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William P. Nash, M.D. Captain, Medical Corps, United States Navy Combat/Operational Stress Control Coordinator Headquarters, Marine Corps Combat Stress.

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Presentation on theme: "William P. Nash, M.D. Captain, Medical Corps, United States Navy Combat/Operational Stress Control Coordinator Headquarters, Marine Corps Combat Stress."— Presentation transcript:

1 William P. Nash, M.D. Captain, Medical Corps, United States Navy Combat/Operational Stress Control Coordinator Headquarters, Marine Corps Combat Stress Injuries

2 Operational Deployment Affects Everyone Everyone deployed to a combat zone is affected by that experience, mentally and physically Some are affected in positive, growth-enhancing ways Some find new meaning in their lives and a stronger spiritual connection But others are injured by their operational experiences, superficially or deeply Most heal from their operational stress injuries, just as most physical injuries also heal in time But a few stress injuries persist long after deployments have ended

3 The Challenge of Operational Stress Management in the Military and VA Discriminating between normal, adaptive responses to combat or operational stress, and those that are pathological Identifying pathological stress reactions early, but without adding the insult of stigma to the injury of stress and trauma Treating stress problems early and effectively, but without promoting disability

4 Most Operational Stress Symptoms Are Transient 50.0% 20.0% 1.6% 7.8% 9.8% 0% 10% 20% 30% 40% 50% 60% Marines in Iraq with Stress Symptoms* Marines in Iraq with Stress Disorders* Marines Who Received Psych Tx in Iraq** Marines Treated in Garrison*** Marine OIF Veterans Treated at VA*** * In two heavily-engaged infantry companies in an urban area ** During OIF-II, Feb 2004 through March 2005 *** Mental Health diagnoses only, FY-02 through FY-05

5 Combat/Operational Stress Trajectories Over Time SYMPTOM BURDEN Diagram courtesy of Bret Litz, PhD, NCPTSD, Boston High Moderate Low Growth PRE-DEPLOYMENT DEPLOYMENT RETURN 3 MOS. POST 6 MOS. POST CHRONIC COURSE RECOVERY COURSE INNOCULATION COURSE RESILIENT COURSE GROWTH COURSE DELAYED COURSE

6 Stigma Prevents Some Service Members From Getting Needed Help Walter Reed Army Institute of Research study: 1709 soldiers and Marines surveyed 3-4 months after OIF-I –17% had symptoms of PTSD, depression, or anxiety –86% of those with symptoms realized they had a problem –45% said they wanted help –29% had received mental health help in the past year Biggest reasons for not asking for help: –65% “I would be seen as weak.” –63% “My leaders might treat me differently.” –59% “My unit might have less confidence in me.” –55% “I couldn’t get time off of work to get treatment.” –51% “My leaders would blame me for the problem.” –50% “It would harm my career.”

7 Greek Warrior Ideal: Arete Ancient Greek ideal of the aristocrat warrior Features of arete: –Strength –Valor –Courage –Fortitude Has continued unchanged in the militaries of the world The foundation of all military core values and identity For a warrior to develop stress symptoms of any kind is to fail to live up to the warrior ideal! Brad Pitt as Achilles in “Troy”

8 The Warrior Ideal and Identity Must Always Be Respected Warriors and veterans with stress symptoms must be helped to preserve their honor, not be encouraged to abandon it Health and pastoral care personnel must be mindful of military cultures Use language that minimizes shame without trivializing potentially disabling problems U.S. Marine Corps solution: stress reactions are either: –Normal, reversible adaptations, or –Irreversible (but usually self-limiting) stress injuries –Like physical injuries, stress injuries are never the sole fault of the individual

9 Some of the “Manageable” Hardships of Operational Deployment PHYSICAL Heat Dehydration Illness Heat Dehydration Illness Cold Sleep deprivation Injury Cold Sleep deprivation Injury COGNITIVE Boredom Being hyper-focused Boredom Being hyper-focused Lack of information Information overload Lack of information Information overload EMOTIONAL Fear of death/injury Fear of failure Fear of death/injury Fear of failure Feeling devalued Loyalty conflicts Feeling devalued Loyalty conflicts SOCIAL Being away from loved ones and friends Being away from loved ones and friends Loss of personal space Isolation Loss of personal space Isolation SPIRITUAL Loss of clarity about life’s purpose Loss of clarity about life’s purpose Loss of innocence Loss of trust Loss of innocence Loss of trust

10 Some of the “Manageable” Hardships of Homecoming PHYSICAL Traffic Crowds Being unarmed Traffic Crowds Being unarmed Access to alcohol and drugs Access to alcohol and drugs COGNITIVE Not knowing how much to tell family, friends Not knowing how much to tell family, friends Loyalty conflicts Boredom Loyalty conflicts Boredom EMOTIONAL Withdrawal from the rush of battle Withdrawal from the rush of battle Feeling unsafe Helplessness Feeling unsafe Helplessness SOCIAL Being separated from buddies and leaders Being separated from buddies and leaders Being overwhelmed/misunderstood by family Being overwhelmed/misunderstood by family SPIRITUAL Difficulty making sense of what happened Difficulty making sense of what happened Guilt Conflicting values Guilt Conflicting values

11 Three Tactics for Normal, Reversible Adaptation to Stress ACCOMMODATENEUTRALIZEDISENGAGE Change yourself to better suit the stressor This makes you more tolerant to that particular stressor This is the goal of all training and education Eliminate or reduce the stressor This lessens the force and impact of that particular stressor A fast way to adapt, but often not possible Detach mentally from the environment, yourself, or both Examples: denial, withdrawal, numbness Stores up stress for later processing

12 Three Phases of Normal Adaptation “In the Groove” Fatigue, Rebound Dread, Alarm Stress Level Time  This time scale could be mere seconds (e.g., an all-out sprint), minutes (a single fire-fight), or months (an entire deployment)

13 Common “Rebound” Changes in Service Members After Deployment Aggressiveness –De-sensitized to aggression –Angry, irritable, agitated because of stress –May even crave violence as excitement Relative numbness –Numb to their own and others’ suffering –Numb to their own and others’ joy Becoming easily frustrated or overwhelmed Feeling alienated from family and friends at home Having a hard time getting back into home/garrison routines

14 Stress Injuries Occur When Stress Is Too Intense or Lasts Too Long Injury – May be more abrupt – A derailment, change in self – Individual loses control – Irreversible (though can heal) Adaptation – A gradual process – Can be traced over time – Individual remains in control – Reversible

15 Three Mechanisms of Stress Injury TRAUMATRAUMA An impact injury Due to events involving terror, horror, or helplessness GRIEFGRIEF A loss injury Due to the loss of people who are cared about FATIGUEFATIGUE A wear-and- tear injury Due to the accumulation of stress over time COMBAT / OPERATIONAL STRESS

16 Operational Stress Injuries Correlate with DSM-IV Diagnoses V62.82 MDD ASD PTSD TRAUMATRAUMAGRIEFGRIEFFATIGUEFATIGUE COMBAT / OPERATIONAL STRESS GAD Panic Adj D/O MDD

17 Traumatic Stress Injuries Abrupt injuries to the brain and mind Due to specific event(s) that provoke: – Terror, horror, or helplessness – Physiological hyper-arousal – Dissociation (abrupt and transient loss of mental integrity) – Damage to necessary or deeply-held beliefs – Shame or guilt

18 Traumatic Events in OIF Multi-casualty incidents (SVBIEDs, ambushes) Friendly fire Death or maiming of children and women Seeing gruesome scenes of carnage Handling dead bodies and body parts “Avoidable” casualties and losses Witnessed or committed atrocities Witnessed death/injury of a close friend or leader Killing unarmed or defenseless enemy Being helpless to defend or counterattack Injuries or near misses Killing someone up close

19 The Greater the Exposure to Combat, the Higher the Risk for PTSD Hoge et al. (2004) Number of firefights in Iraq in OEF & OIF-I Significant PTSD Symptoms (3-4 mos. after OEF and OIF-I)

20 Definition: A stress-induced, abrupt and transient loss of ability to integrate: – Perceptions (external and internal) – Thoughts, emotions, and behavior – Conceptions of the self and the world Three types or aspects – Going blank, like in a trance – Loss of control of one’s body (paralysis, deafness, stuttering, shaking, blindness) – Change in personality (e.g., becoming cruel, fearless, or childlike) Always involves a loss of control — mentally, emotionally, and physically Peri-Traumatic Dissociation

21 Belief in one’s basic safety Belief in being the master of oneself and one’s environment Belief in “what’s right” — moral order Belief that “they” deserved to die, and we deserve to live Belief that our cause is honorable Belief that every Marine and Soldier is valued Belief in the basic goodness of people (especially oneself) Beliefs That Can Be Damaged By Traumatic Stress

22 Failing to act Surviving when others did not Failing to save or protect others Killing or injuring others Helplessness Loss of control Even just having stress symptoms of any kind Causes of Shame or Guilt In Traumatic Stress Injuries

23 Allostatic shifts in set points in brain neurotransmitter systems due to stress –  NE activity, and down-regulation of alpha-2 autoreceptors –  CRF (corticotropin releasing factor) activity –  serotonin activity, and up-regulation of serotonin receptors –  NPY (neuropeptide-Y) activity Hippocampal dysfunction and possible neuronal damage –Cortisol toxicity to glutamate neurons –  BDNF (brain-derived neurotrophic factor) –Excitotoxicity mediated by glutamate NMDA receptors What is Damaged in the Brain in Combat Stress Injuries?

24 Most warfighters are resilient, and recover quickly from combat/operational and homecoming stress Aiding those with persistent stress problems requires sensitivity to military cultures & identity Common “normal” post-deployment stress problems include (1) aggression, (2) substance abuse, and (3) emotional numbness “Stress injuries” occur when stress is too intense or lasts too long The three mechanisms of stress injury are (1) trauma, (2) fatigue, and (3) grief Traumatic stress injuries are comprised of both biological damage to brain systems and psychosocial damage to beliefs and self-esteem Summary


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