Combat Stress Management.pdf - UNC Charlotte Army ROTC

Personal Development Track
Section
3
COMBAT STRESS
MANAGEMENT
Key Points
1 Stress-Related Behaviors
2 Combat Stressors (Causes)
3 Combat Stress Control Techniques
4 Mild Traumatic Brain Injury (mTBI), Post Combat
Stress, and Post-Traumatic Stress Disorder
e
Studies by Medical Corps psychiatrists of combat fatigue
cases…found that fear of killing, rather than fear of
being killed, was the most common cause of battle
failure, and that fear of failure ran a strong second.
BG S.L.A. Marshall (1947)

Combat Stress Management ■ 45
Introduction
Battle fatigue is the approved Army term (AR 40-216) for combat-stress symptoms
and reactions that:
• Feel unpleasant
• Interfere with mission performance
• Are best treated with reassurance, rest, replenishment of physical needs, and
activities that restore confidence.
Battle fatigue can also be present in Soldiers who have been physically wounded or
who have non-battle injuries or diseases caused by stressors in the combat area. It may
be necessary to treat both the battle fatigue and the other problems. Battle fatigue
may coexist with misconduct stress behaviors, which are inappropriate or illegal
behaviors resulting from an increase in stress. Misconduct stress behaviors include
refusing to obey orders, drug or alcohol abuse, fighting with allies, combat refusal,
AWOL or desertion, malingering, mutilating enemy dead, torturing prisoners, killing
noncombatants, looting, pillage, and rape. But battle fatigue itself, by definition, does
not warrant legal or disciplinary action. Several US allies use other terms for battle
fatigue, such as combat reaction, combat-stress reaction, or battle shock. As a Soldier
and a leader it is your responsibility to identify and take action to reduce or remove
stressors that can lead to battle fatigue. To do this you must be able to recognize
stress-related behaviors.
This chapter will focus on the effects of combat stress (i.e., the behavior of those
with combat stress) rather than the causes and will discuss methods to manage it.
Injured Veteran Uses Own Experience to Inspire Others With Traumatic Brain Injuries
battle fatigue
traumatic
psychoneurotic reaction
or an acute psychotic
reaction occurring under
conditions (such as
wartime combat) that
cause intense stress
stress-related
behaviors
symptoms or behaviors
signaling the presence or
onset of physical or
emotional stress
Pfc. Chris Lynch, a former 82nd Airborne Division Soldier who has been living
with traumatic brain injury for the past seven years is reaching out to recently
wounded veterans of Iraq and Afghanistan to help them learn to live with the
disease.
Pfc. Chris Lynch was attending a French commando school in July 2000 when
he fell 26 feet and landed directly on his head. He went into a coma for 45 days
before arriving at Walter Reed Army Medical Center.
Pfc. Lynch was later diagnosed with traumatic brain injury or TBI—an affliction
that’s become a signature injury of the war on terror.
Roadside bombs, mortars and other explosives are taking their toll on
deployed troops’ brains as well as their bodies. Even with Kevlar helmets, there’s
a critical organ this protective gear simply doesn’t adequately protect: the
gelatin-like material that can shift violently inside the skull when confronted by
explosions, sudden jolts or shock waves from blasts.
”When they explode, your skull gets pounded against your Kevlar (helmet),“
Pfc. Lynch said. ”Your brain gets tossed around like an egg in a bucket of water.“

46 ■ SECTION 3
TBI symptoms run the gamut, from slower reaction times to severe emotional
and cognitive problems.
Pfc. Lynch remembers his own experience. When he awoke from his coma, he
had a breathing tube, had lost about a third of his body weight and was
paralyzed on his left side. Even more shocking, he was unable to speak, walk, eat
or dress without assistance.
After months of intensive therapy, both at Walter Reed and at the James A.
Haley Veterans Administration Hospital in Tampa, Fla., Pfc. Lynch slowly relearned
how to walk, talk and do other everyday tasks he once took for granted.
”The 82nd gave me the mentality to drive on,“ he said. ”There are a lot of
speed bumps in life. TBI is just a bigger one.“
Now back at his hometown of Pace, Fla., and medically retired from the Army,
Pfc. Lynch said he understands the trauma troops go through when they’re
diagnosed with TBI. He said he hopes his own experience helps them recognize
that there’s life after a TBI diagnosis and to inspire them to press on.
”It’s definitely eye opening,“ Pfc. Lynch said of his own injury. ”But it makes
you more empathetic and gives you a love for life.“
Seven years after his injury, Pfc. Lynch lives in his parents’ home and continues
to keep a ”drive on“ mentality as he rebuilds his life. He walks 5 to 10 miles a day
along the beach in Pensacola, Fla., ran eight marathons last year, and attended
the National Disabled Veterans Winter Sports Clinic in Snowmass, Colo., in April.
Meanwhile, he just graduated from Pensacola Junior College, where he studied
recreational technology, and plans to continue his studies so he can someday
teach physical education to underprivileged and handicapped children.
But as he looks to his future, Pfc. Lynch said his main focus is on helping other
troops suffering from traumatic brain injuries. He travels extensively to increase
awareness about TBI and launched a Web site that details his own recovery.
”I’ve learned a lot about interpersonal communications and become a public
speaker,“ he said. ”The bottom line is, I try to inspire other people.“
Pfc. Lynch still goes through his own personal hard times. He gets frustrated
when people who hear his still-distorted speech think he’s drunk.
And he still misses his fellow 307th Engineer Battalion Soldiers and pines for
the military career he had to leave behind.
”I miss it,“ he said. ”I miss it every day.“
Army News Service
Stress-Related Behaviors
You should always take preventive actions and address stress symptoms as they appear. If
you ignore the early warning signs, the severity of stress reactions that lead to battle fatigue
can increase. Following are examples of stress-related behaviors:

Combat Stress Management ■ 47
Simple Fatigue. The simple fatigue or exhaustion form of battle fatigue is the most common.
It involves tiredness, loss of initiative, indecisiveness, inattention, and—when extreme—
general apathy. These cases may show some features of the other forms of stress-related
behaviors, especially anxiety and pessimism, but not to the degree that Soldiers cannot rest
and recover in their own unit (duty cases) or in a nonmedical support unit (rest cases).
The tactical situation may call for them to rest in any suitable place that is practical.
Anxiety. The anxious form of battle fatigue is naturally one of the most common, given
the dangers of combat. Symptoms include verbal expressions of fear; marked startle
responses to sights and sounds that are not true threats; overreaction to loud noises; tremors;
sweating; rapid heartbeat; insomnia with terror dreams; and other symptoms of
overexcitement. This form is often seen while Soldiers are close to the danger. Soldiers’
stress may shift to simple fatigue or depressed forms as they evacuate toward the rear.
Depression. The depressed form of battle fatigue is also common. It may resemble the slowed
speech and movement of the simple fatigue form or the restlessness and startle responses
of the anxious form. A Soldier suffering from the depressed form will also have serious
feelings of self-doubt, self-blame, hopelessness, grief, and bereavement. The Soldier may
be pessimistic about the chance for victory or survival. The self-blame and guilt may result
from a Soldier’s perceived or actual failures or mistakes in combat. It may be related to
home-front issues. Or it may be survivor guilt—a survivor’s irrational feeling that he should
have died with members of his unit or in a buddy’s place.
Memory Loss. The memory-loss form of battle fatigue is less common, especially in its
extreme versions. Mild forms include an inability to remember recent orders and
instructions. More serious examples are inability to perform well-learned skills or discrete
loss of memory about an especially traumatic event or period of time. Extreme forms
include disorientation and regression to a pre-combat (for example, childhood) state. Total
amnesia, in which the Soldier leaves the threatening situation altogether, forgets his or
her own past, and is found wandering somewhere else (having taken on another superficial
identity), can also occur. Medical experts who treat Soldiers for stress-related behavior
must also rule out potential physical causes of amnesia such as concussion or substance
misuse (of alcohol, for example).
Physical Function Disturbance. This form of battle fatigue involves disturbances of physical
functions such as disruptions of motor, sensory, and speech functions. The Soldier has
no physical injuries or has injuries that by themselves do not explain the symptoms.
Psychologists and grief
counselors recognize
that people often go
through five stages of
grief when facing a
terminal illness. The
stages can also be
applied to combatrelated
stress situations:
Denial – This can’t be
happening.
Anger – Why me? This
isn’t fair!
Bargaining – Just let
me live to see my
children graduate.
Depression – I’m so
sad. Why bother with
anything?
Acceptance – It’s going
to be OK.
• Motor disturbance includes:
Weakness or paralysis of hands, limbs, or body
Sustained contractions of muscles (for example, being unable to straighten up or
to straighten out the elbow)
Gross tremors; pseudo-convulsive seizures (sometimes with loss of consciousness).
• Visual symptoms may include:
Blurred or double vision
Tunnel vision
Total blindness.
• Hearing-related symptoms may involve:
Ringing (or other noises) in the ears
Deafness
Dizziness.

48 ■ SECTION 3
• Tactile (skin) sensory changes include:
Loss of sensations (anesthesia)
Abnormal sensations, such as “pins and needles” (paresthesia).
• Speech disturbance may involve:
Stuttering
Hoarseness
Muteness.
A Soldier’s physical symptoms often begin as normal but temporary coordination problems,
speech difficulties, or sensory disruption. Physical events, such as explosions, mild
concussion, or simple fatigue can trigger these symptoms. The symptoms are magnified
when the Soldier cannot express emotions because of social pressure or heroic self-image.
Such symptoms may appear more often, therefore, in the “elite” units or groups that show
few other cases of battle fatigue—such as the airborne and Rangers in World War II.
In some cases, the Soldier’s physical “disability” may have a clear symbolic relationship
to the specific emotional trauma or conflict of motivation that the Soldier has experienced.
The disability may make the Soldier unable to do his or her job and so remove the danger,
such as classic “trigger-finger palsy.” Reducing the Soldier’s anxiety and eliminating his or
her internal conflict over combat duties may reinforce the symptoms. The Soldier’s obtaining
the relative luxury of rear-area food, hygiene, and sleep may also reinforce the symptoms.
Not all cases fit that pattern, however. Some Soldiers with significant loss of function
from battle fatigue have continued to perform their missions under great danger.
Psychosomatic Forms. The psychosomatic forms of battle fatigue commonly appear as
physical (rather than emotional) symptoms due to stress. These include:
According to some World
War II battalion
surgeons, the
psychosomatic form of
battle fatigue was the
most common form they
saw at battalion level.
This type of case may
have accounted for a
large percentage of all
patients seen at
battalion aid stations
(BASs) during times of
heavy fighting.
Leaders, medics, and
combat stress control
personnel must never
refer to battle-fatigue
casualties as “psychiatric
casualties.”
• Cardiorespiratory:
Rapid or irregular heartbeat
Shortness of breath
Light-headedness
Tingling and cramping of toes, fingers, and lips.
• Gastrointestinal:
Stomach pain
Indigestion
Nausea/vomiting
Diarrhea.
• Musculoskeletal:
Back or joint pain
Excessive pain and disability from minor or healed wounds
Headache.
Disruptive Forms. Disruptive forms of battle fatigue include disorganized, bizarre, impulsive
or violent behavior; total withdrawal; or persistent hallucinations. These are uncommon
forms, but they do occur. Battle-fatigue symptoms are a way for Soldiers to communicate
without words to comrades and leaders that they have had all they can stand at the moment.
It is important for leaders to create positive expectations and to eliminate the belief that
Soldiers suffering from battle fatigue usually do crazy, senseless, or violent things. Leaders,
medics, and combat-stress control personnel must never refer to battle-fatigue casualties
as “psychiatric casualties.”

Combat Stress Management ■ 49
Combat Stressors (Causes)
Two common themes interact in varying combinations in most battle-fatigue casualties—
loss of confidence and internal conflict of motives.
Loss of Confidence
Battle-fatigued Soldiers have often lost confidence in:
• Themselves—their own strength, alertness, and abilities, or the adequacy of their
training
• Equipment—their weapons and the supporting arms
• Buddies—other members of the small unit, or in the reliability of supporting units
• Leaders, to include:
o The skill and competence of the small-unit leader or the senior leadership
o
o
The leaders’ concern for the Soldiers’ well-being and survival
The leaders’ candor (honesty) or courage.
combat stressors
contributing factors
(sudden exposure,
cumulative exposure,
physical stressors and
stress symptoms, and
home-front and other
existing problems) that
cause battle fatigue
These doubts, plus the Soldiers’ estimate of the threat situation, raise questions in Soldiers’
minds about their chances of surviving and/or succeeding with the mission. Loss of faith
in whether the “cause” is worth suffering and dying for also plays a role. It has been said
that Soldiers join the military services for patriotism, but they fight and die for their buddies
and trusted leaders. Soldiers do not want their comrades or themselves to die for an unjust
cause or for others’ mistakes. A Soldier’s loss of faith in such cases may even spread to a
painful loss of belief in the goodness of life and other spiritual and religious values.

50 ■ SECTION 3
Internal Conflict of Motives
Combat, by its nature, creates conflicts among motives within an individual. The desire
for survival and comfort conflicts with the fears of failure or disgrace and the Soldier’s
loyalty to buddies.
Four Major Contributing Factors
Four major contributing factors cause battle fatigue. When you mix in the two themes
just covered (loss of confidence and internal conflict of motives), you understand better
why battle fatigue happens. The four major contributing factors are:
1. Sudden exposure
2. Cumulative exposure
3. Physical stressors and stress symptoms
4. Home-front and other personal problems.
Any one factor may suffice to produce battle fatigue if it is intense enough. Usually two,
three, or all four factors can collectively produce battle fatigue.
In the transitional, fluid
nonlinear characteristics
of the contemporary
operating environment
(COE), “rear areas” can
no longer be considered
“safe” as in traditional
wars and conflicts of the
past.
Sudden Exposure. This first factor is the sudden exposure or transition to the intense
fear, shocking stimuli, and life-and-death consequences of battle. This occurs most
commonly when Soldiers are committed to battle the first time, but it can happen even to
veteran Soldiers when they come under sudden, intense attack. Soldiers in traditionally
“safe” rear areas may be overwhelmed by the horrible sights, sounds, and consequences
of war without themselves being under fire. This is an occupational hazard for rearward
command and support personnel, including medical staff.
Cumulative Exposure. This second factor is the cumulative exposure to dangers,
responsibilities, and horrible consequences. Such exposure can cause repeated grief and guilt
over the loss of fellow Soldiers. It can also give a Soldier the sense that his or her own luck,
skill, and courage have run out. The rate of accumulation depends on the rate of losses
and the number of “close calls” with disaster and death in the unit, including the Soldier’s
own close calls and injuries. Giving Soldiers periods of rest, recreation, and retraining in
which they can form new supportive, cohesive bonds may temporarily reverse the
accumulation but not stop it completely.
Physical Stressors and Stress Symptoms. This third factor includes the physical stressors and
stress symptoms that reduce a Soldier’s ability to cope. Loss of sleep and dehydration are
especially strong contributors to battle fatigue. Also important are physical overload,
cold, heat, dampness, noise, vibration, blast, fumes, lack of oxygen, chronic discomfort,
poor hygiene, disrupted nutrition, low-grade fevers, infections, and other environmental
illnesses. Preventive medicine can help ward off such stressors. In moderate amounts, such
physical stressors contribute to battle fatigue, but rest and time for restoration reverse them.
In higher doses, they cause serious illness or injury requiring specific medical or surgical
treatment. When the major contributing factors to battle fatigue are physical stresses that
leaders can relieve, treatment is usually simple and recovery is rapid. Physical factors are
not necessarily the cause of battle fatigue, however. When the Soldier is diagnosed, the
absence of obvious physical stressors should not detract from a positive expectation that
the Soldier will rapidly and fully recover.
Home-Front and Other Preexisting Problems. The fourth factor is home-front and
preexisting problems. Israeli studies found that the strongest factor that distinguished

Combat Stress Management ■ 51
Soldiers who were decorated for heroic acts from those who became battle-shock casualties
was whether the casualties had experienced many recent changes on the home front.
Negative home-front problems may be a “Dear John” letter, a sick parent or child, or bad
debts. Or it may be something positive—such as a recent marriage or becoming a parent.
Worrying about what is happening back home distracts Soldiers from focusing their
psychological defenses on combat stressors. It creates internal conflict between performing
their combat duty and resolving their home-front problems or concerns.
Other Stress Factors
The second-strongest factor the Israeli studies found was unit cohesion: The Soldiers
who became stress casualties often went into battle alongside strangers, while those who
became heroes fought alongside unit members they knew well, trusted, and depended
on. These findings confirm observations from previous wars. Other stressors that experts
often cite include lack of information; lack of confidence in leaders, supporting units, or
equipment in comparison with the enemy’s; and lack of belief in the justness of the war.
It is worth noting that individual personality makeup does not predict susceptibility
to battle fatigue. Careful studies by the Army after World War II and by the Israelis since
the Yom Kippur War all show that no clear relationship exists between neurotic traits or
personality disorders and battle fatigue. People with these traits were no more likely to
become battle fatigue casualties and no less likely to be decorated for valor than were those
Soldiers who tested as normal.
There are personality factors that may predict who will be a poor Soldier (or who
may be prone to commit acts of misconduct if given opportunities or excuses). But
these factors will not predict who
will get battle fatigue. There are
good predictors of battle fatigue, but
individual personality type is not
one of them. Anyone may become
a battle fatigue casualty if he or
she confronts too many high-risk
factors. Personality factors, however,
may help predict who is likely to
recover slowly from disabling battle
fatigue. We’ve reviewed what to look
for in the way of battle-fatigue
behaviors, and what can cause them.
Now let’s look at how you can
combat and control battle fatigue.

52 ■ SECTION 3
Soldiers can manage
light battle fatigue by
themselves and with the
help of buddies, unit
medics, and leaders.
Most Soldiers in combat
will have light battle
fatigue at some time.
Duty and rest cases are
not medical casualties
because they are still
available for some duty
in their units. Those
heavy cases who cannot
return to duty or rest in
their unit the same day,
however, are battlefatigue
casualties.
The hold and refer sublabels
of heavy battle
fatigue do not
necessarily mean that a
Soldier is less likely to
recover or will take
longer to recover than
cases treated as rest.
The holding or
evacuation itself often
prolongs the treatment,
however, and decreases
likelihood of full recovery
and return to duty.
Combat Stress Control Techniques
Soldiers can manage light battle fatigue by themselves and with the help of buddies, unit
medics, and leaders. Most Soldiers in combat will have light battle fatigue at some time.
This includes the normal/common signs of battle fatigue listed previously. You do not need
to send Soldiers with these symptoms immediately for medical evaluation; they can usually
continue on duty. If the symptoms persist after rest, however, you should send the Soldiers
to their unit surgeon or physician assistant at routine sick call as cases of heavy battle fatigue.
Heavy battle fatigue requires immediate medical evaluation at a medical treatment facility.
The Soldier’s symptoms may be:
• Behavior that is temporarily too disruptive to the unit’s missions
• A medical or surgical condition that requires observation and diagnosis to rule out
the need for emergency treatment. Medical triage sorts Soldiers with heavy battle
fatigue according to where they can best be treated.
Duty cases are those in which a physician or physician’s assistant sees the Soldier, but can
treat the Soldier immediately and return him or her to duty in his or her unit.
Rest cases must be sent to their unit’s nonmedical combat service support (CSS) elements
for brief rest and light duties. Rest cases do not require continual medical observation.
Hold cases are those whom the triager can hold for treatment at the triager’s own medical
facility because both the tactical situation and the battle-fatigue casualties’ symptoms
permit. This should be done whenever feasible.
Refer cases are those who must be referred (and transported) to a more secure or betterequipped
medical facility, either because of the tactical situation or the battle fatigue
casualties’ symptoms. A refer case becomes a hold case when Soldiers reach a medical
treatment facility where they can be held and treated.
There is no easy rule for deciding whether any specific symptom of battle fatigue makes
the Soldier a case of duty, rest, hold, or refer battle fatigue. That will require your best
judgment based on:
• What you know about the individual Soldier
• The stressors involved
• The Soldier’s response to help
• What is likely to happen to the unit next
• The resources available.
Battle-fatigue symptoms can change rapidly, depending on a Soldier’s expectations. A
successful program to control combat stress prevents unnecessary evacuation and shifts battlefatigue
cases from refer to the hold triage category. More importantly, such a program shifts
many Soldiers from the hold category to the rest and duty categories. This allows them to
recover in their units and keeps them from overloading the health-service support system.

Combat Stress Management ■ 53
Mild Traumatic Brain Injury (mTBI), Post Combat Stress,
and Post-Traumatic Stress Disorder
Both mild Traumatic Brain Injury (mTBI) and post combat stress can negatively affect
Soldiers’ ability to perform their jobs. Whether in combat or in garrison, Soldiers’ inability
to perform as well as they can puts both themselves and their teammates at increased
risk.
This is a serious issue that affects everyone differently – you, your immediate and
extended family, friends, and fellow Soldiers. This issue is as important as any other Soldier
health issue or challenge. The Army’s war-fighting capability depends on it.
Both mTBI and post combat stress may result without visible physical injuries and
may impact on your performance and readiness. Post combat stress is also called Post
Traumatic Stress Disorder, although there are slight differences between the two. If post
combat stress interferes with a Soldier’s ability to do his or her job and enjoy life, and it
seems to continually get worse, it could lead to the mental health diagnosis known as
Post Traumatic Stress Disorder.
Most Soldiers will do well, but for some, persistent symptoms of post combat stress
may require support or medical care.
A Soldier may experience effects of either mTBI or post combat stress following a
significant combat or operational experience. It is also important to understand that a
Soldier may experience effects of both conditions at the same time.
mild Traumatic Brain
Injury (mTBI)
a type of concussion
that results from a blow
to the head and does
not result in an obvious
physical injury
post combat stress
long-term reaction to
combat and operational
exposure that can impact
a person’s quality of life
Post Traumatic Stress
Disorder (PTSD)
a severe form of post
combat stress
Mild Traumatic Brain Injury (mTBI)
It is useful to think of mTBI as a concussion. Unlike a severe Traumatic Brain Injury, in
which there may be a penetrating head injury with an obvious wound, a mild TBI or
concussion results from a hard blow or jolt to the head, a series of blows, or blast exposure
that causes the brain to be shaken within the skull. A good example would be exposure to
the shock wave of an improvised explosive device (IED) explosion. Concussions do not
result in any obvious physical injury. However, they can result in a disruption of brain
functions. Blasts, particularly from IEDs of all types, can result in concussions where the
Soldier may suffer a brief loss of consciousness, confusion, or brief loss of memory about
events before or after the incident. Sometimes people refer to this as “getting your bell
rung.” Some Soldiers who have concussions may “see stars,” feel dazed or confused, report
ringing in the ears, or just feel “not quite right.”
A common mTBI injury is hearing loss. Injured Soldiers may not even realize that they
have a significant hearing loss, and that may add to their frustration. This type of complaint
is common for concussions. It is important for you as a leader to ensure that Soldiers
who experience blasts are evaluated by a medical officer immediately upon returning to
the base camp or forward operating base. Concussions rarely are life threatening. However,
if a Soldier sustains a head injury during combat missions, it is critical that he or she be
evaluated at the earliest possible opportunity.
Many Soldiers who have had a concussion may say that they are “fine,” although their
behavior or manners are temporarily altered immediately after the event. This is where
both leadership and buddy aid are critical.
It is your responsibility to ensure that all your Soldiers suspected of having concussions
are evaluated by a medical officer. You must take into account the medical recommendations
resulting from the evaluation, even if that includes having the Soldier “take a knee” for a
few days. This is necessary because if a Soldier suffers another concussion without having

54 ■ SECTION 3
recovered from the first, the second concussion may cause permanent brain damage. You
may be required to make field decisions to continue executing a mission or use valuable
resources to extract the Soldier. If a Soldier remains oriented and alert, you may delay the
evaluation. However, you must ensure that the Soldier is evaluated as soon as practical.
Soldiers suffering from mTBI are a risk to your unit’s ability to execute missions effectively.
Other Soldiers must be aware of this type of injury and make sure to inform you if
someone is hurt. It is important that medical assistance be provided to any Soldier who is
exposed to a blast or receives a head injury, or begins to complain of symptoms typically
associated with concussion—especially if the Soldier acts differently after that event.
The key to recovery from a concussion is time, knowledge, and education. Nearly all
Soldiers have recovered or will recover.
Remember, however, that concussions are not always combat related. They can also
occur during training, such as combatives or airborne and air assault exercises. That is why
Soldiers must wear safety equipment and you, the platoon leader, must conduct appropriate
risk assessments.
In any case, it is essential that you and your Soldiers know, understand, and recognize
the signs and symptoms of mTBI and post combat stress.
Post Combat Stress
No amount of training can totally prepare a Soldier for the realities of combat. Post combat
stress is a possible outcome of all combat and operational missions. It may develop after
someone has experienced or witnessed an actual or threatened traumatic event.
Most Soldiers are resilient and work through their experiences. The resiliency displayed
by these Soldiers is referred to as mental toughness or Battlemind. Battlemind skills,
developed in military training, provide Soldiers the inner strength to face fear, adversity,
and hardship during combat with confidence and resolution; the will to persevere and win.
Figure 3.1
Concussion Versus Post Combat Stress

Combat Stress Management ■ 55
Figure 3.2
Combat and Operational Missions, and Post Combat Stress
Figure 3.3
What to Look For

56 ■ SECTION 3
However, sometimes even the strongest Soldiers are affected so severely that they will
need additional help. Both the good and bad experiences can follow for a lifetime. Many
warriors will come back better leaders, fathers, or mothers, often more resilient and not
taking life for granted.
But this transition may not be easy for everyone. Every Soldier is at risk of post combat
stress, and between 20 and 30 percent of US military personnel returning from current
combat operations report psychological symptoms. Some may still struggle with anger,
withdraw from those they care about, or have sleep problems. All of these are normal
reactions to abnormal experiences. Soldiers can deal with these problems in positive ways.
Relaxing, resting, and exercise are three good ways to adjust.
If a Soldier continues to have difficulty adjusting to what he or she experienced on
the battlefield, however, this may negatively impact the Soldier’s intimacy with his or her
spouse or other close relationships with friends, family, and coworkers. Soldiers may also
begin to abuse alcohol or other drugs to try to deal with the stress. Casual drinking is
common with many Soldiers, but when used excessively as an attempt to manage post
combat stress, it can actually create more problems. A few beers may help you sleep on a
given night, but it may also slow down your long-term recovery. Those Soldiers who require
significant assistance to cope with the reactions they are having due to their military
experience may be diagnosed with PTSD.
There are three main things you should look out for in the weeks or months after the
event is over and you’re in a safe environment. They include:
1. Re-experiencing the event over and over again
2. Avoiding people, places, or feelings that remind you of the event
3. Feeling “keyed up” or on-edge all the time.
If you or a fellow Soldier is struggling, seek help. It is important to remember, although
a Soldier may not be struggling, his or her battle buddy may be. Combat and operational
experience will affect every Soldier differently.
Soldiers with the highest combat exposure and those conducting missions outside
the wire have higher rates of post combat stress. Those Soldiers experiencing post combat
stress may continue to struggle with symptoms long after redeployment. Some do not
“reset” quickly after coming home and may continue to struggle, even 12 months later.
The Leader’s Responsibility
You must recognize the continued effects of exposure to combat and operational stress.
Understanding these effects will help you and your Soldiers to support one another.
You and your Soldiers have a responsibility to maintain yourselves and to help your
units and battle buddies. The key is to be aware of the symptoms of combat and operational
stress, and to watch for these symptoms in yourself and in your battle buddies. You and
your Soldiers have a duty not to hide symptoms of an illness and to do the right thing:
Seek help when it is needed.
As a leader, you will need to recognize changes and have the courage to step up and
make sure you get help for yourself and your Soldiers. You, more than anyone else, will
recognize if something doesn’t seem right with one of your Soldiers. Do something about
it—nobody needs to go it alone.
Leaders at all levels also have specific responsibilities. Stress conditions affecting Soldiers
are no different than any other injury or illness that causes loss of combat effectiveness.
You need to know where to find help and how to get it to your Soldiers.
Remember that combat and operational stress are part of a Soldier’s experience, and
most Soldiers will successfully adapt to combat conditions. Bear in mind, however, that
some Soldiers may suffer from concussions or may develop post combat stress. Some
may be affected by both. If you get help for your Soldiers, their recovery will be faster and
more complete.

Combat Stress Management ■ 57
The Army has resources to assist Soldiers affected by concussion and post combat
stress. As a leader, you should be aware of them and ensure that your Soldiers get the help
they need.
You should keep two key leadership points in mind:
1. Lead by example. You are not exempt from struggling with concussions or post
combat stress. It is imperative that you take action and lead by example by getting
the help you need.
2. Manage risk. Identify and assess hazards to your Soldiers’ health from mTBI and
post combat stress. As part of controlling or minimizing these hazards, ensure that
your Soldiers receive appropriate care and support. Make sure that you have
coordinated for the resources they need and that those resources are ready to
provide the assistance your Soldiers may require.
You are responsible not only for recognizing symptoms, but also for playing an active
role in facilitating access to, and allowing Soldiers to seek, help and referral.
Always remember that not everyone reacts the same way to potentially traumatic events.
What may be upsetting to one Soldier may not be for another. Do not assume that a Soldier
is unaffected by an event just because you or others were not affected. To do so promotes
a dangerous stigma, which may discourage Soldiers from getting the help they need. You
must act to reduce the stigma associated with seeking help. Not seeking help can worsen
Soldiers’ conditions. It works against a Soldier’s readiness and effectiveness.
Military One Source is a resource that does not treat PTSD but provides up to six free
counseling sessions for needs associated with PTSD—such as stress management, couple’s
counseling, or parent-child problems. These services are confidential, and spouses and
dependents can also use them. The Veterans Affairs Department provides resources for
retired or separated Soldiers and their families, including treatment of PTSD.
Critical Thinking
You are the platoon leader conducting a platoon ambush. Your 3rd Squad Leader,
SSG Suttles, is the security element leader for the ambush. SSG Suttles’ security
element must provide left, right, and rear flank security for the ambush. You took
SSG Suttles on the leaders’ recon so that he could identify where to place his
security teams. During the leaders’ recon, he showed signs of combat stress,
including heightened startle response and excessive sweating. During the final
planning in the objective rally point (ORP), he seemed to have difficulty paying
attention and remembering his key tasks for the ambush. These symptoms seem to
be getting worse as you make final preparations at the ORP. You have less than
three hours to have your ambush in place, and you are two hours from your
forward operating base (FOB). You do not have time to move him back to the FOB
and get a replacement. Requesting a MEDEVAC could compromise the location of
your patrol base and compromise the ambush mission itself. Do you leave SSG
Suttles in the ORP and make his team leader, SGT Newby, the security element
leader, or do you keep SSG Suttles as the security element leader based on his past
performance? SGT Newby reported to your unit three months ago, fresh from the
Primary Leadership Development Course. He did not participate in the leaders’
recon, and there is no time for you to take him back to the objective to recon the
security team positions. What will you do? How can you use the information
presented in this chapter to help you assess SSG Suttles’ condition?
e
• Assistance for
Soldiers and Families
Unit – chaplain/
leadership/buddy
• Post hospital, clinic, or
troop medical clinic
• Mental – Behavioral
Health Services
• Off-post – mental
health professional
• Military One Source:
1-800-342-9647
• Veterans Affairs (VA)
Health care:
1-877-222-8887
PTSD Information Line:
1-802-296-6300

58 ■ SECTION 3
e
CONCLUSION
Know your troops, and
be alert for any sudden,
persistent, or progressive
change in their behavior
that threatens the
functioning and safety of
your unit.
Combat. You and your troops will experience danger and profound physical and
emotional reactions to it. Some reactions sharpen Soldiers’ abilities to survive and
win. Other reactions may produce disruptive behaviors that threaten individual
and unit safety. Soldiers in combat experience a range of emotions, but their
behavior influences their immediate safety and mission success. You must keep
yourself and your unit working at the level of stress that sustains performance and
confidence. When troops begin to lose confidence in themselves and their leader,
they are more likely to suffer adverse stress reactions that cause battle fatigue.
It is important for you to recognize these adverse behaviors at the onset in
order to intervene promptly for the safety and benefit of individual Soldiers and
the unit. These behaviors may take many forms and can range from subtle to dramatic.
Any Soldier who shows persistent, progressive behavior that deviates from
his or her normal behavior may be demonstrating the early warning signs and
symptoms of combat stress. Rather than trying to memorize every possible sign
and symptom, you’ll be able to diagnose combat stress more quickly if you keep
one simple rule in mind: Know your troops. Be alert for any sudden, persistent, or
progressive change in their behavior that threatens the functioning and safety of
your unit.
Concussions (mTBI) and post combat stress are legitimate medical and
psychological conditions, which may require the attention of health-care
professionals. Remember, all Soldiers who have deployed to combat are affected
in some way or another. You need to work to educate yourself and your
subordinates. This is about taking care of each other—and this is about trust.
That trust will sustain you and your unit in combat and will help you to deal with
mTBI and combat stress. Every Soldier needs to trust that the Army is there for
him or her.
Learning Assessment
1. List the seven major categories of behaviors that may indicate the onset of
battle fatigue.
2. Describe some of the physical functions that may be impaired when a Soldier
has battle fatigue.
3. List and explain the two most common themes that are present in Soldiers
with battle fatigue.
4. Define the four major contributing factors to battle fatigue.

Combat Stress Management ■ 59
5. List some of the methods used by Soldiers and medical personnel to manage
or control combat stress.
6. Define PTSD.
7. Define mTBI.
8. Explain the two major leader actions you can take to help your Soldiers
reduce their susceptibility to combat stress or battle fatigue.
Key Words
battle fatigue
stress-related behaviors
combat stressors
mild Traumatic Brain Injury (mTBI)
post combat stress
Post Traumatic Stress Disorder (PTSD)
References
DoD Directive 6490.5, Combat Stress Control (CSC) Programs. 24 November 2003.
DoD Instruction 6490.3, Deployment Health. 7 August 1997.
Field Manual 4-02.51, Combat and Operational Stress Control. July 2006,
Field Manual 6-22.5, A Leader’s Guide to Combat and Operational Stress (Small Unit)
DRAFT. February 2007.
Field Manual 8-51, Combat Stress Control in a Theater of Operations—Tactics, Techniques,
and Procedures. 29 September 1994.
Field Manual 22-51, Leaders’ Manual for Combat Stress Control. 29 September 1994.
Miles, D. (27 June 2007). Injured Veteran Uses Own Experience to Inspire Others With
Traumatic Brain Injuries. Army News Service. Retrieved 25 April 2008 from
http://www.army.mil/-news/2007/06/28/3839-injured-veteran-uses-own-experienceto-inspire-others-with-traumatic-brain-injuries/
Quick Facts: Traumatic Brain Injury; Post-Traumatic Stress Disorder. (23 April 2007).
Department of Defense. Retrieved 17 July 2008 from http://fhp.osd.mil/pdhrainfo/media
/TBI_and_PTSD_Quick_Facts.pdf