Operation Enduring Freedom Research Articles

Using Force Against Terrorists ‘Outside Areas of Active Hostilities’—The Obama Approach and the Bin Laden Raid Revisited

More than 13 years after the launch of Operation Enduring Freedom, the focus of US counterterrorism operations has gradually shifted from Afghanistan and Pakistan to the Arabian Peninsula, Somalia and Northern Africa. The use of drones and Special Forces in these regions causes difficult problems under interna- tional law. In particular, it is often far from clear whether a specific attack or raid triggers application of the law of armed conflict. The White House, therefore, issued a policy guideline in 2013, which states that lethal force will be used 'outside areas of active hostilities' only against targets that pose a 'continuing, imminent threat' to US persons. This policy reflects a conception of the right to self-defence according to which a state may target particularly dangerous persons irrespective of their status under international humanitarian law or human rights law ('self-defence targeting'). It is a characteristic feature of the Obama administration's approach to pick and choose from the legal concepts of self-defence and armed conflict in order to design a flexible normative framework for its operations against Al Qaeda and other extremist groups abroad. The present article focuses on different facets of this approach and shows how both concepts are utilized to justify such operations. The killing of Osama bin Laden in May 2011 was a particularly instruct- ive case since it raised a variety of issues under jus ad bellum and jus in bello.

A National Cohort Study of the Association Between the Polytrauma Clinical Triad and Suicide-Related Behavior Among US Veterans Who Served in Iraq and Afghanistan

We examined the association of posttraumatic stress disorder (PTSD), traumatic brain injury, and chronic pain-the polytrauma clinical triad (PCT)-independently and with other conditions, with suicide-related behavior (SRB) risk among Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF) veterans. We used Department of Veterans Affairs (VA) administrative data to identify OEF and OIF veterans receiving VA care in fiscal years 2009-2011; we used International Classification of Diseases, Ninth Revision, Clinical Modification codes to characterize 211652 cohort members. Descriptive statistics were followed by multinomial logistic regression analyses predicting SRB. Co-occurrence of PCT conditions was associated with significant increase in suicide ideation risk (odds ratio [OR] = 1.9; 95% confidence interval [CI]=1.5, 2.4) or attempt and ideation (OR=2.6; 95% CI=1.5, 4.6), but did not exceed increased risk with PTSD alone (ideation: OR=2.3; 95% CI=2.0, 2.6; attempt: OR=2.0; 95% CI=1.4, 2.9; ideation and attempt: OR=1.8; 95% CI=1.2, 2.8). Ideation risk was significantly elevated when PTSD was comorbid with depression (OR=4.2; 95% CI=3.6, 4.8) or substance abuse (OR=4.7; 95% CI = 3.9, 5.6). Although PCT was a moderate SRB predictor, interactions among PCT conditions, particularly PTSD, and depression or substance abuse had larger risk increases.

Operative treatment of new onset radiculopathy secondary to combat injury.

We set out to describe combat-related spine trauma over a 10-year period, and thereby determine the frequency of new onset radiculopathy secondary to injuries sustained in support of combat operations. We performed a retrospective analysis of a surgical database at three military institutions. Patients undergoing spine surgery following a combat-related injury in Afghanistan or Iraq between July 2003 and July 2013 were evaluated. We identified 105 patients with combat-related (Operations Enduring and Iraqi Freedom) spine trauma requiring operative intervention. Of these, 15 (14.3%) patients had radiculopathy as their primary complaint after injury. All patients were diagnosed with herniated nucleus pulposus. The average age was 39 years, with 80% injured in Iraq and 20% in Afghanistan. The most common mechanism of injury was mounted improvised explosive device (33%). The cervical spine was most commonly involved (53%), followed by lumbar spine (40%). Average time from injury to surgery was 23.4 months; 53% of patients had continued symptoms following surgery, and two patients had at least one revision surgery. Two patients were medically retired because of their symptoms. This study is the only of its kind evaluating the operative treatment of traumatic radiculopathy following combat-related trauma. We identified a relatively high rate of radiculopathy in these patients.

ANTI-TERRORISM POLICY THE USA HAD CARRIED OUT IN AFGHANISTAN: PERIOD OF SUCCESS AT THE INITIAL STAGE OF OPERATION (2001 TO 2005)

The paper explored the warfare in Afghanistan that fol-lowed the acts of terror incurred to New York and Wash-ington on September 11th, 2001, that turned to be an un-precedented terrorist attack over the history of mankind. After the attacks and subsequent to them the U.S had launched an Operation Enduring Freedom, with the purpose of exterminating the leaders of Al Qaeda and of Taliban Movement. At the first stage of operation, the USA has attained some success, both at the field of anti-terrorist military actions and in building the state in Af-ghanistan. However, the situation turned to be soon be-yond the U.S control.

Military deployment and reintegration: a systematic review of child coping.

Child coping with parent military deployment and family reintegration. A systematic review of research literature was conducted to examine the effects of deployment and family reintegration on children in military families. A search of CINAHL, PubMed, Psyc-INFO, and SocINDEX databases was performed using the terms "military family," "military child," "child coping," "deployment," and "reintegration." The search was limited to publications between 2001 and 2014 to focus on the effects of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). Twenty-seven research reports met inclusion criteria. Three themes were extracted: A child's coping is influenced by (a) the child's age and development, (b) the mental health and coping of the non-deployed parent during deployment, and the mental health of both parents during family reintegration, and (c) the pre-existing resilience/vulnerability, cumulative risks, and resources of the child and family.

Neuropsychological and behavioral correlates of impulsiveness in veterans with and without mild traumatic brain injury

Introduction: Previous research has identified a relation between impulsiveness and substance use, as well as performance on certain tests of executive functioning. However, no prior research has investigated these relations in Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn (OEF/OIF/OND) veterans with and without a history of mild traumatic brain injury (mTBI). Method: The present study utilized a sample of 127 veterans (55 controls, 72 mTBI). Relations among health behaviors, cognition, and domain scores (attentional, motor, and nonplanning impulsiveness) of the Barratt Impulsiveness Scale–11 (BIS–11) were examined using regression analyses. Results: Nonplanning impulsiveness was associated with higher Alcohol Use Disorders Identification Test (AUDIT) score. Attentional and motor impulsiveness were not associated with performance on any measures of behavior or cognition. The relationship between nonplanning impulsiveness and alcohol misuse was not influenced by history of mTBI. Conclusions: These results partially support previous findings and indicate that an association between impulsiveness and problematic behaviors exists in OEF/OIF/OND veterans, regardless of TBI history.

The impact of depression on Veterans with PTSD and traumatic brain injury: A diffusion tensor imaging study

A significant proportion of military personnel deployed in support of Operation Enduring Freedom and Operation Iraqi Freedom were exposed to war-zone events associated with traumatic brain injury (TBI), depression (DEP) and posttraumatic stress disorder (PTSD). The co-occurrence of TBI, PTSD and DEP in returning Veterans has recently increased research and clinical interest. This study tested the hypothesis that white matter abnormalities are further impacted by depression. Of particular relevance is the uncinate fasciculus (UF), which is a key fronto-temporal tract involved in mood regulation, and the cingulum; a tract that connects to the hippocampus involved in memory integration. Diffusion tensor imaging (DTI) was performed on 25 patients with a combination of PTSD, TBI and DEP and 20 patients with PTSD and TBI (no DEP). Microstructural changes of white matter were found in the cingulum and UF. Fractional anisotropy (FA) was lower in Veterans with DEP compared to those without DEP.

Penetrating Traumatic Brain Injury: A Review of Current Evaluation and Management Concepts

Penetrating traumatic brain injury (pTBI) remains one of the most devastating and lethal forms of trauma. Prognosis is generally poor and, for those who survive long enough to make it to the hospital, the management of penetrating brain injury presents complex challenges to medical and surgical providers in the civilian sector. Recent experiences in Operation Iraqi Freedom and Operation Enduring Freedom have provided opportunities to study and refine the surgical and medical management of pTBIs that may impact civilian evaluation and management of similar traumas. These experiences demonstrated that aggressive pre-hospital and emergency department resuscitation, followed by immediate surgical management and post-operative intensive care to monitor for and intervene on surgical and medical complications could significantly improve patient outcomes. We begin with a brief case vignette that will introduce a comprehensive discussion on the epidemiology, pathophysiology, evolution of current surgical and medical therapies, complications, and prognostic indicators that may improve outcomes in these challenging cases.

Hearing impairment and tinnitus: prevalence, risk factors, and outcomes in US service members and veterans deployed to the Iraq and Afghanistan wars.

Hearing loss and tinnitus are the 2 most prevalent service-connected disabilities among veterans in the United States. Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn have been exposed to multiple hazards associated with these conditions, such as blasts/explosions, ototoxic chemicals, and most notably high levels of noise. We conducted a systematic literature review of evidence on 1) prevalence of, 2) risk and protective factors for, and 3) functional and quality-of-life outcomes of hearing impairment and tinnitus in US Operations Enduring Freedom, Iraqi Freedom, and New Dawn veterans and military personnel. We identified studies published from 2001 through 2013 using PubMed, PsycINFO, REHABDATA, Cochrane Library, pearling, and expert recommendation. Peer-reviewed English language articles describing studies of 30 or more adults were included if they informed one or more key questions. A total of 839 titles/abstracts were reviewed for relevance by investigators trained in critical analysis of literature; 14 studies met inclusion criteria. Of these, 13 studies presented data on prevalence and 4 on risk/protective factors, respectively. There were no included studies reporting on outcomes. Findings from this systematic review will help inform clinicians, researchers, and policy makers on future resource and research needs pertaining to hearing impairment and tinnitus in this newest generation of veterans.

The Prevalence of Epilepsy and Association With Traumatic Brain Injury in Veterans of the Afghanistan and Iraq Wars

To examine the association of epilepsy with traumatic brain injury (TBI) in Afghanistan and Iraq (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]) Veterans. Cross-sectional observational study. A total 256 284 OEF/OIF Veterans who received inpatient and outpatient care in the Veterans Health Administration in fiscal years 2009-2010. We used algorithms developed for use with International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify epilepsy, TBI (penetrating TBI [pTBI]/other TBI), and other risk factors for epilepsy (eg, stroke). TBI and other risk factors were identified prior to the index date (first date of seizure or October 1, 2009) for primary analyses. Epilepsy prevalence was 10.6 per 1000 (N = 2719) in fiscal year 2010; age-adjusted prevalence was 6.1. Of 37 718 individuals with a diagnosis of TBI, 29 297 Veterans had a diagnosis of TBI prior to the index date. Statistically significant associations were found between epilepsy and prior TBI diagnosis (pTBI: adjusted odds ratio = 18.77 [95% confidence interval, 9.21-38.23]; other TBI: adjusted odds ratio = 1.64 [1.43-1.89]). Among OEF/OIF Veterans, epilepsy was associated with previous TBI diagnosis, with pTBI having the strongest association. Because war-related epilepsy in Vietnam War Veterans with TBI continued 35 years postwar, a detailed, prospective study is needed to understand the relationship between epilepsy and TBI severity in OEF/OIF Veterans.

Correlates of Intimate Partner Violence Perpetrated by Female Partners of Operation Iraqi Freedom and Operation Enduring Freedom Veterans

The problem of intimate partner violence (IPV) is increasingly being studied among military populations, although there is a dearth of research examining IPV perpetrated against male veterans by their female partners. Returning veterans and their partners face several unique difficulties, including psychological and relationship distress, which may be important factors related to the partners’ perpetration of IPV. This study investigates correlates of psychological and physical IPV perpetrated by female partners of male Operation Iraqi Freedom and Operation Enduring Freedom (OEF) veterans. Specifically, the correlates examined include female partners’ relationship satisfaction, depressive symptoms, and posttraumatic stress disorder (PTSD) symptoms as well as veterans’ relationship satisfaction, PTSD symptoms, and psychological and physical IPV perpetration. Results indicated several significant correlates of female partners’ psychological and physical IPV perpetration, including veterans’ psychological and physical IPV, veterans’ and partners’ relationship satisfaction, and veterans’ PTSD symptoms. In regression analyses, veterans’ psychological IPV was the only unique predictor of female partners’ psychological IPV, and veterans’ physical IPV was the only unique predictor of female partners’ physical IPV. Findings emphasize the role of veteran factors in their partners’ IPV perpetration.

Resuscitation During Critical Care Transportation in Afghanistan.

These data describe the critical care procedures performed on, and the resuscitation markers of, critically wounded personnel in Afghanistan following point of injury (POI) transports and intratheater transports. Providing this information may help inform discussion on the design of critical care transportation platforms for future conflicts. The Department of Defense Trauma Registry (DoDTR) was queried for descriptive data on combat casualties with Injury Severity Score (ISS) greater than 15 who were transported in Operation Enduring Freedom (OEF) from 1 January 2010 to 31 December 2010. Both POI transportation events and interfacility transportation events were reviewed. Base deficit (BD) was evaluated as a maker of resuscitation, and international normalized ratio (INR) was evaluated as a measure of coagulopathy. There were 1198 transportation events that occurred during the study period--634 (53%) transports from the POI and 564 (47%) intratheater transports. Critical care interventions were performed during 147 (12.3%) transportation events, including intubation, cricothyrotomy, double-lumen endotracheal tube placement, needle or tube thoracostomy, central venous access placement, and cardiopulmonary resuscitation. The mean BD on arrival in the emergency department was -5.4 mEq/L for POI transports and 0.68 mEq/L intratheater transports (ρ<.001). The mean INR on arrival in the emergency department was 1.48 for POI transports and 1.21 for intratheater transports (ρ<.001). Critical care interventions were needed frequently during evacuation of severely injured personnel. Furthermore, many troops arrived acidotic and coagulopathic following initial transport from POI. Together, these data suggest that a platform capable of damage control resuscitation and critical care interventions may be warranted on longer transports of more critically injured patients.

The warrior’s journey: Sociocontextual meaning-making in military transitions.

Meaning-making and social support have been shown to mediate between traumatic stress and the onset and course of posttraumatic stress disorder (PTSD). Previous research has been relatively unsuccessful in identifying specific and recurring sociocontextual variables for populations vulnerable to trauma. This qualitative study examined how social support and the social environment are associated with meaningmaking among veterans. Semistructured interviews were completed with 12 U.S. combat veterans who served in Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF). The interviews collected information about the sociocontextual meaning ascribed to traumatic experiences as well as the sociocontextual development of the veterans’ postcombat identity. The theoretical narrative that emerged from the qualitative analysis yielded 2 broad constructs: “Becoming Battle Ready” and “Making the Journey Home.” These constructs illustrated the ways in which the social context either facilitated or inhibited how veterans made meaning of combat stressors and postcombat identity. There was no evidence for meaning-making processes that took place on a purely individual level. These findings support the use of interventions that incorporate the social context into traditional trauma treatments.

Clinician Versus Veteran Ratings on the Mayo-Portland Participation Index in Veterans With a History of Mild Traumatic Brain Injury

The Department of Veterans Affairs is encouraging administration of the Mayo-Portland Adaptability Inventory-4 Participation Index (M2PI) to identify long-term psychosocial outcomes of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans with a history of traumatic brain injury (TBI). To evaluate clinician and Veteran interrater reliability and how response validity influences M2PI item ratings. A total of 122 OEF/OIF/OND Veterans who reported a history consistent with mild TBI during deployment and were referred for neuropsychological evaluation following Comprehensive TBI Evaluation. Interrater reliability study. M2PI; Minnesota Multiphasic Personality Inventory-2 Symptom Validity Scale (FBS). Veterans reported greater perceived restrictions than clinicians across all M2PI items and total score. Interrater correlations ranged from rs = 0.27 (residence) to rs = 0.58 (money management) across items, with a total score correlation of rs = 0.60. When response bias was indicated, both Veterans and clinicians reported greater participation restrictions than those reported by Veterans without evidenced response bias. Low interrater correlation is consistent with previous findings. As ratings of clinicians and Veterans should not be interpreted as equivalent, documenting the rater's identity is important for interpretation. Using objective indicators of functional outcome may assist clinician raters, particularly when self-report may be biased.

Correspondence of the Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) Clinical Interview and the VA TBI Screen

Mild traumatic brain injury is the signature injury of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), yet its identification and diagnosis is controversial and fraught with challenges. In 2007, the Department of Veterans Affairs (VA) implemented a policy requiring traumatic brain injury (TBI) screening on all individuals returning from deployment in the OEF/OIF/OND theaters of operation that lead to the rapid and widespread use of the VA TBI screen. The Boston Assessment of TBI-Lifetime (BAT-L) is the first validated, postcombat semistructured clinical interview to characterize head injuries and diagnose TBIs throughout the life span, including prior to, during, and post-military service. Community-dwelling convenience sample of 179 OEF/OIF/OND veterans. BAT-L, VA TBI screen. Based on BAT-L diagnosis of military TBI, the VA TBI screen demonstrated similar sensitivity (0.85) and specificity (0.82) when administered by research staff. When BAT-L diagnosis was compared with historical clinician-administered VA TBI screen in a subset of participants, sensitivity was reduced. The specificity of the research-administered VA TBI screen was more than adequate. The sensitivity of the VA TBI screen, although relatively high, suggests that it does not oversample or "catch all" possible military TBIs. Traumatic brain injuries identified by the BAT-L, but not identified by the VA TBI screen, were predominantly noncombat military injuries. There is potential concern regarding the validity and reliability of the clinician administered VA TBI screen, as we found poor correspondence between it and the BAT-L, as well as low interrater reliability between the clinician-administered and research-administered screen.

Factors associated with psychiatric evacuation among service members deployed to Operation Enduring Freedom and Operation Iraqi Freedom, January 2004 to September 2010.

To calculate the annual rate of psychiatric evacuation of U.S. Service members out of Iraq and Afghanistan and identify risk factors for evacuation. Descriptive and regression analyses were performed using deployment records for Service members evacuated from January 2004 through September 2010 with a psychiatric diagnosis, and a 20% random sample of all other deployers (N = 364,047). A total of 5,887 deployers psychiatrically evacuated, 3,951 (67%) of which evacuated on first deployment. The rate increased from 72.9 per 100,000 in 2004 to 196.9 per 100,000 in 2010. Evacuees were overrepresented in both combat and supporting duty assignments. In multivariate analysis, Army active duty had the highest odds of evacuation relative to Army National Guard (adjusted odds ratio [AOR] 0.852, 95% confidence interval [CI] 0.790-0.919), Army Reserve (AOR 0.825, 95% CI 0.740-0.919), and all other components. Accessions in 2005 had the highest risk (AOR 1.923, 95% CI 1.621-2.006) relative to pre-2001 accessions. Risk for psychiatric evacuation is highest among the Army Active Component. A strong link between multiple deployments or combat-related exposure and psychiatric evacuation is not apparent. Increased risk among post-2001 accessions suggests further review of changes in recruitment, training, and deployment policies and practices.

Changes in burn scar contracture: utilization of a severity scale and predictor of return to duty for service members.

A medical records review of Operation Iraqi Freedom and Operation Enduring Freedom burn injury survivors admitted to the U.S. Army Institute of Surgical Research Burn Center from April 2003 to August 2005 was conducted. The study proposed the use of a newly developed scale, the Burn Scar Contracture Severity Scale, to potentially provide standardization in quantifying burn scar contracture severity. Changes in the active range of motion from in-patient discharge to out-patient follow-up of individuals with upper extremity burn injuries were compared. Changes in the impairment via American Medical Association impairment scores and perceived disability using the disabilities of the arm, shoulder, and hand questionnaire scores from the in-patient discharge to the out-patient follow-up were also compared. A weak, yet positive correlation (r = .417, .451, P ≤ .001) between the proposed scale and the disabilities of the arm, shoulder, and hand questionnaire and the American Medical Association impairment scores was found, respectively. A receiver operating characteristic curve analysis revealed a cut-off score of 6.5 for the burn scar contracture severity scale, indicating that individuals scoring below a 6.5 returned to duty and those scoring above 6.5 did not return to duty. Results suggest that the burn scar contracture severity scale is able to discriminate between the individuals who returned to duty and those who did not return to duty.

The Impact of Military Deployment and Reintegration on Children and Parenting: A Systematic Review.

Hundreds of thousands of children have had at least 1 parent deploy as part of military operations in Iraq (Operation Iraqi Freedom; OIF; Operation New Dawn; OND) and Afghanistan (Operation Enduring Freedom; OEF). However, there is little knowledge of the impact of deployment on the relationship of parents and their children. This systematic review examines findings from 3 areas of relevant research: the impact of deployment separation on parenting, and children's emotional, behavioral, and health outcomes; the impact of parental mental health symptoms during and after reintegration; and current treatment approaches in veteran and military families. Several trends emerged. First, across all age groups, deployment of a parent may be related to increased emotional and behavioral difficulties for children, including higher rates of health-care visits for psychological problems during deployment. Second, symptoms of PTSD and depression may be related to increased symptomatology in children and problems with parenting during and well after reintegration. Third, although several treatments have been developed to address the needs of military families, most are untested or in the early stages of implementation and evaluation. This body of research suggests several promising avenues for future research.

Compulsive sexual behavior among male military veterans: prevalence and associated clinical factors.

Background and aims: Compulsive sexual behavior (CSB) is highly prevalent among men, often co-occurring with psychiatric disorders and traumatic experiences. Psychiatric disorders and trauma are highly prevalent among military veterans, yet there is a paucity of research on CSB among military samples. The aim of this study was to examine the prevalence of and factors associated with CSB among male military veterans. Methods: Surveys were administered to veterans of Operations Iraqi Freedom, Enduring Freedom, or New Dawn at baseline (n = 258), 3 months (n = 194), and 6 months (n = 136). Bivariate analyses and Generalized Estimating Equations were utilized to estimate associations between CSB and the following variables: psychiatric co-morbidity, childhood physical or sexual trauma, pre- and post-deployment experiences, TV/ Internet usage, and sociodemographics. Associations between CSB and specific PTSD symptom clusters were also examined. Results: CSB was reported by 16.7% of the sample at baseline. Several variables were associated with CSB in bivariate analyses; however, only PTSD severity, childhood sexual trauma, and age remained significant in multivariable GEE models. The PTSD symptom cluster re-experiencing was most strongly associated with CSB. Discussion: This exploratory study suggests that CSB is prevalent amongst veterans returning from combat and is associated with childhood trauma and PTSD, particularly re-experiencing. Conclusions: Further study is needed to identify the mechanisms linking PTSD and CSB, define the context and severity of CSB in veterans, and examine the best ways to assess and treat CSB in VA clinical settings.

Family adjustment of deployed and non-deployed mothers in families with a parent deployed to Iraq or Afghanistan.

Almost nothing is known about the family and individual adjustment of military mothers who have deployed to the conflicts in Iraq or Afghanistan (Operations Iraqi and Enduring Freedom, and Operation New Dawn; OIF, OEF, OND), constituting a gap in psychologists' knowledge about how best to help this population. We report baseline data on maternal, child, parenting, and couple adjustment for mothers in 181 families in which a parent deployed to OIF/OEF/OND. Among this sample, 34 mothers had deployed at least once, and 147 mothers had experienced the deployment of a male spouse/partner. Mothers completed self-report questionnaires assessing past year adverse life events, war experiences (for deployed mothers only), posttraumatic stress disorder (PTSD) and depression symptoms, difficulties in emotion regulation, parenting, couple adjustment, and child functioning. Mothers who had deployed reported greater distress than non-deployed mothers (higher scores on measures of PTSD and depression symptoms), and slightly more past year adverse events. A moderate number of war experiences (combat and post-battle aftermath events) were reported, consistent with previous studies of women in current and prior conflicts. However, no differences were found between the two groups on measures of couple adjustment, parenting, or child functioning. Results are discussed in terms of the dearth of knowledge about deployed mothers, and implications for psychologists serving military families.