stress and combat performance - Military Veterans PTSD Reference ...

stress and combat performance - Military Veterans PTSD Reference ...

FM 22-51not speaking. The behaviors may be intended toovercome and turn off a stressor, to escape it, orto adapt to it. They may simply reflect or relievethe tension generated by the internal stressprocess. Any of these different types of stressbehavior may be successful, unsuccessful, or notinfluence the stressful situation at all. They maymake the stressor worse. They may resolve onestressor but create new stressors.g. Combat Stress. This is the complexand constantly changing result of all the stressorsand stress processes inside the soldier as heperforms the combat-related mission. At anygiven time in each soldier, stress is the result ofthe complex interaction of many mental andphysical stressors.2-3. Discussion of Physical Versus MentalStressorsa. Table 2-1 gives examples of the twotypes of physical stressors (environmental andphysiological) and the two types of mentalstressors (cognitive and emotional).2-2

FM 22-51c. Positive stress also applies to mentalstressors (cognitive and emotional), as well as tophysical stressors (environmental andphysiological). Appropriate exposure to mental/emotional stressors is necessary to increasetolerance to them.(1) Armies have known forcenturies about the positive effects of stress inpreparing soldiers for combat. In old-style basictraining (prior to 1970), the drill sergeantdeliberately made himself more fearsome thandeath itself so that the trainee would learn torespond automatically, even in a state of terror.That technique is not useful today becausemodern war requires more small unit cohesion,trust between leaders and those led, and initiativeeven on the part of the junior enlisted soldier.The modern drill sergeant must, instead, requirethe trainees to meet difficult (stressful) standardsand work with the trainees to assure that theymaster them. The result is a well-earned senseof confidence in self, comrades, and leaders thatcan be applied to future demands.(2) The Army knows that airborneand air assault training are not just intended toteach the skills needed to arrive on a battlefieldafter jumping from a low-flying aircraft orrepelling from a helicopter. Their greater valuecomes from requiring soldiers to confront andmaster their extremely strong, instinctive fear ofheights under circumstances which aredeliberately stressful at the time. Duringtraining, this fear builds self-confidence and asense of special identity on completion. (In fact,the training itself is not exceedingly dangerous,statistically speaking. However, the possibilityof death does exist if you are extremely unluckyor fail to do the task correctly. This can contributeto additional stress.)(3) Ranger school is a clearexample of the Army’s recognition of the benefitsof positive stress. A generic ranger courseobjective would read: Perform complex anddifficult physical and mental task under greatpressure, sleep loss, water and food deprivation,and physical fatigue. No one coasts throughranger school. If anyone seems to be coastingthrough, the trained ranger cadre will increasethe demand on that person until he, too, reachesthe stage of stress where he realizes he cannotget through it all alone. Ranger school teachessmall teams and their rotating leaders how tocontrol stress in all the team members so the teamaccomplishes the mission. The training gives theindividual soldier confidence, but even more, anawareness of how stress works in oneself andothers. It teaches stress control, not stressreduction. Often the need for the team and itsindividual members is to play different mentaland physical stressors against each other. Thisis done by increasing some stressors whiledecreasing others to keep the team on its missionand to keep individual soldiers from giving up.d. To some degree, acclimatization tomental (cognitive/emotional) stressors also sharesthat “use it or lose it” feature which is true foradaptation to physical stressors. The airbornequalifiedtrooper may experience more unpleasantstress symptoms when jumping after not havingjumped for many months. The physician mayfind the stress unexpectedly higher whenperforming a potentially risky patient-careprocedure that was once so frequently practicedthat it had seemed to involve no stress at all butwhich has not been performed for some time.However, the memory of successfully masteringthe stressor in the past usually speeds up thereturn of adaptation.e. Tolerance to mental stressors isincreased by successfully facing and masteringsimilar stressors (just as tolerance to physicalstressors is). However, being overwhelmed byemotional or mental stress may temporarily orpermanently impair future tolerance (just asexceeding the ability to cope with physical2-5

FM 22-51stressors may). Up to a point, mental stress (evenuncomfortable mental stress) may increasetolerance to future stress without any currentimpairment. A higher level may cause temporaryoverstrain but may heal as strong or strongerthan ever with rest and restorative processing.More severe overstrain, however, may permanentlyweaken tolerance to future mental stress.As with some cases of damage from physicalstress, the harm done by mental stress may notbe apparent at the time. It may only be apparentlater. There is reason to believe that immediatepreventive measures or treatment can greatly reducethe potential for chronic disability, even incases of extreme emotional overstrain.2-5. Relationship of Stress to Task PerformanceStress is an internal process which presumablyevolves because it helps the individual to functionbetter, stay alive, and cope successfully withstressors. However, there is an optimal range ofarousal (or motivation or stress) for any giventask.a. If there is too little arousal, the jobis done haphazardly or not at all because theindividual is easily distracted, makes errors ofomission, or falls asleep. If arousal becomes toointense, the individual may be too distractible ortoo focused on one aspect of the task. He mayhave difficulty with fine motor coordination andwith discriminating when and how to act. If theindividual is unfamiliar with his own stressreflexes and perceives them as dangerous (orincapacitating, or as a threat to self-esteem), thestress itself can become a stressor and magnifyitself.b. With extreme arousal, the individualmay freeze (become immobile or petrified by fear).Alternately, he may become agitated and flee indisoriented panic. If stress persists too long, itcan cause physical and mental illnesses. Extremestress with hopelessness can even result in rapiddeath, either due to sympathetic nervous systemoverstimulation (such as stroke or heart attack)or due to sympathetic nervous system shutdown(not simply exhaustion). An individual giving upcan literally stop the heart from beating.c. The original purpose of the stressreaction was to keep the person alive. Themilitary requirement for the stress process isdifferent. It is to keep the soldier in that range ofphysiological, emotional, and cognitive mobilizationwhich best enables him to accomplish themilitary mission, whether that contributes toindividual survival or not. This optimal range ofstress differs from task to task. Tasks whichrequire heavy but gross muscular exertion areperformed best at high levels of arousal (Figure2-1). Tasks that require fine muscle coordinationand clear thinking (such as walking point on abooby-trapped jungle trail, or distinguishingsubtle differences between friendly and enemytargets in a night-vision gun sight) or that requireinhibiting action (such as waiting alertly inambush) will be disrupted unless the stressprocess is kept finely tuned. If the stress processallows too much or too little arousal or if arousaldoes not lessen when it is no longer needed, stresshas become harmful.2-6. FatigueFatigue means weariness and/or decreasedperformance capability due to hard or prolongedwork or effort. It reflects the stage where theenergy mobilized by the stress process isbeginning to run down. If the effort continues,the fatigue can build to the point of exhaustion.a. Fatigue can be produced by bothphysical and mental tasks. A well-known exampleof physical fatigue is muscle tiredness. This canbe limited to specific muscles which have been2-6

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FM 22-51overworked. Another example is aerobic fatigue(where the whole body is short of oxygen andperhaps blood sugar, is probably overheated, andis wanting to rest).b. Sleep loss produces a different kindof fatigue which is primarily mental. The sleepdeprivedperson has trouble keeping his mindfocused although he has no decrease in muscularor aerobic work capacity. People with sleep-lossfatigue usually appear tired and slowed down, orthey may also be speeded up, hyperactive, andirritable.c. Continued mental effort on a specifictask, whether it is a task requiring much thinkingor constant attention, produces mental fatigue.That is, performance gets progressively worsewith time, and the person wishes he could stop todo something else. Even a few minutes of break,while the mind does some quite different mentaltasks, substantially relieves the mental fatigueand improves the performance.d. Physical illness can also bring onfatigue. People who have ever had the flu oreven just a cold know how quickly one tires. Theyonly want to rest or sleep.e. Intense emotions also produce fatigue.This is especially true of anxiety and fearbecause they arouse the fight or flight reflexes ofthe physical stress process. This will be discussedlater in justifying the use of the term battle fatigue.f. The level of fatigue experienced maybe influenced by—General well-being of the individual.Work intensity.Task difficulty.Duration of sustained effort.Fatigue can also be influenced by the level ofpreparedness to perform the specific task.(1) For physical fatigue: Amarathon runner may have strong legs, superbaerobic fitness, great health, and self-confidence,but too little arm and shoulder strength to beable to chin himself even once before beingstopped by fatigue.(2) For emotional fatigue: Ahealthy, confident soldier may have learned tocarry his Dragon missile and guide it to its targeteasily in peacetime training. But if he has neverlearned to control his own fear, he may findhimself too quickly fatigued to even carry theweight, let alone keep the missile on target for 10seconds while under real, lethal enemy fire. Hemay, however, still be able to perform simpletasks. In WWII, the following observations andconclusion were made:(a) In the fighting forKwajalein Atoll, troops were halted three timesby enemy fire. Their energy was exhausted eventhough they suffered no casualties and had movedfewer than two miles. In the Normandy invasion,a strong infantry company with many vigorousyoung men hit the beach still fresh. Underintense fire, they found they had to drag theirheavy machine guns across the beach a few feetat a time; when in training, they had been able tocarry the same loads on the run.(b) The Army reachedthe following conclusion from those observations:Fear and fatigue effect the body in similar ways.Fear, like physical work, drains the body ofenergy. This creates a self-perpetuating cycle.The overloaded soldier, feeling tired, becomesmore susceptible to fear. The more fearful hebecomes, the weaker he feels, and the morequickly he becomes fatigued.2-8

FM 22-51combat zone on individual R&R, there may be abrief drop in performance on his return to battle.That drop would be accompanied by a return ofthe anxiety pattern shown by new soldiers (Figure2-2[A]) but the anxiety is much briefer. Thiswould be like the anxiety felt by the airbornequalifiedsoldier who is making a jump after nothaving done so for many months. Predictably,the experienced veteran will regain his combatedge quickly upon returning to battle.c. The Overstressed Veteran. If theunit suffers many casualties, however, and thechance of surviving a long war seems poor, theexperienced soldier’s combat performance beginsto decline. It can occur after 14 to 21 days ofcumulative combat or even after only a few daysof extremely heavy losses. The overstressedveteran becomes more careful, loses initiative,and may be indecisive when he needs to actquickly. Figure 2-2(C) shows the anxiety patternof an overstressed soldier who is doubting hischances of survival. There were too many closecalls in the last battle; too many of his friendswere killed (slowly over time or quickly). Undersuch stress, he feels his own skills are slipping,and it is just a matter of time before he, too, willsurely be killed or maimed. Unless he is giventhe opportunity and help to reduce arousal leveland regain some hope, he will soon fail.2-10

FM 22-51d. Decline of Combat Skills. Howquickly performance declines will usually berelated to how many casualties have occurred andhow close the soldier was to them (both physicallyand emotionally). The decline may be hastenedor slowed by leadership, unit, scenario, and homefront factors such as those discussed in laterchapters and in Appendix A.e. Restoration of Combat Skills. Restand recuperation, preferably with other soldiersin the unit, can substantially restore combatproficiency. Rest would also substantially returnthe anxiety pattern to that of the experiencedveteran (Figure 2-2[B]). This recuperation canbe accomplished with the help of the medicaland combat stress control/mental healthpersonnel at a medical restoration or reconditioningfacility.2-9. Combat Stress Behaviorsa. Combat Stress Behaviors. Combatstress behavior is the generic term which coversthe full range of behaviors in combat, frombehaviors that are highly positive to those thatare totally negative. Table 2-2 provides a listingof positive stress responses and behaviors, plustwo types of dysfunctional combat stressbehaviors—those which are labeled misconductstress behaviors and those which are labeledbattle fatigue.b. Positive Combat Stress Behaviors.Positive combat stress behaviors include theheightened alertness, strength, endurance, andtolerance to discomfort which the fight or flightstress response and the stage of resistance canproduce when properly in tune. Examples ofpositive combat stress behaviors include thestrong personal bonding between combat soldiersand the pride and self-identification which theydevelop with the combat unit’s history andmission (unit esprit). These together form unitcohesion—the binding force that keeps soldierstogether and performing the mission in spite ofdanger and death. The ultimate positive combatstress behaviors are acts of extreme courage andaction involving almost unbelievable strength.They may even involve deliberate self-sacrifice.Positive combat stress behaviors can be broughtforth by sound military training (drill), wisepersonnel policies, and good leadership. Theresults are behaviors which are rewarded withpraise and perhaps with medals for individualvalor and/or unit citations. The positive combatstress behaviors are discussed further inChapter 3.c. Misconduct Stress Behaviors.Examples of misconduct stress behaviors arelisted in the center column of Table 2-2. Theserange from minor breaches of unit orders orregulations to serious violations of the UniformCode of Military Justice (UCMJ) and perhaps theLaw of Land Warfare. As misconduct stressbehaviors, they are most likely to occur in poorlytrained, undisciplined soldiers. However, theycan also be committed by good, even heroic,soldiers under extreme combat stress. Misconductstress behavior can be prevented by stresscontrol measures, but once serious misconducthas occurred, it must be punished to preventfurther erosion of discipline. Combat stress, evenwith heroic combat performance, cannot justifycriminal misconduct. See Chapter 4 for a discussionof misconduct stress behaviors.d. Battle Fatigue. Battle fatigue is alsocalled combat stress reaction or combat fatigue.See Table 2-2 for examples of battle fatigue.Those battle fatigue behaviors which are listednear the top may accompany excellent combatperformance and are often found in heroes, too,These are normal, common signs of battle fatigue.Those that follow are listed in descending orderto indicate progressively more serious or warningsigns. Warning signs deserve immediate attentionby the leader, medic, or buddy to prevent2-11

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FM 22-51potential harm to the soldier, others, or themission. Warning signs do not necessarily meanthe soldier must be relieved of duty or evacuatedif they respond quickly to helping actions.However, soldiers may need evaluation at medicaltreatment facilities to rule out other physical ormental illness. If the symptoms of battle fatiguepersist and make the soldier unable to performduties reliably, then medical treatment facilities,such as clearing station and specialized combatstress control teams, can provide restorativetreatment. At this point, the soldier is a battlefatigue casualty. For those cases, prompttreatment close to the soldier’s unit provides thebest potential for returning the soldier to duty,See Chapter 5 for a detailed discussion of battlefatigue.2-10. Overlapping of Combat Stress BehaviorsThe distinction between positive combat stressbehaviors, misconduct stress behaviors, and battlefatigue is not always clear. Indeed, the threecategories of combat stress behaviors mayoverlap, as diagramed in Figure 2-3. Soldierswith battle fatigue may show misconduct stressbehaviors and vice versa. Heroes who exemplifythe positive combat stress behaviors may suffersymptoms of battle fatigue and may even be battlefatigue casualties before or after their heroicdeeds. Excellent combat soldiers may commitmisconduct stress behaviors in reaction to thestressors of combat before, during, or after theirotherwise exemplary performance. Combatstress, even with good combat behavior, does notexcuse criminal acts. However, it could be takeninto account as an extenuating circumstance forminor (noncriminal) infractions or in determiningnonjudicial punishment under Article 15, UCMJ,for minor offenses.2-11. Post-Traumatic Stress DisorderPost-traumatic stress symptoms are normalresponses after extremely abnormal anddistressing events.a. Post-Traumatic Stress DisorderSigns and Symptoms. As with battle fatigue,post-traumatic stress symptoms come in normal/common and warning signs. These signs andsymptoms do not necessarily make the sufferer acasualty or deserve the label of disorder. It isnormal for the survivor of one or more horribleevents to have painful memories; to have anxiety(perhaps with jumpiness or being on guard); tofeel guilt (over surviving or for real acts of omissionor commission); and to dream unpleasantdreams about it. This becomes PTSD only wheneither the pain of the memories or the actions theperson takes to escape the memories (such assubstance abuse, avoidance of reminders, socialestrangement, and withdrawal) interfere with occupationalor personal life goals.b. Post-Traumatic Stress DisorderPreventive Measures. As with battle fatigue,there is no virtue in suffering, ignoring, neglecting,or hiding post-traumatic stress symptoms.2-13

FM 22-51The normal/common signs deserve routinepreventive measures, such as talking out andworking through the painful memories. Thewarning signs certainly deserve this attention,as self-aid, buddy aid, and leader aid. Goodpreventive measures can head off true PTSDwhich might not show up until years after theincident.c. Relationship Between Post-TraumaticStress Disorder and Battle Fatigue. WhilePTSD and battle fatigue obviously share muchin common, by definition, symptoms are. notPTSD until the trauma is over (post). Therefore,this diagnosis should not be made while thesoldier continues in, or is expected to returnquickly to, the combat mission. As the dottedlines (Table 2-2) show, PTSD can follow battlefatigue (especially if inadequately or incorrectlytreated). Israeli studies confirm earlierobservations that immediate, far-forward treatmentand return to duty protect battle fatiguecasualties against subsequent PTSD. Prematureevacuation of battle fatigue casualties oftenresults in chronic PTSD. However, most cases ofacute, chronic, and delayed PTSD after a warwere not battle fatigue casualties during thebattles.d. Relationship Between Post-TraumaticStress Disorder and Misconduct StressBehavior. Post-traumatic stress disorder oftenfollows misconduct stress behaviors. It may occurin—The victims of others’ misconduct.Those who committed misconductunder stress and are haunted by guilt later.Those who were passive orreluctant participants.Those who simply observedsevere misconduct and its human consequences.Those who were involved asrescuers or care givers.e. Post-Traumatic Stress Disorder andPositive Combat Stress Behavior. Post-traumaticstress disorder can also occur in soldiers (orveterans and civilians) who showed nomaladaptive stress behaviors at the time of thetrauma and who showed positive, even heroic,combat stress behaviors. Even heroes can feeldelayed grief and survivor guilt for lost buddiesor be haunted by the memory of the enemysoldiers they killed in battle.f. Leader Responsibilities to PreventPost-Traumatic Stress Disorder. During theconflict, commanders and NCOs have the additionalresponsibility of preventing or minimizingsubsequent PTSD. The most important preventivemeasure is routine after-action debriefing bysmall teams after any difficult operation (seeChapter 6 for additional discussion). Criticalevent debriefings led by trained debriefing teamsshould be scheduled following exceptionallytraumatic events. Recommended leader actionsare provided in Appendix A. When units orindividual soldiers redeploy home from combat,leaders should debrief them and help preparethem for the transition. As Figure 2-4 illustrates,painful memories do not have to become clinicalPTSD or misconduct stress behaviors. They canbe accepted and diverted into positive growth.Chapter 6 gives more information on PTSD andits prevention and treatment.2-14

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