1. Post-Deployment Mental Health Brief CAPT Bill Nash, MC, USN Operational Stress Control and Readiness (OSCAR) Psychiatrist, 1 st MARDIV Combat Stress Control Coordinator, OIF-II-2, I MEF nashwp@1mardiv.usmc.mil

2. Goals For This Brief 1.Review a few stresses of operational deployment and homecoming 2.Describe the processes of adapting during deployment and re-adapting after coming home 3.Describe the three most common combat-related stress injuries: – Traumatic Stress, including Post-Traumatic Stress Disorder (PTSD) – Operational Fatigue – Grief 4.Offer a few guidelines for how to help stress injuries heal

3. “Stress”: What Is It? Stress is any challenge or demand placed on the body or mindStress is any challenge or demand placed on the body or mind Stress is always both:Stress is always both: –A danger or threat –And an opportunity Stress provokes (requires) an adaptive response (we are never indifferent to it)Stress provokes (requires) an adaptive response (we are never indifferent to it) Stress is continuous and necessaryStress is continuous and necessary Problems arise if stress is too intense or lasts too longProblems arise if stress is too intense or lasts too long Chinese pictogram for “STRESS” “DANGER” “OPPORTUNITY”

4. A Few of the Many Stresses of Operational Deployment PHYSICAL Heat Dehydration Illness Heat Dehydration Illness Cold Sleep deprivation Injury Cold Sleep deprivation Injury MENTAL Alternating between hyper-focused & bored Alternating between hyper-focused & bored Insufficient information Value conflicts Insufficient information Value conflicts EMOTIONAL Fear (of failure) Hatred of the enemy Fear (of failure) Hatred of the enemy Loss of friends Guilt and shame Loss of friends Guilt and shame 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 Life doesn’t make sense like it used to Life doesn’t make sense like it used to Loss of faith Loss of purpose Loss of faith Loss of purpose

5. A Few of the Many Stresses of Homecoming and Reunion PHYSICAL Fast vehicles Traffic Crowds Fast vehicles Traffic Crowds Bright lights, loud noises, fast pace Bright lights, loud noises, fast pace MENTAL Not knowing how much to tell family, friends Not knowing how much to tell family, friends Loyalty conflicts Boredom Loyalty conflicts Boredom EMOTIONAL Grief Feeling unsafe Grief Feeling unsafe Guilt and shame Anger toward leaders Guilt and shame Anger toward leaders SOCIAL Being separated from buddies and leaders Being separated from buddies and leaders Being overwhelmed by family Being overwhelmed by family SPIRITUAL Not understanding why peers suffered/died Not understanding why peers suffered/died Loss of faith Loss of purpose Loss of faith Loss of purpose

6. How Do Marines Adapt to Stress? SURRENDERCONQUERDISENGAGE Change ourselves to better suit the environmentChange ourselves to better suit the environment The goal of all training and educationThe goal of all training and education This makes us more tolerant to a particular stressThis makes us more tolerant to a particular stress Change the environment to better suit usChange the environment to better suit us The goal of all leadershipThe goal of all leadership This lessens the force and impact of that particular stressThis lessens the force and impact of that particular stress Detach mentally from the environment, ourselves, or bothDetach mentally from the environment, ourselves, or both The least effective but most common tacticThe least effective but most common tactic Examples: denial, numbness, detachmentExamples: denial, numbness, detachment

7. Adapting and Re-adapting So, in order to adapt to deployment, Marines have had to change themselves to meet their many challengesSo, in order to adapt to deployment, Marines have had to change themselves to meet their many challenges But they have also become numb (detached) to many of their stressesBut they have also become numb (detached) to many of their stresses To re-adapt to being back home:To re-adapt to being back home: –They will have to change themselves again to meet the new challenges of being back in CONUS –And the numbness and detachment that has built up during the deployment will have to wear off These tasks take time, hard work, and patienceThese tasks take time, hard work, and patience

8. But Some Marines Also Sustain Stress Injuries while Deployed Some Marines and sailors sustain stress injuries due to either the impact of intense stresses or the wear-and-tear of prolonged stressesSome Marines and sailors sustain stress injuries due to either the impact of intense stresses or the wear-and-tear of prolonged stresses Three types of stress injuries to know about:Three types of stress injuries to know about: –Traumatic stress (including post-traumatic stress disorder) –Grief –Operational fatigue Most stress injuries of all types heal up just fine on their ownMost stress injuries of all types heal up just fine on their own But some do not, so it’s important to know how to recognize themBut some do not, so it’s important to know how to recognize them

9. Traumatic Stress: What Is It? An abrupt injury to the brain, mind, and spiritAn abrupt injury to the brain, mind, and spirit Due to specific event(s) involving:Due to specific event(s) involving: 1.Terror, horror, or helplessness Actual or threatened death or serious injury Actual or threatened death or serious injury To self or others in close proximity To self or others in close proximity 2.Damage to necessary or deeply-held beliefs Belief in one’s own basic safety Belief in one’s own basic safety Belief in being the master of oneself and one’s environment Belief in being the master of oneself and one’s environment Belief in “what’s right”— moral order, ethics, expectations Belief in “what’s right”— moral order, ethics, expectations Belief in one’s own basic goodness Belief in one’s own basic goodness 3.Physiological hyper-arousal — “fight or flight” 4.Shame or guilt For failing to meet one’s own expectations For failing to meet one’s own expectations For surviving when others did not For surviving when others did not For failing to save others from harm, especially subordinates For failing to save others from harm, especially subordinates

10. Traumatic Stresses in OIF 1. Multi-casualty incidents (SVBIEDs, ambushes) 2. Friendly fire 3. Death or maiming of children and women 4. Seeing gruesome scenes of carnage 5. Handling dead bodies and body parts 6. “Avoidable” casualties and losses 7. Witnessed or committed atrocities 8. Witnessed death/injury of a close friend or leader 9. Killing unarmed or defenseless enemy 10. Being helpless to defend or counterattack 11. Injuries or near misses 12. Killing someone up close 13. Adverse media, public opinion

11. Traumatic Stress: Symptoms Early symptoms: dissociationEarly symptoms: dissociation –Either an abrupt mental numbness, going blank, a trance-like state –Or, a change in personality (becoming cruel, fearless or childlike) Later symptomsLater symptoms –Re-experiencing Severe (repetitive) nightmares Severe (repetitive) nightmares Flashbacks or intrusive memories or mental images Flashbacks or intrusive memories or mental images –Avoidance and emotional numbing Avoidance of reminders of the traumatic experience Avoidance of reminders of the traumatic experience Or of situations similar in any way to the traumatic experience Or of situations similar in any way to the traumatic experience Feeling “cold”, hard, distant Feeling “cold”, hard, distant –Increased arousal or agitation Can’t calm down or relax, can’t get to sleep or stay sleep Can’t calm down or relax, can’t get to sleep or stay sleep Anxiety (panic) attacks or anger (rage) outbursts Anxiety (panic) attacks or anger (rage) outbursts

12. Other Traumatic Stress Symptoms Poor stress tolerance (easily upset, frustrated)Poor stress tolerance (easily upset, frustrated) Substance abuse and misuse of all kindsSubstance abuse and misuse of all kinds Emotional instability, moodinessEmotional instability, moodiness Short-term memory problemsShort-term memory problems Persisting loss of moral compass, values, impulse controlPersisting loss of moral compass, values, impulse control Paranoia (e.g., being afraid to sleep without a weapon)Paranoia (e.g., being afraid to sleep without a weapon) Hallucinations (seeing or hearing things not there)Hallucinations (seeing or hearing things not there) Unintentional aggressive acts (e.g., domestic violence, startle responses to being touched)Unintentional aggressive acts (e.g., domestic violence, startle responses to being touched) Aggressive fantasies and intentional aggression (e.g., cruising tough neighborhoods, bar fights)Aggressive fantasies and intentional aggression (e.g., cruising tough neighborhoods, bar fights) Guilt over and fear of aggressive impulses (not wanting to be around people any more)Guilt over and fear of aggressive impulses (not wanting to be around people any more) Self-destructive behaviorsSelf-destructive behaviors Feeling like combat is the only place you fit in any moreFeeling like combat is the only place you fit in any more

13. TRAUMATIC EVENT HYPERAROUSALHYPERAROUSAL Time  Anxiety (Dissonance) Level Many people experience symptoms during and after a traumatic stress Many people experience symptoms during and after a traumatic stress Most people heal up quickly and naturally without professional help Most people heal up quickly and naturally without professional help Only 10-20% continue to experience symptoms long term Only 10-20% continue to experience symptoms long term How Traumatic Stress Symptoms Change over Time

14. Operational Fatigue: What Is It? Emotional changes after prolonged exposure to combat/operational stressEmotional changes after prolonged exposure to combat/operational stress –How soon it sets in depends on how severe and continuous the operational stresses have been –Eventually, everyone succumbs if exposure is continuous, even to low-intensity operational stresses Caused by an accumulation of small stressesCaused by an accumulation of small stresses –Danger, hardships –Monotony –Insufficient rest or recuperation More common in officers and SNCOs than in younger troopsMore common in officers and SNCOs than in younger troops –“Old Sergeant's Syndrome”

15. Operational Fatigue: Symptoms Anxiety and panic attacksAnxiety and panic attacks –Worry, tension, difficulty relaxing –Attacks of rapid heart beat: “Soldier’s Heart” Anger and irritabilityAnger and irritability –Temper outbursts –Difficulties handling frustrations InsomniaInsomnia –Can’t get to sleep –Can’t stay asleep Loss of confidenceLoss of confidence Loss of ability to enjoy life or feel pleasureLoss of ability to enjoy life or feel pleasure

16. Grief and Traumatic Grief: What Are They? Grief is how we adapt to the stress of losing someone (or something) important to usGrief is how we adapt to the stress of losing someone (or something) important to us The work of grieving includes both:The work of grieving includes both: –Managing and surviving painful emotions –Relearning the world now without the lost person “Traumatic grief” is a particular type of grief which includes some symptoms of PTSD:“Traumatic grief” is a particular type of grief which includes some symptoms of PTSD: –Intrusive and distressing preoccupations with thoughts about the deceased (often associated with feelings of guilt or shame) –Dissociative symptoms: feeling dazed, stunned, shocked –Loss of trust in one’s own security, trust in the world –Shattered world view; inability to make sense out of the death Like PTSD, traumatic grief can become chronicLike PTSD, traumatic grief can become chronic

17. Steps to Promote Healing from Stress Injuries 1.Get safe: reduce levels of physiological arousal and intense emotion as soon as possible — slow yourself down –Get enough sleep every day (6-8 hours minimum)! –Limit alcohol and avoid drugs (including caffeine)—they’re a trap! –Avoid thinking or talking about painful memories except when you feel safe –Surround yourself with people (buddies, family, ministers, counselors) who make you feel safe as much as you can

18. Steps to Promote Healing from Stress Injuries 2.Stay safe: just say “NO” to violence –Avoid any situations in which you might become violent or lose your temper –Avoid conflict with spouses, family, friends, strangers –Don’t let yourself dwell on violent images or impulses if they pop into your head –Get away from situations which make you angry, if you can –If you need a violence “fix”, try sports or something safe, but only if you can do it without “losing it” –Don’t let yourself drive recklessly or too fast

19. Steps to Promote Healing from Stress Injuries 3.Take care of yourself –Work out regularly; exercise is a natural treatment for stress, anxiety and depression –Make time for yourself; try to keep a balance between work, family, and personal time in your life –If you are bored, find a new challenge to take on in your life –Go to school –Learn a new sport or hobby –Volunteer to help others

20. 4.Remember and talk: once you can recall the details of painful experiences without getting upset, begin telling your story –Tell yourself what happened, in detail; write down your experiences –Tell others whom you trust what happened –Be on guard for twisted, self-destructive thoughts Blaming yourself for something that wasn’t your fault Blaming yourself for something that wasn’t your fault Forgetting that all combat deaths and injuries are uniquely honorable, even if they don’t make sense Forgetting that all combat deaths and injuries are uniquely honorable, even if they don’t make sense –Your goals for remembering and talking are: To weave your fragments of memory into a coherent narrative To weave your fragments of memory into a coherent narrative To begin to put the puzzle pieces together to make a whole picture To begin to put the puzzle pieces together to make a whole picture To forgive yourself and others — may need to make amends To forgive yourself and others — may need to make amends Steps to Promote Healing from Stress Injuries

21. 5.See a doctor: consider medical help if any of the following persist for more than a month: –Can’t get to sleep or stay asleep –Repetitive nightmares that don’t start going away — especially if they wake you up –Panic or anxiety attacks that you can’t control –Rage or anger attacks you can’t control –Thoughts about killing yourself or someone else –Difficulties going out in public or sleeping without a weapon –Alcohol or drug use that’s out of control –Can’t remember and think through the details of what happened because it remains too painful Steps to Promote Healing from Stress Injuries

22. 6.Stay connected: don’t isolate yourself –Stay connected with a community of other marines, sailors, and veterans if you can –Tell your spouse as much as you and your spouse can handle (try to lower the trust barrier between you) –Chaplains, counselors –Church –PTSD groups at Marine Corps Community Services –Vet Centers: www.va.gov/rcs (after release from active duty) www.va.gov/rcs Vista: 760-643-2070 Vista: 760-643-2070 San Diego: 619-294-2040 San Diego: 619-294-2040 –Help others Steps to Promote Healing from Stress Injuries

23. Questions?