Combat Stress

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Combat Stress
2
Overview

• Current Statistics Situation
• Signs and Symptoms
• Leadership Response
• Barriers to Seeking Help
• Referral Sources

3
Current Statistics

• 16.4 OIF-I veterans had stress symptoms 3-4
  months after returning
• 26 of permanent staff have been in combat
  (Desert Storm, Desert Shield, OEF and OIF)
• The percentage of permanent staff will likely
  increase as more Marines PCS from deployable
  units

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Current Situation

• 100 MHU visits where combat has been noted
  since Aug04
• Drill Instructor and Recruiter schools have
  ongoing Combat Stress concerns
• SACC and FAP case management more extensive due
  to multiple concerns (i. e. combat related in
  addition to primary reason for referral
  increase risk and danger)

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Whats Normal and Whats Not?

• Normal Readjustment
• Most will go through some difficulties the first
  few months upon return
• Spouse/Significant other/Kids
• Readjust to garrison work / Change in
  responsibilities
• General malaise or decrease in motivation
• Everyone adjusts differently and at their own
  pace flexibility is advised
• Although there will be some difficulties, serious
  problems will not necessarily occur

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Whats Normal and Whats Not?

• Operational Fatigue
• Upon return, service member may experience some
  of these normal responses to operational stress
• Sense of restlessness or boredom hypervigilance,
  increased response to certain stimuli or
  sensation seeking behavior
• Some decreases in motivation, avoidance of some
  responsibilities, mildly depressed mood, mission
  letdown
• Irritability or less frustration tolerance
• Sleep disruption for a period affects
  mood-outlook
• General medical complaints (fatigue, soreness,
  GI)
• Startle responses re-acclimatizing or
  re-learning

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Whats Normal and Whats Not?

• Operational Fatigue
• Signs of problematic combat stress responses
• Persistent trouble getting to sleep nightmares
• Flashbacks or intrusive images of deployment
• Persistent irritability rage or angry outbursts
• Significant withdrawal avoidance of
  conversations
• Lack of appetite for food, sex, or other pleasing
  things
• Unexplained tearfulness, depression, or suicidal
  thoughts
• Increased alcohol or substance abuse (numbing
  behavior)
• Will be seen in each battalion given human
  nature, deployment, and demands of combat

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Whats Normal and Whats Not?

• Operational Fatigue
• Problematic Stress Responses that may result in
  Misconduct
• Reckless driving / excessive speeding / DUIs
• Misuse or abuse of alcohol and substances
• Domestic Violence or emotional/psychological
  abuse of family members
• Sexual misconduct
• Unauthorized Absence
• Malingering
• GET HELP BEFORE PROBLEMATIC BEHAVIOR ESCALATES

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Problematic Stress Responses

• Mental
• -Poor concentration (forgetful, dissociating,
  vacant stare)
• -Apathy (verbalized or seen through
  self-neglect)
• -Declining performance (change from baseline,
  poor judgments)
• -Indecision / Mental Paralysis (slowed
  thinking, less expressive)
• Emotional
• -Irritability (increased anger with short fuse
  to rage responses,
• hyper-vigilance, jumpiness)
• -Depression (guilt, apathy, hopelessness,
  emotional numbing)
• -Isolating Self / Detachment (no one else can
  understand)
• -Loss of Confidence (in self, unit, mission)
• -Prolonged Anxiety/Vulnerability

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What Problems Can I Expect to See?

• Survey done 3 6 months post OIF
• Examined mental health symptoms reported by
  Marine battalions
• Examined how Marines felt about receiving mental
  health care and the barriers to care
• 15.6 of Marines had significant mental health
  symptoms (Depression / Anxiety / PTSD)

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Adjustment Disorder

• Emotional or behavioral symptoms in response
  within 3 months of the stressor(s)
• Extreme response to stressor
• Social or occupational (academic) functioning
• Is not a grief response
• Does not last longer than 6 months after end of
  stressor

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Acute Stress Disorder

• Traumatic event (combat, rape, car accident)
• Experienced, witnessed or confronted with
  event(s) threatened death or serious injury
• Intense fear, helplessness or horror response.
• Experiencing a sense of numbness, detachment,
  lack emotion
• Depersonalization
• Dissociative amnesia (blacked out trauma)
• Reexperiencing events (intrusive thoughts,
  dreams, illusions, flashbacks.

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Acute Stress Disorder (cont.)

• Reliving experience of distress with reminders of
  event (gunfire or planes flyover) as well as
  triggers in our everyday environment.
• Avoidance of stimuli that cause above.
• Difficulty sleeping, irritability, poor
  concentration

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What Problems Can I Expect to See?

• Depression
• Feeling down or no longer enjoying things, poor
  sleep and appetite, low energy and activity,
  suicidal thoughts
• 7.1
• Anxiety
• Worrying about multiple things, cant control the
  worry, tense, on edge, poor sleep and
  concentration, irritable
• 6.6

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What Problems Can I Expect to See?

• Post Traumatic Stress Disorder
• 12.2
• A traumatic event occurs that overwhelms ones
  sense of control or predictability or sensibility
  (IEDs, graphic loss of life, randomness)
• Creates primitive distrust of your instincts or
  antennaes ability to detect dangercauses
  increased levels of exaggerated readiness a
  conditioned response
• Mental appraisals of events cause chemical
  changes (cortisol increases, Neuropeptide Y (NPY)
  decreases)
• Different dispositions or thresholds for what
  overwhelms a person, regardless of how others
  evaluate it (e.g., randomness)

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What Problems Can I Expect to See?
Collection of Symptoms

• Re-experiencing the event through nightmares /
  day flashbacks
• Startle response
• Irritability
• Restlessness
• Fighting
• Speeding

• Numbing emotions (alcohol, withdrawal, apathy)
• Avoidance of things related to the event or
  talking about it
• Hyper-vigilance in safe places
• Sleep disruption

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What Problems Can I Expect to See?

• Alcohol Concerns
• reported by surveyed OIF Veterans
• Drinking more than intended 35
• Need to cut back on drinking 29
• Drove after drinking several drinks 19

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What Problems Can I Expect to See?

• Aggressive Behavior
• reported by surveyed OIF Veterans
• Got angry, smashed something, punched a wall,
  slammed a door, etc.
• 52
• Threatened a person with physical violence
• 54
• Got into a physical fight
• 29

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How Many Marines Seek Help?

• Surveyed OIF Marine Veterans with some level of
  Combat Stress
• 86 who had a serious problem recognized it
• 45 of those wanted help (55 did not want help)
• 33 received help from a professional
• 24 received help from mental health

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Leadership Responses

• Realize that some Marines may have serious
  symptoms that need attention
• Symptoms observed may not just be a phase but
  may increase and further damage performance
• Make yourself available to your Marines. If a
  Marine asks, listen to him/her and take their
  concerns seriously. Sometimes all a Marine wants
  is for someone to listen, understand and not tell
  him/her that they are a coward.
• Let Marines know that it is healthy to get
  assistance when needed, and that asking for help
  will not affect their standing in the unit
• Source Leadership Training on Post Deployment
  Combat Stress

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Leadership Responses

• Regularly visit and informally assess your
  Marines Leadership by walking around
• Short, informal 11 conversations availability
• 50 to 66 of psychiatric patients present months
  after combat intensity ends recognize this fact
• Look for Marines who cant unwind or exhibit
  major shifts in personality (e.g., irritability,
  apathy)
• Address Marines who question their efforts or
  losses
• Encourage to find the appropriate level of
  assistance

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Important Considerations

• Key ingredient in individual psychiatric problems
  after combat casualties or critical events is a
  lack of support structure
• Elite units marked by their high morale unit
  cohesion suffer lower incidence of combat stress
  reactions when compared to units exposed to
  similar battle conditions
• Social support mitigates perceived intensity of
  stressors and enhances self-efficacy efforts in
  dealing with them
• In listening to Marines, need normalization of
  reactions to difficult situations. Requires
  leadership and not personal insecurities
  regarding emotions/thoughts

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Barriers to Care

• I would be seen as weak 65
• My unit leadership might treat me
  differently 63
• Members of my unit may have less confidence in me
  59
• There would be difficulty getting time off work
  55
• My leaders would blame me for the problem 51
• It would harm my career 50
• It would be too hard to schedule an
  appointment 45
• It would be too embarrassing 41
• I dont trust mental health professionals 38

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Why Dont More Marines Seek Help?

• Stigma
• I would be seen as weak 66
• Leadership would treat me differently 57
• My unit will have less confidence in me 59
• It would harm my career 47
• Access Problems noted (Mental Health/Command)

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Depot Response to Combat Stress
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Questions or Thoughts?What are your needs?