Presentation given at American Psychiatric Association Annual Meeting in San Francisco, CA on 20 May 2009.

1. Kevin Nasky, D.O. Neil Hines, M.D.
Lieutenant, Medical Corps, USN Lieutenant, Medical Corps, USN
Naval Medical Center Portsmouth Naval Medical Center Portsmouth
Edward Simmer, M.D., M.P.H.
Captain, Medical Corps, USN
Senior Executive Director for Psychological Health
Defense Center of Excellence for Psychological Health and Traumatic Brain Injury

2. Disclosures and
Acknowledgments:
 Drs. Nasky, Hines and Simmer report no
competing interests or industry financial
support of any kind.
 The views expressed in this article are those
of the author and do not reflect the official
policy or position of the Department of the
Navy, Department of Defense, or the United
States Government.
Reference(s):

3. October
12, 2000
At 5:15 a.m.
EST, suicide
bombers aboard a
small craft attacked
the USS
Cole, resulting in an
explosion that tore a
gaping hole, 20 feet
by 40 feet, killing 17
sailors and injuring
39.

4.  In the aftermath, a team from Naval
Hospital Sigonella initially provides
mental health support to the crew.
 When the crew returns to Norfolk, VA,
continued support is provided by the
Naval Medical Center Portsmouth
Special Psychiatric Rapid Intervention
Team (SPRINT).

5.  Special Psychiatric Rapid Intervention Team
 Includes Psychiatrists, Psychologists, Psychiatric
Nurses, LCSWs, Chaplains and Neuropsychiatric
Technicians.
 Provides on-site consultation to the Chain of
Command
 Assist local shipboard, port, or air station medical,
mental health, and chaplain personnel with critical
event interventions as applicable.

6.  The original purpose of this data
collection was to screen the crew’s
overall state of mental health to
assist the SPRINT team in needs
assessment.

7.  Toidentify susceptibilities based
on various demographic
characteristics.
 By better targeting individual
needs, we improve our
interventions.

8.  Age
 Gender
 Marital status
 Rank
 Months attached to USS Cole
 Whether the sailor was injured or
medically evacuated

9.  Escorted deceased shipmates
 Relationship to the injured or deceased
 Previously experienced a significant life
event
 Separation from his or her shipmates after
the attack difficult

10.  Ouranalysis evaluated 5
psychometric measures
 The Impact of Events Scale–Revised
(IES-R) and its 3 subscales
○ Intrusion
○ Avoidance
○ Hyperarousal
 Zung Self-Rating Depression Scale
(SDS)

11. Reference(s):

12. Only significant
difference was
that 22-25 year-
olds had higher
avoidance
scores than 26-
29 year-olds.

14. GENDER Females scored
significantly
higher than
males on the
IES-R and the
sense of
Intrusion
subscale.

16. Injured
Service
Members
Reported an
Increased
Sense of
Hyperarousal.

18. Analyses of
rank
demonstrated
multiple
significant
differences
between
groups.

19. TwoCategories of Rank
Compared
 Junior enlisted and NCOs
together (E1-E6)
 All CPO’s and officers
collectively (E7-O5)

20. E6 and below scored
significantly higher than the
E7 and above in all 5
measures.

22. The overall IES-
R scores and
Intrusion and
Hyperarousal
subscores were
higher for those
that had a good
friend injured
or die than
versus an
acquaintance.

24. All five
measures
were
significantly
higher for
those whose
best friend
was injured
or died.

26. Everyone
who reported
separation
from his or
her
shipmates as
difficult
scored higher
in all
measures.

28. Those that had
experienced
significant life
events* had
higher
depression
scores
*e.g. major accident or death in family

30.  Marital status
 Months attached to the USS Cole
 Whether the individual required
medical evacuation
 Travel to the US as an escort
 Having had an acquaintance injured
or killed in the attack

32.  Older age has been associated with
a decreased risk of developing
PTSD.
 We found a higher prevalence of
avoidance in the 22-25 group than
the 26-29.
 Analysis of avoidance unique to this
study

33.  Avoidance — less mature defense
mechanism
 Younger age ≈ affect tolerance
 Should interventions aimed at younger
service members pay particular attention
to avoidance?

34. GENDER
In concurrence
with the literature,
females scored
significantly higher
than males on the
IES-R and
Intrusion subscale.

35. GENDER
Women in the
military suffer
greater trauma
exposure when
compared to
civilian women.

36.  In contrast to our findings, previous
meta-analyses of military subjects
found gender not to be a significant
factor.
 Is this the result of the more
homogeneous trauma exposure
among military men and women?

37. Is female susceptibility
taught?
Different parenting
of boys versus
girls?
• Boys expected to
―suck it up,‖ while
girls are consoled?

38. MARITAL
STATUS
Our Study: No
Significant Effects
A New Zealand study
of Vietnam vets;
however, found that
those with PTSD were
2X as likely to be
divorced than those
without symptoms.

39. MARITAL
STATUS
Our Study: No
Significant Effects
Although the
literature is replete
with evidence that
social support helps
protect against
PTSD, our study
found no significant
effects.

40. MARITAL
STATUS
Evaluating the
predictive value of
marriage as
protective factor
might be more
meaningful if the
quality of the
marriage was also
assessed.

41. MARITAL
STATUS
Perhaps the added
relational stressor
of a troubled
marriage
statistically
obscures presumed
protective effects of
a ―good‖ marriage.

42. RANK
Our data revealed
a strong inverse
correlation
between rank and
both IES-R and
Zung scores.

43. RANK
This was one of
few studies in
which rank was
considered as an
independent risk
factor for PTSD
symptoms.

44. RANK
One challenge to
interpreting these
results is rank has
a high interrelation
with other factors
such as age,
education, and
intelligence.

45. Age
Operational
Awareness
IQ
Anticipation
Rank
Self-
Education
Efficacy

46. Rank as a
Surrogate
for Age
Although rank is often
a surrogate for age,
however age did not
prove to be a
prominent predictive
factor in this study,
which compelled us to
look at other
characteristics rank
may embody.

47. Rank as a
Surrogate for
Education Level
 Rank Education
 An Israeli study found
that lower ranking,
less-educated
soldiers are more
vulnerable to combat
stress reactions than
higher ranking, more
educated soldiers

48. Rank as a
Surrogate for
Education Level
Data from a study
of Vietnam
veterans also
revealed that
higher educational
attainment was
associated with a
lower risk for
developing PTSD.

49. Does a higher level
of education
equate to greater
understanding and
perspective?
 ↑ ego strength
 promote use of
intellectualization as a
defense?

50.  Internal-External Locus Of
Control
―The degree one senses the events
around them as dependent on their
own behavior versus the result of
powers beyond their control and
understanding.

51. External Internal
Locus of Control Locus of Control
Outcomes outside Outcomes within
your control — your control —
determined by ―fate‖ determined by your
and independent of hard work,
your hard work or attributes or
decisions decisions

52. Performance
• Past
Accomplish- Experiences
ments
• Training?
• Modeling by
Vicarious others
Experience
• Training?
Leadership?
SELF-
EFFICACY
• Evaluative
Social
Persuasion feedback
• Leadership?
Physiological
and
Emotional
States

53.  Retired
U.S. Army Lieutenant Colonel
Dave Grossman believes that leaders
who appear to be buffered from
combat trauma have these
characteristics and others, which
together constitute a ―Warrior Spirit.‖

54. Self-Efficacy and Internal Locus of
Control: Components of a
“Warrior Spirit”?
• Grossman: Service
members with this quality
anticipate combat as a
possibility — realistic
expectation of combat
―An attack might be less of a
shock to a Naval Academy
graduate than a service
member whose motivation
to enlist was educational
benefits or occupational
training.

55.  The belief that the lack of a realistic
anticipation of combat forebodes poor
psychological sequelae is not unprecedented.
 J. T. Calhoun, a Civil War Army surgeon,
contended that cases of nostalgia resulted
from recruitment of poorly motivated soldiers
with unrealistic expectations of combat

56.  Increased operational awareness
shields leaders from PTSD.
 Leaders are more ―in the loop‖ as
opposed to a lower ranking members
whose assignments would leave
them tactically uninformed.

57.  Grossman: “A leader’s internal locus of
control is bolstered by having the authority
to respond to aggression.”
 George Bonanno*: “The ability to act on or
influence actions in the immediate
environment confers resilience.”
*Associate Professor of Psychology at Columbia University,

58.  Kushner, et al. demonstrated the
importance of self-efficacy in a study
regarding crime victims, where
perceived lack of control was shown
to predict the development of PTSD.
 A 2-year follow-up study of firefighters
found low self-efficacy was a major risk
factor for PTSD.

59.  Serious combat-related
injuries have been
correlated with ↑
prevalence of PTSD and
depression.
 Should hyperarousal be
a particular focus of
concern when treating
those wounded in
combat?

60.  A 2006 study of
seriously injured U.S.
soldiers (n=613)
 Physical
complications 1 mo
s/p injury correlated
with higher
prevalence of PTSD
and depression at
both 1 and 7 months
s/p trauma

61.  French survivors of terrorist
attacks who were severely
injured were roughly four
times likelier to develop
PTSD that those
moderately injured or
uninjured.
 Severity of injury was
shown to be associated
with a higher risk of PTSD
in victims of the Oklahoma
City bombing.

62.  A normal
bereavement
reaction?
 Reflective of a
positive unit
characteristic –
camaraderie?

63.  We evaluated data collected from
subjects who were all members
of a single military unit…
…who together experienced the
same traumatic event.

64. Strong External Validity
Our sample population is highly
representative of the
subpopulation for which we
hope to provide better care.

65.  We found a strong inverse correlation
between rank and depressive and
PTSD symptoms.
 Many hypotheses attempt to explain
this finding—the answer is likely an
aggregate of those possibilities.

66.  Thisknowledge may prompt
leaders to review how we recruit
and train members of the armed
forces.