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1. Combat StressKieran Dhillon, PsyD, ABPPMilitary Psychology
2. DisclaimerInformation and opinions expressed by Maj Dhillon are not intended/should not be taken as representing the policies and views of the Department of Defense, its component services, or the US Government.
3. Combat StressUsed to describe a set of symptoms“expected, predictable, emotional, intellectual, physical, &/or behavioral reactions of service members who have been exposed to stressful events in combat or military operations other than war.” (DoDD 6490.5, 1999)
4. Combat StressWhat it is not:Psychiatric casualty caused by something other than the intense psychological or physiological stress of combat.MisconductThough its acknowledged that combat exposure can explain misconduct
5. Combat StressCombat Stress does not excuse misconduct
6. IncidenceOIF/OEF vets: USA/USMCinjured/wounded in Iraq 3xs more likely to exhibit PTSD after deploymentInjured/wounded in Afghanistan 2xs more likely to exhibit PTSD after deploymentThose hospitalized during OIF 2xs more likely to endorse MH concerns (35%) on PDHA than non hospitalized (18%)
7. IndicatorsPhysicalCognitiveBehavioralEmotionalMisconductAdaptiveMust examine SxIntensityDurationFrequency Is the behavior typical for this SM?Is the SM a productive mbr of the unit?
8. Physical IndicatorsRespiratory—Short of breath, dizzy, heaviness on chestCardiovascular—pounding, incr HR & BPDigestive—nausea, cramping, vomiting, constipation, diarrhea, decr appetiteElimination System—incr bowel/urinary activity, wetting/soiling selfMusculoskeletal—trembling, shaking, back achesSleep—insomnia, nightmaresOther—HA, vertigo, exhaustion, psychomotor agitation, blurred vision
9. Cognitive IndicatorsHyperalertnessExaggerated/delayed startleInattn, short attn span, concentration probsPoor reasoning & prob solving, faulty judgment Loss of confidence, hope, faithRecurrent intrusive thoughtsFlashbacks, delusions, hallucinations
10. Behavioral IndicatorsMost readily apparent of all CarelessnessImpulsivityFreezingPanicWithdrawalInability to relaxLow energyParalysisStuttering ImmobilityErratic behaviorImpaired duty perfLoss of skillsFailure to maintain equip, personal careRapid speechImpaired sensesSelf medicatingLoss/decr senses1000 yard stare
11. 1000 Yard Stare
12. Emotional IndicatorsAnxietyFearTerrorIrritabilityArgumentativenessResentmentAngerRageGrief Guilt ShameLonelinessDepressionHelplessnessApathyDetachmentNumbnessEmotional exhaustionHysterical outbursts
13. MisconductCan be traced to CS and explain but not excuseThose w a personality d/o may be acting out their psychopathologyMay reflect a breakdown in coping when faced with the horrors of war.
14. Severe MisconductMutilating enemy deadKilling enemy soldiers, noncombatantsTortureBrutalityAnimal crueltyFighting w alliesETOH/drug abuseNeglecting disciplineAWOLDesertingLootingPillagingRapeMalingeringSelf inflicted woundsCombat refusalFragging CS DOES NOT JUSTIFY MISCONDUCT
15. Adaptive IndicatorsUnit cohesionLoyalty to peersLoyalty to leadersIdentification w unit traditionsSense of elitenessSense of missionAlertness Vigilance Exceptional strength & enduranceIncreased tolerance for hardship/discomfortSense of purposeIncreased faithHeroic acts of courageSelf sacrifice
16. Symptom ManifestationTime on Battle FieldInitiallyAdaptation~90+ Days
17. CS Contributing FactorsEnvironmentalPhysicalCognitiveEmotionalInterpersonal/UnitCulturalOperationalBehavioral
18. CS Contributing FactorsEnvironmental—weather, temp extremes, protective gear, work environmentPhysical—hunger, thirst, unfit, sleep depCognitive—Info overload, life threatening situation, sensory overloadEmotional—Precombat mental fitness, anxiety high vs. just enough, process death, disillusionment, survival guilt, accidental killing
19. CS Contributing FactorsInterpersonal/Unit—communication, training, morale, cohesion, confidence (command, equipment, self)Cultural—differences from natives and coalition partners can add frustrationOperational—Transportation vulnerability, #s WIA/KIA, duration of continuous ops, battle intensity, political restraint (SMs may be provoked by population)
20. CS Contributing FactorsBehavioral—Reflect CS, can also contribute to CS:Psych impact of killing (Grossman 1996)Concern about ability to killActual act-- reflexive no conscious thoughtSatisfaction from successfully using training can create a high/rushRemorse, nausea; identification, empathy, sorrow, revulsionRationalization, acceptance—a lifelong process requiring home community’s understanding that killing in combat was just and necessary
21. CS InterventionBrevity—12-72 hour intervention periodImmediate—intervention upon Sx recognitionCentrality—provide intervention away from med/MH casualtiesExpectancy—positive expectation of RTDProximity—Treat in or close to unit or combat situation
22. Ingredients of CSRInterventionsRestSafetyFoodReassuranceGroup SupportReinforce military identityFocus on crisis interventionFocus on RTD
23. Higher Level of CareThose who present with symptoms inconsistent with CS are referredThose not responding to CS Interventions within 72 hours
24. When to RTDFull resolution of Sxs not requiredSMs need to function w confidence to do their jobSM RTD conveys strong message to rest of unit that a safety net does exist and reassures them they will be able to perform their duties
25. Command Consultationfor CS PreventionMorale focusUnit Cohesion—highly preventiveBuild a team identity by overcoming dangers, hardships togetherMinimize individual competitionConfidence in CommandersDemonstrate they know what should be done, how it should be done, who should do it, and how long it will takeInform troops about commander’s intentions and objectives
26. Command Consultationfor CS PreventionConfidence in equipment and self in using toolsEquipment successfully used and in good orderSMs well trained to use equipmentLegitimacy of mission/justness of warLack of belief in mission raises questions about worth of suffering and sacrifice for the cause
27. CS Prevention During Deployment CycleDoD views CS as a community issueMH at forefront of championing community effortEducate SMs and Leaders on principles, contributing factors, emphasize morale issues Exercises simulating combat and BICEPSReintegration training for families and SMs