1. Redeployment Stresses
And Preventive Maintenance For the Mind
LT Michael R. Melia, MC, USN
Combat Stress Control Brief, OIF-II-2,

2. Objectives For This Brief
Basics of “stress” and “adaptation”
Stresses and problems of redeployment
Traumatic stress injuries (including PTSD)
What are they?
How do you identify them?
Operational fatigue (“Battle Fatigue”)
What is it?
How do you identify it?
Ten steps for mental preventive maintenance during redeployment

3. A Few Basics About “Stress” and “Adaptation”
Part One:
A Few Basics About “Stress” and “Adaptation”

4. “Stress” Isn’t Always a Bad Thing
Stress is any challenge or demand placed on the body or mind
Stress is always both:
A danger or threat
And an opportunity
Stress provokes (requires) an adaptive response (we are never indifferent to it)
Stress is continuous and necessary
Problems arise if stress is too intense or lasts too long
“DANGER”
Chinese pictogram for “STRESS”
“OPPORTUNITY”

5. Types of Operational Stresses
PHYSICAL
Heat • Dehydration • Illness
Cold • Sleep deprivation • Injury
MENTAL
Conflicting values or morals
Damaged beliefs • Unmet expectations
EMOTIONAL
Fear • Hatred of the enemy
Death of friends • Shame over failure
SOCIAL
Loss of trust in peers or superiors
Being in a strange/different culture
SPIRITUAL
Loss of meaning to life • Guilt
Loss of faith • Loss of purpose
Stresses come from many different directions and they take many different forms. These are a few of the many stresses we all experience out here, just to illustrate what stress is. A few of these deployment stresses are also very important in redeployment as well, and we will return to these later. Shattered beliefs, conflicting morals, hatred of the enemy, death/injury of friends, shame over failure, being in a strange culture, guilt, loss of purpose. What is most Marine’s greatest fear here in Iraq? Something worse than death—failure. Shame. Now that we are adapted to being in THIS environment, home and family will feel like a strange environment when we get back. Have to re-adapt all over again.

6. There Are Only Three Ways to Adapt to Any Stress
SURRENDER
CONQUER
DISENGAGE
Change yourself to better suit the environment
The goal of all training and education
This makes you more tolerant to that particular stress
Change the environment to better suit you
The goal of all leadership
This lessens the force and impact of that particular stress
Detach mentally from the environment, yourself, or both
Least effective but most common strategy
E.g.: denial, dissociation, numbness

7. Now That We’ve Adapted to Deployment…
To some extent, we have all been changed
Learned how to live and work here in Iraq
Forgotten how to live back home and work in garrison
To some extent, we have all become numb
To fear and danger
To loneliness and grief
So, when we go back home:
We will have to change back again to re-adapt
Our numbness will have to wear off (over days or weeks)

8. Three Phases of Adaptation to Any Stress
Fatigue, Burn-out 
Dread, Alarm
Time 
Stress (Dissonance) Level 
“In The Groove”
This same time-course applies to deployment and redeployment!

9. Phase-Specific Stress Problems
Traumatic Stress Injuries
Operational Fatigue
Time 
Stress (Dissonance) Level
Boredom
Complacency
Specific stress problems are characteristic for different phases of adaptation process. Traumatic stress injuries are due to excessive alarm at the onset of a severe stress. Battle fatiugue is due to using up your resources, becoming burned out. BF happens eventually to everyone if deployed long enough.
This same time-course applies to deployment and redeployment!

10. The Stresses and Problems of Redeployment
Part Two:
The Stresses and Problems of Redeployment

11. Redeployment External Stresses Internal Stresses People Things
Problems
Job
Home
Alcohol & drugs
Thoughts
Feelings
Impulses
Expectations
Conflicts
Injuries
Symptoms

12. External Stresses of Redeployment
Infidelity of spouse/partner
Money problems: “Where did it all go?”
Boredom, lack of excitement
Garrison routine/hassles: back to just training
Family conflicts: everyone’s changed
Vehicles and traffic
Crowds, rude people
Not carrying a weapon
Not being able to fight back any more
Being separated from buddies and leaders
The lure of alcohol and drugs
The press, media and public opinion

13. Internal Stresses of Redeployment
Disillusionment after the homecoming
Bitterness over not being appreciated/understood
Grief and anger over the loss of friends
Still hating the “enemy”
Guilt, shame over surviving or failing in some way
Emotional numbness: to both pleasure & danger
Low frustration tolerance
Anger, irritability, fear, paranoia
Startle responses to loud noises or being touched
Not being able to talk
Not being able to remember
Not being able to make sense of it all

14. Anger and Substance Abuse Problems After OIF-I/II-1 (Infantry)

15. Other Problems After Redeployment
Hazing of junior troops
Suicide
Homicide
Reckless driving
Accidents
Misconduct
Disrespect
Insubordination
U.A.
Loss of motivation and loyalty to unit and Corps

16. More Exposure to Combat Increases Risk for Post-Traumatic Stress Disorder (PTSD)
Percent of Marines and soldiers reporting significant PTSD symptoms 3-6 mos. after OIF-I
Number of firefights in Iraq in OIF-I
— Hoge CW, et al. N Engl J Med 2004; 351

17. Traumatic Stress Injuries
Part Three:
Traumatic Stress Injuries
(Including PTSD)

18. Traumatic Stress Injuries: Definition
Injuries to the brain, mind, and spirit
Due to specific “critical event(s)” involving:
Terror, horror, or helplessness
Damage to deeply-held beliefs
Hyperarousal (heart pounding, laser-beam focus, “adrenaline” pumping)
Shame
May be cumulative

19. Time Course of Traumatic Stress Symptoms After a “Critical Event”
SYMPTOM DURATION:
“Normal”: 0-3 days
Acute Stress Disorder : 3-30 days
PTSD: >30 days
HYPERAROUSAL
Anxiety (Dissonance) Level
Time 
CRITICAL EVENT

20. Examples of Traumatic Stresses 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 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 in close combat
Media, public opinion

21. Traumatic Stress Injuries: Early Features
Dissociation is always immediate; of two types:
Numbness, detachment, or unresponsiveness – like a trance state
Or may just be a persistent change in personality
In either type of dissociation, the individual:
Is cut off from his usual values, feelings, and attachments
Cannot calm his own fear or anger as well
Cannot think as rationally or remember as clearly
Possible behaviors:
“Panic Run” or going berserk (reckless aggression)
Regression: becoming helpless and passive like a child
Freezing or “locking up”
Or, there may be no visible change in behavior

22. Traumatic Stress Injuries: Later Features (PTSD Symptoms)
Re-experiencing
Severe (repetitive) nightmares
Flashbacks or intrusive memories or images
Avoidance:
Of reminders of the traumatic experience
Of situations that look or sound similar (e.g., the CA desert)
Emotional numbing
Feeling “cold”, hard
Feeling detached, not inside your own skin
Increased arousal or agitation
Can’t calm down or relax
Can’t sleep
Exaggerated startle responses
Anxiety or anger attacks

23. Other Common PTSD Symptoms
Poor stress tolerance (easily upset, frustrated)
Substance abuse and dependence of all kinds
Emotional instability, moodiness
Short-term memory problems
Persisting personality changes (loss of morals)
Paranoia (sleeping with a weapon, etc.)
Unintentional aggressive acts (e.g., domestic violence, startle responses)
Aggressive fantasies and intentional aggression (e.g., cruising tough neighborhoods, bar fights)
Guilt over and fear of aggressive impulses
Self-destructive behaviors
Sexual problems (e.g., erectile dysfunction)

24. What is Injured By a Traumatic Stress?

25. Five Brain Systems of the Stress Response
3–Serotonin: Inhibition, Control
4–Amygdala: Threat reactor, Fear and anger
1–Norepinephrine: ”Get up and go”, Energy, Intensity
5–Hippocampus-Prefrontal Cortex: Conscious decisions, Values and beliefs, Courage
2–Dopamine: “Rush”, Motivation, Addiction

26. The Hippocampus- Prefrontal Cortex (PFC) & the Amygdala
HIPPOCAMPUS -PFC
Keeps track of where you are
Makes sense out of all experiences
Manager of belief and value systems
Decision-making, self-control
Hippocampus = “Hard-drive”
PFC = “CPU” of brain computer
PFC
AMYGDALA
Monitors all incoming stimuli
Searches for threats or dangers
Reacts to danger:
– Fear or anger
– Arousal
Triggers reflexive behaviors
Remembers forever!

27. What Happens at the Moment of a Traumatic Experience?
The hippocampus frantically attempts to make sense out of a situation that doesn’t make sense
Because it violates your belief systems
Because it violates your need to be in control
Because it violates your self-concept
If arousal level is high enough…
Neurons in the hippocampus burst and die
The hard-drive in your brain computer crashes!
CRASH!

28. The Hippocampus is Damaged in PTSD…

29. The Charioteer Is Temporarily Knocked Out
And even after the hippocampus recovers, it still can’t make sense of the traumatic memory

30. But the Good News Is… The Hippocampus can heal—but slowly, and
Only if obstacles to healing are removed
Nightmares, flashbacks, panic attacks, blind rages
Shame, guilt
Refusing to “deal with” the memories and losses—you can’t just pretend they didn’t happen
May require treatment to promote healing
Talking therapy, counseling, group therapy
Medications: 6-9 months
Social support and validation
Spiritual support

31. Part Four:
Operational Fatigue

32. Operational Fatigue: Definition
Persisting emotional changes after prolonged exposure to combat/operational stress
Can occur after only days of high-intensity combat
Commonly begins after 90 days of moderate-intensity deployment
Eventually, everyone succumbs if exposure is continuous, even to low-intensity operational stresses
Caused by an accumulation of small stresses
Danger
Monotony
Insufficient rest or recuperation
More common in officers and SNCOs than in younger troops
“Old Sergeant's Syndrome”

33. Operational Fatigue: Features
Depletion of internal resources
Tiredness, lethargy
Apathy
Anxiety and panic attacks
Generalized worry, insomnia, tension, physical symptoms
Panic attacks: “Soldier’s Heart”
Anger and irritability
Insomnia
Can’t get to sleep
Can’t stay asleep
Loss of confidence

34. In Operational Fatigue, the Horses and the Reins Get Worn Out
But the AMYGDALA continues to generate FEAR and ANGER!

35. Mental Preventive Maintenance
Part Five:
Mental Preventive Maintenance

36. Steps for Mental Preventive Maintenance
Know your Marines and sailors
Everyone’s experience of redeployment is different
You cannot order them to feel or think the way you want them to
The only way to know who will be vulnerable to which problems on redeployment is to know them personally
Pay special attention to:
Personal losses (deaths of close friends or a relationship loss)
Traumatic experiences during deployment
Whether an individual has family supports in the rear
Personal moral beliefs and values
History of alcohol or drug abuse in the past
History of violence, fighting, or domestic violence in past
History of depression or suicide attempts in the past

37. Steps for Mental Preventive Maintenance…
Create an environment in which it’s OK to have problems
Your attitude toward mental, emotional, and behavioral problems may determine whether these problems ever get better!
Don’t promote shame—shame prevents healing
Don’t permit stigma
86% of Marines and soldiers with problems after OIF-I recognized them
But only 45% said they would ever get help
66% said they would be perceived as weak if they admitted to a problem
47% said they thought it would harm their careers
Mental health treatment will not end someone’s career

38. Steps for Mental Preventive Maintenance…
Prepare your Marines and sailors for the stresses of redeployment
Teach them about what they may expect
Startle responses, nightmares
Anxiousness in crowds or traffic
Boredom, numbness, craving excitement
Easy frustration, anger outbursts
Warn them about what they should avoid
Alcohol, drugs, reckless driving
Situations in which they may lose their temper
Tell them what they can do to cope
Stay connected with members of unit
Talk about problems with peers, superiors, chaps, doc
Be patient with themselves and their family and friends
Maintain physical fitness—a great stress reliever

39. Steps for Mental Preventive Maintenance…
Informal briefs at small unit level by other experienced Marines—another way to prepare
Find Marines in your unit who have been through it before
Schedule informal briefs at platoon or squad level
Have them describe their own experiences of:
Re-uniting with family and friends
Their own emotional and mental reactions to redeployment
How they reacted to traffic, crowds, alcohol, sex, bar scenes
What worked for them, what didn’t work
Q & A
Open discussion

40. Steps for Mental Preventive Maintenance…
Help your Marines and sailors make sense of their sacrifices, suffering and losses
Symbolic validation
Awards, when due (don’t let these fall through the cracks)
Ceremonies, celebrations
Memorial services, physical memorials
Validation by listening and giving meaning to experiences
Honest sharing of experiences in atmosphere of trust
Reduce sense of being “the only one”
Address any especially traumatic experiences during deployment
Be honest if you can
Answer question: Why did it have to happen?
Tell them what purpose they served!

41. Steps for Mental Preventive Maintenance…
Time off—as much as possible, consistent with other units
For most unit members:
96 hour liberty, then
A few short workdays: for briefs and medical stuff, then
Regular leave, if possible
For IAs and reservists:
A few days at Camp Lejeune for briefs and medical, then
Return to parent unit or home, if possible
Encourage taking time off
To re-adapt to the stresses of being back home
To re-acquaint with family and friends
To address unresolved home or family problems

42. Steps for Mental Preventive Maintenance…
Don’t forget about your Marines who are stuck in the barracks
Ensure leadership and companionship for Marines who can’t go home or don’t have families to go home to
Don’t just let them sit and do nothing or join working parties while the rest of the unit is on leave
Assign SNCOs to be responsible for them
They also must feel valued and appreciated

43. Steps for Mental Preventive Maintenance…
Don’t let your Marines take their stresses out on each other
Discipline can never be relaxed
But all leaders must monitor themselves and subordinates for:
Excessive yelling at subordinates
Abusive language toward subordinates
Threatening of subordinates
Publicly criticizing or shaming subordinates
Assaulting subordinates
It’s easy to go too far when you are feeling stressed or frustrated yourself
Harassing a subordinate “proves” to him that “Semper Fi” is not a two-way street

44. Steps for Mental Preventive Maintenance…
Identify Marines and sailors who have persistent problems (>30 days, or beginning after 30 days)
Task all subordinates to watch for and report any changes in other Marine’s behavior
Increase in anger
Social withdrawal—becoming quiet and avoiding others
Homicide or suicide threats
Changes in military bearing or grooming
Any loss of discipline
Encourage everyone in unit to ask for help if any problems persist for more than 30 days after return to CONUS
Mental Health Brief and Screen: days after return
Early treatment predicts better outcomes!

45. Steps for Mental Preventive Maintenance…
Refer Marines and sailors who need help
Reasons to refer someone for help:
Marine asks for help (even if you don’t believe him)
Severe problems at any point that affect work or home life
PTSD symptoms that persist after 30 days
Resources:
Chaplain, ministers
BAS, hospital ER, other medical personnel
Marine Corps Community Services, Family Services Center
Division Psychiatry
Vet Centers (after release from active duty)
VA Medical Centers (after release from active duty)