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 syndromePTSD

Reexperiences of traumaAvoidance of traumatic remindersIncreased 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

45 days of continuous infantry combat: Double exposure – acute chronic reaction (no delays)some control/ some uncertainty.

War sailor/ concentration camp prisoner: high risk, continuous long duration, no control, high uncertainty.

< 6 years 5 – 50 years

Delayed psychic injury

1944-45 1945 - 1950

The Alta BattalionThe Alta BattalionA 60 Year Follow-Up of A 60 Year Follow-Up of

World War II Combat VeteransWorld War II Combat Veterans Lars Weisæth, MD, PhD

Kolbjørn Øygard, MDKolbjørn Øygard, MDOttar Vold, Cand PhilolOttar Vold, Cand Philol

Arnfinn Tønnessen, PhDArnfinn Tønnessen, PhD  

With the clinical assistance ofWith the clinical assistance ofHåkon Kristiansen, Cand.Psychol.Håkon Kristiansen, Cand.Psychol.

Pål Herlofsen, MD, LtCol.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

Reserve Battalion

IR13/2 Battalion

October 1944 –May 1945

April-June 1940

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 59%

• 2 line: Heavy machine gun units

and mortar units 24%• 3 line: Company staff 14%• 4 line: Supply and logistical units 3%

The conditions during battle

Combat related psychiatric disorder (n=81) Results in percentage

• None: 38 %• Minor: 27 %• Moderate: 25 %• Severe: 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

3. Later during the war

29

5

36

6

4. 1945-1998 0 0

5. No reactions reported 26 32

6. Unknown 2 2

Total 81 100

Used Vailant’s approach to categorise Combat stress exposure

1. Being under enemy fire2. Firing at the enemy3. Killing anyone4. Seeing own/allies killed or wounded5. Seeing enemies killed or wounded6. Being wounded7. Duration

• (1 point 1-21 days of intensity 6+)• (2 points 22+ days of intensity 6+)

8. 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

War related psyciatric symptoms?

Moderate to serious

Some symptoms

No symptoms

Pe

rce

nt

100

90

80

70

60

50

40

30

20

10

0

Combat exposure

Low exposure

Moderate exposure

High exposure

51

2722

29

41

29

1818

65

Levels of combat stress index and psychological reactions, n=71

Life-time somatic health (n=81) Results in percentage

• Very good 29%• Average 39%• Early disability (<55 years) 17,5• Disability after 55 years 2,5• Poor 6%

Life-time somatic health / Combat related psychiatric disorders

Main findings

• 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

• 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 rearEvacuation 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 WeisæthHåkon KristiansenTerje Olav RødArnfinn Tønnessen

HQ Defence NorwayMedical 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)

0

1

2

3

4

5

6

7Mean - all risks

Violence andaggression frome thepopulationIED – (ImprovisedExplosive Device)

Extreme heat

Attacks while undertransport missions

A traffic accident

Frequency of phone contact last month and having a partner (10/10)

50

28

0

38

10

27

50

3

40

05

101520253035404550

No contact 1-3 times Once a week Severaltimes a week

Daily

Single Living in a relationship

Recruitment

Military service

Discharge

Veteran life

Preparation Training –Exercise

The need for a comprehensive approach

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

Symptom PercentageFatigue 21

Skin rash 18

Headache 18

Muscle, joint pain 17

Loss of memory 14

Shortness of breath 8

Sleep disturbances 6

Diarrhea and other gastrointestinal symptoms 5

Other symptoms involving skin 4

Chest pain 4

No complaint 12

Most Frequent Symptoms among 53,835 Participants in the Veterans Affair Registry (1992–1997)

SOURCE: Murphy et al., 1999

Diagnosis (ICD-9-CM) PercentageNo medical diagnosis 27

Musculoskeletal and connective tissue 25

Mental disorders 15

Respiratory system 14

Skin and subcutaneous tissue 13

Digestive system 11

Nervous system 8

Infectious diseases 7

Circulatory system 6

Injury and poisoning 5

Genitourinary system 3

Neoplasm 0

Most Frequent Diagnoses among 53,835 Participants in the Veterans Affair Registry (1992–1997)

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.

SANSJEF 2/6-04 ATO

Post Traumatisk Stress Symptomer – 10 ( PTSS-10) UNIFIL studien viz – IZSFOR-I ( Prosentandel med skåre 4 eller høyere på enkelt item)

UNIFIL IZSFOR-I

• Søvnproblemer 7,4 5,6• Drømmer med mareritt 2,0 1,6• Depresjon, føler seg nedtrykt 7,2 3,2 • Skvettenhet ved plutselige lyder eller brå bevegelser 10,5 10,4• Tendens til å isolere meg fra andre 10,5 3,2• Irritabilitet (blir lett irritert eller sint) 14,2 8,8• At følelsene svinger mye opp og ned 16,1 5,6• Dårlig samvittighet, selvbebreidelser, skyldfølelse 9,6

3,2• Frykt for steder eller situasjoner som kan minne

om hendelser fra tjenesten 2,0 1,6• Anspenthet i kroppen 9,1 4,0

SANSJEF 2/6-04 ATO

Post Traumatisk Stress Symptomer – 10 ( PTSS-10) UNIFIL studien viz – IZSFOR-I ( Prosentandel med skåre 4 eller høyere på enkelt item)

UNIFIL IZSFOR-I

• Søvnproblemer 7,4 5,6• Drømmer med mareritt 2,0 1,6• Depresjon, føler seg nedtrykt 7,2 3,2 • Skvettenhet ved plutselige lyder eller brå bevegelser 10,5 10,4• Tendens til å isolere meg fra andre 10,5 3,2• Irritabilitet (blir lett irritert eller sint) 14,2 8,8• At følelsene svinger mye opp og ned 16,1 5,6• Dårlig samvittighet, selvbebreidelser, skyldfølelse 9,6

3,2• Frykt for steder eller situasjoner som kan minne

om hendelser fra tjenesten 2,0 1,6• Anspenthet i kroppen 9,1 4,0

SANSJEF 2/6-04 ATO

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”.

Alcohol consumption – Have there been any changes over time?

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2002 2003 2004 2005

Year

Pre

vale

nce

of

bin

ge

drin

kin

g

Armed Forces aged 25-44

General Population aged 25-44

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

PTSD case

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)

1 Adjusted for confounder; 2 Confounders plus combat role and problems at home

Things could be worse……

Explaining the differences

0

5

10

15

20

US UK

%PC

L-ca

ses

Before/era OIF/TELIC

US: Hoge et al NEJM 2004; 351:13-22

UK: Hotopf et al. Lancet 2006: 367: 1731-1741

Rates of PTSD: All TELIC versus Combat Infantry OIF

0

5

10

15

20

US UK Canada

%PC

L-ca

ses

Before/era OIF/TELIC/COMBAT

US: Hoge et al NEJM 2004; UK: Hotopf et al. Lancet 2006: Canada; Sareen et al, Archives 2007

Rates of PTSD: TELIC “Teeth arms” versus Combat Infantry OIF

US Brigade Combat Team

6,45,0

9,37,9 7,9

12,9

17,1

12,0

17,0

23,2

6.3

11.5

0

5

10

15

20

25

30

Depression Anxiety PTSD Any MentalHealth Problem

Pe

rce

nt

pre-OIF

3 mth Post OIF

12 mth PostOIF

Source: Land Combat Study (Hoge & Castro)Land Combat Study, Hoge/Castro

Rising rates of PTSD post deployment may not be universal

0

2

4

6

8

10

12

14

16

18

Pre-tour 0months

3months

6months

12months

Hoge, et al. 2004 &2007 - US Reg

Cabrera, et al. 2007 -US Reg

Milliken, et al. 2007 -US Reg

Grieger, et al. 2006 -US Med Evacs

UK

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 (p=<0.0001)

Of the 800 with psychiatric disorders

• 42% report seeking help

• Most are seen in primary care

• Very few receive best evidence-based treatment (CBT); most receive medication

• Broadly comparable with UK and US general population studies