However, what they report two weeks later (below) refl ects symptoms that may differentiate an acute stress reaction (ASR) from an acute stress disorder (ASD).

Most people (like Kevin W.) exposed to a traumatic event who exhibit Acute Stress Reaction (ASR) will recover spontaneously within a few days. Only a minority will develop ASD (like William G.), or some other psychiatric problem. However, since the vast majority of people who survive a catastrophic stressor will be very distressed during the immediate post-disaster aftermath, it is usually impossible to distinguish those who are most likely to recover on their own from those at greatest risk to develop a chronic psychiatric disorder [4].

Within 3–5 days of the September 11, 2001 World Trade Center attacks, 90 % of Americans surveyed nationally reported at least moderate distress while 44 % of respondents reported one or more substantial symptoms of severe distress [5]. In contrast to the high prevalence of normal posttraumatic distress, a much smaller percent of New Yorkers, 7.5 %, developed PTSD within weeks of the World Trade Center attacks [6].

This chapter considers this challenge and reviews current thinking about the best approach for ameliorating normal distress and treating clinically significant problems.

The wars in Iraq and Afghanistan have resulted in PTSD among approximately 15 % US service men and women. Indeed, given the remarkable advances in military medicine and the efficiency of the medical evacuation system, only 10 % of those wounded in battle have died from their injuries compared to 25 % in previous wars [7]. Higher survivor rates are no doubt one reason why psychiatric casualties have assumed such prominence. Another reason is the growth of knowledge regarding the recognition and treatment of posttraumatic reactions and disorders that has informed current military policy and practice [8, 9].

Acute psychological distress or functional incapacity has been a long-time concern of military psychiatry and psychology. Whereas, in the civilian sector, this is called ASR, in a military context, it is called Combat Operational Stress Reaction (COSR). In this chapter we will review COSR as well as ASR since there are specific interventions (e.g., PIES and BICEPS, see below) that the military has developed that are not only important in their own right but because they have greatly influenced interventions developed for civilians such as Psychological First Aid (PFA).

Furthermore, the desire to make troops more resilient, and therefore less likely to develop behavioral, emotional, or psychiatric problems after exposure to traumatic events has caused US military leaders to develop programs with the hope that they will produce psychological, as well as physical, toughness among troops preparing for deployment. The army, marines, navy, and air force have each established resilience programs to enable troops to obtain the psychological protection they need in a war zone. This development coincides with the recent growth in our scientific understanding of resilience which is a very complicated set of attributes that has genetic, psychobiological, cognitive, emotional, behavioral, and social dimensions. We await rigorous evaluation of these military resilience programs to see whether they make a positive difference in post-deployment outcomes.

Many combat injuries have been caused by powerful explosions from roadside bombs, suicide bombers, and explosive devices detonated from vehicles, or rocket propelled grenades and other explosives directed at convoys and troops. In addition to the psychological trauma of exposure to such powerful explosions (which often cause death, injury and major destruction), servicemen and women who survive such events may also have serious head injuries. These concussive injuries are popularly called traumatic brain injuries (TBIs) which may be mild, (which is most common), moderate, or severe (which may cause serious impairment of brain function as well as blindness and other neurological losses).

Since any concussive injury serious enough to, literally, rattle your brain is serious enough to cause traumatic stress, it is not uncommon for PTSD and TBI to occur in the same individual at the same time. For clinicians evaluating such servicemen and women weeks, months, or years after the explosive encounter, it is often difficult to distinguish which symptoms are due to PTSD and which to TBI since there is much overlap, especially with mild TBI [10]. Since this chapter focuses on short-term evaluation and treatment, such long-term issues will not be addressed. What does seem pertinent to the present discussion, however, is that at the present time, it appears that individuals with PTSD and mild (but not moderate or severe) TBI should be offered the same interventions and treatment as those with PTSD, alone. This is obviously a matter of great importance and a high priority area for current treatment planning and research.

Identification of a person with ASR or COSR is based primarily on observation of the severity of their emotional distress and functional impairment. Acute stress reactions may present in a number of ways with different individuals exhibiting different symptoms. In addition to intrusion, dissociative, avoidance, arousal and reactivity symptoms, people with ASR/COSR may exhibit the following symptoms for days or weeks following the trauma [4]:

These reactions may vary from mild to severe. In some cases, there is evidence of more clinical symptoms, such as: intrusive recollections, marked avoidance, dissociation, constricted affect, panic attacks, intense agitation, incapacitating anxiety, severe depression, and grief reactions (over the death or injury of loved ones as well as personal material losses).

At an early stage, the appropriate professional stance is that these are transient reactions from which normal recovery should be expected. In the first meeting following a traumatic event, the following educational information about strong emotional reactions following exposure to traumatic stress should be emphasized.

Key recommendations for these patients include:

There is growing consensus that the best mental health intervention during the immediate aftermath of a traumatic event is Psychological First Aid (PFA). This is an approach designed to ameliorate immediate posttraumatic distress based on the expectation that every survivor, no matter how upset, will achieve normal recovery [11]

Following exposure to a traumatic event, individuals should be encouraged to live their lives as normally as possible and avoid isolating themselves from family, friends, or community-based natural support systems (e.g., neighborhood, school, church, or workplace organizations).

In the event of a natural or man-made disaster, public health approaches in the vicinity of the terrorist attack or disaster site should have both educational and outreach components. Such large-scale, community/societal interventions should be designed to promote resilience and foster recovery among the majority of the population, temporarily suffering from acute posttraumatic reactions. They also need to provide widely accessible information about clinically significant posttraumatic symptoms so that people can make accurate appraisals concerning the magnitude of their own distress as well as that of loved ones and friends. Such a proactive approach should also indicate what type of mental health services might be helpful and where they can be found [11, 12].

Information available through print and broadcast media, Internet sites, and toll-free telephone hotlines rank among key vehicles for carrying out such a public health approach.

In the military, clinicians found that active duty personnel who had an incapacitating anxiety attack (e.g., “battle fatigue” or “combat operational stress reaction”) had better outcomes if treated at a medical unit close to the war zone, such as a mobile army surgical hospital (MASH) unit [14]. Thought to produce rapid resolution of battle fatigue and prevent the later development of what is now called PTSD, military psychological debriefing (PIES) included four main components:

Although the military PIES approach has not been rigorously tested, its apparent success fostered the use of similar interventions for civilians who experienced natural disasters or man-made catastrophes as exemplified by PFA.

A later version of PIES is called BICEPS which is currently utilized by the military.

Concern about mental fitness among fighting troops has naturally led to development of programs to foster mental toughening or resilience among troops before deployment to a war zone. It is obvious that greater resilience should result in fewer incidents of COSR and therefore significantly reduce COSR and more chronic trauma-related mental health problems among servicemen and women. As a result, the US army, navy, marines, and airforce have each developed resilience programs to improve psychological preparation for troops, which are currently operational. The basic principles of such programs are:

Understanding resilience has become one of the major challenges in the trauma field. It is a very complex construct consisting of genetic, psychobiological, cognitive, emotional, behavioral, and social aspects. Since everyone will encounter stress throughout life and more than half of us will be exposed to traumatic stress, it behooves us to learn as much about resilience as possible so that we can equip our children and ourselves, (as well as our military, police, firefighter, and first responder personnel) to prepare for stress as much as possible and to have the necessary coping abilities to confront stressful/traumatic situations when they arise. (See Chap. 5, pages XX–YY, for further discussion of resilience.)

This is an intervention conducted by trained professionals shortly after a catastrophe, allowing victims to talk about their experience and receive information on “normal” types of reactions to such an event. It was first developed for police, firefighters, and first responders to help them cope with the traumatic situations that they encountered on a daily basis as part of their professional responsibilities. It was later adapted by the military and utilized in the war zone. It was predicated on the assumption that the best approach for those who experience a catastrophic event is early detection and timely intervention.

Proponents of psychological debriefing assert that it can abort the onset of a serious mental disorder, can reduce severity and duration once it has taken hold, or can prevent ASR or COSR from progressing to a chronic and incapacitating PTSD or some other debilitating psychiatric disorder [11, 15, 16].