Brief
The
Reports
Effectiveness of a Stress Recovery Unit During the Persian Gulf War B. Johnson,
Lorraine
Sc.D. David W.
Clime,
J.
Marcum,
Michael
possible), and expectancy (expressing the expectation that the soldier will recover and return to duty). The goal is to preserve the fighting strength
M.P.H.,
M.D.
M.D.,
by
Ph.D. Jane L. Intress,
B.S.N.,
M.A.
Since World War I, there has been growing interest in the control and treatment of battle fatigue, or combat stress reactions. Current Army procedures ( 1) emphasize treatment in accordance with Salmon’s pninciples (2) ofimmediacy (treatment as soon as symptoms arise), proximity (treatment as close to the unit as
the
The the
authors were affiliated with U.S. Army Reserve 312th Evacuation Hospital and the Wisconsin ArmyNational Guard 13th
minimizing
personnel
losses
due
to combat stress reactions (1). The principles of immediacy, proximity, and expectancy arose out of the experiences of World War I and resulted in a high rate of soldiers returning to duty during that conflict (2). Those principles were also implemented during World War II, the Korean conflict, and the Vietnam War(3) and by the Israelis during the Lebanon conflict in 1982 (4). During the 1991 Persian Gulf War, the hospital units with which authors
were
affiliated
(two
400-
Health at the University of North Carolina at Chapel Hill, Room 137, North Carolina Memorial Hospital, Chapel Hill, North Carolina 275 14. Dr. Cline is cmical professor and associate director of education and training in the division of child and adolescent psychiatry at the University of Minnesota Medical School in Minneapolis. Dr. Marcum is cmical assistant professor of psychiatry at the State University of New York Upstate Medical Center in Binghamton. Ms. Intress is a cmical specialist in psychiatry at St. Francis Medical Center in La Crosse, Wisconsin.
bed evacuation hospitals) were located together in the combat zone in Saudi Arabia about 1 2 miles south of the Iraqi border. Since we anticipated a large number ofcombat stress neactions and the number of psychiatric personnel was limited, psychiatric teams from the two hospitals joined to implement a stress recovery unit at one ofthe hospitals. The principles ofimmediacy, proximity, and cxpectancy guided development of the unit’s program. The stress recovery unit was modeled after the Israelis’ combat fitness retraining unit (4). However, unlike the Israeli model, the unit was 1cated close to the battle zone and to the soldiers’ units, and it offered treatment for a matter ofdays rather than weeks. The goal oftreatment in the unit was to return recovered soldiers to duty in a short time. This paper describes the program and its effectiveness in meeting its goal. To our knowledge, case studies such as ours have not previously been done with U.S. troops during a war.
Hospital
August
Evacuation Persian
Gulf
clinical
assistant
Hospital
during
War.
Dr. Johnson professor
matology
and
ing
Schools
in the
public
the of der-
health
nurs-
ofMedicine
Public
and
Community
is
Psychiatry
and
1992
Vol.
43
No.
8
unit
program
The stress recovery unit occupied two 20-bed minimal care wards. Cots were used instead of hospital beds. Soldiers were expected to wear their uniforms. No hospital clothing was issued. The psychiatric team consisted of two psychiatrists, three psychiatric nurses, and six psychiatnc technicians. The unit was staffed 24 hours a day by the technicians. On admission, soldiers were informed that the unit was not a hospita!, that they were not psychiatric patients but were just fatigued, and that they would continue to function as soldiers. The program, structured to maintain the military daily routine and discipline, included group therapy conducted by the psychiatnists, physical fitness and recreational activities, breathing and relaxation exercises, rest periods, educational sessions, and work activities in the mess section, hospital laundry, or other areas. The educational sessions, led by a psychiatric nurse, consisted of informal discussions covering one of six topics: fear, anxiety, and the stress response; guilt and shame; griefand loss; mood and affect; positive thinking; and self-esteem and communication.
was not
Individual
part
ofthe
therapy
program.
Methods
Subjects were 22 soldiers with symptoms ofcombat fatigue consecutively admitted to the stress recovery unit between February 16 and March 9, 1991 Their ages ranged from 1 9 to .
41
years.
Fifteen
were
ages of2l and 30 years. soldiers were women. black, 14 were white,
between
the
Three of the Seven were and one was
Hispanic. Nineteen had at least a high school education. All subjects came from either combat support units (engineer, maintenance, ordinance, or communications) or combat service support units (personnel, medical, supply and service, or transportation). All came from the enlisted ranks. Sixteen subjects were from the lower four enlisted ranks (E 1 to E4), and the remaining six were from the upper five enlisted ranks (ES to E9). Soldiers in the upper ranks have more
829
Table
1
Mean
admission
Multiple
and
Affects
discharge
Adjective
scores
Checklist
on
subscaics
ofsoldiers
the summary in a stress recovery
scale of the unit (N= 18)
and
treated
Admission
Discharge
Subscale1
Mean
Anxiety Depression
12.17
3.93
8.56
5.03
22.33
7.39
15.50
8.38
13.50 48.00
5.46 15.76
9.39 33.44
3.58 16.20
Hostility Summary I
Possible
scale (dysphonia) scores
ranged
from
0 to 2 1 on the anxiety
subscale, from 0 to 28 on the hostility subscale, higher scores indicating more severe symptoms.
time in service, more training and experience, and greaten specialization and leadership responsibilities. Eleven subjects were active duty personnd (regular Army), and the others were from reserve units (U.S. Army Reserve or Army National Guard). Each soldier’s combat stress neacnon symptoms were obtained on admission using the symptom list generated by Bar-on and associates during the Lebanon war (5). Their list consisted of 25 items, including anxiety, irritability, social detachment, poor concentration, and sleep disturbances. Two items, “suicidal” and “homicidal,” were added to the checklist. Subjects completed the Multiple Affects Adjective Checklist (MAACL) on admission and at discharge (6). The MAACL consists of 1 3 2 adjectives that describe the subject’s feelings and moods; the individual simply checks all the adjectives that apply currently and for the past
24 hours.
The
checklist
provides
three subsca!es measuring depression, and hostility. MAACL scales have high consistency
(7).
Validity
studies
anxiety, The internal have
shown that MAACL scores are sensitive to several stressor variables (6). Soldiers whose behavior interfered with the performance of their duties were brought to the evacuation hospital, usually by their platoon leader, for psychiatric evaluation. A psychiatrist or psychiatric nurse evaluated each soldier on arrival, and the psychiatnic team determined whether the soldier would be admitted to the stress recovery unit. On admission to the unit, a psychiatrist interviewed each subject and completed the
830
SD
SD
Mean
subscale,
from
0 to 40 on the depression
and from 0 to 89 on the summary
scale, with
symptom checklist. The MAACL was administered to each soldier by a member of the psychiatric team on admission and discharge. Scones on the MAACL served as a measure of the soldiers’ subjective stress level at admission and discharge. Changes in mean scores from admission to discharge were used as an indication of the effectiveness of the stress recovery unit’s treatment program. The paired-sample t test, with a probability level of .05 accepted for statistical significance, was used to analyze those changes. However, because we are describing a case study, not a controlled expeniment, use of this test does not imply that these data are generalizable to other combat populations. Results
Subjects had an average of 1 2 symptoms of combat stress reactions, and more than half of the subjects (55 percent) had between 1 1 and 1S symptoms. The seven most common symptoms were anxiety, depressed affect, irritability, guilt feelings, sleep disturbance, fear, and social detachment. Forty-one percent of the subjects had suicidal ideation. Table I presents the sample’s raw mean scores at admission and discharge for the anxiety, depression, and hostility subscales and the summary scale ofthe MAACL. Four subjects
were
not
included
in those
cal-
culations; three did not complete the MAACL on admission, and one did not complete the instrument on discharge. At discharge, subjects’ mean scores on each scale were substantially lower
August
than
1992
at admission.
Vol.
A mean
43
No.
8
difference of 3.6 was found for the anxiety subscale (t=3.08, df= 17, p< .05, two-tailed), 6.8 for the depression subscale (t=3.88, df= 17, p< .05, two-tailed), 4.1 for the hostility subscale (t=3.74, df= 17, p< .05, two-tailed), and 14.6 for the summary scale measuring overall dysphoria (t=4.01 , df= 1 7, p < .0, two-tailed). We interpreted the changes in the scores as an indication that subjects were experiencing much less stress at discharge than at admission. The mean length ofstay for the 22 subjects was four days, with a range of one to ten days. The majority of subjects stayed between one and three days. Twenty-one returned to duty. One subject with persistent suicidal ideation was evacuated for further evaluation and treatment. Conclusions The unit was the first level of treatment for most subjects. It was located close to their units, enabling visits by unit members. Considering the large amount ofsymptornatology on admission, the average length of stay (four days) was relatively short, and all but one subject were able to return to their units. The decline in anxiety, depression, and hostility as well as dysphoria from admission to discharge was impressive. Both individually and in group sessions, subjects described many apparent stressors, some of which were unique to the experience of being in a combat zone. They included fear of being attacked, not knowing the length of stay in Saudi Arabia, long duty hours with little rest, lack of privacy, infrequent showers, and feelings of having no control over their lives. Almost half of the subjects believed that the leadership in their units was dysfunctional. Some were also concerned with problems at home. Subjects were encouraged to ventilate their anger, fears, and concerns during the group therapy sessions. They showed a great deal of interest, participation, and interaction during those sessions and during the educational sessions. We feel that this group of soldiers benefited from the program of the stress recovery unit. Only one returned for outpatient counseling.
Hospital
and
Community
Psychiatry
Due to the short duration of the war, we were unable to follow up on the other subjects after they returned to their units. Ideally, controlled multisite studies should be planned and ready for implementation to help us learn better ways to maximize treatment outcomes with minimal personnel resources in combat situations.
Fort Sam Houston, Tex, emy ofHealth Sciences, 2.
Salmon
TW:
The
lesson. New York cine 59:933-944,
The authors thank SPC Vernon K. Sommenfeldt and SPC Jeffrey A. Frey for their assistance in collecting and coding the data.
4. Margalit combat Milgram 1986
Control in a Theater of Tactics, Techniques, and Coordinating draft FM 8-51.
Operations: Procedures.
and their of Medi-
1919
by
5. Bar-on clinical
R, Solomon Z, Noy S, et al: The picture of combat stress reactions in the 1982 war in Lebanon: cross-war comparisons, ibid
list.
Stress
Statejoumal
in Time of War. Edited NewYork, Brunnen/Mazel,
NA.
M,
Lubin
for the Multiple
1 . Combat
war neuroses
C, WoznerY, Nardi C, et al: The fitness retraining unit, in Stress
6. Zuckerman References
Acad-
3. Ursano RJ, Holloway HC: Military psychiatry, in Comprehensive Textbook of Psychiatry, 4th ed, vol 2. Edited by Kaplan HI, Sadock B). Baltimore, Williams & Wilkins, 1985
and Coping
Acknowledgments
USArmy,
1990
B: Normative
Affects
Psychological
Adjective
Reports
16:438,
data
Check1965
7. Datel WE, GiesekingCF, Engle EO, et al: Affect levels in a platoon ofbasic trainees. Psychological Reports 18:27 1-285, 1966
Posttraumatic Stress Symptoms Among Soldiers Exposed to Combat in the Persian Gulf Lawrence
A. Labbate,
Michael
P. Snow,
The Persian Gulf conflict with few American troops
Dr. Labbate, Army tivity
War was American experienced
formerly
psychiatry
service Medical
in
a brief deaths. few
chiefof at
the
the U.S.
Department
in the
Ac-
Germany,
Bremerhaven,
is a fellow pharmacology Massachusetts
M.D.
M.A.
clinical psychounit, ACC 815,
General
Hospital,
mental health problems (1); soldiers with psychiatric problems constituted only 6.5 percent ofthe medical evacuations from Southwest Asia (Barham K, persona! communication, 1992). Despite limited casualties, the conflict included isolated instances of intense combat, death by so-called friendly fire, and the attendant psychologica! trauma of war. The chief of the U.S. Army Medical Research Unit for Europe has referred to these incidents as ‘pockets of trauma” (Martin J, personal communication, 1991 The study reported here surveyed one mechanized infantry company exposed to this environment and attempted to identify some of the psychological effects associated with this exposure. Posttraumatic stress disorder sometimes results from exposure to traumatic events such as combat (2). A primary symptom of the disorder is reexpeniencing the traumatic ‘
).
Boston,
Massachusetts
021
14. Mr.
Snow is chief of the property management branch at the U.S. Army Medical Department Activity
in Bremerhaven,
Germany.
The opinions authors’ and reflect
ment ment
Hospital
expressed are the do not necessarily the views of the Departof the Army or the Departof Defense.
and
Community
Psychiatry
August
1992
Vol.
43
No.
8
events. Persons with the disorder usually begin neexpeniencing the traumatic event soon after it has occurred, although the onset of this symptom may be delayed. Many peopie who arc exposed to psychological trauma do not seek treatment immediately after the trauma; they may develop posttraumatic stress disorden later (3,4). Reexpeniencing the trauma often occurs through disturbing dreams or nightmares (5). Sleep disturbances in general are recognized components of posttraumatic stress disorder (6). To examine effects of psychological trauma in soldiers after combat in the Persian Gulf Wan without conducting full diagnostic interviews, we focused on the presence of nightmares and other sleep disturbances. After the Vietnam Wan, alcohol abuse was a common problem of veterans with posttraumatic stress disorder(7,8). Because illegal drugs and alcohol were forbidden in the cultural context in Southwest Asia, they were much less readily available than in Vietnam. We wanted to learn whether this forced abstinence aSfected use of alcohol after the troops returned to their base in Germany and whether soldiers who expenienced nightmares attempted to alleviate them by using alcohol. We hypothesized that despite participating in a brief, victorious campaign that had strong public support, soldiers in a unit exposed to intense combat in the Persian Gulf might show significant, perhaps delayed, psychiatric symptoms and increased alcohol use. Methods The unit surveyed was a mechanized infantry company supporting an armored brigade. No mental health personnel were assigned to the bnigade. The unit was actively involved in
the
brief
ground
war
during
the
Persian Gulf conflict and suffered four deaths from so-called friendly fire. Its mission after the ground war included control of refugees and prisoners of war and destruction of enemy tanks and bunkers. The unit returned to Germany in early May 1991, about two months after the cease-fire. Four months later, in early Sep-
831
The
Reports
Effectiveness of a Stress Recovery Unit During the Persian Gulf War B. Johnson,
Lorraine
Sc.D. David W.
Clime,
J.
Marcum,
Michael
possible), and expectancy (expressing the expectation that the soldier will recover and return to duty). The goal is to preserve the fighting strength
M.P.H.,
M.D.
M.D.,
by
Ph.D. Jane L. Intress,
B.S.N.,
M.A.
Since World War I, there has been growing interest in the control and treatment of battle fatigue, or combat stress reactions. Current Army procedures ( 1) emphasize treatment in accordance with Salmon’s pninciples (2) ofimmediacy (treatment as soon as symptoms arise), proximity (treatment as close to the unit as
the
The the
authors were affiliated with U.S. Army Reserve 312th Evacuation Hospital and the Wisconsin ArmyNational Guard 13th
minimizing
personnel
losses
due
to combat stress reactions (1). The principles of immediacy, proximity, and expectancy arose out of the experiences of World War I and resulted in a high rate of soldiers returning to duty during that conflict (2). Those principles were also implemented during World War II, the Korean conflict, and the Vietnam War(3) and by the Israelis during the Lebanon conflict in 1982 (4). During the 1991 Persian Gulf War, the hospital units with which authors
were
affiliated
(two
400-
Health at the University of North Carolina at Chapel Hill, Room 137, North Carolina Memorial Hospital, Chapel Hill, North Carolina 275 14. Dr. Cline is cmical professor and associate director of education and training in the division of child and adolescent psychiatry at the University of Minnesota Medical School in Minneapolis. Dr. Marcum is cmical assistant professor of psychiatry at the State University of New York Upstate Medical Center in Binghamton. Ms. Intress is a cmical specialist in psychiatry at St. Francis Medical Center in La Crosse, Wisconsin.
bed evacuation hospitals) were located together in the combat zone in Saudi Arabia about 1 2 miles south of the Iraqi border. Since we anticipated a large number ofcombat stress neactions and the number of psychiatric personnel was limited, psychiatric teams from the two hospitals joined to implement a stress recovery unit at one ofthe hospitals. The principles ofimmediacy, proximity, and cxpectancy guided development of the unit’s program. The stress recovery unit was modeled after the Israelis’ combat fitness retraining unit (4). However, unlike the Israeli model, the unit was 1cated close to the battle zone and to the soldiers’ units, and it offered treatment for a matter ofdays rather than weeks. The goal oftreatment in the unit was to return recovered soldiers to duty in a short time. This paper describes the program and its effectiveness in meeting its goal. To our knowledge, case studies such as ours have not previously been done with U.S. troops during a war.
Hospital
August
Evacuation Persian
Gulf
clinical
assistant
Hospital
during
War.
Dr. Johnson professor
matology
and
ing
Schools
in the
public
the of der-
health
nurs-
ofMedicine
Public
and
Community
is
Psychiatry
and
1992
Vol.
43
No.
8
unit
program
The stress recovery unit occupied two 20-bed minimal care wards. Cots were used instead of hospital beds. Soldiers were expected to wear their uniforms. No hospital clothing was issued. The psychiatric team consisted of two psychiatrists, three psychiatric nurses, and six psychiatnc technicians. The unit was staffed 24 hours a day by the technicians. On admission, soldiers were informed that the unit was not a hospita!, that they were not psychiatric patients but were just fatigued, and that they would continue to function as soldiers. The program, structured to maintain the military daily routine and discipline, included group therapy conducted by the psychiatnists, physical fitness and recreational activities, breathing and relaxation exercises, rest periods, educational sessions, and work activities in the mess section, hospital laundry, or other areas. The educational sessions, led by a psychiatric nurse, consisted of informal discussions covering one of six topics: fear, anxiety, and the stress response; guilt and shame; griefand loss; mood and affect; positive thinking; and self-esteem and communication.
was not
Individual
part
ofthe
therapy
program.
Methods
Subjects were 22 soldiers with symptoms ofcombat fatigue consecutively admitted to the stress recovery unit between February 16 and March 9, 1991 Their ages ranged from 1 9 to .
41
years.
Fifteen
were
ages of2l and 30 years. soldiers were women. black, 14 were white,
between
the
Three of the Seven were and one was
Hispanic. Nineteen had at least a high school education. All subjects came from either combat support units (engineer, maintenance, ordinance, or communications) or combat service support units (personnel, medical, supply and service, or transportation). All came from the enlisted ranks. Sixteen subjects were from the lower four enlisted ranks (E 1 to E4), and the remaining six were from the upper five enlisted ranks (ES to E9). Soldiers in the upper ranks have more
829
Table
1
Mean
admission
Multiple
and
Affects
discharge
Adjective
scores
Checklist
on
subscaics
ofsoldiers
the summary in a stress recovery
scale of the unit (N= 18)
and
treated
Admission
Discharge
Subscale1
Mean
Anxiety Depression
12.17
3.93
8.56
5.03
22.33
7.39
15.50
8.38
13.50 48.00
5.46 15.76
9.39 33.44
3.58 16.20
Hostility Summary I
Possible
scale (dysphonia) scores
ranged
from
0 to 2 1 on the anxiety
subscale, from 0 to 28 on the hostility subscale, higher scores indicating more severe symptoms.
time in service, more training and experience, and greaten specialization and leadership responsibilities. Eleven subjects were active duty personnd (regular Army), and the others were from reserve units (U.S. Army Reserve or Army National Guard). Each soldier’s combat stress neacnon symptoms were obtained on admission using the symptom list generated by Bar-on and associates during the Lebanon war (5). Their list consisted of 25 items, including anxiety, irritability, social detachment, poor concentration, and sleep disturbances. Two items, “suicidal” and “homicidal,” were added to the checklist. Subjects completed the Multiple Affects Adjective Checklist (MAACL) on admission and at discharge (6). The MAACL consists of 1 3 2 adjectives that describe the subject’s feelings and moods; the individual simply checks all the adjectives that apply currently and for the past
24 hours.
The
checklist
provides
three subsca!es measuring depression, and hostility. MAACL scales have high consistency
(7).
Validity
studies
anxiety, The internal have
shown that MAACL scores are sensitive to several stressor variables (6). Soldiers whose behavior interfered with the performance of their duties were brought to the evacuation hospital, usually by their platoon leader, for psychiatric evaluation. A psychiatrist or psychiatric nurse evaluated each soldier on arrival, and the psychiatnic team determined whether the soldier would be admitted to the stress recovery unit. On admission to the unit, a psychiatrist interviewed each subject and completed the
830
SD
SD
Mean
subscale,
from
0 to 40 on the depression
and from 0 to 89 on the summary
scale, with
symptom checklist. The MAACL was administered to each soldier by a member of the psychiatric team on admission and discharge. Scones on the MAACL served as a measure of the soldiers’ subjective stress level at admission and discharge. Changes in mean scores from admission to discharge were used as an indication of the effectiveness of the stress recovery unit’s treatment program. The paired-sample t test, with a probability level of .05 accepted for statistical significance, was used to analyze those changes. However, because we are describing a case study, not a controlled expeniment, use of this test does not imply that these data are generalizable to other combat populations. Results
Subjects had an average of 1 2 symptoms of combat stress reactions, and more than half of the subjects (55 percent) had between 1 1 and 1S symptoms. The seven most common symptoms were anxiety, depressed affect, irritability, guilt feelings, sleep disturbance, fear, and social detachment. Forty-one percent of the subjects had suicidal ideation. Table I presents the sample’s raw mean scores at admission and discharge for the anxiety, depression, and hostility subscales and the summary scale ofthe MAACL. Four subjects
were
not
included
in those
cal-
culations; three did not complete the MAACL on admission, and one did not complete the instrument on discharge. At discharge, subjects’ mean scores on each scale were substantially lower
August
than
1992
at admission.
Vol.
A mean
43
No.
8
difference of 3.6 was found for the anxiety subscale (t=3.08, df= 17, p< .05, two-tailed), 6.8 for the depression subscale (t=3.88, df= 17, p< .05, two-tailed), 4.1 for the hostility subscale (t=3.74, df= 17, p< .05, two-tailed), and 14.6 for the summary scale measuring overall dysphoria (t=4.01 , df= 1 7, p < .0, two-tailed). We interpreted the changes in the scores as an indication that subjects were experiencing much less stress at discharge than at admission. The mean length ofstay for the 22 subjects was four days, with a range of one to ten days. The majority of subjects stayed between one and three days. Twenty-one returned to duty. One subject with persistent suicidal ideation was evacuated for further evaluation and treatment. Conclusions The unit was the first level of treatment for most subjects. It was located close to their units, enabling visits by unit members. Considering the large amount ofsymptornatology on admission, the average length of stay (four days) was relatively short, and all but one subject were able to return to their units. The decline in anxiety, depression, and hostility as well as dysphoria from admission to discharge was impressive. Both individually and in group sessions, subjects described many apparent stressors, some of which were unique to the experience of being in a combat zone. They included fear of being attacked, not knowing the length of stay in Saudi Arabia, long duty hours with little rest, lack of privacy, infrequent showers, and feelings of having no control over their lives. Almost half of the subjects believed that the leadership in their units was dysfunctional. Some were also concerned with problems at home. Subjects were encouraged to ventilate their anger, fears, and concerns during the group therapy sessions. They showed a great deal of interest, participation, and interaction during those sessions and during the educational sessions. We feel that this group of soldiers benefited from the program of the stress recovery unit. Only one returned for outpatient counseling.
Hospital
and
Community
Psychiatry
Due to the short duration of the war, we were unable to follow up on the other subjects after they returned to their units. Ideally, controlled multisite studies should be planned and ready for implementation to help us learn better ways to maximize treatment outcomes with minimal personnel resources in combat situations.
Fort Sam Houston, Tex, emy ofHealth Sciences, 2.
Salmon
TW:
The
lesson. New York cine 59:933-944,
The authors thank SPC Vernon K. Sommenfeldt and SPC Jeffrey A. Frey for their assistance in collecting and coding the data.
4. Margalit combat Milgram 1986
Control in a Theater of Tactics, Techniques, and Coordinating draft FM 8-51.
Operations: Procedures.
and their of Medi-
1919
by
5. Bar-on clinical
R, Solomon Z, Noy S, et al: The picture of combat stress reactions in the 1982 war in Lebanon: cross-war comparisons, ibid
list.
Stress
Statejoumal
in Time of War. Edited NewYork, Brunnen/Mazel,
NA.
M,
Lubin
for the Multiple
1 . Combat
war neuroses
C, WoznerY, Nardi C, et al: The fitness retraining unit, in Stress
6. Zuckerman References
Acad-
3. Ursano RJ, Holloway HC: Military psychiatry, in Comprehensive Textbook of Psychiatry, 4th ed, vol 2. Edited by Kaplan HI, Sadock B). Baltimore, Williams & Wilkins, 1985
and Coping
Acknowledgments
USArmy,
1990
B: Normative
Affects
Psychological
Adjective
Reports
16:438,
data
Check1965
7. Datel WE, GiesekingCF, Engle EO, et al: Affect levels in a platoon ofbasic trainees. Psychological Reports 18:27 1-285, 1966
Posttraumatic Stress Symptoms Among Soldiers Exposed to Combat in the Persian Gulf Lawrence
A. Labbate,
Michael
P. Snow,
The Persian Gulf conflict with few American troops
Dr. Labbate, Army tivity
War was American experienced
formerly
psychiatry
service Medical
in
a brief deaths. few
chiefof at
the
the U.S.
Department
in the
Ac-
Germany,
Bremerhaven,
is a fellow pharmacology Massachusetts
M.D.
M.A.
clinical psychounit, ACC 815,
General
Hospital,
mental health problems (1); soldiers with psychiatric problems constituted only 6.5 percent ofthe medical evacuations from Southwest Asia (Barham K, persona! communication, 1992). Despite limited casualties, the conflict included isolated instances of intense combat, death by so-called friendly fire, and the attendant psychologica! trauma of war. The chief of the U.S. Army Medical Research Unit for Europe has referred to these incidents as ‘pockets of trauma” (Martin J, personal communication, 1991 The study reported here surveyed one mechanized infantry company exposed to this environment and attempted to identify some of the psychological effects associated with this exposure. Posttraumatic stress disorder sometimes results from exposure to traumatic events such as combat (2). A primary symptom of the disorder is reexpeniencing the traumatic ‘
).
Boston,
Massachusetts
021
14. Mr.
Snow is chief of the property management branch at the U.S. Army Medical Department Activity
in Bremerhaven,
Germany.
The opinions authors’ and reflect
ment ment
Hospital
expressed are the do not necessarily the views of the Departof the Army or the Departof Defense.
and
Community
Psychiatry
August
1992
Vol.
43
No.
8
events. Persons with the disorder usually begin neexpeniencing the traumatic event soon after it has occurred, although the onset of this symptom may be delayed. Many peopie who arc exposed to psychological trauma do not seek treatment immediately after the trauma; they may develop posttraumatic stress disorden later (3,4). Reexpeniencing the trauma often occurs through disturbing dreams or nightmares (5). Sleep disturbances in general are recognized components of posttraumatic stress disorder (6). To examine effects of psychological trauma in soldiers after combat in the Persian Gulf Wan without conducting full diagnostic interviews, we focused on the presence of nightmares and other sleep disturbances. After the Vietnam Wan, alcohol abuse was a common problem of veterans with posttraumatic stress disorder(7,8). Because illegal drugs and alcohol were forbidden in the cultural context in Southwest Asia, they were much less readily available than in Vietnam. We wanted to learn whether this forced abstinence aSfected use of alcohol after the troops returned to their base in Germany and whether soldiers who expenienced nightmares attempted to alleviate them by using alcohol. We hypothesized that despite participating in a brief, victorious campaign that had strong public support, soldiers in a unit exposed to intense combat in the Persian Gulf might show significant, perhaps delayed, psychiatric symptoms and increased alcohol use. Methods The unit surveyed was a mechanized infantry company supporting an armored brigade. No mental health personnel were assigned to the bnigade. The unit was actively involved in
the
brief
ground
war
during
the
Persian Gulf conflict and suffered four deaths from so-called friendly fire. Its mission after the ground war included control of refugees and prisoners of war and destruction of enemy tanks and bunkers. The unit returned to Germany in early May 1991, about two months after the cease-fire. Four months later, in early Sep-
831
