with severely injured and dead people. Deliberate maltreatment and atrocities, possibly involving civilians. Cultural issues. Separation and home issues. Risk of disease including HIV. Threat of exposure to toxic agents. Mission problems. Return to service. Pathophysiology SNS activation Many of the symptoms initially experienced by people with CSR are effects of an extended activation of the human body's fight-or-flight response. The fight-or-flight response involves a general sympathetic nervous system discharge in reaction to a perceived stressor and prepares the body to fight or run from the threat causing the stress. Catecholamine hormones, such as adrenaline or noradrenaline, facilitate immediate physical reactions associated with a preparation for violent muscular action. Although the flight-or-fight-response normally ends with the removal of the threat, the constant mortal danger in combat zones likewise constantly and acutely stresses soldiers. General adaptation syndrome The process whereby the human body responds to extended stress is known as general adaptation syndrome (GAS). After the initial fight-or-flight response, the body becomes more resistant to stress in an attempt to dampen the sympathetic nervous response and return to homeostasis. During this period of resistance, physical and mental symptoms of CSR may be drastically reduced as the body attempts to cope with the stress. Long combat involvement, however, may keep the body from homeostasis and thereby deplete its resources and render it unable to normally function, sending it into the third stage of GAS: exhaustion. Sympathetic nervous activation remains in the exhaustion phase and reactions to stress are markedly sensitized as fight-or-flight symptoms return. If the body remains in a state of stress, then such more severe symptoms of CSR as cardiovascular and digestive involvement may present themselves. Extended exhaustion can permanently damage the body. Treatment 7 Rs The British Army treated Operational Stress Reaction according to the 7 R's: Recognition – identify that the individual has an Operational Stress Reaction Respite – provide a short period of relief from the front line Rest – allow rest and recovery Recall – give the individual the chance to recall and discuss the experiences that have led to the reaction Reassurance – inform them that their reaction is normal and they will recover Rehabilitation – improve the physical and mental health of the patient until they no longer show symptoms Return – allow the soldier to return to their unit BICEPS Modern front-line combat stress treatment techniques are designed to mimic the historically used