Ver el código de «Combat stress reaction»

==Background==
* Observed in soldiers for centuries previously called Shell Shock, Combat Fatigue, War Neurosis, Battle Fatigue
* Normal predictable stress reaction to the horrors of warfare
* All military personnel at risk but protective factors can lessen risk

===Risk Factors===
''Physical and Mental stressors are often inseparable''
*Situational 
**Unclear Rules of Engagement
**Prior combat exposure
**Military situation- intensity / length of fighting, number killed / wounded
**Role in combat- support troops may be at higher risk of combat psych reactions
**Indirect, unexpected fire
**Brutality of  enemy
*Physical 
**Environmental
***Heat, Cold, Wet
***Difficult Terrain
***Poisons
***NBC Threats
***Noise, Vibration
***Visibility
**Physiological
***Fatigue/Sleep Debt
***Dehydration
***Hunger/Malnutrition
***Poor Hygiene
***Physical fatigue
***Illness and Injury
*Mental 
**INTERpersonal
***Poor/Weak Leadership 
***Unit morale, cohesion
***New to unit
***Sense of social support/isolation
***Loss of a buddy or buddies
***Loss of faith in Leadership, self and/or God
***Information (Too much/little)
***Sensory (Too much/little) 
***Time (Pressured vs. Waiting)
**INTRApersonal
***Homefront Worries- threatened relationship, illness or other family stress
***Fear of death/maiming
***Fear of Cowardice
***Loss of belief in cause
***Sense of Winning or losing
***Isolation/ Loneliness
***Loss, Bereavement
***Anger, Frustration
***Boredom, Inactivity

==Clinical Features==
* Manifests as a variety of physical, emotional, cognitive and behavioral reactions to the stressors of war
* Combat is outside normal range of human experience which can overwhelm coping mechanisms leading to the development of stress reactions
* Signs and Symptoms include:
** Physical - fatigue, jumpiness, aches and pains,  GI upset/nausea, diarrhea/constipation, problems eating, problems sleeping, flinching/shaking, spaced out "thousand yard stare"
** Thinking - poor concentration, difficulty making decisions, flashbacks, nightmares, thoughts of harm to self/others, memory problems, loss of motivation
** Emotional - frustrated/angry, worried, keyed up, guilty/ashamed, depressed/withdrawn, numb, panic attacks, regression, "flat"

==Differential Diagnosis==
*Dehydration
*Hyperthermia/Hypothermia
*Overuse syndromes
*[[Rhabdomyolysis]]
*Adjustment Disorder
*[[Anxiety Disorder]]
*Brief Psychotic Disorder
*[[Depression]]
*Dissociative Disorders
*[[Traumatic Brain Injury]]
*[[Postconcussion syndrome]]
*Post Traumatic Stress Disorder
*[[Substance abuse]]

==Evaluation==
* Obtain reason why service member presents for help
* Listen to crisis story and obtain as much collateral information as possible
* Normalize the reaction
* Consult or refer to mental health professional
* Ensure no medical reasons exist that might explain symptoms

==Management==
* If not physically injured don't evacuate
* Don't treat them as "patients"
* Normalize symptoms as stress response and reassure them that they will get better
* Set up expectation that getting better means return to duty
* Medical Interventions - Keep It Simple
** PIES - Proximity, Immediacy, Expectancy, Simplicity
** BICEPS - Brevity, Immediacy, Centrality, Expectancy, Proximity, Simplicity
** 4 R's - Reassurance, Replenishment, Rest, Restoration
* Medic's role:
** Maintain combat capability
** Restore functioning to return to duty (70-85% can be returned to duty if properly handled)
** Assess and facilitate evacuation for those who cannot return to duty
** Prevent long-term disability
* Simple Treatment
** 3 hots and a cot (food, rest, and sleep)
** Reinforce identity as service member not as a patient
** Activity - structured military work detail, physical exercise and recreation
** Pair older closer to return with younger buddy
** Supportive debriefings
** Provide relief from danger but maintain a tactical atmosphere which is not too comfortable

==Disposition==
* Help in place  - minor cases which can be treated within unit
* Rest - those cases which need non-medical support facility but not close medical or mental health observation
* Hold - those cases which can be observed and treated in theater
* Refer - severe cases which are too disruptive for lower level of care

==See Also==

==References==
<references/>

[[Category:Military]]
[[Category:Psychiatry]]