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Barbara Rich and Ann Whitman, The Dana Foundation (page 1 of 3) Page 1 of 3
Head Injury Increase in Military Highlights Limited Treatment Options: New Research Seeks Answers
War and trauma have always gone hand in hand. Twenty-seven centuries ago in The Iliad, Homer described a psychologically tormented Achilles whose behavior would likely warrant a psychiatric diagnosis today. In the 20th century, we have variously used “battle fatigue,” “shell shock,” “soldier’s heart,” and post-Vietnam syndrome to describe the internal battles many soldiers face when they return from the field.
Today, we call it post-traumatic stress disorder, but the name is relatively new to official psychiatry. It was introduced into the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of clinical psychiatry, only in 1980. Before that, the set of symptoms that came to be classified as PTSD was called traumatic neurosis (DSM-1) or “transient situational disturbances” (DSM-II). War neurosis and other terms have been applied as well.
By any label, it is increasingly clear that current conflicts threaten to leave numbers of soldiers bearing the psychological scars of war. PTSD is only part of the story. Depression, anxiety disorders and interpersonal conflicts are also concerns. Further complicating the picture is the high rate of head injuries in Iraq, which are associated with their own sets of neuropsychiatric consequences.
Head Injury & Mental Health
Head injury has become known as the “signature injury” of the Iraq war. The Web site of the Defense and Veterans Brain Injury Center (DVBIC), a congressionally funded research and outreach agency, cites a brain injury rate of 62% among troops returning from combat duty in Iraq. i The figure is based on a study of 155 soldiers who were screened for traumatic brain injury (TBI) at Walter Reed Army Medical Center in 2003.
Blast-related TBI, an effect of the over-pressurized shock wave that ripples out from an explosion, is a particular concern in the current conflicts. In the Walter Reed study, about half the soldiers reported having been exposed to at least one blast; 60% of these blast victims sustained a brain injury. A study published by Army researchers January 31 in The New England Journal of Medicine ii found that nearly 90% of troops had been exposed to two or more blasts from improvised explosive devices. The results, by Charles Hoge and colleagues at Walter Reed, are among the first data being mined from the military’s new policy to conduct post-combat assessments on all Iraq returnees. The study included more than 2,700 Army infantry solders, who were surveyed in 2006, three to four months after their return from a year-long deployment in Iraq.
There is a growing recognition that blast injuries, like other mild trauma to the brain, can cause subtle neural damage that manifests as cognitive and psychological symptoms. Some problems resolve within days or weeks and some appear to persist long after the injury. In January, the Department of Veterans Affairs (VA) recognized blast-related TBI as a special neurological condition, opening the door to greater disability benefits for affected soldiers.
Unfortunately, there is little evidence-based science to guide policies or clinical practice. Few studies have rigorously tracked the neuropsychological sequelae of head injuries longitudinally, and fewer still have focused on combat trauma. So there are more questions than answers at this point, particularly with regard to the effects of blast injuries on the brain, where the science is surprisingly sparse.
That should change soon. Congress committed more than $150 million to the Department of Defense (DoD) for brain injury research last year alone, and another $14 million goes annually to fund the DVBIC, which is jointly run by DoD and VA. The Defense Advanced Research Projects Agency (DARPA) has launched its own $9 million research blitz; one program is developing helmet-mounted sensors to collect data on blast characteristics such as pressure, electromagnetic pulse, and thermal shock. DARPA researchers and a handful of academic laboratories are also using computer modeling and animal experiments to investigate how blasts impact neural tissue.
TBI + PTSD: Inextricably Linked?
The interplay of TBI and mental health problems, particularly PTSD, has become a vexing issue for the military. Jordan Grafman, a senior investigator at the National Institute of Neurological Disorders and Stroke (NINDS) and member of the Dana Alliance for Brain Initiatives (DABI), has been studying the links in brain-injured Vietnam veterans. He says, “The question is: does somebody simply have PTSD, or have they been exposed to a minor head injury? The diagnosis is difficult because similar deficits may be seen in both cases. How do you tease that apart? It’s also complicated by the fact that we don’t know what the risk factors are for getting a mild head injury if you’ve been exposed to a blast.”
In the Walter Reed research study reported by Hoge et al last month, the researchers found a strong co-occurrence of mental problems in the 15% of soldiers who had suffered mild brain injury (concussive injuries were subdivided to differentiate people who suffered loss of consciousness from those who experienced “altered mental status,” such as feeling dazed or confused, after their injury). Among soldiers reporting loss of consciousness, almost half (43.9%) met criteria for PTSD, compared to about a quarter (27.3%) of those who reported altered mental status.
Part of the problem is that post-concussive symptoms overlap significantly with PTSD symptoms, making it difficult to sort out what is TBI-related and what might be due to an underlying psychiatric problem. Knowing could make a difference in terms of treatment and follow-up care. Moreover, as psychologist Richard Bryant of the University of New South Wales in Sydney, Australia, pointed out in an editorial accompanying the Hoge paper, mild TBI typically occurs in the context of a traumatic event.
From the Dana Foundation. Reprinted with permission. www.dana.org.
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