Post-Deployment Mental Health Brief

1. CAPT Bill Nash, MC, USN Operational Stress Control and Readiness (OSCAR) Psychiatrist, 1st MARDIV Combat Stress Control Coordinator, OIF-II-2, I MEF nashwp@1mardiv.usmc.mil Post-Deployment Mental Health Brief

2. Goals For This Brief • Review a few stresses of operational deployment and homecoming • Describe the processes of adapting during deployment and re-adapting after coming home • Describe the three most common combat-related stress injuries: • Traumatic Stress, including Post-Traumatic Stress Disorder (PTSD) • Operational Fatigue • Grief • Offer a few guidelines for how to help stress injuries heal

3. “Stress”: What Is It? • Stress is any challengeor demand placed on the body or mind • Stress is always both: • A danger or threat • And an opportunity • Stress provokes (requires) an adaptive response (we are never indifferent to it) • Stress is continuous and necessary • Problems arise if stress is too intense or lasts too long “DANGER” Chinese pictogram for “STRESS” “OPPORTUNITY”

4. A Few of the Many Stresses of Operational Deployment

5. A Few of the Many Stresses of Homecoming and Reunion

6. How Do Marines Adapt to Stress? • Change ourselves to better suit the environment • The goal of all training and education • This makes us more tolerant to a particular stress • Change theenvironment to better suit us • The goal of all leadership • This lessens the force and impact of that particular stress • Detach mentally from theenvironment, ourselves, or both • The least effective but most common tactic • Examples: denial, numbness, detachment

7. Adapting and Re-adapting • So, in order to adapt to deployment, Marines have had to change themselves to meet their many challenges • But they have also become numb (detached) to many of their stresses • To re-adapt to being back home: • They will have to change themselves again to meet the new challenges of being back in CONUS • And the numbness and detachment that has built up during the deployment will have to wear off • These tasks take time, hard work, and patience

8. But Some Marines Also Sustain Stress Injuries while Deployed • Some Marines and sailors sustain stress injuries due to either the impact of intense stresses or the wear-and-tear of prolonged stresses • Three types of stress injuries to know about: • Traumatic stress (including post-traumatic stress disorder) • Grief • Operational fatigue • Most stress injuries of all types heal up just fine on their own • But some do not, so it’s important to know how to recognize them

9. Traumatic Stress: What Is It? • An abrupt injury to the brain, mind, and spirit • Due to specific event(s) involving: • Terror, horror, or helplessness • Actual or threatened death or serious injury • To self or others in close proximity • Damage to necessary or deeply-held beliefs • Belief in one’s own basic safety • Belief in being the master of oneself and one’s environment • Belief in “what’s right”— moral order, ethics, expectations • Belief in one’s own basic goodness • Physiological hyper-arousal — “fight or flight” • Shame or guilt • For failing to meet one’s own expectations • For surviving when others did not • For failing to save others from harm, especially subordinates

10. Traumatic Stresses in OIF • Multi-casualty incidents (SVBIEDs, ambushes) • Friendly fire • Death or maiming of children and women • Seeing gruesome scenes of carnage • Handling dead bodies and body parts • “Avoidable” casualties and losses • Witnessed or committed atrocities • Witnessed death/injury of a close friend or leader • Killing unarmed or defenseless enemy • Being helpless to defend or counterattack • Injuries or near misses • Killing someone up close • Adverse media, public opinion

11. Traumatic Stress: Symptoms • Early symptoms: dissociation • Either an abrupt mental numbness, going blank, a trance-like state • Or, a change in personality (becoming cruel, fearless or childlike) • Later symptoms • Re-experiencing • Severe (repetitive) nightmares • Flashbacks or intrusive memories or mental images • Avoidance and emotional numbing • Avoidance of reminders of the traumatic experience • Or of situations similar in any way to the traumatic experience • Feeling “cold”, hard, distant • Increased arousal or agitation • Can’t calm down or relax, can’t get to sleep or stay sleep • Anxiety (panic) attacks or anger (rage) outbursts

12. Other Traumatic Stress Symptoms • Poor stress tolerance (easily upset, frustrated) • Substance abuse and misuse of all kinds • Emotional instability, moodiness • Short-term memory problems • Persisting loss of moral compass, values, impulse control • Paranoia (e.g., being afraid to sleep without a weapon) • Hallucinations (seeing or hearing things not there) • Unintentional aggressive acts (e.g., domestic violence, startle responses to being touched) • Aggressive fantasies and intentional aggression (e.g., cruising tough neighborhoods, bar fights) • Guilt over and fear of aggressive impulses (not wanting to be around people any more) • Self-destructive behaviors • Feeling like combat is the only place you fit in any more

13. How Traumatic Stress Symptoms Change over Time • Many people experience symptoms during and after a traumatic stress • Most people heal up quickly and naturally without professional help • Only 10-20% continue to experience symptoms long term HYPERAROUSAL Anxiety (Dissonance) Level Time  TRAUMATIC EVENT

14. Operational Fatigue: What Is It? • Emotional changes after prolonged exposure to combat/operational stress • How soon it sets in depends on how severe and continuous the operational stresses have been • Eventually, everyone succumbs if exposure is continuous, even to low-intensity operational stresses • Caused by an accumulation of small stresses • Danger, hardships • Monotony • Insufficient rest or recuperation • More common in officers and SNCOs than in younger troops • “Old Sergeant's Syndrome”

15. Operational Fatigue: Symptoms • Anxiety and panic attacks • Worry, tension, difficulty relaxing • Attacks of rapid heart beat:“Soldier’s Heart” • Anger and irritability • Temper outbursts • Difficulties handling frustrations • Insomnia • Can’t get to sleep • Can’t stay asleep • Loss of confidence • Loss of ability to enjoy life or feel pleasure

16. Grief and Traumatic Grief: What Are They? • Grief is how we adapt to the stress of losing someone (or something) important to us • The work of grieving includes both: • Managing and surviving painful emotions • Relearning the world now without the lost person • “Traumatic grief” is a particular type of grief which includes some symptoms of PTSD: • Intrusive and distressing preoccupations with thoughts about the deceased (often associated with feelings of guilt or shame) • Dissociative symptoms: feeling dazed, stunned, shocked • Loss of trust in one’s own security, trust in the world • Shattered world view; inability to make sense out of the death • Like PTSD, traumatic grief can become chronic

17. Steps to Promote Healing from Stress Injuries • Get safe: reduce levels of physiological arousal and intense emotionas soon as possible — slow yourself down • Get enough sleep every day (6-8 hours minimum)! • Limit alcohol and avoid drugs (including caffeine)—they’re a trap! • Avoid thinking or talking about painful memories except when you feel safe • Surround yourself with people (buddies, family, ministers, counselors) who make you feel safe as much as you can

18. Steps to Promote Healing from Stress Injuries • Stay safe: just say “NO” to violence • Avoid any situations in which you might become violent or lose your temper • Avoid conflict with spouses, family, friends, strangers • Don’t let yourself dwell on violent images or impulses if they pop into your head • Get away from situations which make you angry, if you can • If you need a violence “fix”, try sports or something safe, but only if you can do it without “losing it” • Don’t let yourself drive recklessly or too fast

19. Steps to Promote Healing from Stress Injuries • Take care of yourself • Work out regularly; exercise is a natural treatment for stress, anxiety and depression • Make time for yourself; try to keep a balance between work, family, and personal time in your life • If you are bored, find a new challenge to take on in your life • Go to school • Learn a new sport or hobby • Volunteer to help others

20. Steps to Promote Healing from Stress Injuries • Remember and talk: once you can recall the details of painful experiences without getting upset, begin telling your story • Tell yourself what happened, in detail; write down your experiences • Tell others whom you trust what happened • Be on guard for twisted, self-destructive thoughts • Blaming yourself for something that wasn’t your fault • Forgetting that all combat deaths and injuries are uniquely honorable, even if they don’t make sense • Your goals for remembering and talking are: • To weave your fragments of memory into a coherent narrative • To begin to put the puzzle pieces together to make a whole picture • To forgive yourself and others — may need to make amends

21. Steps to Promote Healing from Stress Injuries • See a doctor: consider medical help if any of the following persist for more than a month: • Can’t get to sleep or stay asleep • Repetitive nightmares that don’t start going away — especially if they wake you up • Panic or anxiety attacks that you can’t control • Rage or anger attacks you can’t control • Thoughts about killing yourself or someone else • Difficulties going out in public or sleeping without a weapon • Alcohol or drug use that’s out of control • Can’t remember and think through the details of what happened because it remains too painful

22. Steps to Promote Healing from Stress Injuries • Stay connected: don’t isolate yourself • Stay connected with a community of other marines, sailors, and veterans if you can • Tell your spouse as much as you and your spouse can handle (try to lower the trust barrier between you) • Chaplains, counselors • Church • PTSD groups at Marine Corps Community Services • Vet Centers: www.va.gov/rcs (after release from active duty) • Vista: 760-643-2070 • San Diego: 619-294-2040 • Help others

23. Questions?