prioritizing tasks Difficulty initiating routine tasks Preoccupation with minor issues and familiar tasks Indecision and lack of concentration Loss of initiative with fatigue Exhaustion Autonomic nervous system – Autonomic arousal Headaches Back pains Inability to relax Shaking and tremors Sweating Nausea and vomiting Loss of appetite Abdominal distress Frequency of urination Urinary incontinence Heart palpitations Hyperventilation Dizziness Insomnia Nightmares Restless sleep Excessive sleep Excessive startle Hypervigilance Heightened sense of threat Anxiety Irritability Depression Substance abuse Loss of adaptability Attempted suicides Disruptive behavior Mistrust of others Confusion Extreme feeling of losing control Battle casualty rates The ratio of stress casualties to battle casualties varies with the intensity of the fighting. With intense fighting, it can be as high as 1:1. In low-level conflicts, it can drop to 1:10 (or less). Modern warfare embodies the principles of continuous operations with an expectation of higher combat stress casualties. The World War II European Army rate of stress casualties of 1 in 10 (101:1,000) troops per annum is skewed downward from both its norm and peak by data by low rates during the last years of the war. Diagnosis The following PIE principles were in place for the "not yet diagnosed nervous" (NYDN) cases: Proximity – treat the casualties close to the front and within sound of the fighting. Immediacy – treat them without delay and not wait until the wounded were all dealt with. Expectancy – ensure that everyone had the expectation of their return to the front after a rest and replenishment. United States medical officer Thomas W. Salmon is often quoted as the originator of these PIE principles. However, his real strength came from going to Europe and learning from the Allies and then instituting the lessons. By the end of the war, Salmon had set up a complete system of units and procedures that was then the "world's best practice". After the war, he maintained his efforts in educating society and the military. He was awarded the Distinguished Service Medal for his contributions. Effectiveness of the PIE approach has not been confirmed by studies of CSR, and there is some evidence that it is not effective in preventing PTSD. US services now use the more recently developed BICEPS principles: Brevity Immediacy Centrality or contact Expectancy Proximity Simplicity Between the wars The British government produced a Report of the War Office Committee of Inquiry into "Shell-Shock", which was published in 1922.