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'Where Soldiers Come From' in Context

Hidden War Wounds

According to the U.S. Department of Veterans Affairs' National Center for PTSD, many veterans experience some level of sleeplessness, anger, anxiety, irritability, unwanted memories, guilt, hopelessness or feelings of isolation. If the symptoms become severe or persistent, they are often diagnosed as either post-traumatic stress disorder (PTSD) or major depression. Some troops who have suffered concussions (from IEDs, for example) may be experiencing the effects of traumatic brain injury (TBI).

The current wars in Afghanistan and Iraq are the longest U.S. military operations since the Vietnam War. Operation Enduring Freedom/Operation Iraqi Freedom troops returning from combat have experienced a wide range of psychological responses and mental health problems. According to the U.S. Department of Veterans Affairs' National Center for PTSD, many veterans experience some level of sleeplessness, anger, anxiety, irritability, unwanted memories, guilt, hopelessness or feelings of isolation. The group Iraq and Afghanistan Veterans of America reports that the severity of these symptoms varies widely among individuals, and that a veteran's symptoms may fluctuate over time, cropping up several months or even years after he or she has settled back home. If the symptoms become severe or persistent, they are often diagnosed as either post-traumatic stress disorder (PTSD) or major depression. In addition to these psychological injuries, some troops who have suffered concussions (from IEDs, for example) may be experiencing the effects of traumatic brain injury (TBI), including mood/behavior changes and cognitive impairments. It is not unusual for veterans to be coping with both psychological injuries and TBI, and the effects of these two kinds of injuries can overlap.

Post-Traumatic Stress Disorder (PTSD) and Psychological Injuries

PTSD wasn't recognized by the American Psychiatric Association until 1980, when troops traumatized by hand-to-hand combat, insurgencies and ambushes in the Vietnam War had been back on American shores for years. For some vets, the warning signs appear quickly after deployment. For others, months or years pass before they surface.

According to a 2008 population-based study by the RAND Corporation, Center for Military Health Policy Research, nearly 20 percent of military service members who have returned from Iraq and Afghanistan — 300,000 in all — report symptoms of post-traumatic stress disorder or major depression, yet only slightly more than half have sought treatment. The disorder may include the following:

1. Reliving the event (also called re-experiencing symptoms):
Bad memories of the traumatic event can come back at any time, resulting in nightmares and flashbacks. Triggers such as a car backfiring, which sounds like gunfire, may cause a veteran to relive events of war.

2. Avoiding situations that remind you of the event:
Veterans may try to avoid situations or people that trigger memories of the traumatic event and may even avoid talking or thinking about the event.

3. Feeling numb:
Veterans may find it hard to express their feelings and may not have positive or loving feelings toward other people.

4. Feeling keyed up (also called hyperarousal):
Veterans may be jittery, or always alert and on the lookout for danger, which can cause them to become angry or irritable suddenly or to have a hard time concentrating.

It's thought that by understanding traumatic stress symptoms and reactions better, veterans may be better able to cope with them. Treatment programs include different types of cognitive behavioral therapy (CBT) and a similar kind of therapy called EMDR, or eye movement desensitization and reprocessing. According to the Department of Veterans Affairs, certain medications used to treat depression can also be effective for treating PTSD. According to a 2011 study published by the Journal of the American Medical Association, however, drugs prescribed to treat severe post-traumatic stress symptoms for veterans are no more effective than placebos and come with serious side effects. About one fifth of veterans who seek treatment for post-traumatic stress receive a prescription for an anti-psychotic medication.

In recent years, the U.S. Department of Defense has encouraged the use of "post-traumatic stress (PTS)" or combat-related stress as the preferred terminology for general discussion and understanding of the combat stress response. This is part of an effort to reduce stigma among the general public toward combat veterans, and to differentiate between normal responses to combat situations and the persistent symptoms that may eventually lead to a formal diagnosis.

Traumatic Brain Injury (TBI)

Traumatic brain injury (TBI) is a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. It is not currently known how neurological trauma resulting in TBI exactly interferes with the emergence of PTSD, but like PTSD, traumatic brain injury is difficult to recognize, diagnose and treat. While the creation of mine-resistant ambush-protected armored vehicles has saved many lives, TBIs suffered through these blasts have become known as the new silent signature war wounds of the war in Afghanistan. Because these explosions were at one time deadly, it is unclear what the full effects are of surviving the kind of trauma associated with uncovering IEDs.

While severe TBI can leave a person almost incapacitated, even mild TBI (mTBI) — also known as concussion — can lead to symptoms, including headaches, balance problems, hearing problems, lack of self-control, mood changes, ringing in the ears, problems sleeping and memory loss. Recovery can take years.

Situations in Afghanistan and Iraq, where troops are likely to face multiple deployments and repeated ambushes by roadside bombs or improvised explosive devices (IEDs), are especially conducive to mild TBI. Out of 2 million troops who have served in Iraq and Afghanistan, more than 800,000 have had multiple deployments, many five or more. According to (a multimedia project funded by the Defense and Veterans Brain Injury Center), approximately 80 percent of TBI diagnoses in the military are associated with closed head injuries incurred as a result of blasting or other activities not directly combat-related. A 2009 study published by the American Journal of Public Health documents that troops who face multiple deployments are at a 300 percent increased risk of several mental health outcomes.

Just how many troops are affected is hard to know. Sections of the government have released numbers ranging from 50,000 (Department of Defense) to 115,000 (the Pentagon), while the Brain Injury Association of America estimates the number at 360,000 and RAND corporation has suggested it could be as high as 400,000.

Contributing to the uncertainty are the facts that TBI is difficult to diagnose, and that some soldiers may be reluctant to be diagnosed. The Pentagon found that 60 percent of the soldiers who suffered from TBI symptoms refused help because they worried unit leaders would treat them differently, or that the condition would prevent them from getting jobs as police officers and firefighters after they got out of the service.

The military uses two in-the-field methods to discern damage: the Military Acute Concussion Evaluation, or MACE (a brief clinical exam taken immediately after an incident), and the Automated Neuropsychological Assessment Metrics, or ANAM. Many soldiers have learned how to "trick" the first by memorizing the words they're supposed to recite back to the medics, in order to avoid the stigma of being injured or being separated from their platoons; reliability of results from the ANAM is no better than a "coin flip," according to recent Congressional testimony by Lieutenant General Eric Schoomaker, the U.S. Army's top medical official. ANAM is a computer-based tool designed to detect speed and accuracy of attention, memory, and thinking ability.

Even sophisticated CAT and MRI scans rarely show damage, though a new study at Washington University in St. Louis that used a new scanning technique did show that about one third of American troops who have suffered brain injuries from bomb blasts show immediate evidence of stretched and damaged nerve fibers at both the front and the back of the brain. Brain scans show that for days and even weeks after a traumatic brain injury, the brain's metabolism slows down, leaving some cells starved for energy.

David Hovda, who directs the Brain Injury Research Center at the University of California, Los Angeles says, "During the time when this metabolism is altered, the brain not only is dysfunctional, but it's also extremely vulnerable, so that if it's exposed to another mild injury, which normally you'd be able to tolerate really well, now there can be long-term devastating consequences." Bodi suffered repeated concussions, about 10 in all, before he was kept from going on missions.

According to NPR, brain injury experts are trying to apply lessons from the football field to the battlefield. Brain injury experts say mandatory rest and evaluation are even more important in combat because of new discoveries about the way energy from an explosion appears to reach the brain and cause damage. When somebody is involved in a blast, he or she experiences impact plus blast, which makes a blast injury different from other impact injuries, such as car accident injuries and sports injuries.

Efforts have increased to stop military personnel from suffering multiple concussions. The Pentagon recently released a new policy for the treatment of TBI, which includes a mandatory 24-hour rest period after a blast and a complete neurological assessment for anyone who's had three or more concussions. The United States Congress has mandated that military and veterans' hospitals screen all service members returning from combat assignments. Yet even when TBI is properly diagnosed, it is difficult to treat properly. Often a soldier does not realize he or she has suffered a concussion — symptoms may first surface months or years later. Those who go untreated may find their symptoms worsening over time, with some patients at risk for depression, substance abuse, severe anxiety, obsessive-compulsive disorders, Alzheimer's and suicide. In 2010, almost as many soldiers committed suicide as died in battle.

Experts polled by NPR unanimously agreed that in cases of lasting or severe damage, cognitive rehabilitation therapy (CRT), which retrains patients for tasks such as counting, cooking and memory, is an effective and helpful treatment. CRT takes time, however, and can cost $15,000 to $50,000 per patient. Many patients are treated only with weekly therapy or with medication. According to the U.S. Department of Defense, the majority of those with moderate to severe brain injuries never completely recover prior functioning.

Due to a recent change to the military's recognition of TBI, troops who have suffered a traumatic brain injury are now eligible for the Purple Heart, traditionally awarded to those wounded or killed by enemy action.

Photo caption: Bodi  Credit: Heather Courtney
» American Psychological Association
» Berglass, Nancy. "America's Duty: The Imperative of a New Approach to Warrior and Veteran Care." Center for a New American Security, November 2010.
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» Defense and Veterans Brain Injury Center
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» FRONTLINE. "FAQs —Traumatic Brain Injury."
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» United States Department of Veterans Affairs.
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» Williamson, Vanessa and Erin Mulhall. "Invisible Wounds: Psychological and Neurological Injuries Confront a New Generation of Veterans." Iraq and Afghanistan Veterans of America, January 2009.

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