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

The USS COLE Bombing: Analysis Of Preexisting Factors As Predictors For Development Of Posttraumatic Stress

Kevin Nasky, D.O. Neil Hines, M.D.Lieutenant, Medical Corps, USN Lieutenant, Medical Corps, USNNaval Medical Center Portsmouth Naval Medical Center Portsmouth

Edward Simmer, M.D., M.P.H.Captain, Medical Corps, USN

Senior Executive Director for Psychological HealthDefense Center of Excellence for Psychological Health and Traumatic Brain Injury

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):

October 12, 2000At 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.

October 12, 2000 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).

WHAT IS SPRINT? 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.

In December 2000, the NMCP SPRINT team obtained

demographic and other data from the crew and administered two

psychometric instruments. 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.

To identify susceptibilities based on various demographic characteristics.

By better targeting individual needs, we improve our interventions.

Study Purpose

Demographic and Other Preexisting

DataAgeGenderMarital statusRankMonths attached to USS Cole

Whether the sailor was injured or medically evacuated

Demographic and Other Preexisting

DataEscorted deceased shipmatesRelationship to the injured or

deceasedPreviously experienced a significant

life eventSeparation from his or her

shipmates after the attack difficult

ANALYSIS Our analysis evaluated 5

psychometric measuresThe Impact of Events Scale–

Revised (IES-R) and its 3 subscales○ Intrusion○Avoidance○Hyperarousal

Zung Self-Rating Depression Scale (SDS)

RESULTS

Reference(s):

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

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

GENDER

Injured Service Members Reported an Increased Sense of Hyperarousal.

Analyses of rank demonstrated multiple significant differences between groups.

RANK

Analysis of Rank

Two Categories of Rank ComparedJunior enlisted and NCOs together (E1-E6)

All CPO’s and officers collectively (E7-O5)

Analysis of Rank: Results

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 die than versus an acquaintance.

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.

SEPARATION

Those that had experienced significant life events* had higher depression scores

*e.g. major accident or death in family

Factors Which Had No Significant Effect on Any of the Dependent Variables

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

DISCUSSION

AGE: Our Findings Reflect the Majority of the

Literature 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

Use of avoidance as a defense in younger individuals:

An intuitive finding?

Avoidance — less mature defense mechanism

Younger age ≈ affect toleranceShould interventions aimed at

younger service members pay particular attention to avoidance?

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

GENDERWomen in the military suffer greater trauma exposure when compared to civilian women.

However, the literature on gender is not

conclusive 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?

Is female susceptibility

taught?Different parenting of boys versus girls?• Boys expected to

“suck it up,” while girls are consoled?

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

MARITAL STATUSOur Study: No Significant EffectsAlthough the

literature is replete with evidence that social support helps protect against PTSD, our study found no significant effects.

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

MARITAL STATUS

Perhaps the added relational stressor of a troubled marriage statistically obscures presumed protective effects of a “good” marriage.

MARITAL STATUS

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

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

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

Interrelation Among Rank and Other

Factors

Rank

Age

IQ

Education

Self-Efficacy

Operational Awareness

Anticipation

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.

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

Rank as a Surrogate for

Education Level

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.

↑ ego strength promote use of

intellectualization as a defense?

Does a higher level of

education equate to

greater understanding

and perspective?

Rank as A Surrogate for Self-Efficacy or Internal

Locus of Control 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.

ExternalLocus of Control

InternalLocus of Control

Outcomes outside your control — determined by “fate” and independent of your hard work or decisions

Outcomes within your control — determined by your hard work, attributes or decisions

Performance

Accomplish-ments

•Past Experiences•Training?

Vicarious

Experience

•Modeling by others•Training? Leadership?

Social Persuasion

•Evaluative feedback•Leadership?

Physiological and Emotional States

SELF-EFFICACY

Self-Efficacy and Internal Locus of Control: Components of a

“Warrior Spirit”?

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.”

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.

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

“Warrior Spirit” — Realistic Expectation Of Combat

Is rank a surrogate for ANTICIPATION of

trauma? 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.

Is rank a surrogate for the AUTHORITY to respond to

aggression? 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,

Rank A Surrogate For The Authority : Literature

support 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.

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?

Injured USS COLE Sailors Reported Increased

Hyperarousal

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

Our findings are consistent with the literature on this

topic

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.

Our findings are consistent with the literature on this

topic

A normal bereavement reaction?

Reflective of a positive unit characteristic – camaraderie?

Service members who experienced difficult separations from their shipmates had higher depression scores.

WHY THIS STUDY IS UNIQUE

We evaluated data collected from subjects who were all members of a single military unit…

a Ship’s Crew…who together experienced the same traumatic event.

Strong External Validity Our sample population is

highly representative of the subpopulation for which we hope to provide better care.

WHY THIS STUDY IS UNIQUE

Among the factors we evaluated, rank emerged

as the prominent protective factor.

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.

A Greater Understanding of Factors Subsumed Under Rank

Could Lead to Improved Prescreening or Pre-selection

This knowledge may prompt leaders to review how we recruit and train members of the armed forces.

Questions