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

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

“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”

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.

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

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)

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!

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!

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

What is Injured By a Traumatic Stress?

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

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!

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!

The Hippocampus is Damaged in PTSD…

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

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

Part Four: Operational Fatigue

Operational Fatigue: Definition Persisting emotional changes after prolonged exposure to combat/operational stress Can occur after only 14-21 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”

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

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

Mental Preventive Maintenance Part Five: Mental Preventive Maintenance

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

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

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

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

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!

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

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

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

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: 60-120 days after return Early treatment predicts better outcomes!

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)