Post-Deployment Mental Health Brief CAPT Bill Nash, MC, USN Operational Stress Control and Readiness (OSCAR) Psychiatrist, 1 st MARDIV Combat Stress Control

Post-Deployment Mental Post-Deployment Mental Health BriefHealth Brief

CAPT Bill Nash, MC, USNCAPT Bill Nash, MC, USN

Operational Stress Control and Readiness Operational Stress Control and Readiness (OSCAR) Psychiatrist, 1(OSCAR) Psychiatrist, 1stst MARDIV MARDIV

Combat Stress Control Coordinator, Combat Stress Control Coordinator, OIF-II-2, I MEFOIF-II-2, I MEF

[email protected]@1mardiv.usmc.mil

Goals For This BriefGoals For This Brief

1.1. Review a few stresses of operational deployment Review a few stresses of operational deployment and homecomingand homecoming

2.2. Describe the processes of adapting during Describe the processes of adapting during deployment and re-adapting after coming homedeployment and re-adapting after coming home

3.3. Describe the three most common combat-related Describe the three most common combat-related stress injuries:stress injuries:– Traumatic Stress, including Post-Traumatic Stress Disorder Traumatic Stress, including Post-Traumatic Stress Disorder

(PTSD)(PTSD)– Operational FatigueOperational Fatigue– GriefGrief

4.4. Offer a few guidelines for how to help stress Offer a few guidelines for how to help stress injuries healinjuries heal

““Stress”: What Is It?Stress”: What Is It?

• Stress is Stress is anyany challenge challenge or demand placed or demand placed on the body or mindon the body or mind

• Stress is always both:Stress is always both:– A danger or threatA danger or threat– And an opportunityAnd an opportunity

• Stress provokes (requires) an adaptive Stress provokes (requires) an adaptive response (we are never indifferent to it)response (we are never indifferent to it)

• Stress is continuous and necessaryStress is continuous and necessary

• Problems arise if stress is too intense or Problems arise if stress is too intense or lasts too longlasts too long

Chinese pictogram Chinese pictogram for “STRESS”for “STRESS”

““DANGER”DANGER”

““OPPORTUNITY”OPPORTUNITY”

A Few of the Many Stresses of A Few of the Many Stresses of Operational DeploymentOperational Deployment

PHYSICAL

• Heat • Dehydration • Illness

• Cold • Sleep deprivation • Injury

MENTAL

• Alternating between hyper-focused & bored

• Insufficient information • Value conflicts

EMOTIONAL

• Fear (of failure) • Hatred of the enemy

• Loss of friends • Guilt and shame

SOCIAL

• Being away from loved ones and friends

• Loss of personal space • Isolation

SPIRITUAL

• Life doesn’t make sense like it used to

• Loss of faith • Loss of purpose

A Few of the Many Stresses of A Few of the Many Stresses of Homecoming and ReunionHomecoming and Reunion

PHYSICAL

• Fast vehicles • Traffic • Crowds

• Bright lights, loud noises, fast pace

MENTAL

• Not knowing how much to tell family, friends

• Loyalty conflicts • Boredom

EMOTIONAL

• Grief • Feeling unsafe

• Guilt and shame • Anger toward leaders

SOCIAL

• Being separated from buddies and leaders

• Being overwhelmed by family

SPIRITUAL

• Not understanding why peers suffered/died

• Loss of faith • Loss of purpose

How Do Marines Adapt to Stress?How Do Marines Adapt to Stress?

SURRENDER CONQUER DISENGAGE

• Change Change ourselves to ourselves to better suit the better suit the environmentenvironment

• The goal of all The goal of all training and training and education education

• This makes us This makes us more tolerant to more tolerant to a particular a particular stressstress

• Change theChange the environment to environment to better suit usbetter suit us

• The goal of all The goal of all leadership leadership

• This lessens the This lessens the force and impact force and impact of that particular of that particular stressstress

• Detach mentally Detach mentally from thefrom the environment, environment, ourselves, or bothourselves, or both

• The least The least effective but most effective but most common tacticcommon tactic

• Examples: denial, Examples: denial, numbness, numbness, detachmentdetachment

Adapting and Re-adaptingAdapting and Re-adapting

• So, in order to adapt to deployment, Marines So, in order to adapt to deployment, Marines have had to change themselves to meet their have had to change themselves to meet their many challengesmany challenges

• But they have also become numb (detached) But they have also become numb (detached) to many of their stressesto many of their stresses

• To re-adapt to being back home:To re-adapt to being back home:– They will have to They will have to change themselves againchange themselves again to meet the new to meet the new

challenges of being back in CONUSchallenges of being back in CONUS– And the And the numbnessnumbness and detachment that has built up during and detachment that has built up during

the deployment the deployment will have to wear offwill have to wear off• These tasks take time, hard work, and These tasks take time, hard work, and

patiencepatience

But Some Marines Also Sustain But Some Marines Also Sustain Stress Injuries while DeployedStress Injuries while Deployed

• Some Marines and sailors sustain stress Some Marines and sailors sustain stress injuries due to either the impact of intense injuries due to either the impact of intense stresses or the wear-and-tear of prolonged stresses or the wear-and-tear of prolonged stressesstresses

• Three types of stress injuries to know about:Three types of stress injuries to know about:– Traumatic stress (including post-traumatic stress disorder)Traumatic stress (including post-traumatic stress disorder)– GriefGrief– Operational fatigueOperational fatigue

• Most stress injuries of all types heal up just Most stress injuries of all types heal up just fine on their ownfine on their own

• But some do not, so it’s important to know But some do not, so it’s important to know how to recognize themhow to recognize them

Traumatic Stress: What Is It?Traumatic Stress: What Is It? • An abrupt injury to the brain, mind, and spiritAn abrupt injury to the brain, mind, and spirit• Due to specific event(s) involving:Due to specific event(s) involving:

1.1. Terror, horror, or helplessnessTerror, horror, or helplessness Actual or threatened death or serious injuryActual or threatened death or serious injury To self or others in close proximityTo self or others in close proximity

2.2. Damage to necessary or deeply-held beliefsDamage to necessary or deeply-held beliefs Belief in one’s own basic safetyBelief in one’s own basic safety Belief in being the master of oneself and one’s environmentBelief in being the master of oneself and one’s environment Belief in “what’s right”— moral order, ethics, expectationsBelief in “what’s right”— moral order, ethics, expectations Belief in one’s own basic goodnessBelief in one’s own basic goodness

3.3. Physiological hyper-arousal — “fight or flight”Physiological hyper-arousal — “fight or flight”4.4. Shame or guiltShame or guilt

For failing to meet one’s own expectationsFor failing to meet one’s own expectations For surviving when others did notFor surviving when others did not For failing to save others from harm, especially subordinatesFor failing to save others from harm, especially subordinates

Traumatic Stresses in OIFTraumatic Stresses in OIF

1.1. Multi-casualty incidents (SVBIEDs, ambushes)Multi-casualty incidents (SVBIEDs, ambushes)2.2. Friendly fireFriendly fire3.3. Death or maiming of children and womenDeath or maiming of children and women4.4. Seeing gruesome scenes of carnageSeeing gruesome scenes of carnage5.5. Handling dead bodies and body partsHandling dead bodies and body parts6.6. “ “Avoidable” casualties and lossesAvoidable” casualties and losses7.7. Witnessed or committed atrocitiesWitnessed or committed atrocities8.8. Witnessed death/injury of a close friend or leaderWitnessed death/injury of a close friend or leader9.9. Killing unarmed or defenseless enemyKilling unarmed or defenseless enemy10.10. Being helpless to defend or counterattackBeing helpless to defend or counterattack11.11. Injuries or near missesInjuries or near misses12.12. Killing someone up closeKilling someone up close13.13. Adverse media, public opinionAdverse media, public opinion

Traumatic Stress: SymptomsTraumatic Stress: Symptoms

• Early symptoms: dissociationEarly symptoms: dissociation– Either an abrupt mental numbness, going blank, a trance-like stateEither an abrupt mental numbness, going blank, a trance-like state– Or, a change in personality (becoming cruel, fearless or childlike)Or, a change in personality (becoming cruel, fearless or childlike)

• Later symptomsLater symptoms– Re-experiencingRe-experiencing

Severe (repetitive) nightmaresSevere (repetitive) nightmaresFlashbacks or intrusive memories or mental imagesFlashbacks or intrusive memories or mental images

– Avoidance and emotional numbingAvoidance and emotional numbingAvoidance of reminders of the traumatic experienceAvoidance of reminders of the traumatic experienceOr of situations similar in any way to the traumatic experienceOr of situations similar in any way to the traumatic experienceFeeling “cold”, hard, distantFeeling “cold”, hard, distant

– Increased arousal or agitationIncreased arousal or agitationCan’t calm down or relax, can’t get to sleep or stay sleepCan’t calm down or relax, can’t get to sleep or stay sleepAnxiety (panic) attacks or anger (rage) outburstsAnxiety (panic) attacks or anger (rage) outbursts

Other Traumatic Stress SymptomsOther Traumatic Stress Symptoms

• Poor stress tolerance (easily upset, frustrated)Poor stress tolerance (easily upset, frustrated)• Substance abuse and misuse of all kindsSubstance abuse and misuse of all kinds• Emotional instability, moodinessEmotional instability, moodiness• Short-term memory problemsShort-term memory problems• Persisting loss of moral compass, values, impulse controlPersisting loss of moral compass, values, impulse control• Paranoia (e.g., being afraid to sleep without a weapon)Paranoia (e.g., being afraid to sleep without a weapon)• Hallucinations (seeing or hearing things not there)Hallucinations (seeing or hearing things not there)• UnintentionalUnintentional aggressive acts (e.g., domestic violence, aggressive acts (e.g., domestic violence,

startle responses to being touched)startle responses to being touched)• Aggressive fantasies and Aggressive fantasies and intentionalintentional aggression (e.g., aggression (e.g.,

cruising tough neighborhoods, bar fights)cruising tough neighborhoods, bar fights)• Guilt over and fear of aggressive impulses (not wanting to Guilt over and fear of aggressive impulses (not wanting to

be around people any more)be around people any more)• Self-destructive behaviorsSelf-destructive behaviors• Feeling like combat is the only place you fit in any moreFeeling like combat is the only place you fit in any more

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• Many people experience symptoms Many people experience symptoms during and after a traumatic stressduring and after a traumatic stress

• Most people heal up quickly and Most people heal up quickly and naturally without professional helpnaturally without professional help

• Only 10-20% continue to experience Only 10-20% continue to experience symptoms long termsymptoms long term

How Traumatic Stress Symptoms How Traumatic Stress Symptoms Change over TimeChange over Time

Operational Fatigue: What Is It?Operational Fatigue: What Is It?

• Emotional changes after prolonged exposure to Emotional changes after prolonged exposure to combat/operational stresscombat/operational stress– How soon it sets in depends on how severe and continuous the How soon it sets in depends on how severe and continuous the

operational stresses have beenoperational stresses have been– Eventually, Eventually, everyoneeveryone succumbs if exposure is continuous, even to succumbs if exposure is continuous, even to

low-intensity operational stresseslow-intensity operational stresses

• Caused by an accumulation of small stressesCaused by an accumulation of small stresses– Danger, hardshipsDanger, hardships– MonotonyMonotony– Insufficient rest or recuperationInsufficient rest or recuperation

• More common in officers and SNCOs than in More common in officers and SNCOs than in younger troopsyounger troops– ““Old Sergeant's Syndrome”Old Sergeant's Syndrome”

Operational Fatigue: SymptomsOperational Fatigue: Symptoms

• Anxiety and panic attacksAnxiety and panic attacks– Worry, tension, difficulty relaxingWorry, tension, difficulty relaxing– Attacks of rapid heart beat:Attacks of rapid heart beat: “Soldier’s Heart”“Soldier’s Heart”

• Anger and irritabilityAnger and irritability– Temper outburstsTemper outbursts– Difficulties handling frustrationsDifficulties handling frustrations

• InsomniaInsomnia– Can’t get to sleepCan’t get to sleep– Can’t stay asleepCan’t stay asleep

• Loss of confidenceLoss of confidence

• Loss of ability to enjoy life or feel pleasureLoss of ability to enjoy life or feel pleasure

Grief and Traumatic Grief: Grief and Traumatic Grief: What Are They?What Are They?

• Grief is how we adapt to the stress of losing Grief is how we adapt to the stress of losing someone (or something) important to ussomeone (or something) important to us

• The The workwork of grieving includes both: of grieving includes both:– Managing and surviving painful emotionsManaging and surviving painful emotions– Relearning the world now without the lost personRelearning the world now without the lost person

• ““Traumatic grief” is a particular type of grief which Traumatic grief” is a particular type of grief which includes some symptoms of PTSD:includes some symptoms of PTSD:– Intrusive and distressing preoccupations with thoughts about the Intrusive and distressing preoccupations with thoughts about the

deceased (often associated with feelings of guilt or shame)deceased (often associated with feelings of guilt or shame)– Dissociative symptoms: feeling dazed, stunned, shockedDissociative symptoms: feeling dazed, stunned, shocked– Loss of trust in one’s own security, trust in the worldLoss of trust in one’s own security, trust in the world– Shattered world view; inability to make sense out of the deathShattered world view; inability to make sense out of the death

• Like PTSD, traumatic grief can become chronicLike PTSD, traumatic grief can become chronic

Steps to Promote Healing from Steps to Promote Healing from Stress InjuriesStress Injuries

1.1. Get safeGet safe: reduce levels of physiological arousal : reduce levels of physiological arousal and intense emotionand intense emotion as soon as possible — slow as soon as possible — slow yourself downyourself down– Get enough sleep every day (6-8 hours minimum)!Get enough sleep every day (6-8 hours minimum)!– Limit alcohol and avoid drugs (including caffeine)—they’re a trap!Limit alcohol and avoid drugs (including caffeine)—they’re a trap!– Avoid thinking or talking about painful memories except when you Avoid thinking or talking about painful memories except when you

feel safefeel safe– Surround yourself with people (buddies, family, ministers, Surround yourself with people (buddies, family, ministers,

counselors) who make you feel safe as much as you cancounselors) who make you feel safe as much as you can


2.2. Stay safeStay safe: just say “NO” to violence: just say “NO” to violence– Avoid any situations in which you might become violent or lose Avoid any situations in which you might become violent or lose

your temperyour temper– Avoid conflict with spouses, family, friends, strangersAvoid conflict with spouses, family, friends, strangers– Don’t let yourself dwell on violent images or impulses if they Don’t let yourself dwell on violent images or impulses if they

pop into your headpop into your head– Get away from situations which make you angry, if you canGet away from situations which make you angry, if you can– If you need a violence “fix”, try sports or something safe, but If you need a violence “fix”, try sports or something safe, but

only if you can do it without “losing it”only if you can do it without “losing it”– Don’t let yourself drive recklessly or too fastDon’t let yourself drive recklessly or too fast


3.3. Take care of yourselfTake care of yourself– Work out regularly; exercise is a natural treatment for stress, Work out regularly; exercise is a natural treatment for stress,

anxiety and depressionanxiety and depression– Make time for yourself; try to keep a balance between work, Make time for yourself; try to keep a balance between work,

family, and personal time in your lifefamily, and personal time in your life– If you are bored, find a new challenge to take on in your lifeIf you are bored, find a new challenge to take on in your life

– Go to schoolGo to school– Learn a new sport or hobbyLearn a new sport or hobby– Volunteer to help othersVolunteer to help others

4.4. Remember and talkRemember and talk: once you can recall the details of : once you can recall the details of painful experiences without getting upset, begin telling your painful experiences without getting upset, begin telling your storystory– Tell Tell yourselfyourself what happened, in detail; write down your experiences what happened, in detail; write down your experiences– Tell Tell othersothers whom you trust what happened whom you trust what happened– Be on guard for twisted, self-destructive thoughtsBe on guard for twisted, self-destructive thoughts

Blaming yourself for something that wasn’t your faultBlaming yourself for something that wasn’t your fault Forgetting that all combat deaths and injuries are uniquely honorable, even Forgetting that all combat deaths and injuries are uniquely honorable, even

if they don’t make senseif they don’t make sense– Your goals for remembering and talking are:Your goals for remembering and talking are:

To weave your fragments of memory into a coherent narrativeTo weave your fragments of memory into a coherent narrative To begin to put the puzzle pieces together to make a whole pictureTo begin to put the puzzle pieces together to make a whole picture To forgive yourself and others — may need to make amendsTo forgive yourself and others — may need to make amends


5.5. See a doctorSee a doctor: consider medical help if any of the : consider medical help if any of the following persist for more than a month:following persist for more than a month:– Can’t get to sleep or stay asleepCan’t get to sleep or stay asleep– Repetitive nightmares that don’t start going away — especially if Repetitive nightmares that don’t start going away — especially if

they wake you upthey wake you up– Panic or anxiety attacks that you can’t controlPanic or anxiety attacks that you can’t control– Rage or anger attacks you can’t controlRage or anger attacks you can’t control– Thoughts about killing yourself or someone elseThoughts about killing yourself or someone else– Difficulties going out in public or sleeping without a weaponDifficulties going out in public or sleeping without a weapon– Alcohol or drug use that’s out of controlAlcohol or drug use that’s out of control– Can’t remember and think through the details of what happened Can’t remember and think through the details of what happened

because it remains too painfulbecause it remains too painful


6.6. Stay connectedStay connected: don’t isolate yourself: don’t isolate yourself– Stay connected with a community of other marines, Stay connected with a community of other marines,

sailors, and veterans if you cansailors, and veterans if you can– Tell your spouse as much as you and your spouse can Tell your spouse as much as you and your spouse can

handle (try to lower the trust barrier between you)handle (try to lower the trust barrier between you)– Chaplains, counselorsChaplains, counselors– ChurchChurch– PTSD groups at Marine Corps Community ServicesPTSD groups at Marine Corps Community Services– Vet Centers: Vet Centers: www.www.vava..govgov//rcsrcs (after release from active (after release from active

duty)duty) Vista: 760-643-2070Vista: 760-643-2070 San Diego: 619-294-2040San Diego: 619-294-2040

– Help othersHelp others


Questions?Questions?

Documents

Post-Deployment Mental Health Brief CAPT Bill Nash, MC, USN Operational Stress Control and Readiness (OSCAR) Psychiatrist, 1 st MARDIV Combat Stress Control