Combat stress reaction

Background

  • Observed in soldiers for centuries previously called Shell Shock, Combat Fatigue, War Neurosis, Battle Fatigue
  • Normal predictable stress reaction to the horrors of warfare
  • All military personnel at risk but protective factors can lessen risk

Risk Factors

Physical and Mental stressors are often inseparable

  • Situational
    • Unclear Rules of Engagement
    • Prior combat exposure
    • Military situation- intensity / length of fighting, number killed / wounded
    • Role in combat- support troops may be at higher risk of combat psych reactions
    • Indirect, unexpected fire
    • Brutality of enemy
  • Physical
    • Environmental
      • Heat, Cold, Wet
      • Difficult Terrain
      • Poisons
      • NBC Threats
      • Noise, Vibration
      • Visibility
    • Physiological
      • Fatigue/Sleep Debt
      • Dehydration
      • Hunger/Malnutrition
      • Poor Hygiene
      • Physical fatigue
      • Illness and Injury
  • Mental
    • INTERpersonal
      • Poor/Weak Leadership
      • Unit morale, cohesion
      • New to unit
      • Sense of social support/isolation
      • Loss of a buddy or buddies
      • Loss of faith in Leadership, self and/or God
      • Information (Too much/little)
      • Sensory (Too much/little)
      • Time (Pressured vs. Waiting)
    • INTRApersonal
      • Homefront Worries- threatened relationship, illness or other family stress
      • Fear of death/maiming
      • Fear of Cowardice
      • Loss of belief in cause
      • Sense of Winning or losing
      • Isolation/ Loneliness
      • Loss, Bereavement
      • Anger, Frustration
      • Boredom, Inactivity

Clinical Features

  • Manifests as a variety of physical, emotional, cognitive and behavioral reactions to the stressors of war
  • Combat is outside normal range of human experience which can overwhelm coping mechanisms leading to the development of stress reactions
  • Signs and Symptoms include:
    • Physical - fatigue, jumpiness, aches and pains, GI upset/nausea, diarrhea/constipation, problems eating, problems sleeping, flinching/shaking, spaced out "thousand yard stare"
    • Thinking - poor concentration, difficulty making decisions, flashbacks, nightmares, thoughts of harm to self/others, memory problems, loss of motivation
    • Emotional - frustrated/angry, worried, keyed up, guilty/ashamed, depressed/withdrawn, numb, panic attacks, regression, "flat"

Differential Diagnosis

Evaluation

  • Obtain reason why service member presents for help
  • Listen to crisis story and obtain as much collateral information as possible
  • Normalize the reaction
  • Consult or refer to mental health professional
  • Ensure no medical reasons exist that might explain symptoms

Management

  • If not physically injured don't evacuate
  • Don't treat them as "patients"
  • Normalize symptoms as stress response and reassure them that they will get better
  • Set up expectation that getting better means return to duty
  • Medical Interventions - Keep It Simple
    • PIES - Proximity, Immediacy, Expectancy, Simplicity
    • BICEPS - Brevity, Immediacy, Centrality, Expectancy, Proximity, Simplicity
    • 4 R's - Reassurance, Replenishment, Rest, Restoration
  • Medic's role:
    • Maintain combat capability
    • Restore functioning to return to duty (70-85% can be returned to duty if properly handled)
    • Assess and facilitate evacuation for those who cannot return to duty
    • Prevent long-term disability
  • Simple Treatment
    • 3 hots and a cot (food, rest, and sleep)
    • Reinforce identity as service member not as a patient
    • Activity - structured military work detail, physical exercise and recreation
    • Pair older closer to return with younger buddy
    • Supportive debriefings
    • Provide relief from danger but maintain a tactical atmosphere which is not too comfortable

Disposition

  • Help in place - minor cases which can be treated within unit
  • Rest - those cases which need non-medical support facility but not close medical or mental health observation
  • Hold - those cases which can be observed and treated in theater
  • Refer - severe cases which are too disruptive for lower level of care

See Also

References