JP was a 23-year-old infantryman assigned as a military advisor in Operation Iraqi Freedom. He was deployed to Anbar Province during a time of high operational tempo for the Marines, and JP’s small unit of advisors was no exception. Assigned to an Iraqi Army battalion, he and his fellow Marines were responsible for training and accompanying them on combat missions. He came to Operational Stress Control and Readiness (OSCAR) psychiatry voluntarily at the recommendation of his leadership for assistance with irritability and anger outbursts while on deployment.

JP thought he was doing fine, but not so well in the last 2 months since he deployed. He felt more distressed and edgy while performing combat patrols. He also started having nightmares related to his previous deployment to the same region 18 months earlier. As a result, he did not sleep very well. He also related his sleep problems to having to sleep alongside his Iraqi counterparts. While he knew he was assigned to train and support them, he had trouble trusting them and was constantly vigilant.

His commander was concerned because JP had recently gotten into a physical altercation with one of his fellow Marines. In the fight, JP broke the other Marine’s collarbone, taking him out of operations for 3 weeks while he healed. The commander reported that JP was otherwise a good Marine and stood out in neither a positive nor negative light during the pre-deployment workup. He was not one he expected to be a disciplinary problem, and the commander seemed genuinely concerned that something was wrong.

During the initial interview, JP related a distressing incident from his first deployment. While on patrol in a convoy of Humvees, his squad came across a crowd of people gathered outside a mosque. The convoy had to stop because the crowd partially blocked the road. The vehicles stopped, and the crowd gathered around JP’s vehicle. There was a lot of yelling and finger pointing as was typical when Americans were around. Since no one in the crowd appeared armed, the Marines tried to disperse the crowd peacefully. As they were getting out of their vehicles, a grenade rolled out of the crowd next to JP’s Humvee, literally at his feet. He jumped back into the Humvee immediately and closed the door just as the grenade went off. The detonation did not significantly damage the vehicle or injure anyone.

JP exited the vehicle to see the crowd rapidly dispersing. He recalled seeing a young man staring him down in the crowd, and thought that this was the person who rolled the grenade.

JP’s squad leader ordered the Marines to find and detain the person who dropped the grenade. JP saw the suspicious young man run down a side street and decided to pursue. He said it was hard to remember the specifics now, but he remembers several vivid moments he will never forget. He pursued for less than a minute and then realized he was separated from his squad. Realizing he did not have support and feeling vulnerable, he slowed. It was just then he saw the runner about to disappear. Without thought he raised his rifle to his shoulder, sighted in on the young man, and quickly fired several shots, dropping the fleeing individual to the ground. He remembers he did not take time to yell “stop” or “qef.” He remembers seeing his shot hit the young man’s head and blood and brains flying out.

The next thing he remembers is his squad catching up and walking up to identify the person. When he rolled over the body, he vividly recalls seeing the distorted face of an adolescent boy, somewhere between 12 and 16 years old. He recalls intense feelings of guilt and questioning whether he had done the right thing.

A distraught woman approached and began to cry over the body. He assumed she was the boy’s mother. At that point the squad leader instructed the Marines to leave, and JP did not know what happened to the boy after that. He said this was the first time he had told anyone what happened, and he did not talk about it even with fellow Marines. The investigation found that he was justified in shooting, but he never felt as if it was.

He started having nightmares within days of the event. They continued on and off until about 2 months back home. He never sought any psychiatric treatment, and the nightmares resolved spontaneously. After that he did not think he had a problem. He did not have problems at home between deployments, and thought he would be fine on this one. The nightmares resumed within 2 weeks of returning to his old area of operations. He said he was operating in the same neighborhoods where the events had happened 2 years before. Whenever he went past that mosque he felt particularly uneasy, and did his best to choke it down and not tell anyone.

His nightmares were a vivid replay of running down the side street, feeling alone and vulnerable, shooting and seeing the boy’s face, and the reaction of the woman. He would wake up with his heart pounding and feeling “amped up.” He would go outside and smoke a cigarette and try to settle himself, but that usually took an hour or so to get back to sleep. He said he was worried that some of the Iraqis he worked with were giving information to insurgents and also worried that one of them might attack him or others on his team if they ever had an opportunity. He denied any dissociative episodes, and said he did not feel like he had problems getting distracted or confused, no matter how “amped up” he felt.

He felt intense guilt, still questioning himself whether he was justified in killing the boy. He viewed his actions as “messed up” and the entire mission that led to him shooting as “messed up” as well. These feelings spilled over into questions about his current mission. There was no way his actions could have a positive impact on the future of the country, so why was he putting himself in danger? He felt more and more disconnected from the rest of his team. They all seemed motivated, but they did not understand. Even though he felt this way most of the time, he acknowledged he still had a job to do whether he believed in it or not.

Further, psychiatric review of systems revealed that JP denied depressed mood, and he maintained his normal range of activities and interests prior to deployment. He drank alcohol on weekends with his peers, anywhere from two to ten beers on an occasion depending on whether he intended to get drunk or not. He denied any difficulty at work or in relationships as a result of his drinking. He smoked a pack of cigarettes every 3 days while at home, and that increased to one pack per day while deployed. He was not using any supplements and did not use caffeine. He never had any past episode consistent with mania , and he denied any psychotic symptoms now or in the past.

Describing the fight that got his commander’s attention, JP said the other Marine was someone he never liked and he hated having to patrol with him. He thought the other Marine was overconfident, careless, and made the rest of the team vulnerable. JP got along fine with the other Marines in the unit, but generally kept to himself.

When asked about his reasons for becoming a Marine, he said he was in high school during 9/11, and from that day knew he wanted to serve. He chose the Marine Corps because he wanted to be part of a special group, and the Marines had that appeal for him. He was generally happy with his service to date, but was not sure if he would reenlist or not.