Combat Operational Stress Reaction PDF

Combat operational stress reaction
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Official reprint from UpToDate www.uptodate.com 2013 UpToDate
Combat operational stress reaction Authors Section Editor David Benedek, MD Murray B Stein, MD, MPH Derrick Hamaoka, LtCol, USAF, MC, FS Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Out 4, 2013. INTRODUCTION Every member of a military service who experiences combat is affected to some degree by exposure to combat and the deployment environment. These stressors can affect military personnel in a number of domains: emotional, cognitive, physiologic, and environmental. Combat operational stress reaction (COSR) is a term used to describe the wide range of anticipated, maladaptive psychological and behavioral symptoms, often transient, that may emerge in response to these stressors following exposure to combat or other particularly stressful military operations. The US military uses the COSR designation to identify effected personnel and to intervene, generally with conservative measures such as rest and support. The epidemiology, pathogenesis, clinical manifestations, course, diagnosis, prevention, and treatment of COSR are described here. The epidemiology, pathogenesis, clinical manifestations, course, diagnosis, prevention, and treatment of psychiatric disorders related to stressful experiences, acute stress disorder, posttraumatic stress disorder, and other psychological sequelae of military combat are discussed separately. (See "Acute stress disorder: Epidemiology, clinical manifestations, and diagnosis" and "Treatment of acute stress disorder" and "Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis" and "Pharmacotherapy for posttraumatic stress disorder" and "Psychotherapy for posttraumatic stress disorder" and "Medical care of the returning veteran", section on 'Psychological sequelae'.) DEFINITION Combat operational stress reaction (COSR) is a term used by the US military to describe the wide range of maladaptive mental and behavioral symptoms (see 'Clinical manifestations' below) that can emerge in response to combat. The COSR designation is limited to individuals with some of these symptoms for the first 72 hours following their onset or identification. (See 'Clinical manifestations' below.) The effects of cumulative battlefield stress on military personnel have been recognized for over one hundred years. Older terms to describe the syndrome include shell shock [1,2], soldiers heart [3], battle fatigue [4], and psychoneuroses [5]. The United States (US) military adopted the term combat stress reaction to describe the syndrome in 1999, which was later revised to combat operational stress reaction (COSR) [6]. Individuals are classified as experiencing COSR independently of whether or not they meet criteria for a psychiatric disorder. COSR differs from a psychiatric disorder in several ways: A psychiatric disorder is diagnosed using criteria that specify the signs, symptoms, behaviors, and levels of impairment that must be present to make a diagnosis; there is no threshold number or severity of symptoms that establish the presence of COSR. To reduce stigmatization and encourage military personnel to seek help, the US military explicitly designates COSR as not constituting a psychiatric or medically diagnosable condition. COSR is not included in any version of the DSM [6] or the International Classification of Disease (ICD). (See 'Overlap with psychiatric and medical conditions' below.) If symptoms persist beyond 72 hours, US military protocol calls for further evaluation of the service member Deputy Editor Richard Hermann, MD
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for a psychiatric disorder or medical illness. EPIDEMIOLOGY Combat operational stress reaction (COSR) has been described as highly prevalent in military populations in combat environments [7]. There are no published data on the prevalence of the syndrome or the proportion of service members in combat who receive the designation. PATHOGENESIS The pathogenesis of combat operational stress reaction (COSR) is unknown. The emotional and behavioral symptoms of a COSR-type response to traumatic stress may be related to neurobiological processes believed to underlie acute stress disorder and post-stress disorder [8]. (See "Acute stress disorder: Epidemiology, clinical manifestations, and diagnosis", section on 'Pathogenesis' and "Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis", section on 'Pathophysiology'.) Conceptual framework Components of a conceptual framework for COSR have been developed and are described below. Combat stress Military personnel experience combat stress when witnessing or participating in traumatic events. Other conditions associated with military operations contribute to combat stress, including: Long working hours Austere and dangerous conditions Separation from family and other sources of support The US military describes these stressors collectively as combat operation stress (COS). Responses to combat stress Responses to combat stress can be positive or negative (figure 1). Positive responses to combat stress can include adaptive behaviors, such as [9]: Increased bonding with other individuals in the unit Building of trust and camaraderie in the aftermath of shared challenges, whether failures or accomplishments Increased confidence in personal abilities and abilities of others Adverse responses to combat stress, or COSR, include signs, symptoms, maladaptive behaviors, and impairment. Adverse effects of combat stress on service members manifest in several domains of functioning: cognitive, emotional, environmental, and physiologic [4,10]. (See 'Clinical manifestations' below.) Development over time A military deployment can be thought of as having distinct phases, each with predictable stressors and common responses in service members over time: Pre-deployment phase: Boredom Substance abuse Anticipatory anxiety Initial phase of deployment: Fast-paced operations New environment Exhaustion Marked anxiety Middle phase of deployment: Family concerns
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Final phase of deployment: Stressful if delay in leaving Homecoming: Family readjustment Grief for loss of unit camaraderie Possible risk factors The psychological response to combat and operational stressors is variable. Factors postulated to increase the risk for COSR include [11-13]: History of mental disorders/substance use problems or disorder Nonmilitary stress (eg, family or other relational problems) Prior combat exposure Length of exposure to combat or operational stress Severity of combat or operational exposures History of traumatic events (related to combat or non-combat, such as childhood abuse or sexual assault) Lack of unit cohesion/morale Lack of faith in leadership Inadequate training It has been proposed that a higher risk of developing COSR may be associated with the number of a service members risk factors, their intensity, and the duration of the period of exposure to stressors [14]. CLINICAL MANIFESTATIONS Combat operational stress reactions (COSR) are varied in both manifestations and severity. COSR can present in several domains: physiologic, mental, emotional, and behavioral [4,10]. Signs and symptoms include [11,13]: Physiologic Exhaustion Inability to sleep Somatic signs (eg, sweating, palpitations, nausea) Trembling Numbness Tingling Total loss of function in limbs or body parts Mental Inability to make decisions, process information Difficulty concentrating Nightmares Memory loss Flashback Loss of reality testing/sense of what is real Self-doubt/loss of confidence Apathy Emotional Worry Nervousness Irritability Anger Sadness Fear
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Anxiety Behavioral Inability to complete tasks Distractibility Carelessness Recklessness Misconduct Isolation Inappropriate aggressive outbursts Hypervigilance Immobility Inattention Misconduct may range from minor breaches to violations of the Uniformed Code of Military Justice [10]. COSR may be noticeable as acute behavioral and emotional changes immediately after a particularly stressful event, but COSR may also develop after days or weeks of increased exposure to the rigors of military operations (eg, altered sleep-wake cycles, harsh and austere environments, social isolation). COURSE Reports suggest that the course of combat operational stress reactions (COSR) is highly variable. Many service members have been reported to experience COSR for a self-limited duration of hours to days [10,15]. For others, symptoms and associated impairment persist and, in some cases, meet diagnostic criteria for psychiatric disorders such as acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). There is an absence of published data describing the course of individuals identified as having COSR, including subsequent rates of ASD, PTSD, and other psychological sequelae observed in veterans of military combat, including substance use disorders and suicide. (See "Acute stress disorder: Epidemiology, clinical manifestations, and diagnosis" and "Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis" and "Medical care of the returning veteran", section on 'Psychological sequelae'.) Based on US military data from the first decade of the 2000s, more than 95 percent of individuals assessed as experiencing COSR are returned to duty [4,14]. A small proportion are evacuated, either due to symptoms placing the individual or others at high risk, or due to the persistence of significant symptoms despite intervention. ASSESSMENT Recognition is the first step toward management of combat operational stress reaction (COSR). Service members peers and supervisors are often the first to recognize COSR. Service members may recognize the emergence of COSR in themselves. Common presenting symptoms include: Increased irritability Isolation Diminished performance COSR initial assessments are often completed in austere deployment environments, with limited access to mental health providers, presenting challenges for evaluation and initial assistance. The evaluation attempts to elucidate current symptoms, stressors, and degree of impairment. A priority is to determine elements of a COSR that require immediate attention as well as elements that may be amenable to simple intervention. (See 'Initial management' below.) Other primary elements of an evaluation include: Recent losses, injuries, or exposures to traumatic events (eg, firefights or blasts) A medical history Assessments of safety to self, others, the unit, and the mission The US military places an emphasis on the service members ability to perform his or her job, as occupational impairment may put others within the unit at risk. Collateral sources can provide valuable information about a service members functioning. As an example, the service members supervisor can often provide information about his or her job requirements as well as observations of performance.
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There are no criteria (eg, based on the number, type, or severity of signs or symptoms) that determine the presence or absence of COSR symptoms. The presence of symptoms or behavioral changes (see 'Clinical manifestations' above) of insufficient severity to meet a diagnostic threshold for a psychiatric disorder, but accompanied by functional impairment would generally warrant further evaluation for COSR. Such evaluation would include: Interpersonal problems Living conditions Stressors in unit Stressors with leadership Pace of work Current job Extent of training for job Past deployment history Perceived supports in unit Psychiatric evaluation including mental health history, substance use assessment, and mental status examination Physical exam to rule out medical or neurologic illness If a history of head trauma, possibly imaging to rule out traumatic brain injury Service member concerns about potential stigma can be a barrier to obtaining assistance with a COSR [16], including concerns that: Seeking help could harm his or her career He or she would be viewed as weak Service leaders would lose confidence in him or her OVERLAP WITH PSYCHIATRIC AND MEDICAL CONDITIONS Numerous psychiatric disorders may initially be classified as COSR. The designation is applied to military personnel with widely varying presentations of signs, symptoms, maladaptive behaviors, or impairments due to combat stress. In contrast, diagnosis of a psychiatric disorder is based on the presence or absence of specific symptoms for an established time period, and accompanied by impairment or distress. These disorders are diagnosed via a thorough psychiatric evaluation. As examples, diagnoses of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) require (table 1 and table 2) [17]: An intensely fearful response to experiencing or witnessing a traumatic event The presence of symptoms from each of three clusters: Dissociative Re-experiencing Hypervigilance Significant distress or impairment Specified periods of onset and duration ASD: A minimum of three days following the event, lasting up to four weeks PTSD: A minimum of a month following the event Other psychiatric disorders that may overlap with COSR or may need to be distinguished from the syndrome include major depressive disorder and adjustment disorder. (See "Clinical manifestations and diagnosis of depression" and "Unipolar minor depression in adults: Epidemiology, clinical presentation, and diagnosis", section on 'Differential diagnosis'.) Medical conditions that may need to be distinguished from COSR or identified in patients with the syndrome
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include: Traumatic brain injury (see "Concussion and mild traumatic brain injury") Infectious disease Dehydration/malnutrition Alcohol and other drug withdrawal (see "Opioid withdrawal in the emergency setting" and "Benzodiazepine poisoning and withdrawal" and "Management of moderate and severe alcohol withdrawal syndromes") Chemical or nuclear warfare agents and antidotes (eg, atropine) (see "Chemical terrorism: Diagnosis and treatment of exposure to chemical weapons" and "Treatment of radiation injury in the adult", section on 'Clinical assessment') PREVENTION Primary prevention involves monitoring, identifying, modifying, avoiding, or reducing stressors before they result in dysfunction [18]. Although not formally evaluated for effectiveness, US military practices with potentially preventive effects include: Pre-deployment preparation and training Command enforcement of appropriate sleep-work cycles Identification of social supports within units Adequate resources for nutrition and hydration accompanied by encouragement/reminders to utilize these resources Behavioral health personnel assigned to Combat Stress Control Units who may use screening instruments and outreach programs to monitor stress levels in deployed units To identify service members who may be at higher risk for either combat operational stress reaction or psychiatric disorders, the US military conducts routine, pre-deployment screenings of military personnel prior to deployment through medical record review and questionnaires. INITIAL MANAGEMENT Management of combat operational stress reaction (COSR) over the initial 72 hours generally consists of conservative measures; these may be accompanied by medication or psychotherapy in some cases. Principles The initial management of COSR is guided by the principles of brevity, immediacy, contact, expectancy, proximity, and simplicity (BICEPS). Brevity An initial intervention in COSR lasts no more than one to three days. Immediacy The intervention should be initiated as soon as practically possible. Contact Contact or centrality refers to an emphasis on the involvement of the service members unit leaders in his or her care, in part to remind the service member that he or she continues to be part of the unit. Expectancy Steps are taken to normalize the service members response to stress through: Reassurance that COSR is common and most often transient Encouragement to continue thinking of him or herself as a unit member rather as a patient An expectation that he or she will return to the unit within hours to days Proximity The service member should generally be kept close to his or her parent unit, and kept separate from medical/surgical patients, to preserve his or her identity and connectedness to the unit and mission. Simplicity Initial management of COSR should be simple.
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Other therapeutic principles include: Provide a supportive, nonjudgmental environment. Focus on the service members strengths, training, and identity within the unit. Facilitate accurate and timely communication between service members and the leaders of his or her unit. Communication is best accomplished with service members consent, although US military policy allows communications without consent to assess imminent dangerousness or impaired functioning. A fellow member of the individuals unit may facilitate communication. The principles of psychological first aid (emphasizing safety, calmness, connectedness, hope, and self-efficacy) have been proposed for use in the management of COSR [19,20]. Conservative measures Conservative measures for the individual with COSR include restorative activities such as nutrition, hydration, hygiene, and rest/sleep, as well as communication with supportive individuals in the unit and at home. The efficacy of these measures in COSR has not been evaluated in published clinical trials. Descriptive reports suggest that in many service members experiencing COSR, symptoms abate within hours to days [6,10,15,21]. Pharmacotherapy Short-term benzodiazepines are used adjunctively to treat individuals who experience COSR that includes intense anxiety, agitation, or sleep disturbance in the immediate period following a traumatic event. As an example, clonazepam 0.5 to 2 mg/day in divided doses can be used. The use of benzodiazepines in this population has not been tested in clinical trials [22]. If a service member treated with a psychotropic medication for a COSR returns to active duty, the effect of the medication on his or her work responsibilities (in particular, tasks such as guard duty, driving, and handling weapons) should be evaluated. Persistent symptoms US military protocol calls for reassessment of individuals with persistent symptoms, behaviors, or impairment for the presence of medical conditions or psychiatric disorders after 72 hours [11]. An evaluation may only be available at facilities removed from the operational frontline. Personnel who are returned to duty have ongoing access to resources including unit support, chaplains, and medical and psychiatric care. (See 'Assessment' above and 'Overlap with psychiatric and medical conditions' above.) Rates of persistent symptoms and subsequently diagnosed psychiatric disorders among individuals identified with COSR have not been reported in published research. Rates of posttraumatic stress disorder associated with combat are described separately. (See "Posttraumatic stress disorder: Epidemiology, pathophysiology, clinical manifestations, course, and diagnosis", section on 'Combat'.) SUMMARY AND RECOMMENDATIONS Combat operational stress reaction (COSR) is a term used by the US military to describe the wide range of maladaptive mental and behavioral symptoms that can emerge in response to combat. (See 'Definition' above.) The COSR designation is limited to individuals with stress-related symptoms for the first 72 hours from onset or identification. Individuals with COSR may concurrently be diagnosed with a psychiatric disorder (eg, acute stress disorder). (See 'Definition' above.) COSR is varied in both manifestations and severity. Symptoms of COSR can present in several domains: physiologic, mental, emotional, and behavioral. (See 'Clinical manifestations' above.) Many service members experience COSR for a self-limited duration of hours to days. For others, symptoms and associated impairment persist and, in some cases, meet diagnostic criteria for psychiatric disorders such as acute stress disorder and posttraumatic stress disorder. (See 'Course' above.) Management of combat operational stress reaction (COSR) over the initial 72 hours generally consists of conservative measures, including restorative activities such as nutrition, hydration, hygiene, and rest/sleep, as well as communication with supportive individuals in the unit and at home. (See 'Initial management'
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above.) Short-term benzodiazepines are used adjunctively to treat individuals who experience COSR that includes intense anxiety, agitation, or sleep disturbance in the immediate period following a traumatic event. (See 'Pharmacotherapy' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 14621 Version 2.0
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GRAPHICS Responses to combat operational stress
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DSM-IV-TR diagnostic criteria for acute stress disorder

A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. The person's response involved intense fear, helplessness, or horror B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: 1. A subjective sense of numbing, detachment, or absence of emotional responsiveness 2. A reduction in awareness of his or her surroundings (eg, "being in a daze") 3. Derealization 4. Depersonalization 5. Dissociative amnesia (ie, inability to recall an important aspect of the trauma) C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event D. Marked avoidance of stimuli that arouse recollections of the trauma (eg, thoughts, feelings, conversations, activities, places, people) E. Marked symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness) F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event H. The disturbance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder
Reprinted with permission from: the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association.
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Diagnostic criteria for posttraumatic stress disorder

Criterion A: The person has been exposed to a traumatic event in which both of the following were present:
1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person's response involved intense fear, helplessness or horror. Note: in children this may be expressed instead by disorganized or agitated behavior.
Criterion B: The traumatic event is persistently reexperienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. Note: in children there may be frightening dreams without recognizable content. 3. Acting or feeling as if the traumatic event were recurring (including a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on wakening or when intoxicated). Note: in young children trauma-specific reenactment may occur. 4. Intense psychological distress and/or physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Criterion C: Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
1. Efforts to avoid thoughts, feelings or conversations associated with the trauma 2. Efforts to avoid activities, places or people that arouse recollections of the trauma 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest in participating in significant activities 5. Feeling detached or estranged from others 6. Restricted range of effect (eg, unable to have loving feelings) 7. Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span)
Criterion D: Persistent symptoms of increased arousal (not present before trauma), as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep 2. Irritability or outbursts of anger 3. Difficulty concentrating 4. Hypervigilance 5. Exaggerated startle response
Criterion E: Duration of the disturbance (symptoms in criteria B, C, and D) is more than one month. Criterion F: Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of
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functioning. Specify if:

Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more With delayed onset: if onset of symptoms is at least six months after the stressor
Adapted from: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, American Psychiatric Association, Washington, DC 1994.
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