Armies exist to fight, not go to the hospital. Since military medical officers are primarily occupational physicians, they are required to view hysteria from both the individual and sociocultural perspective, particularly during military operations when group needs outweigh those of the individual; if it were otherwise, no army could fight (1).

Becoming ill is a social process that requires confirmation by others (2). Sick roles are a negotiation among the individual, doctors, employers, and society. These roles conform to cultural mores and norms, and are shaped by issues of class, gender, and the language of distress (e.g., the post-trauma dialectic). Issues of genuineness are also part of this negotiation and soldiers’ illness behavior is open to differing interpretations. Within the strictures of military life and law, commanders are frequently presented with “misbehavior” and must question whether individuals are responsible for their actions. Commanders will contextualize the timing of a soldier’s behavior, that is, why now? What has precipitated it? What will be the impact of this behavior in the individual and the unit? However, when civilians examine military cases, it should be remembered that they will view the case from a civilian paradigm, often in retrospect, from safety and without knowledge of military culture, or understanding or consideration of the responsibility the individuals have for their peers, subordinates, and superiors at the time of their initial presentation.

Objective signs of mental illness or disease may be stigmatized, especially those thought to be disingenuous, or when no organic cause can be found, for example, medically unexplained symptoms which may be diffuse [fatigue, muscle, and joint pains, sweats, memory difficulties, illness, (mis)behavior], or specific symptoms such as paresis, blindness, aphonia, amnesia, or fugue states (3). In a fashion similar to shellshock, the mental condition of posttraumatic stress disorder (PTSD) is currently not stigmatized (4).

Military commanders frequently feel doctors encourage soldiers to seek their discharge through “delinquency and avoiding responsibility for their actions” (5), or by “aiding” or encouraging malingering through their shameful use of “battle fatigue” (includes hysteria, shellshock, neurasthenia, etc.) as an excuse for cowardice (6,7).

Thus, the study of hysteria in a military culture requires attention be paid to its bedfellows: medically unexplained
symptoms, illness deception, and malingering (8). Military psychiatry tells us that attention must be paid to the sociocultural aspects of these diagnoses which lie at the borderline between many boundaries, for example: self/group/society; biological/psychological/social/cultural; disease/illness; neurological/psychiatric; real/imagined; objective/subjective (9). Without understanding and training in military psychiatry, disentangling malingering from shellshock, hysteria, and organic conditions has proven problematic, more so the closer the observer is to any combat action (10). Acute mental illness and malingering are most likely to appear at times of great social upheaval and stress. They are thus commonest in armies that are losing. At such times, group integrity and preservation is of paramount importance and internal threats are more feared than are external ones (11).

Whatever triggers hysteria, it is different in times of peace and war. Like courage, military commanders believe fear and mental breakdown are contagious. During the First World War, the pioneering English psychologist/doctor W.H.R. Rivers (12) believed that the process of enlistment, acculturation, and rigid discipline heightened suggestibility among soldiers, thereby predisposing recruits to hysterical breakdown. Any mental breakdown is an anathema to military culture, ethos, values, and norms, as it interferes with the mission and can put others at risk, both physically and psychologically. Individuals’ failure to discharge the duties in accordance with their given rank is rightly judged harshly by peers, superiors, and perhaps most importantly, by subordinates. Such failure is likely to be seen as self-seeking, shameful, and selfish, given the acculturation involved in enlistment. Opprobrium is more likely when individuals do not “fit in” or have not “pulled their weight.” Breakdowns must be earned. Furthermore, individuals inappropriately labelled and/or managed may be at risk of long-term incapacity and disability, particularly if a pension is granted.

Armies naturally cultivate the warrior paradigm based on concepts of chivalry and maleness in which self-control, comradeship, altruism, endurance, courage, and stoicism are valued as nowhere else in Western societies. Maleness is fostered and shaped through the use of shame sanctions (13) and where failure to function, and to do one’s duty (social role), at whatever level, is a severe stigma due to which all ranks go to great lengths to avoid being seen to fail. At the outset of the First World War, such failure could lead a British soldier to either a court-marshal or lunatic asylum, possibly forever.

The first mention of the link between combat and hysteria is from the Battle of Marathon in 490 BC, where brave behavior on the battlefield was followed by a permanent symptom without physical explanation (14).

The Russo-Japanese War of 1904-1905 produced the first clear records that mental breakdown could occur during and after combat. That such breakdowns had a substantial social component to them was revealed by the observation that soldiers who remained close to the front line and to their units recovered better than those evacuated back to Moscow, a journey of about two weeks. Hysterical symptoms following gassing from Japanese grenades were noted and the thread of this remains in “modern” mass hysteria and societal anxieties triggered by foul smells. The debate in Continental Europe was furthered in 1907 and 1911 when examination of survivors and rescuers involved in explosions on the French vessels Iéna and Liberté revealed emotional change (nervous disturbance). Before World War I, the debate about the unconscious mind was predominantly Continental, involving Charcot, Janet, Freud, Babinski, and Pavlov. In Britain and the United States, this dialectic was anathema for many, given its sexual content (15).