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  • Emotional - frustrated/angry, worried, keyed up, guilty/ashamed, depressed/withdrawn, numb, panic attacks, regression, "flat"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

• Dehydration
• Hyperthermia/Hypothermia
• Overuse syndromes
• Rhabdomyolysis
• Adjustment Disorder
• Anxiety disorder
• Brief Psychotic Disorder
• Depression
• Dissociative Disorders
• Traumatic brain injury
• Postconcussion syndrome
• Post Traumatic Stress Disorder
• Substance abuse

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