Kevin Nasky, D.O.                                      Neil Hines, M.D.
Lieutenant, Medical Corps, USN               Lieut...
Disclosures and
Acknowledgments:
 Drs. Nasky, Hines and Simmer report no
  competing interests or industry financial
  su...
October
12, 2000
At 5:15 a.m.
EST, suicide
bombers aboard a
small craft attacked
the USS
Cole, resulting in an
explosion t...
 In the aftermath, a team from Naval
  Hospital Sigonella initially provides
  mental health support to the crew.
 When ...
 Special Psychiatric Rapid Intervention Team
 Includes Psychiatrists, Psychologists, Psychiatric
  Nurses, LCSWs, Chapla...
 The original purpose of this data
 collection was to screen the crew’s
 overall state of mental health to
 assist the SP...
 Toidentify susceptibilities based
 on various demographic
 characteristics.

 By better targeting individual
 needs, we...
 Age
 Gender
 Marital status
 Rank
 Months attached to USS Cole
 Whether the sailor was injured or
 medically evacua...
 Escorted deceased shipmates
 Relationship to the injured or deceased
 Previously experienced a significant life
  even...
 Ouranalysis evaluated 5
 psychometric measures
  The Impact of Events Scale–Revised
   (IES-R) and its 3 subscales
   ○...
Reference(s):
Only significant
difference was
that 22-25 year-
olds had higher
avoidance
scores than 26-
29 year-olds.
GENDER   Females scored
         significantly
         higher than
         males on the
         IES-R and the
         ...
Injured
Service
Members
Reported an
Increased
Sense of
Hyperarousal.
Analyses of
rank
demonstrated
multiple
significant
differences
between
groups.
TwoCategories of Rank
 Compared
  Junior enlisted and NCOs
   together (E1-E6)
  All CPO’s and officers
   collectively...
E6 and below scored
 significantly higher than the
 E7 and above in all 5
 measures.
The overall IES-
R scores and
Intrusion and
Hyperarousal
subscores were
higher for those
that had a good
friend injured
or...
All five
measures
were
significantly
higher for
those whose
best friend
was injured
or died.
Everyone
who reported
separation
from his or
her
shipmates as
difficult
scored higher
in all
measures.
Those that had
        experienced
        significant life
        events* had
        higher
        depression
        ...
 Marital  status
 Months attached to the USS Cole
 Whether the individual required
  medical evacuation
 Travel to the...
 Older age has been associated with
  a decreased risk of developing
  PTSD.
 We found a higher prevalence of
  avoidanc...
 Avoidance — less mature defense
  mechanism
 Younger age ≈ affect tolerance
  Should interventions aimed at younger
  ...
GENDER
In concurrence
with the literature,
females scored
significantly higher
than males on the
IES-R and
Intrusion subsc...
GENDER
Women in the
military suffer
greater trauma
exposure when
compared to
civilian women.
 In contrast to our findings, previous
  meta-analyses of military subjects
  found gender not to be a significant
  fact...
Is female susceptibility
               taught?
            Different parenting
            of boys versus
            gir...
MARITAL
STATUS
Our Study: No
Significant Effects
A New Zealand study
of Vietnam vets;
however, found that
those with PTSD ...
MARITAL
STATUS
Our Study: No
Significant Effects
 Although the
 literature is replete
 with evidence that
 social support ...
MARITAL
STATUS
 Evaluating the
 predictive value of
 marriage as
 protective factor
 might be more
 meaningful if the
 qua...
MARITAL
STATUS
 Perhaps the added
 relational stressor
 of a troubled
 marriage
 statistically
 obscures presumed
 protect...
RANK
Our data revealed
a strong inverse
correlation
between rank and
both IES-R and
Zung scores.
RANK
This was one of
few studies in
which rank was
considered as an
independent risk
factor for PTSD
symptoms.
RANK
One challenge to
interpreting these
results is rank has
a high interrelation
with other factors
such as age,
educatio...
Age




Operational
Awareness
                                       IQ
Anticipation

                Rank
           Self...
Rank as a
     Surrogate
       for Age
Although rank is often
a surrogate for age,
however age did not
prove to be a
prom...
Rank as a
  Surrogate for
Education Level
   Rank    Education

   An Israeli study found
    that lower ranking,
    le...
Rank as a
  Surrogate for
Education Level
 Data from a study
 of Vietnam
 veterans also
 revealed that
 higher educational...
Does a higher level
      of education
 equate to greater
understanding and
     perspective?

    ↑ ego strength
    pr...
 Internal-External   Locus Of
 Control

 ―The degree one senses the events
   around them as dependent on their
   own be...
External                Internal
Locus of Control       Locus of Control




Outcomes outside       Outcomes within
your c...
Performance
                               • Past
           Accomplish-           Experiences
              ments
       ...
 Retired
        U.S. Army Lieutenant Colonel
 Dave Grossman believes that leaders
 who appear to be buffered from
 comba...
Self-Efficacy and Internal Locus of
         Control: Components of a
                  “Warrior Spirit”?
                ...
 The belief that the lack of a realistic
  anticipation of combat forebodes poor
  psychological sequelae is not unpreced...
 Increased operational awareness
  shields leaders from PTSD.
 Leaders are more ―in the loop‖ as
  opposed to a lower ra...
 Grossman:     “A leader’s internal locus of
   control is bolstered by having the authority
   to respond to aggression....
 Kushner,  et al. demonstrated the
  importance of self-efficacy in a study
  regarding crime victims, where
  perceived ...
 Serious combat-related
  injuries have been
  correlated with ↑
  prevalence of PTSD and
  depression.
 Should hyperaro...
   A 2006 study of
    seriously injured U.S.
    soldiers (n=613)

     Physical
      complications 1 mo
      s/p inj...
   French survivors of terrorist
    attacks who were severely
    injured were roughly four
    times likelier to develo...
 A normal
  bereavement
  reaction?
 Reflective of a
  positive unit
  characteristic –
  camaraderie?
 We evaluated data collected from
 subjects who were all members
 of a single military unit…


 …who together experienced...
Strong External Validity
 Our sample population is highly
  representative of the
  subpopulation for which we
  hope to...
 We found a strong inverse correlation
 between rank and depressive and
 PTSD symptoms.
 Many   hypotheses attempt to ex...
 Thisknowledge may prompt
 leaders to review how we recruit
 and train members of the armed
 forces.
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive ...
Upcoming SlideShare
Loading in …5
×

The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive Disorders

1,913 views

Published on

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

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,913
On SlideShare
0
From Embeds
0
Number of Embeds
14
Actions
Shares
0
Downloads
24
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • Age had been divided into four groups 18-2122-2526-2930 and over No significant differences were found between the other groups
  • Reference(s): Schnurr, P. P., Lunney, C. A., & Sengupta, A. (2004). Risk factors for the development versus maintenance of posttraumatic stress disorder. J Trauma Stress, 17(2), 85-95.Vincent, C., Chamberlain, K., & Long, N. (1994). Relation of military service variables to posttraumatic stress disorder in New Zealand Vietnam War veterans. Military Medicine, 159(4), 322-326.
  • Reference(s):1. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol, 68(5), 748-766.
  • *except for of our observation of slightly higher avoidance scores in the 22-25 year-olds compared with 26-29 year olds)
  • Solomon, Z., Noy, S., & Bar-On, R. (1986). Risk factors in combat stress reaction--a study of Israeli soldiers in the 1982 Lebanon war. Isr J Psychiatry Relat Sci, 23(1), 3-8.
  • Schnurr, P. P., Lunney, C. A., & Sengupta, A. (2004). Risk factors for the development versus maintenance of posttraumatic stress disorder. J Trauma Stress, 17(2), 85-95.
  • Solomon, Z., Noy, S., & Bar-On, R. (1986). Risk factors in combat stress reaction--a study of Israeli soldiers in the 1982 Lebanon war. Isr J Psychiatry Relat Sci, 23(1), 3-8.
  • Self-efficacy theory (Bandura, 1977) suggests that there are four major sources of information used by individuals when forming self-efficacy judgments (see Figure 1). In order of strength, the first is performance accomplishments, which refers to personal assessment information that is based on an individual's personal mastery accomplishments (i.e., past experiences with the specific task being investigated). Previous successes raise mastery expectations, while repeated failures lower them (Gist & Mitchell, 1992; Saks, 1995; Silver, Mitchell & Gist, 1995). The second is vicarious experience, which is gained by observing others perform activities successfully. This is often referred to as modeling, and it can generate expectations in observers that they can improve their own performance by learning from what they have observed (Bandura, 1978; Gist & Mitchell, 1992). Social persuasion is the third, and it refers to activities where people are led, through suggestion, into believing that they can cope successfully with specific tasks. Coaching and giving evaluative feedback on performance are common types of social persuasion (Bandura, 1977; Bandura & Cervone, 1986). The final source of information is physiological and emotional states. The individual's physiological or emotional states influence self-efficacy judgments with respect to specific tasks. Emotional reactions to such tasks (e.g., anxiety) can lead to negative judgments of one’s ability to complete the tasks (Bandura, 1988).Reference(s):1. Strickland, B. R. (1978). Internal-external expectancies and health-related behaviors. J Consult ClinPsychol, 46(6), 1192-1211.
  • Reference(s): personal communication, October 2005)
  • Reference(s):Kushner, M. G., Riggs, D. S., Foa, E. B., & Miller, S. M. (1993). Perceived controllability and the development of posttraumatic stress disorder (PTSD) in crime victims. Behav Res Ther, 31(1), 105-110.Heinrichs, M., Wagner, D., Schoch, W., Soravia, L. M., Hellhammer, D. H., & Ehlert, U. (2005). Predicting posttraumatic stress symptoms from pretraumatic risk factors: a 2-year prospective follow-up study in firefighters. Am J Psychiatry, 162(12), 2276-2286.
  • The USS COLE Bombing: Analysis of Preexisting Factors as Predictors for Development of Posttraumatic Stress or Depressive Disorders

    1. 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. 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. 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. 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. 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. 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. 7.  Toidentify susceptibilities based on various demographic characteristics.  By better targeting individual needs, we improve our interventions.
    8. 8.  Age  Gender  Marital status  Rank  Months attached to USS Cole  Whether the sailor was injured or medically evacuated
    9. 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. 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. 11. Reference(s):
    12. 12. Only significant difference was that 22-25 year- olds had higher avoidance scores than 26- 29 year-olds.
    13. 13. GENDER Females scored significantly higher than males on the IES-R and the sense of Intrusion subscale.
    14. 14. Injured Service Members Reported an Increased Sense of Hyperarousal.
    15. 15. Analyses of rank demonstrated multiple significant differences between groups.
    16. 16. TwoCategories of Rank Compared  Junior enlisted and NCOs together (E1-E6)  All CPO’s and officers collectively (E7-O5)
    17. 17. E6 and below scored significantly higher than the E7 and above in all 5 measures.
    18. 18. 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.
    19. 19. All five measures were significantly higher for those whose best friend was injured or died.
    20. 20. Everyone who reported separation from his or her shipmates as difficult scored higher in all measures.
    21. 21. Those that had experienced significant life events* had higher depression scores *e.g. major accident or death in family
    22. 22.  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
    23. 23.  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
    24. 24.  Avoidance — less mature defense mechanism  Younger age ≈ affect tolerance  Should interventions aimed at younger service members pay particular attention to avoidance?
    25. 25. GENDER In concurrence with the literature, females scored significantly higher than males on the IES-R and Intrusion subscale.
    26. 26. GENDER Women in the military suffer greater trauma exposure when compared to civilian women.
    27. 27.  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?
    28. 28. Is female susceptibility taught? Different parenting of boys versus girls? • Boys expected to ―suck it up,‖ while girls are consoled?
    29. 29. 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.
    30. 30. 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.
    31. 31. MARITAL STATUS Evaluating the predictive value of marriage as protective factor might be more meaningful if the quality of the marriage was also assessed.
    32. 32. MARITAL STATUS Perhaps the added relational stressor of a troubled marriage statistically obscures presumed protective effects of a ―good‖ marriage.
    33. 33. RANK Our data revealed a strong inverse correlation between rank and both IES-R and Zung scores.
    34. 34. RANK This was one of few studies in which rank was considered as an independent risk factor for PTSD symptoms.
    35. 35. RANK One challenge to interpreting these results is rank has a high interrelation with other factors such as age, education, and intelligence.
    36. 36. Age Operational Awareness IQ Anticipation Rank Self- Education Efficacy
    37. 37. 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.
    38. 38. 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
    39. 39. 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.
    40. 40. Does a higher level of education equate to greater understanding and perspective?  ↑ ego strength  promote use of intellectualization as a defense?
    41. 41.  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.
    42. 42. 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
    43. 43. Performance • Past Accomplish- Experiences ments • Training? • Modeling by Vicarious others Experience • Training? Leadership? SELF- EFFICACY • Evaluative Social Persuasion feedback • Leadership? Physiological and Emotional States
    44. 44.  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.‖
    45. 45. 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.
    46. 46.  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
    47. 47.  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.
    48. 48.  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,
    49. 49.  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.
    50. 50.  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?
    51. 51.  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
    52. 52.  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.
    53. 53.  A normal bereavement reaction?  Reflective of a positive unit characteristic – camaraderie?
    54. 54.  We evaluated data collected from subjects who were all members of a single military unit… …who together experienced the same traumatic event.
    55. 55. Strong External Validity Our sample population is highly representative of the subpopulation for which we hope to provide better care.
    56. 56.  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.
    57. 57.  Thisknowledge may prompt leaders to review how we recruit and train members of the armed forces.

    ×