William P. Nash, M.D.

1
Combat Stress Injuries
William P. Nash, M.D. Captain, Medical Corps,
United States Navy Combat/Operational Stress
Control Coordinator Headquarters, Marine Corps
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
60
50.0
50
40
30
20.0
20
9.8
10
7.8
1.6
0
Marines in Iraq
Marines in Iraq
Marines Who
Marines Treated
Marine OIF
with Stress
with Stress
Received Psych
in Garrison
Veterans
Symptoms
Disorders
Tx in Iraq
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
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 couldnt 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 Cold Sleep deprivation Injury
COGNITIVE Boredom Being hyper-focused Lack of information Information overload
EMOTIONAL Fear of death/injury Fear of failure Feeling devalued Loyalty conflicts
SOCIAL Being away from loved ones and friends Loss of personal space Isolation
SPIRITUAL Loss of clarity about lifes purpose Loss of innocence Loss of trust
10
Some of the Manageable Hardships of Homecoming
PHYSICAL Traffic Crowds Being unarmed Access to alcohol and drugs
COGNITIVE Not knowing how much to tell family, friends Loyalty conflicts Boredom
EMOTIONAL Withdrawal from the rush of battle Feeling unsafe Helplessness
SOCIAL Being separated from buddies and leaders Being overwhelmed/misunderstood by family
SPIRITUAL Difficulty making sense of what happened Guilt Conflicting values
11
Three Tactics for Normal, Reversible Adaptation
to Stress
ACCOMMODATE NEUTRALIZE DISENGAGE

• 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
Fatigue, Rebound
Dread, Alarm
Stress Level
Time ?
In the Groove

• 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
16
Operational Stress Injuries Correlate with DSM-IV
Diagnoses
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)
20
Peri-Traumatic Dissociation

• 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 ones 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

21
Beliefs That Can Be Damaged By Traumatic Stress

• Belief in ones basic safety
• Belief in being the master of oneself and ones
  environment
• Belief in whats 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)

22
Causes of Shame or Guilt In Traumatic Stress
Injuries

• 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

23
What is Damaged in the Brain in Combat Stress
Injuries?

• 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

24
Summary

• 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