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Thomas A. Van Dillen, PhD, Brain Injury Professional Page 1 of 6
Introduction:
Created in November 2007, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) brings together eight directorates and six component centers. Their joint goal is to maximize opportunities for warriors and families to thrive through a collaborative global network, promoting resilience, recovery and reintegration for psychological health (PH) and traumatic brain injury (TBI).
The mission of the Resilience and Prevention Directorate of DCoE is to help service members and families build resilience, which is defined as, “a set of actions and attitudes that prepare individuals and groups for adapting to challenging situations, establishing a ‘new normal’ and realizing one’s potential for growth.” In service to this mission, a model of Total Fitness has been developed that incorporates the resilience continuum (Bates, et al., 2010). The resilience continuum is meant to refocus the mindset of leaders, soldiers and care providers from pathology and illness to resiliency and thriving. The Total Fitness model is a larger attempt to address all aspects of military readiness and across operational environments.
Scope of the Problem
Since 2009, it is estimated that over 5,000 U.S. troops have died and 35,000 more have been wounded in action during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (www.defenseling.mil/news/casualty.pdf). Many of our soldiers are surviving what used to be catastrophic, life threatening injuries, but they are often left with difficult recoveries, the majority of which are mild TBIs and post-traumatic stress disorder (PTSD). Approximately 80 percent of TBI diagnoses are associated with closed head injuries incurred as a result of blasting or other activities not directly combat-related (Ranchand et al., 2008).
In a comprehensive review of TBI and its prevalence, RAND reports a “probable” TBI prevalence rate of 19.5 percent. However, estimates have been as high as 22.8 percent for soldiers in an Army brigade combat team returning from a one year deployment to Iraq (Terrio et al., 2009). Moderate to severe TBIs are estimated to be around 10 percent; however, these rates are difficult to validate as the measures themselves have not always been accurate, nor has there been clarity on the diagnostic criteria of TBI. An additional complexity in diagnosing TBI is the overlap of PTSD symptoms that often accompany combat (Hoge, et al., 2009).
Both TBI and PTSD may be diagnostically difficult to distinguish due to the shared neuroanatomical structures, similarity of symptoms, and the fact that service members do not often seek help for fear of being pulled out of the fight and stigma surrounding mental health issues (MHAT, 2008). At the same time, policy makers have increased the focus on efforts to address the needs of these injured service members, raising the level of due diligence to take steps and incorporate procedures that screen for these problems, thus increasing the chances of over diagnosing these problems (Hoge, et al., 2009).
TBI
TBI, defined in the medical literature as a disruption in brain function that is caused by a head injury, has become known as one of the “signature wounds” of the wars in Iraq and Afghanistan due to its high occurrence in post-deployment service members and veterans of these wars (Ranchand et al., 2008). It is also known as the “hidden” injury because service members can sustain injury to the brain without being detected and later developing symptoms that can affect a soldier’s functioning (Tanielian et al., 2008).
At the time of injury, or sometime after, TBI could be classified as mild, moderate or severe.
Mild TBI may cause a brief period of unconsciousness, mild confusion or discomfort, while a more severe injury may cause longer periods of unconsciousness, nausea, vomiting, loss of coordination or other symptoms. Moderate TBI may be diagnosed when the patient experiences a loss of consciousness for less than 24 hours, and up to one week of post-traumatic amnesia. A TBI injury may be classified as severe if it involves more than one day of unconsciousness or more than one week of amnesia (Terrio et al., 2009).
The perceived severity of the injury depends on a number of factors. Clinically, severity of TBI is measured by the Glasgow Coma Scale, seven levels of unconsciousness, and the extent of post-traumatic amnesia. TBI severity may range from “mild,” a brief change in mental status or consciousness after the injury, to “severe,” an extended period of unconsciousness or amnesia. In addition to physical symptoms, mental health diagnoses such as PTSD, depression and anxiety are common for TBI patients, as well as substance abuse. Due to the variable nature of TBI injury and recovery, there is not one standard of care or treatment regimen for TBI; patients’ needs are diverse, depending on the illness severity and the presence of co-conditions (Taber and Hurley, 2010; Tanielian et al., 2008).
TBI in service members does not always come from combat, although blast injuries have received a lot of attention because of the current enemy’s frequent use of explosives that result in blast injuries. Most of these injuries are characterized as mild TBI. In fact, however, most closed head injuries are due to car and motorcycle accidents, training accidents and falls. These injuries can be catastrophic and result in life-changing cognitive problems in the areas of attention, concentration, memory, language processing, perceptual skills, problem solving and judgment, interpersonal skills and emotional functioning. In addition, physical problems that include motor and gait difficulties, headaches, sleep problems and pain can persist, presenting a particular challenge for rehabilitating TBI patients and their families (Adams, 1996). Mild TBI patients have shown the most complete recoveries but, for the majority of those with moderate to severe brain injuries, complete recovery of prior functioning is never achieved (McGrath, 2007).
From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 7, Issue 3. Copyright 2010. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.
Brain Injury Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society. Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription to BIP as a benefit of NABIS membership. Click here to learn more about membership in NABIS.
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