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An important concern of the Iraq and Afghanistan wars
is the effects of Posttraumatic Stress Disorder (PTSD)
along with mild Traumatic Brain Injury (TBI), or Post-Concussion
Syndrome, on veterans. The types of blast explosions from
Improvised Explosive Devices (IED's), coupled with better
protective armor, has led to an increase in coexistence
of these two combat-related illnesses. Sadly, many veterans
are often not aware of the symptoms of either these disorders.
Once home, these veterans report feeling overall poor
health, trouble concentrating, chronic headache pain,
and a variety of stress symptoms and sleep disorders.
The Veterans healthcare system has recognized
the need to address these comorbid conditions. However,
many veterans fail to report their concerns to their healthcare
providers and simply complain about overall infirmity.
A common theme is portrayed in the case example below:
Joseph served three tours of combat duty, one in Afghanistan
and two in Iraq. During his second tour of duty he experienced
a loss of consciousness after the impact of an IED. Later,
when he returned home, his wife noticed subtle but significant
changes in his ability to function. Typically Joseph had
a mellow temperament and effortless sense of humor. Now,
he was short-tempered and impatient. Joseph used to love
to read. He used reading as a way to cope with stress
and unwind at bedtime. Now he was unable to concentrate
and focus, so reading was no longer pleasant. He seemed
moody and frequently complained of headaches. He made
numerous visits to the VA clinic, but would leave each
time frustrated that the doctor was unable to understand
and respond to his feelings of being "unwell."
Joseph's adaptation to the home environment
was mixed. In some ways he was relieved to be home with
his wife and children. In other ways he missed the camaraderie
of his unit. Something was lacking in his life. He described
himself as feeling edgy and yet flat. Nothing felt pleasurable.
He had no sense of joy. He did not recognize the emptiness
that he felt as a symptom of posttraumatic stress disorder.
He did know the nightmares that he would have were a symptom,
but he thought they would subside after he had been home
awhile.
When Joseph had the chance to be deployed
again for a third tour of duty, he also had mixed feelings.
On one hand he hoped that the sense of purpose and structure
of combat duty would fill the chronic emptiness that he
felt. On the other hand he was concerned that he might
end up feeling worse. He worried he might have cancer
or some other serious problem because he couldn't understand
why his head ached so much. He was completely unaware
of the connection to his loss of consciousness and head
trauma and the deleterious symptoms that he was experiencing.
During his third tour, Joseph was
disappointed that he continued to feel the same edginess,
sleep difficulties, headaches and trouble concentrating.
He began isolating himself and wasn't laughing at his
friends jokes. His attitude and humor used to be helpful
to the morale of his unit. Now, he was irritable and cranky
and others avoided him, not wanting to set him off. Joseph
got in arguments over little things and wouldn't let go
of the issue.
When Joseph returned from his third
deployment, his marriage began to deteriorate. Joseph
explained, "I knew in my head that I loved my wife,
but I couldn't feel it anymore." Adding to his relationship
difficulties, Joseph began to drink heavily. He was arrested
on several occasions for fighting. Currently, Joseph is
unable to hold down a job, is living alone, and is currently
facing felony assault charges.
Joseph's case highlights several key points with Posttraumatic
Stress Disorder (PTSD) and Traumatic Brain Injury (TBI).
First, the head trauma is often missed during the medical
assessment of the initial injury. About 15% of people
with mild TBI have symptoms that persist for a year or
more. TBI occurs as the result of the forceful motion
of the head or impact causing a brief change in mental
status (confusion, disorientation or loss of memory) or
loss of consciousness for less than 30 minutes. It sometimes
can be referred to as post concussive syndrome. The most
commonly reported symptoms of TBI are:
- Irritability and mood disturbances
- Fatigue
- Headaches
- Visual disturbances
- Memory loss (especially short term memory)
- Poor attention and concentration
- Sleep disturbances
- Dizziness and loss of balance
- Feelings of depression
- Seizures
- Suicidal thoughts
Other Symptoms Associated with Mild TBI
- Nausea
- Loss of smell
- Sensitivity to light and sounds
- Mood changes
- Getting lost or confused
- Slowness in thinking
These symptoms may not be present or noticed at the
time of injury. They may be delayed days or weeks before
they appear. The symptoms are often subtle and are often
missed by the injured person, family and doctors. Despite
not feeling or thinking normal, the person otherwise looks
normal. Therefore the diagnosis is more challenging to
recognize. Others, such as family and friends often notice
changes in behavior before the injured person realizes
there is a problem. Frustration at work or when performing
household tasks may bring the person to seek medical help.
The inability to describe how and why they are suffering
may create barriers to these veterans receiving proper
care.
What can families do to help?
Learn about PTSD and TBI. Get your loved one to professional
help, but go with them to assist good communication about
the behaviors and symptoms. Collaborate with health care
professionals in the treatment plan. Good care requires
a multidisciplinary team. Following is an example:
Psychologist/Neuropsychologist: Evaluates the extent
of the head injury and PTSD on the individual's functioning.
Provides psychological treatment approaches such as cognitive
therapy, narrative therapy, teaching coping skills and
healthy life style changes.
Speech Therapist: Provides cognitive rehabilitation techniques.
Physical Therapist: Provides specific therapy and help
for balance and hearing problems.
Psychiatrist: Provides medications to relieve symptoms.
Neurologist: Evaluates and treats seizures
Internal medicine: Treats overall health conditions
The treatment of PTSD and TBI requires a comprehensive
approach. The treatment team must collaborate and coordinate
their treatment efforts. PTSD and TBI are treatable. It
is important that veterans and their families are persistent
to request the appropriate care and treatment for their
needs.
For more information on TBI and PTSD:
TBI
http://www.polytrauma.va.gov/understanding-tbi/
http://www.ninds.nih.gov/disorders/tbi/tbi.htm
http://www.traumaticbraininjury.com/
http://www.gao.gov/new.items/d08276.pdf
PTSD
www.giftfromwithin.org
www.ptsdinfo.org http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001923/
http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
http://www.ptsd.va.gov/
http://www.ptsd.va.gov/public/pages/va-ptsd-treatment-programs.asp
http://mfkb.nctsn.org
http://www.nctsn.org/resources/topics/military-children-and-families
Comorbid TBI and PTSD Conditions
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC395832/
http://www.nashia.org/docs/quick_white.pdf
http://www.ptsd.va.gov/professional/pages/traumatic-brain-injury-ptsd.asp
http://armyreservistwife.blogspot.com/
http://neuroanthropology.net/2009/09/22/ptsd-and-traumatic-brain-injury-trauma-inside-out/
Brief Bio:
Dr. Angie Panos is a psychologist and a board certified
expert in traumatic stress with 25 years of experience.
She is the mother of a daughter who is currently serving
in the military. Dr. Panos is on the Chaplain Training
Committee and trains volunteer chaplains for Intermountain
Health Care and Primary Children's Hospital. She is on
the Board of Directors of Gift From Within, a nonprofit
organization that provides education and resources for
trauma survivors and mental health counselors. For more
information contact www.giftfromwithin.org
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