Binding the 'Invisible Wounds'

The Nation struggles to help a deluge of veterans suffering post-traumatic stress and traumatic brain injury.

Ten years of combat in Iraq and Afghanistan under the constant threat of ambush, sniper attack and improvised explosive devices (IEDs) have created an epidemic of hidden wounds among American service members, particularly Army and Marine Corps ground troops and the Sailors and Airmen who support them in the field. Although these invisible wounds would appear less severe than the amputations inflicted by the IEDs, they affect many more service members and can have as much impact on the casualty’s future as the loss of limbs.

The most common of these unseen injuries is the psychological damage inflicted by exposure to acute danger or tragedy, known as post-traumatic stress, or PTS. But despite better-armored vehicles, the proliferation of powerful IEDs has caused a jump in the more harmful traumatic brain injury, or TBI.

The alarming increase in these invisible but very real wounds, and protests from Congress, veterans’ organizations and military family members, have resulted in a torrent of additional resources, research and new programs seeking to prevent or minimize their effects and to treat those injured by what are being called the “signature wounds” of the war on terror.

Efforts to deal with PTS include pre-deployment training to reduce the psychological impact of traumatic events in combat; mental health providers embedded in combat units or located in close-by care centers; more screening for symptoms in theater and at home; and better care for those affected.

For TBI, research is being pressed to improve helmets and vehicles to reduce the shock of explosions. Command directives have been issued to instill greater sensitivity to the effects of concussions and to require steps to prevent re-injury before the brain has had time to heal.

Research also is being pursued on many fronts for improved ways to treat the more than 750,000 service members affected by psychological and physical trauma. That stunningly high number, which grows every day U.S. troops are engaged in Iraq and Afghanistan, have forced unprecedented attention on what is a very old problem.

Old as war itself

PTS has been around probably since man first engaged in organized combat. It was reflected in characters in Sophocles’ ancient Greek dramas. In World War I it was known as shell shock, and in World War II, Korea and Vietnam as combat fatigue or battle fatigue.

One of the major problems in dealing with PTS has been the tendency of leaders to dismiss its seriousness, and of troops to refuse to report the symptoms for fear of appearing weak or harming their careers. A notorious example of that first factor occurred in 1943 when Army Lieutenant General George S. Patton slapped two soldiers he found suffering from psychological breakdown in aid stations in Sicily.

Indicating how that has changed, several top leaders, including Marine Corps Commandant General James Amos, reject the word “disorder,” calling PTS an injury that must be treated.

In a concerted effort to eliminate the stigma that can thwart treatment of PTS, “one of our focuses on the Navy side is to change the culture,” which includes the Marine Corps, said Navy Capt. Richard Bergthold, a leader in the attack on PTS and TBI at the Navy Bureau of Medicine and Surgery in Washington. That effort involves guidelines and training that “goes out to the most senior line officers down to the most junior leaders.”

In addition, Capt. Bergthold said, directives have been issued to help commanders in Iraq and Afghanistan follow new guidelines intended to reduce the effects of PTS and TBI.

PTS can occur when a severe threat or a shocking event is seared into a person’s memory and recurs later in flashbacks or nightmares, or causes other psychological or physical reactions. It can reduce situational awareness in combat or cause detachment in social settings.

TBI occurs when brain tissue is damaged due to a physical blow to the skull, the supersonic shock wave from an explosion or by a penetrating wound.

Studies by several institutions estimate that up to 500,000 military personnel have suffered from PTS and about 270,000 from TBI in the 10 years of war in Iraq and Afghanistan.

But some researchers insist the military “chronically underestimates” the number of TBI cases, due to policy, culture and imperfect detection measures.

Government doctors involved in the fight against PTS and TBI acknowledge that military medicine is scrambling to close the gaps in knowledge, resources and policies for countering the hidden injuries. But they insist progress is being made, under orders from the highest levels of the military and civilian leadership. “We’ve come a very long way,” Capt. Bergthold said, citing the changes since he first arrived at BuMed in 2006.

Making slow progress

Asked if the military is getting better at dealing with the hidden wounds, Navy Capt. Paul Hammer said: “The short answer is yes. We’re making progress. The more difficult answer is: I wish we were making more rapid progress. We have learned a lot over the last decade about both of these conditions, and we continue to learn a lot. We’ve invested an enormous amount in efforts and in research in order to understand these conditions better.”

It’s a challenge to get what they have learned implemented into the system “so what we do is common everywhere, is uniform throughout the system,” he said. Promoting standardization of practice is a major part of Capt. Hammer’s job as director of the Defense Center of Excellence for Psychological Health and TBI, which he said, “is basically the integrator of information” on those injuries for the military.

The goal, he said, is to promote “the translation of research into practical clinical guidelines,” and to ensure that the best practices get widely disseminated.

Capt. Hammer’s organization itself is evidence of the progress. But it is only one of the new or revitalized establishments focusing on PTS and TBI, including his previous unit, the Naval Center for Combat and Operational Stress Control at the Naval Medical Center, San Diego.

Another indicator of progress is the increasingly interservice attack on psychological injuries, Capt. Bergthold said. “Never before, to my knowledge, has the Navy worked so closely with the other services … to provide a coordinated response” to PTS by attacking it “before, during and after deployment,” he said.

That response includes an effort to prevent or minimize the impact of trauma in combat, by adding predeployment training programs to build psychological resilience.

“When you look at post-traumatic stress, it’s also important to understand that everybody who goes into a combat situation is affected by stress,” but not all will develop PTS, Capt. Hammer said. “So what is the mechanism, how do we mitigate that stress, what things can we do, both in the medical community and in the line community, to focus on and deal with the stress?”

Among the psychological conditioning programs added to pre-deployment training, Marines at Camp Pendleton, CA, are testing a concept called “Mind Fitness.” It uses meditation-like exercises to strengthen the ability to focus and control thoughts as a way to relieve stress before it can become PTS.

Help at the front lines

But the major improvements are in the combat theater itself, where new practices, policies and resources that focus on early treatment appear to be making a difference.

The best way to deal with PTS and TBI is to recognize the symptoms early and respond, Capt. Bergthold said. “It can be as easy as buddy care,” where a fellow Marine or sailor who sees something speaks out and gets a buddy pulled off the line for a rest, he said.

That is aided by training individual warriors and leaders to take combat stress and potential brain injuries seriously and act to protect the individual. That training and the intended cultural change are reinforced by leadership directives telling combat commanders they must pay attention to the effects of stress and explosions and take action to ensure prompt treatment.

The orders require rest from combat operations, evaluation and counseling, or other care for possible PTS. They also require everyone who was within 50 meters of an explosion to be evaluated for possible concussion or more serious brain injury, and mandate breaks from operations that could result in re-injury, the doctors said.

“The Marines were ahead of the curve” and “have been taking this issue quite seriously for some time,” said CDR Jack Tsao, director, Traumatic Brain Injury Programs at BuMed.

Adhering to the new rules is made easier by embedding mental health providers in line units and in medical facilities close to the battlefield. “We learned more than a century ago, in World War I, that providing help early, as far forward as possible, was important,” Capt. Hammer said.

“I think in each conflict, in each war since then, the question becomes how exactly do you do that. Embedding providers, medics, in units is extremely helpful because that also addresses the stigma issue. If you have someone who is around all the time, is part of your unit and you’re familiar with, then going to see the mental health provider doesn’t become such a daunting, overwhelming sort of thing,” he said.

The embedded mental health providers train with the combat units before deployment and are with them during missions. They help unit leaders decide when to give Marines or Sailors time to recover from either an emotional or physical blow to their brains. The embedded providers and similar personnel in mobile care teams also are teaching combat personnel psychological first aid, which the Marine Corps calls combat and operational stress first aid, Capt. Hammer said.

Removing the stigma

Another advance is a program the Marines call OSCAR, for Operational Stress Control and Readiness. The Navy’s similar program is Operational Stress Control.

Dr. Thomas Burke, director of psychological health for the Corps, considers the OSCAR program a vital part of the Marines’ effort to minimize the effects of PTS. A key part of that are the OSCAR mentors, non-commissioned officers and officers in each unit who are trained to evaluate Marines who have been exposed to stress, Dr. Burke said.

The mentors use a color-coded system that goes from green, meaning rested and combat ready, to red for a Marine whose ability to function is impaired by stress, he explained. Someone appearing in the intermediate yellow or orange zones will be given rest, counseling and perhaps treatment. Anyone in the red zone receives treatment.

The mentors are supported by the unit’s mental health provider, aided by psychological technicians and “OSCAR extenders,” who are the company and battalion Corpsmen, Capt. Hammer explained.

“So you have a flow of individuals at various levels who can provide assistance to Sailors and Marines under stress at various points,” and if they detect problems will pass them on to the next level of care, he added.

Having the providers within the units or nearby allows early treatment and “lots of screening to make sure people are evaluated,” Capt. Hammer said.

“Those are the kinds of things I think we’re doing better. I think we have a long way to go on stigma … and in making sure that everybody can get the treatment they need. But we’re working on making improvements,” he said.

Capt. Bergthold and Dr. Burke said joint mental health advisory teams surveying units in Iraq and Afghanistan report that the pre-deployment training and other actions appear to have helped reduce the stigma of seeking help and increase support by unit leaders.

Counseling, alternative treatments

To augment the leaders’ elevated attention to the significance of concussions, the services also are experimenting with putting sensors on individuals to measure the effect of explosions, which could eliminate the judgment factor. The Navy is experimenting with a handheld device that can test the mental impact of a blast on an individual, CDR Tsao said.

Navy has established Recovery Care Centers in Afghanistan where Marines and Sailors who have suffered a concussion can get rest, treatment and frequent reevaluation. That has enabled more than 90 percent of those injured to get back into the fight by avoiding the risk of re-injury before they have fully recovered, Capt. Hammer said.

All personnel serving in Afghanistan receive a series of post-deployment health assessments that start within 30 days before or after return to home station, Capt. Bergthold said. They are reassessed three to six months after that, to pick up hidden symptoms that may be newly emerging, he said.

The military is making an aggressive effort to overcome the shortage of mental health providers identified early in the War on Terror. “We have plenty of people in theater … The difficulty, I think, is in CONUS — back here at home,” Capt. Hammer said. The military is competing against a global shortage of mental health providers, the doctors noted.

TBI treatment is complicated because injuries can range from mild — brief unconsciousness, confusion or disorientation and memory loss — to severe — unconsciousness, confusion that lasts more than 24 hours, and memory loss for seven days or more.

The most severe is penetrating TBI, or an open head wound, in which the outer layer of the brain is punctured.

As is the case in most psychological problems, there is a wide range of proposed treatments for PTS and TBI, which have varying levels of research data and scientific foundations, but frequently strong advocates.

Possible treatments for PTS run from yoga to drugs. Medication has met with increasing criticism as studies have shown little to no improvement in patients. Studies by the military and the Veterans Administration have shown some positive results from neuro-feedback treatment and transcendental meditation or TM. Operation Warrior Wellness, created by Jerry Yellin, a World War II Army fighter pilot, and Ed Schloeman, a Marine veteran of Vietnam, and funded by the David Lynch Foundation, is dedicated to making TM treatment available to veterans, military personnel and their families.

Their effort is part of the Army’s resiliency training and is supported by the National Institute of Health, Schloeman, a Marine Corps League member, said.

Some of the PTS treatments also can help reduce the psychological symptoms of TBI. And military and civilian researchers are experimenting with reducing the effects of TBI by treatment in a hyperbaric chamber, which exposes patients to high-pressure oxygen.

There has been “an explosion of research on treatment of PTS,” and the military and VA have worked together to establish best practices for treatment, Capt. Bergthold said. The currently favored approaches are prolonged exposure and cognitive thought therapy.

“What they do is to help the person look at the experiences, walk through the symptomatic reactions that they have from the experiences,” Capt. Hammer said. “Then they do cognitive-based therapies that have homework assignments for the patient to do and discuss with their therapist on a periodic basis. Those work well.”

The DCoE and BuMed constantly evaluate the different treatments being proposed, the doctors said. “There is no magical answer, no silver bullet, no pill that someone can take that will make them all better. It takes a little bit of work to get through it,” Capt. Hammer said.

The two doctors said the military and VA are working far more closely than in the past to ensure that injured service members can make a smooth transition from active duty to the VA system.

DCoE has a wide array of programs and website offerings to assist service members and their families in recognizing the symptoms of psychological injuries and finding help. It also provides online programs that allow an injured person to attempt self-help, to avoid the barrier of accessing either the military or VA care system, Capt. Bergthold said.

Some veterans’ organizations and others complain that the services and the VA still have a long way to go to ensure all injured service members get the help they need to cope with the hidden wounds. Those complaints have been substantiated in a number of court cases that faulted VA for lack of service.

Capts. Bergthold and Hammer acknowledge that additional work is required. But they believe substantial progress has been made and the effort to improve is being pushed from the highest levels of the military.