CAPT Bill Nash, MC, USN

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Combat Stress Injuries
Challenges for the 21st Century

• CAPT Bill Nash, MC, USN
• Combat/Operational Stress Control Coordinator
• Headquarters, Marine Corps

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Challenges

• Taking stock of where past approaches to combat
  stress and PTSD have succeeded, and where failed
• No more epidemics of battlefield stress
  casualties
• But what about warfighters health and
  well-being?
• Clarifying fuzzy thinking about stress reactions
• Are they normal reactions to abnormal events?
• Are they moral weakness, a sickness of will?
• Or are they real, literal injuries?
• Re-examining old doctrines in light of the
  current war, modern culture, and new technologies
• First long war for U.S. since DSM-III defined
  PTSD
• Todays warfighters are very different than in
  the past
• 21st century brain science was unimaginable in
  the past
• Reducing the stigma of PTSD and combat stress
• Alleviating shame
• Limiting real damage to careers and futures

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Rates of Diagnosed Battlefield Stress Casualties
in Four Wars

• These are just the ones who received a diagnosis
  and treatment in theater

Combat Stress Casualty Rates (Percentage of
Troops)
All U.S. Forces I MEF only
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Compared to the Estimated Prevalence of PTSD
Post-Deployment


Combat Stress Problem Rates (Percentage of Troops)
Vietnam Veterans Readjustment Study (1983)
Hoge (2004)
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Why Are Post-Deployment Stress Problems Expected
to Be Greater Than on the Battlefield?
Three Possible Reasons

• Estimates of post-deployment PTSD are
  over-inflated (not a real problem)
• PTSD cases are real but mostly delayed in onset
  (not present during deployment)
• Most PTSD cases are simply not identified in
  their early stages (if ever)

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Marine Mental Health Diagnoses Discharges Each
Year Since 2000
Annual Number of New Cases or PEB Discharges
2.6 of post-deployment Marines are diagnosed
with PTSD each year
CY 2006 estimated from data through November
2006 (Discharges do not include Traumatic
Brain Injury)
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How Often Have Senior Leaders Observed Stress
Reactions in Their Marines?
Significant stress reactions are not rare!
MANY TIMES
NEVER
A FEW TIMES
ONCE OR TWICE
Marine E-8s surveyed anonymously
N 125
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How Often Have Senior Leaders Seen Marines Avoid
Getting Help for Stress Problems?
Avoiding care for stress problems is common!
MANY TIMES
NEVER
ONCE OR TWICE
A FEW TIMES
Marine E-8s surveyed anonymously
N 125
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Why Do Warfighters Avoid Getting HelpDuring and
After Deployment?
Two Different Views of Stress
WARRIORS View
WIZARDS View

• Stress is a weapon in war
• Stress is essential for training
• Stress is unavoidable friction in war
• Stress is a test of manhood
• Stress symptoms are shameful

• Stress is a toxin to be avoided
• Stress is a cause of illness
• Stress is suffering to be relieved
• Stress may even be seen as cruel
• Stress symptoms are only human

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Have we medical and mental healthcare providers
added to the burden of shame and stigma for
combat stress and PTSD?
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History of Combat Stress Theories
STRESS REACTION LABELS AND THEORIES
MEDICAL
misconduct, weakness, bad choices
nostalgia
shell shock, neurosis
gods, vice, fate
insanity, soldiers heart, railway spine
NON-MEDICAL
fatigue, hysteria
stress injury
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1916 The Year We Decided Combat Stress Was a
Sickness of the Will

• Late 19th century larger numbers of railway
  spine cases in railway accident victims caused
  insurance industry backlash, trying to prove
  accidents didnt cause symptoms
• Early 20th century vigorous debate in Europe
  (esp. Germany) and US over whether PTSD symptoms
  were due to trauma or pre-existing weakness
• 1914 WWI began to generate large numbers of
  shell shock cases
• 1915 Thousands of evacuations from the front on
  both sides of the war each month
• No evidence of brain damage could be found in any
• Some shell shock cases had never been in combat
• Very few cases of shell shock among seriously
  injured
• Conversion symptoms could be cured by hypnosis
• Sep, 1916 Congress of neurologists and
  psychiatrists in Munich voted, out of patriotic
  duty to Fatherland, that Nervenshock was due to
  character weakness, not trauma

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Consequences of 1916 Munich Congress on the
Battlefield

• 1916 War Hysteria was defined solely in terms
  of failure to function in ones job
• 1916 Germans, French, and British all set up
  forward combat stress stations
• Stopped evacuating all but the worst cases
• British required C.O.s signature for MEDEVAC
• Returned 60-80 back to duty after brief rest
• PIES principles invented expectancy key
• 1917 British War Office ordered surgeons to stop
  using shell shock instead, all cases labeled
  Not Yet Diagnosed, Nervous (NYDN)
• 1917 Americans entered WWI, following British
  practices

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Consequences of 1916 Munich Congress in the Rear

• If combat stress was due to a sickness of the
  will, then treatment became a contest of wills
• Coercive therapies became standard practice for
  treatment of WWI conversion symptoms
• Hypnosis
• Electric shock treatment until symptoms went
  away (at least a dozen were killed)
• Hot bath treatments up to 48 hours continuously
  immersed in 104 degree bath
• Isolation treatments confined in darkness for
  days, until symptoms went away
• Most conversion symptoms resolved, but what about
  other PTSD symptoms?

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It is important to remember that most
psychiatric casualties are soldiers who
unconsciously seek a medical exit from combat
Jones (1995), War Psychiatry
If We Agreed in 1916 That Combat Stress is Not
Real, When Did We Change Our Minds?
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A Challenge to DoctrineWhats Wrong With this
Pocket Guide for Brain Injury?
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Stress Injuries vs. Stress Reactions
Injury Synonyms
Reaction Synonyms

• Wound
• Damage
• Harm
• Hurt
• Pain
• Blight

Impairment Trauma Maiming Disabling Distortion Wea
kening
Response Answer Reply Rejoinder Operation
Behavior Functioning Working Performing Coping
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Adaptive Coping vs. Stress Injury
Stress injuries can heal

• Injured by stress
• May feel like youve lost it
• Often more abrupt change
• Dont feel like yourself any more
• You lose control

• Bent by stress
• May feel irritable or anxious
• A gradual change
• You still feel like yourself
• You remain in control

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The Evidence That Severe Stress Really Can
Inflict a Literal Injury

• Stress injuries are irreversible
• Trauma cannot be undone
• Trauma causes lasting changes (susceptibility
  and/or growth)
• Stress injuries entail a loss of function
• Loss of ability to regulate physical functions
• Loss of ability to regulate emotions
• Loss of ability to regulate memory
• Loss of moral compass
• Stress injury symptoms are very predictable
• They occur in predictable syndromic groups
• Their natural course over time can be predicted
• Risk and resiliency factors are predictable

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Three Mechanisms of Stress Injury
COMBAT / OPERATIONAL STRESS
TRAUMA
GRIEF
FATIGUE

• An impact injury
• Due to events involving terror, horror, or
  helplessness

• A loss injury
• Due to the loss of people who are cared about

• A wear-and-tear injury
• Due to the accumulation of stress over time

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Stress Injuries Correlate with DSM-IV Diagnoses
COMBAT / OPERATIONAL STRESS
TRAUMA
GRIEF
FATIGUE
ASD
GAD
Adj D/O
V62.82
MDD
Panic
MDD
PTSD
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What is Damaged in Stress Injuries?

• In the Brain
• Messenger chemicals get depleted
• Set points in control systems get shifted
  (allostasis)
• Excessive and persistent arousal (phys/emotional)
• Possible literal damage to the hippocampus from
  cortisol and excessive excitation
• In the Mind
• Necessary and deeply-held beliefs are cracked
• Self-worth and self-confidence are shaken
• Sustaining attachments may be lost
• Ability to integrate memories is damaged
• In the Spirit and Relationships
• Life doesnt make sense like it used to
• Ability to forgive and feel forgiven is damaged
• Trust and connection to others is damaged

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The Brain Systems of Stress
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The Brain Systems of Stress
Amygdala
CRF
Hippocampus Prefrontal Cortex
Norepinephrine, Adrenaline
Serotonin, GABA
Dopamine, Endorphins
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The Two Charioteers the Amygdala and the
HippocampusPrefrontal Cortex (PFC)
PFC
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The Hippocampus Damaged by Severe Stress
Crap! Dissociated again!

• Three possible mechanisms of injury to
  hippocampus
• Cortisol toxicity
• Slowed regrowth
• Excitoxicity bursting of over-excited neurons

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Beliefs That Can Be Damaged By Combat or
Operational 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)

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Causes of Shame or Guilt In Operational 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

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How Stress Injury Approach Helps Meet 21st
Century Combat Stress Control Challenges

• It gives equal attention to the two goals of
  combat/operational stress control
• Readiness and occupational functioning
• Long-term health and well-being
• It reduces the burden of shame for personal
  responsibility for failure to cope
• Injuries are part of the cost of doing business
• Injuries are no ones personal fault
• It demystifies mental and behavioral function for
  warfighters by focusing on fundamental biology
• It attempts to synthesize impacts of stress
  injuries on brain, mind, and spirit
• It affords warfighters the respect they deserve

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Let Today Be That Day
When Did We Decide That Combat Stress and PTSD
Are NOT Primarily a Sickness of Will?
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