sickness may be able to perform adequately in 
military life, it is believed that the chances of recurrence 
are so great that all with such a history should be rejected. 
Education.—A marked difference was noted between 
Table 13.—Persistent infantile traits 
Item 
Patients 
Controls 
Enuresis 
24 
3 
Temper tantrums 
4 
2 
Thumb sucking 
20 
0 
Stuttering 
6 
1 
Night terrors 
4 
0 
Nail biting 
15 
8 
Sleep walking 
4 
0 
Sleep talking 
3 
0 
Timidity 
3 
2 
Considered "sickly” by family 
3 
0 
"Nervousness” 
10 
0 
Headache (no history of trauma) 
2 
8 
Claustrophobia 
0 
1 
Fear of heights 
0 
3 
Fear of storms 
1 
0 
Fear of dark 
2 
2 
Fear of water 
1 
5 
Two or more of these traits present 
25 
10 
Three or more traits present 
11 
3 
The presence of a single trait in an individual may be 
of questionable significance, but a combination of several 
would seem of sufficient importance to justify further in- 
vestigation. Again it should be emphasized that few traits 
(with the exception of persistent enuresis) are in them- 
selves of sufficient importance to justify rejection, but that 
the presence of one or more relatively minor defects may 
guide the investigation so that unstable persons may be 
identified before they become actual casualties. 
37 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
the two groups in regard to education, although the age 
differences were relatively insignificant. Twenty-two of 
the patients had only an eighth-grade training or less, and 
38 had less than a high school education; 26 were high 
school graduates. Of the controls 40 were graduates from 
high school and 35 had some college training. 
Participation in social activities.—An attempt was made 
to determine the individual’s participation in the social 
activities of his community, with due regard to the limita- 
tions found in certain sparsely populated areas. Of the pa- 
tients, 3 were considered to be above the average for tak- 
ing part in social enterprises, while 64 were said to be 
average. Thirty-three were noted to be very inactive so- 
cially. Of the controls, 89 were active members of com- 
munity groups. 
Criminal record.—Of the patients, nine had been ar- 
rested for multiple minor offenses and one had served a 
term in an Army prison for being AWOL. In the control 
group six had been arrested for traffic violations. 
Personality.—Seventy-eight of the controls considered 
themselves to be "extroverts,” while 22 were listed as 
"introverts." Of the patients, 36 were noted as quiet and 
seclusive while 30 more were classed as "introverts” mak- 
ing an outwardly adequate social adjustment. One of the 
patients had been subject to marked mood swings for a 
number of years. Thirty-three of the patients were con- 
sidered to be extrovert in type. 
Employment record.—In the control group, 85 were 
listed as good or adequate in regard to income, perform- 
ance of work, and ability to cooperate satisfactorily with 
superiors. Six were listed as fair or indifferent in these 
qualities, while 8 had done no regular work because of 
schooling and 1 had shifted from one job to another with 
little apparent reason for change. 
Twenty-one of the patients had held no regular jobs 
because of school, and 13 had never worked because of 
emotional or intellectual defects, making them unemploy- 
able. Twenty-one had never held one job for any length of 
time, but had shifted from one to another, usually chang- 
ing because of restlessness or minor dissatisfaction. Six of 
the men were noted by employers as undesirable for vari- 
ous reasons. Forty had good work records. 
Alcohol or drugs.—There were no instances of drug 
addiction in this group. In the control group, 20 were 
listed as abstainers from alcohol, 79 as moderate or 
"social” drinkers, and 1 said that he regularly drank to 
excess. Of the patients, 85 drank moderately or very in- 
frequently, whereas 15 were listed as heavy drinkers. 
Emancipation from home.—In making this study the 
frequency with which severe nostalgia appeared was note- 
worthy. Flicker and Weiss (9) have discussed this prob- 
lem. In 33 patients homesickness was a prominent feature. 
In 77 cases the entry into the military service was the first 
experience away from home. 
Of the control group, 35 had never lived away from 
home for more than a day prior to their entering the Navy, 
and 65 had been away from home for periods of at least 
several months. Eighteen of the controls stated that they 
had been very homesick during the early training camp 
period, but had been able to adjust satisfactorily. 
Combination of factors.—As noted previously it is rare 
that a man will be rejected because of a single unfavor- 
able factor in his history. The determination of one or two 
such factors should lead to a search for others and a more 
careful evaluation of the individual. The cases presented 
here were reviewed with this in mind, the following items 
being considered: (1) Mental illness in family; (2) de- 
velopmental abnormalities; (3) school history; (4) crim- 
inal record; (5) history of previous mental illness in pa- 
tient; (6) personality of patient; and (7) employment 
record. 
Seventy-one of the patients listed unfavorable items in 
two or more of the categories noted above. Twenty-three 
had three or more unfavorable listings, 19 four or more, 
11 five or more, and 5 were noted in six instances. Six 
of the controls listed unfavorable items in three of the 
categories, while 2 were listed in two places. 
COMMENT 
In the course of this small study certain factors were 
noted which, it is believed, would be of value in gaging 
a man’s fitness for military service. During the investiga- 
tion rather complete histories were taken, but all ele- 
ments are not reported here as they seemed of compara- 
tively little significance in these groups and were of ques- 
tionable value for inclusion in a social record to be used 
for induction centers. Such items were parentage, siblings 
(number and relation to patient), religion, type of com- 
munity from which the man came (urban, rural), etc. 
Although some of this data could be obtained from the 
individual examined, more satisfactory results would be 
anticipated if it were received from objective sources, such 
as investigations by social workers. 
The following points should, we believe, be included 
in any social study; (1) Character of the family relation- 
ship; (2) history of mental illness in the family; (3) per* 
sistent infantile traits; (4) previous mental illness; (5) 
educational history; (6) social life; (7) criminal record; 
(8) sex; (9) employment record; (10) use of alcohol 
or drugs; and (11) degree of emancipation from home. 
(The boy who has never learned to make his own deci- 
sions, who is still emotionally dependent on his home and 
parents, may make a satisfactory military adjustment, but 
he will suffer in so doing, and his chances of failure are 
38 Chapter/.-PSYCHOSES IN NAVY INDUCTEES 
greater than those of the boy who has achieved some de- 
gree of freedom from familial bonds.) 
Prior to the war careful investigations were made of 
each man enlisted in the Navy. It is believed that the 
investment in time and money would be well justified 
should brief social service studies be carried out in each 
community on men subject to induction, the results being 
made available as confidential information to the psychi- 
atric member of the examining board. The most satisfac- 
tory approach to this problem certainly lies in prevention. 
Once the illness has manifested itself the road to recovery 
is long and uncertain—costly to the service, the patient, 
his family, and his country. 
SUMMARY 
1. One hundred white male (Navy and Marine) psy- 
chotic (including one neurotic) patients at St. Elizabeth’s 
Hospital, Washington, D. C, were studied in an effort 
to determine factors which, had they been known earlier, 
might have served as grounds for rejection by the induc- 
tion centers. 
2. All of these one hundred men were hospitalized be- 
cause of a mental illness before they had served 15 days 
on active military duty. 
3. A control group of one hundred hospital corpsmen 
was studied, the average length of service of this group 
being months. 
4. The two groups were compared in regard to age, 
parentage, siblings, family life, illness in the family, early 
development, previous mental illness, education, social 
activity, criminal record, personality, employment record, 
use of alcohol and drugs, and degree of emancipation from 
the home. 
5. The patient group displayed a greater number of so- 
called "psychiatric determinants” than did the controls. 
The desirability of having such data available at the induc- 
tion center is obvious. 
6. The need for social service histories as an aid to 
psychiatric selection of inductees is stressed. 
REFERENCES 
1. Ebaugh, F. G.: Misfits in military service. Dis. Nerv. System 
4; 293-298, October 1943. 
2. Cooley, M.: Economic aspect of psychiatric examination of 
registrants. War Med. 1: 372-382, May 1941. 
3. Rosenberg, S. J., and Lambert, R. H.; Analysis of certain 
factors in histories of 200 soldiers discharged from the 
Army for neuropsychiatric disabilities. Am. J. Psychiat. 
99: 164-167, September 1942. 
4. Billings, E. G.; Ebaugh, F. G.; Morgan, D. W.; O'Kelly, 
L. I.; Short, G. B.; and Golding, F. O.: Comparison of 
100 Army psychiatric patients and 100 enlisted men. War 
Med. 4: 283-298, September 1943. 
5. Bullard, D. M.: Selective service psychiatry; schizoid and 
related personalities; mood disorders and psychopathic 
personalities. Psychiatry 4: 231-239, May 1941. 
6. Hall, R. W.; Peculiar personalities; disorders of mood; 
psychopathic personality. War Med. 1: 383-386, May 1941. 
7. Ebaugh, F. G.: Psychiatry in war. Texas Rep. Biol. & Med. 
1: 41-51, 1943. 
8. Duval, A. M., and Hoffman, J. L.: Dementia praecox in 
military life as compared with dementia praecox in civil 
life. War Med. 1; 854-862, November 1941. 
9. Flicker, D. J., and Weiss, P.: Nostalgia and its military 
implications. War Med. 4: 380-387, October 1943. 
39 CHAPTER 8 
NEUROPSYCHIATRIC CLINIC AT A NAVAL 
CONSTRUCTION TRAINING CENTER* 
With the origin of the "Seabees" there arose a rather 
novel situation in Navy recruiting. For the first time the 
Navy began organizing a large number of highly skilled 
tradesmen for a definitely specialized type of activity. 
Due to the select nature of the group and because of its 
Higher mean chronological age we felt that the distribu- 
tion and nature of the neuropsychiatric problems found 
might differ from those usually found in a naval receiving 
or training station. It is for this reason that we are present- 
ing our findings during the first 6 months of the clinic’s 
operation. 
The neuropsychiatric clinic was formed at Camp Allen 
in May 1942. Its personnel consisted of a neuropsychia- 
trist, a psychologist, and a yeoman. Because of the ex- 
tremely large number of recruits passing through the sta- 
tion and our limited personnel, it was found impossible 
to interview each man as he came through the receiving 
line. Consequently it was decided to depend on cases 
referred to the clinic during the training period of six to 
eight weeks allotted to each man. All departments in- 
volved in handling the men during their stay in Camp 
Allen or Camp Bradford were aware of the clinic’s 
existence and its desire to see all men who were expe- 
riencing undue difficulty in falling into the activities of 
their group, as well as men who were constant visitors to 
battalion sickbays, were bed wetters, etc. In addition, prob- 
lems were referred to the clinic by the battalion medical 
officers. The commanding officer likewise directed to this 
department all suspicious cases appearing at mast. 
It is quite probable that many cases were missed which 
might have been picked up if each recruit had been inter- 
viewed by this department. However, the policy of having 
every case causing suspicion in the minds of the regimental 
training and medical officers referred to us, brought forth 
many that assuredly would have been missed in a short 
interview on the examining line. 
During the interval with which we are dealing there 
were 668 patients referred to the clinic for study. This 
number does not include those examined for intellectual 
suitability for elective surgery, and does not include re- 
visits of individuals for rechecks or minor psychotherapy. 
The disposition of these 668 cases is given in table 14: 
Table 14.—Disposition of cases seen by N-P department 
Cases 
seen but not discharged from the service 
341 
Cases 
seen and discharged from the service 
255 
Cases transferred to hospital for discharge 
72 
Total 
668 
The prime function of the NP clinic is to discharge 
from the naval service those individuals who are unfit be- 
cause of a neuropsychiatric disorder. Of the 668 subjects 
examined by the NP clinic, 255 were discharged from 
the naval service. Table 15 shows the various diagnoses at- 
tached to the discharges of the subjects. 
Sixty-eight cases of enuresis were sent home. This is 
26.6 percent of all the cases discharged. In many cases we 
had the mattress and the bedding examined to verify the 
patient’s story. No case was discharged on history alone, 
the patient had to wet his bed at least once while in camp. 
It was in this group, however, that we lost some excellent 
naval material. These men were well educated, expertly 
trained, and extremely anxious to do their duty and remain 
in the Navy. Many of these subjects consciously withheld 
the information of their enuresis from the recruiting of- 
ficer due to their desire to get into the Navy. Many others 
just "slipped by." We used as much care as possible in 
evaluating the enuretic history of these subjects. It. was 
felt, however, that if a subject would deliberately wet his 
* By Stanley M. Dillenberg, Lieutenant Commander (MC) U.S.N.R., 
and Bernard Locke, Lieutenant H-V(S) U.S.N.R. Received for publication 
November 25, 1942. 
40 Chapter 8.—NEUROPSYCHIATRIC CLINIC 
bed to evade naval service, he was not the type of indi- 
vidual we wanted. Fourteen of the cases of enuresis oc- 
curred in the one Negro battalion that was formed. This 
made the incidence of enuresis among the Negroes some 
40 times greater than among the whites. 
Thirty-six men were eliminated for mental deficiency. 
This is 14.1 percent of all the cases discharged. Twelve 
of the 36 men were Negroes. Since the proportion of the 
Negroes to the white men who came through during this 
interval was roughly 1 to 40, the incidence of mental de- 
ficiency in the Negro group was almost 20 times as great 
as in the whites. These mental defectives were eliminated 
after a careful clinical evaluation of their performances on 
acceptable measures of intelligence such as the Bellevue 
adult scale of intelligence or the Terman-Merrill revision 
of the Binet, and an evaluation of their social and economic 
backgrounds. A mental age of 9J/2 to 10 years for the 
Negroes and 10y2 to 11 years for the whites was usually 
considered as the lowest acceptable level for retention in 
the service. 
Table 15.—List of reasons for discharge 
Acromegalia 1 
Alcoholism, chronic 27 
Arteriosclerosis, cerebral 2 
Constitutional psychopathic states: 
Emotional instability 7 
Inadequate personality 11 
Paranoid personality 1 
Sexual psychopathy 2 
Dementia paralytica 1 
Drug addiction 1 
Encephalitis ; 2 
Enuresis 68 
Epilepsy: 
Grand mal ... 31 
Petit mal 5 
Glioma 1 
Hypochondriasis 3 
Mental deficiency 36 
Migraine 10 
Narcolepsy 1 
Neuritis: 
Brachial 1 
Sciatic 1 
Post concussion syndrome 2 
Posttraumatic encephalopathy 2 
Psychoneurosis: 
Anxiety neurosis 6 
Compulsion neurosis - 1 
Hysteria 17 
Neurasthenia 5 
Somnambulism 10 
Total 255 
Epilepsy was the next most frequent cause for rejection. 
These cases were most frequently picked up when they had 
a seizure while in camp which was reported by an eye 
witness. Practically all epileptic subjects did everything in 
their power to conceal their history of seizures and would 
not volunteer the information of their own accord. It is 
very possible that some epileptics have gone out with bat- 
talions, as the men are only kept in this camp from 6 to 8 
weeks and it is not infrequent for longer periods than that 
to elapse between seizures. This, unfortunately, cannot be 
avoided. Thirty-six men were eliminated for epilepsy—31 
for grand mal and 5 for petit mal. This is 12.1 percent of 
the total number of men surveyed. Frequently eye wit- 
nesses of the seizures were called to give descriptions. Red 
Cross investigation was also done on a number of cases 
to determine authenticity of statements. 
Due to the older age group of men examined a much 
higher incidence of chronic alcoholism was found than is 
seen in most training stations. Twenty-seven men were 
sent home for this reason. This is 10.6 percent of all cases 
discharged. Discretion was used in eliminating chronic 
alcoholics. If a man was a steady, constant imbiber but 
always worked hard, never lost a job because of drinking, 
had never been in conflict with the authorities, and ap- 
parently would be valuable to the Navy, we would be in- 
clined to keep him on probation. Our tendency was to- 
ward leniency. On the other hand, if the subject was a 
heavy drinker, was arrested frequently because of ethylism, 
tried several cures without success, gave up or lost jobs 
because of drinking, or went A. O. L. or A. W. O. L. on 
several occasions, he was discharged from the Navy. Or 
if he was inadequate, never held a good job, he was 
eliminated. This also was the procedure if the stigmata of 
chronic alcoholism were marked, such as tremors, flushed 
facies, memory defects, peripheral neuritis, etc. Acute 
alcoholics were kept in the ward for a few days, given 
salts, thiamine, and sedatives. Only after this was an es- 
timate made of the subject’s ability to withstand naval 
routine. 
Twenty-nine subjects were discharged from the Navy 
with the diagnosis of psychoneurosis of one type or an- 
other, as indicated in table 15. This is 11.3 percent of the 
group surveyed. It was in this group that the greatest prob- 
lems arose. Many men coming from civilian life had con- 
siderable difficulty adjusting themselves to Navy regime. 
Numerous psychoneurotic symptoms would appear which 
would be transitory and purely situational. These would 
disappear after the men had an opportunity to adjust 
themselves to their new way of life. It was the practice of 
the NP board never to survey a man with the diagnosis 
of psychoneurosis until all organic possibilities were ruled 
out and the subject was followed at least two or three 
weeks while attempting to do full Navy routine. Many men 
41 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
were kept in the Navy with mild psychoneurotic symptoms 
and they undoubtedly will make excellent sailors. The 
history in these cases is a very important factor and was 
gone into with great care. The type of work done in civil- 
ian life, the amount of work missed because of their psy- 
choneurosis, the frequency with which they had to visit 
their physician were important factors in determining 
whether or not a case should be surveyed. It will be noted 
that more than half the cases were discharged because of 
hysteria. In these cases all necessary consultations were had 
and reported as normal. All relevant laboratory work was 
done and reported as normal. Treatment in these cases con- 
sisted of psychotherapy, suggestion, physiotherapy, etc., 
and then if their hysterical complaints did not clear up 
they were considered for discharge. 
The constitutional psychopathic states comprised 21 
cases, or 8.2 percent, of the cases eliminated. This group 
contained the more obvious misfits. They just could not 
fit themselves into the routine of the Navy. They would 
not take orders, would be A. O. L. or A. W. O. L. with- 
out apparent cause, they would have temper tantrums, 
emotional instability, and numerous trips to the brig and 
before the captain at mast. Here again the history was im- 
portant. These individuals were found to be the same mis- 
fits in civilian life as in the Navy. They were unable to 
keep a job, were vagrant, were arrested frequently, never 
made much money, and on the whole were totally inade- 
quate from the start. 
Ten subjects were sent home because of somnambulism 
(3.9 percent). We are compelled to eliminate somnambu- 
lists for obvious reasons, and several excellent men were 
lost to the Navy because of this condition. Here again the 
men must have been seen walking in their sleep by some- 
one in camp. No case was discharged on the history alone. 
Migraine caused the dismissal of ten men from the 
Navy. The headaches had to be incapacitating and associ- 
ated with gastro-intestinal or visual symptoms or both. In 
several cases a therapeutic test was given with gynergen 
with spectacular results. In every case that this substance 
was tried the headache was definitely relieved. The 
gynergen was given subcutaneously and in most cases 
caused a mild gastro-intestinal upset and a feeling of light- 
headedness. Despite these untoward symptoms the sub- 
jects were most grateful for the relief given. 
The two chief reasons for sending patients to the hos- 
pital for discharge were that they were too ill to get home 
by themselves or that they had had previous service in the 
Navy or Marine Corps. A few cases were sent to the hos- 
pital for dismissal when the diagnosis was obscure, and 
further observation and laboratory tests were indicated. 
Our follow-up consisted of calling the hospital weekly. In 
almost all cases the discharge diagnosis was obtained 
(table 16). 
Table 16.—Cases sent to hospital for discharge 
Alcoholism, chronic 4 
Amnesia 1 
Congenital deformity 2 
Constitutional psychopathic states: 
Emotional instability 1 
Inadequate personality 2 
Sexual psychopathy 1 
Dementia paralytica 4 
Dementia praecox 14 
Disseminated sclerosis 2 
Epilepsy: Grand mal 4 
Fibroma, multiple 1 
Intraspinal injury 1 
Manic depressive psychosis 8 
Migraine 1 
Neuritis: 
Musculospiral . 1 
Sciatic 2 
Paranoid state 1 
Post concussion syndrome 1 
Psychoneurosis: 
Anxiety neurosis ... 4 
Compulsion neurosis 2 
Reactive depression 2 
Spinal-cord tumor 1 
Spinal-cord disease 1 
Unclassified 11 
Total 72 
Twenty-six of the seventy-two patients referred to the 
hospital were sent because of psychosis. Fourteen had 
schizophrenia, eight manic depressive psychosis, and four 
dementia paralytica. This comprises 36.1 percent of all 
the cases sent to the hospital for discharge. For obvious 
reasons all the psychoses were so transferred. 
Eleven cases were sent to the hospital for discharge be- 
cause of diseases which were unclassified in this clinic. 
This was 16.6 percent of the total number of patients sent 
to the hospital for elimination. This group consisted of 
some psychoses, vague neurological disturbances, and 
severe psychoneuroses. 
Four cases of chronic alcoholism were sent to the hos- 
pital. They were sent because of previous naval service or 
because they were too disturbing to keep in our ward, 
where facilities to handle such cases were entirely inade- 
quate. 
Three hundred and forty-nine cases were seen by the 
NP board but were returned to duty. Table 17 gives the 
distribution of these cases. Eighty-seven of this group 
were not neuropsychiatric problems and were sent to other 
departments for diagnosis and disposal. Sixty-four were 
considered to be mild psychoneuroses and were returned 
42 Chapter 8.—NEUROPSYCHIATRIC CLINIC 
as fit for duty. Most of these cases were seen only once and 
apparently adjusted themselves to naval life shortly after 
we saw them. Many were followed for several weeks, and 
with mild psychotherapy and assurance were able to go 
back to their work and adjust satisfactorily. Fifty-three 
cases were returned to duty with "no disease.’’ Headache 
was a very frequent complaint (23 cases). All organic 
causes for these headaches were ruled out either by an eye, 
ear, nose, and throat consultation, or x-ray, refraction, etc. 
The history and type of headaches were not suggestive of 
migraine nor were the headaches incapacitating. This 
group was classified as cephalalgia and in most instances 
relief was obtained by mild analgesics. Twenty-one cases 
of peripheral neuritis were sent back to duty as the dis- 
ability was not incapacitating. Most cases were relieved by 
high-vitamin therapy and psysiotherapy. Several cases of 
meralgia paresthetica were included in this group and re- 
sponded fairly well to treatment. 
Table 17.—Cases seen and sent to duty 
Alcoholism 15 
Borderline intelligence 15 
Cephalalgia 23 
Dementia pugilistica (mild) 1 
Habit spasm 1 
Heat prostration 4 
Herpes zoster _ 2 
Inadequate personality 11 
Malingering 5 
Meniere’s syndrome 1 
Migraine 7 
Myositis 4 
Nightmares 1 
No disease 53 
Not neuropsychiatric 87 
Nostalgia 10 
Old spine injury 2 
Paranoid personality „.. 1 
Peripheral neuritis 21 
Post concussion syndrome (mild) 8 
Psychoneurosis (mild) 64 
Sciatica 3 
Stammering 2 
Total 341 
SUMMARY AND CONCLUSIONS 
In the first 6 months of the clinic’s operation, 668 cases 
were referred for examination. Of this number 341 were 
returned to duty or referred to other departments. Two 
hundred fifty-five were given special order discharges and 
72 were transferred to the naval hospital for elimination. 
Almost 50 percent of the cases seen (327) were dis- 
charged either directly or by transfer to the hospital. Since 
we heard that most recruit induction stations were dis- 
charging 4 to 6 percent of the men coming through 
for neuropsychiatric disturbances, our average of approx- 
imately 0.75 percent appears quite low. We feel that this 
is due to the fact that, for the most part, our recruits were 
more mature, they were hand-picked, and the majority 
highly specialized artisans rather than a pure random 
sampling. Undoubtedly some undesirables slipped by, 
but we feel that if they were not discovered during the 
2-months’ training period, which was of a severe type, it 
is improbable that these individuals presented any serious 
problems in the field. 
While this method of weeding out undesirables was 
applicable with the type of group with which we had to 
deal, we do not advocate the discontinuance of the usual 
neuropsychiatric interview on the induction line, as we 
feel that it has a most important function to perform. 
43 CHAPTER 9 
FUNCTIONS OF A PSYCHIATRIST IN A NAVY YARD’ 
There was a steadily increasing number of requests at 
this station in World War II for psychiatric consultations 
for the Navy and Marine Corps personnel, and the need 
for psychiatry among the more than 75,000 civilian work- 
ers also became increasingly obvious, both in the selection 
of those men during pre-employment physical examina- 
tions and in the adjustment of their problems after em- 
ployment. The strain of their work resulted in a large 
number of neurotic manifestations as well as in some 
malingering. Close liaison between the medical officer in 
charge and the psychiatrist was vital. 
The influx of discharged veterans seeking employment 
made the work of the psychiatrist increasingly important. 
Because of the high percentage of discharges for neuro- 
psychiatric reasons, these men became the special problem 
of the psychiatrist. Careful consideration of their indi- 
vidual problems was essential. 
The types of cases seen are suggested by listing the acti- 
vities for a representative month: 
2Total number of neuropsychiatric examinations made 752 
Daily average 29 
These were divided as follows: 
New applicants (veterans) 238 
New applicants (4F) 129 
New applicants (others) 208 
Civilian workers (rechecks) 125 
Navy, Marine Corps, and Coast Guard personnel 52 
Total number of physical examinations for employment 
(including psychiatric examinations) 3,237 
(Only those whose physical condition was ques- 
tionable were seen by the medical officer of the Labor 
Board.) 
Total number of physical examinations for recheck (in- 
cluding psychiatric examinations) 1,537 
All these cases reviewed by the medical officer of the 
Labor Board. 
Employees of the yard, regardless of veteran status, are 
reexamined to determine fitness at the request of their 
personnel supervisors or at their own request, whenever 
indicated. Psychiatric examination is made whenever there 
is a possible psychiatric basis for a physical complaint. A 
special effort is made to rescreen veterans for more suit- 
able jobs whenever legitimate reasons for doing so are 
found. 
Psychiatric examinations are given only to those vet- 
erans applying for jobs who were discharged from the ser- 
vices for neuropsychiatric reasons. Selection is extremely 
important, both for the good of the veteran and that of the 
yard. The man who had a nervous breakdown after a few 
weeks or months of boot camp or basic Army training is 
unlikely to adjust to the noise and bustle and discipline of 
a Navy yard. However some have already demonstrated 
by previous satisfactory civilian employment that their 
unadaptability applies only to the armed services. These 
men can be accepted with fair assurance of satisfactory 
work. The veteran discharged after combat duty with war 
neurosis of the anxiety type may adjust to Navy yard work 
if assigned to work which he likes in surroundings where 
the noise and confusion is not too great. He is unlikely to 
adjust to noisy surroundings if startle reaction, irritability 
and anxiety still continue. Only a small percentage is con- 
sidered unfit for any duty in the yard. 
No veteran who is honorably discharged is rejected for 
employment. A job is found for him. Even those with bad 
conduct and undesirable discharges are usually given a job 
in the hope that they can be rehabilitated. Few of these 
give serious trouble. They are, however, subject to a pre- 
liminary investigation by the Civil Service Commission. 
They are unacceptable to the Commission only if con- 
victed of desertion. Lesser offenses are penalized only by 
the loss of veteran’s preference. 
New applicants in the 4F category are given psychiatric 
examinations if they have been so classified for neuropsy- 
chiatric or for unknown reasons. A large percentage of 
these are acceptable on the practical theory that although 
’By Harold J. Harris, Lieutenant Commander (MC) U.S.N.R. 
2Since the above was written there has been a further increase in psychi- 
atric examinations made. During the month of January 1945, 818 such 
exminations were made. 
44 Chapter 9.-FUNCTIONS OF A PSYCHIATRIST IN A NAVY YARD 
they may be questionable or poor material for the armed 
services they may be satisfactory for the type of civilian 
work for which they have already shown adaptability. 
Many of these, however, fail to live up to expectations and 
must later be released. Rarely is the overt homosexual or 
definite psychopath acceptable. 
Other civilian applicants receive psychiatric examina- 
tions if there is any obvious indication for it, such as his- 
tory of a neuropsychiatric condition, obvious peculiarities 
of behavior noted during physical examination, or evi- 
dence of defective mentality. Jobs can be found for the 
majority of those with limited intelligence, above the level 
of moron, but not for the psychopaths, severe psychoneu- 
rotics or psychotics. Those recovered, or in remission fol- 
lowing psychotic episodes, are employable under the reg- 
ulations if they have had at least 6 months of satisfactory 
employment following discharge from the mental hospital. 
Those accepted are frequently subject to recurrence and 
must be reexamined and found unfit, temporarily or per- 
manently. 
Sixteen-year-old boys, applying as apprentices, are seen 
for a rapid psychiatric check-up and estimation of mental 
capacity, if they have failed to complete iy2 years of high 
school. Most of those in the limited intelligence group, 
with little mathematical or general knowledge, have 
worked out well. Those found weak in mathematics are 
employed in painting, shipfitting, blacksmithing or foun- 
dry work, rather than as machinists, electricians or sheet- 
metal workers. 
Civilian workers are given psychiatric examinations 
(rechecks) either at the request of their superiors because 
of obvious behavior abnormalities, or because routine 
physical examination has revealed the necessity for such 
evaluation. They are then classified as "unfit perman- 
ently," "unfit temporarily” (pending treatment), "unfit 
for assigned duties’’ (with a view to rescreeuing for other 
work or placing them in limited duty status), or "fit." 
As medical officer of the Labor Board the psychiatrist 
reviews the findings and recommendations after physical 
examination of each of the persons sent in for recheck 
examinations each month. The need for further evalua- 
tion from the psychiatric viewpoint is often seen. 
Navy, Marine Corps and Coast Guard personnel are 
seen by the psychiatrist at the request of the medical of- 
ficers in the sickbays of the yard, or of the medical officers 
or pharmacist’s mates on ships tied up at the docks. Many 
Marines on limited duty in the yard are seen and an oppor- 
tunity is afforded to recommend change of duty when 
indicated, or return to hospital with a view to discharge 
from the service when it is obvious after adequate obser- 
vation that they cannot adapt to the service. The line of- 
ficers of the Marine Corps directly refer men who come to 
their attention, including the stragglers who turn them- 
selves in at Navy yards. The decongestion of Marine bar- 
racks’ brigs is made possible by prompt psychiatric exam- 
ination of prisoners. 
Evaluation of industrial injuries involving (or pur- 
porting to involve) the central nervous system is one of 
the major problems on which the psychiatrist is consulted. 
There are many head injuries, the vast majority of which 
are trivial or at least mild, with no intracranial complica- 
tions. The train of symptoms induced in emotional indi- 
viduals as well as in psychoneurotics is too well known to 
require discussion. Malingering is not rare. Many instances 
are found in which the working conditions or trauma 
have been precipitating factors in the appearance of the 
more serious neuroses or psychoses. The importance of 
recognizing them promptly is obvious. 
USE OF CORNELL SELECTEE INDEX 
Use of the Cornell Selectee Index3 as a starting point 
for virtually all of the psychiatric examinations has ef- 
fected so much saving of time as to make possible the ex- 
amination of large numbers of persons, occasionally as 
many as 60 in a day. Over 9,000 such forms were executed 
in the 12-month period ending 15 February 1945. The 
Index has the additional advantage of serving as a per- 
manent record. 
A notable fact is that greater truthfulness in answering 
such questions as "Have you ever had a fit or convulsion?" 
or "Have you ever had a nervous breakdown?’’ is found 
in the written answer than in the verbal one. Using the 
significant answers on the Index as a starting point, infor- 
mation which leads to accurate conclusions can be rapidly 
obtained. Previously denied epilepsy, for example, is 
frequently diagnosed by following up the questions on 
the Index. 
The Index contains virtually all the necessary questions 
that the psychiatrist would ask. The examinee fills out his 
form while waiting for examination. The form is then 
quickly rated, significant answers and totals are noted 
and are followed up by oral questioning. The number of 
psychiatric examinations made in the yard each month 
steadily increased from 202 in April 1943 to 818 in Jan- 
uary 1945. Even with the use of the Cornell Selectee 
Index this number taxed the ability of one psychiatrist. 
Without use of the Index much of the work would have 
been done less accurately or neglected. 
The cover page of the Index, form C, has space for the 
examinee’s name, age, date, occupation, grade reached in 
3 Information concerning the Index and the forms themselves are obtain- 
able from the authors, Weider, A., Mittlemann, B., Wechsler, D., and 
Wolff, H. G., New York Hospital, 525 East 68th St., New York, N. Y. 
45 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
school, address, month and year of birth, and very simple 
questions such as: "What is the capital of the U. S. A.?’’ 
and "Put a line under the countries fighting on our side: 
Russia, Japan, England, Germany.” 
The first inside page lists 44 jobs or occupations with 
directions to encircle the "L” or "D” after those which 
the examinee might like or dislike. A stencil is furnished 
the examiner quickly to evaluate the job preferences, 
which are then noted in the scoring box. The distribution 
and number of likes and dislikes gives a ready idea of the 
feminine trend and of the degree of withdrawal of the 
subject. Those showing 9 or more significant answers or 
3 or fewer likes are given special psychiatric attention. 
The second inside page has 52 questions to be answered 
by encircling the "G" "P” or "?” to indicate "good,” 
"poor” or "questionable” in an attempt to evaluate the 
examinee’s self-esteem. These are recorded as the num- 
ber of significant "poors” and the total number of "ques- 
tionables” in the scoring box by means of another stencil. 
Those showing 12 or more significant "poors” or 30 or 
more "questionable” answers receive psychiatric appraisal. 
The last page of the form is devoted to symptoms in- 
dicating psychogenic or psychosomatic complaints, as in- 
dicated by significant answers which are quickly scored as 
before. Persons showing a score of 15 or more receive 
special psychiatric appraisal. The stencil is marked to pick 
up various "stop-questions,” affirmative answer to any 
one of which would also call for special psychiatric ap- 
praisal. 
A simplified form (N) may be used instead of form C. 
It consists of a copy of the last page of Form C. It gives 
less information but has been found useful, especially for 
evaluation of boys such as the 16-year-old apprentices. 
This list of questions is adequate for estimation of the 
psychoneuroses but throws less light on their cause than 
does use of the more complete form. The simplified form 
scores the total number of psychoneurotic determinants 
and the stop questions only. 
The Index affords a qualitative means of obtaining 
necessary psychiatric information, regardless of use of the 
stencils. Page 3 of form C (or form N) is in essence a 
standardized psychiatric interview which is self-admin- 
istered and gives a quick, reliable screening method for 
detection of neuropyschiatric and psychosomatic disorders. 
SUMMARY 
The functions of a psychiatrist in the Navy yard are 
manifold. Psychiatric examinations are done for a steadily 
increasing percentage of new applicants for employment. 
Those most likely to be inept are immediately detected and 
either rejected or referred to other agencies. 
Similar examinations are done as a part of re-examina- 
tion (rechecks) of a steadily increasing percentage of those 
requiring re-evaluation after employment. Personnel of 
the Navy, Marine Corps and Coast Guard are afforded 
prompt psychiatric examination on the station. An over- 
all picture of all physical examinations for new employees 
is obtained. AH re-examinations of civilian employees are 
reviewed, from both a physical and a psychiatric viewpoint. 
This system results in better selection of applicants for 
the various jobs and of jobs for the physically or psychia- 
trically handicapped applicants. Increased efficiency and 
saving of time is effected in examination and disposition 
of Navy, Marine Corps and Coast Guard personnel. 
The rehabilitation program of the Government is facili- 
tated by classification of psychiatric cases and cooperation 
in job-selection between the psychiatrist, the civilian per- 
sonnel of the Labor Board and the Civil Service Com- 
mission. 
46 SECTION II 
EXAMINING PROCEDURES CHAPTER 10 
A RAPID DETERMINATION OF INTELLECTUAL 
ADEQUACY FOR THE NAVAL SERVICE' 
The inductees examined by the psychologists and psy- 
chiatrists at this station present a peculiar problem when 
a determination of their mental ability is desired. The rea- 
sons for this difficulty are: 1. Many of the recruits possess 
a language handicap which makes it difficult for them to 
express themselves in English even though they are able 
to understand the examiner. 2. Inasmuch as illiteracy per 
se is not considered a cause for rejection, some method 
had to be found for determining the intellectual ability of 
illiterate recruits without resorting to reading. 3. Many 
of the recruits are unable to write more than numbers or 
their own names. 4. The practice I problem of time has to 
be considered, because the recruits have to be examined 
as part of a continuous physical examination. 
For purposes of selection, all that is required is a quick 
estimate of intelligence which will classify a man as either 
mentally defective or not mentally defective. Only the 
men whose intellectual level seems questionable are tested. 
If found adequate, they are sent on to duty without fur- 
ther question. If, however, they are found lacking they 
are given further tests.2 
Some test was sought, therefore, which could be ad- 
ministered and scored quickly, which required no reading 
on the part of the inductees and which required them to 
write nothing more than numbers or their names. Many 
tests were considered but were found unadaptable to our 
requirements. The device to be described here, entitled 
Differentiation Test, was constructed especially to fit the 
situation. 
The subject is given an answer sheet on which he is'to 
write his name, age, and number of school grades com- 
pleted. Then there is read aloud a list of 14 questions, to 
which the answers in every case but one are numbers. The 
administration of the test requires approximately 5 min- 
utes. The following is a copy of the test together with the 
time limits permitted for each question: 
DIFFERENTIATION TEST 
Question Time-seconds 
How many eggs are in a dozen? 5 
31 Hffwmany minutes are in an hour? 5 
3. How many quarts are in a gallon? 5 
4. How many States are in the United States? 5 
5. How many feet are in a yard? 5 
many sides does a square have? 10 
7. If three lemons cost 5 cents, how many lemons can you 
buy for a quarter? (Repeat) 30 
8. If you bought 9 cents’ worth of candy and gave the man 
25 cents, how much change would you get back? 
(Repeat) 20 
9. How many days would it take you to shoot down 28 
planes if you shoot down 4 each day? (Repeat) 30 
tall, do you think, is the average woman? 10 
11. How many stripes are in the American flag? 5 
12. How far do you think it is from England to the United 
States? About how many miles? 15 
13. When is Abraham Lincoln’s birthday? 15 
14. (Digit span) 9-4-3-6- (practice—not scored) 
3-1-7-4-2 ( (either one correct) 
S-5-7-6-3 j 
This test was administered to 100 inductees together 
with the verbal portion of the Wechsler-Bellevue Scale. 
On the basis of an item analysis, the items were rearranged 
in order of difficulty with the exception of the digit span 
which was reserved for the final portion of the test, inas- 
much as it required separate instructions. Next it was de- 
sired to. find that point on the scale which would serve as 
a differentiation point between adequacy of intellectual 
functioning and inadequacy or suggested inadequacy. 
An inspection of table 18 will reveal the discrimination 
value of the test. Column 1 is the score on the test. Col- 
umn 2 shows the number of recruits in the sample of 100 
1 By Joseph G. Colmen, Lieutenant, junior grade H-V(S) U.S.N.R. 
2Because time was short only 3 subtests of the Wechsler-Bellevue Scale 
were used: Similarities, digit span and arithmetic. Wechsler, D.: Measure- 
ment of Adult Intelligence. Williams & Wilkins, Baltimore, 1941. p. 248. 
49 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 18.—Results of test in WO subjects 
Score on test 
Number of 
inductees 
obtaining 
score 
Wechsler-Bellevue Scale (verbal) 
Defectives 
Borderlines 
Dull Normals or better 
Column 1 
Column 
Column 
Column 
Column 
Column 
Column 
3 
4 
5 
6 
7 
8 
Number 
Percent 
Number 
Percent 
Number 
Percent 
14 
0 
13 
0 
12 
3 
100 
11 
4 
1 
25 
3 
75 
10 
16 
6 
62 
10 
38 
9 
16 
11 
69 
5 
31 
8 
19 
16 
84 
3 
16 
7 
15 
14 
93 
1 
7 
6 
13 
2 
15 
10 
77 
1 
8 
5 
5 
2 
40 
3 
, 60 
4 
2 
1 
50 
1 
50 
3 
4 
4 
100 
2 
3 
3 
100 
1 
0 
0 
0 
Total 
100 
12 
62 
26 
subjects obtaining those scores on the test. Columns 3 
through 8 indicate the classifications received by these 
recruits on the verbal portion of the Wechsler-Bellevue 
Scale. Of these, columns 3, 5, and 7 show the number of 
recruits obtaining that classification, whereas columns 4, 
6, and 8 give those numbers converted into percentages. 
The percentages have more significance because they show 
at a glance how the Differentiation Test and Wechsler- 
Bellevue Scale conform. The percentages of Dull Normals 
or better can be seen to decrease as the scores on the Dif- 
ferentiation Test decrease. The Borderlines increase, then 
decrease in a humped curve as the scores on the Differen- 
tiation Test decrease. The percentages of mental defec- 
tives can be seen to increase as the scores on the Differen- 
tiation Test decrease. 
Although 12 percent of those tested scored below 65 
on the verbal portion of the Wechsler-Bellevue Scale, it 
must not be assumed that 12 percent of the incoming re- 
cruits are defective. The indication is that of those referred 
for psychologic examination 12 percent were found to be 
inadequate intellectually. To present this more clearly, 
a sample of 5,787 recruits was taken. Of this number, 
about 4 percent were referred for psychologic examina- 
tion, but of the entire group only about y2 of 1 percent 
were found to be mentally defective. Nearly 12 percent of 
the referrals, however, were mentally defective. 
It must not be assumed that the men v ho did score 
below 65 on the verbal portion of the Wechsler-Bellevue 
Scale were summarily discharged from the service. It 
means only that these men were transferred to the neuro- 
psychiatric service for intensive psychologic examination 
and further disposition, either to duty or discharge. 
It will be observed, nevertheless, from table 18, that in- 
ductees scoring 8 or better on the Differentiation Test 
can be considered safely as being above the mental de- 
fective range, because in this category, in one category 
below it, and in all categories above it, none of the men 
tested by the Wechsler-Bellevue Scale scored as a mental 
defective. The percentage of men apparently who can be 
thus tested and classified in 5 minutes is 58. The group 
scoring 7 may be sent to duty without too much risk, thus 
bringing to 73 the percentage of referrals who can be 
tested and classified in little more than 5 minutes. The 
other 27 percent will require some additional testing. 
In practice this procedure should serve to reduce the 
number of suggestive mental defectives and thus allow the 
psychologists more time for thorough examinations of 
other recruits. 
50 CHAPTER 11 
NEUROPSYCHIATRIC SCREENING OF A MILLION MEN' 
THE FUNCTION OF THE NEUROPSYCHIATRIC CLINIC AT A NAVAL TRAINING CENTER 
It is the function of the neuropsychiatric clinic at a 
naval training center to weed out, during the original 
training period, those mentally unfit for Navy life. The 
result is a more efficient personnel entering Navy routine 
from "boot camp,” and a minimum of maladjusted, un- 
happy individuals. 
Those "mentally unfit for Navy life” include all re- 
cruits having any mental, neurological, or psychosomatic 
difficulties which are of such severity that the individual 
will be more of a detriment than an asset to the Navy. 
Those rejected are not necessarily mentally unfit for a less 
rigorous civilian life. 
The psychiatrist or psychologist assigned to such duty 
is apt to find himself between two opposing viewpoints. 
It is well that he adopt a "middle-of-the-road” attitude, 
and continually bear in mind his fundamental objective; 
"To reject only those who, in his opinion, would be more 
of a detriment than an asset; and to accept only those who, 
in his opinion, will be more of an asset than a detriment.” 
The opposing viewpoints, mentioned above, are quite 
natural results of human nature working under different 
environmental circumstances and under different motivat- 
ing conditions. 
The job of the recruiting station on the one hand, dur- 
ing voluntary enlistment, is to "sell the Navy to prospec- 
tive sailors,” so that the Navy will be able to meet its per- 
sonnel requirements. When the percentage of rejections 
runs high at the training center, the recruiting officer is 
likely to feel that some of his efforts have been in vain. 
On the other hand, when the percentage of rejections 
runs low, those whose job it is to train efficiently an un- 
organized group into a smooth-running, well-organized 
company in a relatively short time are apt to feel that they 
are being handicapped by certain recruits who are a little 
slower in learning, or who are having some trouble in 
adjusting to their new mode of life. 
In addition to the two mentioned examples, other in- 
dividuals may lean toward one or the other viewpoint and 
may tend to exert pressure on the psychiatrist and psychol- 
ogist. The family and people in the home town, the draft 
board, even those in government positions representing 
the areas from which the recruits are coming, may feel 
that certain individuals should or should not be in the 
service, or that the percentage of rejection is either too 
high or too low. Then, of course, the recruit exerts his 
influence. Some recruits will, either consciously or sub- 
consciously, develop almost any psychosomatic symptoms 
in order to be discharged, while others will beg to stay 
in service, in spite of known neuropsychiatric or psycho- 
logical handicaps. 
If the psychiatrist and psychologist are consistent in 
following the above formula (to reject only those who 
would be more of a detriment than an asset, and to ac- 
cept only those who would be more of an asset than a 
deteriment), and if there is a variation in the quality of 
the incoming recruits, then one would expect a corres- 
ponding fluctuation in the percentage of rejections. 
It is the purpose of the present article to present a 
monthly percentage of rejections throughout an approxi- 
mate 5-year period, involving the examination of over a 
million men, and to analyze the possible relationship be- 
tween the rise and fall of the percentage rejected and the 
factors which might cause corresponding variations in the 
quality of incoming recruits. In addition, since psychia- 
trists and psychologists are human, and therefore subject 
to variations in judgment, the records may show some 
variations in the percentage of rejections which are due 
in part to the attitude and techniques of those making 
the judgments, rather than to the variations in the quality 
of recruits. 
,By Elbert CReitzel, Captain (MC) U.S.N.R.; Vernon L. Miller. Com- 
anc* eorge Lieutenant Commander 
51 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
THE PROCEDURE OF DETERMINING THOSE 
UNFIT FOR NAVY LIFE 
When recruits report to the training station a brief psy- 
chiatric and psychological examination is included as a 
part of the general medical examination. Those who evi- 
dence serious neuropsychiatric difficulties are referred 
directly, as "admits,” to the neuropsychiatric clinic. The 
less serious cases, who indicate possibilities of inability to 
adjust to Navy life for neuropsychiatric or psychological 
reasons, are given a 3-week period of trial duty. This 
period is the same as for other recruits, with the exception 
that at the end of the period the company commander 
writes a report describing his opinion of the recruit’s ad- 
justment to Navy life. This report is sent to the neuro- 
psychiatric clinic and the recruit is interviewed at the clinic. 
Depending upon (a) the nature of this report, (b) the 
seriousness of the neuropsychiatric or psychological condi- 
tion, and (r) the recruit’s motivation and subjective ex- 
periences, he is (a) admitted as a patient, (b) given a 
further 3-week period of trail duty, or (c) released to full 
duty. 
In addition to the company commander, any officer 
dealing with the recruit’s training, the chaplain, or a med- 
ical officer in another clinic, can refer the recruit to the 
neuropsychiatric clinic for examination. The recruit may 
also report to the neuropsychiatric clinic voluntarily if he 
feels he is having difficulty in adjustment. AH of these 
referrals are dealt with in the same way as the trial duty 
cases. 
When a recruit is admitted to the clinic as a patient, he 
is (a) given more thorough neuropsychiatric and psycho- 
logical examinations by the psychiatrist and psychologist; 
(b) is interviewed by the Red Cross psychiatric social 
worker (attached to the clinic) in an effort to adjust vari- 
ous personal and family problems; and (c) if any organic 
brain involvement, brain injury, or convulsive disorder is 
suggested, an electroencephalographic examination is 
made of all brain areas. 
When all of the data are gathered, the recruit appears 
before the aptitude board, ’ consisting of a minimum of 
one psychiatrist, one psychologist, one medical officer, 
and one line officer who deals with recruit training. All 
aspects of the case are then considered together his in- 
telligence, his psychosomatic and neuropsychiatric condi- 
tion, his company commander’s report of trial duty, and 
the recruit s own motivation and wishes. Consideration 
of the latter factors may be interpreted from an altruistic 
standpoint; however, experience has shown the recruit’s 
motivation to be just as important as the other factors in 
determining his aptitude for the service. On the basis of 
all of these factors the aptitude board then decides 
whether the recruit shall be discharged by reason of un- 
suitability or shall continue in the naval service. 
ANALYSIS OF FACTORS DETERMINING 
PERCENTAGE DISCHARGES 
Figure 2 shows the number of recruits given psychiatric 
and psychological screening examinations at the U. S. 
Naval Training Center, Great Lakes, each month from 
April 1942 through December 1947. Months are indicated 
by the first letter of the name of the month. Figure 3 
shows the percentage admitted to the neuropsychiatric 
clinic and the percentage discharged as unsuitable for 
naval service, during the same period. 
It is figure 3, the percentage discharged, in which we 
are mainly interested. Some tell us that the percentage has 
been too high, others insist that it has been too low. The 
fundamental contribution of the neuropsychiatric clinic 
to the efficiency of the naval service is not to obtain a 
certain percentage discharged, be it high or low. The 
fundamental purpose of the neuropsychiatric clinic is to 
examine each individual, to accept him if he will be an 
asset to the service or to reject him if he would be a detri- 
Figure 2. 
52 
Figure 3. Chapter 11.-NEUROPSYCHIATRIC SCREENING OF A MILLION MEN 
ment to the service. The only error of the neuropsychiatric 
clinic is to accept a man who turns out to be a detriment, 
or to reject a man who would have been an asset. 
The percentage discharged is merely a by-product of 
this fundamental objective. When the quality of incoming 
recruits is poor the percent rejected must of necessity be 
high; when the quality of incoming recruits is good the 
percentage discharged will automatically drop. 
Figure 3 shows considerable variation. Moderate varia- 
tion is expected in any measurement. More significant 
variations should be explainable by events and conditions 
which determine the quality of those being examined. 
The remainder of this section will therefore be an at- 
tempt to trace the curve throughout the war and early 
postwar periods and to explain the causative factors for 
significant high and low percentages discharged. 
Low regions of the curve should correspond with su- 
perior recruits, high regions with inferior recruits. The 
judgment and technique of the psychiatrist and psycholo- 
gist should be a constant factor, but being subject to error, 
some discharge variation may have to be explained by 
variations in the behavior of the neuropsychiatric staff. 
In tracing the relationships between causative events 
and their effects on the curve, one should bear in mind 
that the curve may not change abruptly the same month 
as the causative event. On the one hand, events may be 
anticipated by the public and the potential recruit may 
decide to enter the Navy on the basis of an expected con- 
dition. On the other hand, there is a lag. An event may 
affect the quality of recruits, but the discharge of those 
recruits may occur any time during the 3-month training 
period. With this double spreading effect, one may ex- 
pect high and low regions on the curve near the time of 
the causative event. 
THE EARLY MONTHS OF THE WAR 
During the first half-year of the war, the majority of 
people had not yet adjusted their life activities to the new 
situation. Most people continued working in the same 
locality. Some were drafted, but they went into the Army, 
for the Navy was then on a voluntary basis. A war had 
begun, and we seemed to be on the losing side. The future 
looked dark, military life was dangerous. The safest thing 
to do was to wait until the draft card arrived. 
Recruits who voluntarily enlisted at this time were, in 
general, superior specimens of high motivation and in- 
itiative. Less than 1 out of 200 of these recruits were dis- 
charged, less than one-twentieth of the percentage of a 
year later, about one-eighth of the average throughout the 
rest of the war. 
A factor in addition to the quality of recruits during 
this period was that the neuropsychiatric clinic was still 
in process of organization, which may have decreased the 
percentage screened out. 
THE SECOND HALF-YEAR 
By the second half of the first year of the war, more 
people were adjusting to the new situation. It was becom- 
ing the usual, rather than the unusual thing, to volunteer 
for the service. Figure 2 shows how the incoming recruits 
increased from 12,000 to 42,000 per month during this 
period. They volunteered, but they had delayed in doing 
so. They were not quite so well motivated as their prede- 
cessors. Within 2 months the percentage discharged rose 
from y2 t0 over 3 percent. 
THE BEGINNING OF THE NAVY DRAFT 
In February 1943, the Navy, for the first time, began 
to draft. Incoming recruits no longer were coming by 
choice, those with initiative and daring were fewer, many 
wished they were back hotae. Within a 5-month period 
the percentage discharged rose from below 4 to over 10 
percent, the highest point during the war. 
THE USE OF ADDITIONAL PSYCHIATRISTS AT 
RECRUITING AND INDUCTION STATIONS 
When the percentage discharged reached its peak, fol- 
lowing the beginning of the Navy draft, concern devel- 
oped regarding the number of rejectees. Consequently, 
about May 1943 the Navy sent out additional psychia- 
trists to improve screening procedures at some recruiting 
and induction stations. As a result, the percentage dis- 
charged from the training centers dropped about June and 
never returned to the high peak of early 1943. 
THE SEASONAL CYCLE 
A glance at the curve from the middle of 1943 to the 
end of 1946 shows a tendency toward a seasonal variation. 
The percentage tends to drop during the summers and rise 
during the winters. It appears that (a) there is a better 
selection of recruits during the summer, (b) neurotic 
tendencies become relaxed during the balmy days, or (c) 
psychiatrists and psychologists become less severe in their 
examining during the warmer days. 
One may further note that in 1943, 1944, and 1945, 
the peak of the winter rise occurred in December. In De- 
cember homesickness increases, the desire to be home for 
Christmas coupled with the inability to do so intensifies 
the strain of military training. During this period more 
recruits come to the clinic with nervous tension, headaches, 
and dizzy spells. These conditions occur partly on the vol- 
untary level, bordering on malingering, but also at the 
subconscious level. The nervous tension really does become 
worse. 
53 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
It is interesting to note that in 1946 the percentage 
drops during December. The present article was in prepa- 
ration during that time and the psychiatrists and psycholo- 
gists became aware of the "Christmas peak.” The aware- 
ness of the effect probably caused an overcompensation 
in the minds of the examiners, so that a special effort was 
made to avoid sending any one home who might be mal- 
ingering. As a result the "Christmas peak” became re- 
versed for 1946. In 1947 all boots entering before Thanks- 
giving were allowed 2 weeks’ Christmas leave. As a re- 
sult a Christmas peak did not occur. 
THE END OF THE WAR 
With the end of the war in August 1945, the service 
was no longer a dangerous organization to be in. There- 
fore, it became an escape mechanism for many who could 
not adequately adjust at home, at school, or at work. 
Many recruits entered the service as an act of spite after 
an argument with the girl friend or with the family. As a 
result many incoming recruits were maladjusted indi- 
viduals. They could not adjust to civilian life and they 
could not adjust to military training. Consequently the 
winter peak following the end of the war was the highest 
of the winter peaks. 
THE SUSPENSION OF THE NAVY DRAFT 
In January of 1946 the Navy Draft was suspended. 
The incoming recruits were those who wanted to be in the 
service and their motivation was therefore higher. The 
percentage discharged in early 1946 showed a quick drop 
from the winter peak. 
THE DIMINISHING OF THE GI BILL OF RIGHTS 
On 6 August 1946 the educational benefits of the GI 
bill of rights were decreased for further incoming recruits. 
As a result, those interested in furthering their education 
were less likely to enlist. The average intellectual level 
of the recruits became lower, and the number of dull 
normal and borderline intelligence cases increased. These 
were less able to adjust to Navy training and more entered 
the clinic for this reason. 
THE PRESENT TREND 
The early 1947 trend of Navy recruits has been de- 
scribed by the authors in a separate article.2 This trend 
revealed that an unusually large number of recruits at 
that time were of low intelligence and that a very large 
number of them were using the Navy as an escape from 
civilian maladjustments, a composite of points previously 
described under the headings "The End of the War” and 
"Diminishing of the GI Bill of Rights.” These tendencies 
led to increasing percentages of discharges through May 
1947, but with the closing of school, the quality and in- 
telligence of the average recruit was greatly raised by the 
influx of high school graduates, bringing the percentage 
of discharges for June 1947 down to 1.93 percent. Al- 
though rather large numbers of low intelligence are again 
finding their way into the Navy, considerable numbers of 
recruits who have completed high school are still coming 
in. The elimination of mustering-out pay for those enlist- 
ing after 30 June 1947 appears to have had no appreciable 
effect on the quality of enlistees. In addition, the neuro- 
psychiatric clinic has made a conscious effort to discharge 
only those recruits who in the opinion of all members of 
the aptitude board are entirely beyond salvaging, due to 
the increasing need for replacements because of the large 
number of expiring enlistments during this latter period. 
The paradoxical crossing over of the curves in May 1947 
was due to the accumulation of a backlog of dischargees 
from April who were not discharged until the following 
month. This was repeated in September 1947. 
TYPES OF DISORDERS DETERMINING UNSUITABILITY 
An analysis of discharges for 1946 gives a general idea 
of the types of conditions which render the recruit unfit 
for Naval service. Table 19 gives the nearest percentage of 
each condition encountered. Many patients exhibit a com- 
bination of two or more of the disorders; the classification 
is based on the most pronounced condition of each case. 
Table 19. An analysis of the neuropsychiatric diagnoses for 
the rejection of recruits 
Diagnosis and reason for discharge: Percentage 
Personality disorder 64 
Enuresis 11 
Mental defective 5 
Intracranial injury and neurological 4 
Somnambulism 3 
Migraine 3 
Epilepsy: 
Grand mal . 1 
Petit mal 1 
Convulsive disorder (psychomotor and mixed) 1 
Psychopathic instability 1 
Psychoneurosis (anxiety reaction) _ 1 
Psychoneurosis (unclassified) 1 
Schizoid personality 1 
Speech defect 1 
Pathologic sexuality I 
Psychoses 1 
Knox, G. W.: Psychiatric Screening 
in the Post-war Navy. Published in mimeograph form by the Medical De- 
partment, U. S. Naval Training Center, Great Lakes, 111., April 1947 
15 pp. 
54 Chapter 11.-NEUROPSYCHIATRIC SCREENING OF A MILLION MEN 
It is quite evident that personality disorder (inability 
to make an adequate social adjustment) is the outstanding 
reason for discharge. This is the expected result, since the 
Navy is a social organization where cooperation and har- 
mony between individuals is the most fundamental nec- 
essity. Many cases of personality disorder are accompanied 
by a mild nervous condition, dull normal intelligence, or 
both. 
Although a mental defective diagnosis was given to 
only 5 percent of the cases, this condition in milder form 
contributed to the decision of Unsuitability for many cases 
otherwise classified, especially of the personality dis- 
orders. The classification of mental defective is given only 
to those of moron level or below (less than 70 I. Q.). 
Many personality disorder cases were either of borderline 
intelligence (70 to 80 I. Q.) or of dull normal intelligence 
(80 to 90 I. Q.). Twenty percent of all dischargees were 
below normal intelligence, 15 percent falling within the 
I. Q. range of 70 to 90 and 5 percent being below 70. 
Seventeen percent of all dischargees exhibited symp- 
toms suggestive of organic involvements and were there- 
fore given electroencephalographic examinations. Results 
indicated that only 7 percent actually had organic involve- 
ments, the other 93 percent being functional in nature, 
but 10 percent of all cases had functional disorders which 
simulated symptoms of organic conditions. 
SUMMARY 
There has been considerable debate concerning the per- 
centage of recruits which should be discharged from the 
naval neuropsychiatric clinics of the training centers. 
Consequently a survey was made of the neuropsychiatric 
dischargees out of over a million recruits examined in 
approximately a 5-year period at the world’s largest naval 
training station, throughout the war and early postwar 
periods. 
The discharge of a certain number of recruits, be it high 
or low, is not the fundamental objective of the neuropsy- 
chiatric clinic. The fundamental objective is to discharge 
only those who would be more of a detriment than an 
asset and to retain those who will be more of an asset than 
a detriment. 
With this objective, a fluctuation in the percentage dis- 
charged is expected with a variation in the quality of in- 
coming recruits. This variation in the quality of recruits 
was determined by many changing conditions throughout 
the war and postwar periods. 
Some of the factors which determined the fluctuation in 
the quality of recruits, and, consequently, in the percent- 
age discharged, are pointed out. 
Acknowledgment. — The authors are indebted to Capt, Earl Richison 
(MC) USN, for valuable advice in the preparation of this article; to the 
numerous officers attached to the Neuropsychiatric Unit of U. S. Naval 
Training Center, Great Lakes, 111., since April 1942, for accumulation of 
the data; and to Bertha P. Kuznik, PhM2c, V-10 USNR, and Neal R. 
Roy, PhMjc, USN, for assistance in' preparation of the manuscript and 
charts. 
55 CHAPTER 12 
A PSYCHOMETRIC PROCEDURE FOR SCREENING 
MENTAL DEFECTIVES’ 
This chapter describes a clinical psychometric method 
designed for the specialized procedure of screening at the 
Neuropsychiatric Observation Unit of the United States 
Naval Training Station, Sampson, New York. The de- 
mands of screen testing have resulted in the development 
of a somewhat new and different interpretation of the use 
of test items in mental measurement. 
The customary aim of mental measurement has been to 
obtain a large sample of behavior from a variety of test 
situations in order to make an estimate of average mental 
ability. The purpose of screen testing is to predict from 
as few items as possible whether a particular person’s 
ability is above a given minimum. In this there is no ques- 
tion of the complete evaluation of a person’s abilities—his 
strong points, his weak points, his maximum range of 
capacity—but a question only of acceptability for satisfac- 
tory naval service. 
Customary or over-all mental testing requires testing 
conditions that often are not available. It requires that the 
subject be well motivated; that conditions and directions 
be standardized; that the person be relatively free from 
fear of the examiner and in rapport with the examiner. 
Screen testing, on the other hand, can and frequently must 
be administered under a variety of conditions, mental 
states, and time limits. The latitude permissible derives 
from the fact that the goal of screen testing is not the tra- 
ditional I. Q. or mental-age score but the detection of 
supraminimal ability. This does not require a large and 
representative sample of a testee’s behavior but only 
enough of a sample to establish whether ability is above 
a given level. 
Tests that attempt to determine an I. Q., M. A., or other 
over-all evaluation include failures in the final score as 
well as successes in specific test items; the final score is 
thus attenuated by the failures. Screen tests, by contrast, 
disregard specific failures because a subject is not penal- 
ized for failing a specific item if he is able to pass another 
item of equal difficulty. In the screen tests only discrim- 
inatory items are used; that is, items which are concen- 
trated at the borderline level where the acceptable may be 
separated from the questionable recruit candidates. The 
probability has been empirically determined to be at least 
99 in 100 that anyone who passes one of the tests has an 
I. Q. above 70 and therefore is not mentally defective. 
These test items require no elaborate testing conditions 
except that they must be administered individually; they 
can even be interpolated in the conversation of the inter- 
view. Even such brief and apparently casual tests have 
been shown to have an error of less than 1 percent. 
It has been found that a few selective items may be ar- 
ranged in a graded series (to be referred to later as the 
five-phase program), so that the examiner may quickly 
weed out the men who need more intensive examination. 
The saving of time is of practical importance, because a 
great deal of the screening has to be done on the "re- 
ceiving line’’ during the final physical and mental reex- 
amination of the recruits before they enter training. By 
the screen tests, in a few minutes it is possible to certify 
as acceptable a large number of recruits and thereby save 
more time for careful examination in the borderline cases. 
There is no short-cut method of examination in these 
cases. No man should be presented to the Aptitude Board 
(for consideration for discharge from the service) who 
has not been thoroughly and intensively observed and 
tested. 
The actual program consists of a five-phase procedure 
which groups test items in five levels of intensity of test- 
ing, each successive level sampling more of the person’s 
mater*al was prepared in August and September 1943, by Harold 
M. Hildreth, Lieutenant H-V(S) U.S.N.R. ; h Arthur Wheeler, Jr., Lieu- 
tenant, junior grade D-V(S) U.S.N.R., and Stanley B. Williams, Lieu- 
tenant, junior grade H-V(S) U.S.N.R. 
56 Chapter 12.-A PSYCHOMETRIC PROCEDURE FOR SCREENING 
total abilities. These stages can best be described by fol- 
lowing the course of a recruit through testing. 
PRELIMINARY SCREEN TESTS 
Phase 1.—The tests consist of brief oral questions, such 
as definitions, arithmetic problems, number-series and 
reading comprehension. Superficially similar questions 
have frequently been used by interviewers, but the bat- 
tery of items used in these screen tests has been carefully 
selected and statistically validated (J). As a result, the 
tests, although brief, have predictive value. From a posi- 
tive response to a single question, such as: "What does 
’tolerate’ mean?” the psychologist can predict that the re- 
cruit on further testing will prove to have a mental age 
above the Navy’s minimum. The error of this prediction 
is statistically determined. If there is a negative response 
to the question, no prediction whatever may be made and 
no general statement of the recruit’s intelligence is justifi- 
able. All that is indicated by a negative response (failure) 
is the need for further testing. Following a negative re- 
sponse to three or more of the screen test items, the recruit 
is sent to the Neuropsychiatric Unit where he undergoes 
the other four stages of the testing program. If a recruit 
passes this preliminary screen test, he is sent to training. 
It is emphasized that the procedure described is not, 
strictly speaking, intelligence testing and is in no way a 
substitute for it. It is primarily a means of meeting a prac- 
tical situation. It is a useful way of dividing incoming re 
emits into two groups, the acceptable and the questionable. 
At Sampson the questionable group comprised about 10 
percent of all those seen by the psychologist; thus a great 
deal of time was saved by this first phase. On further 
testing, this group was reduced in number. Many of the 
doubtful candidates were sent to training duty.2 
Phase 2.—In most cases phase 2 is administered in the 
neuropsychiatric ward. It consists of two paper-and-pencil 
tests from the Kent Battery: Arithmetical Reasoning and 
Easy Directions, each requiring 2 minutes’ testing time. 
The two tests can be given and scored in 6 minutes. These 
tests have been described elsewhere (2) (3) (4) (3). 
They are used here as separate screen tests, apart from the 
complete Kent Battery. On the basis of 6 months’ experi- 
ence, certain critical minimum scores have been deter- 
mined, which, if exceeded by a recruit, indicate accepta- 
bility and thereby obviate the need for more extensive 
testing. These minimum scores are; 17 points on the Easy 
Directions combined with 2 points on the Arithmetical 
Reasoning (raw scores); or 11 points on the Easy Direc- 
tions combined with 3 points on the Arithmetical Reason- 
ing (raw scores). 
Less than 1 percent of all recruits who have exceeded 
the minimal scores have later been considered rejectable 
by the Aptitude Board. Although the Aptitude Board’s 
decisions are based on over-all criteria, which fluctuate 
from time to time, they probably represent the best single 
estimate of service aptitude available at present. It is worth 
while to mention also that the distribution of scores made 
by rejected recruits shows a sharp break between 10 and 
11 points on the Easy Directions test; many score 10 and 
below and only a few score 11 or higher. There is likewise 
a similar sharp break between 2 and 3 points on the Arith- 
metical Reasoning. 
At present, if a recruit equals or exceeds the minimal 
score in the phase 2 tests, he is immediately sent to train- 
ing, provided that the interview does not reveal any gross 
behavior disorder. If the recruit scores below the minimal 
level, he is carried on to phase 3 of the testing program. 
Phase 3.—Phase 3 consists of the remainder of the 
Kent Battery; namely, the Revised EGY and the Verbal 
Opposites. Together these require from 5 to 10 minutes' 
examining time. Again, on the basis of accumulated cases, 
statistical analysis showed that if a man who had scored 
less than the minimal scores on the tests in phase 2 attains 
a score equivalent to 12 years’ mental age (raw score 24) 
or better on the EGY, he will not prove to be rejectable 
by the Aptitude Board on grounds of mental deficiency. 
Likewise, if he scores 13 years (raw score 18) or better 
on Verbal Opposites, he will meeet the Navy’s minimal 
requirements. Similarly, if he scores a mental age of 10 
or higher on all the tests of the Kent Battery, he is sent 
to duty. If he scores below these minimal levels, he is 
retained for further observation and is tested under phase 
4 of the program. 
Phase 4.—A fairly satisfactory judgment of intelli- 
gence level can be obtained by the use of three of the 
verbal sub-tests of the Wechsler-Bellevue Scale (Infor- 
mation, Arithmetic, and either Similarities or Compre- 
hension) (6). These can be administered in about 20 
minutes, and together with the Kent Battery comprise a 
fairly solid basis for predicting success of the recruit in 
naval training. 
Usually the recruit who is given these tests is the man 
who falls slightly below the criterion level on the Kent 
Battery. Not infrequently he will score high enough on 
the abbreviated Wechsler-Bellevue Scale for the psychol- 
ogist to be sure that he meets at least the minimum 
standards. Such a recruit is sent immediately to duty with- 
out further testing. If he does not score higher, and 
2 A check on the effectiveness of the screening is the number of rejectable 
recruits discharged during their subsequent training period. In 5 months, 
these cases amounted to only two-tenths of 1 percent of all cases referred to 
the psychologists. This compares favorably with the number reported from 
stations where the longer Kent Battery is reported as used for screening "on 
the line.” 
57 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
therefore remains in the doubtful category, phase 5 is 
administered. 
Phase 3.—Phase 5 is not rigidly defined. It consists of 
any one or all of the following tests: Complete Wechsler- 
Bellevue, Revised Beta Examination, Stanford-Binet, Otis 
Self-Administering Test, the Rorschach Ink-Blot test, and 
such other special tests as are clinically indicated. It is this 
fifth phase which requires so much of the examiner’s time 
and which is necessary for a complete evaluation of a 
questionable case. Usually the complete Wechsler-Belle- 
vue test is given. Every recruit who is brought before the 
Aptitude Board with recommendation for discharge for 
reasons of mental deficiency is given the tests in phase 5. 
c’:ffers from the usual procedure in that it comes fifth 
in the "scree g” program rather than first or second, 
in order to economize examination time. 
CONCLUSION 
It cannot be emphasized too strongly that such a five- 
phase procedure as has been described is only a tool at 
the disposal of the clinical psychologist. In using this 
objective instrument, he must exercise his experienced 
judgment. He must always evaluate test data in the light 
of observed behavior and background, and, as every 
clinical psychologist knows, there are cases in which 
exceptions must be made. 
The usual case history is taken of every recruit who 
reaches phase 2 of the program. Personality factors, lan- 
guage handicap, bizarre responses, and anomalous be- 
havior disorders are detected in the case history interview. 
This serves as a check against test information, 
REFERENCES 
1. Hildreth, H. M.: Single-item tests in psychometric screen- 
ing. In preparation. 
2. Hunt, W. A.; Wittson, C. L.; Harris, H. I.; Solomon. 
P.; and Jackson, M. M.: Psychometric procedures in de- 
tection of neuropsychiatrically unfit. U. S. Nav. M. Bull. 
41: 471-480, March 1943. 
3. Kent, G. H.: Emergency battery of one-minute tests. J. 
Psychol. 13: 141-164, 1942. 
4. Ibid.: Tentative norms for Emergency Battery. J. Psychol. 
15: 137-149, 1943. 
5. Ibid.: Written tests for clinic. J. Genet. Psychol. 44: 49-68, 
1934. 
6. Rabin, A. I.: Short form of Wechsler-Bellevue Test. J. Appl. 
Psychol. 27: 320-324, 1943. 
58 CHAPTER 13 
A NEUROPSYCHIATRIC QUESTIONNAIRE 
FOR CROUP EXAMINING* 
The questionnaire presented here was developed to 
meet the needs of a large neuropsychiatric service in a 
naval hospital. Designed as an aid in psychiatric examin- 
ing, it has proved useful both as a time-saver and as an 
instrument of investigation. 
Essentially the questionnaire is a group method of 
conducting a preliminary psychiatric interview and ob- 
taining the psychiatric history. Group methods are rela- 
tively new in psychiatry, except in the field of psycho- 
therapy, and may eventually have considerable usefulness. 
One basis for this expectation is the steady develop- 
ment of personality tests and adjustment inventories. 
Although intended primarily for use with "normals,” the 
widespread use of these psychometric devices by business 
and industry has demonstrated the utility of group meth- 
ods for eliciting significant personnel information. More 
recently psychologic tests for aviation cadets have shown 
that pertinent and reliable biographic data can be ob- 
tained by means of a questionnaire. 
Each person is, of course, an individual problem. 
Clearly it is absurd to think that any group psychometric 
device can supplant the personal interview. Such devices 
may, however, supplement the interview to a valuable 
degree and allow a more effective distribution of the 
examiner’s time. 
An adequate and comprehensive history is important 
for every neuropsychiatric patient, but no part of the 
psychiatric examination is more time consuming. A great 
many questions must be asked. Most of these questions 
are answered negatively, because in many respects the 
patient’s personal and family background is not unusual. 
Discovering the unique and atypical elements in a pa- 
tient’s past life—the primary purpose of the history— 
requires a disproportionate amount of the examiner’s 
time. It is the function of the questionnaire to do this 
questioning, and to uncover the significant information 
without expenditure of time and energy on the part of 
the examiner. 
At the time of the personal interview the patient’s 
questionnaire can be reviewed in a minute or two. Details 
which are not clear may be investigated further. The re- 
mainder of the time ordinarily spent on the history is 
then available for investigating the immediate reaction- 
pattern of the patient, for discussing the problems which 
seem most important to him, and for psychotherapy. 
Wording of the questions of the questionnaire is the 
result of considerable experiment. Experience has shown 
that in their present form they are easily comprehended 
and answered by the patient. 
Scanning of the questionnaire has been facilitated for 
the examiner by casting the questions in a yes-no form. 
"Yes” indicates positive information. Most of the ques- 
tions are answered negatively, indicating average or typi- 
cal experience. 
We have labeled the questionnaire, in the form given 
to patients, Interview Questionnaire. 
INTERVIEW QUESTIONNAIRE 
FROM: Your Ward Medical Officer. 
Your Ward Medical Officer will have a personal interview 
with you as soon as possible. In the meantime you can help by 
giving in advance some of the information he will require. Con- 
sider these questions as though he were asking them personally, 
and keep them confidential. If there are any you would rather 
not answer, leave them blank. There will be time later to talk 
more about the things that seem most important to you. 
Name 
(Last Name) (First Name) (Initial) 
Rate Date 
CC 1. What is your chief complaint or trouble at the present 
time? 
2. What other complaints or difficulties do you have 
PI 3. When did you first notice these symptoms? 
* By Harold M. Hildreth, Lieutenant H(S) U.S.N.R., and Joel M. Hill, 
Commander CMC) U.S.N.R. 
59 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
4. When did they begin to get worse? Give details 
5. When did you first go on the sick list for these com- 
plaints? 
6. Where? 
7. Tell all the hospitals or other medical activities where 
you were treated, and give the dates 
PH 8. Where were you born? 
Date of birth 
9. How many children including yourself were there in 
the family? 
10. Where did you come in the family; were you first, sec- 
ond, third, or what? 
11. When you were growing up did you live with some- 
one besides your parents most of the time? 
If so, with whom? 
12. Were you sick a lot during childhood? 
What serious illness did you have, and at what age? 
13. Were you inclined to be nervous or high-strung? 
14. Did you feel you were punished more than the average 
child? 
15. Were you the favorite child in the family? 
Did others consider you the black sheep of the family? 
16. Did you stammer or stutter? 
If so, at what age did you stop? 
17. Did you talk in your sleep? 
If so, at what age did you stop? 
18. Did you walk in your sleep? 
If so, at what age did you stop? 
19. Did you wet the bed? 
If so, at what age did you stop? ... 
20. Did you bite your fingernails? 
If so, at what age did you stop? 
21. Were you afraid of the dark? 
Up to what age? 
22. Did you often have bad dreams or nightmares? 
23. Were you inclined to be overconscientious? 
24. Did you feel lonely quite a bit of the time? 
25. Did you have a hot temper? 
26. Did you have the feeling nobody cared much about 
you? 
27. Did you feel uncomfortable in crowds? 
28. Did high places frighten you? 
29. Name any special fears you had 
30. What was the last grade you completed in school? 
How old were you when you stopped? 
31. How many grades did you fail? 
Which ones? 
32. Did you find it hard to learn? 
33. Were you fighting with the teachers much of the time? 
34. What sort of work did you do after you left school? 
Tell the different jobs you had and how long you held 
them 
35. How many times were you fired? 
36. Were you inclined to fight with the boss quite a bit? 
37. If you have any form of recreation or sport or any 
hobby you are especially interested in, list it here 
38. Did you ever run away from home? 
If so, how old were you? What was the 
reason? 
39. Were you ever arrested, or in a juvenile court, or in a 
reform school? If so, give the details 
of it 
40. Have you "bummed” around the country? 
If so, tell about it 
41. Were you ever picked up for vagrancy? 
42. How old were you when you became conscious of your- 
self sexually? For example, how old were you when 
you first learned about masturbation? 
and how old were you when you began sexual activity 
with the opposite sex? 
43. Are you married or single? If you are 
married how old were you at the time? 
Were you ever married before? Have 
you ever been separated or divorced? 
If you have any children, how many? 
How do you get along with your wife? 
44. Have sexual problems worried you a good deal? 
Did they worry you when you were younger? 
45. What church did you go to when you were young? 
46. How much religious interest do you have now; are you 
more interested or less interested than the average 
person? 
47. Has there been any marked change in your religious 
attitudes at any time during your life? 
If so, tell about it 
48. Have you ever been hit on the head and knocked out? 
If so, give dates and details 
49. Have you ever had fainting spells? 
If so, give details 
50. If you ever had a nervous breakdown, or if you were 
especially nervous at some period of your life, tell 
about it 
51. When did you enlist? 
52. When were you called to active duty? 
53. What was your rate then? 
54. What is your present rate? 
55. List any military or naval service you had before this 
enlistment 
56. If you have had foreign shore duty tell where it was 
and how long you were stationed at each place 
57. If you have had sea duty what ships were you attached 
to? 
How long? 
58. If you have been in combat, where was it? 
59. How many air raids have you been through, if any? 
Where? 
60. If you have had any naval or military offenses, give 
details 
60 Chapter 13.-A NEUROPSYCHIATRIC QUESTIONNAIRE FOR GROUP EXAMINATION 
FH 61. If your father is living, state how old he is 
Is he in poor health? If so, what is his 
trouble? 
62. If your father is not living, how old was he when he 
died? What did he die from? 
How old were you when he died? 
63. If your mother is living, how old is she? 
Is she in poor health? If so, what does 
she suffer from?,. 
64. If your mother is not living, how old was she when 
she died? How old were you 
when she died? 
65. Were your parents ever divorced or separated? 
If so, how old were you at the time? 
66. How well did your parents get along with each other? 
67. Did any of your relatives (father, mother, brothers, 
sisters, aunts, uncles, cousins, grandparents) ever have 
a nervous breakdown?- If so, give as 
much information as you can about it 
68. Did any of your relatives have convulsions or fits? 
If so, give details 
69. Have any of your relatives been in trouble with the 
law? If so, give details 
70. Have any of your relatives committed suicide?.... 
If so, give details 
ME 71. Do you feel sad and depressed quite often? 
Most of the time? 
72. Are you often moody? Most of the time? 
73. Do you feel irritable and bothered by little things? 
Most of the time? 
74. Are there times when you feel panicky, without know- 
ing quite why you feel that way? 
75. Do you have a general feeling that something is about 
to happen to you? 
76. Do you have any worries? If so, describe 
them 
77. Describe how you feel 
78. How do other people feel and act toward you? 
79. What do you think ought to be done for you? 
80. How soon do you feel you’ll be able to return to duty? 
VALIDITY AND RELIABILITY 
The neuropsychiatric questionnaire described here has 
been given three tests for validity and reliability. 
1. For 100 patients questionnaires filled out on admis- 
sion were compared with duplicate questionnaires filled 
out from three to eight weeks later. In most cases an 
almost verbatim consistency was found. The exceptions 
were a few psychotics, for whom the second questionnaire 
mirrored the progress of the psychosis. 
2. Questionnaires were compared with histories taken 
in routine manner by ward psychiatrists. Most of the 
positive information elicited by either method was found 
to have been elicited by both. On the average, however, 
one item of information uncovered by oral interview was 
missed by the questionnaire; and three items brought out 
by the questionnaire were overlooked in the interview. 
3. Both questionnaires and interviews were compared 
with social service histories obtained in the course of 
hospital routine from outside sources. Using these his- 
tories as a criterion, questionnaires and interviews were 
compared in regard to the number of information items 
which were confirmed, the number refuted, and the num- 
ber missed entirely. The two methods were found to be 
equally accurate, although the number of items missed 
by the questionnaire was smaller. 
Information obtained by the questionnaire, then, is 
fully as accurate and noticeably more complete than that 
obtained by an oral interview as performed under normal 
working conditions on a crowded neuropsychiatric serv- 
ice. It can be seen that when the questionnaire is used, 
even a few minutes of supplemental oral questioning will 
enable the examiner to achieve results definitely superior 
to those ordinarily obtained in from 20 to 30 minutes of 
interviewing. 
ADVANTAGES 
Economy of time is the greatest single advantage of 
this group method of history-taking. As in the case of 
group psychotherapy, however, there are by-product 
values to be derived from the use of the questionnaire. 
Morale.—One or two hundred patients brought in at 
one time means some men will have to wait a week or 
more for a complete interview. If these patients are given 
the questionnaire to fill out at once, morale is sustained 
for many days. The patients feel that thoughtful provision 
has been made for them, and that they have received im- 
mediate personal attention; consequently they are more 
content to wait their turn for an interview. 
It is important to remember that most of the patients 
in a naval hospital are young. From their school experi- 
ence they are accustomed to group tests, direct questions 
with true-false or multiple-choice answers, and question- 
naires. They lack the resistance of the older generation 
to putting down on paper information about themselves. 
As products of modern education they not only accept, 
but are favorably inclined toward, efficient group 
methods. 
Rapport.—Preliminary rapport is established by the 
questionnaire. When the patient comes in for an inter- 
view he has already had an opportunity to talk about 
himself in writing, and consequently feels the examiner 
understands some things about him. 
How old were you when he died?... 
61 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
The intimate and personal way in which patients re- 
spond to the questionnaire is illustrated by the following 
quotations: 
Question 13 (nervous?): "Yes, doctor, I have been 
nervous all my life, far back as I can remember.” 
Question 24 (lonely?): "Yes, that is just how I always 
felt.” 
Question 39 (reform school?) : "I was in St. Anthony’s 
Reform School for 6 years.” 
Question 43 (get along with wife?); "We fight quite 
a bit over my drinking, when I’m home.” 
Question 49 (fainting spells?): "In the past I've 
fainted on several occasions from what I thought was 
being overheated; fainted once in front of hundreds of 
people during a Christmas play—in which I was one of 
the saintly actors!—(Never did live it down).” 
Question 67 (nervous trouble in family?) : "One broth- 
er had insanity for about a year, but has been drafted into 
Army.” 
Question 69 (relatives in trouble?): "My uncle was 
in jail for shooting and cutting up a couple of men.” 
Question 73 (feel irritable?): "Yes, I do. O.K. with 
something definate (sic) to work forward to.” 
Question 74 (panicky?): "That’s right, I sometimes 
think I’m going to die in a few minutes.” 
Question 80 (return to duty?): "You’re the Doctor. 
Whenever you say so.” 
Time for the patient.—The questionnaire not only 
gives the examiner more time, it also gives the patient 
more time. He has an opportunity to go into detail about 
his problems. He is not hurried. 
The number of patients to whom this factor of time 
is important is surprisingly large. Those who stutter, or 
find it hard to talk, particularly welcome the opportunity 
to fill out the questionnaire. Frequently patients will 
spend 2 or 3 days on it, working in intervals of a few 
minutes each. A typical comment is: "When I talk to the 
doctor I get confused and can’t remember what I want to 
tell him. This way I can put it all down when I think 
about it.” 
Significant reactions.—Willingness to fill out the ques- 
tionnaire provides an interesting sidelight on the patient. 
At one extreme are those patients who return the ques- 
tionnaires, blank, within a few minutes. Disgust and 
scorn accompany it. "I won’t fill out that damn thing. It’s 
kid stuff.” "It’s a lot of .” Urging is futile for these 
men, but their reaction should be noted, because it is 
significant. We have found that these patients, almost 
without exception, turn out to be psychopaths. Occasion- 
ally paranoid personalities will respond in a similar 
manner. 
At the opposite extreme are the combat and operational 
fatigues. Fatigue patients sit down and start working at 
once on the questionnaire. They may be shaky and able 
to work for only a few minutes at a time, but invariably 
they fill it out carefully and in detail. They take it for 
granted that it is for their own good or the doctor would 
not be asking them to do it. 
An element of relief is also evident in these fatigue 
patients as they work. Speech is often an effort, yet they 
want to talk about themselves. The directed questioning 
of the questionnaire appears to give them a feeling of 
articulateness. Nor is it infrequent for these patients, after 
being stimulated into thinking more objectively about 
themselves, to reach the interview with an increased 
sense of perspective and insight. 
Accessory information.—A number of impressions of 
diagnostic value come as a by-product of the question- 
naire. Illiteracy, for example, is evident at once. The edu- 
cational level of the patient can be estimated fairly closely 
by his use of words. Mental deficiency reveals itself by 
answers which demonstrate lack of comprehension of the 
question. The catatonic often blocks completely when 
faced with the specific task of the questionnaire, even 
though his ward behavior may have shown no gross ten- 
dency toward a stuporous reaction. 
Those paranoids who are willing to fill out the ques- 
tionnaire reveal their reaction-pattern in two ways. Some 
of them show the stiff perfectionist handwriting associ- 
ated with the meticulous paranoid. And some of them 
fill out the questionnaire with a solid set of negative 
answers. As in an oral interview, they portray themselves 
as too perfect. 
Aphasia is quickly apparent. One aphasic stated his 
chief trouble as "can’t talk," and wrote he was ready for 
duty. "As soon as am better to talk and at home I will glad 
back to the submarine.” 
Schizoid reactions and early dementia praecox manifest 
themselves by unusual or bizarre responses. One patient, 
for example, in describing how he felt, wrote: "Anger 
and Judgment rule my thoughts.” Another patient stated 
he would be able to return to duty "when I learn Life.” 
Special uses.—Neuropsychiatric consultations on med- 
ical or surgical patients are expedited with the question- 
naire. When the neuropsychiatric staff is particularly bur- 
dened, the referring officer can help materially by having 
the questionnaire filled out by the patient in advance of 
the consultation. 
The instructional value of the questionnaire should 
also be mentioned. Interns at this hospital, familiarizing 
themselves with psychiatric procedures, have discovered 
the questionnaire is a useful guide in interviewing 
patients. 
62 CHAPTER 14 
PSYCHIATRIC SCREENING TESTS AT A 
PRECOMMISSIONING CENTER’ 
The problem of the construction and use of mass screen- 
ing devices to aid in the detection of those men unfit for 
military service by reason of psychological inadequacy or 
psychiatric deviation has been the subject of frequent re- 
port. In most instances, however, these reports have dealt 
with findings on men at the recruit or induction stage, 
and the various tests have been standardized and validated 
on this preservice or early service population. 
While it is true that the need for mass devices is not so 
pressing at present, it is felt that the findings from the 
present study, which was made in an attempt to test 
whether the screening techniques found so useful at the 
early service level continued to have validity and selective 
power when used with subjects having had longer, ardu- 
ous, and dangerous duty, are of interest historically and 
have definite implications for the continuation of screen- 
ing methods. The man who has "shipped over” for imma- 
ture and impulsive reasons (often solely to obtain the 
30-day leave), the man who has re-enlisted because the 
anxiety created in the attempt to readjust to civilian life 
was too great, and the "Regular” whose motivation has 
deteriorated with peace are instances in point, and are 
not infrequent in the author’s experience. 
With the change in function at this particular station 
from a "Boot” training center with men arriving into 
service directly from civilian life to a precommissioning 
center where all arriving for assignment had completed 
r’ecruit training and the majority had already had sea duty, 
including combat experience, the psychiatric screening pro- 
gram had to be geared to detect not only those "missed” 
by previous examinations but also those in whom some 
deviation had developed during or because of their service. 
Because of the limitation of personnel the utilization of 
some sort of screening device to detect the men requiring 
more extensive psychiatric attention was imperative. The 
two screening devices in use at this station during the re- 
cruit-training days, the Cornell Selectee Index,2 and the 
Naval Personal Inventory No. 2, had proved of great value 
in the detection of the unfit and the misfit, and it was de- 
cided to continue these tests with the longer service group. 
Accordingly, all men coming to .this station for assign- 
ment, with the exception of those coming directly from 
initial recruit training, were given these two tests as a part 
of their initial processing upon arrival. Those achieving 
scores in the critical ranges were subject to psychiatric in- 
terview from which the man might be sent on to unre- 
stricted duty, noted for subsequent check, or admitted 
to the neuropsychiatric unit for further study. Other 
sources of admission to the neuropsychiatric unit were by 
way of consultation after referral from dispensaries and 
administrative offices. 
In this survey the results from these 2 screening tests 
are compared for 2 groups. The control group is comprised 
of 1,936 men arriving at this station in the early months 
of 1943. From this group are excluded several processing 
groups (men are formed in groups of 60 for processing) 
known to be made up exclusively of men reporting to this 
station following a "survivor’s leave," and of men known 
to have been transferred from their previous assignment 
because of unsatisfactory service. The primary considera- 
tion for inclusion in the control group was that, in a period 
of 3 months following their arrival on this station, none 
of these men had been admitted to the neuropsychiatric 
unit. The other group consisted of 206 men who had been 
admitted to the neuropsychiatric unit during the same pe- 
riod, with the only selection criterion being the availability 
of the original screening test blanks. Of this particular 
group approximately 5 percent had been admitted to the 
'By Roland C. Moore, Lieutenant Commander, H(S) U.S.N.R. 
questions1 wTsubseriati°n °f C S’ L* F°rm N' indudin8 the » "stop 
63 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
neuropsychiatric unit directly from the screening exam- 
ination, and approximately 25 percent as the result of 
subsequent psychiatric re-check. The majority of the re- 
mainder were referred to the unit from dispensaries, either 
as a "first contact" or prior to the time for being called for 
checking. A small percentage were referred from chap- 
lains’ and administrative officers. Only 17, or 8.2 percent, 
of this group were restored to duty—all of the others were 
either separated from the service or transferred to a naval 
hospital as in need of treatment or prolonged observation. 
Figure 4 shows the percentage distribution of scores for 
the Personal Inventory for both the control and admission 
groups. 
Inspection of the statistics underlying these curves re- 
veals that the average score for the control group was 5.05, 
while the mean score for the admission group was 11.36, 
and that only 10 percent of the control group equaled or 
exceeded a Personal Inventory score of 11, where 64 per- 
cent of the admitted group reached or exceeded this score. 
Here the question of "cutting score’’ arises. Choice of a 
particular score as critical must of necessity be a function 
of the time and personnel available. Table 20 shows the 
cumulative percentages for the various possible scores oc- 
curring in the two groups. 
Setting the "cutting score” too low places an undue 
burden on limited interviewing personnel—a critical 
score that is too high results in too many "misses,” and 
while it has been the experience of the author that a 
goodly share of "misses” reach psychiatric attention by 
way of other sources, too great laxity in this respect is 
reflected in morale factors and in ineconomies of time and 
personnel. As based on the above figures a "cutting score’’ 
set at 9 will have brought to attention 75 percent of those 
Table 20 
Score on personal inventory 
Admits 
Nonadmits 
19 
Percent 
0.9 
4.7 
Percent 
0 
.1 
18 or greater 
17 or greater 
11.0 
.4 
16 or greater 
16.3 
.8 
15 or greater 
25.0 
1.5 
14 or greater 
35.1 
2.6 
13 or greater 
45.1 
4.5 
12 or greater 
53.3 
6.5 
11 or greater 
64.4 
10.1 
10 or greater 
71.1 
14.1 
9 or greater 
75.9 
18.3 
8 or greater 
81.2 
23.8 
7 or greater 
83.6 
31.2 
6 or greater 
88.4 
39.0 
5 or greater 
92.2 
46.5 
4 or greater 
93.1 
57.2 
3 or greater 
95.5 
68.9 
2 or greater 
98.4 
82.9 
1 or greater 
99.3 
94.1 
(0 or greater 
100.0 
100.0) 
eventually requiring admission to a psychiatric service, 
and the "false positive" group will have been only 18 
percent of the total number being processed. 
Figure 5 shows the percentage distributions for the 
scores on the Cornell Selectee Index for the same two 
groups. Here the average Cornell Selectee Index score lies 
below 1 for the control group, and the average score for 
the admission group is computed at 1.9. Once again only 
approximately 10 percent of the control group reach or 
exceed the average score of the admission group. 
Table 21 lists the cumulative percentages of the separate 
scores from the Cornell Selectee Index as an aid to select- 
ing an efficient critical score. 
Cornell Selectee Index score 
Admits 
Nonadmits 
11 
Percent 
0.4 
Percent 
0 
10 or greater 
.8 
0 
9 or greater 
1.2 
0 
8 or greater 
1.2 
.1 
7 or greater 
1.6 
.1 
6 or greater 
4.0 
.2 
5 or greater 
7.8 
.4 
4 or greater 
16.0 
1.3 
3 or greater 
32.5 
50.9 
72.7 
4.6 
2 or greater 
10.5 
1 or greater 
24.6 
(0 or greater 
100.0 
100.0) 
Table 21 
Figure 4.—Distribution of personal inventory score. Solid lines, men 
admitted to N. P. unit (2061; broken lines, men never admitted to 
N. P. unit (1,9361. 
64 Chapter 14.-PSYCHIATRIC SCREENING TESTS AT A PRECOMMISSIONING CENTER 
Thus, a critical score of 1 on the Cornell Selectee Index 
would be expected to cover 72 percent of the eventual ad- 
missions, while bringing about the interviewing of 24 
percent of the group being processed as "false positives.” 
It has been the experience of the author that "false 
positives” occur more frequently with the Selectee Index 
than is the case with the Personal Inventory. This may be 
partially due to the all-or-none wording of some of the 
Index items, and to the apparent tendency for some of the 
items to lend themselves to habitual misinterpretation. For 
example, the man who had nonepileptic convulsions in 
infancy, the man who detected fleeting traces of blood in 
seasickness vomitus, the conscientious man who received 
three parking tickets, and the man who in haste does not 
notice the word ''mental” preceding "hospital” on the test 
blank, consistently swell the "false positive” group because 
of their affirmative responses. It has been our practice be- 
cause of this effect to control the testing situation as closely 
as possible, with the identical instructions, designed to 
minimize this tendency, given to each group. 
Since many of the "noncritical” items of the Cornell 
Selectee Index have to do with anxiety and related symp- 
toms, and since so many of the men in this study had been 
through dangerous and strenuous duty, it was considered 
advisable to determine the distribution of scores for the 
entire Cornell Selectee Index scale rather than for only 
those items originally regarded as significant. Figure 6 
gives this distribution, and a marked differentiation is 
again apparent. Cumulative percentage analysis indicates 
that 80 percent of the admission group reached or exceeded 
a total score of 6 points as against 18 percent of the con- 
trol group. 
Because of the wide range in the percentages of the 
two groups responding significantly to the various items 
of the two tests it seemed advisable to make an item anal- 
ysis with a view to identify those items offering the 
greater differentiating power. Accordingly, the frequen- 
cies of significant responses for all the items of both 
scales were subjected to Chi Square testing. It was found 
that the differences in the percentages giving "abnormal” 
responses between the admission group and the control 
group failed of significance at the 1 percent level in the 
case of 3 items only—No. 7 of the Personal Inventory, 
and Nos. 16 and 30 of the Selectee Index. 
The most useful items are obviously those responded to 
significantly by a heavy proportion of the admitted group, 
and at the same time by relatively few of the control group. 
On the Personal Inventory scale 16 of the items received 
significant response from over 50 percent of the admis- 
sion group. In all but 4 of these items the percentage of 
admitted cases responding significantly exceeded the cor- 
responding percentage of significant responses in the con- 
trol group at a ratio of 2 or greater to 1. The four items 
where this ration was smaller than 2 to 1 are items 1, 4, 
14, and 17. The items where fewer than 50 percent of 
the admitted group responded significantly were Nos. 2, 
5, 7 (where the difference between admissions and con- 
trols is not real), and 12. Except for No. 7, the ratio for 
Cornell Selectee Index (Part) Score 
Figure 5.—Distribution of Cornell Selectee Index (stop) scores. Solid 
lines, men admitted to N. P. unit (2061; broken lines, men never 
admitted to N. P. unit II ,936). 
65 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
these items as between admissions and controls is better 
than 2 to 1. Thus, a revision of this scale eliminating the 
8 items just mentioned would be expected to possess ample 
differentiating power. 
In respect to the Cornell Selectee Index scale, the pro- 
portion of items satisfying the criterion of occurrence of 
significant responses in over 50 percent of the admission 
cases, and a minimal ratio of 2 to 1 frequency over the 
control group occurrence is smaller. Only 9 items meet 
this requirement. These are Nos. 1, 2, 6, 7, 8, 9, 19, 
20, and 23. It is noted in passing that 7 of these items are 
among those items considered noncritical in the original 
standardization. Items 16 and 30 do not differentiate 
between the 2 groups. Of the remaining items the ratio 
in the direction of more frequent occurrence in the admis- 
sion group is 2 to 1 or greater except in the case of No. 4. 
However, the percentage of occurrence in many of these 
items is small—less than 10 percent in 10 of them. Such 
items might economically be eliminated on the basis of 
infrequency, particularly in the light of the author’s ex- 
perience that the categorical nature of the significance ol 
those items is open to question; otherwise they should be 
modified to enhance their categorical value. There is no 
question but that at the recruit level or induction level 
these items in question are of greater importance. 
In summary, then, it has been the experience of the 
author that both the Personal Inventory and the Cornell 
Selectee Index, used as preliminary screening instruments 
to select men who should come to psychiatric attention, 
are valuable aids, particularly when time and personnel 
are limited, and that furthermore these tests show a dif- 
ferentiating power when used with the long-service group 
which is comparable to that found when dealing with 
men at the induction level. Of the two tests the Personal 
Cornell Selectee Index (Vkolel Score 
Figure 6.—Distribution of Cornell Selectee Index (whole) scores. 
Solid lines, men admitted to N. P. unit (266); broken lines, men 
never admitted to N. P. unit 1490). 
Inventory seems to offer better results. Its items are shown 
to contain a greater proportion of those with heavily selec- 
tive power, and fewer "false positives” result from its use. 
Against these factors is one point where the Cornell 
Selectee Index has the advantage in that the Cornell Se- 
lectee Index samples a wider variety of symptom com- 
plexes, but the true occurrence of some of these at the 
long-service level is so rare as to make this advantage 
largely academic. 
66 CHAPTER 15 
MENTAL MECHANISMS AND MORALE FACTORS 
OF NAVAL RECRUITS IN TRAINING* 
Morale has but one meaning for a military organiza- 
tion. It is the mental mechanism by which the consciously 
directed efforts of all the men succeed in attaining the 
goal of the organization; victory at the lowest cost in the 
shortest time. Anything which may thwart or hinder this 
effort is evidence of low morale. High morale is always 
accompanied by recognition of conscious effort on the 
part of the participant; knowledge that he is working 
toward the solving of a problem or the attainment of a 
goal. 
Seldom does a man upon entering the military service 
have any understanding of his duties or responsibilities 
to his organization. He may have identified his participa- 
tion with some vague purposes but he has not identified 
himself with any organized group or effort and has only 
scanty knowledge of what his participation is to be. This 
is particularly true in a nation where militarism is not an 
integral part of the individual’s personality. 
It is the primary concern of those charged with the 
orientation of men and the supervision of military per- 
sonnel, to direct the thinking and actions of individuals 
toward practices and habits designed to accomplish 
morale by direction and integration. A group of men 
entering military service is composed of as many different 
personalities as there are members in the group. It cannot 
be too strongly emphasized that each man in the group 
is obsessed with his own particular points of view, his 
personal ambitions and his personal problems. For some, 
war is adventure; for others a chance to "get away from 
it all;” for still others there may be a pecuniary considera- 
tion. Some enter the service because of inevitability or 
sense of responsibility and shape their efforts toward 
creating or effecting their own particular niche in the 
military picture. Others set up barriers against the un- 
pleasant elements of their situation. A few, however, 
appear to be concerned with what they can personally do 
to attain victory at low cost. Despite popular opinion, 
many appear to be interested in a personal low cost with 
little regard for collective and aggregate low cost (both 
in lives and material) . 
The first step toward the attainment of "good” or 
"high” morale is the elimination of factors or conditions 
which cause low morale and the avoidance of situations 
which will reduce morale. It is the purpose of this chapter 
to discuss four factors which are believed to be primary 
causes of low morale. 
The factors which contribute most to this condition 
may be grouped into four major categories: Disorganiza- 
tion; special privileges; uncertainty; and lack of purpose. 
DISORGANIZATION: ITS INFLUENCE ON MORALE 
Disorganization portends confusion and lack of defi- 
nite purpose. Men like to know that the vehicle on which 
they are traveling is able to make the journey. Despite 
excellent intentions no man can feel sure of performance 
or of his ability to attain his goal, if he lacks faith in the 
structure of his organization. 
Most men recognize disorganization or poor organ- 
ization no matter how limited their own administrative 
abilities may be. The obvious solution to faulty organiza- 
tion is reorganization. It is not within the province of 
this paper to discuss methods of organization but rather 
to point out that lack of it is an important contributing 
factor in the destruction of morale. 
SPECIAL PRIVILEGES AS EFFECTORS OF 
LOW MORALE 
The fundamental principle of American philosophy is 
equal opportunity. This is a principle which has carried 
* By Crawford N. Baganz, Lieutenant Commander (MC) U.S.N.R. 
Robert J. Mearin, Lieutenant (MC) U.S.N.R., and Walter A. Woods, 
Ensign D-V(S) U.S.N.R. 
67 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
over into our military organizations. It carries with it the 
assurance that each man has the same opportunity and is 
subject to the same discipline. This is a right which a man 
does not relinquish upon entry into service. He expects 
equal opportunity for advancement, an equal right to 
present his problems to his superiors, an assignment of 
duty in keeping with his qualifications, and equitable 
punishments. 
The morale difficulties which arise from special privi- 
leges have two primary sources, i.e., (1) consciously 
granted special privileges, and (2) special privileges re- 
sulting from a concatenation of circumstances. The for- 
mer must obviously be avoided. Men quickly distinguish 
unusual liberality to favored individuals or groups and 
the reaction is one of justifiable resentment. 
The unconscious granting of special privileges by a 
fortuitous combination of events is much more dangerous 
and less likely to be recognized as such. For example, ill 
considered liberties, hasty recommendations for promo- 
tion, and impromptu judgments create the illusion of 
inequality. All set the fortunate individual apart and 
effect serious damage to the morale of the others. The 
man who finds himself convicted by his superior before 
presenting his case is also the victim of unconscious 
special privilege. 
The very nature of men is a complicating factor which 
adds difficulty to this problem of equal opportunity. 
Some are retiring and others are aggressively ambitious. 
It is as necessary to insure that the first group have equal 
opportunities presented to them, as it is to temper the 
overambitious personality. 
UNCERTAINTY: MORALE REQUIRES A 
FACTUAL BASIS 
The daily experience of practicing psychiatrists bears 
out the old adage "the worst fears are the fears of the 
unknown.” If the converse is true, effort expended in the 
elimination of factors which produce uncertainty will 
do much to increase the morale of the individual members 
of any unit. As a result of our observations a number of 
causes of uncertainty were noted. Since the direct ques- 
tionnaire method of determining relative frequency and 
order of importance of such causes is not feasible in a 
military organization, the factors are simply listed below. 
1. Inadequate understanding of the relationship of the man to 
his unit. 
2. Insufficient knowledge of duties, responsibilities, opportuni- 
ties and penalties. 
3. Ignorance of the general military purpose of his group. 
4. Inequalities of pay or promotion. 
5. Lack of communication with family and friends. 
6. Concern over creature comforts. 
7. Rejection of the individual by other members of his group. 
LACK OF PURPOSE: MORALE IMPLIES A 
PURPOSIVE BEHAVIOR 
A definite purpose or objective, clearly understood by 
all, is one of the greatest factors in morale. These objec- 
tives of an organization are of two types; immediate and 
long range. A unit may function for a period of time with 
only the long-range type, i.e., "we are out to win this 
war;” but the sense of accomplishment following the 
completion of scheduled work is a requisite for continued 
high morale. It has been observed in this study that a 
concrete attainment is far more gratifying than routine 
progress toward the goal ideal. 
CONCLUSIONS 
Unfortunately, the problems presented here do not 
lend themselves to specific solutions or methods of treat- 
ment. They are instead "red-flag” warnings for respon- 
sible officers, things to be avoided. The existence of 
these problems reflects an unhealthy morale situation. 
It is the problem of each officer to determine when these 
problems arise (better still to assure that they never do 
arise), analyze the situation and determine the proper 
solution based on the facts disclosed. 
It should not be forgotten that in wartime the majority 
of personnel have no military interests beyond winning 
the war; that as a group they cannot be expected after so 
brief a period of indoctrination, to be other than a 
"civilian navy.” 
68 SECTION III 
CONDITIONS IN ACTIVE SERVICE CHAPTER 16 
NEUROPSYCHIATRIC PROBLEMS ON A BATTLESHIP* 
This chapter is a review of some of the problems of 
neuropsychiatric disease, as encountered aboard a battle- 
ship which has been overseas and engaged in operations 
against the enemy for 31 months, and of the efforts of 
the medical department to cope with it. It is based on a 
study of over 100 cases. It is felt that a description of the 
nature of the diseases encountered and the results of our 
efforts to treat them may be of value to medical officers 
assigned to shipboard duty as well as to hospital per- 
sonnel to whom such cases are referred. 
NATURE OF THE NEUROPSYCHIATRIC DISEASES 
ENCOUNTERED 
It became apparent to the present medical officers, soon 
after they came aboard this ship, that one of the major 
medical problems with which they were faced was that 
of dealing with a large number of men who came to sick 
call repeatedly with a plethora of complaints, for which 
no "organic” cause could be found, and for which no 
medical treatment seemed to avail. A record was kept on 
each of these men. Each was seen by a medical officer on 
several occasions. A thorough history was taken on him, 
and a physical examination was done. Various laboratory 
tests were performed in cases in which they seemed indi- 
cated, to the limit of the capabilities of a ship of this type. 
Some men were sent to hospitals or hospital ships for 
consultations on doubtful points. Others were kept in the 
sick bay for observation or treatment, as indicated. In 
this manner a large number of cases were investigated. 
Because we have kept a file card on every man who came 
to sick call, we know that during the past 18 months we 
have seen fully 80 percent of the crew at one time or 
another, and that nearly all of the men aboard who had 
neuropsychiatric complaints have been studied. 
It became evident to us that in nearly all of our patients 
we were dealing with what is basically a single syndrome, 
with variations on the theme. It was easily diagnosed in 
most cases, and the diagnosis made upon a "positive” 
basis, and not by exclusion. It was, in our opinion, essen- 
tially an "anxiety syndrome” and substantially the same 
as that which was called the "effort syndrome” in World 
War I. (1). 
These patients, as they appear in the sick-call line, have 
a characteristic "sad and worried look.” They seem tired, 
dejected, and at the same time suspicious, and anxious 
to convince the doctor of the reality of their symptoms. 
Their presenting complaint may be any one of several: 
Epigastric distress and nausea, restlessness and nervous- 
ness, pain around the heart, recurrent headache, or 
chronic fatigue. Sometimes they present themselves with 
a clearly hysterical paralysis, or with symptoms referred 
to an actual organic illness of a minor nature—classically 
"flat feet” or "backache.” 
Regardless of the initial complaint, careful questioning 
and a system review will reveal that all of them also have 
either all or several of the following symptoms, which 
are here enumerated: 
Headache is very common, and seen in nearly all of 
these men. It may have any form: Constricting, squeezing, 
temporal, frontal, occipital, "like a pressure right here,” 
or a mixture of several forms. Localizing signs suggestive 
of intracranial disease are absent, although the patient 
often attributes it to his "sinuses” or his "constipation.” 
It is recurrent, and usually has been present since child- 
hood. 
Precordial or presternal pain is very common also. It 
is described as "sticking” or "constricting,” and is 
usually localized just over the apex of the heart. It is not 
severe, but it is recurrent and alarming. Sometimes it is 
described as "all over the left side.” It almost never radi- 
ates in the manner of angina pectoris, and it is never 
related to exercise—in fact, exercise often will abolish it. 
Patients often complain of a "feeling of gas around the 
heart.” In addition, they frequently say they have "pound- 
*By Lawrence E. Hinkle, Jr., Lieutenant (MC) U.S.N.R. 
71 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
ing of the heart,” which is generally noticed after slight 
exertion, but classically occurs just after they have gone 
to bed. When a man says, "Doc, I can’t go to sleep be- 
cause my heart pounds, and I can’t lie on my left side at 
night because it bothers me so,” the complaint is almost 
pathognomonic. 
These people have frequent sighing respirations. They 
often find it difficult to breathe (especially in closed, 
warm spaces) and say that they "can’t take a deep breath.” 
They also complain of dizzy spells when they arise sud- 
denly from a sitting or lying position. Fainting is not 
uncommon among them. 
Probably the most common single initial complaint of 
our patients is epigastric distress in some form. Usually 
it is described as a "burning” or "gripping” pain, located 
in mid-epigastrium, and usually, but not always, post- 
prandial in occurrence. Sometimes it is relieved by food 
and soda, and often it is accompanied by sour eructations 
and heart-burn, so that only an x-ray can establish the 
absence of a peptic ulcer. On the other hand, it is so 
often accompanied by morning nausea, dislike for the 
sight of food, a poor appetite, and intolerance for unusual 
foods (asparagus or pineapple juice, for example) that 
the differentiation may be suspected from the first. In 
addition to the gastric symptoms, spastic constipation is 
not uncommon, and a "lump in the throat” is occasionally 
complained of. 
Urinary symptoms are not common, but occasionally 
one sees a man who complains that he has to get up sev- 
eral times at night to urinate, or that he has to do so 
frequently in the daytime. Questioning will reveal that 
he passes only a small amount of clear urine each time, 
that there are no other urinary symptoms, and that there 
is no history of urinary disease. The urine is normal on 
examination. 
Almost without exception these patients sleep poorly. 
They say that it "takes at least an hour to get to sleep.” 
They are often night-owls, who stay up until very late 
because they are "not sleepy.” Usually they sleep lightly, 
but not always. Often they complain of nightmares or 
weird dreams. Almost universally they have morning 
fatigue. It is very rare to find one who does not say that 
he is "tired” when he wakes up. When a man complains 
that he is "tireder when I get up than when I go to bed,” 
one can almost make the diagnosis forthwith. This morn- 
ing fatigue is often accompanied by a feeling of weak- 
ness, which wears off during the day, leaving the patient 
feeling all right in the afternoon. 
In the daytime these people are restless, and often 
irritable and excitable. They "can’t sit still.” Frequently 
they cannot tolerate crowds or closed spaces. 
A small or finicky appetite is common among them, 
and it is very rare that one is found aboard this ship who 
does not smoke excessively and drink large amounts of 
coffee. It is not unusual to find a man who drinks 20 large 
mugs of coffee each day, and smokes 2 packs of cigar- 
ettes. 
The physical examination correlates well with the his- 
tory. It reveals an unhappy and worried man, with a gen- 
erally hyperactive autonomic nervous system. A sad face 
is so usual among patients of this sort that the hospital 
corpsmen have nicknamed them the "long-faced men.” 
There is a fine tremor of the outstretched hands; the 
palms are moist and clammy; there is axillary sweating, 
even in a cold room; the pulse may be very rapid, but 
usually it is about 80 or 90, and of small volume. Sighing 
respirations may be seen. Epigastric tenderness often 
appears in those who complain of epigastric pain, and a 
spastic colon can be palpated in some who have spastic 
constipation. Hyperactive deep reflexes appear about half 
of the time. 
The widespread notion that people with symptoms of 
this type have an "asthenic” body build has proved in 
our cases to be entirely erroneous. It is true that there are 
many of them who are tall, thin, and slack-muscled; but 
the fat, the chubby, and the robust are just as common 
as the thin. 
The past history and the family history are almost with- 
out exception significant. They will be discussed at greater 
extent later. Suffice it to say here that it is rare to find a 
patient with this syndrome who does not give a past his- 
tory of various prodromal nervous stigmata in childhood, 
and who does not give a family history of having had 
one or both parents with similar symptoms, and of having 
been raised in a disrupted home in which parental love 
and guidance were lacking; and there is hardly one of 
them in whom some deep seated conflict or insecurity 
cannot be discovered. 
There can be no doubt that we are dealing with a true 
psychosomatic syndrome. Laboratory tests confirm what 
the history and physical examination suggest. In the 
patients with "epigastric distress” a high gastric acidity 
often can be demonstrated. The very anxious ones some- 
times run an afternoon temperature of 99.4 to 99-8 as 
they lie in bed in sick bay (2). Those with circulatory 
symptoms show poorly compensating cardio-vascular sys- 
tems, with persistent tachycardia after slight exercise; 
others, paradoxically, show a fall in pulse-rate several 
minutes after exercise. Those who smoke excessively 
sometimes have ventricular extrasystoles. A physician who 
persists in seeking an "organic cause” (in the usual sense 
of the word) for the complaints of these patients will find 
72 Chapter 16.—NEUROPSYCHIATRIC PROBLEMS ON A BATTLESHIP 
enough "red herrings” to keep him busy and suspicious 
for months. 
The diagnosis is always made upon a positive basis, not 
upon a single symptom, but upon the presence of the 
whole syndrome. It can almost be said that regardless of 
the type of psychoneurosis present this syndrome can be 
found in whole or in part. An unhappy and irritable man 
is seen. He has one of the common presenting symptoms, 
such as epigastric distress. The history shows that he has 
been restless also, that he sleeps poorly, awakens tired, 
has headaches, is constipated, and smokes heavily. He is 
sweating in his axillae, and there is a fine tremor of his 
outstretched fingers. He has "always been a little ner- 
vous.” He was a shy child. His mother had a nervous 
breakdown. Physical examination and laboratory tests are 
as previously described. Such is the usual patient. 
The knowledge of the significance of this syndrome 
has greatly facilitated the diagnosis of many cases. "Pain 
in the leg” after an alleged "fall,” can be suspected of 
being hysterical from the very first, if this syndrome is 
present. A few days of observation and neurological tests 
will usually rule out ruptured intervertebral disc and 
other organic lesions. "Backache” or "flat feet” to which 
intolerable—and intractable—symptoms are referred, can 
be recognized as a "fixation” symptom, if the anxiety 
syndrome is also present. Even though there is a slight 
functional scoliosis, or moderate pronation of the feet, 
it can be recognized from the first that psychiatric as well 
as physical treatment will be necessary to effect a cure. 
Of course, one must never forget the true "organic 
diseases” which the syndrome simulates. Hyperthyroid- 
ism and peptic ulcer must always be considered, and ruled 
out. Perhaps these diseases differ from this syndrome 
more by degree than by nature, and develop from it. 
Organic heart disease must be sought for and suspected. 
Intracranial neoplasm and chronic sinusitis may be pres- 
ent in those with headache or they may have migraine, 
or any one of the many other causes of headache. And of 
course there is nothing to prevent a patient with the 
anxiety syndrome from having an "organic disease” also. 
However, if the nature of the syndrome and its specificity 
is recognized from the first, many fruitless laboratory 
procedures are avoided. There are probably a very great 
many men in the Navy who are receiving prostatic mas- 
sages, wearing orthopedic shoes, or undergoing extensive 
x-ray studies, who could be helped more by firm but 
kindly explanation of the nature of their symptoms, and 
an attempt to help them adjust to Navy life. 
Actually, this anxiety syndrome is only the somatic 
expression of a psychic disorder. In every case the history 
reveals the patient to have had either some pre-existing 
evidence of psychic instability, or a profound and recent 
psychic trauma (such as the sudden revelation of a wife’s 
infidelity). However, we have resisted the temptation to 
hang the label "psychoneurotic” on these men, despite 
the fact that if we had to admit them to the sick list, per- 
haps 95 percent of them might be so diagnosed. Most of 
them were outwardly well adjusted in civil life; nearly 
all of them, as we shall show, have made adequate sailors. 
Although their symptoms may be regarded as "psycho- 
neurotic,” their illness is usually not profound enough 
to warrant the diagnosis "psychoneurosis.” Nor do they 
have true "operational fatigue,” as we shall show also. 
We have found it to be a grave therapeutic mistake, in 
most cases, to give a man either of these diagnoses and 
admit him to the sick list. It only convinces him that he 
is a "sick man.” It gives him a peg to hang his hat on. 
Most of these patients have simple anxiety states, which 
are amenable to ambulatory shipboard treatment. 
NATURE OF THE SERVICE TO WHICH THESE 
MEN WERE EXPOSED 
The men in whom these diseases appeared were mem- 
bers of the crew of a ship which has been overseas for 31 
months. It has taken part in 11 Pacific campaigns, 7 shore 
bombardments, and 1 major fleet action. It has been under 
air attack perhaps half a hundred times. During nearly 
all of this period it has been operating in tropical waters. 
It has been hot and crowded. Its crew has stood a "watch 
in three” for months on end. Cruises of up to 6 weeks 
duration have been broken only by a brief stay in some 
bleak Pacific atoll, during which ammunition loading and 
repairs were constantly under way. A man who has been 
aboard for the full 934 days of operation will have had a 
total of 914 hours, or 38 days, available for recreation off 
the ship (on some small tropical sandpit on which recrea- 
tion consists of a swim and 3 cans of warm beer) and 21 
days’ leave in the United States. 
For all this, the service aboard a ship of this type is 
comfortable compared to that aboard most other vessels. 
Creature comforts—warm food, a varied diet, ice cream, 
moving pictures, laundry service—are never lacking. "Safe- 
ty” is as great as can be found upon a combatant ship. 
Utter boredom and chronic fatigue, however, these men 
share with all other men at war, and in no less measure. 
Are these men suffering from operational fatigue? 
In 98 percent of our cases, the symptoms were found 
to be "service aggravated”—that is, they are worse now 
than they were when the individual came into the service. 
On the other hand, in what sort of people have these 
symptoms appeared? In 87.3 percent of our cases there was 
a past history of neuropsychiatric symptoms before entry 
into the service. Either they had their present symptoms in 
73 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
a milder form (most of them did), or they showed those 
childhood and youthful stigmata which are generally 
agreed to predispose to neuropsychiatric disease: Excessive 
shyness, night terrors, sleepwalking, bedwetting, inability 
to adjust to school, a high truancy or juvenile delinquency 
record, running away from home, changing from job to 
job without sufficient cause, and so on; most of them had 
the childhood stigmata, and their present symptoms as 
well, before their induction. In addition, 86.3 percent of 
them had a family history conducive to neuropsychiatric 
disease, in the sense that it showed one or more of the fol- 
lowing: One or both parents who were extremely nervous 
or had a "nervous breakdown"; a home broken by divorce, 
infidelity, the early death of a parent, alcoholism, or some 
similar cause; or the absence of parental supervision and 
affection for the child. In 78.4 percent of the cases both 
the family history and the past history were positive. Only 
5.9 percent of the cases were negative in both respects; 
about half of these were considered "reactive depres- 
sions,’’ and the remainder consisted of boastful, resentful, 
and un-cooperative individuals who are suspected of con- 
cealing a part of their history. 
Neuropsychiatric disease on this ship has appeared al- 
most entirely among the predisposed. 
the hospital from this ship during the past 18 months for 
neuropsychiatric disease, only one showed a negative past 
history, and had clearly been through enough strenuous 
action (on another ship) to warrant the belief that the 
symptoms had developed de novo since entry into the 
service. 
A careful evaluation of all of our cases by rate and 
division showed only one type of duty aboard this ship 
which might be conducive to true "operational fatigue’’— 
that of radioman. The incidence of anxiety states among 
these men was about twice as high as among the rest of 
the crew. Positive family histories were present, but not 
as striking as in most other cases. There is no doubt that 
the work of the radiomen is gruelling. They stand one 8 
hour watch in three, guarding the circuits. During these 
watches they spend alternate hours copying code at a rapid 
rate, a job which requires the utmost speed and concen- 
tration, and the remainder of the time transcribing what 
they have taken down, another job requiring great atten- 
tion to detail, although it is regarded as a "rest" from tak- 
ing code. Their work goes on in port just as it does at sea; 
sometimes it is heavier in port. It continues Sundays and 
holidays without a break. A high degree of nervous fatigue 
develops among the operators, and even those who are 
not susceptible to the development of anxiety states be- 
come stale and tired. 
TREATMENT USED, AND RESULTS OBTAINED 
The treatment of these cases has been of the simplest 
sort. The medical department of this ship does not in- 
clude a specialist in psychiatry, and no complex psychiatric 
therapy was attempted. We tried merely to enable these 
men to carry on and to be effective sailors, and to prevent 
their illness from reaching proportions which would re- 
quire hospitalization. 
By the time each man had told his whole history, in- 
cluding the nearly always significant family and past his- 
tory, the nature of his symptoms was usually suspected by 
him. The first move was to explain his condition to him 
and the causes of it. If necessary, several discussions were 
held with him. He was told that his symptoms were annoy- 
ing, but that they were common to his condition, and 
would not hurt him. It was impressed upon him from the 
very first that he was not really "sick,’’ and he was as- 
sured that he would be treated aboard this ship, and that 
he would get better as time went on. Such family prob- 
lems and financial difficulties as could be alleviated by 
arrangement with the chaplain and various relief agencies 
at home were so attacked, and conflicts within the man’s 
division were ironed out where it seemed wise to do so. 
However, these people are of such nature that if one 
of their problems is removed they will usually find another 
Table 22.—Incidence of neuropsychiatric disease 
Total time overseas 
Percent of 
patients 
Percent of 
crew 
31 months or more1 
38.6 
35 
17 to 31 months 
12 
20.1 
Less than 17 months 
49.4 
44.9 
'The incidence is just as high among those who have been aboard less 
than 5 months. 
Prolonged duty of this type per se does not appear to 
cause neuropsychiatric disease. The incidence of neuro- 
psychiatric disease is shown in table 22. It can be seen that 
neuropsychiatric disease is no more common among those 
who have been aboard 31 months, than among those 
who have come aboard recently. 
An investigation of the histories of our patients shows 
that the causes of their anxiety were these, named in the 
order of their importance: (1) Anxiety over the family 
situation at home; (2) sexual (i. e. "love") conflicts; (3) 
inability to adjust to the shipboard routine and to "get 
along" with their shipmates and petty officers; and (4) 
worries about personal health. Not over 5 percent ad- 
mitted to any anxiety over their own safety, although per- 
haps 25 percent admitted having nightmares about the 
ship sinking, etc. 
It is not permissible to give figures for patients hos- 
pitalized, but it can be said that of those patients sent to 
74 Chapter 16.—NEUROPSYCHIATRIC PROBLEMS ON A BATTLESHIP 
to worry about, and the result of this line of treatment has 
not been gratifying in most cases. Their main conflict is 
with military life, and cannot be removed if they are to 
be retained in the service. 
Further therapy to the patient himself was on physio- 
logical lines. Men who were acutely upset and "jittery” 
were admitted to the sick bay for several days and sedated 
with barbiturates until they had "cooled off.” It was ex- 
plained to them that cigarettes and coffee only increased 
their "nervous tension,” and they were given stern 
orders to "cut it out.” Of course, very few of them ac- 
tually stopped smoking, but most of them gave up the 
coffee and cut down the cigarette consumption materially, 
to their great benefit. They were also told of the necessity 
of getting some form of relaxation in the afternoon, pref- 
erably physical exercise, to "take the steam off” and make 
them sleep better. They were urged again and again to 
exercise, no matter how "tired” they felt. If they had been 
shore based, instead of being aboard ship where it is dif- 
ficult to obtain exercise in any form, doubtless we would 
have had better results with them. As it turned out, those 
who actually did exercise found that the increased "physi- 
cal fitness” of their cardiovascular system greatly de- 
creased their distressing pounding of the heart and extra- 
systoles, and "improved their wind”; they were more 
physically tired at bedtime, slept more soundly, and awoke 
less fatigued. 
Unless the case proved intractable to all other forms of 
therapy, we attempted to avoid the use of medications. 
The reduced consumption of coffee and cigarettes, the 
avoidance of the most highly seasoned foods, and in- 
creased rest and exercise, went a long way to abolishing 
"epigastric distress”; the symptoms which remained usual- 
ly responded to one or two "soda mint” (flavored sodium- 
bicarbonate) tablets after meals. The constipated were 
not given laxatives; they were told that it would not hurt 
them if they had a bowel movement only once in 2 days, 
and it did not. Every effort was made to prevent them 
from worrying about their health. They were always en- 
couraged to stop worrying about having an ulcer, and "let 
the doctor worry about it.” Only occasionally were men 
given phenobarbital. It was found that sedation, except 
for men confined to the sick bay, was unsatisfactory. 
From the point of view of enabling these men to "carry 
on” and become adequate sailors, our results have been 
eminently satisfactory. Only 5.4 percent of our patients 
have received quarterly marks for proficiency in rate which 
were below 3.0. Ninety-five percent of them received 
grades above 3.5 in conduct, and 81.6 percent of them 
were marked 4.0. The number of courts-martial and cap- 
tain’s masts awarded them was no higher than those which 
would usually be awarded to a random sample of the crew. 
On the other hand, they might still be labeled "psycho- 
neurotics” if we wished to do so. Their basic nature is 
unchanged, and unfortunately, their symptoms often per- 
sist; but most of them have developed insight into their 
condition, and have adjusted their conscious thoughts, 
at least, to staying out here and "getting on with the war.” 
The following tables indicate the response of our pa- 
tients to treatment, with respect to insight and alleviation 
of symptoms: 
Table 23.—Insight and conscious adjustment to "carrying on” 
Degree of insight 
Percent of 
patients 
None 
5.8 
50 percent or less 
15.1 
50 percent to 90 percent 
32.6 
90 percent or more 
46.5 
Degree of alleviation 
Percent of 
patients 
3.5 
18.6 
25 percent improved 
24.4 
50 percent improved 
25.6 
16.3 
90 percent improved 
11.6 
Table 24.—Alleviation of outward symptoms 
We are particularly impressed by the improvement 
made by our patients with hysterical "paralyses” and 
paresthesias. We have seen 13 of them. One was hospital- 
ized. The remaining 12 are still aboard, every one of them 
has recovered entirely from his hysterical symptoms, and 
has remained free of them over observation periods of up 
to a year. 
CONCLUSIONS 
1. Regardless of the neuropsychiatric names by which 
it may be called, the neuropsychiatric disease seen aboard 
this ship is largely in the form of a psychosomatic anxiety 
syndrome, and it is not of a severe nature. It can be diag- 
nosed on a positive basis from the history and physical 
examination. 
2. The vast majority of the neuropsychiatric problems 
which are present aboard this ship have appeared only in 
men who can be shown to have had neuropsychiatric 
symptoms previous to their induction. 
3. Except in the case of radiomen, there is no evidence 
that the neuropsychiatric disease which has developed 
aboard this ship has been caused by the strenuous nature 
of the duty to which the men have been subjected. The 
provoking cause is the removal of a susceptible individual 
75 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
from his civilian environment and his introduction into a 
new environment to which he must adjust. 
4. Proficiency, conduct, and punishment records on 
neuropsychiatric patients show that these men, as treated 
aboard this ship, have made satisfactory sailors. In this 
connection, however, it must be admitted that this ship 
has never had to face the ordeal of suffering heavy casu- 
alties, and the performance of these men under such cir- 
cumstances has not been tested. They have performed 
well in many air attacks, some of which were pressed home 
with vigor. Less than 15 percent of those which we have 
attempted to treat have had to be hospitalized because of 
failure. 
REFERENCES 
1. Jones, M. and Scarisbrick, R.; Effort intolerance in sol- 
diers; review of 500 cases. War Med. 2: 901-911, Nov. 
1942. 
2. Friedman, M.: Etiology and pathogenesis of neurocircula- 
tory asthenia; hyperthermia as one of the manifestations 
of neurocirculatory asthenia. War Med. 6; 221-227, Oct. 
1944. CHAPTER 17 
NEUROPSYCHIATRIC EXPERIENCES 
IN ADVANCE BASE UNIT’ 
Follow-up information in doubtful neuropsychiatric 
cases and evaluation of the results of "screening" pro- 
cedures for naval recruits are obtained with difficulty. A 
unique opportunity, however, to examine a group of men 
from the neuropsychiatric standpoint, to live with them, 
and to observe their subsequent course, resulted in calling 
attention to some psychiatric errors and pointed the way 
to more efficient detection and disposal «f the psychi- 
atrically unfit. 
The experiences constituting the subject matter of this 
chapter occurred while serving with an advance base unit 
during its organization, transportation overseas, and stag- 
ing period at the advance area. 
The group composing the unit was organized at a 
training center in the United States for the purpose of 
training for duty and transportation to an overseas base. 
The unit consisted mostly of technician ratings who were 
specialists in the various activities pertinent to an ad- 
vance base. 
Upon completion of the training period, the unit was 
shipped overseas to a staging area, where it remained sev- 
eral months. At this area many ratings were employed in 
various activities about the base. Of necessity much of 
the work was unrelated to the specialties in which the men 
were rated. 
Finally the unit left this area and moved forward to 
establish its own advance base. When this had been dgne 
the original unit was formally dissolved, and the personnel 
remained as base personnel. 
The following observations were made over the 9- 
month period in which the unit was in commission. 
Procedures at the training center.—At the training 
center in the United States, each man assigned to the unit 
was given a physical and neuropsychiatric examination to 
determine his fitness for overseas duty. Notes were taken 
of the findings and of the impressions of the psychiatrist 
and these were filed for future reference. Thus when a 
patient was referred for consultation later on, it was pos- 
sible to obtain the file and compare original impressions 
with those obtained at consultation. The advantages of 
keeping this file were obvious; it served as a valuable 
check on patients’ later statements of having had com- 
plaints of long standing, such as headache, enuresis, and 
"nervous trouble," and enabled the psychiatrist to observe 
his own sources of error. 
The type of examination given was a brief (3 to 5 
minutes) "screening" examination modeled on that de- 
veloped by Wittson and his coworkers2 at the United 
States Naval Training Station, Newport, Rhode Island. 
This was supplemented by return visits of persons whose 
fitness was doubtful. As much time as necessary was al- 
lotted to these return visits. As a result of this procedure, 
every patient examined was placed in one of the three 
following categories: (1) Rejected and transferred to a 
U. S. Naval Hospital; (2) accepted for overseas duty with 
a notation of "doubtful” on his file card, with findings; 
and (3) accepted for overseas duty with negative neuro- 
psychiatric findings. Accordingly these three groups are 
referred to as "rejected,” "doubtful,” and "negative.” 
The following information was obtained in the "screen- 
ing” examination: Name, rate, age, social status, married 
or single, church, years in school, history of headaches, 
dizzy or "faint" spells, convulsions, "nervous trouble,” 
enuresis, somnambulism, stutter, arrests, alcoholism, head 
injuries, and serious physical illnesses, kind and duration 
of last civilian employment, presence of psychotic, psycho- 
neurotic or "psychopathic” manifestation, and neuro- 
pathologic conditions. 
JBy Kenneth Kelley, Lieutenant Commander (MC) U.S.N.R. 
2Wittson, C. L. ; Harris, H. I.; and Hunt, W. A.; Detection of neuro- 
psychiatrically unfit. U. S. Nav. M. Bull. 40: 340-346, April 1942. 
77 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 25.—Distribution and disposal at training center 
Original category 
No. 
examined 
Percentage 
referred for 
consultation 
Percentage 
to duty after 
consultation 
Percentage 
transferred 
964 
3.52 
2.38 
1.14 
84 
21.4 
17.84 
3.57 
30 
100 
During return visits of "doubtful” patients, any sug- 
gestion of neurologic or psychiatric tendencies obtained in 
the first interview was amplified and investigated. 
Prophylactic procedures.—It was thought that the long 
voyage overseas, with its delays at anchor in various ports 
and the resulting inactivity, would provide a considerable 
morale problem and a strain on the unstable. This proved 
to be correct. In order to combat this condition, lectures 
were given to groups, mostly hospital corpsmen, on morale 
and its promotion. The points stressed were the desirability 
of the following: (1) Understanding and discussion of 
war aims; (2) awareness of the universality of fear in 
appropriate situations and of minor manifestations of 
"nervousness”; (3) cultivation of social insight and judg- 
ment; (4) a frank recognition and discussion of the prob- 
lems of adjustment to discipline, to periods of inactivity, 
to crowding, to the uncertainties of the future, and to phys- 
ical discomfort; (5) the cultivation of all possible extra- 
curricular activities or "hobbies”; (6) the acquisition of 
knowledge of one’s environment and of facility in making 
specific adaptations to it. 
In addition informal talks on subjects of general in- 
terest, designed to provide information and stimulate 
thought on "hobbies,” world affairs, and the prospective 
environment, were given. 
The result of these talks was difficult to evaluate, but 
many contacts with the men led to the belief that they 
were of considerable prophylactic value. 
Consultation procedures.—On board ship, and at the 
staging area, medical officers were made aware of the 
facilities for neuropsychiatric consultation. Information 
concerning complaints and their immediate history was 
solicited from medical officers, divisional officers, and 
from shipmates of the men who were referred for consul- 
tation study. Upon request psychiatric examination was 
conducted according to standard practice, and the findings 
recorded. Finally reference was made to the patient’s file 
card, and recommendations relative to disposition were 
communicated to the senior medical officer. 
Treatment.—Treatment facilities were limited because 
of the lack of facilities for hopitalization and observation, 
the large case load from referrals, and the impossibility 
of establishing any routine times or places for treatment 
interviews. 
Reassurance and constructive advice, or recommenda- 
tion for transfer to a hospital was all that could be done 
in most cases. In some instances, however, more extended 
and repeated therapeutic interviews were carried on, aimed 
at emotional catharsis and the promotion of superficial 
insight. Deep psychotherapy was out of the question be- 
cause of the short time available and the impossibility of 
any regularity or system. 
Every man not transferred had to be considered satis- 
factory for duty within a few days. As a systematic thera- 
peutic program of any magnitude could not be followed, 
a few patients were carried along with infrequent casual 
interviews, but the majority could be seen only two or 
three times. 
Treatment of chronic borderline neurotics and unstable 
personalities consequently proved unsatisfactory under 
the circumstances. It is doubtful whether treatment of the 
chronic unstable and unfit can ever be adequate at ad- 
vance bases—a potent reason for making every possible 
effort to "screen” these persons before they leave the con- 
tinental United States. It is true that about two-thirds of 
the referral patients were handled successfully without 
the necessity of transfer. But these were mostly mild, acute, 
reactive types, easily yielding to simple measures. It is be- 
lieved, however, that more would have had to be trans- 
ferred had no therapy been available. 
Table 26.—Marital status 
Percentage of 
whole 
group 
Percentage of 
training- 
center 
transfers 
Percentage of 
referrals 
returned 
to duty 
Percentage of 
referrals 
transferred 
Percentage of 
total 
psychopathology 
seen 
Married 
28.3 
71.7 
44.8 
55.2 
55.2 
44.8 
50 
50 
50 
50 
Single 
78 Chapter 17.-NEUROPSYCHIATRIC EXPERIENCES IN ADVANCE BASE UNIT 
Table 27.—Age distribution 
Age 
Percentage of 
whole 
group 
Percentage of 
training- 
center 
transfers 
Percentage of 
referrals 
returned 
to duty 
Percentage of 
referrals 
transferred 
Percentage of 
total 
psychopathology 
seen 
17-26 
77.4 
65.5 
57.9 
78.5 
67.3 
27-36 
18.8 
24.1 
31.6 
14.4 
23.4 - 
37-46 
47-56 
3.7 
0.1 
10.4 
10.5 
7.1 
9.3 - 
The figures shown in table 25 indicate that about two- 
thirds of all those men who had to be taken out of the 
unit for neuropsychiatric reasons within 9 months, were 
rejected at the training center. Theyjdso show that neuro- 
psychiatric referrals were times as frequent 
and transfers about three times as-frequent among the 
"doubtfuls” as among the "negatives." 
The marital status of the examinees is seen in table 26; 
figures representing the percentage of married or single in 
the group indicated are given. 
These figures show that the proportion of neuropsy- 
chiatric patients who were married was greatly in excess 
of the proportion of married men in the whole popula- 
tion. The age distribution is seen in table 27. 
These figures indicate that the proportion of 17- to 26- 
year-olds in the total psychopathology group seen was less 
than their proportion in the whole population; the reverse 
was true of the 37- to 46-year-olds. 
Table 28 shows the diagnoses among the group "re- 
jected” at the training center. 
Table 29.—Conditions causing refection after leaving States 
Diagnosis 
Original category 
’’Doubtful” 
"Negative” 
Dementia praecox 
1 
4 
Psychoneuroses 
0 
1 
Constitutional psychopathic states 
1 
3 
Posttraumatic personality disorders 
0 
3 
Psychosomatic problems 
1 
0 
Totals 
3 
11 
Table 30 shows the diagnoses among those returned to 
duty after overseas referral for consultation. 
Table 30.—Conditions causing referral after leaving States 
Diagnosis 
Original category 
"Doubtful” 
"Negative” 
Psychoneuroses 
1 
3 
Constitutional psychopathic states 
9 
11 
Psychosomatic problems 
1 
0 
Migraine 
2 
1 
Posttraumatic personality disorders.... 
I 
0 
Malingering 
0 
1 
"Nonpsychiatric” 
1 
7 
Totals 
15 
23 
Table 28.—Conditions causing rejection at training center 
Dementia praecox 
1 
Psychoneuroses 
7 
Constitutional psychopathic states 
15 
Posttraumatic personality disorders 
4 
Epilepsy 
1 
Enuresis 
1 
Stuttering 
1 
Total 
30 
From tables 26 to 30 it will be seen that of a total of 52 
men who were referred for consultation after being 
shipped out, 8 were "nonpsychiatric,’’ 1 was a malingerer, 
14 were transferred, and 29 were returned to duty after 
simple therapeutic procedures. In other words, about two- 
thirds of the psychopathology found could be successfully 
treated by the simple methods described. 
The patient with enuresis who was rejected at the 
training center was likewise found inadequate, immature, 
and unstable. ' 
The case of "stuttering" rejection was so severe that 
the individual, at times of stress, could not, for minutes 
at a time, make himself understood. 
The diagnoses of those patients transferred after ship- 
ping out are listed in table 29. 
Tables 28 and 29 show the relative preponderance of 
various types of personality disorders (constitutional 
psychopathic states) as disabling psychiatric disabilities. 
Among the schizophrenics, two-thirds were completely 
missed at the examination for overseas service, a fact which 
suggests extreme difficulty in detecting them before regres- 
sion sets in and the need for special care in the examina- 
tion of "schizoid personalities.’’ 
79 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Only four inverts came to the attention of the psychia- 
trist. One had been classified as "doubtful” in the United 
States; he adjusted after superficial therapy. Three had 
been undetected at the training center; one of these had 
to be transferred in an anxiety state, and two adjusted 
after superficial therapy. It is not to be supposed that the 
three who adjusted were "cured,” but rather that they 
adapted to their situation, carried on with reasonable ef- 
ficiency, and caused no trouble. 
One of the men with posttraumatic personality disorders 
transferred after shipping out had received a head injury 
at the training center 10 days before leaving. He was 
without symptoms when he was shipped out. 
One "doubtful” patient was transferred, with the diag- 
nosis of constitutional psychopathic state, after leaving the 
United States. He displayed considerable anxiety and was 
inadequate. He was returned to duty from an overseas 
base hospital, the only one in the series so returned, just 
as the unit was dissolved. By the time he rejoined the unit 
his condition was exactly the same as before his transfer. 
The patients listed as "nonpsychiatric” were mostly dis- 
ciplinary problems, whose behavior could not be estab- 
lished as psychopathologic, and who were reported to 
the referring officer as "administrative problems,” as also 
were most of those with a diagnosis of constitutional psy- 
chopathic state. 
COMMENT 
In discussing the findings it is necessary to bear in mind 
the history of the unit; it was never at any time a front- 
line combat echelon and consequently the conditions re- 
ported had no relation to combat fatigue or combat trauma. 
On the other hand there was always the possibility of sub- 
marine or air attack, and there were long periods of in- 
activity, or of routine labor mostly unrelated to the spe- 
cialized training of the persons involved. 
Disregarding details concerning causative factors, and 
pending a thorough review of the case histories, it is pos- 
sible to assign major importance to the following condi- 
tions: Constitutional predisposition; preexisting psycho- 
pathologic behavior patterns; separation from former re- 
lationships of emotional dependence; unstable business and 
domestic affairs at home; inadequate appreciation and 
understanding of war aims and of the mission and out- 
look of this particular unit; inadequate resources in the 
individual for sublimation, such as hobbies or study; an 
environment involving considerable physical discomfort; 
unconscious homosexual tensions arising from the pro- 
tracted and inescapable intimacies in an exclusively male 
social body; and a general lack of social insight and judg- 
ment. 
In view of the opinion frequently expressed that hetero- 
sexual deprivation, as such, is often of etiologic signific- 
ance, it is interesting to note that this did not appear as a 
causal factor in any case observed. Moreover the majority 
of these men had not even spoken to a woman in 9 
months. 
Certainly the most productive means of attack on psy- 
chiatric disease in this type of unit is prophylaxis, both by 
adequate "screening” before shipping out and by efforts 
to minimize or forestall the effects of the aforementioned 
factors. 
Regarding screening, there is one hazard which must 
be pointed out. Not infrequently division officers and 
others in authority over the men will protest against the 
medical officer’s recommendation for rejection of a cer- 
tain person, alleging that he is indispensable to the unit, 
or that "the Navy will make a man of him,” or the like. 
Errors of this type have convinced the writer that better 
results are to be expected when reliance is placed upon 
expert rather than lay judgment. Once chronic psycho- 
pathosis of any magnitude appears, treatment at any ac- 
tivity short of a psychiatric hospital in the continental 
United States is useless. These people simply cannot 
adapt themselves to the exigencies of this kind of situa- 
tion, and their presence as psychiatric cripples contributes 
to the instability and inefficiency of the entire unit. There 
is no prospect that treatment overseas will enable them to 
"pull their own weight.” This opinion, however, does 
not apply to the acute neuroses of war. Persons with su- 
perficial, minor complaints that can be dealt with by re- 
assurance and catharsis in a few interviews can be bene- 
fited considerably. 
80 CHAPTER 18 
PSYCHIATRIC PREPARATIONS FOR COMBAT 
IN A MARINE DIVISION* 
The psychiatric measures undertaken in preparation for 
combat, in a Marine Corps division during its last months 
of training in the final staging area, are most important. 
The objectives sought in the work done on a tropical 
island just south of the equator in the Southwest Pacific 
were: (1) The elimination of the psychiatric unfit; (2) 
the promotion of mental health; (3) the inauguration of 
preventive psychiatric measures in actual combat; and (4) 
the preparation for the care of psychiatric casualties in 
the field. 
Elimination of the psychiatric unfit.—Though the 
screening of the psychiatric unfit is chiefly the responsi- 
bility of psychiatric units in induction stations, recruit 
training camps, and other advance training centers, a num- 
ber of cases are first detected in the final staging area. In 
the final month of training, 38 patients had to be hospital- 
ized for medical survey. Of these it is considered that 14 
could have been detected earlier in their training, 20 were 
incapacitated because of psychiatric illness connected with 
combat or with other service conditions, and 4 developed 
a psychiatric disorder unassociated though coincident with 
service life. Brief histories of typical cases follow. 
CASE REPORTS 
Case 1.—A 23-year-old Marine was referred for psychiatric 
consultation because of his frequent disciplinary offenses, often 
associated with his apparent inability to understand orders given 
to him. He had been unable to learn in school, but had been 
pushed along to the seventh grade because of his size. Several 
times in civilian life he was jailed for such offenses as extreme 
profanity or flying into uncontrollable rages. On examination 
he was found to have an I. Q. in the moron range, and decided 
psychopathic tendencies. 
Other cases that could have been detected earlier in 
training include 6 schizophrenics, 3 epileptics, 1 feeble- 
minded, a psychosis unclassified, a psychoneurotic, and a 
homosexual. 
Case 2.—A 20-year-old Marine was referred because of a 
variety of neurotic complaints which did not respond to sympto- 
matic treatment. He had been overseas 28 months, having seen 
action at Tarawa and Saipan. His symptoms began following 
his last campaign and increased in severity as further combat 
became imminent. His past history was irrelevant. He had com- 
pleted the tenth grade in school, and had worked successfully 
as a machinist’s apprentice. He was considered suffering from 
operational fatigue. 
There were 19 other cases similar to case 2. 
Case 3.—A 21-year-old Marine was referred by his command- 
ing officer following a letter received from his wife expressing 
concern regarding his mental condition. His letters had become 
strange and incoherent. The past history was unrevealing. He 
had served satisfactorily in two combat operations. The family 
history revealed that his mother was confined in a state mental 
institution. On examination the patient was clearly psychotic, 
with blunted affect, distortion of thought processes, ideas of 
unworthiness, and auditory hallucinations. A diagnosis of 
schizophrenia was made. 
Among the other cases unrelated to service conditions 
were another schizophrenic, an acute manic, and a man 
with migraine. In addition to the 38 patients who were 
hospitalized, 23 others were seen in the same period and 
were returned to duty after treatment. Most of these had 
mild neurotic symptoms associated with prolonged over- 
seas duty. In the subsequent combat operation, none of 
these became psychiatric casualties. 
Promotion of mental health.—After consultation with 
the commanding general, who was most cordial and co- 
operative, it was decided that a direct mental hygiene ap- 
proach to the enlisted men in their final stage of training 
would be unwise, because of the danger of being more 
disturbing and provocative than helpful. It was thought, 
however, that a series of talks on psychiatric subjects 
would be most useful for the officers. These consequently 
were given to groups in the various regiments of the divi- 
sion. 
*By Philip Solomon, Lieutenant Commander (MC) U.S.N.R. 
81 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
The talks were brief, lasting about 20 minutes. They 
stressed the military importance of psychiatric casualties, 
both in reduction of total strength and in effect on the 
morale of the remaining men. A parallel was drawn be- 
tween mental health and physical health. It was pointed 
out that physical health was more than the absence of dis- 
ease, that it was a positive matter involving the develop- 
ment of robust musculature, endurance, resistance to in- 
fection, and, in military life, particular immunity toward 
those physical diseases prevalent in the various war thea- 
ters, such as tetanus, typhoid, typhus, cholera, yellow fever, 
smallpox, and plague. 
Similarly mental health comprises such positive ele- 
ments as alertness, resourcefulness, high spirits and morale, 
courage, and particular immunity toward the chief psy- 
chiatric disorder of war, "combat fatigue.” In the produc- 
tion of mental health in troops the following topics were 
discussed: Good leadership, with the recognition of the 
enlisted man as an individual; thorough training, result- 
ing in self-confidence (the antidote to fear) under all 
battle situations; strategic orientation, knowledge of what 
we are fighting for; tactical orientation, understanding of 
the purpose and importance of the particular military mis- 
sion; morale measures, including the full utilization of 
recreation officers, chaplains, and Red Cross representa- 
tives. 
Preventive psychiatric measures in actual combat.—Of- 
ficers were impressed with the importance of a proper 
attitude toward the man who is a psychiatric casualty in 
battle. Such a man is not to be considered a moral weak- 
ling, since any man, including the officers themselves, 
may be the victim if he is sufficiently exposed to the cau- 
sative factors. The chief causative factors discussed were: 
Extreme and prolonged physical fatigue, lack of proper 
food, lack of water, insufficient sleep, exposure to cold 
and wet, and the psychologic effects of acute danger to 
oneself with the sight of others killed and maimed. 
It was recognized that all of these are often unavoidable 
in a military operation. The purely military demands and 
exigencies must come first despite cost in men. Particu- 
larly is this true in the traditional Marine policy of ag- 
gressiveness and rapid attack. A quick win, notwith- 
standing casualties, may well save lives in the end. But in 
assessing the cost, officers must not lose sight of, or un- 
derestimate, the potential losses inherent in exposing men 
for too long a period to the catastrophic forces of war. 
Emphasis was placed on the value of more frequent rota- 
tion of men in the front lines, of providing as far as pos- 
sible the elementary comforts of life, of rewards for the 
foot-slogging infantryman, and during rest periods, of the 
few luxury elements that are available even in the field. 
In this last connection the full utilization of the Red Cross 
field representatives was urged. It was added that at 
times, when such a thing is possible, it is a tremendous 
morale booster to let men know when their period of or- 
deal is scheduled to end. 
It was admitted that despite all efforts, some psychia- 
tric casualties are inevitable. The importance of recogniz- 
ing these cases as early as one recognizes physical casual- 
ties was emphasized, since immediate treatment is just as 
urgent in the one case as in the other. A comparison was 
drawn between the fighter and the familiar truck tire. 
Each can be retreaded if steps are taken before the wear 
is too great. But once the wear is allowed to go through 
the vital fabric, there is a "blowout” and each is through. 
In mild cases officers may take matters into their own 
hands and provide the necessary rest and rehabilitation. In 
more serious cases, however, the aid of the medical officer 
should be sought. 
A word was added regarding officers themselves. 
Though they are undoubtedly more stable as a group than 
the enlisted men, they are human and have their breaking 
point. Since defection or loss of an officer is far more 
serious from a military point of view than that of an en- 
listed man, it is all the more important for officers to rec- 
ognize the early symptoms of combat fatigue in themselves 
and obtain proper care. The chief early symptoms were 
mentioned (unusual fatigability, loss of appetite, insom- 
nia, battle dreams, irritability, emotional instability, in- 
creased startle reaction, inability to concentrate, absent- 
mindedness, and general inefficiency). It was stressed that 
all of these are but exaggerations of the normal, and that 
many of us have some of these symptoms from time to time 
without the necessity for considering ourselves abnormal. 
Preparations for the care of psychiatric casualties 
Medical officers in the division were indoctrinated in the 
psychiatric theory regarding the aforementioned causes of 
combat fatigue. Plans were made for the treatment of pa- 
tients as near the front as possible. Patients with symp- 
toms could be kept overnight in the battalion or regimental 
aid stations, given mild sedation and reassurance, and 
urged back to duty the next day. The more severely af- 
fected would be treated in the division field hospital. 
Arrangements were made for the establishment of a 
psychiatric ward, preferably at some distance from the 
surgical wards. Special supplies in the way of sedatives in 
quantity, and materials for restraint were obtained, not 
without some little difficulty. A group of hospital corps- 
men was selected, using the criteria of educational attain- 
ment and agreeable personality, and those chosen were 
trained in the theory and practice of psychiatric nursing. 
The interest of these men was stimulated by lectures and 
reading material. The services of the chaplains were en- 
82 Chapter 18.—PSYCHIATRIC PREPARATIONS 
listed through personal contacts, so that the morale value 
of religious observance could be utilized to the fullest. A 
talk was given to the group of Red Cross field directors 
assigned to the division, and one man was especially de- 
signated to serve the patients in the psychiatric ward. All 
these men proved keenly interested in the problems of the 
psychiatric casualty and many suggestions were forth- 
coming regarding ways of boosting the morale of the pa- 
tients through personal attention and the provision of rec- 
reational and comfort items. CHAPTER 19 
FATIGUE* 
Once a chronic type of emotional illness is established, 
return to active duty is contraindicated. This policy is 
based on previous war experience. It is recognized, how- 
ever, that any well adjusted individual, subjected to severe 
physical and emotional strain may become temporarily ill. 
At the same time he may be a desirable individual for 
retention in the naval service. 
One of the most commonly encountered symptoms in 
all diseases is fatigue. It is especially prominent in person- 
ality disorders. The understanding of this symptom is es- 
sential for the proper differentiation of the acute from 
the chronic types of emotional illness. 
The word fatigue, although universal in medicine, has 
a different meaning to every physician. In Webster’s dic- 
tionary the definition is brief, concise and practical: 
"Fatigue is the loss of power due to continued work, but 
removable by rest.’’ With this as a foundation it is essen- 
tial to review fatigue as seen in medical practice. Judged 
from its presence in various scopes of medical sciences, 
fatigue is a vague term. Throughout the years it has been 
a problem for investigation in medical research. To some 
physicians fatigue is a disease entity. To others, it is 
considered a symptom of a disease. Psychologists stress the 
biochemical products influencing the metabolism of the 
central nervous system. Psychiatrists, dealing with the 
personality responses, express many theories as to its 
production. Muncie (i) quotes Dill as saying: "There 
appears to be little prospect of developing a simple and 
adequate hypothesis regarding the origin and nature of 
fatigue.’’ This statement followed long periods of exten- 
sive research. It demonstrates the complexity of the prob- 
lem of fatigue in medicine. 
This present study will endeavor to take up fatigue as 
the total personality responses to work and stress. This 
would include the subjective symptoms and objective 
physical signs. The laboratory findings, chemical and 
physical, cannot be overlooked. Finally the total person- 
ality reactive tendencies must be stressed. Each individual, 
therefore, will vary according to his heredity, construction 
and personality responses to life situations. 
Most authorities agree that there are two main types of 
fatigue, the acute and chronic. Unfortunately, they fre- 
quently are seen in combination, which confuses the total 
picture. Under the present wartime conditions it is im- 
possible to treat chronic personality disorders in base hos- 
pitals. Therefore, this study will emphasize the acute type 
of fatigue. An attempt to understand the acute without 
knowledge of the chronic type is impossible. Fatigue in 
general must be reviewed. All the facts must be analyzed 
and integrated. 
DISCUSSION 
Pillsbury (2) emphasized the chemical reactions, phy- 
siologic changes and the emotions as factors in the pro- 
duction of fatigue. However, an attempt to distinguish 
between mental and physical fatigue from a personality 
concept is impossible. McDougall (3) felt that fatigue 
was a state of raised synaptic resistance throughout the 
nervous system. It is manifested by subjective symptoms 
and objective signs. He and Hollingworth (4), using the 
same test object, recorded experimentally opposite results. 
Certain alterations occur normally while observing an 
ambiguous object. Fatigue produced a retardation and an 
acceleration of the rate of alterations. This might be ex- 
plained by the individual personality response to the ex- 
periment. McFarland (3) in his studies on pilot fatigue 
in aviation found no single cause for this entity. He em- 
phasized the factors associated with flying conditions and 
the influences of physiological factors as 02 etc. upon the 
organism. He also stressed the emotions from personal 
conflicts as they affected the pilot’s health. Muncie stressed 
the individual personality response in discussing the nor- 
mal psychobiology of fatigue. He showed the normal 
variation in the individual. It is a well known fact that 
one recovers quickly with rest from great physical effort. 
•By Francis J. Hamilton, Lieutenant (MC) U.S.N.R. 
84 Chapter 19.—FATIGUE 
Also, prolonged mental stress requires a longer rest period 
prior to recovery. 
Thus it is evident that separation of the various factors 
in fatigue is a difficult problem. It is due to a combination 
of many complex reactions representing the total psycho- 
biologic response of the organism to work, mental, physi- 
cal, and usually in combination. It will vary in each in- 
dividual according to his personality reactive tendencies 
The only way to evaluate its presence is by a complete 
study of the total personality functions in each case. It is 
evident that many psychologic, biologic and somatic 
theories have been formulated. Fatigue, as a psychobio- 
logic reaction, is the only adequate explanation. It is 
frequently present in civil life. Under the stress of modern 
war it will occur more easily and readily. In the following 
an attempt will be made to observe its presence clinically 
with emphasis on military psychiatry. For practical pur- 
poses, fatigue may be divided into the acute and chronic 
types. 
In the acute type the subjective symptoms of weakness, 
lassitude and tiredness are usually in harmony with the 
physical findings on examination. These will vary in each 
case but are usually those of weight loss, insomnia, de- 
hydration, and other physiologic concomitants. The his- 
tory will reveal long-continued stress, physical, emotional, 
or both. Although insidious in its onset, the clinical mani- 
festations will usually begin abruptly. The emotions will 
be in keeping with the previous personality reactive ten- 
dencies and hence will vary. Tension, fear, or anxiety will 
be outstanding. However, depression, apathy, or other 
affective responses may be present. Irritability, seclusive- 
ness, lack of interest, or enthusiasm might be the prod- 
romal symptoms. 
These reactions might be seen in the following types 
of personality disorders: 
1. Exhaustion syndrome. 
2. Depressive reactions of all types. Manic-depressive, 
tension depressions, situational or any basically affective 
illness. 
3. Acute anxiety states with their closely allied panics. 
4. Postinfectious states. 
5. Delirious reactions due to infections, drugs, and ex- 
haustion. 
This leads to an important topic, the recognition of 
acute fatigue in these various personality disorders, and 
decision as to whether or not return to active duty is 
warranted. 
Sargant (6) reported interesting observations on the 
British soldiers at Dunkerque in 1940. He applied the 
term "exhaustion syndrome.’’ The soldiers had a masklike 
facies, sallow complexion and a few had a pill-rolling 
tremor of the hands. There was a history of a long period 
without food, sleep or rest. Severe physical and emotional 
stress with long continuous marching had been present. 
Some were tense and anxious while others were apathetic. 
Several talked with pressure regarding their harrowing 
experience. Others were mute and negativistic. In gen- 
eral, their sleep was broken and characterized by terrifying 
dreams. Many showed the usual findings of weight loss, 
dehydration, and physical exhaustion. Should this type of 
reaction come under observation, certain possibilities exist. 
First, the patient might recover rapidly within a period 
of 1 to 3 weeks. The previous personality adjustment 
being satisfactory, with convalescence he could return to 
active duty. However, should recovery be prolonged, des- 
pite his previous personality adjustment, he should not 
be returned to active duty. The experience of psychiatrists 
in military and civil practice justifies this disposition. 
Once a personality substitute reaction has been utilized 
in a life situation, later in times of stress it is apt to 
recur. The pattern is like a conditioned reflex, which, once 
established, occurs more readily and with less strain. 
Depressive fatigue as seen in affective illnesses should 
not be difficult to recognize. The family history, previous 
attacks, and present difficulties should be helpful. The 
mood statement and psychiatric examination should clar- 
ify the total picture. In addition, depressive fatigue has 
certain distinguishing qualities. It is mood determined. 
There is a lack of initiative with the feeling of sadness. 
The diurnal variation is characteristic, being worse in the 
morning and improving as the day progresses. It is partly 
alleviated by effort and activity. Once this type of fatigue 
has been established the obvious disposition is not to re- 
turn the patient to active duty. Gillespie (7) described 
the anxiety reaction (depressive state) seen in combat. 
This type usually occurs in obsessive individuals working 
under severe mental stress. It is frequently observed in 
officers. The long continued effort in unfamiliar surround- 
ings with new work results in a fatigue reaction. The 
symptoms and signs as described by Gillespie suggest a 
chronic type of fatigue reaction. It certainly has many of 
the characteristics of a depressive illness. However he 
emphasized the presence of restlessness and apathy more 
than the depressed mood. In this type of reaction there are 
present probably features of both acute and chronic 
fatigue. Should the symptoms and signs prevail follow- 
ing the institution of treatment over a limited period, then 
the chronic fatigue will be the primary problem. If this 
is established and confirmed, the individual would not be 
fit for return to active duty. Delirious reactions with ex- 
haustion resulting from infections and drugs, etc., need 
individual care and study. The typical syndrome with 
85 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
clouding of consciousness, disorientation, fear and hal- 
lucinations, should clear up rapidly with prompt and ap- 
propriate treatment. If the review of the previous life 
adjustment is satisfactory, return to active duty is justi- 
fiable. However the chronic types, as seen in hysteria, 
manic states, and schizophrenic reactions, show evidence 
of total personality dysfunction. The appropriate disposi- 
tion in such cases should be as permanently unfit for 
active duty. 
There is a type of fatigue which is quite difficult to 
evaluate. It is that reaction which follows postinfectious 
states, especially influenza and pneumonia. A similar phe- 
nomenon is.the debility seen in hyperthyroidism and bru- 
cellosis. In order to determine the disposition of these 
complicated cases, one would have to evaluate the in- 
dividual problem. Therefore his life situation, previous 
adjustments, etc., must be judged according to one’s com- 
mon sense. At the same time, it must be remembered that 
active duty in the Navy usually implies ability to do any 
task which he may be called upon to perform, either at 
sea or on land. 
Thus in the acute type one would expect a history of 
exposure to marked physical and emotional stress. The 
subjective complaints would be in keeping with the 
physical findings on examination. The emotions will be 
in keeping with the previous personality reactive ten- 
dencies and therefore vary. The onset will be acute, on 
the surface at least. Most important will be the recovery 
with a brief period of treatment. The physical condition 
is primary and the emotional factor is secondary. Possibly 
a theoretical case illustration might help clarify the issue. 
Any person under the stress of modern war or combat 
might be exposed to long and protracted physical and 
emotional expenditure. In battle conditions, facilities for 
proper nourishment, rest, and diversion must be unattain- 
able at times. Sufficient quantity of fluids and normal 
physical hygiene will be absent. The deaths of comrades 
and other harassing experiences must be distressing to 
the emotions of the individual. Under such circumstances, 
one’s so-called "resistance threshold” must be quite high 
to prevent fatigue. This combination in sufficient propor- 
tion might produce symptoms and signs of fatigue in 
any normal person. The physical reactions and total per- 
sonality responses will be different in each individual. 
Certain specific rules must be applied in each case prior 
to the establishment of acute fatigue as an entity, if return 
to active duty is made the objective. Three things are 
essential: 
1. There must be a history of prolonged work, physi- 
cal, mental, or both, with some exposure to severe physical 
stress. 
2. Complete recovery with rest and treatment must 
take place within several days to 4 weeks at the most. 
3. Complete psychiatric studies, including family, and 
personal history should be made. The personality study 
and the preceding must show a reasonably well adjusted 
individual. 
Chronic fatigue is a totally different problem. From 
the standpoint of treatment in the Navy, it is of purely 
academic interest. In this paper we are concerned with 
the clinical application to naval psychiatry. Ross (8) and 
Muncie (9) state that fatigue of a chronic and disabling 
sort without any evidence of organic disease must be 
considered 'emotional.” This viewpoint is shared by 
most workers in all fields of medical practice. Symptomat- 
ically, the individuals will complain of "being tired.” 
Others will be "exhausted,” or "too tired to do anything.” 
At times the only complaint is that "I’m weak.” There 
will be difficulty in beginning, performing, or completing 
a task adequately. Initiative is paralyzed physically and 
mentally. At times the desire for work is present; how- 
ever the somatic motor response is lacking. Ross points 
to a common observation, the selectivity of this type of 
reaction. An illustration and common observation of this 
fact is the ability of these individuals to talk for hours 
with a physician without effort. Nevertheless, they become 
exhausted quickly and rapidly while conversing with an 
emotionally involved parent or relative. The many sub- 
jective complaints are not in keeping with the actual 
physical state observed. Occasionally a state of physical 
exhaustion is observed. However investigation will show 
that it is secondary and not primary. The long-standing 
anxiety or tension affects body metabolism. Sleep has been 
disturbed over a long period. There is altered gastric 
motility with consequent vascular and secretory disturb- 
ances. This leads to gastro-intestinal symptoms and loss 
of weight. Thus, the actual physical condition observed 
is indirectly the result of emotional stress. 
Followers of some psychiatric schools would probably 
not agree with many of these explanations. However, the 
interesting observations of Ross on psychiatric treatment 
over a number of years are self-explanatory. He found 
that those individuals who recovered with rest alone actu- 
ally improved through the efforts of the physician. The 
psychotherapy on the psychiatrist’s part at times was prob- 
ably unknown to him. 
The emotions as a factor in this reaction are stressed 
by all writers. An excellent military illustration is cited 
by Ross in World War I. The British soldiers in the re- 
treat from Mons had little food, sleep, or rest for a week. 
Sufficient fluids and distraction from their plight were in- 
adequate. When finally relieved of their peril, the entire 
86 Chapter 19.—FATIGUE 
regiment was physically exhausted. With 2 or 3 days of 
rest, most of the men were able to return to battle. This 
group had acute fatigue or exhaustion. Another smaller 
group was never again fit for duty. Their difficulties had 
their onset prior to the actual physical stress. Interestingly 
enough, neither group was conscious of fatigue during 
the actual exposure while furnished with a psychologic 
objective. However once relieved of the threat of anni- 
hilation, the symptoms developed. The chronically dis- 
abled group improved with rest, but not totally or com- 
pletely. For a period of psychotherapy seemed to be re- 
habilitating them. However all improvements seemed to 
cease with the establishment of the pension system. This 
system, although humanitarian in chronic personality dis- 
orders, is not constructive or conducive to successful treat- 
ment. It encourages a parasitic life attitude with regard 
to ambition, goals, and strivings. Hence the very sense 
of security it supplies freezes the emotional energy es- 
sential for a healthy life. Although necessary and essential 
in many individuals, it makes psychiatric treatment im- 
possible in a large number of individuals. 
Dejerine, as quoted by Ross, gives another example of 
emotions affecting fatigue. A regiment in a long march 
requires frequent rest periods because of fatigue. How 
ever, when the band suddenly plays martial music, all 
symptoms of fatigue disappear. This is explained by dis- 
tracting the troops from their thoughts of family, home, 
and various conflicts. It also actively attracts their atten- 
tion and relieves boredom. Chronic fatigue, according to 
Muncie is a neurotic reaction due to emotionally tinged 
attitudes. It is the personality dysfunction arising from 
drifting, monotony, boredom, and chronic futility feel- 
ings. These individuals, in childhood, are dependent types 
and continue this attitude throughout life. As adults, their 
goals and strivings are not attainable. In some the lack of 
a true life goal makes daily living a monotonous existence. 
Longitudinal sections of their life chart reveal neither 
major victories nor defeats. Frequently the same pattern 
of reaction was present in the parents. 
Clinically, chronic fatigue, unlike the acute type, is 
present in practically all personality disorders; 
1. Psychoneuroses of all types, especially those char- 
acterized by anxiety. 
2. Both phases of affective reactions, especially the 
depressive types of illness. 
3. Many schizophrenic reactions. 
4. Practically all illnesses associated with the involu- 
tional period. 
5. It is a physiologic process with aging, but also an 
early symptom of cerebral or generalized arteriosclerosis. 
Thus although more characteristic of some personality 
disorders, it is present in practically all types of reactions 
which deal with altered personality function. 
This last fact leads to the problem whether or not cer- 
tain personality types are more susceptible to fatigue in 
military service. The British psychiatrists (10) have 
made important observations in their experiences. They 
found that individuals between the third and fourth de- 
cade of life and especially those above the fourth decade, 
fatigue more easily. Therefore they should be studied 
more closely before enlistment into the armed forces. 
Again, those subjects whose habitus or constitution is 
either above or below the average individual had a higher 
incidence of fatigue and personality disorders. At the 
same time certain types of men who had suffered many 
illnesses in the past, irrespective of the nature of the con- 
dition, usually proved easy subjects for fatigue. Eventu- 
ally they were unfit for military service. Another type of 
person who reacts more readily to fatigue with strain is 
the obsessive individual. He is above average intelligence, 
usually passive and inclined to be rigid. In general, he is 
usually single, somewhat sensitive and timid. This in- 
dividual is apt to worry and fret to excess. In unfamiliar 
surroundings with increased responsibility, he finds ad- 
justment to military life rather difficult. In order to ac- 
complish his work in a perfectionistic manner, he really 
overcompensates. The result of the vicious cycle is an 
increased susceptibility to fatigue and personality dis- 
orders. 
Therefore, the emotional difficulties due to lifelong 
defects in personality functions are characteristic in chron- 
ic fatigue. The etiologic factors which might operate are 
immaterial. From a naval standpoint, the primary object 
is to eliminate these patients from active duty, with their 
rehabilitation to civilian life a secondary consideration. 
Prophylaxis at the recruiting stations for all personnel 
will make an efficient combat force. The physical defects 
in chronic fatigue are secondary when present, and re- 
covery requires a long period of psychiatric treatment. 
This is impossible in the present status of naval medicine. 
Neither the time, facilities, or physicians are available for 
such a gigantic task. 
SUMMARY 
Fatigue is usually found to be an accompaniment of all 
types of disease. It is especially significant in personality 
disorders. Actually, it is a syndrome which manifests its 
presence by subjective symptoms and physical signs. The 
ratio between the two determines the varieties, acute and 
chronic. The former is characterized by many physical 
factors and secondary emotional problems. The latter 
type, in the absence of any organic disease, is always emo- 
tional. Hence it follows that the subjective complaints 
87 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
predominate and the physical findings are of lesser im- 
portance. It is impossible to group or differentiate either 
type of fatigue without the study of each individual case. 
The evaluation of the personality function must include 
not only the horizontal, but especially the longitudinal 
cross section of the individual. The total personality must 
play a role in the production of fatigue. Certain com- 
ponents will seem to play a leading role. However to em- 
phasize the intellectual functions and at the same time 
avoid the somatic component would be negligence. The 
emotions, with the resulting conflicts from instinctive 
feelings, family relationships, etc., play a major role. It 
would be an incomplete study to disregard any one part 
of personality function. Fatigue is the total personality 
reaction to work, mental, physical, or both. In order to 
aid a "fighting Navy,’’ the acute type of fatigue should 
be stressed. The exhaustion syndrome described previ- 
ously, with certain absolute qualifications, would be a 
close simile. Chronic fatigue, in the absence of any struc- 
tural disease, is always due to personality difficulties. At 
the present time the obvious disposition is to return these 
individuals to civil life. Caution and conservatism should 
be the guide in evaluating any illness in which fatigue is 
the outstanding symptom. 
REFERENCES 
1. Muncie, W.: Psychobiology and Psychiatry; A Textbook 
of Normal and Abnormal Human Behavior. The C. V. 
Mosby Co., St. Louis, Mo., 1939. 
2. Pillsbury, W. B.: Fundamentals of Psychology. 3d edition. 
The Macmillan Co., New York, 1934. 
3. McDougall, W.: Outline of Abnormal Psychology. Charles 
Scribner’s Sons, New York, 1926. 
4. Hollingworth, H. L.: Perceptual fluctuation as fatigue 
index. J. Exper. Psychol. 24; 511-519, May 1939. 
5. McFarland, R. A.: Military symposium; fatigue in aircraft 
pilots. New England J. Med. 225: 845-855, November 
27, 1941. 
6. Sargant, W.: Physical treatment of acute war neuroses; 
some clinical observations. Brit. M. J. 2; 574-576, Novem- 
ber 14, 1942. 
7. Gillespie, R. D.: Psychological Effects of War on Citizen 
and Soldier. W. W. Norton & Co., Inc., New York, 1942. 
8. Ross, T. A.: The Common Neuroses; Their Treatment by 
Psychotherapy. 2d edition. William Wood & Co., Balti- 
more, 1937. 
9. Muncie, W.: Chronic fatigue. Psychosom. Med. 3: 277- 
285, July 1941. 
10. Diethelm, O.: Treatment in Psychiatry. The Macmillan 
Co-., New York, 1937. 
11. Henderson,. D. K., and Gillespie, R. D.: A Text-Book 
of Psychiatry for Students and Practitioners. 5th edition. 
Oxford University Press, New York and London, 1940. 
88 CHAPTER 20 
TREATMENT OF COMBAT FATIGUE IN A 
FORWARD-AREA HOSPITAL* 
Other publications (1) (2) (3) have described spe- 
cific technics for the treatment of combat fatigue, such as 
hypnosis, intravenous sodium pentothal combined with 
narcosynthesis, and modified insulin therapy. These di- 
verse methods have apparently all been about equally suc- 
cessful, which fact has aroused the speculation that some 
more fundamental factor common to all has at least in 
part been responsible for the therapeutic successes 
achieved. In this article yet another form of therapy will 
be described and an attempt will be made to account for 
the similar results attained by these divergent methods. 
The neuropsychiatric department of this forward-area 
hospital has during the Pacific campaigns received a 
number of combat casualties, the majority diagnosed as 
combat fatigue. Of these, 80 percent have been returned 
to duty. The majority of these patients were young Ma- 
rines, some with considerable previous battle experience, 
others relatively recently overseas. 
Our criteria for "Fatigue, combat” were rather strict. 
Any patient who gave a past history with more than mild 
psychoneurotic traits was excluded from this study, and 
only those were considered who had been well adjusted 
socially and free of psychoneurotic tendencies. 
Upon admission these men presented the rather uni- 
forrh clinical picture which has been frequently described. 
In our opinion these presenting symptoms may be roughly 
divided into two general groups: (1) Symptoms of anx- 
iety, either frankly manifested in conscious fear, night- 
mares, startle reaction, weight loss, tremors, irritability, 
restlessness, insomnia, tachycardia, and/or anxiety exhib- 
ited in transient conversion phenomena such as amnesia, 
paralyses, or aphonia; and (2) socio-psychologic symp- 
toms, such as feelings of shame because of fear, guilt for 
having failed one's comrades, feelings of dissatisfaction 
with the service, with the war and the conduct of the war, 
feelings of inferiority and inadequacy, homesickness, and 
a marked preoccupation with the family, particularly 
parents, who are often thought to be sick. 
The emotional dislocation responsible for the enumer- 
ated socio-psychologic symptoms, is also responsible, we 
believe, for a change in the patient’s general attitude. 
Crispell (4), from a study of 500 men, has described the 
following attitude as being typical, with which we fully 
agree . . . He is "quite upset by his experiences, he did 
not want any more battles for awhile—perhaps never 
again; if some more battles had to be fought, then some- 
body else ought to fight them; he thought that he ought 
to go home right away.” Depending upon the particular 
individual, the symptoms of one group would be more 
marked than the symptoms of the other; in some the anx- 
iety features predominate, in others guilt and dissatisfac- 
tion are the outstanding findings. But in every one of the 
patients, symptoms of the two general groups were present 
to a pathologic degree. 
Except for a few patients, this was the first hospital 
reached following evacuation from the combat zone; in a 
great majority less than 10 days had elapsed between evac- 
uation from the beachhead and hospitalization here. While 
enroute, because of excellent care, many of the anxiety 
symptoms had considerably abated, but it is our impression 
that in not a few patients the socio-psychologic symptoms 
had become enhanced. 
It seemed to us, after a few of these men had been 
studied, that the concept of combat fatigue had a twofold 
connotation, and that the admission symptoms as de- 
scribed above bore this out. As the diagnosis literally car- 
ries, these men were tired and were tired of combat; that 
is, they had been subjected to almost constant danger of 
* By Joseph W. Owen, Commander (MC) U.S.N.R. ; Carl G, D. Till- 
man, Lieutenant (MC) U.S.N.R., and Richard A. Brunner, Lieutenant, 
junior grade (MC) U.S.N.R. 
89 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
injury and destruction, had worked hard physically, had 
had minimum rest and food, and had lived under ex- 
tremely primitive conditions. These factors may well be 
the ones responsible, at least in part, for the anxiety mani- 
festations. 
On the other hand, combat fatigue appeared also to 
involve a more subtle, yet quite definite socio-psychologic 
feature. These men had been emotionally sustained and 
morally encouraged by their membership in a group, that 
is, their unit or outfit, but concurrently with the onset of 
combat fatigue came an altered relationship to this group. 
With a change in this relationship the man quickly ceased 
being an efficient combatant and became instead an iso- 
lated, frightened, homesick individual deprived of his up- 
to-then sustaining emotional ties with his group. His at- 
titude toward the group underwent a marked change in 
that he became critical and fed up with his companions, he 
felt he was through with the service, and he desired to re- 
turn, literally and psychologically, to earlier, more pro- 
tective and emotionally more sustaining persons, such as 
parents and others at home. 
The treatment of combat fatigue involves not only 
evacuation from combat, rest, cleanliness, adequate nutri- 
tion, and medical care, but also a psychologic re-orienta- 
tion toward the group of which the man had been a mem- 
ber until the time of his illness. The relief from anxiety 
and all its concomitants is to a certain extent attained by 
the mere physical facts of removal from the combat area, 
hospitalization and proper physical care. For the psycho- 
logic re-orientation, a special program had to be evolved. 
In order to re-awaken in the patient the feeling of be- 
longing to a group and the desire to remain within the 
same, we deliberately fostered a group spirit within the 
neuropsychiatric department as a whole. This was accom- 
plished by encouraging a general therapeutic intent in 
the staff personnel, particularly the hospital corpsmen 
and nurses. The general objective of the department— 
return to duty of patients—was repeatedly emphasized to 
the point of its becoming axiomatic. 
Lectures covering the elementary aspects of psychiatry 
were given by the neuropsychiatric medical officers. Corps- 
men and nurses were specifically indoctrinated and en- 
couraged to maintain an optimistic attitude toward the 
patients. A general atmosphere was built up in which it 
was taken for granted that the patients would return to 
duty after a relatively brief period of hospitalization. The 
department was able to arrange an active recreational pro- 
gram to which a psychiatrically trained chief pharmacist’s 
mate was assigned, and in which staff members participat- 
ed freely. An active occupational therapy program was also 
instituted, and through joint efforts of all staff members 
a fully equipped workshop was gradually assembled, in 
which patients and staff members alike spent much time 
under informal circumstances. 
The patient is absorbed into an actively functioning, 
well integrated group, with which he can identify himself 
providing his general physical condition permits. We have 
found that as soon as the patient becomes an active and 
participating member of the local group, so to speak, the 
psychologic re-orientation will carry through and he will 
himself express his desire to return to his own former 
outfit. These are the general features of the program 
which has gradually been evolved. 
Upon admission, the neuropsychiatric combat casualties 
are greeted and briefly interviewed by the head of the 
department, who at that time roughly segregates the pa- 
tients into (1) the recoverable, combat fatigue cases which 
as far as possible go to a special ward, and (2) the chronic, 
psychoneurotic and psychotic types (a minority), who as 
early as possible are segregated from the recoverables. 
Physical examinations and brief neuropsychiatric evalua- 
tions are completed within 24 hours after admission so 
that treatment for all minor physical ailments can be im- 
mediately instituted, requests for consultations with other 
services made, and perhaps most importantly, so that the 
patient from the start is made to feel that the regaining of 
his health is the primary concern of all. Brief lectures ex- 
plaining the general organization of the ward and the du- 
ties and privileges of patients are given by the ward med- 
ical officer during the first few days. 
During the first 24 hours the patients may remain in 
or on their beds at will, but subsequently no patient may 
lie on his bunk during the day unless specifically permit- 
ted by his medical officer. The reason for this rule is ex- 
plained to the patients, who themselves soon realize that 
little sleep may be expected at night if the day hours are 
spent on or in bed. The patients are urged to participate 
in the quite active recreational program, such as baseball, 
volleyball, badminton and swimming parties. Those who 
for physical and/or psychologic reasons do not feel up to 
active participation are nevertheless urged to accompany 
the group as spectators. 
Every effort is made to make the patients comfortable, 
but certain duties are assigned them from the start. With 
the hospital corpsmen and under the supervision of the 
nurse they are responsible for the cleanliness and orderli- 
ness of their own beds, lockers, and the ward as a whole. 
A general atmosphere of friendliness is deliberately built 
up on the ward by the staff, without loss of necessary dis- 
cipline and military courtesy. Sick call, for example, is 
made with the patients at attention, but during sick call 
each patient is given full opportunity to talk over his 
symptoms. 
90 Chapter 20.-TREATMENT OF COMBAT FATIGUE 
The daily ward-routine is organized along the following 
lines: 
0530—Reveille. 
0545—Every patient polices his bunk, locker and immediate 
area. 
0630—Breakfast. 
0730—Sick call. 
0800—Ward details. 
0900—Ward closed to patients who go for games, to work- 
shop, work in garden, Red Cross building, or to as- 
signed places within hospital compound. 
1100—Return to ward; clean up for noon meal. 
1130—Chow. 
1230—Rest period on ward. 
1330—Ward closed for 2 hours, same activities as at 0900, 
with addition of swimming parties twice weekly. 
1530—Return to ward; clean up for evening meal. 
1700—Chow. 
1800—Rest and free period. 
1900—Sick call. 
1930—Movies, general hospital entertainments. 
2130—Lights out. 
With few exceptions, the patients take their meals in 
the general mess hall after the first week in the hospital. 
Whenever meals are served on the ward, the patients eat 
in a group at a large table at one end of the ward; a sheet 
serves as tablecloth and attractiveness and cleanliness are 
encouraged. Patients wait upon themselves and clean their 
dishes in rotation. Corpsmen occasionally join the patients 
at their table. Smoking on the ward is restricted to this 
one end; smoking on or near the bunks is not allowed. 
As far as possible, a homelike atmosphere is created; by 
the same token each patient is expected to treat and con- 
sider the ward as his temporary home. Visits by patients 
from other hospital departments are not encouraged; such 
contacts are made to a sufficient degree in the general 
mess hall. 
The workshop building is a 16- by 16- by 10-foot stand- 
ard Marine tent erected immediately adjacent to one of the 
neuropsychiatric wards and so arranged that access to it 
is gained only through the department entrance. Its deck 
is made of scrap lumber; along two walls are solid work 
benches with vises. Over and under the benches are shelves 
and lockers for tool storage. The shop is surprisingly light, 
cool and well ventilated; from 10 to 12 patients are ac- 
commodated without crowding. 
No tool is hospital issue; thus the hospital maintenance 
department is not deprived of any implements and has no 
claims upon the shop. The tools have been gradually pro- 
cured from other outfits as they move out from this area, 
some were surveyed as worn out and have been repaired 
by ourselves, others are not properly tools but improviza- 
tions of utility. Power tools have not been procurable but 
would be highly desirable. A remarkable variety of objects 
may be fashioned in wood, metal, and plexiglass by the 
use of a file, saw, plane, and a few drills. The shop is for 
the exclusive use of neuropsychiatric patients and staff. 
A third activity centers around the grounds between 
the neuropsychiatric buildings. Here a rock garden has 
been laid, and plants, bushes, orchids and palm sprouts 
have been transplanted. Shop-made chairs and benches 
and pingpong tables are placed around the grounds. In 
one corner a vegetable garden has been planted, the 
produce of which is zealously guarded by all. 
During his first 10 days of hospitalization, each patient 
is thoroughly examined by a psychiatrist. Explanations and 
reassurance are given during the anamnesis, and with suit- 
able patients additional psychotherapeutic sessions are 
held, singly or in groups of three to four. All are encour- 
aged to come to the psychiatrist with any problems. 
For relief of anxiety, methods have been used as varied 
as the personalities of the patients. For some, hypnosis 
has uncovered areas of amnesia and other conversion 
manifestations; for others, intravenous sodium pentothal 
and hypno-analysis have had beneficial cathartic effect; 
for yet others, sedatives by mouth have been sufficient. 
For some patients, cold sheet packs have been of equal if 
not greater benefit than chemical sedation. Men greatly 
underweight with poor appetites have been given insulin 
up to 60 units daily in order to stimulate the appetite. 
We have, however, gained the impression that for the 
alleviation of the acute anxiety symptoms no one method 
is superior to another; the treatment of these must be de- 
termined by the needs of the patient. As a rule medica- 
ments are used as little as possible and it is clearly ex- 
plained to both patients and hospital corpsmen that the 
sooner one can do without drugs the sooner one will be 
well. In general the symptoms of fatigue and anxiety 
which properly are a part of combat fatigue, have been 
found to disappear within about 2 weeks under the treat- 
ment outlined above. 
The psychologic re-orientation, which we believe is 
equally necessary for recovery, is attempted also from the 
day of admission. By being encouraged to participate in 
sports in which corpsmen, nurses and doctors already ac- 
tively participate, the patients soon feel a comradeship 
and before long teams and tournaments develop. It is re- 
markable to observe how quickly a disgruntled and dis- 
satisfied patient will take an interest in a competitive 
sport, if he is properly approached. 
In the same way the workshop provides a variety of op- 
portunities for making things for one’s self, in conjunc- 
tion with a larger group. In this shop "basket weaving" is 
discouraged but realistic objects are encouraged, especially 
those of a warlike nature. Thus 105-mm. shell casings are 
91 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
made into ash trays, models of P-38s, hinges and corner 
fittings for sea chests, etc.; enemy trophies are repaired 
and polished; native hardwoods are carved; and bits of 
aluminum and plexiglass from junked planes become 
identification disks and watch bands. Each patient keeps 
as his own that which he makes in the shop. As long as 
the staff as a whole participates in and maintains an enthu- 
siastic attitude toward the shop activities, the patients will 
soon enter in and as it were "join the group.” It is im- 
portant that the shop be maintained as a therapeutic means 
and its facilities restricted to this purpose at all times. 
Once the anxiety symptoms have been relieved, and the 
identification with the department "group” has been made, 
it is gratifying to observe how smoothly and spontane- 
ously the membership feeling for the original unit or outfit 
returns. Within 2 to 3 weeks, many of the men spontane- 
ously express a desire to rejoin their outfits, i.e., return to 
duty; with others it is only necessary for the medical of- 
ficer to point out that the patient’s life has become as ac- 
tive and productive as prior to his illness, and he sees the 
point of returning to his activity. 
It must be noted that these patients upon discharge 
from this hospital have rejoined their outfits but have not 
directly returned to combat, as the particular campaigns 
from which they were evacuated were already over by the 
time of their hospital discharge. It has, however, been 
made clear to the patients that by rejoining their old 
combatant unit they necessarily and automatically soon 
come in line for further combat duty. 
An active recreational and occupational therapy pro- 
gram such as described, in itself has a direct benefit in 
building up a man’s self-confidence and creative ability. 
A game such as baseball has a reassuring effect on a man’s 
self-confidence especially when well played before an au- 
dience; it supplies means of discharging pent-up aggres- 
sions through the physical activities involved and through 
the continuous banter that passes back and forth. The re- 
vival of old skills and the learning of new ones in the shop, 
visibly embodied in the finished product for all to behold, 
give to most men a healthy glow of self-satisfaction. 
We feel, however, that in addition such a program is 
distinctly of therapeutic benefit because it is a group ac- 
tivity. Thirdly, and perhaps of major importance, the 
morale of the staff, particularly that of the hospital corps- 
men, remains high when they actively partake in the build- 
ing up and maintenance of such a program; and as the 
corpsmen have the most frequent contacts with the pa- 
tients, high morale among the former will effect the same 
in the latter group. During the first few months we were 
in operation and before plans had been formulated and 
materialized, the return-to-duty percentage of combat 
fatigue patients was strikingly lower than that subsequent- 
ly achieved. The growth and expansion of the whole 
therapeutic program has been paralleled by a steady rise 
in recovery rate. 
We are highly appreciative of and admire the recrea- 
tional, occupational, and morale-building work of the 
American Red Cross. Many of our patients have availed 
themselves of their hospitable facilities. We do feel, how- 
ever, that the combat fatigue patients require in addition 
a recreational and occupational set-up which has been de- 
liberately infused with a specific therapeutic intent; such 
a program is for obvious reasons outside the scope of the 
American Red Cross. 
About 4 weeks is the optimum time of hospitalization 
here. At the end of this time the patients should feel 
physically well, should have gained weight, should be free 
of overt anxiety and should desire to be back with their 
former comrades. Whereas few patients could stand to 
see a war movie at time of admission, they should now be 
able to view the same with relative objective detachment. 
As an experiment, several patients were kept an additional 
month; no additional benefits were observed from the 
prolonged stay. For patients of this type to remain longer 
than 4 or 5 weeks only prepares the soil for the growth 
of "hospitalitis.” 
The combat fatigue patients who did not return to duty 
from here were evacuated to the rear for further treatment 
and disposition. Their further course is not known to us. 
They had in general a more traumatic childhood history 
than those who recovered; had a higher incidence of 
broken homes, of paternal alcoholism, of parental deser- 
tion or death. Several had been childhood stutterers who 
after combat suffered exacerbations which were not suffi- 
ciently allayed while here to warrant return to duty. 
These men were all somewhat improved, but either their 
anxiety symptoms persisted despite all treatment, or their 
feelings of guilt, depression and attitude of "being 
through,” remained to such an extent that we did not feel 
justified in returning them to their outfits. They were 
transferred from here with the diagnosis of Fatigue, com- 
bat, as past history revealed no more evidence of precom- 
bat neuroses than shown by the men who did recover. 
Finally the local geography and topography must be 
given consideration and due credit. By being treated here, 
the men remained in an area close to and essentially simi- 
lar to the combat area, but free of its dangers. The phys- 
ical environment here reminded them as little of "home” 
as it did on the scene of combat. By being evacuated to 
this area the patient is in no sense nearer "home” than he 
was while with his outfit—as a matter of fact, the latter, 
by its long time associations, seems more like "home” 
92 Chapter 20.-TREATMENT OF COMBAT FATIGUE 
than does the hospital. That "home” (U.S.A.) exerts a 
fatal attraction was clearly noticeable whenever a draft of 
surgical or psychotic patients was being made ready for 
evacuation to the States; on such days there was a distinct 
lowering of general morale on wards otherwise marked 
by their cheerfulness. 
In conclusion it is suggested that the similar recovery 
rates achieved by other workers may at least in part be 
due as much to the intensity of the treatment as it is due 
to the treatment itself. In order to carry on any of these 
methods (hypnosis, sodium pentothal, modified insulin) 
much attention and care is required from the medical of- 
ficers and the hospital staff; only organized and well-in- 
tegrated teams can carry out these procedures. The staff 
and ward personnel must be geared for treatment in order 
to undertake successfully these therapeutic methods, and 
we believe that this very organization of therapeutic in- 
tent into a group, the staff, has in itself considerable 
therapeutic benefit for men wkh combat fatigue. 
SUMMARY 
A therapeutic program has been described for combat 
fatigue patients which we believe has at least in part been 
responsible for an 80-percent recovery rate in a forward- 
area hospital. This program is twofold, consisting of: (1) 
Active and specific treatment of anxiety symptoms and 
physical fatigue, individualized for each patient; and (2) 
a deliberate inculcating of an enthusiastic group feeling 
among all staff members, so that the patient is provided a 
substitute group with which to identify himself. This 
temporary group-membership supplies the identification 
and membership feeling with his own combatant unit, 
which the patient lost incidental to his developing combat 
fatigue. 
An enthusiastic staff spirit can be stimuated by attention 
to interpersonal relationships and by the use of such 
proven psychiatric technics as occupational and recrea- 
tional therapy programs actively participated in by the 
staff. By patience and by the use of improvisations, such a 
program can be organized even in a forward-area hospital. 
When the anxiety symptoms have been treated and 
abated, and when the patient has become a temporary 
member of the hospital "group,” he is physically and psy- 
chologically ready to return to duty. 
REFERENCES 
1. Fisher, C. (New York): Hypnosis in treatment of neuroses 
due to war and to other causes. War Med. 4: 565-576, 
December 1943. 
2. Grinker, R. R., and Spiegel, J. P.: Narcosynthesis; psycho- 
therapeutic method for acute war neuroses. Air Surgeon’s 
Bull. (No. 2) 1: 1-5, February 1944. 
3. Sargant, W.: Physical treatments of acute psychiatric states 
in war. War Med. 4: 577-581, December 1943. 
4. Crispell, R. S.: Neuropsychiatric combat casualties (includ- 
ing war neuroses). Pac. Fleet Med. News 1: 16-19, Novem- 
ber 1944. 
93 CHAPTER 21 
PSYCHONEUROSES PRECIPITATED BY COMBAT* 
The incidence of psychoneuroses in the armed services 
in World War II was so great as to make it one of the 
major problems brought to the attention of the psychia- 
trist. These disturbances are found under war conditions 
among the civilian population, selectees, dfaftees, and 
soldiers and sailors on active duty. The variation in the 
intensity of the psychoneurotic symptoms and of mal- 
adjusted behavior has resulted in the introduction of 
such terms as "battle reaction’’ and "combat fatigue.’’ 
It is possible in most instances to differentiate between 
patients whose symptoms are precipitated by unusual 
conditions, such as battle or shipwreck, in which the 
patient is exposed to unusually powerful stimuli oc- 
curring in dramatic sequence and those who develop 
symptoms without exposure to combat. The former group 
is usually referred to as "traumatic" or "combat" neuroses. 
It is this group of patients that is the major concern of 
this paper. 
The purpose of this study was to ascertain whether 
patients with persistent psychoneurotic symptoms which 
were precipitated in combat, had a past history of similar 
or other psychoneurotic complaints. In addition, an at- 
tempt was made to study various physiologic functions 
under laboratory conditions of rest and stimulus, in order 
to compare the results with those obtained from psycho- 
neurotic patients who had not been exposed to combat 
experience, and from a series of normal control subjects. 
In a previous survey undertaken for neuropsychiatric 
data on the survivors of shipwreck, two groups of in- 
dividuals were studied. The first was a group of 25 
psychoneurotic patients who were survivors of shipwreck 
or sinking by enemy action, and the second was a control 
group of 41 survivors from shipwreck or sinking who 
had no neuropsychiatric symptoms. These studies included 
an investigation of the past history and an appraisal of 
the current symptoms in an interview lasting one-half 
hour. 
It was found that 72 percent of the psychoneurotic 
patients gave a history of having had psychoneurotic symp- 
toms in civil life prior to entering the Navy. In contrast 
to this, only 11 percent of the control group of 41 sur- 
vivors, when studied by the same method gave a history 
of psychoneurotic symptoms prior to enlistment. Of the 
patient group, 23 (91 percent) were troubled with dis- 
turbing dreams and difficulty in sleeping, and 18 (72 per- 
cent) had poor appetite and weight loss. In the control 
group only 2(5 percent) were troubled with disturbing 
dreams or complained of poor appetite and showed loss 
of weight. 
It was interesting to note further that 8 of the psycho- 
neurotic group (32 percent) had suffered physical injury 
as against 23 of the control subjects (56 percent). 
In order to check and evaluate the results of this survey 
another study was made of 26 patients with psycho- 
neuroses precipitated by combat conditions. These were 
patients whose symptoms did not respond to the usual 
therapeutic measures available aboard ship or in the com- 
bat zone but were sufficiently serious and incapacitating 
to necessitate transfer to a base hospital in this country. 
The symptoms had been present in most cases for over 
3 months and in some cases for as long as 1 year after the 
initial combat experience. At the time of the examination 
most of these patients were not suffering from other ill- 
ness or injury and in most instances the physical and 
neurologic examinations were within normal limits. 
As a control series for these patients with combat or 
traumatic neuroses, a second group was selected of 23 
subjects who were not ostensibly suffering from any neuro- 
psychiatric complaints or disorders and who had not 
come to the attention of the medical staff. These men were 
of the same age distribution as those with combat neuroses 
and had been through similar combat experiences. These 
* By Robert S. Schwab, Lieutenant Commander (MC) U.S.N.R. ; Jacob 
E. Finesinger, M.D., and Mary A. B. Brazier, Ph.D. 
94 Chapter 21.-PSYCHONEUROSES PRECIPITATED BY COMBAT 
subjects are referred to in this paper as the control series. 
In addition, a third group of 25 psychoneurotic subjects 
was studied who had not been exposed to combat, and 
whose symptoms developed while in military service at 
a shore station within the limits of the continental United 
States. This group is referred to as noncombat neuroses. 
All three series of subjects were selected at random and 
were studied in essentially the same way. The nature of 
the procedure was described to the man and no one was 
examined against his will. It was explained that this clin- 
ical study would not appear in the health record and that 
they, therefore, need have no apprehension about its in- 
fluence on any medical decisions as far as the Navy was 
concerned. In addition an electroencephalographic exam- 
ination was made and the men were all subjected to an 
auditory stimulus, during which records of respiration, 
heart rate, and muscle tension were made. The data 
obtained from these various measurements are presented 
as follows. 
INTERVIEW 
The interview was conducted by a civilian psychiatrist 
and was modeled after a "controlled” interview which 
had been used in a previous study of 150 normal college 
students now training in the Navy. The interview which 
lasted 30 to 45 minutes was held in a closed room and 
arranged so that it could be taken down in its entirety 
by a stenographer in an adjoining room without the sub- 
ject’s being aware of the procedure. An attempt was made 
to keep the interview in the form of a free conversation, 
yet essentially the same topics were discussed with all of 
the subjects. The following topics were dealt with: 
1. The present illness, with special emphasis on a 
description of the symptoms. 
2. School and job history, with emphasis on psycho- 
neurotic symptoms and social adjustment. 
3. A brief family history, with emphasis on psycho- 
neurotic symptoms and medical illnesses present in the 
other members of the family and on the subject’s adjust- 
ment to his family. 
4. Early childhood history with emphasis on the pres- 
ence of psychoneurotic symptoms and neurotic traits. 
The stenographic records of the interviews were studied 
and the subjects were divided into four groups on the 
basis of the following criteria: 
1. Severe psychoneurosis. These were individuals who 
complained of definite psychoneurotic symptoms which 
had been present for long periods of time and which were 
severe enough to be disabling. These patients had a history 
of many neurotic traits in childhood, and a diagnosis of 
a specific psychoneurosis could be made on the basis of 
symptoms present before the patient had enlisted. 
2. Moderate psychoneurosis. These subjects com- 
plained of psychoneurotic symptoms present occasionally 
for only short periods of time, and which on the whole 
were not disabling. In this group, however, a diagnosis 
of a specific psychoneurosis could be made on the basis 
of symptoms present before the subject had enlisted. 
3. Minimal psychoneurosis. In these subjects the his- 
tory revealed psychoneurotic symptoms which were only 
very occasionally present, and not in any way disabling 
or severe. There was no history of neurotic traits in child- 
hood. On the basis of the history, as obtained during the 
interview, it was not possible to make a diagnosis of a 
typical psychoneurotic syndrome. 
4. No psychoneurosis. In these patients there was no 
history of psychoneurotic symptoms and no neurotic traits 
in childhood were reported. 
RESULTS 
The incidence of symptoms reported in the group of 
patients with combat neurosis is presented in figure 7. The 
striking finding was the large percentage of gastrointes- 
tinal symptoms (85 percent). The patients described feel- 
ings of shakiness, jitteriness of the stomach, feelings of 
turning and jumping inside. The symptoms peculiar to 
this group were the severe reaction to loud or even ordi- 
nary noises, and the presence of repetitive anxiety dreams, 
depicting in most cases some aspect of the combat experi- 
ence. The other symptoms of headache, trembling hands, 
palpitation or precordial pain found in most cases were 
typical of anxiety neurosis. The most common diagnosis 
was anxiety neurosis, which occurred in approximately 
80 percent. Most of the other cases were diagnosed as 
hysteria. 
SYMPTOMS OF TRAUMATIC NEUROSIS (26 CASES) 
AS OBTAINED ON INTERVIEW 
HEADACHE 
TREMBLING HANDS 
STARTLE REACTION 
"NERVOUS" STOMACH 
UPSETTING DREAMS 
FALPITATION 
DISTURBED SLEEP 
BREATHING DIFFICULTY 
PRECORDIAL OR CHEST PAIN 
INCIDENCE % 
95 
Figure 7. PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
From the history obtained during the interview, 80 per- 
cent of the combat neuroses group could be classified as 
having severe or moderate psychoneurosis and a further 
12 percent had minimal symptoms. Only 8 percent were 
diagnosed as having no psychoneurosis. Of the 10 patients 
with noncombat neuroses, 9 had a past history of either 
severe, moderate or minimal symptoms. The same inci- 
dence of psychoneurotic symptoms was found in an addi- 
tional group of 15 noncombat neuroses by study of their 
clinical histories. A review of the histories of 25 unse- 
lected civilian patients with psychoneuroses studied in 
the same laboratory, showed that all of these patients had 
psychoneurotic symptoms previous to the hospital admis- 
sion (fig. 8). 
Of the control subjects exposed to combat without 
apparent psychoneurotic symptoms, only 17 percent gave 
a previous history of psychoneurotic symptoms. This com- 
pares rather strikingly with the findings in a series of 150 
college normals studied previously. In this group a past 
history of symptoms was elicited in 15 percent of the 
subjects (fig. 8). 
It is of interest to compare these data with the findings 
in the naval health records of these patients and in their 
examinations by naval personnel. A study of the health 
records of the 26 patients with combat neurosis revealed 
that a statement describing the existence of psychoneurotic 
symptoms prior to admission to a naval hospital was found 
in only four of these records (fig. 9). Only three of these 
subjects were diagnosed by psychiatrists at those stations 
as having pre-existing psychoneurosis, i. e., before admis- 
sion to the naval hospital. 
In the routine neuropsychiatric investigation during a 
stay of approximately 2 weeks before diagnosis and dis- 
posal, it was found that 21 patients or 80 percent showed 
some history of psychoneurotic symptoms prior to enlist- 
ment. Of this group 65 percent had moderate or severe 
symptoms and 15 percent mild or minimal. A comparison 
of the percentage of subjects with previous neurotic 
symptoms, as described in the health record prior to the 
base hospital admission, in the routine hospital examina- 
tion, and in the specially controlled interviews is shown 
in figure 9. 
The principal groups of symptoms which brought these 
patients to the hospital are shown in figure 10. A number 
of them had more than one complaint, but their most 
obvious difficulty was the inability to perform their rou- 
tine duties. 
PREVIOUS HISTORY OF . 
PSYCHONEUROTIC SYMPTOMS 
ENLISTED NAVY PERSONNEL 
23 26 25 ISO 25 
EXPOSED TO COMBAT TRAUMATIC PSYCHO- COLLEGE CIVILIAN 
WITHOUT NEUROSIS NEUROSIS NEUROSIS NORMALS NEUROSIS 
PER CENT 
OF 
SUBJECTS 
LABORATORY FINDINGS 
Electroencephalogram.—A standard recording was 
made from 6 scalp electrodes, one-half hour after the 
subject had ingested 100 cc. of 50-percent glucose in water 
Figure 8. 
PRINCIPAL SYMPTOM GROUPS WHICH BROUGHT 
PATIENTS TO HOSPITAL 
IN 26 CASES 
AS FOUND BY 
26 CASES 
INABILITY TO WORK 
IRRITABILITY WITH 
SENSITIVITY TO NOISE 
SLEEP DISTURBANCES 
WITH NIGHTMARES 
STOMACH COMPLAINTS - 
ANOREXIA- WEIGHT LOSS 
HEADACHE— DIZZY 
SPELLS 
NAVY HEALTH 
RECORD 
NAVY HOSPITAL 
STUDY 
M. G. H. 
INTERVIEW 
INCIDENCE IN PER CENT 
Figure 9. 
96 
Figure 10. Chapter 21.-PSYCHONEUROSES PRECIPITATED BY COMBAT 
to ensure a normal blood sugar level. The necessity for 
this procedure in the control conditions for recording 
EEC’s has been described elsewhere. 
The tracings from all these subjects were, on gross in- 
spection, apparently normal and they were therefore sub- 
jected to a detailed method of analysis which has been 
developed in this laboratory for the grading of normal 
electroencephalograms. For this purpose, the recording of 
the bipolar occipital potentials during normal breathing 
is accurately measured for frequencies of component waves 
and also for voltage. From such measurements many char- 
acteristics of the electroencephalogram can be analyzed 
and studied. 
In the present work the characteristic receiving special 
study was the distribution of dominant frequencies. By 
dominant frequency is meant the frequency in cycles per 
second of the majority of the waves present. It has been 
found in previous research on civilian psychoneuroses that 
the distribution of dominant frequencies differed from 
that of normal controls (which centers around 10 cycles), 
in that the most prevalent dominant frequency was at 9 
cycles with subsidiary peaks in the faster frequencies at 
11 and 12.5 cycles. 
The EEC’s of the group with combat neuroses were 
therefore compared with those of 31 civilian psycho- 
neurotic patients and 115 college students considered 
normal. The results are shown in figure 11. 
It will be seen that the distribution curve for the group 
of combat neuroses is very close to that of the college 
student normals excepting for the fact that the two peaks 
in the fast frequency range found in the civilian psycho- 
neuroses are again present in this series. The interpreta- 
tion of these findings is a matter for future investigation. 
Auditory stimulus test.—The purpose of this test was 
to record the reaction of the subject to a disturbing audi- 
tory stimulus. This consisted of an extremely high-pitched 
whistle of mixed frequencies and of great intensity, blown 
for a period of 3 minutes. During this stimulus period, 
for 3 minutes preceding it and for a 3-minute recovery 
period following it, recordings were made of the heart 
rate, muscle tension and respiration. 
The heart rate was recorded from standard electrocar- 
diographic leads by an ink-written oscillograph; the same 
instrument recorded simultaneously the electromyogram 
from surface electrodes attached to the flexor carpi muscle 
of the subject. Thus any gripping movement or tensing 
of the hand resulted in an increase of potentials from the 
muscle. These potentials were not only recorded on the 
electromyogram but were also led through an integrator 
working on the principle of a condenser which discharged 
every time a certain amount of electricity collected. Each 
discharge of the condenser was automatically recorded on 
the same tracing as the electromyogram, and this record 
gave a measurement of the tension of the muscle. The ven- 
tilation was recorded by having the subject breathe into 
a Benedict-Roth type of metabolism apparatus equipped 
with a ventilometer. The ventilation was measured di- 
rectly from the breathing record and corrected for surface 
area, which was determined by means of the Boothby- 
Sandiford nomograph. 
In figure 12 a summary is given of the reactions of the 
three groups of subjects to this auditory stimulus. It is 
very striking that in all 3 types of response, i. e., heart 
rate, muscle tension and ventilation, the control group 
was the most stable and reacted least to the sound of the 
whistle. The greatest reaction to the stimulus was ob- 
served in the patients with noncombat neuroses. This is 
brought out most clearly in the muscle tension response. 
REACTION TO WHISTLE STIMULUS 
NAVY PERSONNEL 
COMBAT EXPERIENCE 
WITHOUT NEUROSIS 
TRAUMATIC NEUROSIS 
NON-TRAUMATIC NEUROSIS 
DISTRIBUTION OF THE DOMINANT 
ALPHA FREQUENCY IN 3 GROUPS 
28 TRAUMATIC NEUROSES (NAVY> 
115 COLLEGE NORMALS 
31 CIVILIAN PSYCHONEUROSES 
PER CENT 
INCREASE 
VENTILATION 
HEART-RATE 
MUSCLE 
TENSION 
Figure 1 1, 
Figure 12. 
97 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
DISCUSSION 
This report indicates that a past history of psycho- 
neurotic symptoms was found in approximately 90 per- 
cent of naval personnel who were diagnosed as having 
a persistent combat neurosis. In the control series, a his- 
tory of psychoneurotic symptoms was found in less than 
20 percent of the subjects. As a rule the symptoms present 
in the control group prior to enlistment were less severe 
and in most cases less incapacitating. It is to be noted that 
of the patients with combat neurosis about 25 percent 
had been in service for over 2 years. This fact would in- 
dicate that some patients who in combat develop severe 
psychoneurotic symptoms may, in the absence of combat 
conditions, adjust sufficiently well to do their duties with 
a reasonable degree of efficiency. Of men new to the 
service, in spite of the history of neurotic symptoms be- 
fore enlistment, those with combat neurosis had, for the 
most part, been able to get along in civilian life without 
hospitalization or treatment for their symptoms. 
It is difficult at present to determine exactly the degree 
of psychoneurotic symptoms which should keep a man 
out of the service. This study indicates that, were all 
individuals in whom was elicited a history of psychoneu- 
rotic symptoms to be excluded from the armed forces, we 
would be rejecting almost 20 percent of men who were 
able to carry out their duties under combat conditions 
without coming to the attenion of the naval neuropsychia- 
trists. On the other hand, we would also be excluding over 
80 percent of the individuals who subsequently developed 
combat neurosis. From the statistical point of view it 
would seem that a greater efficiency in selection would be 
achieved by excluding all men in whom a past history of 
psychoneurosis exists. This would be especially wise if 
there were an abundance of manpower. 
Patients who develop symptoms without actual exposure 
to combat situations are more vulnerable than those who 
develop combat neurosis. It would seem that in these pa- 
tients the psychoneurotic reaction is elicited by stimuli of 
much smaller intensity than is the case in the patients with 
combat neurosis. The auditory stimulus test corroborates 
this impression by showing that, when exposed to the 
stimulus, these patients (noncombat neurosis) had a 
greater reaction in respect to measurements of muscle 
tension, ventilation and heart rate than did the patients 
with combat neurosis. 
Our data revealed that almost every subject exposed to 
combat conditions reacts to the overwhelming stimuli 
with subjective feelings of fear and with palpitation, short- 
ness of breath, chest pain, gastric symptoms and tremors. 
In many, the reactions are of short duration and rarely 
recur when the individual is removed from the stimuli. In 
other individuals the reaction persists for a prolonged 
time. In some patients the reaction, after a slow period of 
extinction, readily returns in relation to combat stimuli 
or associated stimuli. Symptoms which last 4 to 5 weeks 
after exposure to combat conditions, and which are suffi- 
ciently aggravating for admission to a base hospital are 
found in patients usually giving a past history of psycho- 
neurotic symptoms. These symptoms can be readily elicited 
when neuropsychiatric studies can be made by qualified 
personnel. 
SUMMARY 
Three groups of naval personnel were examined in this 
study; 26 cases of combat neurosis, 25 cases of neurosis in 
individuals not exposed to combat, and 23 control cases 
exposed to combat without development of neurosis. 
This study revealed the following results: 
1. A past history of psychoneurotic symptoms was 
found in approximately 90 percent of both groups with 
neurosis, but in only 17 percent of the control series. 
2. The most striking symptoms in the combat neurosis 
group were gastro-intestinal disturbances (85%), severe 
reaction to noise, presence of disturbing nightmares and 
headaches. The reason for their admission to the hospital 
on the other hand, in over 90 percent of the cases, was 
their inability to do their work. 
3. The most common diagnosis was anxiety neurosis 
which accounted for 80 percent of the combat neurosis 
group. 
4. The electroencephalograms of the combat neurosis 
group were seen to have some of the characteristics which, 
in another study, have been found to differentiate the 
EEC’s of patients with psychoneuroses from those of nor- 
mals. 
5. An auditory stimulus was found to have more effect 
on the ventilation, heart rate and, in particular, on the 
muscle tension, of the group of noncombat neuroses than 
on those with combat neuroses, the control group being 
least affected by the stimulus. 
98 CHAPTER 22 
COMBAT FATIGUE AND WAR NEUROSIS' 
Much has been written on the "war neuroses," some 
descriptive, volumes statistical, a great majority interpre- 
tive and dynamic, very little that can be applied directly 
to these problem cases by the medical officer of general 
training who must handle them in their critical stage. 
Agreement has not been reached even on the answer to 
"What is a war neurosis?” Certainly all are agreed that the 
usual psychoneuroses encountered in peacetime should 
not be termed "war neuroses” simply because they occur 
in a war setting. Removing these, we are left with a group 
of cases which do not conform entirely to the nosological 
criteria of psychoneuroses, and which can be classified as 
such only with some difficulty. It is this group of cases in 
which we are interested, actually presenting more a ques- 
tion of psychoneurotic symptoms in previously stable per- 
sons, than of true psychoneuroses. We are confronted at 
once with the problems of what to call these cases and 
how to delineate clearly the syndrome variously called 
"war neurosis," "traumatic neurosis,” and, of late, "com- 
bat fatigue.” These three terms are used interchangeably 
throughout most of this paper, with some discussion later 
as to which is the most acceptable. None seem to us par- 
ticularly desirable, descriptive, or accurate, any more than 
the "shell shock" of the first world war, but we are forced 
to admit that we have no better suggestion to make. 
Rado has considered the "traumatic neurosis” a result 
of the breakdown of the normal "emergency control" 
mechanisms of the personality by an overwhelming 
trauma, and in therapy suggests the desensitization of the 
patient to the traumatic experience. Gillespie has con- 
sidered some of the symptoms in the light of a "condi- 
tioned response” to the noises of battle, especially the so- 
called "startle reaction" (starting, tremulousness, palpita- 
tion, and fear, on sudden noise). With this in mind, Mc- 
Laughlin and Millar have used recordings of combat 
noises as an adjunct to psychotherapy of war neuroses, 
with reported good results. Kardiner has presented an 
extensive monograph based on the careful study of chronic 
cases from World War I, and has attempted to separate 
the group as an entirely different type of psychoneurosis, 
which he considers with the psychosomatic neuroses as 
"physioneuroses.” He points out, as pathognomonic, repe- 
titious catastrophic dreams, especially dreams in which 
essentially the traumatic situation, or a portion thereof, is 
re-enacted. Autonomic phenomena are common, as are 
psychosomatic complaints. The startle reaction is extremely 
frequent. As psychologically traumatic in origin, Kard- 
iner groups a great variety of cases varying from anxiety 
states to schizophrenia and epilepsy, from a clinical point 
of view having in common only the listed symptoms, and 
the fact that each had its onset following a traumatic ex- 
perience. For the chronic cases, suggested therapy is based 
primarily on a prolonged psychotherapeutic procedure, and 
removal of secondary gain from the neurosis by overhaul 
of the pension system. For the acute cases, rest, a sympa- 
thetic atmosphere, and the discharge of emotion from the 
traumatic situation are suggested. In Kardiner’s opinion, 
the last should be accomplished at the conscious level by 
interview, rather than by abreaction under hypnosis as was 
commonly practiced in World War I. 
A most valuable contribution to the literature from the 
World War II has been made by Sargant and Slater in an 
article on the "Acute War Neuroses" encountered follow- 
ing Dunkirk. Their cases demonstrated "that men of rea- 
sonably sound personality may break down if the strain 
is severe enough." They were of the opinion that while 
their cases may have had some predisposing constitutional 
factors in comparison with the average population, they 
nonetheless had made a satisfactory adaptation to army 
’By George N. Raines, Lieutenant Commander (MC) U.S.N., and Law- 
rence C. Kolb, Lieutenant (MC) U.S.N.R. 
2The authors present this article to those doing the general work of the 
Navy with the idea of summarizing for those outside psychiatry certain 
facts concerning ''war neuroses,'' so that they may be available for practical 
application. The work of others has been borrowed from freely; the expe- 
rience is our own. The cases cited have been contributed by all the members 
of the neuropsychiatric staff of the Norfolk Naval Hospital, Portsmouth, 
Va., who should be recognized as coauthors: Lt. Comdrs. S. M. Smith, 
W. B. Cline, L. A. Schwartz, and Lt. D. T. Dodge, all of the Medical 
Corps, U. S. Naval Reserve. 
99 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
life, and the previous history indicated in most cases a 
man of normal intelligence, personality, and work record. 
The stress required to produce a break-down of such per- 
sonalities was of an altogether different order from any 
to which they could expect to be subjected in ordinary 
life. The patients presented signs of marked physical ex- 
haustion, and mental symptoms of "anxiety, sleeplessness, 
terrifying bad dreams, a feeling of inner unrest, and a 
tendency to be startled at the least noise.” "The course 
taken by these patients under treatment was uniformly to- 
ward improvement.” 
By far the most significant publication for those dealing 
with these problems in a naval service, is the article 
by Margolin, Kubie, Kanzer, and Stone entitled "The 
Nature and Incidence of Acute Emotional Disturbances in 
Torpedoed Seamen of the Merchant Marine Who Are 
Continuing at Sea.” A common type of acute neurotic 
reaction seen in land combat was not encountered in this 
study, i. e., the acute panics and stupor reactions, it ap- 
pearing that these men did not survive the sinking of their 
ships. Even with such cases eliminated, the investigation 
met with persistent symptoms of some degree in 75 per- 
cent of the men examined, an inordinately high occur- 
rence. Of these, only one third, or 25 percent of the total 
examined, showed sufficiently severe reactions to be dis- 
qualified for return to sea as psychoneurotic. Besides ad- 
mitting that the number of men examined is small (40), 
the authors attempt to qualify the high incidence of emo- 
tional disturbances by pointing out certain predisposing 
factors in the personalities involved, in particular the psy- 
chological problems which had driven many of the sub- 
jects to the sea as a means of livelihood, and the improper 
and inadequate training which many of them had received 
for certain phases of combat duty. Nonetheless, the fact 
remains that in the first carefully conducted study of men 
subjected to the stresses of naval combat, a tremendous 
incidence of "neurotic” symptoms has been encountered. 
The psychiatric screening program of the Navy will 
undoubtedly reduce the incidence of "neuroses” consid- 
erably over that reported above, but unfortunately no one 
has as yet been able to formulate any definite criteria for 
the rejection of men suspected of being predisposed to 
"traumatic neurosis.” Symptoms occur inexplainably in 
men who by all concepts are well within the limits of 
normal personality. The most careful studies have not re- 
vealed a personality structure common to these multiple 
cases. What personal problem could 3 out of 4 men carry 
to produce the same or quite similar symptoms? Why, as 
reported by Love, do "individual infantry units of ap- 
proximately equal standards of training and stress show 
notable divergencies in the number of neurotic casualties”? 
Extremes of 1 case and 27 cases admitted from equal in- 
fantry units are reported. Is any group of men so malad- 
justed that it can produce 75 percent of its number with 
a neurotic syndrome? Under such circumstances the ab- 
normal becomes the normal, and what at first glance ap- 
pears pathological may at second clearly be physiological. 
It is our belief that the psychological mechanisms associ- 
ated with "traumatic neurosis’’ are so fundamental as to 
be present in all men, and are of concern only in deter- 
mining the extent of the neurotic response, not its content. 
As a corollary, the precipitating force lies in the person- 
ality’s environment, hence to some extent is controllable. 
These are primary facts in preventive and curative therapy. 
The ordinary psychiatric problems of peacetime occur 
regularly in the setting of war and take coloring from the 
combat situation, usually in the form of the cardinal symp- 
toms of "war neurosis.’’ These cases must be set aside in 
their own group; they are irrecoverable to the military 
service. Their backgrounds are those of the psychoneu- 
rotic; childhood insecurity, parental rejection, faulty in- 
heritance, early evidence of maladjustment, and imma- 
turity. In war they are curable exactly as are their peace- 
time counterparts. They require extensive and prolonged 
psychotherapy. As far as the Navy is concerned, they must 
be evacuated as rapidly as possible from combat areas and 
discharged from the naval service for therapy at the gov- 
ernmental agencies established for that purpose. In spite 
of their combat seasoning, it is difficult to classify them 
as "war neuroses,” and in handling them the feeling is 
always present that the patient would have reached his 
current degree of disability under almost any environ- 
mental condition. Examples are given later on in this 
paper. Of especial interest to us is that under certain con- 
ditions, a profound psychoneurotic can pass through 
combat experience, show no handicap during action from 
his illness, emerge disabled by his psychoneurosis, but 
with no evidence of any "traumatic neurosis.” The in- 
creased responsibility of a promotion may render such a 
man disabled after he has weathered combat experiences 
known to break others. It is in the separation of the psy- 
choneurotics with traumatic coloring that the medical of- 
ficer must be prepared to exhibit a great degree of diag- 
nostic sensitivity. 
The characteristic symptom of the "traumatic neurosis” 
is undoubtedly the "repitious catastrophic nightmare.” 
In its absence the diagnosis is suspect. It usually reenacts 
the traumatic scene, or some portion thereof. It is always 
accompanied by a pathognomonic, childlike emotional 
pattern; the effect of fear persists even after awakening, 
so that the patient feels compelled to leave his bed, walk 
around, seek human companionship. In the adult this 
100 Chapter 22.-COMBAT FATIGUE AND WAR NEUROSIS 
combination of events is rarely met except in the "trau- 
matic neurosis.” 
Closely following the nightmare in frequency is the 
"startle reaction.” Sudden loud noises, by day or by night, 
produce in the unhappy victim a sudden start, accompa- 
nied by the physiological evidence of anxiety; tremor, 
dilated pupils, sweating, dry mouth, flushing or pallor, 
palpitation. Not infrequently, in the more acute stages, the 
startle reaction breaks over into actual panic; the patient 
runs for the nearest exit, or screams hysterically, or upsets 
nearby furniture, or stands transfixed laughing and crying 
uncontrollably. This panic is extremely contagious among 
other members of the ship’s crew, and is the most gen- 
erally disturbing external evidence of the war neurosis. 
One ship returning with the survivors of a torpedoed 
transport crew, unfortunately had a loose hatch cover over 
the living compartment in which they berthed. Each time 
a sudden movement of the ship caused the cover to slap, 
the entire group of survivors made a panicky start for the 
lifeboats, many from a comparatively sound sleep. Four 
of this group were admitted to this hospital immediately 
after arrival in the United States. It is because of this star- 
tle reaction that other ships find it extremely difficult to 
assimilate survivors of certain ships into their own crews. 
Five cases were admitted from such a ship after they de- 
veloped acute panics during target practice. All were in 
different parts of the ship, from the bridge to the engine 
room, and their total effect was so disturbing that the 
commanding officer directed the medical officer, "For my 
sake, get them off of here.” 
Accompanying these symptoms is what has been de- 
scribed by Kubie as "a subtle personality change.” The 
victims lose their cheeriness, become morose, silent, sullen, 
irritable, intolerant of noise or argument, withdrawn. Not 
infrequently they show a peculiar vacant staring expression 
that suggests the affectless facies of the schizophrenic. 
Alcohol is very commonly resorted to as a relief from the 
psychic torture which they endure. Because of their neu- 
rotic symptoms, many become disciplinary problems. A 
quiet, well behaved, although somewhat immature Marine 
aviator tells his colonel in no uncertain words where the 
latter can put his squadron of planes; a coxswain with 3 
years of service, having never bee-n on report, is A.W.O.L., 
and returns only when his family finds out he is not on 
leave, becomes worried over his mental symptoms and 
brings him back. The personality change is a subsidiary 
rather than a cardinal symptom, as the nightmare and 
startle reaction, and is the most variable feature of the ill- 
ness. It may be scarcely noticeable, or it may be profound. 
It may be a symptom of "war neurosis,” or it may in it- 
self be indicative of a major psychoneurosis or psychosis. 
Accompanying these symptoms frequently is a fourth 
clinical manifestation which is not essential for the diag- 
nosis, but is extremely common, a guilt reaction with emo- 
tional depression. As noted by Kubie, "Perhaps the worst 
situation occurs whenever a group of men are trapped in 
a spot from which only a few can escape. Escape from 
such a predicament leaves the survivors haunted by the 
memory of those who were left behind, with a sense of 
guilt as great as if they had murdered them.’’ In lesser 
degree, this feeling of guilt, with its consequent emo- 
tional tone of depression, occurs in many survivors of dis- 
asters in which a number of the original group were lost, 
regardless of the circumstances of survival. The higher the 
percentage of the original group that is lost, the greater 
is the possibility of the appearance of guilt in the sur- 
vivors, and on occasions the guilt appears to be lessened 
to some degree by hardships which may have been en- 
dured to survive. In addition to revealing itself in depres- 
sion, the sense of guilt leads to protestations that nothing 
could have been done by anybody for those who were lost, 
and to the survivor’s careful exposition of his own efforts 
to save others. 
We believe that the traumatically determined emotional 
disturbance in itself goes no further than these symptoms; 
beyond lies the true psychoneurotic, easily diagnosed by 
longitudinal history. In the presence of conversion hys- 
teria, marked free anxiety, enurosthenia, compulsions, and 
obsessions, or psychosomatic manifestations in the cardio- 
vascular, gastro-intestinal, or other organ systems, we have 
invariably found one of the classical psychoneuroses. 
For our purposes, then, we have established four arbi- 
trary criteria for the diagnosis of "war neurosis,’’ or "com- 
bat fatigue”; 
1. A stable personality prior to appearance oj the trau- 
matically determined emotional disturbance.—There 
should be no objective evidence of maladjustment in child- 
hood or adolescence. Walking, talking, habit forming, 
should have occurred at about the usual age. The school 
and work record should indicate stability, without undue 
disciplinary problems having arisen, without frequent 
changes in employment, without undue conflict with civil 
authorities, without unusual revolt against parental dis- 
cipline. A normal heterosexual adjustment should have 
been reached if the patient is of sufficient age. In this re- 
spect, medical officers are warned against paying too much 
attention to minor variations, except after comparing 
these rigidly with the personality traits of men similar in 
age and background to the one under study. Cultural dif- 
ferences of various parts of the country must be recognized 
in this connection. 
2. A combat experience oj sufficient intensity to render 
101 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
it feasible as a precipitating agent.—The mere threat of 
combat is not enough to produce neurotic symptoms in 
men other than those specifically predisposed, i. e., the 
psychoneurotics. The combat experience should be exam- 
ined carefully in its relation to the patient; there is no di- 
rect relationship between the severity of the experience 
and the severity of symptoms. Here the personality of the 
individual undoubtedly contributes to the picture, in the 
amount of reaction produced by a stimulus. Thus, a boy 
rejected by his father in childhood will be much more pro- 
foundly affected by the loss of a superior petty officer or 
officer whom he has accepted as a father substitute than 
would a shipmate, otherwise similar, who had needed no 
such substitute. The environmental setting should be ex- 
amined with particular care, with special reference to cer- 
tain contributing factors such as what did the patient think 
of his officers, how well did he know his job, how well 
did he know his shipmates, what were his relations with 
the human beings around him and with his ship, and how 
much did he suffer with physical fatigue. 
3. Objective evidence of subjective anxiety.—The pa- 
tient suffering with war neurosis does not discuss his com- 
bat experience with equanimity. He sweats, he trembles, 
he flushes or pales, he swallows frequently, he smokes in- 
cessantly. No malingerer can imitate successfully the deli- 
cate timing of the physiological effects of anxiety. When 
the battle description rolls out smoothly, search more 
carefully for a psychoneurosis or a psychosis. 
4. Recoverability.—It is our belief that all true "war 
neuroses” will recover in a comparatively short period of 
time with even relatively superficial therapy. When symp- 
toms persist in disabling degree beyond 2 months under 
treatment, either the treatment is not adequate, or the psy- 
choneurosis is not simply "combat fatigue” and has its 
roots in a deep-seated emotional conflict which long ante- 
dated the traumatic experience. By recovery, we mean the 
disappearance of nightmares, startle reaction, and the 
symptoms of personality change previously mentioned. 
Objective evidence of anxiety disappears from the combat 
discussion. These people are extremely sensitive to war 
movies reproducing battle scenes and sounds; so much so 
that the sensitivity can be used in differential diagnosis, 
and as evidence of recovery. When such a patient can sit 
through actual combat scenes in the movie, without feeling 
anxiety or tension, without having to leave or feeling un- 
duly restless, without feeling depressed afterward, and 
without resultant dreams, he may be considered fully re- 
covered from the traumatic experience. This testing must 
be used carefully; the sensitivity to movies persists long 
after all other symptoms have subsided. One of our pa- 
tients had over 5 years in the Navy, in spite of having 
walked in his sleep on many occasions in his life, at least 
nine times after enlistment. Following the sinking of his 
ship in June 1942 he suffered with nightmares and startle 
reaction for a period of 6 weeks, but did not seek medical 
care. In February 1943, long after the subsidence of all 
his symptoms, and his apparent complete rehabilitation 
to the service, he attended the war movie "In Which We 
Serve." He felt depressed and restless afterward, and that 
night his "catastrophic nightmare” recurred for the first 
time in 7 months. He arose from his bunk, asleep, and 
actually abandoned ship by leaping over the side. He later 
stated with some humor that he awakened in mid-air, but 
it was too late to go back. 
When these criteria are satisfied, we deal with a group 
of patients who may be saved for further military duty, 
although their reaction to combat, even after recovery, may 
preclude their return to actual line duties at sea. The war 
is yet too young for adequate statistics to govern the com- 
plete handling in these cases, but it is believed that even 
relatively severe cases which do not go beyond the stated 
boundaries will adjust adequately to limited duty, and 
eventually probably will be able to endure actual combat. 
We know that even the mild cases must be given a period 
of time in which to "digest” the emotional trauma in- 
curred before again being exposed to combat conditions; 
repeated traumatic experiences at too short an interval in- 
crease the severity of the ultimate disability. 
In the etiology of the "traumatic neurosis," the per- 
sonality, as has been stated, is chiefly of importance in de- 
termining the severity of the neurotic symptoms under a 
given stimulus. In this connection we find two personality 
types, diametrically opposed to one another, which appear 
to be of greatest importance in predisposition and which 
suggest a bad prognosis. These are the emotionally and 
intellectually immature persons, with a great deal of de- 
pendence, and at the other end of the scale, the fully 
matured, independent older men. While there is no direct 
correlation between chronological age and emotional ma- 
turity, the personalities usually associated with age below 
18, and above 38, comprise this group which appear to be 
particularly susceptible to the combat situation. It is not 
meant that those in the intermediate groups are not sus- 
ceptible, or that these types inevitably suffer traumatic 
neurosis. Other factors being equal, the younger and the 
older men are the most disturbed emotionally by combat, 
and recover more slowly. 
Of more direct importance in the production of symp- 
toms is the setting of interpersonal relationships in which 
the traumatic event occurs. In the patients’ own stories of 
the precipitation of neurosis four factors have occurred, 
singly or grouped, in too great frequnecy to be ignored: 
102 Chapter 22.-COMBAT FATIGUE AND WAR NEUROSIS 
1. The patient entered combat without faith and con- 
fidence in his leader.—This may be petty officer, commis- 
sioned officer, commanding officer, division commander, 
force commander, or higher, depending on the rank and 
duties of the victim. This arises from any one of several 
situations. The superior may be incompetent, or being 
competent, may have given the impression of incompe- 
tency of his juniors. The important point is not the actual 
ability of the superior, but the junior’s estimate of his 
ability. The leader may have held his position for such a 
short period of time before combat that his juniors are 
uncertain and in doubt as to his ability; on the other hand, 
he may, through familiarity with his troops, have exposed 
his normal weaknesses in extramilitary matters, thus cast- 
ing doubt in the minds of those under him on his ability 
to command. It is this latter possibility which makes ur- 
gently necessary the restraint of normal personal relation- 
ships between officers and the men who will serve under 
them in combat. Any incident which strengthens faith in 
the leader lessens the occurrence of neurotic symptoms, 
hence a winning army or a winning ship produces fewer 
cases than one which loses. A ship which has given a good 
account of herself, even though finally sunk, leaves a less 
emotionally disturbed group of survivors. Similarly, loss 
of faith in leadership, even after combat, may produce 
symptoms based on the previous traumatic experience. 
Thus a yeoman who survived the sinking of a combatant 
ship under extremely traumatic personal circumstances 
(personally witnessed loss of close friends, great danger 
to self, and long hours in the water) had no reaction 
noticeable to himself more than mild startle response until 
he began to prepare the reports of the engagement. He 
then discovered that mistakes had been made in the con- 
duct of the engagement, and immediately developed night- 
mares, restlessness, and anxiety in response to noise. 
From the standpoint of the patient, his lack of faith 
may arise from his own considerable ability as compared 
with the lack of experience and youth of the officers under 
whom he serves. This may account to some extent for the 
predisposition contributed by age; with greater maturity 
greater value is placed on life, there is less belief in the 
infallibility of humans, a more critical perceptive toward 
all is adopted. The rapid expansion of the Navy may give 
us many ships in which the officers are of less experience 
and younger than many of their crew, a potentially dan- 
gerous situation psychologically. 
2. The patient teas insufficiently trained, did not know 
his job or his ship as thoroughly as he should.—Careful 
and adequate training is of the utmost importance in pre- 
vention of war neurosis. All observers agree that in the 
heat of battle men react at an automatic level; they do 
what they have been taught to do, and nothing else. When 
a gun platform was on fire, ammunition handlers who had 
been trained to overboard ready ammunition in case of 
fire continued to dispose of it properly even when the men 
about them were blown to bits performing the same duty. 
At least some of the patchy amnesias for combat details are 
due to an attention defect at the time, rather than to active 
repression of unpleasant memories. Such amnesias, when 
the events are recovered, reveal themselves as of no par- 
ticular importance to the patient or his illness. It appears 
that complete training will greatly reduce the incidence 
of acute psychiatric casualties during combat, as well as 
more protracted illnesses later. Fear reactions are much 
less common in those performing duties they know well, 
even though the duties themselves may not provide an 
outlet for aggression or the normal anxiety experienced 
under fire. This has been noted by others, and Sargant 
quotes a high military authority as stating that, "Shell 
shock is nothing but insufficient training.” 
3. The patient entered combat surrounded by new ship- 
mates, men who were comparative strangers to him, and 
whose conduct under fire he had not had time to estimate. 
—In this respect a man is between two fires; if he is 
among close friends of long acquaintance, he is emotion- 
ally wrung by witnessing their maiming and destruction; 
if he is among new shipmates his own sense of personal 
danger is greatly enhanced. The latter situation is the more 
intolerable to him. Ships with hurriedly assembled crews, 
or with high percentages of new men on board, may be 
expected to contribute an unduly high number of "war 
neuroses.” 
4. The patient experienced the combat situation when 
he was suffering with marked physical fatigue.—The out- 
standing role of fatigue in all these syndromes has been 
recognized and stressed by each investigator of the sub- 
ject. Whatever the usual mechanisms of defense against 
this type of emotional disturbance, it is certain that they 
are weakened and reduced by prolonged physical exer- 
tion, hunger, exposure, lack of sleep, irregular habits. 
Fatigue is particularly important in land troops; the men 
of naval forces are more apt to have some opportunity for 
rest between engagements. Such rest, however, may be 
broken by general alarms, drills, abortive attacks, and so 
on, so that it falls considerably short of true rest. "War 
neurosis” may be expected much more commonly among 
land troops, but conversely, such symptoms as occur may 
be expected to respond much more readily to simple rest. 
Fatigue has been such a prominent part of the etiological 
background of these cases, that it has been suggested as 
an alternate name for this syndrome which scarcely quali- 
fies for the diagnostic title of "neurosis.” 
103 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
We are not prepared to say just why the above factors 
produce symptoms. Complete analysis of a number of such 
cases would undoubtedly reveal certain fundamental psy- 
chological mechanisms through which the symptoms are 
produced. It is our belief, however, than any such psycho- 
logical mechanisms as exist are common to a great major- 
ity of men, that their eradication is impossible, and that 
therefore, their importance can be minimized in the pre- 
vention and treatment of "war neurosis” in the present 
state of our knowledge. We believe that the four factors 
delineated above can be controlled to some extent, and 
thus utilized in the prevention of "war neurosis” or com- 
bat fatigue. 
Two other observations concerning etiology, especially 
important therapeutically, are the facts that: (1) Diffi- 
culty in returning a patient to combat duty is increased in 
direct proportion to the distance from the front to which 
the patient has been evacuated, and (2) all symptoms are 
liable to aggravation in the presence of loved ones; friends, 
relatives, spouse, family. In the latter situation, the trau- 
matic anxiety and concomitant disturbances are particu- 
larly apt to attach themselves to the emotional ramifica- 
tions of family life and become irreparably fixed. A pa- 
tient who suffered with nightmares of some degree, and 
moderate startle reaction, found it unnecessary to consult 
a physician concerning them for 3 months after the sink- 
ing of his ship; During this period he was busily engaged 
in the affairs surrounding decommissioning of the ship 
and was quite able to handle his nervous reactions without 
outside aid and without undue concern on his part. Imme- 
diately following his return home on survivor’s leave, 3 
months after the sinking, he was met with newspaper pub- 
licity, innumerable calls from the families of other men 
from the same town who had been on his ship, and within 
24 hours was suffering such attacks of anxiety that he 
called his family physician for examination. In this par- 
ticular case, the man was especially foresighted in that he 
returned at once to naval command when his physician in- 
formed him that he probably had "heart trouble.” The 
efficacy of therapy is shown in the fact that he now is back 
on limited active duty, in spite of receiving only the most 
superficial sort of treatment. Less fortunate patients re- 
main in the vicinity of their families, and may easily ripen 
their transient symptoms into a full-blown psychoneurosis 
in the misguided warmth of love. 
It is extremely difficult for those accustomed to work- 
ing with psychoneuroses to consider the "war neurosis,” 
as delineated herein, a true neurosis. The occurrence of 
psychoneurotic symptoms in an otherwise stable and non- 
neurotic personality is a remarkable and striking phenom- 
enon, one which will bear careful study and observation. 
This collected group of symptoms does not occur in iso- 
lated form in the personality; they may be incorporated 
with underlying emotional conflict to form any gradation 
of a true psychoneurosis, with fundamental mental de- 
ficiency to produce a bizarre picture, with an incipient 
psychosis of either the affective or schizophrenic type, 
actually even with organic brain damage or with epilepsy. 
It is this incorporation, however, which produces the wide 
variety of response to combat conditions, and not the trau- 
matic emotional disturbance itself. The universality of the 
picture, the stereotypy of the symptom response, the ex- 
tremely shallow depth of the uncomplicated cases, the 
absence of previous marked emotional disorder in so many 
victims of "war neurosis,” all suggest that here we are 
dealing with something quite different from the usual psy- 
choneurosis. Names such as "war neurosis,” "traumatic 
neurosis,” "traumatophobia,” all suggest the alliance with 
classical neuroses which we do not believe exists directly. 
It has been suggested that the term "combat fatigue” be 
applied to the uncomplicated syndrome. This title carries 
with it no connotation of emotional instability or of future 
recurrence, and would seem to be the best of names sug- 
gested thus far, although actually the fatigue of combat is 
only one of the several factors involved in the production 
of symptoms. Those cases which develop complicating 
symptoms of conversion, anxiety, compulsion, epilepsy, or 
what not, should be called by their proper diagnostic titles 
of psychoneurosis (hysteria or other), for that is what they 
are, and in them the combat is only an incident. We can- 
not stress too much that in these complicated cases pre- 
senting secondary signs, the treatment, prognosis, and dis- 
position are exactly the same as for the same disability 
occurring in a peacetime setting, except as they be altered 
by the secondary gain possible (under the pension system) 
to any disability occurring during war. 
Before entering into a discussion of therapy, the follow- 
ing illustrative cases of combat fatigue, with its complica- 
tions and differential diagnosis, are presented. 
CASE REPORTS 
Case 1.—This 24-year-old patient, a boatswain’s mate, first 
class, who had 1 year and 2 months active duty in the United 
States Naval Reserve was admitted to the hospital for neuro- 
logical examination when he complained of slight weakness of 
the left shoulder and was observed to have wasting of the supra- 
scapular muscles. 
The patient is a tall handsome young man, the eldest son of 
a sound middle-class family, which had always been secure finan- 
cially. Although an indifferent student at a large city high school, 
he was outstanding athletically as a prominent member of the 
football, baseball, basketball, and swimming teams. After leav- 
ing school he held several positions of a minor nature, though 
performing satisfactory work, and in addition served 2 years in 
104 Chapter 22.-COMBAT FATIGUE AND WAR NEUROSIS 
the United States Navy, receiving a disciplinary discharge in 
1940, which he deliberately incurred at his family’s urging. The 
patient subsequently married and is happy at home with his wife 
and child. 
He served on cargo and transport ships in the Pacific prior 
to the opening of the North African campaign and was twice 
officially commended for meritorious duty during this period. 
During his duty in the Atlantic he witnessed a tanker explode 
and was upset in noticing mangled bodies sweeping past his 
ship. He was transferred to another ship shortly before the North 
African invasion. After the original landing on the North African 
coast the patient injured his shoulder during a fall while diving 
into a foxhole as the enemy planes strafed the beach. He was 
then exposed to the sight of his friend who had been mutilated 
by the loss of his Teg during this engagement, and later wit- 
nessed the sinking of four transports and the narrow escape of 
his own ship following a submarine- torpedo attack. He returned 
to this country, continuing on duty at his own request although 
suffering terrifying nightmares recapitulating his war experi- 
ences and becoming unusually alarmed and apprehensive when 
exposed to previously innocuous sounds. His wife noticed his 
sensitivity and his unwillingness to attend cinemas that depicted 
combat scenes but at no time did he consider his symptoms suf- 
ficiently severe to necessitate medical aid. They were only elicited 
by direct questioning during the neurological examination. The 
patient was found to present atrophy and weakness of the 
muscles supplied by the suprascapular nerve as well as a costo- 
chondral dislocation of the first left rib. He declared that the 
psychological symptoms mentioned before had become less dis- 
turbing and less frequent during the previous 3 months. 
Following 4-weeks’ treatment for the injury to the shoulder 
the patient was returned to duty. At no time during the period 
of hospital observation was he observed as restless, agitated, 
sleepless, or apprehensive. 
Comment.—This previously stable 24-year-old man developed 
fleeting restlessness, nightmares, and sensitivity to otherwise in- 
nocuous sounds following his exposure to combat. The symp- 
toms were never disabling and had, according to his own state- 
ment, subsided in frequency and intensity during the intervening 
3 months. This type of mild disturbance rarely arrives in hos- 
pital and can be handled easily aboard ship if recognized. 
Case 2.—This 18-year-old radioman had 1 year and 3 months 
service in the United States Navy prior to his admission to the 
hospital with symptoms of anxiety and depression. 
The patient is the youngest son in a happy artisan family of 
four children. He was the favored child but throughout his 
early life gave no indication of instability. At school he was an 
average student and later was president of his high-school class 
and an outstanding football player. At the outbreak of war, 
he enlisted in the naval service with the consent of his parents, 
and immediately after completing his recruit training was de- 
tailed aboard a destroyer where the morale was high. He made 
many close friends and with personal assistance of the com- 
munications officer, who helped him with the radio work, made 
a rapid advancement in rate. 
The destroyer was part of the screen of an aircraft carrier 
engaged in the Coral Sea Battle, the raid on the Gilbert and 
Marshall Islands, and later the Battle of Midway. At the onset 
of each engagement the patient felt apprehensive but once firing 
commenced he became entirely composed and attentive to his 
duties. While the destroyer was lying alongside a Stricken air- 
craft carrier following a bombing attack during the Battle of 
Midway, June 1942, the patient heard the warning of "torpedo 
wakes.” He was then sitting alone in the emergency radio room 
aft, arose, saw the white wakes approaching the ship, resumed 
his post until suddenly thrown out of his seat when the torpedo 
exploded beneath him. He ran from the shack, cut down some 
life rafts, plunged overboard and swam rapidly away from the 
ship. As the depth charges of the sinking ship exploded he was 
dazed and coughed up blood. He reached a nearby raft, which 
was later evacuated by another destroyer. He was then cognizant 
that his best friend, his immediate chief, and the communica- 
tions officer, had all been killed. On being taken aboard the 
ship he collapsed. Following his return to the naval base, it was 
learned that he had suffered blast injury to the chest and abdo- 
men which eventually necessitated intestinal resection. During 
convalescence from this operation he first had terrifying night- 
mares in which various scenes related to the sinking of the de- 
stroyer were continually repeated, and which wakened him in 
a state of anxiety. Sudden noises also produced unusual appre- 
hension. He felt fatigued and tired, but on his return to the 
mainland was well enough to request return to duty in spite of 
the symptoms, and to marry 4 months after the injury. His wife, 
a young irresponsible girl, resented his desire to remain home, 
deserted him within the month and was found to be unfaithful. 
This precipitated a depression with acute anxiety, preoccupation 
with his combat experiences, his marriage, and worry over pains 
in the operative scar, loss of appetite and insomnia. An attempt 
to annul the marriage failed and as he was unable to obtain leave 
he went A. W. O. L. in order to contact his family and obtain 
their help. When the patient turned himself in at the receiving 
station his emotional disturbance was noted and he was trans- 
ferred to this hospital. 
He was admitted to the medical service on January 29, 1943. 
There was no evidence of physical disease but his insomnia, 
anorexia, constipation, and fatigue were observed and psychiatric 
study was requested. The patient was listless, dejected, and 
emotionally labile. Discussion of his battle experiences was dis- 
tressing to him and he described in detail his sensitivity to 
sounds and various combat scenes in motion pictures. The latter 
stimulus invariably led to anxiety. After 1 month of treatment 
on the psychiatric service, assistance in correcting his marital 
affair, and reassurance concerning the disciplinary measures to 
be taken against him, improvement was noted. He was more 
energetic, content, slept well, commenced to eat, gained some 
weight, and again desired to return to duty. Nightmares were 
infrequent, he was again able to attend movies and sounds were 
less disturbing to him. It was possible for him to describe his 
war experiences without tension. A Board of Medical Survey 
recommended his return to limited active duty for a period of 
no less than 6 months following his discharge from the hos- 
pital, under the diagnosis of combat fatigue. 
Comment.—This previously stable adolescent, with a long 
period of service aboard a combatant ship, developed catastrophic 
nightmares, "startle,” and fatigue, as well as severe blast in- 
juries to the chest and abdomen, following the torpedoing of 
his ship. The psychological symptoms were aggravated follow- 
ing his rejection by his wife and were then complicated by de- 
pression, anxiety, restlessness, and resulted in his first breach of 
regulations. 
Case 3■—This 24-year-old lieutenant had 1 year and 16 days 
active duty in the United States Marine Corps prior to his ad- 
105 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
mission to this hospital for study concerning an "emotional 
instability.” 
At birth he lost his mother and was placed in the hands of 
an aggressive but affectionate aunt and a colorless uncle. As the 
only child in the home he was pampered and spoiled, but at the 
age of 18 years decided to return to his very successful father, 
who had meanwhile married and had two children by his second 
wife. The readjustment was difficult but successful; at first he 
felt resentment toward his stepmother, who seemed unduly criti- 
cal and appeared to discriminate against him. He entered college 
in accordance with his father’s wish. He pursued a dilatory 
course, though active in athletics and social affairs. However, on 
the side, he methodically and conscientiously carried out a re- 
search program for a chemical company as a means of obtaining 
funds for himself. 
The patient left college to enter Marine Corps aviation when 
the opportunity presented. He had had over 200 flight hours 
prior to his transfer to a Pacific island base in April of 1942. 
There, due to equipment limitations, the group obtained only a 
few hours flight per month and did not have the opportunity 
of combat practice as a unit. He was quartered with, and became 
unusually close to, his commanding officer. The patient was a 
member of the dive bomber unit attacking the Japanese fleet in 
June. His oldest companions in the squadron were shot down 
in flames before his eyes, his commander and a large proportion 
of the squadron were lost. He put his bomb on an aircraft carrier 
before returning to base and then was exposed to shelling by a 
submarine during the following night. Shortly after the return 
of the survivors, both he and his surviving squadron mates pre- 
sented evidence of an intense emotional reaction. He was rest- 
less, tense, irritable, and unable to sleep. At night he repeatedly 
recapitulated the horrifying combat experience in dreams and 
during the day was unduly upset by sounds reminiscent of 
bombing. He commenced to drink, was morose, reticent, and 
irresponsible, and ignored the usual courtesies given senior 
officers. His confidence in his flying ability disappeared, he was 
fearful of killing himself or others, and repeatedly considered 
various schemes for self-injury in order to escape from the dis- 
tressing situation. Following a rebuke by his commanding officer, 
after collision of a plane in his three-plane section with an Army 
plane, his anxiety became so marked that he demanded to be 
transferred to an Infantry company. In rapid succession he re- 
ceived three changes of station in the succeeding 4 months, 
finally ending in an Infantry company. These transfers served 
further to undermine his security; he believed from comments 
made that an effort was being made to oust him from the corps. 
On admission to the hospital he was anxious, restless, over- 
active, and sleeping poorly. He had feelings of guilt and was 
sheepish over a recent award of the Navy Cross. He stated that 
he was unable to attend movies containing battle scenes. "The 
first thing you know, you are right up there in it.” Under treat- 
ment the patient regained his composure, was again affable, en- 
thusiastic, assured, and pleasant. The nightmares subsided, startle 
was less pronounced, he was able to attend movies, resumed 
aviation gunnery practice, and repeatedly expressed his desire 
to return to aviation though not certain of his ability to perform 
as a fighter pilot. Accordingly after 3 months he was brought 
before a Board of Medical Survey and recommended for return 
to limited active duty with ground aviation for a minimum of 
6 months prior to reconsideration for flight duties. The diagnosis 
was combat fatigue. 
Comment.—This rather immature lieutenant, previously with- 
out symptoms of emotional instability, with an inadequate train- 
ing period prior to a dive bombing attack in which his com- 
manding officer was killed, developed nightmares, anxiety, re- 
sponse to startle or to recapitulations of combat scenes in movies, 
and a personality change characterized by morose irritability, 
alcoholism, irresponsibility, insecurity, and lack of confidence. 
The symptoms were aggravated by the undermining influences 
of a rapidly changing environment and of an unsympathetic, mis- 
understanding attitude of both medical and line officers who 
contacted him following the combat experience. 
Case 4.—This 17-year-old seaman had 7 months’ active duty 
prior to his admission to the hospital with an undetermined 
diagnosis of intracranial injury. 
He is the third of four boys in a family of six. His father is a 
"shell-shocked” veteran of World War I, now alcoholic and a 
chronic complainer. The mother is migrainous. The home was 
kept discordant by parental quarrels; nevertheless, the patient, 
though of retiring and quiet nature, adjusted well at school, 
was accepted by his classmates, and was not considered tem- 
peramentally unstable. 
Following his enlistment in the naval service, he received 
3 weeks basic training and was detailed aboard a transport for 
drill in amphibious operations. The patient had hoped for duty 
aboard a combat ship of the line. Three weeks prior to the 
departure of the convoys for the North African engagement, he 
was transferred to another ship. There he was barely acquainted 
with his new shipmates when the engagement opened. His im- 
mediate chief was regarded by him with little respect as an 
"old man.” The seaman was extremely apprehensive as his 
landing boat approached the beach during the opening opera- 
tions, but quickly regained composure when not exposed to fire. 
The following day he was frightened to the point of believing 
his legs were paralyzed when an enemy plane strafed the ship 
and he threw himself on the deck. The fourth day the ship was 
suddenly torpedoed. He was blown against the bulkhead and 
struck his head, but was not injured and quickly climbed down 
a net into a tank lighter below. While throwing out lines to men 
struggling in the water he was fascinated by their cries and 
amazed to see some cast aside their life jackets. After helping 
one man aboard the patient felt so weak that he lay upon the 
deck and later had to be assisted ashore. The following day a 
plane killed a French woman in town and he morbidly examined 
her body and the leg wounds of a sailor wounded in the same 
raid. He then realized how tense and anxious he felt, and in 
the following weeks had difficulty in sleeping, being repeatedly 
awakened by dreams in which his ship was torpedoed or he was 
shot in the leg. While aboard the transport returning home, he 
and the men in his division were quartered in a forward com- 
partment. During a prolonged storm the group repeatedly 
rushed to the boat deck in panic when a loose hatch cover 
slammed above them. He was given a 30-day leave after arriving 
in this country but the change in his personality was so con- 
spicuous to his family that his mother shortly sought medical 
advice concerning his symptoms. 
On return to duty the patient complained of headaches and 
dizziness, and was transferred to this hospital for study. As 
there was no evidence of organic disease, psychiatric examina- 
tion was requested. His extreme restlessness, amounting to agita- 
tion, his inattentiveness and irritability were immediately ap- 
parent. He was unable to concentrate, expressed death fears, and 
106 Chapter 22.-COMBAT FATIGUE AND WAR NEUROSIS 
presented the history of nightmares and sensitivity to sounds 
reminiscent of combat. His, sleep was broken almost nightly by 
terrifying dreams. With sedation and psychotherapy there was 
some diminution in the restlessness, the insomnia, and his re- 
sponse to startle. He put on weight, but continued to complain 
and insisted upon his inability to return to duty. It was evident 
that he would not again adjust in the service. On a mental test 
he attained an intelligence quotient of only 69. Accordingly, he 
was brought before a Board of Medical Survey and recom- 
mended for discharge under the diagnosis of psychoneurosis, 
anxiety neurosis, incurred in the' line of duty. 
Comment.—This dependent, youthful seaman, with a dull 
mentality, who was raised in a discordant home by a neurotic, 
alcoholic father and a highstrung mother, presented no evidence 
of emotional instability prior to his traumatic combat experi- 
ence. He then developed nightmares, startle, and a personality 
change marked by agitation, anxiety, and preoccupation, with 
the complaints of headaches and dizziness. The case study illus- 
trates the importance of a psychopathic background, and the 
contributing factors of inadequate training, indifference to lead- 
ership, and low morale. The repeated panics during the voyage 
home have probably further served to deepen the patient’s anxiety 
by the process of conditioning. 
Case 3.—This 28-year-old corporal had 2 years and 4 months 
service in the United States Marine Corps prior to his admis- 
sion to this hospital. 
He is the youngest of five children. The brother now is in the 
naval service and the three sisters are married. The father is a 
successful Illinois farmer, the mother suffers hypertension and 
is irritable and fretful. The patient is his mother’s favorite. His 
childhood was not unusual; he completed grade school at 15 
with an average record and worked steadily as a laborer or a 
farmer until his enlistment in the Marine Corps. His sexual life 
has been promiscuous and he has not married. A review of his 
health record showed that the patient had requested medical 
study on June 13, 1941, following three acute attacks of pal- 
pitation associated with vague apprehension of death. As no 
medical cause could be discovered for his symptoms he was re- 
turned to duty with the statement that the complaints were re- 
garded as "functional in origin.” Sedatives were prescribed for 
treatment. 
The patient was a member of a Marine unit at the time that 
the Japanese attacked Pearl Harbor. As he and members of his 
company were leaving the mess hall they observed some planes 
dropping torpedoes and thought that they were witnessing a 
sham maneuver until explosions took place and the planes com- 
menced to strafe the fields. The patient, with some companions, 
immediately rushed to a storeroom, broke out a machine gun, 
mounted it near the hospital, and manned the; gun during the 
succeeding attack. He witnessed the explosion of the U. S. S. 
Arizona, saw men in his company shot down by the strafing 
planes, and was later nauseated as the burned and maimed were 
carried into the nearby hospital. For the next 36 hours his com- 
pany was busy preparing and manning machine gun positions 
upon the beach while awaiting an expected invasion. The com- 
pany was kept active for a period of 3 weeks and as the tension 
decreased the patient developed anxiety, was unable to sleep 
well, commenced to have nightmares which awakened him in 
extreme apprehension with palpitation, choking, and dyspnea. 
Following exposure to any sharp sound suggestive of an air 
raid he felt weak, sick, tremulous, and perspired freely. He 
made no complaint and continued duty. As his symptoms per- 
sisted for months after his evacuation to this country he became 
fnorose, irritable, restless, depressed, and fearful of developing 
a "nervous breakdown.” For this reason, the patient sought 
medical advice in October 1942, 10 months after his combat 
experience. 
On admission to the hospital there was no evidence of 
physical disease. He was conspicuously restless, tense, anxious, 
resentful and irritable, and easily startled by slight sounds. Care- 
ful observations of his sleep disclosed that he had difficulty 
initiating sleep and then frequently awoke during the night. The 
patient was unwilling to discuss his experience at Pearl Harbor 
though induced to give a chronological account of his activities. 
He was thought to be actively repressing certain of his experi- 
ences and never produced dream content. 
With psychotherapy and sedation, he became more composed, 
was able to perform simple details about the hospital com- 
pound, gained weight, slept soundly, and conversed with ease 
on other subjects than his battle experience. This subject imme- 
diately aroused his anxiety, and he became irritable, anxious, 
flushed, and excited. In spite of continuous treatment over a 
period of 3 months his improvement was considered insufficient 
to allow his return to even limited duty. Therefore a Board of 
Medical Survey recommended his discharge under the diagnosis 
of psychoneurosis, anxiety neurosis, considered to have been in- 
curred in the line of duty. 
Comment.—This patient was observed to suffer anxiety 
seizures many months prior to the outbreak of war. His single 
battle experience, coming as a surprise and without adequate 
preparation, resulted in aggravation of this already established 
neurosis and complicated it by engrafting thereupon a "startle" 
response to sound and a mild depressive reaction. 
Case 6.—This 2I-year-old seaman had 7 months’ service prior 
to his admission to this hospital with the complaints of weak- 
ness of his legs, nervousness, poor appetite, and inability to 
sleep. 
The patient is one of a large family, of Italian immigrant 
parentage. Throughout his adolescence he considered himself 
physically weak and unfit for strenuous physical effort such as 
athletics. He was a sensitive, retiring individual, and worried 
about a severe case of acne. Due to his pallid complexion, he 
thought he had anemia. In the year previous to his enlistment 
he had attempted to work as a fisherman but after twice suffer- 
ing severe fright following falls into the sea, gave up this oc- 
cupation. 
On enlistment in the naval service, he was selected for further 
study by the psychiatrist at the naval training station due to his 
conspicuous insecurity, but was sent to duty after the receipt of 
an innocuous social service report. He was then assigned to the 
Amphibious Force when his recruit training was complete, and 
was placed aboard a transport. There he repeatedly visited sick 
call with such complaints as weakness, tension, fatigue, diarrhea, 
and vomiting, and was actually in bed during the days before 
his ship approached the North African coast during the original 
landing operations in November of 1942. The patient however 
served as a coxswain for one of the landing boats. His transport 
was torpedoed on the fourth day after the first landing. He im- 
mediately went overboard, swam about supported by a life jacket, 
and was shortly picked up by a barge. No sooner was he grasped 
than he collapsed, had to be pulled aboard, and was still unable 
to support himself upon his legs when put ashore several hours 
107 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
later. He was one of the members of the division that was placed 
in the forward hold of a returning transport where the men re- 
peatedly rushed to the boat deck in panic when a loose hatch 
cover slammed and led them to fear another torpedoing. 
Shortly after his return to this country he was admitted to the 
hospital with the diagnosis of anemia and the symptoms men- 
tioned above. As there was no clinical evidence of anemia he 
was returned to duty 14 days later. The patient then received a 
31-day survivor leave, but on return to duty complained of weak- 
ness of his legs and fatigue. In view of these complaints he was 
readmitted following interview with a psychiatrist, who regarded 
the patient as of long standing neurotic make-up and did not 
consider that his combat experience had aggravated his condi- 
tion. It is of interest that the patient denied nightmares, was not 
restless or unduly anxious when exposed to sharp sounds. In 
spite of treatment and observation over' a 2-month period, his 
complaints persisted and the patient was therefore recommended 
for discharge from the service by a Board of Medical Survey 
under the diagnosis of constitutional psychopathic state, emo- 
tional instability, which was considered to have existed prior to 
enlistment. 
Comment.—This patient, in spite of a long-standing neurotic 
complaint, was capable of performing his duties during combat 
operations but did not develop any of the symptoms of the trau- 
matic state, though exposed to considerable stress. However, 
following the sinking of his ship, his exposure to combat, and 
his return to this country, he reproduced the neurotic symptoms 
that had previously preoccupied him. 
Case 7.—This 20-year-old patient, a seaman, second class, 
had 5 months and 7 days active duty in the United States Naval 
Reserve prior to his admission to this hospital. 
He is the second of five children, the eldest of the three boys. 
His father is a laborer. As a child the patient was shy and re- 
tiring, was unusually sensitive to teasing, had nightmares and 
walked in his sleep until the age of 12 years, and was enuretic 
until 9 years old. Following the death of his father, the patient, 
then 9 years old, fainted after developing palpitation, precordial 
distress, weakness, and a feeling of anxiety. These symptoms 
have recurred throughout the intervening years whenever he has 
been exposed to the stress of frustrating situations. He did poorly 
in school, with four grade failures, and then accepted employ- 
ment irregularly. He has since been intermittently alcoholic, 
always dependent upon his mother, and now upon his wife, for 
security. 
He was detailed to a fast minesweeper after 3 weeks training. 
Two months later the patient was engaged in the landing opera- 
tions along the North African coast. The patient was posted as 
lookout. As the ship approached the coast it was greeted by 
some gunfire and he saw shells splash in the water several hun- 
dred yards away. His heart commenced to pound, the precordial 
heaviness recurred, and his legs felt weak. He sat down on the 
deck, thus deserting his post and allowing the other men to 
carry on without him. As the ship was exposed to no other gun- 
fire and had an otherwise uneventful trip the patient presented 
no further symptoms until after the return voyage to the United 
States. Then he had another similar attack while lying in his 
bunk in a crowded section of the ship, and due to his obvious 
discomfort, with complaints relating to his abdomen and chest, 
he was transferred to this hospital for medical observation. 
In the hospital, he presented the history and symptoms re>- 
corded above, declared that he was unable tp adjust in crowds 
or noisy situations, and was preoccupied with worry concerning 
his wife, a chronic invalid. The physical, neurological, and 
laboratory studies failed to reveal evidence of organic disease 
but a social service report confirmed the history presented by 
the patient and further stated that he had "been ill all his life.” 
A test of his mental ability showed that he had an intelligence 
quotient of 73. Accordingly he was brought before a Board of 
Medical Survey and recommended for discharge under the diag- 
nosis of constitutional psychopathic $tate, inadequate personality. 
Comment.—This 20-year-old patient with a border-line men- 
tal defect a*nd a long history of insecurity and general inade- 
quacy had for many years been preoccupied with somatic com 
plaints relating to his heart which had been recurrently noted in 
emotionally distressing situations. This neurotic complaint caused 
him to desert his post aboard ship at the onset of battle opera- 
tions but fortunately this act did not result in serious conse- 
quences to others. At no time was he exposed to a combat situa- 
tion sufficient to produce combat fatigue. 
Case 8.—This 31-year-old ensign had 7 months and 21 days 
active duty in the United States Naval Reserve prior to his ad- 
mission to the hospital with a simple fracture of the twelfth 
dorsal vertebra. 
He is the only son of a successful, energetic, and righteous 
businessman, and was happily brought up by his stepmother 
after his mother lost her life when the patient was 6 years of age. 
An average student at school, he entered the merchant marine 
at the age of 17 years and had worked his way to a first officer’s 
license by the time he was 25 years. Then the patient married 
and accepted a position ashore as a foreman of stevedore gangs. 
In 1938, while at this job, he became depressed, slept poorly, 
had feelings of inadequacy, felt excessively fatigued, and ex- 
perienced crying spells throughout a period of 12 months. He 
did not seek medical care, and blamed his mood disturbance 
entirely upon overwork and the type of people with whom he 
had to associate. He quickly recovered after impulsively quitting 
this job, and was performing in a highly successful manner as a 
salesman when he reenlisted in the United States Naval Reserve. 
His previous commission had been canceled at the time he dis- 
continued going to sea. 
The patient was immediately placed aboard an armed trans- 
port and in spite of his junior rank was given considerable re- 
sponsibility because of his previous experience at sea. He was 
the assistant to the executive officer, stood senior watches, 
arranged battle drill, and was placed in charge of the after 5-inch 
gun. In August of 1942, while the ship was running trials, he 
again felt run-down and fatigued, and was at times so depressed 
that he had uncontrollable weeping spells. For this reason, he 
spent a full week in bed in the sickbay. Nevertheless, he resumed 
his duties when the ship joined the North African invasion fleet. 
Early one morning, nearing the African coast, the ship was struck 
by a torpedo which exploded the after magazine, wrecked his 
gun, and threw him into the air some 15 feet. In spite of frac- 
turing his back, he ordered his men to another gun, and pain- 
fully dragged himself into the wrecked compartment below, 
from which steam was escaping and where he heard the cries 
of injured men. There he was shocked by contact with the 
mangled and dismembered bodies of his own men. A half hour 
later the patient entered the sickbay in shock secondary to the 
back injury but recovered quickly and was again at his post 2 days 
later. Throughout the succeeding 3 weeks the ship was bombed 
daily by planes, and eventually was thrown upon the rocks dur- 
108 Chapter 22.-COMBAT FATIGUE AND WAR NEUROSIS 
ing a severe storm. The repeated calls to general quarters, the 
fear of sinking, loss of sleep, and continuous responsibility led 
to deepening depression, and restless sleep. He began to dream 
of bombing and sinkings, of general quarters alarm, and fre- 
quently awakened with a start. There was a recurrence of an 
anxiety nightmare that he had in childhood. Sharp sounds led 
to acute anxiety. Following his eventual collapse from the ex- 
cruciating pain in his back, and the x-ray discovery of the frac- 
ture 3 weeks after the injury, he was evacuated to this country. 
While aboard the returning, transport the patient learned that 
the men on this ship were not stationed in the magazine in the 
manner that he had arranged for his crews. The already existing 
guilt feelings concerning the death of his men were magnified. 
The return to this country was first followed by relief, but 
shortly after his admission to this hospital he again felt tense, 
fearful, apprehensive, depressed, and insomniac, and the night- 
mares recurred. He was anxious when planes flew overhead or 
when sirens or whistles were heard, and was unable to attend 
movies due to his self-identification with the actors. In particular, 
he plunged himself into the movie, "Caught in the Draft,” and 
instead of laughing at this comedy, left, tortured by the fear of 
the hero who was to be forced into gunfire. He was self-accusa- 
tory, declared himself a coward, and expressed a hatred of the 
sea and the service and all that went with it. Only when at 
home on leave from the hospital did the patient feel happy and 
as the day of return approached there was a quick resurgence 
of the depression. As he failed to improve under treatment and 
was considered to be suffering a depressive psychosis complicated 
by his combat experience, he was recommended for prolonged 
hospital care and .eventual retirement by a Board of Medical 
Survey. 
Comment.—This commissioned officer had a depressive epi- 
sode of the manic depressive type 4 years prior to reporting for 
active duty and was entering another attack 2 months before 
exposure to combat. This second depression, which at its onset 
consisted of feelings of fatigue and despondency, and short 
periods of uncontrolled weeping, was aggravated after a horrify- 
ing combat experience, and complicated by the characteristic 
startle reaction to sound and by nightmares. These dreams con- 
sisted not only of simple war recapitulations, but also of child- 
hood anxieties. Here the combat-induced emotional disturbance 
became incorporated in an incipient major psychosis. 
TREATMENT 
The preventive treatment has been clearly indicated in 
the foregoing. Little of it lies in the hands of the medical 
officer. All men placed in a position of even small respon- 
sibility should be carefully scrutinized with regard to their 
fitness therefor. Particularly, officers should be selected 
with the greatest of care. Any officer who creates a feeling 
of distrust in the men under him should be removed at 
once, and the causes behind the impression should be 
examined carefully. Commanding officers should be most 
ruthless in weeding out inapt officers and those who per- 
form poorly under fire. Adequate, competent officers, 
more than any other single factor, will prevent the occur- 
rence of acute psychiatric casualties during combat and 
the presence of combat fatigue in the crew. 
Men need thorough training in all aspects of their work 
before engaging in actual combat. Any method of increas- 
ing training adequacy will greatly increase the effective- 
ness of the ship in combat on psychological grounds alone. 
The medical officer should assure himself that his own 
corpsmen are thoroughly drilled in the duties of their 
department, and, in addition, should see that the remain- 
der of the crew are completely indoctrinated in the prin- 
ciples of first aid. Nowhere more than in the psychiatric 
casualties of war is it demonstrated that knowledge helps 
to banish fear. 
No ship should attempt to meet combat conditions 
until the crew has been assembled for a reasonable length 
of time, and the men have come to know each other fairly 
well. To do so is to invite disaster. Wherever possible, 
crews should be assembled early in the fitting out of the 
ship, and kept together thereafter. As a. matter of policy, 
shifting of men from one unit to another should be kept 
to an absolute, unavoidable, minimum. 
That fatigue should be avoided as far as possible goes 
without saying. Unfortunately, this extremely important 
point, as a general rule, is beyond the control of anyone. 
It is almost axiomatic in war that men are pushed to 
the very limits of their physical tolerance; and some- 
times beyond. Ships’ officers, however, should see that 
every opportunity to obtain needed rest is seized upon, 
and where combat is expected in the near future, all sub- 
sidiary work should be scheduled in such a way as to 
allow the maximum amount of rest to each man on board. 
When circumstances permit, directed recreational activ- 
ities should be utilized to prevent the psychological fati- 
gue known as staleness. Naval units are considerably more 
fortunate in this respect than land troops, and every possi- 
ble advantage should be taken of this good fortune. 
These preventive measures are recognized and sub- 
scribed to by the Navy. It is obvious that not all can be 
provided in any given situation, and that these things 
must be modified by the exigencies of war. We may expect 
a certain percentage of psychiatric casualties from all en- 
gagements. Should, however, any ship show an unusually 
high incidence of combat fatigue, the circumstances sur- 
rounding the engagement should be investigated at once, 
with particular reference to the factors mentioned. It must 
be remembered that whenever a large number of casual- 
ties have arrived in a hospital from a given ship, there 
are surely a great many more who did not seek medical 
aid, and who are exposing some other ship to the dam- 
aging influence of their contagious panic. In dealing with 
the neuroses of war, we find that "morale” is not some 
ethereal myth, but a tangible problem composed chiefly 
of sound leadership, good training, familiarity with ship- 
109 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
mates, and lack of fatigue. Unless these conditions are 
met, no amount of propaganda will raise morale. 
The active therapy of combat fatigue is relatively 
simple and quite effective. The primary indications are 
two: Rest and emotional desensitization of the patient to 
the traumatic experience. Rest is obtained by the use of 
barbiturates with a free hand, and with them it is possible 
to manage cases on board combatant ships long before 
they reach a hospital; as a matter of fact, if properly 
handled, many may never need hospitalization. There is 
no sleight of hand or secret about the use of the drugs; 
remembering the toxic limitations, enough is given to 
put the patient asleep and keep him asleep. Just how long 
a period of rest is needed early, no one can say; the indi- 
cations must be met for the individual. An immediate rest 
period of at least 48 hours probably is advisable, al- 
though, of course, a less extensive time will have some 
value if the longer period is rendered impossible by 
operating conditions. Patients kept asleep longer than 48 
hours will need special nursing care to prevent pulmonary 
complications, and special attention to feeding and fluids. 
It is seldom necessary to carry out such a prolonged period 
of narcosis, and in cases where indicated, it probably 
would be safer to allow the patient a waking interval of 
12 hours before further narcosis while he is still on board 
ship. In hospitals, of course, any degree of prolonged 
narcosis can be carried out in accordance with the estab- 
lished routines. Most medical officers will be tremen- 
dously surprised to see the enormous improvement in 
their so-called "neurotics” after this prescribed period of 
rest. 
Regardless of the improvement obtained by rest, the 
emotional desensitization should be begun immediately 
thereafter. For the successful management of any case a 
sympathetic attitude on the part of medical personnel in 
attendance is indispensable. Too many such patients have 
been accused of "gold-bricking” or have been ignored. 
Emotional desensitization consists simply of encouraging 
the patient to tell of his combat experience in an atmo- 
sphere of mutual understanding and respect. In a great 
many cases seen aboard ship, the patients themselves will 
accomplish much of this if grouped together, thus more 
or less treating each other. If time permits, each patient 
should be allowed to tell his story to the medical officer 
at least once, and the doctor should note what elements 
in the story are most disturbing to the individual. With 
an eye on the objective evidence of tension and anxiety, 
the medical officer can soon tell which of his patients are 
well, which need more attention from him to recover on 
board ship, and which will have to be evacuated. He will 
find his time well spent; a number of men will be saved 
for the ship, and others will avoid a long disablement. 
A certain percentage of cases will require evacuation 
from the ship to improve. In this regard attention is in- 
vited again to the maxim that the farther from the front 
line a patient moves, the more difficult it becomes thera- 
peutically to return him to combat duty. Early, accurate 
diagnosis is therefore imperative. Every effort should be 
made to give each patient sufficient therapy in the first 
hospital he reaches, without repeated evacuations farther 
and farther from action. Once recovered, he can be moved 
away from the front line with less danger of recurrence 
and of fixation of the symptoms. The therapy given in 
hospitals is simply a continuation 'of that outlined. The 
patient should be seen by a psychiatrist in daily interviews 
of not less than 30 minutes at first, decreasing in fre- 
quency as indicated. Prolonged therapy is not necessary 
in pure combat fatigue; cases which do not respond with 
some rapidity to rather superficial discussion of the com- 
bat experience and its relationship to the individual pa- 
tient, will not recover sufficiently to return to duty under 
any form of therapy, and should be moved on toward a 
point where they can receive prolonged therapy. 
In this connection, a previously mentioned corollary of 
treatment is important; men should be given a certain 
period of time to "digest” the emotional turmoil of one 
traumatic experience before being exposed to another. 
This is important even in the ship’s company which pro- 
duces no profound combat fatigue, and should be accom- 
plished where possible. It is urgently necessary for patients 
who have suffered with the fully developed syndrome of 
nightmares, startle, and personality change. In these 
latter cases, it is best accomplished in a center where 
directed recreation and physical work are available, and 
not in the overprotective emotionally charged atmosphere 
of their homes which they meet on survivors’ leave. No 
leave should be permitted any man who suffers with these 
symptoms. Regardless of other considerations, including 
his own and his family’s demands, he should be sleeping 
well, having no nightmares, and exhibiting no startle re- 
action before he is allowed leave. The reasons for this 
have been pointed out and demonstrated in the cases 
presented. 
The disposition of cases has been suggested at every 
point. Those who have suffered with uncomplicated com- 
bat fatigue and who have recovered in 2 to 3 months of 
treatment, or less, are good material for retention in the 
service. As a general rule, they should be returned to the 
duty they feel capable of handling. Those who have recov- 
ered on board their ships need never leave them; those 
who have recovered in hospitals near the action may re- 
turn to their units after a period of controlled rest and Chapter 22.-COMBAT FATIGUE AND WAR NEUROSIS 
relaxation as described; those who have been evacuated 
to the continental United States, should be returned to 
limited duty ashore for not less than 6 months, by a Board 
of Medical Survey. Each recurrence of the symptoms of 
combat fatigue darkens the prognosis for that attack, and 
renders return to combat duty less likely. Men who have 
had limited duty ashore prescribed should be reexamined 
after 6 months to determine their fitness for sea, if their 
services are needed again for combat duty. 
Again it is pointed out that the occurrence of symptoms 
of conversion hysteria, and the occurrence of anxiety, not 
connected with startle, are of bad omen. These men will 
eventually reach hospitals in the United States, where 
they will be found very unresponsive to treatment until 
their discharge from the naval service is assured. They 
should be treated, and intensively, to prevent their per- 
manent disablement. The therapeutic methods advanced 
by Kardiner appear to be the methods of choice for these 
individuals. Even after recovery, they are not suitable for 
retention in the military service, and should be brought 
before a Board of Medical Survey for discharge. Their 
discharge need not wait recovery; frequently the Survey 
Board is the therapeutic agent necessary to initiate recov- 
ery. Under governmental organization, the Veterans’ 
Administration is charged with the rehabilitation of these 
men, and arrangements should be made for them to re- 
ceive the proper treatment from this agency. The Navy 
Medical Corps at this time has its hands full in accom- 
plishing its primary objective, that of maintaining a 
physically effective fighting fleet. CHAPTER 23 
ANALYSIS OF PSYCHIATRIC PATIENTS TRANSFERRED 
TO THE UNITED STATES FROM AN OVERSEAS BASE* 
This report is based upon the study of psychiatric 
patients transferred from an overseas dispensary to the 
United States. 
The histories are analyzed in order to give a clearer 
understanding of the background of each patient in this 
group, to emphasize the predisposing factors and to de- 
termine the conditions that precipitated the psychiatric 
disorder which made these individuals unfit for further 
service. 
Only a very few of the entire group of patients saw 
enemy action of any kind so this can be eliminated from 
consideration. The factors of fatigue and exhaustion do 
not play a part as few of the patients were subjected to any 
physical discomfort prior to admission to this dispensary. 
Out of our entire group there were six patients who were 
in combat with the enemy prior to transfer to this dis- 
pensary and the experiences resulting from combat were 
believed to be precipitating factors in the psychiatric dis- 
order in this small number. 
Age.—The ages of these patients range from 17 to 48 
years with an average of 26.7 years (table 31) . The largest 
number of patients in any group was 7 (21 years of age) 
and more than half of the patients were in the age range 
of 17 to 24 years (ratio 34:54). 
Birthplace.—The patients in this group gave as their 
birthplaces 22 states and 2 foreign countries. The larger 
number of patients were reared in cities and were accus- 
tomed to the variety of interests afforded by larger cities. 
The two patients born in foreign countries came to the 
United States when young and made their homes in the 
northern United States. 
Home conditions.—During the examinations a careful 
inquiry was made into the home conditions during the 
childhood period of each patient to ascertain the presence 
♦By James N. Williams, Commander (MC) U.S.N.R. 
of conflicts in the home, the stability of the parents and 
the degree of parental guidance given. Such factors as 
security, attention and congeniality in the home were con- 
sidered important during this developmental period, 
Upon the basis of these factors the homes were classified 
as good, fair, and poor. It is not surprising to find that 
of this group, 25 men were from homes that were defin- 
itely classified as poor, based upon the above standard 
with little consideration given the actual financial status 
of the family. The homes of 20 of these patients were 
classified as fair and only 9 as good. It is realized that 
this arbitrary classification is open to question and further 
investigation may reveal factors that would cause a change 
of opinion, but the results obtained would not alter the 
ratio of the group. 
Education.—The education of this group varied widely 
from grade school to college and a clearcut separation 
cannot be made. Some of the patients attended high school 
for 1 or 2 years and this overlapping would cause con- 
fusion if this were listed as simply high school education. 
Similarly the same situation exists with those who at- 
tended college for periods of less than 1 year. It was 
found that only 14 of this group completed high school 
and that 6 attended college for 1 year or more. The re- 
maining 34 patients received less than a high school 
education and of this number 18 had less than an eighth 
grade education. 
A consideration of the education of this group of 
patients gives helpful suggestion when further analysis is 
made and is an aid in understanding the individual. The 
34 individuals who revealed less than a high school edu- 
cation were not feebleminded as there was only one such 
case diagnosed and other factors are needed to explain 
why these individuals failed to continue in school. There 
are two important conditions, other than feebleminded- 
ness, that are responsible for early discontinuance of 
112 Chapter 23.—ANALYSIS OF PSYCHIATRIC PATIENTS 
Table 31.—Age groups 
Adjustment in civil life.—The patient’s adjustment in 
civil life prior to enlistment in the service could not be 
accurately determined as the history was obtained entirely 
from the patient. The standard used in obtaining some 
idea of past adjustment consisted of evidence of difficulties 
in school, if any, work-record, whether the patient 
changed jobs frequently or had difficulty in obtaining 
work, antisocial conduct, interest in activities other than 
work, and social attitude. 
Using the above factors the adjustment of this group 
was divided into good, fair, and poor. There were 8 
patients classified as good, 21 as fair and 25 as poor. 
These figures are rather surprising in that less than half 
supposedly were poorly adjusted in civilian life. This can 
be explained only by the fact that all the history was ob- 
tained from the patients with no verification possible. 
If additional history could have been obtained from mem- 
bers of the families of these patients, it is possible that a 
larger number would be designated as poor. 
Diagnosis.—The psychiatric classification of the pa- 
tients is listed in table 33 and the Navy nomenclature is 
used. The majority are classified as constitutional psycho- 
pathic states. Although this is not descriptive of the condi- 
tion in all instances, it does indicate that the disorder is 
characterized by emotional instability and inability to 
adjust properly in any environment. 
The next largest number of patients had psychoneu- 
roses. There were a few psychoses in the group. The dura- 
tion of the psychiatric disorders could not be accurately 
determined as it was necessary to depend upon the history 
obtained from the patient. In the larger number of pa- 
tients in this group, the detailed history obtained would 
certainly indicate that they were always poorly adjusted. 
Several gave a history of previous treatment for various 
disorders. 
The schizophrenic individuals apparently were in a 
state of partial remission upon enlistment and then an 
exacerbation occurred when they were confronted with 
duty away from the United States. It is realized, however, 
that the rapid psychiatric examination necessary when a 
large group of men is sent to a base for training could not 
possibly detect all the abnormalities. 
To obtain the information contained in this report re- 
quired many hours with each patient and the use of vari- 
ous methods, other than direct interview. It is interesting 
to note that three patients in this group had previously 
received bad conduct discharges from the Navy and after 
the lapse of years were allowed to enlist again. 
Physical condition.—The physical state of this group 
of patients was good with few exceptions, and there was 
no evidence of any organic disease. Each patient had a 
Age 
Number 
17 
2 
18 
3 
19 
6 
20 
6 
21 
7 
22 
5 
23 
2 
24 
3 
25 
2 
27 
3 
28 
1- 
29 
2 
30 
1 
2 
32 
3 
36 
1 
1 
1 \ 
4l 
1 
4s 
48 
1 
school. One is a poor home situation and the other a per- 
sonality disorder. The first is obvious from the descrip- 
tion of the homes of these patients and the second will 
be substantiated by the psychiatric diagnosis. 
Table 32.—Birthplaces 
State 
Number 
Alabama 
1 
Connecticut 
2 
Florida 
1 
Georgia 
1 
Indiana 
1 
Iowa 
1 
Kansas 
1 
Kentucky 
3 
Maine 
2 
8 
Massachusetts 
Michigan 
3 
Nebraska 
1 
North Carolina 
1 
New Jersey 
1 
New York 
3 
Ohio 
2' 
Pennsylvania 
9 
South Carolina 
Texas 
Virginia 
— 
2 
I- 
3 
West Virginia 
2 
Wisconsin 
2 
Foreign 
2 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 33.—Diagnoses 
ried. Many of the patients who were unmarried said that 
they were engaged or intended getting married when the 
war is over. The married men with one exception denied 
any conflicts in the home and professed to be happily 
married. 
SUMMARY 
A group of patients from the Navy and Marine Corps 
were transferred to the United States because of psychi- 
atric disorders which rendered them unfit for further duty 
at this base. An analysis was made of the important factors 
obtained from the histories of these patients to give a cross 
section of the life history and type of psychiatric disorder. 
These patients did not improve after intensive treatment 
of various kinds and it was necessary to transfer them to 
the United States. 
The striking factor is the short period of foreign duty 
prior to hospitalization in an area free from enemy action 
and affording security. Apparently the wave of patriotism 
and excitement of training enabled these men to conceal 
their psychiatric disorders for a short period but soon 
after leaving the United States there was an exacerbation. 
Homesickness did not play a major role in these disorders 
as these patients were not capable of making an adjust- 
ment in their own homes. 
A study of these patients emphasizes the need for men- 
tal hygiene units located at boot training bases in the 
United States. These units could closely cooperate with 
officers responsible for preliminary training of the men. 
During preliminary training the men could be referred 
directly to such a unit for an interview and could be en- 
couraged to report voluntarily to discuss any problem 
causing difficulty. Such a plan would facilitate adjustment 
in the Navy and prevent the precipitation of a psychiatric 
disorder in an unstable individual. 
Frequently a longer period of training is needed for 
some individuals to adjust. When instability is not de- 
tected an individual sent to a foreign base for duty usually 
manifests psychiatric symptoms after a short period. This 
factor is illustrated in this group of patients and indicates 
that present screening is not adequate, especially where 
selectees are concerned. 
Diagnosis 
Number 
4 
1 
1 
2 
Constitutional psychopathic state, emotional 
26 
Constitutional psychopathic state, paranoid 
personality 
1 
Constitutional psychopathic state, inadequate 
3 
Psychoneurosis, anxiety type 
4 
Psychoneurosis, hysteria 
Psychoneurosis, post-traumatic 
1 
1 
Psychoneursois, compulsive type 
3 
Psychoneurosis, situational neurosis 
2 
Epilepsy 
1 
Chronic alcoholism 
1 
Somnambulism 
2 
Feebleminded with psychosis 
X' 1 S 
L 
complete examination consisting of physical, neurologic 
and laboratory tests, and when indicated spinal fluid ex- 
amination, x-rays, and electrocardiograms were also made. 
There was no evidence of syphilis in this group; the his- 
tory as well as serologic tests were negative. 
There was no evidence of any neurologic disorder in 
this group of individuals. 
Length of service.—The patients in this group had 
markedly varying periods of service, the longest 16 years 
and the shortest 6 months. The majority of patients (26) 
had less than 1 year of duty prior to admission to the 
dispensary and there were only 6 that had more than 2 
years’ duty. 
The other important factor is the duration of foreign 
duty prior to admission to the dispensary. The longest 
period of duty was 18 months and the shortest 2 weeks. 
The majority of patients (44) had less than 10 months’ 
duty outside of the United States and there were only 8 
that had more than 1 year of foreign duty. 
Marital status.—The larger number of patients in this 
group were unmarried (41) and there were only 13 mar- 
114 CHAPTER 24 
PSYCHIATRIC DATA COMPILED AT A UNITED STATES 
NAVAL PERSONNEL SEPARATION CENTER* 
There have been a number of comprehensive reports 
on the evidence of neuropsychiatric disorders at induction 
and recruiting stations. The types of defects, both physical 
and emotional, have been evaluated in adequate numbers 
of selectees for both this country and that of Great Britain. 
It is generally agreed that between 40 and 50 percent of 
inductees are rejected for various reasons and from 15 to 
20 percent for neuropsychiatric disorders or personality 
defects, often mild and masked enough not to be a prob- 
lem in civilian life. 
In spite of this screening some 20 percent of battle 
casualties and 30 to 40 percent of medical discharges car- 
ried neuropsychiatric diagnoses. 
It is therefore of importance to see if, in the final dis- 
charge examination of the naval enlisted man from an 
actual duty status, there is any appreciable incidence of 
neuropsychiatric complaints or disabilities. It is to be 
noted here that this material does not represent any hos- 
pitalized patients but does include any that may have been 
some time on a neuropsychiatric service, who recovered 
sufficiently to be sent back to duty, which in some cases, 
was limited to the territorial United States. 
The separation center processed from 600 to 1,400 
subjects daily and some 40,000 had passed through at the 
time of the compilation of this report. 
The data described does not include anything like the 
whole number but is limited to unselected samples and 
groups and includes a total of 7,823 subjects. 
There are essentially two parts to the material described. 
The first part was a study of the completed physical exam- 
ination papers from which the following was obtained: 
(1) Intention of filing disability pension claim. 
(2) Evidence of neuropsychiatric complaints and diag- 
nosis in the health record or in the period of actual mili- 
tary duty. 
(3) Evidence of visual defects alone where no other 
defect is found, both corrected and uncorrected by lenses. 
(4) Evidence of orthopedic, genito-urinary, or other 
physical defects not requiring hospitalization. 
(5) The evidence of the presence of pilonidal cysts. 
(6) The percentage of separatees with no physical or 
psychiatric defect. 
(7) The evidence of insignificant, minor defects not 
a problem to the subject such as fine tremors, deviated 
septums in the nose, acne of the body, moderate tonsillar 
enlargement, hemorrhoidal tabs, and mild degrees of flat 
feet. 
(8) The presence of a resting pulse of over 100 which 
remained above 100 three minutes after exercise. 
The second part of the investigation involved the psy- 
chiatric examination of groups of these men. 
The first group were those who told the medical officers, 
not psychiatrists, that they had in their records a neuro- 
psychiatric diagnosis or had had while in the service psy- 
chiatric or emotional problems. The subjects all had their 
records checked by hospital corpsmen for such diagnosis 
as an additional measure. 
All such subjects were referred to the psychiatrists who 
appraised the nature and severity of their symptoms and 
determined whether hospitalization was necessary. 
The low percentage of such subjects, i. e., 2.4 percent 
led us to believe many men were withholding histories of 
neuropsychiatric trouble for fear admission would delay 
or prevent separation from the service. 
Since 7 percent of the total group were running resting 
pulse rates over 100 for no apparent reason, it seemed a 
good idea to explore these tachycardias. Accordingly, any 
subject with a resting pulse of over 100 was referred to the 
psychiatrist. It was pointed out in the resulting interview 
that this was a survey or experimental study in no way set 
up to delay or alter separation. 
•By Robert S. Schwab, Commander (MC) U.S.N.R. 
115 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
It was found that 40 percent of such tachycardias had 
mild psychoneurotic histories and 4 percent histories of 
moderate psychoneurotic symptoms. To control this, 100 
men with no increase in pulse rate and no obvious neuro- 
psychiatric story were interviewed by the psychiatrist. In 
this control series, 10 percent gave histories of mild neu- 
rotic symptoms and none of moderate or severe. This 
agrees with other such control series. 
The summary of the collected data is shown in table 34. 
It is to be noted that the average subject interviewed 
here, whether he had a mild history of neurotic symptoms 
or not, successfully adjusted to the demands of military 
naval service in wartime. The small percentage of those 
with moderate neurotic histories also fitted into their mili- 
tary environments without hospitalization but did have 
difficulty in so doing and might have done better in a 
civilian war project. 
The point to be emphasized is that about 15 percent 
of the armed forces do their combat and other duties 
efficiently and successfully in spite of definite neurotic 
symptoms in their past lives. From other studies it is 
known that the serious long standing combat and opera- 
tional psychiatric casualties come from men with such 
histories and exclusion of all such men might therefore 
reduce significantly the incidence of poor psychothera- 
peutic results. 
The problem of mild neurotic histories being unmasked 
by the presence of resting pulse rates of over 100 confirms 
the thesis that unstable personalities correlate with un- 
stable physiology. Excluding those that overindulge prior 
to the examination or who had mild infections (colds) 
the figure of 44 percent shows that this group is worth 
keeping an eye on by the psychiatrist when men are dis- 
charged or inducted. 
COMPARISON OF TACHYCARDIA SUBJECTS WITH 
CONTROL SUBJECTS AS TO LENGTH OF 
OVERSEAS SERVICE 
It is noted that the tachycardias with positive neuro- 
psychiatric findings are 59 percent of the group that were 
overseas less than 18 months whereas they represent only 
38 percent of the group out over 18 months. 
There was no essential difference in the men examined 
with normal pulse rates in this respect. 
Of the tachycardias with neurotic histories, 31 percent 
had pulses over 90 on induction and over half of these, 
or 18 percent, of the group had entrance resting pulses of 
over 100. Of the tachycardias not giving neurotic histories, 
19 percent had entrance resting pulses over 90 and only 
one-tenth of those over 90 or 1.7 percent of the whole 
pulses over 100. This would indicate that a recurring 
tachycardia is good reason to suspect a neurosis. 
An example of tachycardia with a neurosis picked up 
by interview because of the presence of the tachycardia is 
as follows: 
A 36-year-old divorced machinist's mate, first class on separa- 
tion after 21/2 years of service, of which 2 years were overseas 
in a noncombat area, was referred because of a resting pulse of 
112 which after exercise remained at 116. On entry, pulse was 
96. Past history showed presence of persistent nail biting, enure- 
sis to 14, difficulty with sleeping, a delicate stomach, shyness at 
school, subject to excessive worry and overconcern about health 
Table 34.—Summary of data found from examination of 7,823 
individual records 
Number 
found 
Percent 
Intention of filing pension claim 
2 66 
3.4 
Ordinary incidence of neuropsychia- 
trie history in record 
186 
2.4 
Visual defect corrected 
464 
5.9 
Visual defect uncorrected 
1,072 
13.8 
Other physical defects 
2,023 
28.6 
Pilonidal cyst 
125 
1.6 
Minor disability 
815 
10.4 
Tachycardia (resting pulse 100) 
547 
7.0 
No defect 
3,997 
51.2 
DISCUSSION 
The type of psychiatric interview which lasted about 10 
minutes, covered questions about childhood and pre-en- 
listment neurotic symptoms such as bedwetting, sleep- 
walking, nail biting, unreasonable fears of dark, noise, 
confined spaces, shyness, spells of anxiety, difficulties in 
adjustment in school—homework—sex or other social 
contacts, and histories of chronic somatic vulnerability in 
the gastrointestinal tract or cardio respiratory system as 
well as headaches, dizzy or faint spells, etc. The subject 
was also asked about his service history—length of time 
overseas and ability to tolerate the stresses of fatigue, com- 
bat, and domestic separation. Data as to length of service, 
time overseas, and combat experience is shown in table 35. 
Table 35 
Overseas under 18 
months 
Overseas over 18 
months 
Tachy- 
cardia 
Normal 
pulse 
Tachy- 
cardia 
Normal 
pulse 
Combat experience, no 
N. P. findings 
3 
16 
28 
25 
Combat experience, 
N. P. findings 
5 
1 
10 
2 
No combat experience, 
no N. P. findings 
8 
11 
8 
10 
No combat .experience, 
N. P. findings 
11 
3 
12 
1 
116 Chapter 24.—PSYCHIATRIC DATA COMPILED 
with cancerphobia. Marriage was stormy and sexually unsatis- 
factory ending in divorce. Overseas he worried and complained 
a good deal yet he never turned in and his health record is free 
of entries of this trouble or hospitalization of any sort. He ap- 
parently did his job well in spite of his problems. 
An example of tachycardia with no neurotic history 
follows: 
;A 21-year-old single gunner with a resting pulse on separa- 
tion of 124 was seen because of this pulse. After exercise it re- 
mained at 110. On entry 5 years before it was 62. He had been 
overseas 2 years on a ship in combat most of the time. There 
was no history of neurotic traits or illness and all adjustments 
were healthy and normal. 
The percentage of 51.2 for separatees with no defects 
seems low for a body of men previously on active duty— 
but if the 10.4 percent for minor disabilities and the 5.9 
for corrected vision be included, the percentage is around 
66 percent which is what one might expect. 
SUMMARY 
The examination forms of 7,823 separatees showed an 
incidence of psychoneurosis as obtained in routine way 
of only 2.4 percent. 
Seven percent of the men had resting pulses over 100. 
Of these, nearly half, or 44 percent, or an additional 3 
percent of the whole group, gave histories of definite 
neurotic traits or complaints not sufficient to put them on 
sick list or interfere with naval service. In a control group 
of 100 men with no record or physiological evidence of any 
instability, 10 percent admitted very mild neurotic symp- 
toms that w-ere not serious enough to bother them in the 
service. There are therefore three groups of separatees 
with some neuropsychiatric problems: (a) 2 percent who 
have had frank episodes that brought them to the sick list 
with entries in the record, (b) 3 percent who by a fast 
pulse show an underlying sensitivity but who kept at work 
and out of the medical department records, (c) 10 per- 
cent with history of milder symptoms that show up only 
in a psychiatric interview—a total of 15 percent that 
should be kept in mind psychiatrically for the future. 
Acknowledgment.—The author thanks Capt. J. C. McCutchen, U.S.N., 
commanding officer, and Capt. F. S. Cruickshank (MC), U.S.N.R., for 
help and cooperation in preparing this paper. . 
117 CHAPTER 25 
METHOD OF PRACTICING PREVENTIVE PSYCHIATRY 
IN A NAVAL PERSONNEL SEPARATION CENTER’ 
The chief function of the medical department of a 
naval personnel separation center is to aid in the separa- 
tion of men from the Navy at a maximum speed by rapidly 
finding and reporting the physical and mental disabilities 
of separatees (with emphasis on disabilities incident to or 
aggravated by service conditions). In our opinion, how- 
ever, the psychiatric division in such a medical depart- 
ment, in addition to its function in finding and reporting 
neuropsychiatric problems constituting disabilities, is in a 
position to make an important further contribution to the 
work of the separation center along the following lines: 
(1) Information as to the services offered in local com- 
munities by psychiatric clinics and by other facilities for 
the rehabilitation of veterans can be given to men who 
have psychoneurotic reactions calling for more or less 
intensive treatment but who are not so disabled as to war- 
rant delaying their discharge for such treatment; (2) 
Many "normal” separatees with less deep-seated personal 
adjustment problems can be provided with effective men- 
tal hygiene through brief interviews in the psychiatric 
division itself; 2 and (3) Data of psychiatric interest con- 
cerning separatees can be collected and evaluated. 
In a naval separation center the large numbers of men 
being discharged (or returned to inactive duty) each day 
and the rapidity with which these men must be examined 
have led to mass physical and laboratory examinations of 
an "assembly line” type. The psychiatrist is last in the 
line of medical examiners in order to have the benefit of 
reviewing the results of the general medical examinations. 
However, because the psychiatric division usually has very 
few psychiatrists and no available trained psychiatric as- 
sistants, such as psychologists and social workers, it cannot 
provide even 3-minute interviews with each separatee. 
Certainly no time would be available for providing the 
services outlined if every dischargee were to be seen by the 
psychiatrist. For this reason, at the Naval Personnel Sepa- 
ration Center, U. S. Naval Base, Bremerton, Washington, 
where only one psychiatrist is permanently assigned, the 
psychiatric division has been organized so as to utilize 
the capacities of the psychiatrist as fully as possible. 
A screening process has been devised to select separatees 
for interview with the psychiatrist on the basis of one or 
more of the criteria from the following three records. This 
screening is performed by four hospital corpsmen trained 
by the psychiatrist. 
1. The health record.—This detailed report of a man’s 
medical history, and clinical and laboratory findings from 
the time of his induction or enlistment to the time of his 
separation from the Navy is, with few exceptions, avail- 
able for every man. The hospital corpsmen are trained to 
select for interview with the psychiatrist all men whose 
health records reveal that during military service they 
have had a diagnosis of (a) neurologic illness (including 
various forms of neurosyphilis and intracranial injuries), 
(b) psychiatric disability (including combat or opera- 
tional fatigue), or (c) disorders such as irritable colon, 
chronic lumbar myositis, and tachycardia, which often 
have important emotional components. 
2. Naval medical department Form Y (1939)-—This 
is the report of physical and laboratory examinations as 
made in the separation center. To aid in conserving the 
psychiatrist’s time, abnormalties of station, gait, speech, 
reflexes, and fine movements are recorded by previous ex- 
aminers. The hospital corpsmen are trained to refer to 
the psychiatrist for further neurologic examination and 
evaluation any man whose Form Y shows such deviations. 
They select for psychiatric interview the men whom pre- 
1 Written by Lester L. Hasenbush, Lieutenant, junior grade (MC) 
U.S.N.R., with the assistance of Grace G. Hasenbush, B.A. 
2 The Civil Readjustment Services available in separation centers deal with 
problems involving the rights of veterans, education and vocational plan- 
ning. and the like, but do not provide for psychiatric interviews. 
118 Chapter 25.-METHOD OF PRACTICING PREVENTIVE PSYCHIATRY 
vious medical examiners recommend for such interviews 
and also men whose reports show possible psychosomatic 
illness. 
3. A psychiatric questionnaire for separatees.—This 
has been compiled by the psychiatrist to serve as a self- 
administered means of obtaining information of psychi- 
atric interest concerning each separatee. Its present form 
evolved gradually out of our experience. It is sufficiently 
concise to be printed on one side of an 8- by 13-inch sheet 
of paper. The questions were carefully framed so as to be 
easily understood, and those that proved confusing were 
altered. Some of the questions are quite broad and gen- 
eral in scope so as to screen out, with a brief questionnaire, 
not only separatees with psychoneurotic reactions or neu- 
rologic disorders, but also "normal” men with lesser con- 
cerns that might prove significant in terms of mental 
health. The form of the questionnaire shown on the next 
page was used. 
The simple introduction that follows the brief identify- 
ing seems, in general, to have been successful in ex- 
plaining to the separatee the possible usefulness of the 
questionnaire to him and in encouraging him to answer 
the questions frankly. The identifying data and questions 
No. 1 through No. 13 were designed primarily to pro- 
vide the psychiatrist with a few succinct clues as to the 
background of men interviewed; unlike the remainder of 
the questionnaire, these are not used as a basis for select- 
ing men for psychiatric interview. Questions No. 14 
through No. 24 were framed to obtain information con- 
cerning somatic preoccupations or symptoms of possible 
neurologic or psychosomatic significance. In conjunction 
with this group, questions No. 15 through No. 39 were in- 
tended to elicit manifestations of deep-seated psychiatric 
problems as well as of personal adjustment difficulties in 
relatively normal men. 
It is to be noted that certain specific questions referring 
to enuresis, drug addiction, a history of mental illness, 
and the like, which are commonly included in psychiatric 
questionnaires have been omitted. Our experience indi- 
cates that such problems usually come to the attention of 
the authorities during the course of a man’s military serv- 
ice and result in his discharge long before he is due to 
reach a separation center.3 
As each separatee reaches the psychiatric division, he 
turns over to a hospital corpsman his health record and 
Form Y and in turn receives a questionnaire. The hospital 
corpsman gives him individual instruction to read and fill 
it out in one of the adjoining rooms. Questionnaires are 
answered in three fairly quiet rooms, each provided with 
a large enough table to allow each of six men to write with 
some privacy. A man is given as much time as he needs, 
but most men finish in less than 10 minutes. 
After a questionnaire has been answered, a hospital 
corpsman, using a stencil, checks it in a few seconds and 
selects to see the psychiatrist men with answers falling 
into any one of the following categories: (1) An affirma- 
tive response to question No. 24 indicating worry about 
some sex problem, or to No. 39 indicating serious worries 
about family matters; (2) Six of more "significant” re- 
sponses to questions No. 14 through No. 39 inclusive 
(often there is an affirmative response to question No. 24 
or No. 39 among the six or more "significant” responses 
which results in overlaping of these two criteria) ; (3) Five 
or more "I don’t know” answers on the entire question- 
naire; and (4) A request to see the doctor. If such a re- 
quest is made by a man who would otherwise not be 
interviewed, the hospital corpsmen inquire as to the gen- 
eral nature of the problem that the man wishes to discuss 
if this has not been indicated at the end of his ques- 
tionnaire. Then the hospital corpsmen select for interview 
with the psychiatrist men wishing to discuss matters per- 
taining to his field and refer elsewhere in the medical 
department separatees with surgical or medical problems 
having no obvious psychosomatic implications. 
If the hospital corpsmen select a separatee for inter- 
view with the psychiatrist, the health record, Form Y, 
and questionnaire are sent with him to the interview. All 
others pass through the medical department without see- 
ing the psychiatrist. 
The screening process is sufficiently flexible to bring to 
the interview a fairly constant number of separatees 
hourly. On the average the psychiatrist sees 5 or 6 men 
an hour. This represents from 10 to 12 percent of the 
usual number examined in the medical department. When 
more than this number of men are being examined, the 
proportion reaching the psychiatrist can be decreased, for 
example, by using the questionnaire to screen for inter- 
view men with 9 or more (instead of 6 or more) "signifi- 
cant” responses. The flexibility of the screening process 
also permits the psychiatrist to reach for investigative pur- 
poses, in addition to those ordinarily screened, special 
groups of separatees, such as men who have a past history 
of having been "knocked out,” and men with gastro- 
intestinal complaints. 
To aid in evaluating the screening process, 300 con- 
secutive interviews of men screened routinely were an- 
alyzed. Of these only 42 (14 percent) revealed no prob- 
lems in neurology or preventive psychiatry. Men with 
interviews falling into this group either had a combina- 
tion of "significant” responses which on discussion 
3 It is possible, of course, that occasional men with problems of these types 
are able to conceal them successfully and to function adequately in the 
Navy. Such persons could also easily elude detection in their brief contact 
with the medical department of the separation center. 
119 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Medical Department, U. S. Naval Personnel Separation Center 
PUGET SOUND NAVY YARD, BREMERTON, WASHINGTON 
Last Name (Print).... Initials Rate Age 
Birthplace No. of School Grades Completed 
Single Married Ever Divorced Wife Dead 
PSYCHIATRIC QUESTIONS FOR SEPARATEES 
The following questionnaire deals with your personal life and general health. The doctors don’t have much time to talk with each 
separatee. Therefore, if your answers show that you have some worries, you will have a chance to talk things over with a doctor 
who may be able to give you some hints on how to help yourself to get squared away. 
This is NOT A TEST. There are NO RIGHT OR WRONG ANSWERS. Your answers will be kept CONFIDENTIAL and 
will NOT become a part of any official records. Answer TRUTHFULLY to the best of your ability. NONE OF YOUR ANSWERS 
WILL IN ANY WAY BE HELD AGAINST YOU. 
Just make an "X” after each question in the column under Yes, No, or I Don’t Know, according to which answer applies best to 
YOU. DON’T RUSH, but your first hunch as to the answer is probably the one you should put down. Please answer ALL the 
questions. Look at the SAMPLE LIST on the wall or talk to the corpsman if you don’t understand what to do. 
1 Have yon had more than months of active service? 
Yes 
No 
I Don’t 
Know 
1 
2 
3 
4 
5 
4. Have you taken part in at least one major engagement? 
5. Are you a survivor of a ship that was hit in enemy action? 
6 
7 
7. Have you ever been arrested for anything other than minor traffic violations? 
8. Have you had malaria, filariasis (mumu) or a serious disease, wound, injury or operation 
in the service? 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24 
25 
9. Have you some ideas about what kind of work you want to do after you leave the service?..., 
10. WiU yon live in the state where yon lived before yon joined the service? 
11. As a civilian did yon live chiefly in rnral areas (places under 2,S00 population)? 
17. In 1030 was your home still in the state where yon were horn? 
13. Were you usually happy during your childhood? 
14. Do your stomach and bowels usually feel well and work all right? 
15. Does your heart worry you? _ .. 
16. Do you get bad head or neck aches more often than once a month? 
17. Do your back and limbs usually feel all right and work well? 
18. Do you often get shaky or sweat for no reason that you can understand? 
19. Do you sometimes get dizzy or have fainting spells? 
20. Are you bothered with serious eye, ear, nose, or throat trouble? 
21. For your age, do you think that you get tired too easily? 
22. Do you usually sleep well? 
23. Is your appetite usually all right when you have good chow? 
24. Are you worried about some sex problems? 
25. Are you bothered by crowds or noisy places? _ .. . 
26. Do you often lose your temper? 
26 
27 
28 
29 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
27. Do you find it difficult to make friends? 
28. Have you any fears that you don’t understand very well? 
29. Have you any unpleasant thoughts that keep coming back? 
30. Are your feelings easily hurt? 
31. Can you usually keep your mind on what you are doing?. . . 
32. Do you feel that you’ve had a raw deal? 
33. Is your memory usually fairly good? 
34. Are you usually cheerful and in good spirits?. . 
35. Have you been nervous for months at a time?.. . 
36. Do you believe that most men of your age are better men than you? 
37. If you can get it, do you drink two quarts of liquor (or more) a week? 
38. Have you had more than two courts martial in the service? 
39. Have you any serious worries about family matters? 
If you want to see a doctor about something that worries you, write in a few words below (or tell a corpsman) the general sub- 
ject you want to take up 
120 Chapter 25.-METHOD OF PRACTICING PREVENTIVE PSYCHIATRY 
proved of no real significance in adversely affecting per- 
sonality, had problems which were primarily medical or 
surgical, answered questions carelessly, misunderstood 
them, or were illiterate. Two hundred fifty-two men (84 
percent) had problems involving their personal adjust- 
ment. Of these only one (0.3 percent) required transfer 
from the personnel separation center to a naval hospital 
for treatment and eventual medical discharge because of a 
serious psychiatric disability (paranoid state). Six men 
(2 percent) had problems primarily of neurologic nature. 
With regard to the proportion of the men reaching the 
psychiatrist through each of the three records used for 
screening, it was found that 273 (91 percent) were se- 
lected on the basis of one or more of the criteria obtained 
from answers to the questionnaire, 31 (10.3 percent) on 
the basis of one or more of the criteria outlined in connec- 
tion with the health record, and 7 (2.3 percent) on the 
basis of one or more of the criteria discussed in connection 
with Form Y. A scattering of men were screened for 
interview because of findings in more than one of the 
three sets of records. 
Of 273 men screened out on the basis of the question- 
naire, 161 (58.9 percent) showed "significant” responses 
to 6 or more questions between Numbers 14 and 39 in- 
clusive, 95 (34.8 percent) answered questions No. 24 or 
No. 39 (or both) indicating worries concerning sexual 
or family matters, 5 (1.8 percent) answered 5 or more 
questions with "I don’t know,” and 59 (21.6 percent) 
requested to see the doctor. As the total of these various 
percentages is 117 percent, it is apparent that a number 
of the men fulfilled more than one of the criteria for 
selection for interview. 
To further evaluate this screening process, 100 separa- 
tees with questionnaires showing not more than 2 "signifi- 
cant” responses to questions Numbers 14 through 39 
were selected for interview from the group of men who 
would ordinarily not reach the psychiatrist. These men 
were interviewed with the same care and technic employed 
with those who were referred through the screening 
process. In none of these 100 men was there any recogniz- 
able neurologic disorder, or deep-seated personality dif- 
ficulty requiring hospitalization prior to separation or 
referral to a psychiatric clinic or related facility after re- 
turn to civilian status. Seven (7 percent) appeared to be 
"normal” persons with problems in personal adjustment 
such as can be profitably discussed in a brief mental hy- 
giene interview. Thus it was felt that, because of the 
emotional stability and maturity of this group as a whole, 
and because of the reluctance of some of these men to 
see the psychiatrist, these 100 separatees had little to gain 
from preventive psychiatry or neurology. This is in con- 
trast to the high percentage (86 percent) of the 300 men 
who reached the psychiatrist as a result of the screening 
process. 
The screening process thus appears to be effective in 
bringing to the psychiatric examiner a high percentage 
of the separatees with personal adjustment problems that 
they are willing to discuss in this situation. It is not within 
the scope of this article to discuss in detail the types of 
problems encountered or the psychiatric technics that have 
proved especially useful in single brief mental hygiene 
interviews. It might be noted in passing, however, that 
at the separation center most of the men are seen at a time 
when their release from service conditions is near, and 
before they are squarely confronted with the problems of 
civilian readjustment. 
The great majority of those interviewed are "normal” 
persons with rather superficially determined emotional 
conflicts arising largely out of marital and other familial 
stresses, inadequate sex education, trying past experiences 
in the service, and challenges anticipated on return to 
civil life. In such persons it is common to find undue 
fatigability, and many other somatic concerns and tension 
symptoms, anxieties, irritability, and the like. Only a small 
minority of men interviewed (perhaps 5 percent) have 
personality problems of such intensity or complexity as 
to warrant referral to a psychiatric clinic or related facility 
(if such is available in his home community) * 
It appears that the questionnaire often succeeds in help- 
ing to prepare a man to understand and accept the general 
purpose of the interview and to feel comfortable in bring- 
ing up for discussion questions of importance in his life. 
The questionnaire, the health record, and Form Y con- 
stitute a time-saving device in the interview situation be- 
cause they serve to focus attention promptly on pertinent 
problems. In evaluating the effectiveness of the short 
mental hygiene interview, our experience has shown that 
with these aids, despite limited time (usually not more 
than 10 to 12 minutes for each interview), it is very often 
possible to obtain the seperatee’s confidence and to make 
the interview an experience of practical value to him. The 
psychiatrist, through his interest in the man, his encourage- 
ment of the expression of feelings, his furnishing informa- 
tion and correcting misinformation, often seems to be help- 
ful in bringing a man closer to the satisfactory handling 
of conflicting needs. It is conceivable that such services 
occasionally aid men in avoiding more disruptive malad- 
justments at a later date. 
The questionnaire described here has made available a 
4The "Directory of Psychiatric Clinics and Related Facilities.” com- 
piled by the National Committee for Mental Hygiene (1944) and the "List 
of Fellows and Members of the American Psychiatric Association" (1944) 
were useful in such referrals. 
121 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
body of data regarding the possible relationship to mental 
health of (1) certain diverse factors in military experience, 
such as overseas and combat operations, and length of ser- 
vice; and (2) selected factors involving previous civilian 
experience, such as rural versus urban background, the 
occurrence of interstate migration, a man’s own evaluation 
of his emotional life during childhood, and the like. The 
presentation and evaluation of such data are not within the 
scope of this article, but it is believed that a study along 
these lines might be helpful in furthering a better under- 
standing of the emotional problems of servicemen and 
veterans. CHAPTER 26 
MENTAL HEALTH OF MEN DISCHARGED 
UNDER THE POINT SYSTEM* 
Routine psychiatric screening of men discharged from 
the Navy is not uniformly required as is the psychiatric 
examination of men entering the service, and experience 
at this activity does not indicate that there is any urgent 
need for the extremely careful psychiatric examination 
which, in the case of recruits, aimed at keeping out the 
unfit. 
At this activity, which has been a separation center for 
a west coast naval district for many months, the psychia- 
trists have seen men discharged for a great variety of rea- 
sons—inaptitude, overage, underage, convenience of the 
government, bad conduct, undesirable, and, in the case of 
servicewomen, pregnancy. When the point system was an- 
nounced for the separation of general naval personnel 
from the service, there was some local curiosity as to the 
types of men being discharged and their general mental 
health. The senor medical officer initially required the 
psychiatrists to add a short note to the form Y, comment- 
ing on the incidence of abnormal psyche. To assist in get- 
ting objective data on a large number of men to supply this 
information, recourse was had to the standard personality 
inventories. 
The routine use of the Wilkins-Miles Self-Description 
Inventory for over a year at this activity was prompted by 
the fact that the inventory was standardized so that there 
was a maximum of simplification, all questions puzzling 
to literates of the mental age of 11 years or less being ex- 
cluded. The routine use of this inventory on all dischargees 
over a year’s period supplied the psychiatrists with certain 
"stop” questions which were found to be critical questions 
with survivors of ship sinkings and with men being dis- 
charged to civil life. Average time of administration of 
the SDI has been found to be 14 or 15 minutes whether 
administered in groups or individually. 
The need for a much shorter form became paramount 
when the large number of separatees began to arrive, and 
this led the psychiatrist to construct a form which could be 
completed in little more than a minute, required minimal 
directions, and could be scored by scrutiny. The questions 
finally selected on the basis of this psychiatric consensus 
were: 
* By Vayle S. Briden, Commander (MC) U.S.N., and Walter L. Wilkins, 
Lieutenant Commander H(S) U.S.N.R. 
(Last name) (First name) (Age) (Rank or Rate) 
1. How long have you been in the service? (months) 
2. How long overseas? (months). 
3. How many major engagements?. 
4. Do you usually feel well and strong? „ Yes No 
5. Do you often have indigestion or stomach trouble?. Yes No 
6. Do you ever have any dizzy spells? , Yes No 
7. Did you ever have any nervous trouble before entering the service? Yes No 
8. Have you had any nervous trouble since entering the service? „ ..... Yes No 
9. Do you have headaches as often as once a month? Yes No 
10. Are you happy and sad by turns without knowing why? Yes No 
11. Are you ever bothered by the feeling that people are reading your thoughts? Yes No 
12. Do you sometimes have a feeling that things around you are not real? Yes No 
13. Are you in just as good health as when you came into the service? Yes No PHYSICAL AND PSYCHOBIOLOGICAL S1ANDARDS AND EXAMINATIONS 
Items 1 through 3 are for the general orientation of the 
psychiatrist. Items 4 through 13 are answered merely by 
encircling the Yes or No. Items 4 and 13 should be 
answered Yes; all the remaining items should be answered 
No. Any deviation from this is considered an unhealthy 
response and can be told at a glance at the sheet. The ques- 
tionnaire has some space at the bottom of the sheet for 
additional notes by the psychiatrist which he may wish to 
make during the interview. This brief questionnaire was 
administered to the first thousand men separated under 
the point system, a group which included 131 officers and 
869 men. This is considered to be a representative samp- 
ling of men being discharged. The median number of 
months of active duty was 43 (Q3 of 52 months; Qx of 
35.4 months). The number of major engagements par- 
ticipated in by these men in general followed a J-curve, 
with a mode of zero but a range up to 15 major engage- 
ments. 
Tarlh 37.—Specific responses checked by separatees 
Item No. 
Officers 
Men 
Total 
Percentage 
4. Feel well 
0 
12 
12 
1.2 
5. Stomach trouble 
3 
83 
86 
8.6 
6. Dizzy spells 
7. Nervous before 
4 
72 
76 
7.6 
entry 
8. Nervous since 
2 
22 
24 
2.4 
entry 
9 
133 
142 
14.2 
9. Headaches 
16 
186 
202 
20.2 
10. Mood shifts- 
11. People reading 
5 
58 
63 
6.3 
your thoughts 
12. Feeling of un- 
0 
12 
12 
1.2 
reality 
3 
21 
24 
2.4 
13. Good health 
15 
167 
182 
18.2 
percent. Again psychiatric interview indicated that none 
of these complaints were of deep psychiatric significance. 
Not a single psychotic was detected through the psychi- 
atric interview, and not a single officer or man was trans- 
ferred to the local naval hospital for disposition or more 
extended observation. 
In the case of functional complaints, entry was made 
on the terminal form Y, but no man was thought to be in 
such a mental state that his discharge need be held up 
even so much as a.day. These data suggest that the mental 
health of the ordinary separatee is very good indeed, con- 
sidering length of service, amount of time spent in com- 
bat, and so on. Whether such a conclusion is valid or not 
only time can tell. 
Comparative data upon a group not quite so stable at 
the time of their being seen by the psychiatrists are pre- 
sented in tables 38 and 39, wherein the number of items 
checked by the survivors of a heavy cruiser are shown. This 
Table 36.—Number of unhealthy responses by separatees on the 
short questionnaire 
Number of responses 
Officers 
Men 
Total 
Percentage 
0 
95 
478 
573 
57.3 
1 
19 
192 
211 
21.1 
2 .. 
13 
111 
124 
12.4 
3 
3 
39 
42 
4.2 
4 
1 
26 
27 
2.7 
5 
0 
15 
15 
1.5 
6 .. 
0 
6 
6 
.6 
7 
0 
1 
1 
.1 
8 
0 
1 
1 
.1 
The great majority of these men had surprisingly few 
complaints which could be considered of psychiatric sig- 
nificance. The total number of unhealthy responses for 
the group is shown in table 36. Fifty-seven percent had no 
unhealthy responses; nearly four-fifths had only one such 
response; nine-tenths had only two. No difference be- 
tween officers and men could be noted. 
The specific responses which these men were likely to 
check can be noted in table 37. Twenty percent complained 
of headaches, but psychiatric interview, which of course 
was focalized by the particular items checked, showed that 
these headaches were crippling in extremely few cases and 
in no instance required hospital observation. Eighteen per- 
cent felt that their health was not quite as good as when 
they entered the service. Fourteen percent complained of 
some nervousness, but this turned out, in the next inter- 
view, to be vague and certainly insufficient to hold up a 
man’s return to civil life. 
It is significant that the stop questions aimed at detec- 
tion of possible schizoid trends were so infrequently 
checked; items 11 and 12 were checked by only 1 and 2 
Table 38.—Number of unhealthy responses by survivors on the 
short questionnaire 
Number of responses 
Number 
of 
unhealthy 
responses 
Percentage 
0 
53 
19.2 
1 
56 
20.2 
2 
59 
21.3 
3 
35 
13.9 
4 
29 
10.7 
5 
18 
6.6 
6 
16 
5.5 
7 
4 
1.4 
8 
1 
0.4 
9 
1 
0.4 
124 Chapter 26.—MENTAL HEALTH OF MEN DISCHARGED UNDER THE POINT SYSTEM 
Table 39.—Specific responses checked by survivors 
severe psychic trauma as a climax to rather severe combat 
duty and experience. Only 19 percent had no unhealthy 
responses upon the questionnaire. The group is signifi- 
cantly different from the sej aratees, but this is to be ex- 
pected, considering the rec( icy of the traumatic experi- 
ence. 
The specific complaints of the survivors are shown in 
table 39- Clinical impressions of mild depression and 
fatigue on this group are borne out by the items checked on 
the short questionnaire. Twice as many survivors as sep- 
aratees complained of bad headaches; over four times as 
many complained of dizzy spells; and twice as many com- 
plained of nervous trouble. Differences on items 11 and 12 
also appear to be of significance, and yet only two men 
were held over because of these items, and they were 
allowed to go on leave the next day. 
In the case of survivors, the examining psychiatrist, feel- 
ing that leave is one of the best of therapies, tried to get 
every survivor to his home and to the beneficial environ- 
ment presumed to exist there. Very frequently a man was 
sent on survivor’s leave, with the object of the man’s bene- 
fiting from his leave and then reporting for psychotherapy 
at his station. 
Item No. 
Number 
of 
unhealthy 
responses 
Percentage 
4. Feel well 
16 
5.9 
5. Stomach trouble 
50 
18.4 
6. Dizzy spells 
90 
33.1 
7. Nervous before entry 
20 
7.3 
8. Nervous since entry 
86 
31.3 
9. Headaches 
111 
40.8 
10. Mood shifts ... 
88 
32.3 
11. People reading your thoughts 
25 
9.2 
12. Feeling of unreality 
47 
17.3 
13. Good health 
89 
32.7 
particular cruiser went down very quickly, and the total 
number of casualties was great, being tentatively estimated 
at two-thirds of the ship’s complement. The survivors 
spent 5 days in the water before being rescued. Upon ar- 
rival in the United States, they were routinely screened by 
the psychiatrists, who found in their individual interviews 
precisely the differences shown in the tables. 
These 272 men represent a group which had undergone 
125 SECTION IV 
DELINQUENTS AND 
DISCIPLINARY INFLUENCES 
Note.—In order to clarify any confusion which may be 
present in regard to naval places of confinement in con- 
nection with the following article, it is believed that the 
following information is pertinent. 
During World War II the Navy had several Discipli- 
nary Barracks in various parts of the United States as well 
as brigs at the naval stations. It also had naval prisons 
at Portsmouth, N. H., and at Mare Island, California. 
It was ordinarily the function of the disciplinary bar- 
racks to receive prisoners who were serving sentences of 
courts martial. The brigs ordinarily retained men await- 
ing courts martial or other disciplinary action. 
In 1946 the Secretary of the Navy issued a directive 
changing the name of the Naval Prison, Portsmouth, 
N. H., to the U. S. Naval Disciplinary Barracks, Ports- 
mouth, N. H. The Naval Prison at Mare Island, Cali- 
fornia, was changed to the U. S. Naval Retraining Com- 
mand, Mare Island, California. 
At the present time (1949) the Navy has four major 
places of confinement; (1) U. S. Naval Disciplinary Bar- 
racks, Portsmouth, N. H., (2) U. S. Naval Disciplinary 
Barracks, Terminal Island, San Pedro, California, (3) 
U. S. Naval Retraining Command, Norfolk, Va., and (4) 
U. S. Naval Retraining Command, Mare Island, Cali- 
fornia. 
These receive only prisoners who have been tried by 
court martial and are serving sentence. Where practical, 
prisoners who are considered to be the most likely mate- 
rial for ultimate restoration to duty in the Navy are sent 
to one of the retraining commands, while those serving 
the longer sentences and for the more serious offenses are 
sent to one of the two disciplinary barracks. CHAPTER 27 
THE ROLE OF THE PSYCHIATRIST IN THE 
NAVAL DISCIPLINARY BARRACKS* 
To understand and evaluate the role of the psychiatrist 
in the naval disciplinary barracks it is necessary to have 
an adequate estimate of the function and role of this naval 
institution itself. And it is well to bear in mind also that 
whenever one considers the milieu in which the psychia- 
trist does his work one must also be cognizant of the 
predominant emotional and attitudinal milieu as it is 
expressed by the medical and nonmedical associates in his 
immediate environment. This is particularly pertinent in 
relation to a correctional or penal institution and is of 
primary importance when one is dealing with an institu- 
tion that must be at one and the same time custodial, dis- 
ciplinary, eliminative, and rehabilitative. And these many 
functions that the disciplinary barracks itself must carry 
out day by day and the emphasis placed on one or the 
other of them will be determined in turn, by the attitudes 
held by the individual psychiatrist himself and his associ- 
ates relative to the future value or lack of value to the 
naval service of the prisoner himself. 
The naval disciplinary barracks is the "ultima ratio 
regis"—the "last argument” of an exasperated and sorely 
tried naval service. The population of the naval discipli- 
nary barracks and its counterpart in the Army, therefore, 
probably represents the purest strain of nonconformity 
and maladjustment of young men in the post-adolescent 
age group that one can obtain anywhere. Viewed as ob- 
jectively, as scientifically, or as medically as one can, this 
population by its manifest desertion of its duty to the 
nation in peril can (if we are not careful) arouse in us 
feelings of resentment and aggression. That just such an 
attitude is held today by some of the nonmedically trained 
is not at all surprising. Nor is it surprising that measures 
taken (or not taken) relative to the rehabilitation and re- 
education of these men may be determined in large part 
by our feelings and attitudes concerning these men as a 
group rather than by scientific evaluations of the indiv- 
iduals comprising the group. And I would emphasize that 
the psychiatrist may be just as vulnerable to such swings 
in attitude concerning the naval (or even intrinsic) worth 
of the men under his care as is the most ardent disciplin- 
arian. 
In short, the psychiatrist in the naval disciplinary bar- 
racks attempts to play the role of the medical man who is 
interested in correction, amelioration, or elimination of 
the problems of the individual man and he must play this 
role in a milieu set up to administer justice and mild 
discipline fo a group, as a group, the offense in 99 percent 
of the cases being the same, i. e., that without authority 
they left their appointed places and went elsewhere to 
follow their own desires and wishes regardless of the harm 
their defection might cause their country or their col- 
leagues. For this they are punished by loss of liberty and 
within the limitations set up by naval law the psychiatrist 
must demonstrate that he has something to offer in the 
care, treatment, and disposition of these men that will be 
of help to the naval service and to the naval personnel 
involved. 
At the outset, however, it should be stated, I think, that 
the greatest mistake that can be made by the psychiatrist 
in a military correctional institution is for the psychiatrist 
to assume that he can practice his profession as it is prac- 
ticed in civilian life. Continued and exclusive interest in 
the individual alone, or even as a major emphasis, by the 
psychiatrist in the military service of a nation (and par- 
ticularly if the nation be at war) would seem to me to be 
the most startling evidence of lack of adaptability on the 
part of the psychiatrist himself. Naturally he does not 
have to set aside his ideal of practice but he certainly must, 
for the time being, be content with only a rough approxi- 
* By George E. Gardner, Commander (MC) U.S.N.R. 
129 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
mation to that ideal. Otherwise his effectiveness will be 
entirely lost and he himself will be miserable. 
However, one can, I believe, outline five functions or 
areas of function assumed or covered by the psychiatrist 
in the naval disciplinary barracks at the present time. 
These five functions are in the order of importance and 
involvement of time: I. Diagnostic; II. therapeutic; III. 
forensic; IV. educational; and V. research. We shall deal 
with these five functions in detail. 
I. The most important present-day function of the 
psychiatrist in the naval disciplinary barracks is diag- 
nosis and the suggestions for disposition made on the 
basis of this diagnosis. In short, the psychiatric depart- 
ment of a naval disciplinary barracks can be considered 
one of the best examples extant of an outpatient psychi- 
atric "clinic”—a clinic in which all men should be seen at 
least once in a diagnostic interview by a psychiatrist or by 
a well-trained clinical psychologist or psychiatric social 
worker, the work of the latter two groups to be super- 
vised and reviewed by the psychiatrist himself in staff 
conference. 
At the present time, the routine plan in most naval 
disciplinary barracks is as follows: Upon entrance to the 
naval disciplinary barracks, whether first offenders or 
not and regardless of what action they are awaiting, dupli- 
cate entrance sheets with the man’s name, rate, and of- 
fense are sent to the psychiatrist. These men are seen in 
diagnostic interview and are tested by group test and by 
additional individual scales if group test results seem to 
warrant it. On the basis of these preliminary examinations 
a man may be referred to the out-patient division of the 
naval hospital for a more detailed neurological examina- 
tion or for an electroencephalogram. When all data 
thought necessary to make a psychiatric diagnosis are 
gathered on the individual man, the entrance sheet is filled 
out stating whether the man is: (a) Psychopathic and 
hence is being sent into the naval hospital for considera- 
tion for medical survey; (h) normal, nonepileptic, non- 
feeble-minded, and hence ready for trial; or (c) ready for 
trial with the opinions and recommendations of the 
psychiatrist. Here the psychiatrist can include findings on 
the man pertinent to responsibility, mitigating circum- 
stances in man’s family or previous life that he thinks 
would be of interest to the commanding officer, recorder, 
or to the judge advocate. The filled-out entrance sheet is 
sent immediately to the disciplinary officer concerned for 
his information and forwarding. By this procedure the 
psychiatrist has taken from the trial list the feeble-minded, 
the epileptic, the obviously psychopathic, the sex offend- 
ers, and the rare psychotics that are found in the naval 
disciplinary barracks population. The time and expense 
involved in trial is saved and the man is well on his way 
to be eliminated from the service as mentally unfit, un- 
adaptable, or undesirable. If the hospital or the body 
reviewing a recommended survey disagree with the 
psychiatrist’s opinion of a prisoner he can be tried directly 
following his return from the hospital. 
I think it is a pertinent digression at this point to sug- 
gest that much time and expense (and also many needed 
hospital beds) would be saved if the naval disciplinary 
barracks psychiatrist and his clinic team (psychiatrist, 
psychologist, and social worker) could present their ma- 
terial on mentally unfit cases to a survey board meeting 
periodically in the disciplinary barracks to consider such 
cases rather than following the costly and time-consuming 
routine of sending a man to occupy a hospital bed for 
2 or 3 weeks (sometimes for months) under "observa- 
tion.” Certainly such hospitalization is probably not neces- 
sary in the feebleminded and epileptic group though it 
will still be necessary in the questionable or borderline 
cases. 
As can be seen from the foregoing, the diagnostic role 
of the psychiatrist in the naval disciplinary barracks, is, 
for the most part eliminative, aimed at the necessary dis- 
charge from the service of all those whose poor mental 
condition or characterological defects (constitutional or 
acquired) are of such a type and severity as to render their 
future contribution to the naval service very questionable 
or definitely harmful. But even in these cases it can be 
the beginning of a rehabilitative procedure if the man 
himself is advised as to where he can receive help in his 
home community and if the home community is informed 
through social service agencies, notably the Red Cross, 
that the man is being returned to civilian life and will 
need all the help that local rehabilitation programs can 
offer. To see that responsible bodies in the local com- 
munities are notified of the psychiatric needs of a return- 
ing sailor can be considered one of the functions of the 
disciplinary barracks psychiatrist. 
Now it might be well for a moment to consider sources 
of "material” or the means of referral of patients to the 
disciplinary barracks psychiatrist other than through the 
routine entrance sheets mentioned previously. As naval 
disciplinary barracks are constituted and operated at the 
present time a considerable proportion of the prisoner 
population may be transferred to a particular disciplinary 
barracks after trial. These are men serving sentence and in 
many instances they have not been screened psychiatrically 
since they first evidenced difficulty in adjusting in the 
service. There are four ways in 'Nvhich these men can come 
to the attention of the psychiatrist for a diagnosis. 
130 Chapter 27.-THE ROLE OF THE PSYCHIATRIST 
First, they most frequently and most easily come under 
the observation of the physician at daily sick call. The 
nature of the complaint, the method of presentation of 
symptoms, or the repeated appearances of the man at the 
sick call, all tend to arouse the interest of the psychiatrist 
and the man is given an appointment for a diagnostic 
interview in the psychiatric department. 
It is the opinion of the author that the psychiatrist him- 
self should hold daily sick call (procedures vary in various 
disciplinary barracks, depending on their size and per- 
sonnel) but if he does not, certainly he should attend sick 
call in the company of the physician primarily responsible 
for the physical care of the men. For it is only in this way 
that many men who may be missed during routine exam- 
ination, or those who develop a psychoneurosis or psycho- 
sis during their incarceration, will be discovered and re- 
ferred for diagnosis or treatment. The superimposition of 
the frustration attendant upon being sentenced and im- 
prisoned may in itself be just enough to cause a mental 
break in a man who previously appeared normal. Or the 
"defenses” (physical or mental) that he brings to bear 
at such times may be so extreme as to render him abnor- 
mal, i.e., definitely psychoneurotic or psychotic. And he 
is more than likely to appear before the doctor at sick call 
for help. 
A second source of case material is the referrals from 
the disciplinary barracks chaplain. Men who are troubled 
by their own inner conflicts, or who are troubled by per- 
sonal and material conditions in their homes, both of 
which may have led directly to the offense against naval 
discipline with which they now stand charged, bring such 
problems to the chaplain and ask for his opinion and 
guidance. As a matter of fact, after many months of very 
close association and collaboration with the work of chap- 
lains on duty in a naval disciplinary barracks, I am con- 
vinced that 90 percent of the problems referred to him 
by the men (as contrasted with the remaining 10 percent 
which are concerned with spiritual matters) are problems 
that definitely call for the ministrations and advice of the 
trained social worker and particularly of the trained 
psychiatric social worker. 
Most chaplains are aware of the psychiatric significance 
of many problems, or of certain constellations of symp- 
toms, both of which immediately tell him that the case is 
a medical one and the man is to be sent forthwith to the 
psychiatrist for diagnosis. However, the psychiatrist 
should not lose sight of the necessity for counseling with 
the chaplain in order that the latter will have a clearer idea 
of the psychiatrist’s concern and interest. 
Third, the commanding officer, the line officers, or the 
guards oftentimes will be the first to notice an apparent 
mental deviation in those men who do not enter the dis- 
ciplinary barracks before their sentence and hence miss the 
routine psychiatric check. More than this, the aforemen- 
tioned line officers and guards are in the best positions 
possible to first note abnormalities because they have the 
men under close observation at drill, in classes, on work- 
ing parties, during recreation periods, or in the various 
prisoner compartments. The psychiatrist does get referrals 
from these men. He undoubtedly gets more of them when 
the guards are well chosen for their ability to handle men 
and when the psychiatrist makes known to them that cer- 
tain difficulties in discipline and in the administration of 
it can spring from underlying conflicts that call for psy- 
chiatric help. The guards must be made aware of the 
facilities and functions of the psychiatric department if it 
is to be expected that they use it properly and enough. 
Fourth, and finally, the routine psychometric (group) 
examination of all men entering the disciplinary barracks, 
whether they are to be tried at the present activity or 
whether they already have been tried, will enable the 
psychiatrist to eliminate the feebleminded individual, as- 
suming, of course, that the man’s past academic work, and 
social histories corroborate the suspicious findings of the 
standardized test. Also, every man whose I. Q. by group 
test is found to be below 70 should be re-tested in the 
psychological department with an individual intelligence 
test such as the Bellevue-Wechsler scale. Together with 
these a psychiatric diagnostic interview is secured and 
recommendations advanced. 
II. (a) The psychotherapeutic role of the psychiatrist 
in the naval disciplinary barracks at the present time is 
a rather limited one. Surely he does his best by vis a vis 
psychiatric interview to aid the men who come to him for 
help. Also, he is able to select from the sick call all the 
cases he can possibly see in the time available for such 
work. But he definitely cannot make therapy his major 
function. This is true not only because of the limited num- 
ber of hours per week that can be devoted to this work 
with the individual man but it is also limited by the length 
of time the men themselves are under the restriction of 
the disciplinary barracks. Many of the men are in the 
disciplinary barracks for sentences of 5 to 10 or 30 days, 
some are there only until tried, some come after trial, some 
are in close confinement, bread and water cases, etc. Fin- 
ally, long term cases usually are not kept in such institu- 
tions but are transferred to the naval prison after a short 
stay in the disciplinary barracks. 
On the other hand, fruitful and worthwhile individual 
psychotherapeutic work can be done with cases exhibit- 
ing: (I) Hysteriform types of reactions; or (2) mild 
reactive depressed states, both of which are sudden re- 
131 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
against the dawning fact of the "awfulness” and 
seemingly interminable length of the imprisonment ahead. 
These reactions are usually seen early in the prisoner’s 
stay and they usually take the anxious, conversion, or agi- 
tated forms. (A transient paranoid type of reaction is very 
much less in evidence among these men.) These men can 
be helped by the psychiatrist and the help given in rela- 
tion to these attitudes in the early stage of imprisonment 
may have considerable effect on their later naval service 
when their sentence ends and they are restored to duty. 
(b) The most effective type of psychotherapy that can 
be used in the disciplinary barracks is group psychother- 
apy. Lectures and discussion on personal problems that are 
to be faced by all men, discussion of naval usages and 
customs, lectures on the aims of the nation and the service 
in war and in peacetime plus the role of the individual in 
carrying them out, all can aid in returning the offender 
to duty with a different and worthwhile attitude to the 
service and in respect to his own individual worth. Movies, 
reading, posters, and radio programs all have a supple- 
mentary part to play in this group therapy. 
All such group therapy, if it is to succeed, must be 
given to smaller, more or less homogeneous groups within 
the prison population. Selection of groups as to more or 
less the same criteria (age, I. Q., number of offenses, and 
length of sentence) will make group work more effective. 
The selection of the groups, the methods of presentation 
and the "course contents” should be the joint results of 
close collaboration between the psychiatric, psychological, 
and educational officers of the activity. 
(c) A third type of therapy that is carried out in the 
disciplinary barracks is remedial therapy for nonreaders 
or borderline illiterates. Every disciplinary barracks of 
500 or more men will have in it a group of otherwise men- 
tally normal men who have never had the opportunity to 
learn to read or who, having the opportunity to learn, 
could not take advantage of it because of the existence of 
a technical reading disability. In most instances in these 
particular cases, the inability to read contributed at least 
indirectly to their difficulties in the Navy and in some of 
the cases it was the direct cause of their infraction in that 
they could not read muster rolls, transfer lists, and rules 
and regulations. These men will probably make acceptable 
members of the naval service once they have learned to 
read and they are eternally grateful for the interest and 
help given them. Naturally all of the remedial work is 
directed at the man’s naval service and the reading ma- 
terial is drawn from the words and phrases that the man 
will encounter in his service period. To this group of 
illiterates are added those men who themselves feel that 
they should have added training in reading even though 
they may have second and third or fourth grade learning 
ability. 
III. A third role of the psychiatrist in the naval dis- 
ciplinary barracks is best called his "legal” or "forensic” 
role in that it has to do with his functions as a specialist 
on human behavior as it concerns the administration of 
naval law. We have already cited the necessity for pretrial 
psychiatric examination of all men entering the disciplin- 
ary barracks. To this function also is added the periodic 
conferences with the disciplinary officer in "borderline” 
or questionable cases, the presence of the psychiatrist for 
the defense or for the prosecution when the question of 
"sanity” or "responsibility” has been raised, the evalua- 
tion of cases selected by the commanding officer at cap- 
tain’s mast to aid the captain in determining whether the 
case in hand is a disciplinary or a medical one. Finally, his 
opinion is sought by boards dealing with clemency or 
recommendation for restoration to duty of offenders pre- 
viously awarded bad-conduct discharges. All of these 
"forensic” functions should be carried out by the psychi- 
atrist in each disciplinary setting. Needless to say, for this 
work it is necessary for the psychiatrist to equip himself 
with the minimum adequate legal knowledge by taking 
the naval correspondence course in military law. 
IV. All of these functions of the psychiatrist, diagnos- 
tic, therapeutic, and forensic lead directly to a fourth 
function, the educational. We do not mean by this the 
education of the prisoners, for that is the role of the educa- 
tional officer of the activity. But the psychiatrist’s educa- 
tional role to which I refer here is in the training of the 
men associated with him to a realization of the signifi- 
cance of some types of human behavior, i. e., the signifi- 
cance of such behavior relative to the abilities and respon- 
sibilities of human beings for their acts and their value as 
harbingers of the individual’s probable future worth as a 
serviceman or as a citizen. The significance of aggression, 
the question of responsibility, the reactions to frustration, 
the desires and needs of men whether in the service or out 
of it, these have to be particularly stressed and re-empha- 
sized with all personnel delegated to guard and care for 
the naval prisoner with the ultimate aim that all dealings 
with the prisoner will have as their goal the rehabilitation 
and return to conscientious duty of all men who are by 
personality endowment capable of so returning, and re- 
turning with an attitude concerning themselves and the 
service that should make for success as a serviceman. One 
of the most lasting and worthwhile functions that the 
psychiatrist can carry out will be found to have been just 
this one I am now stressing, the education of his non- 
medical naval associates in a few simple but nonetheless 
fundamental psychiatric concepts. 
132 Chapter 27.-THE ROLE OF THE PSYCHIATRIST 
V. Finally, the psychiatrist in the disciplinary barracks 
has another, perhaps minor, but nevertheless important 
function and duty, the duty to do research in that particu- 
lar branch of psychiatric work in which his superiors 
placed him. He should amass data, and with it control 
data, in order that some light shall be shed on what types 
of individuals can and do succeed in the Navy as con- 
trasted with those who become chronic naval misfits and 
failures with the great losses in money and time that the 
acceptance or reinstatement of such men entail. The psy- 
chiatrist in the disciplinary barracks can and should work 
out predictive schemes and probabilities that will enable 
the naval enlistment bodies to eliminate (insofar as it is 
humanly possible to predict) those men who we now see 
in the finished product of the chronic offender. Such 
studies aimed at the better selection and retention of men 
must be continuous as in the case of our colleges and uni- 
versities where data are constantly being collected and 
evaluated. Our country is going to need a large and effici- 
ent Navy for many years to come and the problem or 
personnel selection will still be one of the greatest prob- 
lems to be faced. The psychiatrist in the disciplinary'bar- 
racks should make his contribution to this all-important 
problem of selection through pointing out definitely estab- 
lished scientific methods the type of man the Navy does 
not want, ever. 
Finally, the psychiatrist at all duty stations can be of 
considerable aid to his country if he turns the spotlight 
upon himself and upon his own specialty to determine, in- 
sofar as he can, what kind of a role he should play in the 
various naval activities to which he may be assigned not 
only for the performance of creditable duty at some possi- 
ble future date but to better enable the medical-officer 
procurement branch to select and assign psychiatrists in 
some distant struggle that may befall the nation years 
hence. The necessary training background for psychi- 
atrists in their particular type of work, the role of the 
clinical psychologist, and the need for trained psychiatric 
social workers are all problems which are important to the 
Bureau of Medicine and Surgery and an elucidation of 
beneficial and feasible plans regarding them are a part of 
what might well be termed the "research function” of the 
psychiatrist assigned to all naval establishments at the 
present time, including the activities designed to care for 
disciplinary cases. 
In summary, there are outlined the present functions of 
the psychiatrist stationed in the naval disciplinary bar- 
racks with a few hints as to how he might possibly func- 
tion better in the future. In conclusion, it should be stated 
again that the activity which we are considering here is 
not a psychiatric pavilion, nor should it be looked upon 
as such, but it is a disciplinary barracks where within 
the limitations set by such a correctional institution the 
psychiatrist functions. In carrying out these multiple func- 
tions, he will have the happy privilege of bringing to bear 
on this whole problem all of the advances in knowledge 
that comprise the fundamental bases of modern psychiatry 
and penology. 
133 CHAPTER 28 
THE NAVAL OFFENDER' 
MOTIVATING FACTORS 
Far-west ] 
3.44 percent 
Midwest 
16.67 percent 
Northeast 
34.88 percent 
The thousands of men, awaiting or undergoing discip- 
line, idle or only partially employed while in confinement, 
presented a challenge during our manpower shortage. 
In a peacetime Navy the problem of the offender was not 
so pressing. If a man by repeated offenses indicated that 
he was incorrigible, he was discharged from the service. 
Many whose patterns of delinquent behavior were not too 
well established were taken in hand by officers and petty 
officers long experienced in the handling of men and 
gradually molded into useful, well trained and disciplined 
seamen. New men, homesick and confused, tempted to 
desert, would be helped by a veteran crew. The training 
was more leisurely and the demands not as great. To the 
young lad the Navy became a father substitute. The mar- 
ried man with the strong family attachment was not the 
problem he is today, because those men did not often join 
the Navy. 
With the greatly expanded Navy and the relaxing of 
its former rigid standards for acceptance, the multiplica- 
tion of behavior problems was inevitable. The methods of 
the peacetime Navy were found not entirely suitable or 
expedient for both the increased number of offenders and 
the new problems which they brought with them. 
The widespread induction of men at rapid speed into 
the service has introduced many psychopaths, mental de- 
fectives, illiterates, physically handicapped, and emotion- 
ally unstable, as well as delinquents, in spite of the fact 
that an effort to screen them has been made. Practically 
every variety of offender, including the sexually perverse, 
has been detected and when indicated eliminated. These 
supply many of the disciplinary problems in the Navy. 
They eventually become part of some "brig” population. 
These men represent nearly every State in the Union. 
Figure 13 presents the geographic distribution of 582 
cases selected at random. 
Southwest 
1.54 percent 
Southeast 
43.47 percent 
The offenders from whom the data for this study has 
been collected were admitted to the disciplinary barracks 
of the U. S. Naval Receiving Station, Norfolk, Virginia, 
over a period of approximately one month. These men 
are admitted for disciplinary action following findings at 
captain’s mast or sentence of summary court-martial, or 
while being held pending transfer to a naval prison in 
pursuance of sentence of general court-martial. 
All men when admitted fill out an interview question- 
naire prepared by the psychiatric unit. This questionnaire 
supplies pertinent information regarding the man’s status 
in the Navy, a brief review of his duty history, the nature 
of the present offense and previous offenses, family and 
home backgrounds, marital status, educational and de- 
linquency histories prior to entrance into the Navy, na- 
ture of his physical complaints, and the man’s own per- 
sonal opinion regarding the Navy, his duty, and his own 
evaluation of his adjustment to the naval service. In addi- 
tion to this he indicates whether he desires to discuss any 
personal problems in private. 
The questionnaire is used as a supplement to an inter- 
view by a psychologist experienced in clinical procedures 
as well as in delinquency problems and the field of cor- 
rection. The psychologist is on the alert for emotional and 
psychiatric problems that may be the motivating factors 
back of the offenses. In such cases the men are referred to 
a psychiatrist for evaluation and proper disposition. Hos- 
pitalization rather than discipline has often been indicated. 
One thousand such questionnaires have been selected 
at random from the files of the psychiatric unit. These 
form the background for the data of this study. They 
Figure 13. 
‘By H. Robert Otness, Lieutenant H(S) U.S.N.R., and George A. W. 
Stouffer, Jr.. Lieutenant H(S) U.S.N.R. 
134 Chapter 28.-THE NAVAL OFFENDER 
furnish facts relative to the sociologic and psychologic 
make-up of the offenders and supply interpretations of 
their motivations. 
All the motives of human behavior are not known. 
Much, however, has been discovered regarding man’s in- 
tellectual status, his emotional strivings and thwartings, 
the influence of body on mind and vice versa, the relative 
influences of nature and nurture, the importance of happi- 
ness on one’s job and the effects of failure and success, 
the value of adequate childhood training and guidance, 
the value of avoiding placing square pegs into round 
holes, and many other facts pertaining to the adjustment 
of man to society. 
Although man comes into existence through a fairly 
uniform pattern he is subjected to a great variation in the 
factors of and the type of home and social 
culture in which he must develop. The importance of a 
happy childhood, well directed, planned and encouraged, 
in the preparation for adult living, need not be elaborated 
upon here. 
Although these facts are not readily observed in man’s 
personality, they nonetheless explain some of his reactions 
to life as a whole and are frequently basically responsible 
for his attitudes. 
The data obtained in this investigation have been 
grouped or classified under various headings to facilitate 
presentation to the reader. The information expressed in 
terms of percentages is based on 1,000 naval offenders 
unless otherwise stated. The percentages of these same fac- 
tors for the Navy as a whole are not available. 
4. 
Stepfather 
11.1 
5. 
Stepmother 
7.5 
6. 
Has brothers or sisters 
91.98 
7. 
Has half-brothers or half-sisters 
9.4 
8. 
Reared in a foster home or orphanage 
4.6 
9. 
Thinks he had a happy home while growing up... 
_.. 86.3 
Percent 
1. 
Single 
66.99 
2. 
Percentage of those married, having children 
51.8 
3. 
Happily married 
82.7 
MARITAL STATUS 
EDUCATIONAL BACKGROUND 
1. Range of schooling 
None to 3rd-year college 
(average 9.43 grades) 
2. Did well in school 
72.3 
1. 
Played “hookey" in school 
47.7 
2. 
Has been in juvenile courts 
11.0 
3. 
Has been arrested in civilian life 
27.1 
4. 
Has been in jail (detention) 
22.1 
5. 
Has been in reform school 
3.1 
6. 
Has been in prison (sentence) 
3.0 
DELINQUENCY BACKGROUND 
ATTITUDE TOWARD NAVY 
Fine 
44.8 
1. 
How well does he like the Navy j 
Fair 
42.6 
Not at all 
12.5 
(Fine 
36.7 
2. 
How well does he like his duty •< 
Fair 
35.8 
[Not at all 
27.5 
3. 
How well 
does he think he is getting 
[Fine 
25.3 
along in 
i the Navy 1 
Not at all 
26.6 
FACTORS OF INSTABILITY 
GENERAL CONSIDERATIONS 
1. Complains of trouble in sleeping 
34.5 
2. Considers himself to be a nervous person 
47.3 
Percent 
1. Proportion of naval offenders 
as to 
Regular and 
Reserve status 
(Regular 
15.3 
) Reserve 
84.7 
2. Enlisted or drafted 
(Enlisted 
60.9 
( Drafted 
39.1 
3. Percentage having had sea duty. 
53.1 
4. Percentage having had combat duty 
21.65 
5. Percentage having survived disaster at 
sea 
1.7 
6. Average length of service in the Navy 
12.15 mo. (range 2 
to 55) 
7. Average age 
..20.45 yrs. (range 15 
to 37) 
8. Percentage as to rating 
\ Rate 
13.0 
1 Non-rated 
87.0 
9. Offender from ship or shore 
[Shore 
56.3 
fShip 
43.7 
10. First offender or recidivist 
1 First 
45’.0 
1 Recidivist 
55.0 
11. Average number of offenses per offender...2.52 (range 
1 to 8) 
“NP" REFERRAL 
1. Referred to the psychiatrist for further study 11.1 
1. States that he has personal problems he wishes to 
discuss 38.2 
PERSONAL PROBLEMS 
Personal problems (not tabulated) center chiefly 
around domestic difficulties (financial, health, marital), 
concern about personal health, need for legal advice or 
Red Cross aid, dissatisfaction with duty in Navy, and 
worries about the outcome of present offense or in connec- 
tion with allotment or pay account irregularities. 
General considerations.—The high proportion of Re- 
serve offenders is to be expected in view of the present 
great preponderance of Reserve personnel. The pre-Pearl 
Harbor men are the seasoned sailors and have become ad- 
justed to the demands of sea duty, to being away from 
home and to Navy life in general, but the introduction of 
the hazards of war has been new for both groups. The 
adjustment of men to sea duty is important. More consid- 
eration could be given by the seasoned crew to the new 
FAMILY BACKGROUND 
1. 
Father living 
2. 
Mother living 
3. 
Parents divorced or separated 
18.43 
135 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
sailor coming aboard his first ship. His training in boot 
camp has been rapid and none too thorough. Early dis- 
couragement on first assignment, combined with fear and 
the anticipation of danger have had their share in produc- 
ing "AOL” offenders. 
The length of time in service does not seem to be as im- 
portant as does the amount of responsibility and incentive 
the man has had in making a nonoffender. The correla- 
tion between length of service and number of offenses is 
not too significant. Age alone is not a good guide. The 
problems of the adolescents and the older men vary. The 
younger have the difficulty of submission to authority, 
while the older men have physical and domestic hurdles. 
Frequently men with very little or no ability are sent to 
Service Schools, while others with good high school and 
some college education are held back—both misfits be- 
coming disgusted with the service, and potential offenders. 
With the increased temptation on shore, more men be- 
come offenders than when on board ship. Dissatisfaction 
with duty, lack of consideration on the part of superiors, 
fear, seasickness, poor ship morale, callow officers and 
seasoned sailors, are all important factors. 
The first four to seven months in the Navy produce 
many first offenders. Often the return of the offender to 
his ship at the end of his confinement results in a recidi- 
vist, his reputation being already established. Duty reclas- 
sification would save many men and would constitute all 
the rehabilitation needed in certain cases. Court-martial 
involving fines aggravates the home economic problems 
and results in a repeated offense, the home obligation 
seeming greater than the sense of patriotic duty. Recidi- 
vists are to be expected among the mental defectives, il- 
literates and the psychopaths. 
Family background.—The potency of the childhood 
and family backgrounds in shaping the personality must 
not be overlooked. The solidarity of a good home reflects 
itself in the stability of its members. The insecurities of 
childhood produce instabilities in adult life. Broken homes, 
divorced parents and mistreatment place an indelible mark 
on children, and are common background findings among 
delinquents. A recent study of civilian delinquents2 
showed 78 percent with fathers living, 83 percent with 
mothers living, and 22 percent with parents divorced, in 
contrast to a nondelinquent group having 93 percent 
fathers living, 90 percent mothers and 4 percent divorced. 
The problems of the large indigent family, the farm boy 
needed at home, the subtle implications of the "only 
child,” the over-protected home, the child from orphan- 
age or foster-home, all create potent attitudes in the indi- 
viduals and give them life-long frustrations. 
Marital status.—The married man finds it difficult to 
be away from home, often for the first time. Because of 
the unwillingness or inability of the wife to carry on the 
battle on the home-front he is tormented with economic 
problems. The tragedy of unfaithfulness and divorce 
enters. He may have fixed obligations of payments on 
home or on insurance; he may have business interests with 
outstanding obligations, as well as many other emotion- 
ally frustrating situations. 
Educational background.—This has a very important 
bearing on the production of naval offenders and is close- 
ly tied up with the selection and classification of men. 
The mental defectives, the illiterates, the defective-illiter- 
ates, and the educationally retarded groups that are coming 
into the service in large numbers are constantly over- 
whelmed by the demands made on them by the Navy. To 
escape the unpleasant they go AWOL, or become offenders 
through their lack of comprehension of tasks to be done 
or through being misunderstood. Their psychologic make- 
up is difficult to understand by the untrained. The men 
with good schooling who are placed in inferior duty as- 
signments are also dissatisfied, unhappy men. A school 
background of ' .playing hookey” and of difficulty with 
teachers is a forerunner of delinquency. 
Delinquency background.—A recent report3 stated that 
about 2 percent of all school children are problem cases, 
and that 4 out of 5 of these become overt delinquents, and 
3 out of 4 overt delinquents become criminals. As com- 
pared with these civilian figures, it can be readily seen 
that the naval offenders show a high rate of delinquency 
potentiality. About half of them had "hookey” records. 
There are also relatively high percentages of civil arrests 
and jail detentions. Although the percentage of reform 
school and prison cases is small, it is significant in con- 
sidering insubordination. The influence of former inmates 
of reform schools and prisons upon the potentially non- 
delinquent must not be treated lightly; the younger men 
often select such a figure for hero worship and think that 
that is part of being a "salty sailor.” 
Health complaints.—Forty-three and seven-tenths per- 
cent of the 1,000 men registered some physical complaint 
on admission to the brig. Many of these complaints were 
psychosomatic in type, precipitated by the struggling with- 
in oneself to rationalize the offense and to gain attention 
and pity. It is interesting to note how old complaints and 
old injuries, that existed many years prior to enlistment, 
became "alive” again on confinement in the brig. 
* Middleton, W. C, and Fay, P. S.; Comparison of delinquent and non- 
delmquent boys with respect to certain attitudes. J. Social Psychol 18- 
155-158, August 1943. 
H- and Teeters, N. K.: New Horizons in Criminology. 
Prentice-Hall Inc., New York, 1943, p. 945. 
136 Chapter 28.-THE NAVAL OFFENDER 
Attitudes toward Navy.—About 87 percent of the naval 
offenders indicated that they liked the Navy, leaving 13 
percent who disliked it. This latter group may be a serious 
one in influencing the attitudes of others. That 27.5 per- 
cent did not like their duty indicates the need for some 
effort at more appropriate reassignment. The 26.6 per- 
cent of offenders who feel that they are not getting along 
in the Navy, are those unhappy in their work, inefficient, 
and on the way to becoming chronic offenders through 
discouragement. 
Factors of instability.—The large percentages who had 
sleep disturbances and nervous feelings may suggest a 
prevalent psychoneurotic make-up. Emotional problems 
of fear, the aftermath of combat, the tension that accom- 
panies confinement, plus the perseverative nature of a 
neurotic childhood all are factors in the behavioral in- 
stabilities observed. 
"NP” referrals.—The relatively small percent of "NP” 
referrals (neuropsychiatric), in comparison to the other 
percentages cited, should not be misconstrued as unim- 
portant. Within this group there have been several psy- 
chotics who were potential menaces to shipmates and civil 
society. Hospitalization rather than confinement was the 
need. All "NP” cases are not hospital cases; some are less 
serious mental hygiene problems. This 11.1 percent does 
not include the psychopathic personality group (constitu- 
tional psychopathic states), 
CONCLUSIONS 
This study has been a survey of some of the important 
psychologic and sociologic factors among naval offenders, 
and offers some explanations for their poor adjustment in 
the Navy. The 1,500 offenders considered represent about 
3,750 offenses, and 7,500 weeks (conservative minimum 
estimate of 2 weeks per offense away from duty), or about 
1,260,000 man-hours, spent in confinement. 
Each ship and station should seek out the important 
factors within its organization that may be contributing 
unknowingly to the offender problem in the Navy. 
137 CHAPTER 29 
THE NAVAL PERSONAL INVENTORY 
AND THE NAVAL OFFENDER 
U. S. Naval Disciplinary Barracks 
Hart’s Island, New York, N. Y.* 
port on the use and interpretation of the Inventory will be 
issued in the near future.” 
Those acquainted with the literature in the field of 
criminology are cognizant of the numerous studies of de- 
linquent groups with various "personality scales” and the 
varying degrees of success in predicting antisocial be- 
havior by means of these scales, (i, 2, 3, 4, 3, 6.). The 
present research consists of a preliminary attempt to evalu- 
ate 1,239 Navy court-martial prisoners with the Navy En- 
listed Personal Inventory and to determine the extent to 
which this Inventory might be used in pointing out those 
individuals who may be expected to become disciplinary 
problems through some psychopathological pattern. 
The Navy Enlisted Personal Inventory consists of two 
parts one of which is an abbreviation of the Cornell Se- 
lectee Index and the other a short form of the Shipley In- 
ventory. The description of the purpose of the Navy Per- 
sonal Inventory is quoted below; 
"Scoring and Interpretation: This instrument is de- 
signed to select that portion of the population for whom 
psychiatric investigation is most strongly indicated. It 
should not be used for 'cutting’ or eliminating personnel 
independently of psychiatric confirmation. Individuals 
scoring above certain levels on either part should be re- 
ferred for psychiatric interview. If all individuals in the 
population are routinely examined, then individuals scor- 
ing above the prescribed levels would warrant more in- 
tensive investigation than the remainder. 
"It should be noted that the 'Investigating Scores’ are 
merely tentative and vary for different service groups. In- 
dividuals score at or above the levels indicated below 
should be considered for psychiatric referral. A further re- 
For Amphibious 
For Submarine 
Personnel 
Personnel 
Part 1. . . . 
.... 10 or above 
. . .8 or above 
Part 2. . . . 
.... 1 or above 
. . ..1 or above” (7) 
INVESTIGATING SCORES 
This scale was given to 1,239 unselected individuals at 
a naval disciplinary barracks. The group was made up of 
1,121 white men and 118 Negroes. Of the total, 243 were 
awaiting trial and 996 were serving sentences of General 
Courts-Martial. Those serving sentences were further cate- 
gorized into groups which were ultimately to be discharged 
with a Bad Conduct or Dishonorable Discharge and those 
who were to go back to duty after serving their sentences. 
Scores for each of the groups on Part I of the inventory 
are given in Table 40. A statistical breakdown of these 
findings as presented in Table 41 reveals that if a score of 
8 were to be used as the cutting point for further examina- 
tion 50.2% of the total group would fall in this category. 
The scores for each of the sub-groupings are fairly similar 
and the differences are not statistically significant, with 
the exception of the difference between the whites and 
Negroes. The difference here is 14.8% in those checking 
8 or more questions and the standard error of the differ- 
ence is .047. The critical ratio therefore is 3.1 and the 
chances are better than 99-9 out of 100 that this differ- 
ence is statistically significant. In considering the relia- 
bility of the sampling we find that the chances are better 
than 99.9 out of 100 that in none of the groups would the 
true percentage fall below 41%. 
From this we must assume that approximately one out 
of every two men entering the brig scores sufficiently high 
to warrant being picked out for special study. Although 
norms for the general Navy population are not available 
* By Bernard Locke. Lt. Comdr., H(S), U.S.N.R., and A. C. Cornsweet 
Lt. Comdr., H(S), U.S.N.R. 
138 Chapter 29.—THE NAVAL PERSONAL INVENTORY AND THE NAVAL OFFENDER 
to the writers at this time it is apparent that this figure is 
high. 
Line 5 of Table 41 gives the average number of signifi- 
cant questions checked by each of the groups. Here again 
the number for the Negro group is somewhat higher than 
for the white. 
Table 42 gives the distribution of scores on the critical 
or "stop” questions of Part II of the inventory for the 
same groups. Breaking this down statistically in Table 43 
we find that from 57.2 percent to 89.0 percent of the in- 
dividual groups have checked at least one critical "stop” 
question; with the average for the total population studied 
being 77.6%. Here, as might be expected from Part I, 
there is a marked, and statistically significant, difference 
between the Negroes and whites, the relative percentages 
being 89.0 and 76.4 respectively. However, another dif- 
ference, which was not expected on the basis of Part I 
(and which the writers are at a loss to explain at this 
time), was the score made by the group awaiting trial. 
Only 57.2 of the individuals in this group checked a sig- 
nificant answer as compared to 78.9, 76.3, and 77.6% 
for those to be discharged, those serving sentence and the 
total group respectively. 
Considering the reliability of the sampling again we 
Table 40.—Distribution of Scores on Part I, Navy Enlisted Personal Inventory 
Score 
Awaiting 
Trial 
Bad 
Conduct or 
Dishonorable 
Discharge 
Back 
to 
Duty 
Total 
Group 
Negro 
White 
0 
5 
2 
9 
16 
0 
16 
1 
14 
11 
36 
61 
1 
60 
2 
10 
25 
49 
84 
5 
79 
3 
11 
26 
65 
102 
11 
91 
4 
18 
24 
55 
97 
5 
92 
5 
13 
22 
46 
81 
5 
76 
6 
16 
21 
39 
76 
4 
72 
7 
24 
22 
54 
100 
12 
88 
8 
14 
17 
49 
80 
12 
68 
9 
13 
18 
37 
68 
9 
59 
10 
19 
21 
50 
90 
3 
87 
11 
18 
22 
38 
78 
10 
68 
12 
13 
14 
40 
67 
8 
59 
13 
13 
20 
29 
62 
9 
53 
14 
8 
15 
39 
62 
7 
55 
15 
13 
9 
25 
47 
10 
37 
16 
11 
7 
16 
34 
3 
31 
17 
5 
5 
8 
18 
3 
15 
18 
1 
2 
7 
10 
0 
10 
19 
4 
0 
2 
6 
1 
5 
20 
0 
0 
0 
0 
0 
0 
Totals 
243 
303 
693 
1239 
118 
1121 
Table 41,—Individuals Checking Eight or More Significant Questions on Part I 
Awaiting 
Trial 
Bad 
Conduct or 
Dishonorable 
Discharge 
Back 
to 
Duty 
Total 
Group 
Negro 
White 
1. Total Number of Cases 
243 
303 
693 
1239 
118 
1121 
2. Number of Cases Checking Eight or More 
Significant Questions 
132 
150 
340 
622 
75 
547 
3. % of Total Checking Eight or More 
Questions 
54.3 
49.6 
49.1 
50.2 
63.6 
48.8 
4. Standard Error of Percentage 
.043 
.028 
.019 
.014 
.044 
.014 
5. Average Number of Significant Questions 
Checked 
8.5 
7.8 
7.8 
7.9 
9.2 
7.8 
6. Standard Deviation of Mean 
4.8 
5.0 
4.8 
5.4 
4.5 
4.7 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
find that if the entire group of naval offenders were to 
be studied the percentage of the total group would fall be- 
tween 71.5 and 81.1%. In light of these findings it ap- 
pears that approximately three out of every four individ- 
uals coming to a Navy brig would have been selected by 
Part II of the Naval Enlisted Personal Inventory for spe- 
cial duty. Here again the norms are not available for com- 
parison but it is quite obvious that our findings are high 
enough to merit consideration. 
Table 44 presents the distribution of answers to all of 
the questions of Part II of the inventory, including the 
non-critical as well as the critical questions. Since, at the 
moment, we have no basis for comparison they are pre- 
sented in order that those non-brig activities which may 
have built up some norms may use them as a check in 
validation. 
Table 45 presents an analysis of the responses of 200 
brig inmates to the 32 questions of Part II. From this we 
find the non-critical complaints most frequently checked 
are: 
Question No, Cases 
2—Are you easily upset or irritated? 115 
5— Do you have the feeling of being watched while you 
are at work? 75 
6— Do you often have pressure or pains in the head? 78 
7— Do you often have spells of dizziness? 76 
8— Do you often shake or tremble? 76 
19—Do you often have difficulty in falling asleep or stay- 
ing asleep? 87 
Table 42.—Distribution of Scores on "Slop” Questions—Part II 
Navy Personal Inventory 
Score 
Awaiting 
Trial 
Bad 
Conduct or 
Dishonorable 
Discharge 
Back 
to 
Duty 
Total 
Group 
Negro 
White 
0 
50 
64 
164 
278 
13 
265 
1 
66 
69 
149 
284 
23 
261 
2 
40 
52 
129 
221 
16 
205 
3 
30 
45 
84 
159 
10 
149 
4 
20 
35 
64 
119 
17 
102 
5 
16 
12 
43 
71 
8 
63 
6 
12 
9 
28 
49 
13 
36 
7 
5 
6 
10 
21 
7 
14 
8 
0 
6 
11 
17 
2 
15 
9 
0 
1 
5 
6 
2 
4 
10 
1 
2 
4 
7 
4 
3 
11 
0 
1 
0 
1 
0 
1 
12 
0 
1 
0 
1 
1 
0 
13 
2 
0 
2 
4 
1 
3 
14 
1 
0 
0 
1 
1 
0 
15 
0 
0 
0 
0 
0 
0 
16 
0 
0 
0 
0 
0 
0 
Totals 
243 
303 
693 
1239 
118 
1121 
Table 43.—Individuals Checking One or More "Stop Questions” on Part II 
Awaiting 
Trial 
Bad 
Conduct or 
Dishonorable 
Discharge 
Back 
to 
Duty 
Total 
Group 
Negro 
White 
1. Total Number of Cases 
243 
303 
693 
1239 
118 
1121 
2. Number of Cases Checking One or 
More Stop Questions 
139 
239 
529 
961 
105 
856 
3. % of Total Checking One or More 
Questions 
57.2 
78.9 
76.3 
77.6 
89.0 
76.4 
4. Standard Error of Percentage 
.032 
.023 
.016 
.012 
.029 
.010 
5. Average No. "Stop Questions” 
Checked 
2.3 
2.3 
2.3 
2.3 
3.7 
2.1 
6. Standard Deviation of Mean 
2.3 
2.3 
2.3 
2.3 
3.1 
2.2 Chapter 29.—THE NAVAL PERSONAL INVENTORY AND THE NAVAL OFFENDER 
Question No. Cases 
20—Do you sometimes have nightmares? 99 
23—Do you get spells of exhaustion or tiredness? 102 
Similarly the critical questions that are most heavily 
weighted are: 
Question No. Cases 
9—Do you suffer badly from frequent severe headaches?.. 66 
10—Have you ever vomited blood? 50 
25—Have you suffered from severe long-lasting pains in 
the stomach that have been relieved by food? 61 
32—Do you drink more than 2 quarts of whiskey a week? 51 
Table 46 presents the psychiatric impressions on 100 
unselected cases scoring 8 or above on Part I of the Naval 
Personal Inventory. These impressions were obtained 
from the men’s records and were written prior to the ad- 
ministration of the Inventory. If we include straight be- 
havior disorders (classed as "Undisciplined”) in the posi- 
tive findings we note that 90 percent of the cases have 
Table 44.—Item Analysis—Part II—200 Unselected Cases 
Question No. 
Cases 
Question No. 
Cases 
1 
79 
17 
51 
2 
115 
18 
55 
3 
73 
19 
87 
4 
58 
20 
99 
5 
75 
21 
41 
6 
78 
22 
60 
7 
76 
23 
102 
8 
76 
24 
16 
9 
66 
25 
61 
10 
15 
26 
10 
11 
18 
27 
9 
12 
18 
28 
10 
13 
16 
29 
27 
14 
50 
30 
19 
15 
23 
31 
15 
16 
7 
32 
51 
Table 45.—Distribution to Total "Yes” Answers Tart II Naval Personal Inventory 
Score 
Awaiting 
Trial 
Bad 
Conduct or 
Dishonorable 
Discharge 
Back 
to 
Duty 
Total 
Group 
Negro 
White 
0 
22 
25 
61 
108 
3 
105 
I 
6 
15 
60 
81 
6 
75 
2 
12 
26 
36 
74 
3 
71 
3 .. 
15 
18 
42 
75 
9 
66 
4 
11 
15 
35 
61 
4 
57 
5 - 
13 
13 
40 
66 
3 
63 
6 
13 
20 
44 
77 
8 
69 
7 
15 
15 
19 
49 
7 
42 
8 
7 
19 
45 
71 
8 
63 
9 - 
22 
16 
33 
71 
8 
63 
10 
14 
21 
34 
69 
5 
64 
11 
7 
14 
30 
51 
7 
44 
12 
14 
18 
27 
59 
4 
55 
13 - 
14 
9 
33 
56 
5 
51 
14 
13 
15 
30 
58 
4 
54 
15 
14 
10 
21 
45 
4 
41 
16 
7 
5 
28 
40 
1 
39 
17 
7 
5 
26 
38 
6 
32 
18 ..... „ .. ..... „ 
3 
11 
12 
26 
8 
18 
19 
2 
2 
11 
15 
1 
14 
20 . .. 
1 
2 
6 
9 
3 
6 
21 
5 
4 
8 
17 
3 
14 
22 
1 
1 
4 
6 
3 
3 
23 - 
1 
4 
3 
8 
2 
6 
24 
0 
0 
1 
1 
1 
0 
25 
2 
0 
1 
3 
0 
3 
26 
0 
0 
2 
2 
1 
1 
27 
1 
0 
1 
2 
0 
2 
28 
1 
0 
0 
1 
1 
0 
29 - 
0 
0 
0 
0 
0 
0 
30 
0 
0 
0 
0 
0 
0 
31 
0 
0 
0 
0 
0 
0 
32 
0 
0 
0 
0 
0 
0 
Totals 
243 
303 
693 
1239 
118 
1121 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 46.—Psychiatric Diagnosis on 100 Unselected Cases 
Scoring 8 or Above on Part / 
been classified as not being psychiatrically negative. When 
one compares this with the results obtained for 100 indi- 
viduals who scored below 8 (Table 47) we find a strik- 
ing contrast. Here, if the "undisciplined” classification is 
included again we find that only 55 percent show some 
psychiatric aberration as compared to the 90 percent in the 
other group. 
Although a cutting score of eight gives only 10 percent 
false positives it does miss a considerable portion of true 
positives in the group studied and the writers plan to in- 
vestigate this point further. 
An attempt at prognosticating the number of previous 
offenses (exclusive of Captain’s Masts) by means of 
scores on Part I of the inventory proved valueless as is 
indicated in Tables 48 and 49. The average number of of- 
fenses for those scoring below eight is 1.45 as compared 
to 1.54 for those scoring above eight. The difference be- 
tween the two means is not statistically significant. 
SUMMARY AND CONCLUSIONS 
The present investigation has attempted to evaluate the 
Naval Enlisted Personal Inventory as a tool in predicting 
naval delinquencies. Employing the suggested "cutting” 
scores of eight for Part I and one for Part II we have 
found that Part I alone would pick out 50.2 percent for 
investigation. 
Statistically reliable differences were found between the 
whites and Negroes and both portions of the scale; the 
Negroes scoring considerably higher on both portions. 
A statistically significant difference was found between 
those awaiting trial and those serving sentence on Part II 
of the inventory but not on Part I. This difference has not 
been explained. 
High scores on Part II of the inventory were validated 
by check against psychiatric examination. 
The scale does not serve as an aid in predicting num- 
ber of naval offenses. 
REFERENCES 
1. Asher, E. J., and Haven, S. G.: The Reactions of State Cor- 
rectional School and Public School Boys to the Questions 
of an Emotional Inventory. Journal of Juvenile Research 
XIV (1930), pp. 96-106. 
2. Quilford, J. P.. An Attempted Study of Emotional Ten- 
dencies in Criminals. Journal of Abnormal and Social 
Psychology XXI (1926-1927), pp. 240-244. 
3. Hargan, J.: The Reaction of Native White Convicts to the 
Bernreuter Personality Inventory. The Psychological Clinic 
XXII (1933-1934), p. 138. 
Diagnosis 
Cases 
Negative 
10 
Undisciplined 
12 
Immature 
12 
Constitutional Psychopathic States 
Inadequate Personality 
15 
Emotional Instability 
14 
Criminalism 
4 
4 
Psychoneurosis - 
14 
Combat Fatigue 
2 
Chronic Alcoholism 
8 
' Neurological Disorders 
4 
Schizoid Personality 
1 
100 
Table 47.—Psychiatric Diagnosis in 100 Unselected Cases 
Scoring Below 8 on Part I 
Diagnosis 
Cases 
Negative 
45 
Undisciplined 
11 
Immature 
18 
Constitutional Psychopathic States 
Inadequate Personality 
8 
Emotional Instability 
9 
Criminalism 
3 
Borderline Intelligence 
4 
Psychoneurosis 
1 
Chronic Alcoholism 
1 
100 
Table 48.—Previous Courts-Martial in 100 Unselected Cases 
Scoring 8 or Above on Part I 
Number of Courts 
0 
Cases 
29 
1 
20 
2 
27 
3 
16 
4 
5 
5 
1 
6 
0 
7 
1 
100 
Mean — 1.54 
Table 49.—Previous Courts-Martial in 100 Unselected Cases 
Scoring Below 8 on Part I 
Number of Courts 
Cases 
0 
27 
1 
35 
2 
15 
3 
.. 16 
4 
4 
5 
7 
6 
1 
100 
Mean — 1.45 
142 Chapter 29.—THE NAVAL PERSONAL INVENTORY AND THE NAVAL OFFENDER 
4. Horsch, Alfred C, and Davis, R. A.: Personality Traits of 
Juvenile Delinquents and Adult Criminals. Journal of 
Social Psychology IX (1938), pp. 57-65. 
5. Locke, B.: Various Factors in a Penal Population. Journal of 
Criminal Law and Criminology. XXXIII (Nov.-Dee. 
1942), pp. 316-320. 
6. Slawson, J.: Psychoneurotic Responses of Delinquent Boys. 
Journal of Abnormal and Social Psychology. XX (1925- 
1926), pp. 261-281. 
7. Manual for Navy Enlisted Personal Inventory. Form 2. (Jan- 
uary 1945), p. 1. 
143 CHAPTER 30 
PSYCHIATRIC EVALUATION OF THE 
NAVAL DELINQUENT* 
Although actual hostilities of World War II have long 
ceased, the problem of delinquent conduct among naval 
personnel still presents an imposing question for con- 
sideration even in peacetime. To that end, so-called naval 
retraining commands have been established in various 
parts of the country for the study and consideration of 
the typical naval offender. 
Chappel (i), in a statistical study conducted by the 
Corrective Services Division of the Bureau of Naval Per- 
sonnel, found that only one-third of 1 percent of the 
combined strength of Navy, Marine Corps, and Coast 
Guard was in confinement at any time as a result of trial 
by general court martial. This low percentage of delin- 
quency, he believed, was due to a variety of causes among 
which were: 
1. High, caliber of service personnel motivated by due 
patriotism and love of country and the freedom for which 
one engaged in battle. 
2. The Navy’s high standard of indoctrination, dis- 
cipline, and leadership. 
Chappel also revealed that the number of naval per- 
sonnel in confinement at any time during the last war was 
1 percent lower than the high peak reached in World War 
I. It may be concluded, then, that although the problem 
of delinquency is a serious one, it involves but a small 
percentage of naval manpower. Studies made by the 
Bureau of Naval Personnel point out also that 94 percent 
of all naval prisoners have committed military offenses 
involving unauthorized leave or absence over leave, 
whereas only 6 percent have committed offenses which 
ordinarily would land an offender in civilian court, such 
as theft, assault, sex offenses, and the like. 
The author had a tour of duty as naval psychiatrist 
assigned to the special type of naval disciplinary estab- 
lishments on Yerba Buena Island in San Francisco Bay 
where were located the brigs and the various naval courts 
and was present at Captain’s Mast and observed every type 
of offender from his first appearance before the command- 
ing officer to his later appearances at a deck, summary, or 
general court martial. Every prisoner was given a com- 
plete neuropsychiatric study, and any special request, be 
it from judge advocate, the defense counsel, or the pris- 
oner himself, was honored by a more complete review 
including a social service study. It is from this general 
group that some 2,000 cases have been chosen to reveal 
the types and percentages in contradistinction to a group 
of 13,727 men who were screened "off the line” in a naval 
training station (2). 
In the interest of thoroughness this pertinent problem 
has been approached along lines of social control and the 
inquiry pressed in different directions. A questionnaire 
was devised in detail so that considerable data could be 
obtained from the numerous headings (3). It was then 
given to the 2,000 men who were told that the material 
thus obtained would not be used against them, and that 
they need not sign the questionnaire unless they wished 
to do so. Each prisoner filled out the questionnaire in 
private, which took about 20 minutes. The questionnaire 
itself was designed as an adjunct to the personal neuro- 
psychiatric interview which was given routinely. The 
neuropsychiatrist was always on the alert for any psychi- 
atric problem which might have been a definite motivating 
factor behind the specific offense. In many cases, if the 
problem became sufficiently important, the man was not 
allowed to go to the brig but instead was sent to the 
hospital for a more detailed study. 
DISCUSSION 
The early work of Locke, Cornsweet, Bromberg, and 
Apuzzo (4) revealed that in a group of 1,063 offenders 
* By Louis D. Boshes, Lieutenant Commander (MC) U.S.N.R. 
144 Chapter 30.-PSYCHIATRIC EVALUATION OF THE NAVAL DELINQUENT 
Table 50.—Neuropsychiatric diagnosis in discipline cases 
otic but not illegal. However, naval absence without leave 
or absence over leave, particularly when the offender 
misses the sailing of his ship, is absent from a draft, or 
misses his mobile unit, can become a very serious offense. 
Finally, if absences continue in great numbers they can 
have very serious consequences insofar as war effort or 
military organization in peacetime is concerned. What, 
then, is the cause of delinquent conduct among naval per- 
sonnel? What is the relationship of the delinquency to 
family difficulties? What are some of the fundamental 
emotional and environmental causes? Usually there are 
surface reasons and deep reasons. In a former study were 
listed some routine ones given by men to excuse them- 
selves for having taken unauthorized leave (.5): 
FREQUENT REASONS FOR UNAUTHORIZED LEAVE 
1. No reason. 
2. I did not like my present duty. 
3. Sickness in the family. 
4. I got drunk. 
5. Not enough leave—no leave. 
6. Trouble at home. 
7. I overslept (hotel didn’t awaken). 
8. I didn’t like ship I was on. 
9. Train was delayed. 
10. Can’t stand work on the ship. 
11. Wanted foreign duty. 
12. Requested sea duty. 
13. I objected to restriction. 
14. Wanted to visit my family. 
15. Became nervous on job. 
16. Do not like the Navy. 
17. Didn’t get proper medical care. 
18. I was homesick. 
19. I wanted to have some fun. 
20. I wanted to see my wife and baby. 
21. I wanted to get married. 
22. I got sick while on leave. 
23. Couldn’t get along with officers on ship. 
24. I felt like staying over. 
25. Fear of the sea. 
26. Didn’t like Navy regulations. 
27. I am a homosexual. 
28. Trouble with shipmates. 
29. Thought they were trying to frame me. 
30. No opportunity for advancement. 
31. Mother kept me home—under age. 
32. Afraid of combat. 
33. I am best suited for civilian work. 
34. I thought I wouldn’t get caught. 
35. Detained by civil police. 
36. To see girl friend. 
37. Can’t keep away from girls. 
38. Didn’t want foreign shore duty. 
It is not difficult to understand that overindulgent 
mothers might influence sons, or that overdependent wives 
might cause husbands to become naval offenders. These 
relatives hardly seem to realize that in so doing they be- 
Diagnosis 
Cases 
Constitutional psychopathic state (all types) 
282 
Psychoneurosis (all types) 
216 
Combat fatigue 
21 
Operational fatigue 
12 
Pathologic sexuality 
50 
Schizophrenia 
2 
Schizoid personality 
1 
Personality disorder 
16 
Chronic alcoholism 
14 
Drug addiction 
3 
Somnambulism 
6 
Enuresis 
8 
Immaturity 
6 
Mental deficiency 
12 
Motion sickness 
2 
Conscientious objector 
3 
Neurological disorders 
7 
No disease 
1,585 
Total 
2,046 
Table 51.—Summary of neuropsychiatric discharges among 
inductees 
Diagnosis 
Cases 
1. Constitutional psychopathic states 
4,280 
a. Inadequate personality 
.... 2,294 
b. Emotional instability 
.... 164 
c. Sexual psychopathy 
.... 98 
d. Paranoid personality 
... 118 
e. Criminalism 
73 
/. Schizoid personality 
.... 86 
2. Psychoneurosis (all types) 
3,419 
3. Mental deficiency 
1,043 
4. Enuresis 
876 
5. Post-traumatic syndrome 
683 
6. Migraine 
236 
7. Somnambulism 
562 
8. Convulsive disorders 
441 
9. Illiteracy 
390 
10. Neurological disorders 
540 
11. Alcoholism 
897 
12. Immaturity 
236 
13. History of psychosis 
74 
Total 
13,727 
there was a loss of some 90 man-years of service through 
the aggregate absences. These authors were also in agree- 
ment with Chappel in that they found only a very small 
percentage of the total naval manpower involved. It may 
also be pointed out, however, that in pre- or post-war 
civilian life one may remain away from his job without 
permission. During a war this may be considered unpatri- 
145 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
come accomplices in a military offense. It is not at all 
uncommon for a disciplinary establishment to receive 
letters written by relatives explaining reasons for a hus- 
band’s or son’s absence and at the same time asking for 
mitigation or amelioration. Such a letter is received very 
quickly when allotments are discontinued. The family 
does not seem to be able to understand that inasmuch as a 
prisoner is contributing no service he cannot receive pay; 
or that a bad conduct discharge or even a dishonorable 
discharge deprives the prisoner of his mustering out pay 
and the benefits provided by the G. I. Bill of Rights. It is 
difficult, obviously, to ask relatives of service men to with- 
hold distressing information from them concerning family 
stresses and problems, nor can we ask them always to 
write cheerful and encouraging letters. In many instances 
such as in the following illustration does one continue to 
offend. 
Example.—L. J. D., S2c, a farmer from Minneapolis was 
AOL or AWOL each time his wife wrote him a letter actually 
"sending” for him. Once he had to do the painting of a fence, 
another time to help at the delivery of an expected baby, the 
third time to help bring in the crop, and the fourth time to re- 
place a drunken farm hand. 
There is a degree of goodness in every man, but with 
strength and weakness in all, not all men outside of pris- 
ons are necessarily good, nor are all men in confinement 
entirely bad. Actually, the author has seen few men in 
naval custody who were really vicious and antisocial. For 
the most part they were only irresponsible and inadequate. 
Over a long period of time traces of weakness may be 
revealed. Usually these men originated in homes which 
were broken, dislocated, and loaded with strife. The 
routine history revealed poverty, lack of security, neglect 
in infancy and childhood and continued lack of affection 
later, difficulties in school, on the job, and in the com- 
munity. These men have records of shifting jobs and 
numerous arrests and apprehensions. When a difficulty 
arises they seem to be able to do only one thing—run 
away. That was their reaction also in the naval service. 
Whenever pressure, either on shore establishments or 
aboard ship became acute they would take unauthorized 
leave. Actually, should a more pleasant situation than the 
one existing at the present time offer itself, the naval 
offender will choose the former. Many a man who has 
been at sea for a long time, or in a foreign post for several 
months with a perfect conduct record, will, upon arriving 
in the United States ask immediately for leave which he 
considers he deserves. It is understandable that such leave 
must sometimes be refused, with the result that the man 
goes AWOL. 
What, then, are the deeper reasons behind these of- 
fenses? First, table 1 reveals that in this sample group 
the psychiatrically sick were definitely a minority. In other 
words, the great majority of these men were considered 
mentally well. However, they did exhibit personality dif- 
ficulties which eventually brought them before the naval 
courts of justice. Many of them were salvageable and for 
that reason certain cases interesting enough for study and 
research will be presented later in this paper. 
Many men in this group reveal in their rationalizations 
definite neurotic reactions. For example, some pointed out 
that their officers looked frightened in combat or at sea 
which is explainable as projected anxiety. Many a man 
complained that sea duty was monotonous enough to be 
feared thus revealing his own insecurity. During the war 
some of these Navy men stated that they preferred the 
Atlantic Theater to the Pacific Theater, which was again 
immaturity. 
Locke, Cornsweet, Bromberg, and Apuzzo advanced 
the following reasons for naval offending. The average 
youth who enters military service during wartime is sub- 
jected to a new kind of life differing considerably from 
his previous one. Some can adjust to restraint and to 
authority while others cannot. Bromberg, Apuzzo, and 
Locke (6) noted that the basic difficulty in desertion and 
similar offenses lies first in the overt reaction of anxiety 
induced by frustration of some sort, and second, that there 
is an antiauthoritarian attitude and anxiety which produce 
antagonism toward authority and discipline. Otness and 
Stouffer (7) felt that actually this may be allied to adoles- 
cent rebelliousness which may sometimes arouses guilty 
feelings and later anxiety. A separation anxiety may be 
seen at training center, in combat areas before, during, or 
after battle, or even in peacetime. These anxiety attacks 
may be numerous and may include headache, dizziness, 
backache, heart pains, and gastric disorders. Brady and 
Hildreth (8) observed similar findings in a disciplinary 
group in naval hospitals. Occasionally enuresis and pre- 
occupation with sexual difficulties may be seen among 
those who leave ships illegally. These men may worry 
about masturbation or may have a fear of being impelled 
to attack shipmates homosexually. Leicher (9) predicted 
much of this behavior in a group of new recruits, an 
observation also made by Baganz (10). 
Example.—J. H. D., MM2c. A 19-year-old male was over 
leave giving as his reason that he had feared he was homosexual 
and therefore went AOL for 10 days, during which he lived 
with a girl whom he had picked up in order to prove that he 
was sexually potent. His history revealed poor sex training, a 
marked mother attachment, and, in general, inadequate prepara- 
tion for the service. 
Occasionally a man will wish to be alone, stating that 
he is intolerant of noise, and will become irritable and 
wish to fight anyone. Usually these fantasies appear at 
night during which time a man could actually become 
wild and destroy anything about him. 
146 Chapter 30.-PSYCHIATRIC EVALUATION OF THE NAVAL DELINQUENT 
An important dynamic force behind naval offending is 
the inability to stay away from home. Early insecurity 
developed by this situation may be replaced by an anxiety 
symptom, tolerated for a short time, but eventually over- 
whelming the individual. Especially here is seen the ex- 
treme parental attachment, particularly of the matriarchal 
type. 
Example.—D. A. R., S2c, age 17, a member of a closely knit 
Italian family in which he was the youngest child, was AWOL 
for 7 months because his mother cried incessantly when he was 
at home on leave. As he was about to return to duty she told 
him she had had a dream in which he was lost when his ship 
was sunk. He was, of course, easily persuaded to remain at 
home. 
Anxiety due to separation from home and mother is 
rarely found to be uncomplicated for usually there is seen 
some element of hostility directed against the parents. 
This hostility is explained as a defense against deep de- 
pendency needs which the individual cannot express 
freely and which, therefore, he transfers to the Navy and 
its officers. 
Antiauthoritarian attitudes are also allied to separation 
and it may be found that a complaint such as sea sickness 
may mask hidden hostilities toward officers as parent sur- 
rogates. This group is independent, self-willed, has fun 
at its own convenience, and outwardly hates officers. This 
type of behavior may be seen in the rebellious immature 
adolescent, up to and including the murderer. Most of 
them have some neurotic ailments. When seen by the 
psychiatrist it is easily demonstrable that beneath the cloak 
of arrogance may be seen dependencies which have never 
been completely eradicated. Rarely will these men obey 
orders because this means to them weakness. With pun- 
ishment, their antagonism toward authority increases. In 
other words, then, we have here on the one hand antagon- 
ism toward authority, and on the other, dependent needs; 
these two together with fear produce illegal behavior. 
What is the make-up of the ordinary offender? He is 
usually seen to be basically not delinquent, but rather, 
immature and poorly indoctrinated from the military 
viewpoint, and quite incapable of adopting a good atti- 
tude toward military requirements. As a matter of fact, 
he considers his offense no more serious than being truant 
from school. Usually he is the youngest in the family, 
sometimes an only son. The family itself has been loosely 
knit with poor supervision of the children. The offender 
always enjoyed freedom from restraint, left school be- 
cause he didn’t like it, boasts openly of the number of his 
truancies, but decries his poor occupational record as well 
as his feeble social contacts. He does not mind stating that 
the Navy ought to send him home and keep him there. 
Since the ship doesn’t please him he might as well be 
transferred to another, etc. We see, thus, poor indoctrina- 
tion in this immature individual whose background of 
inadequacies can hardly make of him good naval timber. 
Another common group of offenders are those who 
were accustomed to moving about without restraint. These, 
too, were fundamentally nondelinquent. They were asocial 
but yet held responsible jobs with good wages. Induction 
was never eagerly sought. They liked their home com- 
forts, were closely domesticated, attached to wives, moth- 
ers, or grandparents, and had many family responsibilities. 
When refused liberty or leave, they simply return of their 
own accord to the scene of their emotional problems. 
They deny vehemently their exaggerated sense of loyalty 
to their families and state that consideration for country 
comes first with them. They reveal strong egocentric qual- 
ities and all through life carry on a veritable tug-of-war 
with authority, regimentation, and restraint. 
Example.—P. J. F., S2c, in a period of 10 months in the 
service, all "Stateside,” had two offenses including a 2-day AOL 
with ship missed. It was noted that he was markedly attached to 
his wife who considered him rather in the light of a child be- 
cause of his numerous indefinite ailments. In spite of this type 
of make-up, the man was making a salary of $15,000 a year as 
secretary to the president of a nationally known firm. 
CONSTITUTIONAL PSYCHOPATHIC INFERIORITY 
This large group actually forms one of the most dis- 
rupting elements in society, not only in wartime but in 
peacetime as well. A true psychopathic personality is one 
who appears normal on the surface, but has a deep-seated 
abnormality causing him to be an inveterate troublemaker. 
I quote the description of this disorder as given by the 
Surgeon General of the United States Army: 
Under this heading is placed an ill-defined, more or less 
heterogenous group of conditions in which the patients, although 
they do not suffer from congenital defect in the intellectual 
sphere, manifest a definite defect in their ability to profit by ex- 
perience. They are unable to respond in an adult social manner 
to the demands of honesty, truthfulness, decency, and considera- 
tion of their associates; they are emotionally unstable and not to 
be depended upon; they act impulsively, with poor judgment; 
they are always in conflict with the law. They do not take kindly 
to strict discipline. Such persons have a decided influence upon 
their associates, and upon the morale of the organization, for 
they will not conform to recognized authority and they derive 
much satisfaction from cultivating insubordination in others. 
Frequently they make a favorable impression, are neat, talk well, 
and are well-mannered. In this general group are to be placed 
many homosexual persons, grotesque and pathological liars, 
vagabonds, inadequate personalities, petty offenders, swindlers, 
kleptomaniacs, alcoholic persons and, likewise, those highly un- 
stable and arrogant persons called pseudoquerulents ("guard- 
house lawyers”) who forever are critical of authority and im- 
bued with a feeling of abuse and lack of consideration of their 
fellows. 
Neuropsychiatrists early in the war encountered many 
147 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
of these psychopaths who came into the Navy through the 
efforts of well meaning, but short-sighted judges before 
whom these men had appeared charged with some crime. 
The well-intentioned, but poorly informed judge would 
rule, "I will suspend sentence if you will enter the armed 
services.” Some branch of the service then acquired an- 
other troublemaker. This practice was discouraged, but it 
took time to educate the judiciary. 
The psychopath is usually seen to be a rather intelligent 
and well-built individual, who, at a casual glance may 
impress one favorably, but the psychiatrist soon identifies 
him as the chronic misbehaver whose history will reveal 
that since childhood he has been a difficult problem at 
home, school, at work, and in the community. He is most 
skillful in offering excuses and often so deft and glib that 
he can talk himself out of any difficulty. When he is dis- 
charged from the Navy, no matter what his type of dis- 
charge, those who know him will remark that once again 
he has been able to evade his responsibility. Such instances 
arouse the resentment of shipmates and of the general 
public, but these men must be handled realistically, for 
they are "bad actors.” Ordinary persuasive reasoning or 
even punishment cannot reach them, and it is question- 
able whether time and energy spent on their training or 
rehabilitation is worth while. Medical men in the service 
feel that the Navy is better off without them. Actually, 
later and better information must be obtained on them 
for they do need help. 
Example.—R. L. M., Pvt. U. S. M. C, a 22-year-old male 
whose preservice record revealed poor schooling with two grades 
failed, a shifting job record with numerous discharges, drinking 
since his sixteenth year, and many apprehensions by the police. 
During the past year before being picked up on a long AWOL 
charge it was found that he had been married three times. His 
service record over a period of 5Va years revealed 61 Captain’s 
Masts, 2 deck courts martial, 2 summary courts martial, and 
2 general courts martial. He had been "busted” twice. Charges 
included AOL, AWOL, sleeping on watch, disobedience of 
orders, stealing a caterpillar tractor, a jeep, a motorcycle, a plane; 
playing with crooked dice, throwing a firecracker at a Marine 
general, striking officers, and other misdemeanors. 
PSYCHONEUROSIS 
In this group we find men with physical and mental 
symptoms of psychogenic origin. The decision to be made 
is whether or not the condition is so severe as to warrant 
rejection. If the man’s symptoms have not prevented him 
from working regularly and maintaining a normal family, 
social, and occupational routine, he is rarely considered a 
medical problem. Some attempt is made to give the in- 
dividual insight into his condition. 
The psychoneurotic usually unconsciously converts his 
anxiety into physical symptoms. These, in the autonomic 
spheres, are the familiar flushing, sweating, tremor, derm- 
atographia, the so-called "irritable” or "soldier’s heart,” 
or "effort syndrome,” stomach difficulties, dyspepsia, diar- 
rhea, and frequent urination. The neurotic cannot over- 
come his nervousness no matter how hard he tries, even if 
he is honest. The more he attempts to control himself the 
more nervous he becomes. He gives a history of regularly 
visiting dispensaries asking for the cause of his "nervous- 
ness.” Encountered are cases of the so-called conversions, 
such as hysterical paralysis, motor and sensory defects. If 
these complaints are such that a definite physical cause 
cannot be found, an attempt is made to ferret out the 
etiology elsewhere. If handled properly and wisely the 
individual may be saved for useful service after discipline 
has been completed. 
Under the psychoneuroses are listed the amnesias, a 
condition encountered regularly. The term "amnesia” has 
been used loosely to include any temporary loss of mem- 
ory. It is generally suggested that this must also include 
loss of one’s identity as well as loss of memory for time, 
place, names, and events. The most frequent causes are: 
(a) alcohol; (b) pathological or physiological brain dis- 
turbance; (c) disturbed physiology of the brain such as is 
found in epilepsy, so-called post epilepsy fugue, or furor, 
for which the patient is amnesic and during which crimes 
may be committed. The literature is replete with writings 
on the relation of epilepsy to crime; (d) psychological 
causes in which one deals primarily with hysterical fugues 
which usually clear up within 24 hours—others within a 
few months; (e) functional psychoses as may even be 
seen in depressions; (/) feigned amnesias which gener- 
ally present the greatest problems. 
For example: A prisoner has committed a misdeed and 
his immediate defense is to disclaim any memory of it. 
Usually it is rather easy to detect such simulation because 
the misdeed is planned and the motive, therefore, appar- 
ent. The patient, upon repeated questioning, usually gives 
himself away. However, a detailed history of the patient’s 
life frequently reveals him to be a psychopathic person- 
ality with rather good intelligence and it may be necessary 
to resort to other sources of information such as friends, 
families, and social agencies for the complete picture. 
Sometimes a period of observation is needed to permit 
persistent questioning in an effort to determine the con- 
sistency of the patient’s behavior. I might add that a case 
of true amnesia, if it exists in a hysterical type of in- 
dividual, warrants leniency. Occasionally, with the ap- 
proval of the courts and with the consent of the prisoner, 
hypnosis or narco-synthesis may be employed. As might 
be expected, the longer a man has been "over the hill” 
the more likely is he to say that he does not remember 
what he did during that period of time. 
148 Chapter 30.-PSYCHIATRIC EVALUATION OF THE NAVAL DELINQUENT 
Example.—L. M. S., S2c U. S. N. R., revealed a preservice 
record including poor environmental origins, a broken, dislocated 
family, schooling only through the fifth grade, a poor work 
record, numerous arrests for diverse offenses including petty 
larceny, maltreatment of children, vagrancy, and a history of 
three divorces. In service over a period of 20 months, all "State- 
side,” he had an AOL charge of 14 months. Narco-synthesis 
revealed that he had picked up a woman in Los Angeles with 
whom he lived for 14 months during which time he worked 
driving a truck. During the interview he stated that he often 
wanted to return but that he "just didn’t have the nerve.” 
THE FATIGUE STATE 
There were many men with combat or operational fa- 
tigue who had committed offenses. They fell into two 
groups, each with particular motivating dynamic factors. 
Those in which anxiety symptoms were dominant often 
developed states of maximal fear and in panic ran away 
from their ships or bases. Had they remained they would 
have found themselves in a situation where the conflict 
between the dominant instinct of self-preservation and 
the danger incident to combat would have been enhanced 
to an excruciating degree, making unbearable the anxiety 
symptoms they already possessed. The other group had 
dominant symptoms of hostility and resentment. They 
were almost paranoid in the expression of their resentment 
which was directed toward their superiors who stood to 
them for parental substitutes who had failed to protect 
them. It seemed to them that their officers conceived plans 
to lead them into the combat zone as an expression of per- 
sonally directed aggression, and the patient prisoners dis- 
played their resentment and frustration by counteraggres- 
sion. 
The dicta for combat or operational fatigue as presented 
by Raines and Kolb are: (1) increased tension and rest- 
lessness; (2) insomnia and battle dreams; (3) startle re- 
action and personality changes with emotional instability 
predominating; (4) irrational sense of guilt. 
We had about 20 patients who came under this category 
and they were restored to full duty when they were dis- 
i charged from a special hospital to which they were sent 
from this station. 
Example. J. A. H., WTlc, U. S. N., had been in service 
for a period of 6 years most of which time had been spent at 
sea participating in practically every major offensive of the war. 
Symptoms of combat fatigue in this man increased to such an 
extent that he finally went AOL for 15 days, but later turned 
himself in, voluntarily. Subjective symptoms and objective,evi- 
dence were so clear-cut that he was hospitalized, his condition 
treated, and he was restored to duty with no charges. 
PATHOLOGICAL SEXUALITY 
This large group of cases included the numerous homo- 
sexuals usually encountered. To evaluate these individuals 
was sometimes a very difficult task. A patient might have 
been a basic homosexual all his life, or he might have 
been a homosexual by chance, by opportunity, by profit, 
or by social gain. Occasionally he revealed his latency 
under the influence of alcohol or other drugs. Naturally 
we looked for psychic traces of effeminacy such as may 
appear in taste, in thinking, in gait, in actions, but these 
are not always present in either the passive or active types 
of homosexual. Many of these men protested loudly that 
they had had or were capable of having heterosexual ex- 
periences, but it is well known that homosexuals have the 
usual heterosexual wishes and longings, but that they are 
repressed because of deep seated fears of heterosexuality. 
Childhood sexual experiences of a fearful nature, espe- 
cially those due to severely repressive parental attitudes 
toward such expressions as sexual curiosity, sex play, and 
masturbation, may, in the child’s development, shift him 
toward homosexuality. Such an individual is likely to 
reach maturity with many fearful associations with hetero- 
sexuality. Under Navy conditions such as present in sub- 
marines or other ships, in close quarters, homosexual be- 
havior may break out in men whose previous behavior has 
been consistently heterosexual. This was also seen at times 
in some of the brigs. 
Example.—J. D. S., PhMlc, revealed in his preservice record 
a poor marital history with three marriages "on the rocks.” Over 
the period of 4 years and 3 months he had been in the service 
he had done considerable drinking and upon two occasions was 
accused of immoral behavior and drunkenness. His last accusa- 
tion had been accompanied by numerous witnesses to his homo- 
sexual activities. He revealed, characteristically, a high pitched 
voice, feminine body configuration, and was egocentric and 
satirical. Other psychic traits of effeminancy including taste, 
mimicry, thinking, and gait were present. Investigation revealed 
basic homosexualism throughout his entire life. 
PSYCHOSIS 
Rarely was there seen a case of frank psychosis. Upon 
numerous occasions men were brought in with acute psy- 
chotic episodes following extensive drinking. 
Example.—R. S., Flc, appeared of his own accord stating 
that he was depressed, suicidal, and that he was being "forced” 
into his type of disturbed thinking. Mental content revealed 
hallucinations, delusions, and paranoid thought. He wrote a 
suicidal poem but was thwarted in an attempt to kill himself. 
ALCOHOLISM 
Alcoholism was the old bugaboo which was always 
present particularly in some of the older individuals who 
were slated for discharge diagnosis of ''over age.” Those 
who had been on foreign duty would, when they returned 
to this country, go out on a drinking bout and be returned 
in discipline status with every sign and symptom of acute 
alcoholism. There were some who presented signs of true 
chronic alcoholic deterioration, but they were in the mi- 
nority. Most of the men who came to my unit had signs 
149 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
of acute alcoholism. Some developed definite alcoholic 
hallucinations while in the brig. There were several cases 
of impending D. T.’s. These men stated that they had 
begun drinking at a fairly early age and had continued all 
through life. 
Example.—R. B. M., Sic, in his preservice record revealed a 
long checkered history of inadequacy based upon alcoholism. He 
had been drinking since the age of 14 years, and admitted to 
having lost at least 20 jobs because of alcohol. In the service 
over ll/2 years, he had appeared at Captain’s Mast 6 times, all 
on drinking charges. Actually he revealed no deterioration per 
se, but it was obvious that he could not adjust in the service 
and was discharged. 
DRUG ADDICTION 
Now and then there appeared an occasional addict who 
was either referred for smoking illegal cigarettes or who 
had turned himself in because he feared he was going 
insane. When a suspected narcotic user was apprehended, 
it was the policy to investigate the entire barracks for the 
use of the drug usually centers in a group. At no time was 
anyone seen in an advanced stage of marihuana addiction. 
Cocaine and opium ran second and third to marihuana as 
the drug of choice, probably because these two were more 
difficult to obtain. 
SOMNAMBULISM AND ENURESIS 
Both these conditions were occasionally seen, but more 
particularly in those individuals who were in the brig. 
Customarily the prisoner reported his problem to the 
guard who then brought him to the physician for examina- 
tion. In many cases the enuresis was found to be willful. 
Somnambulism, too, was seen to exist when men were in 
custody. Red Cross Social Service reports were usually ob- 
tained on these men, and close checks made were to ascer- 
tain the validity of their complaints. In any event these 
men had to serve out their sentences. 
IMMATURITY 
Occasionally young men of less than the approved age 
were brought in for evaluation and, in spite of their good 
past records, many were eliminated in terms of immaturity. 
An intellectual evaluation of these men was first made. 
Many begged to be permitted to remain in the service, 
stating that they would fulfill their sentences and return 
to service because they were at least physically mature. 
Example. M. C., Sic, was found through a social service 
study to be but 13 years of age. He had bribed a woman to pose 
as his mother to sign his service certificate of consent. In the 
service over a period of 8 months, he had a series of six offenses. 
MENTAL DEFICIENCY 
There were a good many men encountered who were 
found by psychometric examinations to be mental defec- 
tives. The Kent test, checked later by the Wechsler-Belle- 
vue scale, revealed their classification. 
Example.—E. E. S., S2c, a dishwasher aboard a cargo ship 
with a preservice record of just two years of schooling, had been 
a farm hand in a very backward community. He was now ap- 
prehended for drinking heavily and stabbing a shipmate. His 
psychometric performance yielded an IQ of 39 on the Wechsler- 
Bellevue scale, classifying him as an imbecile. 
MALINGERING AND SUICIDE 
Malingering is much less commonly seen than is gen- 
erally supposed. Simulated suicide was not uncommon, 
usually a gesture in which, for example, a wrist was 
scratched with a razor blade. Pseudosuicide attempts in- 
cluded pseudo-strangulation just before a guard was to 
pass a cell, drinking of antiseptic foot baths, swallowing 
pins, electric bulbs, knives, and so on. All guards were in- 
structed to report immediately any depression or change 
of attitude on the part of a prisoner. It was recognized, 
however, that if a man wanted to die he could not be pre- 
vented from doing so regardless of all the precautions 
taken. Anyone who handles unstable patients knows that 
he is going to have some mortality sometime. 
Example.—R. A., S2c, who revealed a poor preservice and 
service record, warned the members of the deck court that he 
would commit suicide if sentenced. Back in his cell he swallowed 
an open safety pin which perforated his esophagus resulting in 
a mediastinitis. It was only through heroic measures that this 
man’s life was saved. 
MISCELLANEOUS OFFENSES 
Offenders with organic brain damage were seen regu- 
larly. The careful study of these men included neurolog- 
ical and psychometric investigations. Some sequelae of 
meningitis were seen which were ample reason for unto- 
ward behavior resulting in disciplinary infraction. Head 
injuries always warranted intense study. 
Example.—R. T. W., Pvt. U. S. M. C., sustained a severe 
tempero-parietal lesion, the result of a gunshot wound. This 
examiner considered that this man had sufficient organic brain 
damage with resulting personality changes to cause his untoward 
behavior. 
UNUSUAL CASES 
There were cases which held more humor than pathos. 
A marine was seen who went AWOL for 5 years because 
he was "bawled out” by his sergeant. A Navy man was 
AOL for 3 years and was found hauling vegetables to a 
naval base. He stated that he considered that occupation 
as patriotic as his former one. One offender drove a Navy 
bus for a year before being picked up. Another worked 
with the FBI for 11 months before his finger prints caught 
up with him through the efforts of the FBI. Several of- 
fenders joined the Army or the merchant marine. One 
prisoner won $25,000 in a dice game and when com- 
150 Chapter 30.-PSYCHIATRIC EVALUATION OF THE NAVAL DELINQUENT 
polled to pay $14,000 in taxes, went ’'over the hill.” An- 
other offender during his AOL period worked as a civilian 
bricklayer constructing the brig in which he was eventu- 
ally housed. Another was found to have a small printing 
press on which he turned out amazingly accurate liberty 
cards and leave papers which he sold at fancy prices. He 
was picked up when the authenticity of his official liberty 
card was questioned. 
CONCLUSIONS 
A suggested plan, then, for the disposition of discip- 
linary cases which have some psychiatric condition is pre- 
sented: (a) A true and accurate determination of the facts 
of the violations of regulations, with particular attention 
paid to determining whether there was present an element 
of criminality against the person or property of others; 
(b) if no criminality is involved and the individual is 
found to be suffering from a psychiatric disorder, this 
person should, in my opinion, be given a special order 
discharge as soon as possible; (c) however, if criminality 
is found to exist, the case should be tried and prior to sen- 
tencing, a board consisting of at least one psychiatrist 
should make a recommendation as to whether the sentence 
should be carried out in a naval prison or in an institution 
for the criminal insane. 
Traditionally, there will be some opposition to the spe- 
cial order discharge of individuals who have had discip- 
linary charges brought against them, as the feeling exists 
in some lay and professional quarters that prisoners re- 
ceiving such a discharge are "getting away with some- 
thing.” Whether punishment should or should not be 
avoided is not the important point here. The question to 
be decided is whether punishment and disciplinary action 
will be of any value to this man, the Navy, or to his home 
community later. The type of individual who reacts well 
to naval discipline and punishment is no different from 
the individual who reacts well to civil discipline and pun- 
ishment. The efficiency of the disciplinary programs in 
the military services is deservedly high, but no amount of 
any type of discipline or punishment can effectively act as 
a corrective when there is not present a sense of responsi- 
bility, an ability to learn by experience, or a desire for fu- 
ture security. It is absurd to expect men to make a proper 
military adjustment when they have been unable to adjust 
to previous civil and legal disciplinary actions. If repeated 
punishment in the past has failed to correct a chronic de- 
linquent, it is scarcely to be expected that disciplinary ef- 
fort, time, and expense expended during a national emer- 
gency will be successful. 
It should not be forgotten that the code of the Navy 
presupposes honesty and honor which affords a year- 
around opportunity for crime on the part of the naval per- 
sonnel who lack these attributes. It is important, especially 
now with the new type of recruit, that the percentage of 
repetition of crimes might be more acute. 
The problem of delinquency in the naval service is one 
which merits much thorough and intensive study, for 
knowledge of the psychodynamics of the personality of 
the naval delinquent can provide a basis for the rational 
approach to his reeducation and orientation as well as aid 
greatly in determining the direction of a successful pro- 
gram of therapy. 
REFERENCES 
1. Chappel, R. A.: Naval offenders and their treatment. Fed- 
eral Probation 9: 3-7, April-June 1945. 
2. Southworth, F. C, Jr., Boshes, L. D., and Lewinski, 
R. J.: Neuropsychiatry at Great Lakes Naval Training 
Center. Dis. Nerv. System 6: 5-17, Jan. 1945. 
3. Boshes, L. D. and Hermann, P.; Study of the naval de- 
linquent by questionnaire. J. Crim. Law & Criminology. 
In press. 
4. Locke, B., Cornsweet, A, C, Bromberg, W., and 
Apuzzo, A. A.: Study of 1,063 naval offenders. U. S. 
Nav. M. Bull. 44: 73-86, Jan. 1945. 
5. Boshes, L. D.: Psychiatry of the naval offender. Hosp. 
Corps Quart. 19: 1--6, April 1946. 
6. Bromberg, W., Apuzzo, A. A., and Locke, B.: Psychologic 
study of desertion and overleave in the Navy. U. S. Nav. 
M. Bull. 44: 558-568, March 1945. 
7. Otness, H. R., and Stouffer, G. A. W., Jr.: Naval of- 
fender; motivating factors. U. S. Nav. M. Bull. 44: 1029- 
1035, May 1945. 
8. Brady, J. P., and Hildreth, H. M.: Characteristics of a 
disciplinary group in a naval hospital. U. S. Nav. M. 
Bull. 45: 500-505, Sept. 1945. 
9. Leicher, J. D.: Psychopathology of a selected population 
of naval offenders. Am. J. Psychiat. 101; 726-730, May 
1945. 
10. Baganz, C. N.: Psychiatric aspects of delinquency in the 
Navy. J. Crim. Psychopath. 4; 459-464, Jan. 1943; Dis. 
Nerv. System 4: 82-84, Mar. 1943. 
11. Lindner, R. M.: Rebel Without a Cause. Grune & Strat- 
ton, New York, N. Y., 1944. 
12. Sherman, I. C.: Problems in the Psychiatric Institute: A 
Dynamic Era of Court Psychiatry, 1914-1944. The Psy- 
chiatric Institute of the Municipal Court of Chicago. 
Chaplin-Shealy Co., Chicago, 111., 1945. p. 88. 
13. Raines, G. N., and Kolb, L. C.: Combat fatigue and war 
neurosis. U. S. Nav. M. Bull. 41:923-936, July 1943; 
1299-1309, Sept. 1943. 
151 CHAPTER 31 
STUDY OF 1,063 NAVAL OFFENDERS' 
This study consists of an attempt to evaluate, from a 
psychologic and psychiatric standpoint, a series of factors 
which might be associated with the production of the be- 
havior leading to incarceration in a naval brig. One thou- 
sand sixty-three consecutive, unselected, court-martial ad- 
missions to a naval disciplinary barracks were analyzed. 
The reasons for confinement are listed in table 52. From 
this table it becomes evident immediately that the prob- 
lem is almost entirely one of absence over leave, and ab- 
sence without leave, since 94 percent of the total admis- 
sions were for these reasons. The emphasis in this survey, 
therefore, has been placed on these two principal offenses. 
The following factors were analyzed: 
1. Causes for admission. 
2. Length of time A.O.L., A.W.O.L. 
3. Previous naval offenses. 
4. Previous civil offenses. 
5. Surface reasons for offenses. 
6. Education and intelligence. 
7. Age of offenders. 
8. Marital status. 
9. Racial distribution. 
10. Nativity of parents. 
11. Psychiatric findings. 
12. Length of service prior to first offense. 
13. School delinquencies. 
The seriousness of unauthorized absences from the 
Navy from the standpoint of manpower is indicated in 
table 53, which shows the length of time lost to the service. 
The total time that the 1,000 men under consideration 
were absent is 32,833 days. The 758 who were absent over 
leave were away for 25,278 days, and the 242 absent with- 
out leave stayed away for a total of 8,555 days. The aver- 
age length of time for the total group was 33.83 days; for 
the absent-over-leave cases 33.09 days; and for the absent- 
without-leave cases 36.25 days. 
Table 52.—Reasons for admission 
Reason 
Number 
of cases 
Absence over leave 
758 
Absence without leave 
242 
Accidental shooting 
8 
Possession of another man’s property 
7 
Shirking duty 
6 
Theft of government property 
5 
Forging and selling liberty cards 
4 
Disobedience of orders 
4 
Defrauding Government 
3 
Breaking arrest 
3 
Insolence to officer 
3 
Tampering with TI S. mails 
2 
Leaving post without being relieved 
Drunk and disorderly 
Bringing liquor aboard ship 
2 
2 
2 
Taking a prisoner on liberty 
2 
Refusing to work 
1 
Investigation _ 
1 
Stealing automobile 
1 
Material witness—manslaughter 
1 
Held for action of civil authorities 
1 
Scandalous conduct 
1 
Violation of censorship regulations 
1 
Asleep on watch 
1 
Assault of petty officer 
1 
Sodomy 
1 
Total 
1,063 
These averages are not a true indication of the central 
tendency of the groups, however, because they are skewed 
by the few who stayed away for one or more years. Thus 
a better idea of the "average” length of time is expressed 
by the medians; these are 16.23 days for the total group; 
15.93 days for the A.O.L. group, and 23.20 for the 
A.W.O.L. group. These 32,833 days lost to the service 
are exclusive of the time lost after the apprehension or 
return of these men. If the length of time that these men 
*By Bernard Locke, Lieutenant H(S) U.S.N.R.; Albert C. Cornsweet, 
Lieutenant Commander H(S) U.S.N.R.; Walter Bromberg, Lieutenant 
Commander (MC) U.S.N.R., and Anthony A. Apuzzo, Lieutenant Com- 
mander (MC) U.S.N.R. 
152 Chapter 31.-STUDY OF 1,063 NAVAL OFFENDERS 
Table 53.—Length of time A.O.L. and A.W.O.L. 
Number of days 
A.O.L. 
A.W.O.L. 
Total 
1-5 
105 
48 
153 
6-10 
169 
33 
202 
11-15 
109 
31 
140 
16-20 
56 
12 
68 
21-25 
54 
18 
72 
26-30 
39 
18 
57 
31-35 
21 
10 
31 
36-40 
21 
5 
26 
41-45 
29 
5 
34 
46-50 
22 
7 
29 
51-55 
16 
8 
24 
56-60 
13 
14 
27 
61-65 
10 
3 
13 
66-70 
8 
4 
12 
71-75 
10 
1 
11 
76-80 
11 
1 
12 
81-85 
7 
4 
11 
86-90 
6 
3 
9 
91-95 
5 
2 
7 
96-100 
2 
1 
3 
101-105 
3 
3 
6 
106-110 
1 
0 
1 
111-115 
5 
0 
5 
116-120 
7 
1 
8 
121-125 
1 
0 
1 
126-130 
2 
0 
2 
131-135 
3 
0 
3 
136-140 
0 
0 
0 
141-145 
1 
0 
1 
146-150 
3 
1 
4 
151-155 
0 
0 
0 
156-160 
0 
2 
2 
161-165 
0 
1 
1 
166 and over 
19 
6 
25 
Total 
758 
242 
1,000 
Figure 14.—Length of lime A.O.L. or A.W.O.L. 
analysis of table 54 it can be assumed that the proportion 
of repeaters in the Navy will increase as time goes by, 
since the number of recruits is steadily decreasing propor- 
tionately. 
Table 55 indicates that 16.7 percent of this group of of- 
fenders had come in conflict with civil authorities prior to 
their entering the Navy. Since the group is essentially a 
young one, the fact that over 1-6 percent have already been 
in trouble in civil life appears to be heavily weighted. This 
becomes even more evident when one considers the fact 
that the personnel of the Navy is essentially a select one, 
in that numerous felons and habitual delinquents are de- 
nied admission to the Navy on original application. The 
number of civil offenses is demonstrated graphically in 
figure 16. 
Since the offense of desertion during time of war is so 
serious that a sentence of death may legally be prescribed, 
it is imperative to examine the motivation for this be- 
havior as ascribed by the men themselves. Table 56 lists 
the surface reasons given by the men for their absences. 
Examination of this table reveals an almost universal dis- 
regard for the seriousness of the present conflict and a 
hedonistic, egocentric, and, at times, neurotic attitude on 
the part of these offenders. 
By way of illustration, the greater number of men ad- 
mitted, upon questioning, that the pressing need to see 
their families was satisfied in one or two of the fifteen or 
twenty days A.O.L., the balance of the time being spent 
in "doing the town.” Again, many men who found naval 
medical attention "inadequate” for their ailments, did 
not bother to consult a civilian physician in all the time 
that they were out, or even during their civilian status prior 
to entering the Navy. The psychologic basis for the type 
were kept from their duties awaiting trial, awaiting sen- 
tence, and serving sentence, is added, the totals become 
truly staggering. When it is further considered that these 
thousand cases represent approximately 3 months’ admis- 
sion to only one brig, the problem of lost manpower in 
the Navy approaches a critical point. Figure 14 shows 
graphically, the number of days lost by the 1,000 men 
under consideration. 
A further feature of the seriousness of this problem is 
presented in table 54 and figure 15, which show the dis- 
tribution of naval courts-martial prior to the immediate 
offense for the group studied. It shows that 53.8 percent 
of the group are repeaters, many of them after a period at 
duty of less than a week. One of the repeaters in this group 
had had 12 previous courts-martial. This figure must be 
viewed in the light of the following consideration. From 
153 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
gence, a record was kept of the replies to the question 
"What is the highest grade which you completed in 
school?” These are presented in table 57 and figure 17. 
The average amount of schooling completed for the entire 
group is 9.3 grades. Thirty-four of the men had had some 
college training and 719 had gone beyond grade school. 
When this is compared with the norms for the general 
population and with those obtained by Locke3 of 14,812 
civil reformatory and prison inmates one finds that the 
naval prisoners are slightly better educated than the civil 
prison group and the general population. 
Table 55.—Distribution of civil offenses prior to entering Navy 
Number of offenses 
Number of cases 
0 
833 
1 
95 
2 
23 
3 
15 
4 
10 
5 
7 
6 
4 
7 
0 
8 
1 
9 
1 
10 
4 
11 
1 
12 
1 
15 
1 
16 
1 
25 
1 
31 
1 
50 
1 
215 
1,000 
Figure 15.—Previous Naval offenses—exclusive of captain’s mast. 
of rationalizations presented by these men has been de- 
scribed elsewhere2. 
Since it might be assumed that the reason for these de- 
linquencies is largely due to lack of education and intelli- 
Table 54.—Distribution of previous Naval offenses exclusive 
of captain’s mast 
Number of offenses 
Number of cases 
0 
462 
1 
299 
152 
2 
3 
51 
4 
18 
5 
10 
6 
2 
7 
4 
8 
0 
9 
0 
10 
1 
11 
0 
12 
1 
78 
1,000 
Since it has been accepted that intelligence and educa- 
tion are closely correlated, it may be assumed that the 
naval prisoners under discussion compare favorably in 
intelligence with the general population from which they 
come. Table 62 indicates that only 19 individuals were of 
borderline or deficient intelligence following examina- 
tion, confirming the conclusion that this group has not be- 
come delinquent because of insufficient intellectual endow- 
ment. 
Table 58 and figure 18 show the distribution of ages of 
these offenders. The mean age is 21.55 years and the 
median is 19.64 years. Since 50 percent of the group is 
roughly 20 or more years old, it would be difficult ter 
ascribe the high incidence of unauthorized absences to 
"boyish” irresponsibility. 
Table 59 indicates marital status. The majority, 70.4 
percent, are unmarried; 27.9 percent are married; and 1.7 
percent divorced, separated, or have had their marriages 
annulled. 
2Bromberg, W.; Apuzzo, A. A. ; and Locke, B.: Study of motivation for 
desertions and over leaves in the Navy. Read at the Centennial Meeting, 
American Psychiatric Association, Philadelphia, May 15, 1944. 
3 Locke, B.: Various factors in a penal population ; J. Crim. Law & Crimi- 
nol. 33: 316-320, November-December 1942. 
154 Chapter 31.-STUDY OF 1,063 NAVAL OFFENDERS 
Table 56.—Stated reasons for going A.O.L. or A.W.O.L. 
Marriage: 
1. To be engaged 
1 
2. To be married 
22 
3. To marry girl he had impregnated 
6 
Total 
29 
"Was late, so I took more time" 
24 
Would like: 
1. To be transferred 
3. 
2. Overseas duty 
3 
3. Submarine duty 
3 
4. Promotion 
3 
5. Aviation duty 
2 
6. Amphibious duty 
2 
7. East coast duty 
2 
8. More action 
2 
9. Armed Guard duty 
1 
Total 
21 
Needed at home (financial, help on farm, etc.) 
15 
Wasn’t drawing any pay (because of fines for previous 
offenses) 
9 
"Got disgusted” 
9 
Stayed home at mother’s request (under age) 
6 
"Got a crazy spell (my head tells me to do things)” 
6 
Stayed with a woman 
6 
Missed train 
5 
Couldn’t find ship 
5 
"Believed I was on authorized leave or liberty” 
3 
"They were trying to frame me” 
2 
To oblige another man who was going A.W.O.L 
2 
"Can’t keep away from girls” 
1 
Girl friend pregnant—wanted to find responsible party 
1 
"To go home and beat a guy up” 
1 
"Sea bag stolen and I got mad” 
1 
Total 
72 
Illness: 
1. Became ill while on authorized leave or liberty 
20 
2. To obtain medical attention (naval care i 
made- 
quate) 
22 
3. Chronic seasickness 
27 
4. Repeated headaches 
20 
5. Other illness or disability which interfered 
with 
duties 
9 
6. Nervousness (including fear of sea, gunfire, etc.) 
44 
7. Homosexual 
4 
8. Drug addict 
2 
9. Illness, including death, of parents and siblings 
71 
10. Illness of wife (including pregnancy) 
39 
11. Illness of children 
7 
Total 
265 
Don't like: 
1. The Navy 
26 
2. The ship 
40 
3. Officers on the ship 
25 
4. Shipmates 
10 
5. Present duty: 
a. Sea duty 
26 
b. Shore duty 
24 
c. Mess attendant 
4 
d. Armed Guard 
2 
e. Amphibious 
2 
f. Engine room 
1 
Total 
160 
Went home: 
1. Homesick 
45 
2. To see: 
a. Parents 
26 
b. Wife and children 
35 
c. Siblings 
9 
d. "Girl friend” 
6 
e. Friend 
2 
f. Grandparents 
1 
3. To be home for holidays 
6 
Total 
130 
Leave: 
1. No leave granted 
39 
2. Inadequate leave granted 
14 
Total 
53 
Drunk 
77 
Resented restriction (wanted to be free) 
35 
Felt like staying over (to have a good time) 
32 
Family trouble: 
1. Personal domestic difficulties 
20 
2. Parental domestic difficulties 
11 
Total 
31 
Table 57.—School grades completed 
Grade 
Number of cases 
Ungraded 
3 
0 
1 
1 
1 
2 
4 
3 
6 
4 
12 
5 
13 
6 
36 
7 
116 
8 
216 
9 
195 
10 
187 
11 
114 
12 
89 
13 
30 
14 
4 
Total 
1,000 
155 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
OFFENSES 
Figure 16.—Distribution of civil offenses prior to entering Navy. 
Table 58.—Distribution of ages 
Age 
Number of cases 
15 
4 
16 
10 
17 
52 
18 
180 
19 
175 
20 
126 
21 
103 
22 
81 
23 
63 
24 
31 
25 
20 
26 
20 
27 
23 
28 
15 
29 
18 
30 
23 
31 
8 
32 
6 
33 
4 
34 
7 
35 
7 
36 
5 
37 
4 
38 
2 
39 
2 
40 
1 
41 
2 
42 
3 
43 
0 
44 
2 
45 
2 
46 
1 
Total 
1,000 
Figure 1 7.—Academic grades completed. 
Figure 18.—Distribution of ages. 
Table 59.—Marital status 
Single 
704 
Married 
279 
Divorced, separated, or annulled 
17 
Total 
1,000 
Table 60 gives the racial distribution found in this 
group and table 61 the country of origin of each of the 
immediate parents of these prisoners. Table 60 appears to 
indicate that the number of Negro offenders is propor- 
tionately far beyond that which would be expected from 
their actual number in the naval service. 
156 Chapter 31.-STUDY OF 1,063 NAVAL OFFENDERS 
alcoholism were not made unless the clinical picture was 
clearly demonstrable, and, unless there was a history of 
aberrant behavior other than the offense which led to the 
present difficulty. 
Table 61.—Country of origin of parents 
United States 
1,350 
Italy 
176 
Ireland 
100 
Poland 
66 
Germany 
49 
Canada 
39 
England 
33 
Austria 
23 
Holland 
16 
Czechoslovakia 
13 
Scotland 
12 
France 
11 
Spain 
10 
Greece 
10 
Puerto Rico 
10 
Lithuania 
9 
Portugal 
9 
Russia 
8 
Yugoslavia 
7 
Norway 
7 
Hungary 
6 
Mexico 
5 
Sweden 
4 
Syria 
4 
British West Indies 
4 
Finland 
3 
Cuba 
2 
Nova Scotia 
2 
Brazil 
2 
Denmark 
2 
Armenia 
2 
Romania 
2 
Philippine Islands 
1 
Turkey 
1 
Newfoundland 
1 
Guatemala 
1 
2,000 
Figure 19.—Psychiatric findings. 
Table 60.—Racial distribution 
White 
918 
Negro ... , 
79 
Red (American Indians) 
2 
Yellow (Chinese) 
1 
Total 
1,000 
The findings in table 61 must be viewed in the light of 
the proportion of seamen in the Navy, born of foreign- 
born parents. Without a comparison of the nativity back- 
grounds in personnel in the Navy as a whole and those on 
a disciplinary status, no definite conclusion can be drawn 
from this table of parent nativity of first-generation Amer- 
ican seamen. It must also be kept in mind that the men 
studied came predominantly from the Eastern seaboard. 
Table 62 and figure 19 indicate the psychiatric diag- 
noses that were made in each of these 1,000 cases. From 
these we note that 21.9 percent of the cases present de- 
monstrable neuropsychiatric disorders, and as such are 
poor material for the naval service. The diagnoses of 
psychopathic personality, psychoneurosis, and chronic 
Table 63 and figure 20 present an interesting aspect of 
this problem. The greatest number of offenses occur 
shortly after boot training, usually during boot leave, and 
before the individual has had a taste of action. This group 
usually gives as its reason for unauthorized absence "home- 
sickness” and the desire to "have a good time before I 
get shipped out.” The frequency then drops off for a few 
months and then rises rapidly in the eighth and ninth 
months. This rise is apparently brought about by the fact 
that the men have completed a tour of duty in which they 
have seen some action and feel that, as a result, they are 
entitled to leave or more leave than they have been granted. 
157 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 63.—Length of service prior to first offense 
exclusive of captain’s mast 
Months 
Cases 
Months 
Cases 
1 
12 
25 
7 
2 
45 
26 
7 
3 
89 
27 
3 
4 
90 
28 
2 
5 
108 
29 
4 
6 
62 
30 
8 
7 
51 
31 
3 
8 
73 
32 
2 
9 
81 
33 
5 
10 
46 
35 
2 
11 
39 
36 
2 
12 
40 
37 
1 
13 
26 
38 
4 
14 
38 
40 
1 
15 
28 
41 
1 
16 
30 
47 
2 
17 
19 
51 
1 
18 
17 
52 
1 
19 
9 
56 
2 
20 
13 
58 
1 
21 
13 
65 
1 
22 
6 
73 
1 
23 
3 
144 
1 
24 
10 
165 
1 
252 
1 
Total 
1,000 
MONTHS of SE2VICE 
Figure 20.—Length of naval service prior to First court martial 
Table 64 throws an interestng light on this group. 
Thirty-two percent of these men admitted to truancy while 
in school; 6.4 percent had been expelled from school one 
or more times; 2.2 percent had been suspended at least 
once, and 1.4 percent had spent some time in truant or re- 
Table 64.—Academic delinquencies 
Truancy: 
Occasional 
139 
Frequent 
181 
320 
Expulsions: 
One 
49 
Two 
7 
Three 
6 
Four 
2 
64 
Suspensions: 
One 
13 
Two 
5 
Three 
4 
22 
Admissions to truant schools 
14 
14 
Total 
420 
Table 62.—Psychiatric diagnoses 
Diagnosis 
Cases 
No disease 
781 
Psychopathic personality 
82 
Psychoneuroses 
72 
Chronic alcoholism 
29 
Mental deficiency 
19 
Neurologic disorders 
12 
Psychoses 
5 
Total 
1,000 
SUMMARY AND CONCLUSIONS 
form schools. Since the type of behavior involved in tru- 
ancy parallels that found in unauthorized absences from 
the Navy, it is interesting to note the high incidence of 
truancy in the sample studied. It tends to indicate that the 
activities of many of these men conform to patterns of be- 
havior established long before any contact with service life. 
A series of factors has been studied in an attempt to 
determine the extent to which they might be involved in 
producing unauthorized absences for the naval service. 
1. The seriousness of the problem was demonstrated 
by the fact that in the 1,000 cases studied in detail the 
Navy lost 90 man-years of service through absences, apart Chapter 31.-STUDY OF 1,063 NAVAL OFFENDERS 
from the time lost while these men were in a disciplinary 
status. 
2. Repeaters comprised 53.8 percent of the number of 
admissions and the indication is that this proportion will 
become larger as enlistments in the Navy (voluntary or 
by selection) decrease. 
3. It was found that 16.7 percent of the men had his- 
tories of civilian arrests prior to entering the Navy. It is 
felt that this percentage is relatively high because of the 
fact that many habitual offenders are not permitted to enter 
the Navy. 
4. The reasons given by the men for their A.O.L. or 
A.W.O.L. status varied greatly from the true psychologic 
activation. The stated motivations were the desire to aid 
or be with the family, particularly in times of illness, per- 
sonal illness, and the need for a rest after seeing action. 
The psychologic drives were the desire for pleasure; ag- 
gression against authority; and frequently neurotic or im- 
mature factors. 
5. The men studied were found not to be inferior in 
intelligence or education from the population from which 
they derived. 
6. Records revealed that 42 percent of the group had 
been in trouble in school because of frequent truancies, 
suspensions and expulsions. 
7. The mean age for the group was 21.55 years and the 
median 19.64. This indicates that chronologically at least, 
if nothing more, the men were old enough to appreciate 
the seriousness of their offenses. 
8. Approximately 30 percent were or had been married. 
The balance had never been married. 
9. The group included 79 Negroes. Since this was 7.9 
percent of the total group, it appears to be far out of keep- 
ing with their total representation in the Navy. However, 
this is purely an impression and must be checked against 
their actual number in the service. 
10. Definite neuropsychiatric disorders'were found in 
21.9 percent of the cases. These individuals are not suit- 
able Navy material and should be discharged eventually 
because they are a continual source of trouble, not only 
because of their own inability to adjust, but also because 
of the difficulties which they cause among their shipmates 
in the integral unit of a fighting ship. 
11. Absences were found to come most frequently after 
the completion of boot training and after the first tour of 
active duty. 
12. The general conclusion indicated that a longer 
period of training, screening after the first test of duty, 
and a program of reeducation to develop maturity, might 
reduce unauthorized absences from the Navy. 
159 CHAPTER 32 
A PSYCHOLOGIC STUDY OF DESERTION 
AND OVERLEAVE IN THE NAVY* 
The purpose of this paper is an attempt to evaluate the 
psychologic factors underlying the offenses of absence 
over leave and absence without leave among naval per- 
sonnel. The material on which this study is based com- 
prises enlisted men sent to the U. S. Naval Receiving Sta- 
tion Disciplinary Barracks, Hart’s Island, New York, 
referred for summary or general court-martial action. As 
shown in the previous chapter (1) it may be said that in 
a sampling of our material, 71.3 percent were for A.O.L.; 
23-3 percent for A.W.O.L.; and the remaining 5.4 per- 
cent involved shooting and involuntary manslaughter, 
breaking arrest, bribery, theft, infraction of regulations, 
and sex cases. Thus it can be seen that the former group 
of offenders constitutes an important source of interfer- 
ence with planned naval activity because of the large 
number of man-days lost. 
In order to estimate the presence and frequency of men- 
tal disease among these casts, each summary and general 
court-martial admission was given a psychiatric and psy- 
chologic screening examination. Table 62 from chapter 
31 analyzes the sampling in terms of psychiatric diag- 
noses. Our findings in the sample studied indicate that 
psychiatrically sick individuals are in the minority. This 
group comprises the psychotic and prepsychotic, psycho- 
pathic, mental defective, chronic alcoholic and psycho- 
neurotic individuals. These men are not salvageable and 
are of no value to the highly specialized services of 
the Navy. If they are not screened out in induction sta- 
tions, training stations, special schools, or naval hospi- 
tals, they can and should be screened out in the disciplin- 
ary barracks. We are left, therefore, with a large group of 
psychiatrically well individuals who although "normal” 
exhibit personality difficulties or emotional and behavior 
reactions that bring them before court-martial boards. 
Since these men are theoretically salvageable, our prac- 
tical interest in saving man-days in the military service 
lies in this direction. 
As an aid in understanding the motivation for misbe- 
havior in the Navy, the reasons given by the men them- 
selves for their misconduct were studied and contrasted 
with what could be learned of the inner emotional sources 
of their behavior. The former are listed as "surface rea- 
sons”; the latter as "psychologic formulations.” 
The rationalizations offered by the men themselves 
cover a wide range of reasons. The diversity of reasons for 
overleave is indicated in the following list of responses: 
No reason. 
I do not like my present duty. 
Sickness in the family. 
I got drunk. 
Not enough leave—no leave. 
Trouble at home. 
I objected to restriction. 
Wanted to visit faqpily. 
Became nervous on the job. 
Do not like the Navy. 
Didn’t get proper medical care. 
I was homesick. 
I wanted to have some fun. 
I wanted to see wife and baby. 
I wanted to get married. 
I got sick while on leave. 
Couldn’t get along with officers on ship. 
I felt like staying over. 
Seasickness. 
Fear of the sea. 
I overslept. 
I didn’t like the ship I was on. 
Train was delayed. 
Can’t stand work on the ship. 
Wanted foreign duty. 
Requested sea duty. 
Didn’t like Navy regulations. 
* By Walter Bromberg, Lieutenant Commander (MC) U.S.N.R. ; An- 
thony A. Puzzo, Lieutenant Commander (MC) U.S.N.R., and Bernard 
Locke, Lieutenant H(S) U.S.N.R. 
160 Chapter 32.-A PSYCHOLOGIC STUDY OF DESERTION AND OVERLEAVE 
I am a homosexual. 
Trouble with shipmates. 
Thought they were trying to frame me. 
No opportunity for advancement. 
Mother kept me home—under age. 
Afraid of combat. 
I am best suited for civilian work. 
I thought I wouldn’t get caught. 
Detained by civil police. 
To see girl friend. 
Can’t keep away from girls. 
Didn’t want foreign shore duty. 
Some rationalizations observed are patently neurotic 
reactions as seen in the complaint that the officers on a ship 
"looked scared" (a projected anxiety), or a fear of the 
monotony of the sea (insecurity). Others are immature 
aims, as a wish to be in the Pacific theater rather than the 
Atlantic theater or the reverse; the wish to have some fun, 
and the like. In spite of the apparent heterogeneity of 
the surface reasons, a closer scrutiny indicates that the 
basic psychologic formulations are not so widely divergent 
as might at first appear. 
In examining the emotional dynamics of the situation 
at the time of the offenses of this psychiatrically "normal" 
group, we find a somewhat different alinement of motiva- 
tions for "going over the hill.” In the following groups 
the formulations were based on a reconstruction, from 
case histories and examination, of the emotional situations 
underlying the offenses in the same sampling of cases. 
Psychologic Formulations for Absence Over Leave 
1. Reactions based on emotional problems; 
a. Anxiety producing (hidden) antagonism toward au- 
thority and discipline. 
b. Reaction to passive dependency—"separation anxiety.” 
Displaced reaction to emotional deprivation with infan- 
tile elements, including panic reaction to sea, to ship, 
to combat. 
c. Displaced frustration from marital and home problems. 
d. Aggravation of feelings of inferiority. 
e. Psychic invalidism (malingering) and hysterical conver- 
sion symptoms. 
f. Anxiety reactive to homosexual impulses. 
2. Reactions based on personality attitudes: 
a. Emotional and social immaturity. 
b. Willful, negative attitude toward Navy. 
c. Egocentric, narcissistic character. 
d. Open expression of antagonism toward authority. 
e. Adolescent rebelliousness—good prognosis. 
f. Accidental. 
g. Negative. 
h. Unascertained and incomplete. 
The question to be answered was, what were the driv- 
ing forces, envisaged in terms of emotionally toned im- 
pulses, that were responsible for desertions among these 
"psychiatrically well" individuals. At the outset it ap- 
peared that, with a knowledge of the requirements of war, 
with months or years of association with strict naval dis- 
cipline, and with pride in the uniform and traditions of 
the service, only impulses related to strong emotions could 
impel so many men into the act of desertion. However, 
strong effective motivations have not always been found 
in this series of cases. Frequently the mere discrepancy be- 
tween the values that the immature or egocentric individ- 
uals have and those of the service, was the basic force 
making for disciplinary breaches. Reactions of antagonism 
toward authority springing from conscious attitudes of 
defiance, based on immature social values as well as on 
deeper personal, perhaps unconscious, emotional reac- 
tions, proved almost as frequent. These two classes of 
motivation will later be discussed in detail. 
In general we could subsume these reactions under at- 
titudinal or emotional reactive headings. The general con- 
clusions to be drawn from these psychologic formulations 
are that the basic difficulty in desertion and similar offenses 
lies in (i) the overt and behavioral reaction to anxiety 
induced by frustration of some sort, and (2) an anti- 
authoritarian attitude. 
Reactions based on emotional problems.—Although the 
emotional dynamics underlying the several behavior re- 
actions which eventuate in seamen going A.O.L. are clear 
in most cases, it is not easy to demonstrate clear-cut clin- 
ical pictures. Thus group 1 a, "anxiety producing antagon- 
ism toward authority and discipline," is allied to group 
2 e, "adolescent rebelliousness—good prognosis,” with 
the exception that the display of antagonism arouses guilt 
feelings and hence anxiety in the former. Group 1 b, "sep- 
aration anxiety,’’ represents an important complex of dy- 
namic situations which proves to be the nuclear emotional 
problem of many of these individuals. Group 1 c comprises 
displaced neurotic reactions with every sort of variation, 
similar to those gathered under group 1 b. 
In group 1 d, previously unnoticed inferiority feelings 
become aggravated to the point of clinical entities; they 
partake also of some of the elements of group 1 b, but 
have their own specific psychologic causes. Group 1 e, 
"psychic invalidism," likewise gave neurotic reactions in 
men who previously considered themselves well and who 
then showed subclinical entities. Here again the separation 
anxiety described under group 1 b was frequently a factor. 
Group 1 f, "anxiety reactive to homosexual impulses," is 
self explanatory. 
The highly individualistic character of reactions should 
be emphasized. These are based on emotional problems 
which nevertheless have enough consistency of underlying 
psychopathosis to be recognizable. Hence we have chosen 
for description the outstanding type of psychopathologic 
process encountered which is best described as separation 
anxiety. 
161 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
It is not intended to rename the condition which has 
been variously called war neurosis, war hysteria, or combat 
fatigue. The phrase "separation anxiety" merely denotes 
a well-defined group of anxiety manifestations having a 
common psychopathologic basis. In this sense separation 
anxiety is a symptom, not a new disease. English military 
psychiatrists (2) have been particularly impressed by the 
appearance of separation anxiety among their fighting men 
during and after battle. Like many psychologic symptoms 
in response to emotional trauma, separation anxiety may 
appear at some distance in time following the trauma. 
Thus separation anxiety was noted by men in training 
stations, on the battle front, in active combat and in some 
areas far from the scene of aggressive activity. 
In this study we have encountered its symptoms as 
anxiety attacks which have on occasion been prolonged 
and which were sometimes expressed in psychosomatic 
symptoms. Headache and dizziness were predominating 
symptoms. The headache varied in type, usually frontal or 
temporal, and was increased by activity or bending. Often 
history of a former head injury which was quiescent for 
several years is held by the enlisted man to account for the 
headache. Medication with analgesics provided no relief, 
nor did placebos help the complaint. "Black-out" spells, 
and fainting attacks, occurring especially at night, were 
frequent symptoms. Careful examinations never revealed 
organic neurologic signs; the attacks were not epileptic. 
The fainting was always associated with dizziness which 
did not respond to medication. Often these cases are con- 
sidered instances of malingering because there are no ob- 
vious medical causes and no positive medical or labora- 
tory findings. Clinically these cases often occur in men of 
slight physique whose symptoms might be considered by 
some as being those of a constitutional psychopathic state. 
Another psychosomatic symptom is back pain which 
suggests sacro-iliac sprain. It may last weeks to months 
without any history of injury or any clinical signs of spon- 
dylitis. The backaches are associated with headache and 
have the same general characteristics. Cardiac neurosis 
and symptoms of gastric neurosis were not especially com- 
mon in our series. Only an occasional case of palpitation 
was noted, although abdominal pain without organic basis 
or serious bowel dysfunction has been observed. 
Enuresis and preoccupation with sexual problems were 
fairly frequent occurrences. These subjects often were 
enuretic on shipboard only after they had been on the sea 
for awhile. The sexual problems were more pressing. 
Worry about masturbation and a fear of being impelled to 
homosexual attacks on shipmates while in the disciplinary 
barracks were prominent. The subjects insisted on bring- 
ing it to the medical officer’s attention as a symptom of 
their illness. 
Another symptom was the wish to be alone, added to an 
intolerance to the noise incident to barrack or shipboard 
life. Frequently this intolerance took the form of extreme 
irritability, a wish to fight those about them. Some of the 
subjects felt they could not tolerate any noise, and were 
in a state of agitation after a night in the dormitory, even 
requesting solitary confinement. 
A corollary of this irritability with shipmates is an im- 
pulse to destroy objects, or to become "wild” and belliger- 
ent, though this latter was not always expressed in actual 
physical combat. Frequently they indulged in fantasies of 
a boyish type directed against officers or shipmates, boast- 
ing about what they would do to them. These mutilating, 
destructive fantasies came and went at intervals during 
the day and especially at night and were complained of as 
annoying to the patient who experienced them. As might 
be expected the irritability was associated with anxiety 
attacks, which were especially irritating at night and were 
combined with insomnia. Nightmares were very frequent, 
the dreams having an almost constant element of injury 
and destruction to self and others. 
Our experience has shown that the dynamic situation 
behind this condition is the inability to be away from 
home. The insecurity developed by separation from home 
—which appears as anxiety symptoms—can be tolerated 
for awhile but soon overwhelms the subject. The anxiety 
can be considered as a sign of the degree of insecurity ex- 
perienced by the ego. When the emotional implication of 
the fact of separation from home breaks past the ordinary 
conscious defenses, such as promise of adventure, novelty 
of sea duty, pride in the service, or competitive spirit with 
shipmates, feelings of insecurity and often anxiety or panic 
ensue. The subject "cannot stand" being away from home 
at a station or at sea. Regression results in that the sub- 
jects behave as if they could not live and carry out their 
service responsibilities. The symptoms can be considered 
as a conversation mechanism, whether they be psychoso- 
matic complaints or regressive behavior patterns. 
Thus the spectrum of symptoms ranges from anxiety 
to enuresis, from dizziness and headache to childish irri- 
tability which "prevents” the proper performance of their 
duties. Why there is an inability of the ego to withstand 
feelings of insecurity in the face of emotional deprivation 
is a highly individual matter which depends upon the 
emotional conditioning by the parents of the individual 
during his early years. 
Cases of intolerance to separation from mother and 
home were rarely found to be uncomplicated. There was 
almost always added some fraction of hostility against a 
parent. This hostility, we have learned, is a defense against 
deep dependency needs which the ego cannot express 
freely. Frequently this hostility is transferred to the Navy 
162 Chapter 32.-A PSYCHOLOGIC STUDY OF DESERTION AND OVERLEAVE 
and its officers, or to an indifferent object such as the sea, 
the individual claiming intolerance of the monotony of 
sea life. The presence of hostility links persons with sepa- 
ration anxiety with those whose behavior was featured by 
anti-authoritarian attitudes. Seasickness often is a mask 
for hidden hostility. An example of a dependent youth 
who showed marked separation anxiety with a moderate 
accompanying hostility reaction is illustrated in the follow- 
ing case; 
CASE REPORTS 
Case 1— An 18-year-old seaman was in the Navy 5Va months 
before he went A.W.O.L. for 59 days. During his first 7 weeks 
at training camp he adjusted, but at a specialty school during the 
next month he became nervous, unable to concentrate and fell 
down in his work markedly. While'in transit with a draft of men 
to a port, his train passed through the railroad station of his home 
town, and he was seized by an impulse to get off the train. 
While at home he felt more comfortable, and spent his time 
with his mother and with girl friends. He said that he went home 
to straighten things out because he knew he would be going to 
sea. Underlying this rationalization was a strong wish to be with 
his mother and to "settle things” with his father, i.e., ameliorate 
his guilt toward the latter. He spoke constantly of his wish to 
become engaged to a girl, so he could have some tie when he 
went to sea. 
On first examination, the subject described an episode of neu- 
rotic confusion with nervousness and uneasy feelings during his 
period in the specialty school, ending with his impulsively jump- 
ing off the train before his draft had reported to the new station. 
The subject was restless and talked with an overcompensating 
sense of self-confidence which soon passed, revealing a depend- 
ent, insecure youth. He gave a history of rages over little things, 
directed at both parents. He fights frequently and usually loses. 
He states that he is a great worrier about details. He is intelligent 
and has an interest in mechanical things. 
His mother was described as an overprotecting individual; his 
father was apparently a neurotic person with whom subject 
was constantly at odds over petty matters. 
The subject was an only child. Both parents tried, one in an 
indulgent way and the other behind a screen of rivalry (father), 
to fashion his life. The interplay between father and son appeared 
to be due to the unconscious wish of the subject to taunt his father 
into giving him more love. 
Three months after initial examination the subject presented 
a better picture of adjustment and seemed eager to return to sea. 
There were still symptoms of separation anxiety, such as occa- 
sional nightmares and an adolescent attitude of cocksureness 
which compensated for his inner insecurtiy. The immediate stim- 
ulus of his separation anxiety panic was the circumstance of his 
imminent sea duty. His great fondness for dogs and his almost 
obsessive drive for a fiancee are indicative of his great desire for 
love. The basic impulse to absent himself from service was based 
on deep emotional deprivation centering around the home. A 
few sessions during which this problem Was thoroughly discussed, 
provided sufficient insight on emotional support to allow him to 
return to duty with the prospect of being able to adjust. 
Reactions based on personality attitudes—In the pres- 
ent state of psychiatric experience, the group featured by 
immaturity and aggressive feeling toward authority (2 a 
and 2 e), cannot be regarded as fixed personalities in the 
way we regard the psychopathic personality. The anti- 
authoritarian groups, 2 b and 2 d, are independent, self- 
willed, follow no orders, insist on "having fun" at their 
own convenience, and have an openly expressed hatred of 
their officers. The egocentric characters, group 2 c, shade 
off on the one side to so-called criminal psychopaths, and 
to rebellious, immature adolescents on the other. This be- 
havior is motivated by a specific negative attitude toward 
authority, combined with an admixture of neurotic ele- 
ments. Those men who "go over the hill" because they 
strongly dislike the Navy, show on examination evidences 
of neurotic reaction toward their parents. Further prob- 
ing demonstrates that underneath their uncooperative, ar- 
rogant attitude toward authority, dependency needs exist 
which are quite similar to those occurring in the first group 
discussed, namely, reactions based on emotional problems. 
Submission to authority is considered to be a weakness, 
and antagonism toward authority is a reaction hiding 
from the individual the existence of passive, dependent 
elements in his makeup. In the psychopath, this aggressive 
component becomes fixed in the character; in the rebellious 
adolescent there is still enough elasticity of the ego to 
allow the aggressive defense against submissiveness to be 
neutralized under the pressure of contact with older men. 
The particular prognosis of each individual as far as the 
naval service is concerned, depends on his ability to ma- 
ture. From a psychologic point of view our finding is sig- 
nificant in that in these antagonistic men a deep current of 
insecurity exists. One piece of evidence is the frequent 
occurrence of aggressive impulses turned toward the self 
which appears in the form of self-destructive fantasies, 
suicidal attempts, existing along with truculence and 
hatred for the Navy. 
The mixture of expressed anger against authority and 
introjected anger within the self, appears in various pro- 
portions in the case material. The emotional currents range 
in their expression from cases showing simple separation 
anxiety to persistent hatred against the Navy. Although 
the latter group appears to be psychopathic with a chron- 
ically antisocial attitude, closer scrutiny provides a key to 
the meaning of the psychopathy demonstrated. It becomes 
clear that hatred against the Navy masks deep anxieties. 
The following case will illustrate the point. 
Case 2.—A 19-year-old enlisted man was brought to the dis- 
ciplinary barracks after absence over leave of 5 days. He stated 
that he "hated the Navy,” and "hated gold braid.” He had been 
in the Navy more than 2 years, having served at sea most of that 
time. He had had 12 offenses in the Navy, some of them of a 
serious nature. At one time he was said to have struck a warrant 
officer and another time he attacked and "beat up” a commis- 
sioned officer while on shore. In civilian life he had been ar- 
163 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
rested six times for offenses ranging from vagrancy to suspicion 
of felony, but there were no prison sentences. 
Upon arrival at the disciplinary barracks he stated clearly that 
he wished to be discharged from the Navy and therefore went out 
of his way to disobey regulations. He gave a story which, if true, 
indicated a severe psychopathic condition in which sadistic 
elements were prominent. He said his time was spent in thinking, 
plotting and planning to kill people with whom he had had even 
petty misunderstandings. He had a particular dislike for officers, 
and had already beaten up two of them unmercifully. He had 
numerous contacts with homosexuals in which he robbed them 
of their money. He said that he felt like murdering anyone whose 
blood he saw shed. When he tried to stop the bleeding nose of 
his brother he became infuriated and a relative watching the epi- 
sode pulled him away in alarm. There was a possibility that con- 
siderable fantasy admixture was present in his story. He was re- 
stored to duty aboard ship but was immediately A.W.O.L. for 
a period of 21 days after announcing that he wished to be dis- 
charged from the Navy. 
In his daily contact with the examiner, he showed more de- 
pression as it became clear to him that his wish to be discharged 
from the Navy by breaking the rules would not be countenanced. 
He showed signs of depression, spoke about crushing his foot 
under a truck, of cutting off his fingers so that he would be dis- 
abled and hence be discharged from the Navy. He said that while 
on his last A.O.L. he had wandered around the streets, sleeping 
in railroad stations, and playing with the idea of jumping under 
a train to end his life. He wrote to his mother saying she would 
hear from him no more, and planned never to see his wife again. 
Shortly before he was apprehended he met a girl who said she 
had syphilis, and he purposely had intercourse with her in order 
to contract tbe disease. During later interviews he expressed great 
feelings of debasement, refusing to be treated for a penile lesion 
in the hope that it was syphilis and it would invade his blood 
stream. He said he wanted to live a reckless life, devoted to 
doing what he pleased without regard to civil authority. He 
would rather lose a hand than stay in the service and obey the 
naval authorities. During the later depressed period when he 
entertained self-destructive ideas, some of his antagonism toward 
the officers, expressed in speech and indicated in behavior, di- 
minished. 
COMMENT 
The study of enlisted men who for varying periods 
have deserted the Navy in wartime has brought several 
factors into the foreground. The majority of these indi- 
viduals go "over the hill” for two reasons. The first of 
these is the presence of an emotional conflict which is dis- 
placed onto the Navy. The second is the evoking of under- 
lying antagonism toward authority by the regulations and 
discipline of the Navy. 
Most military psychiatrists agree that fear is present in 
all normal fighting men. They also agree that the under- 
lying personality of the soldier or sailor is a strong factor 
in determining whether the ego of the enlisted man will 
become so inundated by fear and neurosis as to become 
unusable in the service. As Raines and Kolb (3) have 
pointed out, no one has yet been able to formulate criteria 
for diagnosing neuroses in men, who though clinically 
well, are predisposed to war neurosis. 
We found in this series that the basic problem in the 
personality of men who go overleave is a combination of 
dependence needs and antagonism toward authority on 
which fear reacts to produce untoward behavior. The find- 
ing is again repeated, that emotional immaturity, which 
dips into marked passive dependence on the parents and 
home, usually symbolized by the mother, provides the 
neurotic background which turns normal fear into flight 
and dissatisfaction into desertion. 
These cases have shown a wide range and combination 
of dependence needs and antagonisms in each individual 
offender. It can be said, from our experience, that no de- 
sertion occurs without an anti-authoritarian attitude, open 
or hidden, existing along with a need for protection and 
dependence, whether covered by anxiety or compensated 
for by toughness. 
The problem which presents itself then is the mitigation 
of these two forces to the end that desertions and absence 
over leave will decrease. It is to be borne in mind in this 
discussion that we have excluded all types of disease which 
could be so diagnosed and deal solely with individuals 
who are "normal” psychiatrically. Emotional immaturity 
has two potent counterforces, i.e., time, and the emotional 
support of new figures in the environment. Naval expe- 
rience agrees with that of Army observers who find that 
the military organization and war supply psychologic fac- 
tors to temper men (4). The tempering of the average 
man, i.e., his adjustment to military service, goes on grad- 
ually during the first year or so of military life. Modifica- 
tions of old values, supplanting of emotional ties by new 
bonds, and the gradual submerging of the individual’s 
personality, become perceptible as the average recruit de- 
velops into a fighting man. 
How can the process be aided in the immature youth 
in whom it does not occur spontaneously? It is best ac- 
complished by minimizing the threat of danger evoked 
by the man’s way of interpreting his leaving home for the 
service. 
In this process a vital factor is the emotional tone of 
the officers, both line and staff, who are in contact with 
the man. It is the officers who act as therapists, whether 
they are aware of it or not, who furnish the emotional 
nourishment on which the enlisted man feeds. This is the 
only technic of treatment which is feasible in the present 
naval setup. It has been our practice through firm yet 
understanding discussion with the men, to attempt to offer 
this emotional background. The contact should be brief, 
pointed, but not critical, and above all, must be persistent. 
At the same time that emotional support is given, ration- 
alizations, excuses, incorrect emphasis and even the tern- 
164 Chapter 32.-A PSYCHOLOGIC STUDY OF DESERTION AND OVERLEAVE 
porary paranoid projections present in any large organi- 
zation must be swept aside. 
Even in the case of men who are repeaters, and who 
avow that they do not like the Navy, it is felt that re- 
peated therapeutic contacts—when backed by the author- 
ity of the Navy—will prove of value in time in immature 
individuals. But long before the maturing influence of 
military service can be brought to bear, the more potent 
forces of his community in general and his parents in par- 
ticular, have been operating on the dependent, immature, 
neurotic youth. 
Reviewing the situation regarding youths with an out- 
wardly anti-authoritarian attitude, the same considerations 
come to mind. It is interesting that adolescents in this 
country are emotionally toned against the war even at this 
time. Sherman (5), who surreptitiously examined 7,000 
high school children in Chicago regarding their attitude 
toward the war, found that 53 percent were antagonistic, 
critical, indifferent or confused about this country’s place 
in the war. 
Since the exigencies of the war and the naval service 
prevent starting any long-scale program, it becomes evi- 
dent that more immediate measures should be instituted. 
From the standpoint of the present problem, a longer 
period of basic training and indoctrination appears to be 
the only method of enabling us to modify the noticeable 
dependence of so many recruits. 
REFERENCES 
1. Locke, B.; Cornsweet, A.; Bromberg, W.; and Apuzzo, 
A. A.: Study of 1,063 naval offenders. U. S. Nav. M. Bull. 
44; 73-86, January 1945. 
2. Fairbairn, W. R. D.: War neuroses, their nature and signi- 
ficance. Brit. M. J. 1: 183-186, February 13, 1943. 
3. Raines, G. N., and Kolb, L. C.: Combat fatigue and war neu- 
rosis. U. S. Nav. M. Bull. 41: 923-936, July, 1299-1309, 
September 1943. 
4. Maskin, M. H., and Altman, L. L.: Military psychody- 
namics; psychological factors in transition from civilian to 
soldier. Psychiatry 6: 263-269, August 1943. 
5. Sherman, M.: Attitudes of youth of high school age toward 
the war. Psychological Bulletin 40: 294-299, April 1943. 
165 CHAPTER 33 
THE PSYCHOTIC NAVAL PRISONER* 
It is the purpose of this paper to consider the naval 
prisoner who is hospitalized because of a psychosis. De- 
spite screening procedures there are admitted to the serv- 
ice many men who seem unable to conform to the require- 
ments of the group and soon become involved in discip- 
linary difficulties. In the majority of cases the problems 
to be considered are those of discipline, morale, adequate 
indoctrination, and intensive training in group activities. 
In some, however, the offense is a reflection of an inability 
to adjust to the group, based on intellectual or emotional 
defects. 
In the naval service an effort is made to detect the men- 
tally-ill offender by repeated screening at the disciplinary 
barracks and by medical observation at all places of de- 
tention. The presence of a mental illness in the prisoner 
is of great concern, as, by virtue of the illness he may be 
held not responsible for committing the offense, or in- 
competent to stand trial, or too ill to serve sentence. The 
psychotic prisoner is immediately hospitalized, and after 
a period of observation has until recently been sent to St. 
Elizabeth’s Hospital, Washington, D. C. Such men are not 
committed to the hospital as "insane” but are ordered 
there for observation and treatment. 
During the period from December 1941 to December 
1944, thirty-four active duty Navy patients (2 Coast 
Guard, 9 Marine, 23 Navy) were admitted to the crim- 
inal division of St. Elizabeth’s Hospital. All of these men 
were general court-martial prisoners. Some had only been 
recommended for general court martial, others had been 
tried but not sentenced, while others were actually serving 
sentences. The illnesses necessitating their transfer to a 
hospital became manifest while they were awaiting trial, 
serving sentence, or in many instances they were a more 
obvious cause or accompaniment of the offense, thus lead- 
ing to early hospitalization. The men were studied by the 
usual psychiatric interviews, supported by various psycho- 
logic tests and by social histories obtained from the nearest 
relatives. 
These men were remarkable for their youth. Thirty- 
three were less than 30 years of age, and 12 were under 
20 years. The youngest was 17 years, the oldest 42. There 
was only one officer in the group and of the remaining 33 
only 5 were rated men (above the rate of seaman, first 
class, or corporal). 
The majority of cases (23) had been hospitalized less 
than 1 month before transfer to St. Elizabeth’s; only 4 had 
been hospitalized more than 3 months before transfer. 
The time spent at St. Elizabeth’s was as follows: Less than 
3 months, 5 cases; from 3 to 6 months, 10 cases; from 6 
to 12 months, 15 cases; and more than 12 months, 4 cases. 
In table 65 are shown the diagnoses of this group as es- 
tablished after an observation period of at least 1 month. 
Table 65.—Diagnoses of 34 general court-martial naval 
prisoners at St. Elizabeth’s Hospital 
Psychopathic personality without psychosis 
Psychopathic personality with psychosis 
5 
4 
1 
1 
9 
3 
— 14 
1 
1 
1 
1 
1 
2 
3 
— 8 
1 
Dementia praecox: 
Hebephrenic type 
Catatonic type 
Mixed type 
Undifferentiated type 
Psychosis with epilepsy 
Psychosis with mental deficiency 
Undiagnosed psychosis: 
(chronic alcoholism—syphilis) 
(prison reaction) 
(inadequate personality) 
(affective and schizoid features) 
no additional descriptive term 
Psychoneurosis (mixed type) 
Total 
34 
* By Otto Allen Will, )t., Lieutenant (MC) U. S. N. 
Received for publication 8 May 1945. 
166 Chapter 33.-THE PSYCHOTIC NAVAL PRISONER 
In table 66 the patients’ courses in the hospital are 
summarized. 
There is no question that all of these men had shown 
definite evidence of a mental illness before admission to 
St. Elizabeth’s Hospital. Nevertheless during their stay at 
that hospital 11 showed no evidence of psychosis and 17 
showed only minimal residual symptoms of their illnesses. 
Twenty-eight of these men displayed no mental abnor- 
mality that necessitated any restriction beyond that afford- 
ed by the general wards of the psychiatric hospital. The 
Table 68.—Offenses committed by 34 general court-martial 
naval prisoners confined at St. Elizabeth’s Hospital 
Offense 
Number of 
cases 
Desertion (AOL or AWOL over 30 days) 
14 
Repeatedly AOL or AWOL 
8 
Homicidal assault 
2 
Striking officer 
3 
Disobeying orders, disrespectful language to 
superior officer 
2 
Murder 
3 
Fraudulent enlistment 
I 
Disobedience (set free prisoners under his guard) 
1 
Total 
34 
Table 66.—Course in St. Elizabeth’s Hospital of 34 general 
court-martial naval prisoners 
Course 
Number of 
patients 
Not obviously psychotic 
11 
Uneventful (only slight evidence of mental 
abnormality) 
17 
Grossly psychotic 
6 
Total 
34 
Only six of the men had committed crimes which 
clearly indicated their serious potential danger to society 
and hence necessitated strict prison supervision. The 
crimes of these six men were as follows: 
1. Murder—three cases (in two of these cases all charges 
had been dropped before the men were hospitalized 
at St. Elizabeth’s). 
2. Homicidal assault on a guard at Portsmouth Naval 
Prison. 
3. Homicidal threats with knife, and previous criminal 
record. 
4. Homicidal assault with gun during psychotic episode 
while on duty aboard ship. 
The intelligence of the majority of these men was meas- 
ured at the hospital by the Stanford-Binet or the Wechsler- 
Bellevue scales. In a few cases intelligence was judged by 
school and occupational performance or by reports of in- 
telligence tests made at schools or other hospitals. Table 
69 shows the distribution of the members of this group by 
intelligence. 
transfer to this hospital was made so that all of the facili- 
ties of a large psychiatric institution would be available to 
the patient. 
In table 67 is shown the condition of the patient at time 
of discharge from St. Elizabeth’s. The group marked "un- 
improved” includes 4 men who were discharged by court 
order in response to writs of habeas corpus prior to dis- 
charge from the Navy and thus were returned to custody 
in other naval facilities. 
Table 67.—Condition on discharge from St. Elizabeth's Hospital 
of 34 general court-martial naval prisoners 
Condition 
Number of 
patients 
Not insane 
6 
Recovered 
5 
Social recovery 
5 
Improved 
6 
Unimproved 
8 
Retained 
4 
Total 
34 
Table 69.—Distribution by intelligence of 34 general court- 
martial naval prisoners (it St. Elizabeth’s Hospital 
Intelligence 
Number of 
cases 
Mental defective 
1 (IQ 51) 
2 
Borderline defective 
Dull normal 
8 
Normal 
18 
Superior 
3 
Very superior 
2 
Total 
34 
Many of these men had served rather short periods of 
active duty prior to committing the offense which led to 
imprisonment or hospitalization. Only 10 had over 2 
years of service, 19 had been on duty less than a year, and 
15 less than 6 months. The shortest period of service was 
26 days, and the longest was 7 years 8 months. 
In table 68 are listed the offenses committed by these 
men. 
Of this group only 5 showed above average intelligence, 
and 11 were rated as dull normal or below. 
Through histories taken from patients and relatives an 
167 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
effort was made to study the pre-service life of these men. 
The more significant facts obtained are listed under appro- 
priate headings following: 
The family background.—Twenty-four of the men were 
considered to have come from markedly unstable homes 
(marred by such things as alcoholism of one or both 
parents, divorce, illness, or parental strife). In six cases 
the father had deserted the family during the patient’s 
early childhood. In five cases the father died before the 
patient was five years of age, and in three cases the mother 
had died during this period. In three instances the father 
was alcoholic and in two the mother was alcoholic. Four- 
teen of the patients spent their early life in orphanages or 
the homes of foster parents. 
Mental illness in the family.—In seven cases the be- 
havior of the patient’s father was so unusual that it could 
be considered as evidence of a mental illness. Examples 
of such behavior are shown next: 
1. Peculiar, inadequate, seclusive. 
2. Alcoholic, cruel, "peculiar.” 
3. "Shell shocked" in World War I with residual symptoms 
since. 
4. Cruel, alcoholic, a bully—beat his children brutally. 
5. Killed wife and committed suicide while his small children 
stood by watching. 
6. A thief—deserted family—unstable. 
7. Died while a patient in a mental hospital. 
One mother displayed behavior suggestive of a psycho- 
pathic personality. Another mother died while hospital- 
ized because of an illness diagnosed as catatonic dementia 
praecox. 
Previous mental illness.—Nine of the patients had dis- 
played behavior that was definitely psychotic or strongly 
suggestive of a mental illness prior to entering the mili- 
tary service. These are summarized following: 
1. Vague spells of amnesia. 
2. Discharged from U. S. Army because of "mental deficiency 
and neurosis”—shortly thereafter (1942) in two State 
mental hospitals, where he was classified as undiagnosed 
psychosis. 
3. Four enlistments in military service: 
a. USMC—18 months’ service— 1935 given undesirable 
discharge after 7 months AOL. 
b. U. S. Army—9 years’ service—given medical discharge 
in July 1941 because of depression and suicidal at- 
tempt. 
c. USN—4 months’ service—given BCD in May 1942 be- 
cause repeatedly AWOL. 
d. USN—25 days’ service—present enlistment (fraudu- 
lent). 
4. Change of personality at 16 years, at which time private 
physicians made diagnosis of dementia praecox. 
5. Frequent hospital admissions because of alcoholism and psy- 
chopathic behavior. 
6. Marked mood swings. 
7. Severe depression at 15 years—no medical care. 
8. On several occasions saw psychiatrist who diagnosed "psycho- 
neurosis.” 
9. Peculiar "spells” since age of 5 years—during such episodes 
was mute and exhibited bizarre behavior. 
Only three of the group showed previous hospitaliza- 
tion because of mental illness. 
Education.—In tables 70 and 71 are summarized the 
school records of these men. 
Table 70.—Formal education of 34 general court-martial naval 
prisoners at St. Elizabeth’s Hospital 
School grade finished 
Number of 
cases 
Fourth grade and below 
5th-8th grades 
2 
11 
9th-10th grades 
12 
1 lth-12th grades 
4 
High-school graduates 
3 
1 year college 
1 
College graduate (AB) 
1 
Total 
34 
Table 71.—Scholastic record of 34 general court-martial naval 
prisoners at St. Elizabeth’s Hospital 
Record 
Number of 
men 
Poor 
14 
Fair 
18 
Good 
2 
Total 
34 
Seven of the men were in much difficulty because of 
chronic truancy; 9 were behavior problems in school 
and gave evidence of apparent early inability to conform 
to group requirements. As shown in table 70, 25 of the 
men had less than a tenth-grade education, and only 5 
were high school graduates. Only 2 men showed good or 
superior academic work, the other 32 being rated as fair 
or poor. 
Personality.—An attempt was made to separate these 
men into groupings indicative of certain terms commonly 
used to describe "personality types.’’ The classification was 
made on the basis of a review of the social histories, per- 
sonality studies, and observations made at the hospital. 
Nine of the men gave a history of enuresis beyond the 
age of 6 years, two being enuretic during the present ill- 
ness. Four stuttered during childhood, four had frequent 
temper tantrums, and two suffered from night terrors. 
Marital status and sexual adjustment.—Twenty-three of 
the men were single. Eleven had been married, but of 
168 Chapter 33.-THE PSYCHOTIC NAVAL PRISONER 
Table 72.—"Personality type” of 34 general court-martial 
naval prisoners at St. Elizabeth’s Hospital 
any length of time. In the past he has shown symptoms of 
an unstable personality, having been enuretic beyond the 
age of 6 years, and being subject to marked mood swings. 
He found it difficult to adjust to the military service, had 
little motivation to support him during the difficulties of 
the training period, greatly resented discipline and any 
display of authority, and was repeatedly AOL and AWOL. 
He was sent to the brig and recommended for general 
court-martial, but while awaiting trial became depressed, 
tearful, seclusive, and displayed obviously abnormal be- 
havior, with the result that he was sent to the sick bay 
and finally to St. Elizabeth’s Hospital. At'that hospital he 
made a good adjustment, showing little evidence of psy- 
chosis and rapidly improving in an environment that, 
while restricting, was not punitive. After a few months 
in the hospital he was given an honorable medical dis- 
charge from the service and released. 
This group is noteworthy for the lack of hardened 
criminals and for the comparatively minor nature of the 
crimes. It is a serious military offense to be AOL or 
AWOL, but in many of these cases the infractions of rules 
were a reflection of the individual’s long-standing inability 
to make any prolonged adjustment to the restrictions of 
his group. In civilian life only a few of these men would 
have been sent to a criminal institution. In nearly all serv- 
ice cases charges are dropped at the recommendation of a 
board of medical survey and the majority of these men are 
then discharged from the hospital as soon as the military 
discharge is received. 
Some attention should be devoted to the group called 
"psychopathic personality.” Like much of psychiatric 
nomenclature, this is a purely descriptive term, being ap- 
plied to certain patterns of behavior which are manifest 
throughout the greater portion of the individual’s life and 
first display themselves in early childhood. The cause or 
causes of such behavior are not known, but many authori- 
ties have considered "constitutional’’ factors to be of 
prime etiologic importance. It is well known, however, 
that similar behavior may be shown after cerebral damage 
from anoxemia, toxemia, or trauma. Recent studies have 
suggested that in some "psychopaths" there is a marked 
cerebral cortical dysrhythmia as demonstrated by the elec- 
troencephalogram, possibly indicative of cortical malfunc- 
tion that interferes with proper social adjustments. Careful 
psychiatric investigation has shown that in some "psycho- 
paths” the antisocial behavior may be explained by psy- 
chologic trauma experienced during the formative years. 
It seems clear that "psychopathic behavior" cannot be 
explained on a single basis, but may result from one or 
more of a number of causes. It is probable that the term 
"constitutional psychopathic state” should be applied only 
Type 
Number of 
cases 
''Introvert-” 
24 
"Extrovert” 
6 
Undetermined 
4 
Total 
34 
these six were divorced, three separated, and only two 
were on good terms with their wives. 
Twenty-seven of the men reported no gross sexual dif- 
ficulties, but the study of the sexual life was admittedly 
superficial. Two men displayed marked conflict over mas- 
turbation; one had engaged in both heterosexual and 
homosexual activities and often secretly dressed in 
women’s clothing; four apparently had never displayed 
any interest in sexual matters. 
Antisocial activities.—Eleven of the men in this group 
had been involved in antisocial activities prior to entering 
the military service, as noted next: 
1. Term for larceny—1934. 
2. Threatened life of foster father and was reported to police. 
3. Numerous juvenile court entries for theft, sexual advances to 
young girls and other petty crimes. 
4. State Training School inmate—larceny. 
5 and 6. Petty theft. 
7. Grand larceny. 
8. Theft and drunkenness. 
9. Disorderly conduct. 
10 and 11. Misdemeanors. 
Six of the men had been regular and heavy consumers 
of alcohol for some time prior to committing their military 
offenses. None of the patients gave a history of drug ad- 
diction. 
Pre-service employment record.—Two of the men had 
worked only on the parent’s farm or in his business. Eleven 
had never had any regular employment before entering 
the military service. Nine had shown a shifting occupa- 
tional adjustment. Six had made a very poor work record, 
giving a history of being discharged, etc. Only six had a 
record of steady, satisfactory employment. 
COMMENT 
The "average man" in this group is young, single, and 
below the grade of corporal or seaman first-class. He Is of 
about average intelligence, has completed less than 10 
years of school with average or poor grades and'only fair 
behavior. He came from an unstable home—an environ- 
ment poorly suited for the development of the more de- 
sirable social traits. He is "introverted,” has had some 
minor conflicts with the law, and has never held a job for 
169 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
to those individuals whose abnormal behavior has been 
manifest since early childhood and cannot be explained 
or understood despite careful medical and psychologic 
investigations. We question the validity of the term when 
applied to those with a history of severe cerebral trauma 
or those who spend their early years in social environ- 
ments that would be obviously detrimental to the develop- 
ing personality. There were nine men in this study diag- 
nosed as psychopathic personality. Only two of these nine 
had a "negative” history and might be called "constitu- 
tional psychopaths.” It is interesting to note that both of 
these individuals were reared in foster homes. The family 
background of the other seven is briefly summarized next: 
1. Father was a drug addict and psychotic. Patient was cared 
for in foster home after the age of 8. At age of 5 he was 
unconscious for 7 days after a head injury and skull frac- 
ture. 
2. Mother and father were divorced before patient was born. He 
was cared for in a series of private schools, having no home 
life, and becoming a spoiled, egocentric individual. 
3. Patient was born after prolonged labor and use of instruments. 
He was unable to nurse and was fed by gavage during his 
first year. At 8 years had encephalitis, following which he 
showed marked personality change. In this case there is 
possible cerebral injury from two causes—birth injury and 
encephalitis. 
4. Parents were separated when patient was infant and he was 
cared for by unstable grandmother. There was no parental 
supervision; governed only by peculiar, emotionally inse- 
cure elderly female. Patient made good school adjustment 
to ninth grade and his behavior was more that of a pro- 
found neurotic. 
5. Father died when patient was 5 years old. Stepfather was 
alcoholic, cruel, and abusive. Family was on relief and home 
life was torn by poverty, quarreling, and drunkenness. 
6. Father was a ' shell shocked” war veteran who deserted moth- 
er when patient was 5 years of age. Family was on relief 
and markedly insecure. Patient's IQ was 78. Here the 
patient is handicapped by poor home environment and a 
defective mentality. 
7. Father had a violent temper, beat mother, and subsequently 
was sent to prison. Mother was sexually promiscuous and 
displayed psychopathic” behavior. Parents were later di- 
vorced. Paternal grandfather was an alcoholic and a suicide. 
Patient never had security in a home which was marked 
by abuse and neglect. 
It is very difficult in the cases listed to insist that these 
individuals bear a constitutional taint and are not rather 
products of extremely unfavorable environments. Constitu- 
tion and environment cannot be (and should not be) en- 
tirely separated, but we believe that each case of "psycho- 
pathic” behavior should be carefully studied and the term 
"constitutional" used only with the greatest of caution. 
It is interesting to note that six of the men insisted that 
they had "faked” their mental symptoms in order to es- 
cape punishment for their offenses. Three of these men 
were diagnosed as psychopathic personality, two as un- 
diagnosed psychosis, and one as dementia praecox, mixed 
type. It is not uncommon for patients recovering from a 
psychotic episode to state that they assumed their symp- 
toms and were not actually ill. Such action usually seems 
to be the result of fear and shame, the patient preferring 
to be known as a malingerer than as one who was psy- 
chotic. In these men there was no evidence of malingering, 
as all had shown definite evidence of profound person- 
ality disorders prior to coming to this hospital. 
SUMMARY 
1. During the period from December 1941 to Decem- 
ber 1944, thirty-four general court-martial naval (Coast 
Guard, Marine, Navy) prisoners were admitted to St. 
Elizabeth’s Hospital, Washington, D. C. as psychotic 
patients. 
2. Twenty-eight of these men were below the grade of 
petty officer. 
3. Thirty-three of the men were below 30 years of age; 
12 below 20 years. 
4. Nineteen of the men had served less than 1 year of 
military duty. 
5. Only 5 of the men had more than average intelli- 
gence; 11 were rated as dull normal or below. 
6. Twenty-four of the men came from markedly un- 
stable homes. 
7. Nine had shown evidence of a mental illness before 
entering the military service. 
8. The majority had less than a tenth-grade education 
and had made only fair or poor scholastic records. 
9. Twenty-four were introverted, seclusive. 
10. Eleven had previous criminal records, and only a 
few had a good work record. 
11. In twenty-two cases the offense was AOL, AWOL, 
or a combination of the two. 
12. In their inability to adjust satisfactorily to the mili- 
tary service the majority of these men displayed a chronic 
failure to make any lasting social ties—a reflection of 
rather profound personality defects. 
13. These men are in need of rehabilitation, as nearly 
all are returned to the community when discharged by the 
military service. 
14. An effort is being made to study each patient in 
terms of his personality structure, intelligence, and voca- 
tional interests. In this way these men will be guided into 
a suitable vocational training program when they leave 
the hospital, with the hope that they will thus be helped 
to find a more stable, productive place in society. 
170 CHAPTER 34 
A STUDY OF 200 VIOLATORS OF GENERAL 
COURT-MARTIAL PROBATION' 
Probably the most serious aspect of the naval discip- 
linary problem is that of recidivism. Personnel assigned 
to disciplinary barracks are well aware of this problem. 
Probably personnel of the psychiatric units meet the im- 
pact of recidivism more clearly since all naval offenders 
admitted have contacts with the psychiatric office. 
Considerable interest has been shown in attempts to 
salvage residual manpower among the more serious naval 
offenders through the establishment of retraining com- 
mands for general court-martial offenders. There is yet 
much to be done in attempting to understand the first of- 
fenders and the recidivist for petty offenses to keep these 
men from becoming general court-martial cases. Confine- 
ment and court-martial procedures apparently are not the 
answers since these seldom alleviate the motivations back 
of the naval offender. 
Recidivism is a serious problem and one that costs the 
Navy vast sums in dollars and in manpower, including that 
of the enlisted men confined and the enlisted men and 
officer manpower to care and maintain disciplinary bar- 
racks and retraining commands. 
Recidivism, if not checked or its solution not deter- 
mined early, will ultimately result in the general court- 
martial procedure—a very expensive procedure for all 
concerned. 
This article is a study in recidivism as exemplified in 
200 enlisted men who had finally been awarded a general 
court martial after several previous offenses, and served 
time and who were later restored to duty on probation and 
who subsequently broke probation by another offense 
which required further disciplinary disposition. 
The term probation as used in the Navy is practically 
synonymous with the term parole as used in the civilian 
sense implying that a man who has been an offender has 
been returned to duty and on trial with some kind of sus- 
pended sentence over him. 
Since each of these men had been interviewed by two 
or more members of the psychiatric office, considerable 
data were collected on them and form the basis for this 
article. A follow-up on the recommendations made by the 
psychiatric office is also reported to the extent of available 
data. 
It is felt that were the motivations for the recidivism 
completely understood by the personnel in charge of these 
men, the ultimate general court martial and discharge 
from the service might have been avoided in certain cases, 
or the discharge from the service brought about sooner thus 
alleviating the prolonged expense. 
Recidivism intimates a twofold probability: (1) that 
of the shortcomings of the man himself, and (2) that of 
the failure of the naval personnel to fully understand the 
man and the motivations. The clash of these misunder- 
standings often results in a naval recidivistic offender. 
The difficulties involved herein are well recognized. 
The 200 probation violators considered herein were 
studied with the attempt to determine if possible any 
prognostic symptoms or traits that would aid in predicting 
the success or failure of the general court-martial offenders 
when released, or prior to release on probation or parole. 
Much of the data to be used have been taken from a 
special questionnaire2 filled out by the offenders them- 
selves supplying information about their naval history, 
nature of present and previous offense, family background, 
marital status, educational achievement, civilian delin- 
quency records, physical health status, stability, personal 
problems, and attitudes in the Navy. 
1By William C. B. Johnston, Commander (MC) U.S.N.R., and R. Rob- 
ert Otness, Lieutenant Commander H(S) U.S.N.R. 
2 Johnston, W. C. B. ; Otness, H. R.; and Stouffer, G. A. W.( Jr.: 
Method of psychological screening of naval offenders. Mil. Surgeon 97: 
300-306. Oct. 1945. 
171 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
The clinical interpretation and significance of bio- 
graphical data in the understanding of human behavior 
in its development are well recognized by psychiatrists 
and psychologists who are trained to deal with human 
beings. 
The data and discussion that follow aim to describe the 
backgrounds of these 200 men, presenting first certain data 
that have bearings on their personal life and civilian status. 
Table 73 presents the geographical distribution of these 
men by home States. The number are somewhat influenced 
by the fact that the disciplinary barracks serves several 
southern states. 
A tabulation of religious preferences indicated that 136 
(68 percent) were Protestant; 54 (27 percent) Catholic; 
2 (1 percent) Jewish; 5 (2.5 percent) none; and 3 (1.5 
percent) others. The data indicate that this factor has little 
or no bearing on the present problem under investigation. 
age 16 to 17 up to and including 36 to 37 years, being 
somewhat skewed toward the younger ages as would be 
expected. 
Family background.—The following briefly summa- 
rizes some interesting facts concerning the family and 
home status. The impact of these factors in shaping their 
lives is well recognized by psychiatrists and psychologists. 
It is equally important in understanding the actions of 
naval offenders since home attachments play such a large 
role in the motivations for offenses. 
Of these 200 men there were 51 (25.5 percent) whose 
fathers were not living and 37 (18.5 percent) whose 
mothers were not living. Thirty-five (17.5 percent) of 
the families were divorced or separated. Twenty-two cases 
reported a stepfather living and 16 a stepmother living. 
There were 49 (24.5 percent) who reported that they did 
not have happy homes as boys growing up. Seven were 
raised in an orphanage or foster-home. 
The influence of home instability in the personality ad- 
justment of civilian delinquents is well known and may 
be just as real with the offenders in the Navy where this 
factor has perseverated. 
These 200 men were from families where they had 
brothers and sisters ranging from none to 9- There were 
425 brothers, 445 sisters, 52 half brothers and 51 half 
sisters, a grand total of 973 siblings or at an average rate 
of 4.8 per man. There were 12 "only children” and 2 
"only children" with half siblings. 
This factor in relation to the parental situation may ex- 
plain the poor adjustment in the Navy of certain men who 
are obligated to care for a family. 
Educational background.—The highest grades com- 
pleted and reported by these men ranged from 3d through 
14th or sophomore in college. The mean or average grade 
of schooling was 9-3, median being 7.6 and the mode at 
8th. This compares well with that of 1,000 unselected 
naval offenders. 
The total number of grades completed for the group 
was 1,640 and the total time spent in school in complet- 
ing these grades was 1,859 years, revealing an educational 
progress retardation of 219 years or at about 1.13 years 
per person. 
Thirty-five percent of these men reported that they did 
not learn well in school and 42 percent stated that they 
"played hookey.” These data indicate some early mani- 
festations of instability and nonconformity to a routine 
related both to mental and personality aspects. 
Reasons jor quitting school.—The various reasons stated 
were reclassified into the groupings shown in table 74. 
Table 73 
State 
Number 
Arkansas 
1 
California 
1 
Connecticut 
2 
Delaware 
3 
Florida 
2 
Georgia 
4 
Illinois 
4 
Indiana 
7 
Iowa 
2 
Kentucky 
6 
Louisiana 
4 
Maryland 
9 
Massachusetts 
7 
Michigan 
6 
Mississippi 
3 
Missouri 
2 
New Jersey 
9 
New York 
28 
North Carolina 
27 
Ohio 
5 
Pennsylvania 
18 
Rhode Island 
2 
South Carolina 
10 
South Dakota 
1 
Tennessee 
12 
Texas 
4 
Virginia 
11 
West Virginia 
9 
Washington 
1 
Total 
200 
Age.—The age distribution of these men revealed that 
the average or mean age was 22.12 years, median 20.77 
years, and mode at 19 years. The age range extended from 
172 Chapter 34.-A STUDY OF 200 VIOLATORS 
Table 74 
Traits of the psychopathic personality type are observed 
in the listing (table 76) of the kinds of civilian offenses 
reported by the man himself. This list as reported by the 
men themselves is assumed to be very incomplete but it 
does give a general cross section of the offenses committed. 
Ninety-three offenses are reported and thirty-eight kinds. 
To work 
118 
18 
6 
3 
1 
1 
3 
2 
2 
4 
15 
3 
2 
6 
4 
2 
Economic 
Death of parent - 
Separation of parents 
Delinquent aspects. . 
To join armed forces 
To join CCC 
Difficulty in learning 
Lack of interest 
To get married 
"No reason” 
No information 
Total 
200 
Table 76.—Summary of civilian offenses reported 
Offenses against the person; 
1 
Assault and battery 
1 
Drunk and fighting 
I 
Fighting in movies 
1 
Rape and stealing 
1 
Hit and run 
I 
Offenses against property: 
Stealing bicycle 
1 
Robbing and stealing 
1 
Stealing 
7 
Stealing and drunk 
1 
2 
Receiving stolen goods 
I 
Breaking and entering 
2 
Larceny 
1 
Robbery 
2 
Steal car 
1 
Entry 
1 
Miscellaneous offenses: 
Drunk 
18 
Drunk and disorderly 
2 
Late hours - 
1 
Investigation 
1 
Bad conduct 
1 
Gambling and fighting 
1 
Drinking 
6 
Hauling liquor and drunk 
1 
Drunk and reckless driving 
3 
False arrest 
1 
Jail breaking 
1 
Speeding 
6 
Driving without license 
1 
Running away from home 
3 
2 
3 
1 
! 
1 
1 
From table 74 it becomes quite apparent that the pres- 
sure of home problems has been experienced by many of 
these men early in life. It is also recognized that there is a 
tendency to project the reason for poor school success on 
the home situation. 
Civilian delinquency.—That many of these men had 
had difficulty in adjustment in civilian life prior to the 
Navy is indicated by the data in table 75. Fifty-eight per- 
cent of these men showed early delinquent tendencies 
through truancy. 
Table 75 
Ca 
Number 
ses 
Percent 
Times 
Played hookey 
116 
58 
Trouble with cops 
44 
22 
Juvenile courts 
32 
16 
Arrested 
71 
35.5 
381 
In jail 
53 
26.5 
335 
In reform school 
6 
3 
7 
In civil prison 
5 
2.5 
5 
It is noted that of the 71 men who reported arrests there 
were at least 381 arrests reported or at a rate of 5.3 per 
man. The number of times ranged from 1 to 75. The 53 
who had been in jails had been in a total of 335 times or 
at a rate of 6.3 times per man. Number of times ranged 
from 1 to 75. 
These data indicate that with many of these men that 
some form of delinquent attitude or behavior has per- 
severated in their character since childhood and it is no 
special surprise that maladjustment in the naval service 
has resulted. 
Marital status.—Of these 200 cases there were 87 who 
were married with 44, or 51 percent, of them with a total 
of 91 children or at the rate of 2.06 per marriage. Forty- 
three, or 49 percent, have no children reported. Of this 
married group 65, or 74 percent, reported being happily 
married while 22, or 26 percent, were not. Ten men re- 
ported they were divorced or separated. 
173 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
PREVIOUS MILITARY BACKGROUND 
NAVAL BACKGROUND 
Table 77 
Status.—Thirty-five, or 17.5 percent, of these men were 
Regular Navy and 165, or 82.5 percent, were Reserve. Of 
these 117, or 58.5 percent, were enlisted while 83, or 41.5 
percent, were drafted. These figures are probably not too 
significant in the analysis of the offender when the pro- 
portions are considered for the total Navy. 
Distribution by rates.—Of the 200 cases there were 194 
who were in the nonrated branch of the Navy while 6 
men were rated. (See table 79 for distribution.) 
That the nonrated men predominate may suggest some 
psychological factor in the field of incentive. The impor- 
tance of proper classification of men in accordance to their 
abilities and interests need not be elaborated upon here. 
This is a fundamental consideration in human engineer- 
ing. The nonutilization and nonrecognition of a sailor’s 
talents often lie at the bottom of a disgruntled sailor’s 
attitude. 
Number 
Type of discharge 
Honorable 
Dishonor- 
able 
Bad con- 
duct 
Navy 
2 
2 
Army 
4 
4 
Merchant Marine 
1 
1 
CCC 
23 
16 
7 
National Guard 
1 
1 
Total 
31 
22 
7 
2 
Table 77 summarizes the types of previous military serv- 
ice these men reported along with the type of discharge 
obtained. These data indicate the poor adaptation that 
some of these men have made previously to military life 
and has a bearing on their present adjustment in the Navy. 
Thirty men reported 31 previous military services. 
Table 78 
Months 
Total 
months in 
service 
Distribution of 
Months 
sea duty 
ervice (months) 
Months 
on shore, 
U. S. A. 
Months 
overseas shore 
duty 
84 
1 
74 
1 
68-70 - 
1 
65-67 
62-64 
59-61 
1 
56-58 
53-55 
50-52 
2 
47-49 
3 
44-46 
1 
1 
41-43 
1 
38-40 
4 
35-37 
5 
2 
1 
32-34 .. . 
10 
1 
29-31 
20 
1 
3 
26-28 
10 
1 
1 
23-25 
22 
1 
4 
20-22 
26 
5 
17-19 
19 
3 
5 
14-16 
28 
1 
15 
11-13 
37 
2 
13 
1 
8-10 
9 
6 
16 
5-7 
10 
3 
1 
2-4 
18 
1 
2 
0-1 
1 
0 
19 
62 
Total 
200 
67 
67 
67 
174 Chapter 34.—A STUDY OF 200 VIOLATORS 
Table 79 
with naval offenders has found that many offenders are 
victims of some residuals of combat or operational neu- 
rosis and they have run away from the aggravating factors. 
Place of present offense.—It is of interest to note that 
of these 200 offenders there were 31 who committed their 
last offense and broke probation from a ship and 169 from 
some shore station. This is partly due to the fact that men 
are not always accepted well back aboard ship after being 
an offender and this is very contrary to the rehabilitation 
efforts that are made with them while ashore. The policy 
of restricting men from liberty at shore stations after they 
have been released from long confinement also explains 
many of these probation violators. 
Summary of previous offenses.—This section summa- 
rizes briefly the number of offenses reported by the men 
on the questionnaire. It is felt that this number is a bare 
minimum and that it is very likely that there are many 
petty offenses that were not listed. 
These 200 men reported 702 offenses on their records 
or at an average of 3.5 offenses per man. One man reported 
16. 
The great costs of the courts martial and confinements 
alone with this group of men need not be elaborated upon 
for their significance. The problem and cost of naval reci- 
divism are evident from the figures reported in table 81. 
These data, indeed, raise the great importance of analysis 
and treatment of first offenders with the hope of alleviat- 
ing the underlying motivations to forestall recidivism in 
the Navy. 
Physical and health complaints.—With confined men 
it is not surprising to find a preponderance of complaining 
men. It is recognized that many of these complaints are 
organically justified. It is also recognized that many are 
psychosomatic in type precipitated by the demands and 
restrictions of the confinement. Men frequently resort to 
complaints to avoid duty and work as well as to satisfy 
Nonrated 
Number 
Percent 
S2C 
160 
80 
Sic - - 
6 
3.0 
F2C 
14 
7.0 
Flc 
3 
1.5 
StM3c 
1 
.5 
StM2c 
8 
4. 
HA2c 
2 
1.0 
194 
97.00 
Rated 
Number 
Percent 
GM3c 
2 
1.0 
CM3c 
1 
.5 
SC3c 
1 
.5 
SSMC3c 
1 
.5 
MM2c 
1 
.3 
6 
3.0 
Analysis of service (in months).—Due to revisions of 
the questionnaire used in obtaining information on these 
men, complete data were not available on the break-down 
of the months of sea duty and oversea shore duty. Table 78 
presents a cross section of these data revealed by the data 
so obtained. 
The mean or average length of service for these men 
was 22.4 months, with approximate range from 8 to 84 
months. 
The mean length of sea duty was 10.2 months for a 
sample of 46 men, the range being from 2 to 46 months. 
A sample calculation on 67 men indicated an average of 
15.1 months spent on shore in the United States. 
Highlights of sea duty.—The data in table 80 briefly 
summarizes some factors relative to the nature of the sea 
duty. In individual cases these factors are significant in 
understanding the motivation back of offenses. Experience 
Table 80 
Number 
Number 
Percent 
In combat? 
Yes 
62 
Yes 
19 
9.5 
No 
138 
No 
181 
90.5 
[Atlantic 
43 
Yes 
20 
10 
Where? 
Pacific 
15 
Ship hit? 
No 
180 
90 
Both 
4 
Sunk? 
Yes 
5 
2.5 
With enemy ship? 
Yes 
19 
No 
195 
97.5 
No 
181 
Survivor? 
Yes 
6 
3 
Enemy subs?... 
Yes 
45 
No 
194 
97 
No 
155 
Survivor leave? 
Yes 
4 
2 
Enemy planes? 
Yes 
32 
No 
196 
98 
No 
168 
175 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
Table 81.—Summary of total offenses reported 
These trends suggest the need of giving these factors 
their full reliable significance in the handling and restor- 
ing to duty of this group of men. 
Very often the confinement with its accompaniment of 
loss of pay and the allotment to the family merely aggra- 
vates the causes for recidivism when it is associated with 
home and family adjustment problems. Since the pressure 
of home problems is greater than the sense of duty, it is 
not surprising to have men break probation through be- 
coming disgusted and disgruntled alone. 
Personal or self reasons are often on a neurotic or psy- 
choneurotic basis which are not unusual observations 
among the psychopaths and the emotionally unstable. 
The reasons grouped under the Navy suggest problems 
in the fields of classification and assignment and the im- 
pact of administrative policy toward these men. 
The reasons given are shown in table 82 under their 
respective headings. 
Number of offenses 
Number 
of cases 
Total 
offenses 
16 
1 
16 
8 
1 
8 
7 
3 
21 
6 
7 
42 
5 
29 
145 
4 
46 
184 
3 
60 
180 
2 
53 
106 
Total 
200 
702 
their craving for some sort of sympathy and individual 
consideration as an attempt to rationalize and minimize 
their offense and confinement on a pity basis. 
Of the 200 men herein studied 115 of them registered 
physical and health complaints when admitted to the dis- 
ciplinary barracks. A total of 178 complaints of 52 kinds 
were reported. The list suggests both the organic and psy- 
chogenic factors. Sick call privilege is extended to all men. 
A sampling of men revealed that approximately 40 per- 
cent reported a history of operations, serious illnesses and 
accidents. There were 45 percent who reported trouble 
sleeping and 52 percent who considered themselves as 
nervous persons. 
Attitudes in the Navy.—Certain deductions about the 
personality of these men can be made from the analysis of 
the attitudes expressed toward the Navy. This is an im- 
portant factor in understanding recidivism. Whether or 
not the Navy is responsible for these attitudes is a moot 
question. In any event the reshaping of antagonistic atti- 
tudes is a difficult problem and has many naval administra- 
tive implications. The force of attitudes in relation to ef- 
ficiency is a well recognized factor. 
Reasons stated for breaking probation.—From a prog- 
nostic point of view the reasons or motivating factors back 
of breaking probation are very important considerations 
in the salvage of naval offenders. Some of these men re- 
ported multiple reasons. The reliability of these reasons 
might be questioned in individual cases. There were 212 
reasons reported from 192 men. Eight men gave no reason. 
The reasons were grouped into three classes on the 
basis of what seemed to be the immediate causes, namely, 
(1) home and family; (2) personal or self; and (3) the 
Navy. 
The groupings strongly indicated the pressure of home 
and family (44 percent), and personal or self (33 per- 
cent), while the Navy accounted for about 23 percent of 
the reasons. 
Table 82 
Home: 
Family illness 
Family deaths 
Marital disharmony 
Home conditions 
Homesick for family 
Financial 
28 
1 
10 
19 
33 
1 
Personal or self: 
Drinking 
Disgusted 
Overslept 
23 
2 
3 
Disobedience 
Personal 
2 
Fear of sea 
8 
Missed train 
Theft 
3 
1 
To have good time 
To get married 
To see girl friend 
Sexual deprivation 
To visit brother 
Can’t stand crowds 
Assault and robbery 
Join Merchant Marine 
4 
3 
2 
3 
1 
1 
1 
1 
Physical health 
11 
Navy: 
No liberty 
Refused emergency 
Wants BCD 
Wants sea duty 
Mistreatment 
To get out of Navy 
Did not want oversea duty 
Dislike duty 
Dislike Navy 
26 
1 
1 
3 
7 
6 
1 
3 
1 
176 Chapter 34.-A STUDY OF 200 VIOLATORS 
Psychiatric evaluations.—As has been stated previously 
each of these men had been interviewed by at least two 
members of the psychiatric office. An evaluation of the 
total man was made relative to his value for the naval 
service. Since the interviews often revealed a history load- 
ed with instability and psychopathy, it became obvious 
that many of these men should not have been restored to 
duty following their confinement by sentence of general 
court martial. 
The psychiatric evaluations and recommendations made 
on these men following their breaking probation indicated 
that 176 or 88 percent were of no or little additional value 
to the Navy while 26 or 12 percent were considered of suf- 
ficient value to recommend restoration to duty for another 
trial. 
The impression obtained from interviews with naval 
offenders suggested the futility of confinement in reshap- 
ing many of these men into valuable material for good 
naval service since confinement does not alleviate or eradi- 
cate the motivating recidivistic factor. 
It is again emphasized that these psychiatric evaluations 
with recommendations were made prior to the Captain’s 
Mast for the offense that broke the probation. 
Outcomes of Captain's Masts—Each of these 200 men 
appeared at Mast for the offense that broke the probation. 
The outcomes or "readoffs” of the courts are summarized 
in table 84. 
From the table it is noted that 17 men were handled by 
an additional court less than a general court martial and 
were restored to duty. Thirty-two men were ordered to 
serve additional time and then restored to duty. Hence, 
from the 200 cases there were 49 cases who ultimately were 
Table 83 
Number 
Percent 
fFine 
53 
26.50 
Like Navy? 
Fair. . 
104 
52.00 
Not at all 
43 
21.50 
["Fine 
40 
20.00 
Like duty? 
Fair 
85 
42.50 
Not at all 
75 
37.50 
fpine 
11 
5.50 
Getting along? 
Fair 
61 
30.50 
Not at all 
128 
64.00 
Table 84.—Summary of dispositions following the Captains’ Mast 
Sentence 
Dishon- 
orable 
discharge 
Bad con- 
duct dis- 
charge 
Proba- 
tion re- 
voked 
Proba- 
tion and 
back to 
duty 
SCM 
Deck 
Mast 
Total 
Years: 
15 
1 
1 
4 
4 
4 
3 
3 
39 
2l/2 
2 
1 
3 
2 
27 
12 
39 
i v2 
1 
4 
5 
1 
3 
3 
Months: 
11 
10 
1 
1 
9 
1 
2 
3 
8 
2 
1 
3 
7 
7 
7 
6 
9 
7 
5 
1 
6 
9 
4 
6 
6 
3 
1 
1 
2 
50 
3 
3 
10 
66 
Total 
71 
29 
50 
32 
3 
3 
10 
198 
Note: 1 case had escaped, and 1 case was dismissed. 
177 PHYSICAL AND PSYCHOBIOLOGICAL STANDARDS AND EXAMINATIONS 
restored to duty. This would indicate that about 75 per- 
cent of naval offenders violating probation on a general 
court martial are judged by the courts as poor material to 
restore to duty while the psychiatric evaluations places 
this at 88 percent. The further adjustment of these men 
when restored to duty is not known at the time of this 
study, hence the reliability of the judgments and evalua- 
tions of the courts are not known. Many of the men were 
still serving time while this study was being completed. 
SUMMARY AND CONCLUSIONS 
This study has been an attempt to unfold some prog- 
nostic factors from the backgrounds of 200 General Court 
Martial cases who had broken probation that might be 
helpful in the selection or recommendation of future 
cases who are serving time on General Court Martial of- 
fenses and are being considered for restoration to duty. 
The conclusions strongly indicate that there is no single 
factor, or even a group of selected factors, that can be used 
with 100-percent prediction. The aura of the interview, 
the evaluation of the total personality of the man by 
trained interviewers in relation to the facts of the back- 
ground have a greater predictive value. However, the fac- 
tual side of this study suggests the following as important 
considerations in deciding against restoring a violator of 
a General Court Martial probation back to duty: 
1. Home background.—Unstable home with large fam- 
ilies; disharmony between parents; separation and divorce; 
unsatisfactory foster home placements. 
2. Marital.—Disharmony; inadequate wife to cope 
with family problems; unfaithfulness on part of wife and 
neglect of children. 
3. Civilian delinquency.—Background of truancy, ju- 
venile courts, reform school experience, civilian arrests. 
4. Educational.—Poor school success because of poor 
adjustment to routine; mental subnormality and subse- 
quent frustration in Navy; poor utilization of good ability 
and training by Navy in relation to classification and as- 
signment. 
5. Rates.—Lack of ambition to progress after long time 
in Navy. (This must be carefully considered in relation to 
policy of quotas and complements.) 
6. Sea and combat duty.—The emotional impact of 
prolonged tension at sea and combat, exhaustion, appre- 
hension, and other neuropsychiatric symptoms, including 
anxiety from separation from family. (Shore duty is good 
therapy for such a person.) 
7. Recidivism.—Repeat offenders with poor motivation 
or with home problems that cannot be alleviated by the 
Navy to the satisfaction of the man. 
8. Physical.—Chronic complainers with psychoneurotic 
complaints given as reasons for offense. 
9. Attitudes.—Poor or antagonistic attitudes toward 
the Navy prior to the General Court Martial.' 
10. Psychiatric evaluation—This over-all evaluation 
by experienced professional people considers these factors 
and many others in relation to the problem. 
178