Norge i krig?
Utfordringer i møte med soldater som drar i
krigen
Risikokommunikasjon
Oppfølging av soldater med traumer
Lars Weisæth
NKVTS/UiO/Forsvarets sanitet
Årsmøte NAMF/NFAM
Oslo 7 mai 2010
Psychic trauma
”At first denied, then exaggerated,
thereafter understood - and finally
forgotten.”
(Shephard, 2000)
The post traumatic stress syndrome
PTSD
Reexperiences of trauma
Avoidance of traumatic reminders
Increased arousal
A core element in effective therapies is
EXPOSURE
3 types of dangers
1. Concrete/ manifest
(can be seen, heard, smelt, felt, etc)
2. Anticipated danger (threat)
3. Silent danger
(cannot be perceived directly)
Psychic traumatization
The acute reaction:
Disturbed or lost capacity to think
Overwhelming or paralyzed affects
(emotional anestesia)
Reduced behavioural control
4 TYPES OF DANGER EXPOSURE – POSTTRAUMATIC STRESS REACTIONS
Inescapable shock trauma – acute reaction, most often temporary reactions
Brief repetitive – accumulating reactions
1944-45 1945 -
1950
45 days of continuous infantry combat: Double exposure – acute chronic reaction (no delays)
some control/ some uncertainty.
Delayed psychic injury
< 6 years
5 – 50 years
War sailor/ concentration camp prisoner: high risk, continuous long duration,
no control, high uncertainty.
The Alta Battalion
A 60 Year Follow-Up of
World War II Combat Veterans
Lars Weisæth, MD, PhD
Kolbjørn Øygard, MD
Ottar Vold, Cand Philol
Arnfinn Tønnessen, PhD
With the clinical assistance of
Håkon Kristiansen, Cand.Psychol.
Pål Herlofsen, MD, LtCol.
Norwegian Centre for Violence and Traumatic Stress Studies
Unirand, University of Oslo
11 ECOTS – June 2009
The Alta Battalion study
• Retrospective controlled, clinical study of a
population of veterans
• Total battalion strength 1940: N=793
• Alive, traced and examined veterans, 1998:
n=87 (100% response rate)
• Complete data on 81 veterans (10,2% - 2002)
• Control group consisted of the reserve
battalion (not deployed to area of operation)
WW II Exposure(s)
April-June 1940
October 1944 –May 1945
Alta Battalion
October 1944 –May 1945
Reserve Battalion
April-June 1940
IR13/2 Battalion
Mortality study
No apparent increase in mortality was found among the
combat veterans compared to non-combat veterans and
civilian groups matched for age, place of birth and living
Demography (n=81)
•
•
•
•
•
Privates: Conscripts year classes 1915-18
80% with grammar school only
81% from coastal and fjord communities
75% enlisted, 25% NCOs and officers
98% completed national service
• 83% completed neutrality-guard duty, 1939-40
(observing the Finnish-Soviet war – the Winter War –
across the border)
Battalion deployment (n=81)
Line of duty, percentages
• 1 line: Rifle companies
Light machine gun units
• 2 line: Heavy machine gun units
and mortar units
• 3 line: Company staff
• 4 line: Supply and logistical units
59%
24%
14%
3%
The conditions during battle
Combat related psychiatric disorder (n=81)
Results in percentage
•
•
•
•
None:
Minor:
Moderate:
Severe:
38 %
27 %
25 %
9%
Time of onset for psychological reactions
Time of onset
Frequency
Percent
1. During the campaign
19
24
2. Within days/weeks after
demobilization in 1940
29
36
3. Later during the war
5
6
4. 1945-1998
0
0
26
32
2
2
5. No reactions reported
6. Unknown
Total
81
100
Used Vailant’s approach to categorise Combat stress
exposure
1.
2.
3.
4.
5.
6.
7.
Being under enemy fire
Firing at the enemy
Killing anyone
Seeing own/allies killed or wounded
Seeing enemies killed or wounded
Being wounded
Duration
•
•
8.
(1 point 1-21 days of intensity 6+)
(2 points 22+ days of intensity 6+)
Intensity
•
•
(1 point highest level of intensity = 6 )
(2 points highest level of intensity = 7)
Three groups of Service stress exposure
Three groups according to combat exposure levels
% N=71
Low (3-5) 24 % 17
Intermediate ( 6) 24 % 17
High (7 + ) 52 % 37
Levels of combat stress index and
psychological
reactions, n=71
100
90
80
70
60
65
50
51
40
41
Combat exposure
30
29
Percent
20
29
27
Low exposure
22
18
18
10
0
Moderate exposure
High exposure
No symptoms
Moderate to serious
Some symptoms
War related psyciatric symptoms?
Life-time somatic health (n=81)
Results in percentage
•
•
•
•
•
Very good
Average
Early disability (<55 years)
Disability after 55 years
Poor
29%
39%
17,5
2,5
6%
Life-time somatic health /
Combat related psychiatric disorders
Main findings
• No apparent increase in mortality was found
among the combat veterans compared to noncombat veterans and civilian groups matched for
age, place of birth and living
• No cases within the post-traumatic stress
spectrum were identified in the non-combat
battalion
• About 30% of the combat veterans suffered from
partial PTSD
• Few of the partial PTSD cases had comorbidity
or reduced work capacity
• No cases of significantly delayed PTSD were
identified
Summary - Lessons learned
1. There is such a thing as ”Normal combat veterans
complaints” that should be distinguished from
psycho-pathology. Avoid stigma.
2. Friendly fire - talk openly about it (”fog of war”).
3. Combat veterans - check their health at later call-ups,
such as at manoeuvres.
4. Prevent comorbid disorders: alcohol!
5. If somatic health problem - suspect psychological
injury. Ask about sleep!
6. If psychological injury - suspect somatic problem
7. Meaningfulness: Symbolic effect was sufficient.
Definition: Combat Stress Reaction
• A passing reaction in a previously fit
soldier who is overwhelmed by combat
stress resulting in reduced combat
effectiveness or is temporarily combat
incapacitated
Forward Psychiatry (1/2)
PIE – proximity, immediacy, expectancy
BICEPS – brevity, immediacy, centrality,
expectancy, proximity, simplicity
1. Protection: Remove the soldier from the
most exposed battle area, but if possible
2. No evacuation to the rear
Evacuation may imply:
1. Personal failure,
2. Safety gain.
3. Loss of group cohesion
Forward Psychiatry (2/2)
3. Immediacy: Early intervention
4. Role of soldier, not patient
5. Restore: Rest and sleep
6. Psychological support
7. Recovery and Rehabilitation
through activity
8. Positive expectancy of recovery and
return to duty
A need to adapt the NATO psychiatric doctrine
to the 21st century?
• How to balance individual health among
combat stressed soldiers with manpower
needs?
• Address: Individual needs, family, and life
situation
• High quality of mental health services in
combat theatre
• Integrate mental health services into corps
medical services, participator in the unit,
do not outsource military psychiatry /
psychology
New challenges?
•
•
•
•
•
New geopolitical situation
New threats
New enemies
Changed, “modern” asymmetric warfare
Everyone owns a media outlet:
e.g. Internet beheadings on web.
Media reporting in real time, affecting the
families and the “home front”
Common mistakes
• One-sided organic / biomedical
approach, i.e. the organ system of the
zeitgeist is studied for signs of damage
• Moral
• Inflated – psychological, including
problematic conflict of compensation –
i.e. the problem of secondary gain.
• Lessons learned: combined biomedical
and psychosocial approach.
KIA:WIA:CSR ratios – still valid /
useful?
• Green helmet: Peace enforcement
• KIA:WIA:CSR
• 1 : 4 : 1
• Blue beret: Peace keeping
• KIA:WIA:CSR
• 1 : 4 : 20 ??
• CBRN: 1 : 4 : 2 ?
Is the current generation of military
health personnel repeating errors of
the past?
• Real, not yet understood phenomena, or
new versions of old problems?
• PTSD – epidemics?
• Medically unexplained illnesses:
– Gulf War syndrome
– Depleted Uranium etc
High risk factors for veteran
suicides
• UN Peacekeeping veterans (Thoresen
2006)
– Civil status
– Repatriation
– Separation / loss of partner
• New risk factor: Frequent reuse of
soldiers increase divorce / separation
rate
• Consequences ?
In summary
• The need to be aware of historical lessons learned in
the field
• Balancing the need of the organisation with the clinical
need of the individual.
• Perceived “meaningfulness” while fighting the war on
terrorism: “unclear” enemy – the role of mass media
and public support for the participation.
• The need to address and involve the families,
examples: “two career families”, the need to inform /
correct media risk picture during service abroad.
• Work proactively to lessen the stigma of mental health
problems – for instance by integrating physical and
mental health systems for veterans?
Perception of risks, threats and
a meaningful service
Norwegian First Contingent in Iraq – IZ SFOR 1
A research project from Division of Disaster Psychiatry - MUKS
Lars Weisæth
Håkon Kristiansen
Terje Olav Rød
Arnfinn Tønnessen
HQ Defence Norway
Medical Staff
The IZ SFOR-1 study (2/10)
•
•
•
•
•
Background: Weisæth and
Håkonsen were on an Inspection
trip in December 03 and decided to
conduct a research project
Format: Questionnaire survey.
Questionnaire 25 pages, estimated
response time 1 hour
When: During the last week of
service in Iraq.
Survey carried out by dr Røed.
Prof Weisæth, maj Røed and maj
Kristiansen during inspection trip
December 2003
Summing up open ended concerns
(5/10)
•
Family most worried about:
– The safety situation
– That the soldiers should be wounded
or killed
– The Norwegian medias’ description
of the situation in Iraq.
•
Risks and threats in Iraq:
–
–
–
–
•
IED – (Improvised Explosive Device)
Public crowds
Traffic situation
Direct Attack on camp
Personal concerns
– IED – (Improvised explosive device)
– Stone throwing / public crowds
– To be shot at
An IED attack with a lucky escape for a
Norwegian captain - Photo by Geir Løvhaug
Six dimensions of risk perception
(6/10)
Mean - all risks
7
6
Violence and
aggression frome the
population
IED – (Improvised
Explosive Device)
5
4
3
Extreme heat
2
1
Attacks while under
transport missions
Re
du
ce
Tr
us
t
led
ge
no
w
K
Pr
ot
ec
t
en
er
al
G
Pe
rs
on
al
0
A traffic accident
Frequency of phone contact last month and having a partner
(10/10)
50
45
40
35
30
25
20
15
10
5
0
Single
Living in a relationship
50
40
38
28
27
10
5
3
0
No contact
0
1-3 times
Once a week
Several
times a week
Daily
The need for a comprehensive approach
Veteran
life
Recruitment
Preparation
Training –
Exercise
Discharge
Military
service
Various approaches to prevention:
•
•
•
•
Selection of personnel
Training / preparing
Organizing
Early interventions and appropriate
and sufficient follow up.
Protective factors
•
•
•
•
•
•
•
•
Training
Motivation
Discipline
Weaponry and offensive equipment
Protective gear
Group cohesion
Trust in leadership
Medical support
Debriefing controversy
• Wrong use of an intervention method may be harmful
• Only briefed personnel should be debriefed
• NATO / COMED approach:
– Psychological debriefing is a group based, standardized early
intervention that is a technique used for military personnel, forming a
predefined group, who have been exposed to a potentially traumatic
event (PTE), also called a critical incident. One important goal of this
intervention is to re-establish group cohesion, support and combat /
operational fitness.
– Commanders are expected to user their skills, as leaders, to discuss
with their subordinates the experiences they have shared.
– Mitchell’s approach has to be adapted to a military environment, i.e. the
leadership role, not use “external” to lead the session.
– Post deployment debriefing is not psychological debriefing and should
not be considered to be such.
– When psychological debriefing employing mental health professionals is
used it should be undertaken with informed consent, be voluntary and
be done in groups.
– Routine psychological debriefing is not recommended.
“Daily service life” stressors and
potentially traumatic events (PTE)
•
Every day – service life stressors:
–
–
–
–
–
–
Too much work, to little rest/sleep
Not enough privacy
Tough living conditions
Isolation from friends and family
Risk communication to the families
Adapting to climate, time zone, various dimensions of a hostile
local environment and cultural challenges
– The role of accumulated stress
•
Potentially traumatic events
–
–
–
–
–
Threat to life intensity, duration
Physical injury severity, localisation
Witness experiences: emotional/geographical closeness, degree of
helplessness
Loss of buddy in same unit
Threat to integrity, impossible choices, humiliation
Managing: before, during and after:
Before:
• preparing both individuals and organisations
• Organisational level:
– Threat and risks assessments
– Medical intelligence
– Policies and guidance documents, including training,
screening and intervention programs
• Individual level:
– Realistic expectations of the service and what they might
accomplish.
– Before deployment a “departure” program
– Positive response and result expectancies
Managing during: ethical challenges
• Realise possible conflict between the
need of the organisation and the needs
of the individual, and that the mental
health professional might found
her/himself in an ethical squeeze.
• The need to balance the organisational
need of the organisation, for instance
the manning need of the Defence
force, with the clinical need of the
individual.
Managing after: surveillance of mental health –
“How do you sleep?”
• Three dimensions of sleep as an indicator:
– Falling asleep easily?
– Uninterrupted – without anxiety dreams /
nightmares
– Normal rested awakening (as opposed to a too
early awakening)
• If these factors good – our studies indicate
95% chance the veteran is not traumatised
• Sleep inquiries: Found to be non invasive –
acceptable inquiry
Managing after: To avoid negative
labels
• “Normal reactions to abnormal
situations”, “natural veteran reactions”.
• There is a need to use language that is
both understandable and acceptable
for soldiers – i.e. instead of
hyperarousal use “tactical awareness”.
Managing after: Is there a need for
specialised veteran mental health care
system?
• Challenges:
– Civilian health care system often lack both
resources and competence on veteran combat
soldiers reactions and problems
– Stigma associated with “mental health” – veterans
(and soldiers) will not use the system to get help.
• Should veterans have a separate mental
health care system, or be included in the
civilian health care system?
The Gulf War ”syndrome”
• A large number of Gulf war veterans have had a range
of health problems that they attributed to their
participation in the 1990-91 Gulf War.
• Their unexplained illnesses included: chronic fatigue,
muscle and joint pain, loss of concentration,
forgetfulness, headache and rash.
Results of the Iowa study
SOURCE: Iowa Persian Gulf Study Group, 1997
Most Frequent Symptoms among 53,835 Participants in
the Veterans Affair Registry (1992–1997)
Symptom
Percentage
Fatigue
Skin rash
Headache
M uscle, joint pain
Loss of memory
Shortness of breath
Sleep disturbances
Diarrhea and other gastrointestinal symptoms
Other symptoms involving skin
Chest pain
No complaint
21
18
18
17
14
8
6
5
4
4
12
SOURCE: Murphy et al., 1999
Most Frequent Diagnoses among 53,835 Participants
in the Veterans Affair Registry (1992–1997)
Diagnosis (ICD-9-CM)
No medical diagnosis
M usculoskeletal and connective tissue
M ental disorders
Respiratory system
Skin and subcutaneous tissue
Digestive system
Nervous system
Infectious diseases
Circulatory system
Injury and poisoning
Genitourinary system
Neoplasm
Percentage
27
25
15
14
13
11
8
7
6
5
3
0
SOURCE: Murphy et al., 1999
Exposures in the 1990-91 Gulf War
•
•
•
•
•
•
Smoke from oil-well fires, (visible on satellite images from February 9,
extinguished by November 1991).
Paints, solvents, petroleum fuels and their combustion products
Organophosphate nerve agents (e.g. Sarin),
Vaccinations for anthrax, botulinum toxid and infectious diseases
(cholera, meningitis, rabies, tetanus, typhoid), some 150 000 soldiers
received anthrax vaccination, the effect of multiple vaccinations is
uncertain.
The Drug Pyridostigmine bromide (PB – part of the carbamates), PB
was used as a pre-treatmend for exposure to nerve agents. 5 328 710
doses of PB were fielded, 250 000 personnel took PB during the war.
Depleted Uranium (DU), which is 40% ”less” radioactive than naturally
occurring uranium.
Post Traumatisk Stress Symptomer – 10 ( PTSS-10)
UNIFIL studien viz – IZSFOR-I
( Prosentandel med skåre 4 eller høyere på enkelt item)
UNIFIL IZSFOR-I
7,4
5,6
2,0
• Søvnproblemer
• Drømmer med mareritt
1,6
• Depresjon, føler seg nedtrykt
• Skvettenhet ved plutselige lyder eller brå bevegelser
• Tendens til å isolere meg fra andre
• Irritabilitet (blir lett irritert eller sint)
• At følelsene svinger mye opp og ned
• Dårlig samvittighet, selvbebreidelser, skyldfølelse
3,2
• Frykt for steder eller situasjoner som kan minne
om hendelser fra tjenesten
• Anspenthet i kroppen
SANSJEF 2/6-04 ATO
7,2
10,5
10,5
14,2
16,1
3,2
10,4
3,2
8,8
5,6
9,6
2,0
9,1
1,6
4,0
Post Traumatisk Stress Symptomer – 10 ( PTSS-10)
UNIFIL studien viz – IZSFOR-I
( Prosentandel med skåre 4 eller høyere på enkelt item)
UNIFIL IZSFOR-I
7,4
5,6
2,0
• Søvnproblemer
• Drømmer med mareritt
1,6
• Depresjon, føler seg nedtrykt
• Skvettenhet ved plutselige lyder eller brå bevegelser
• Tendens til å isolere meg fra andre
• Irritabilitet (blir lett irritert eller sint)
• At følelsene svinger mye opp og ned
• Dårlig samvittighet, selvbebreidelser, skyldfølelse
3,2
• Frykt for steder eller situasjoner som kan minne
om hendelser fra tjenesten
• Anspenthet i kroppen
SANSJEF 2/6-04 ATO
7,2
10,5
10,5
14,2
16,1
3,2
10,4
3,2
8,8
5,6
9,6
2,0
9,1
1,6
4,0
Three most positive – three most negative
aspects of the service in Iraq
• Three most positive aspects
– Teamwork
– To do the job I have trained and prepared for
– Excitement
• Three most negative aspects
– To be separated from family and friends
– The physical conditions in the area of operations
– Journalists and the media coverage
SANSJEF 2/6-04 ATO
Meaningful service?
• One out of two judge that the Norwegian force
contribution in Iraq to a high degree have been
successful
• Two thirds believe that their own contribution to the
Norwegian force contribution to a high degree have
been successful.
• One out of three – will to a little degree or not at all
recommend duty in Iraq to a friend.
• One out of five does totally, or partly agree that they
in periods have experienced the services as
meaningless (the change in security situation, has
had rather little impact on the perception of
meaningfulness).
SANSJEF 2/6-04 ATO
In summary
•
•
•
•
•
•
•
•
Teamwork, excitement, and doing the job one is prepared to do is most
frequently mentioned positive aspects.
To be separated from family, the physical conditions in AO and the
journalists / media coverage is the most frequently mentioned negative
aspects.
The soldiers own motivation and skills reported as most important
factors for successfully completion of tasks in Iraq.
IED, extreme heat and hostile public crowds as the most significant
risks.
IED as a risk is very often mentioned as a personal concern, and is
perceived as a risk that is “Impossible to protect against”
Some 80% had experienced stone throwing from public crowds, while
16% confirmed to have been in a situation they judged to have involved
a real death threat.
Even though servicing was a strain on relationships and the family
situation, nobody agreed as a serious problem to have been lacking
enough support from home while servicing.
There are some indications that serving in the “First contingent” makes
the service especially challenging – some recommends “shorter
contingent duration for first contingent”.
SANSJEF 2/6-04 ATO
Alcohol consumption –
Have there been any changes over time?
50%
Prevalence of binge drinking
45%
40%
35%
30%
25%
20%
15%
10%
5%
Armed Forces aged 25-44
General Population aged 25-44
0%
2002
2003
2004
Year
2005
What socio-demographic factors are
associated with heavy drinking?
• being under 25 years of age (1.5)
• not having children
• having a parent with a drink or drug problem
• being single
• being a smoker
• pre-enlistment adversity (4.0)
The association between the difference of expected
and actual length of last deployment and psychological
symptoms (PTSD)
OR (95% CI)1
OR (95% CI)2
Actual = expected
1.0
1.0
Actual < expected
1.0 (0.6, 1.8)
1.1 (0.7, 1.8)
Actual > expected
2.3 (1.2, 4,2)
2.4 (1.2, 4.6)
PTSD case
Adjusted for confounder; 2 Confounders plus combat
role and problems at home
1
Things could be worse……
Explaining the differences
Rates of PTSD: All TELIC versus
Combat Infantry OIF
Before/era
OIF/TELIC
%PCL-cases
20
15
10
5
0
US
UK
US: Hoge et al NEJM 2004; 351:13-22
UK: Hotopf et al. Lancet 2006: 367: 1731-1741
Rates of PTSD: TELIC “Teeth arms” versus
Combat Infantry
OIF
Before/era
OIF/TELIC/COMBAT
%PCL-cases
20
15
10
5
0
US
US: Hoge et al NEJM 2004;
UK
UK: Hotopf et al. Lancet 2006:
Canada
Canada; Sareen et al, Archives 2007
30
US Brigade Combat Team
pre-OIF
23,2
25
3 mth Post OIF
Percent
20
15
12,0
10
7,9
6.3
12,9
11.5
6,4
17,1
17,0
12 mth Post
OIF
9,3
7,9
5,0
5
0
Depression
Anxiety
Source: Land Combat Study (Hoge & Castro)
Land Combat Study, Hoge/Castro
PTSD
Any Mental
Health Problem
Rising rates of PTSD post deployment may not
be universal
18
16
Hoge, et al. 2004 &
2007 - US Reg
14
12
Cabrera, et al. 2007 US Reg
10
Milliken, et al. 2007 US Reg
8
Grieger, et al. 2006 US Med Evacs
6
4
UK
2
0
Pre-tour
0
3
6
12
months months months months
Sundin et al, in press
Veterans: barriers to care
• Compared with still serving,
veterans were more likely to report:
• Barriers to access: e.g. I don’t know
where to get help (p=<0.0001)
• Negative experiences: e.g. I have
had previous bad experiences with
mental health professionals (p=<0.001)
• Stigma: e.g. My boss discourages
the use of mental health services
Of the 800 with psychiatric
disorders
• 42% report seeking help
• Most are seen in primary care
• Very few receive best evidencebased treatment (CBT); most
receive medication
• Broadly comparable with UK and
US general population studies