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Combat injuries may be as old and storied as war, but assaults on the brain have become one of the leading wounds afflicting the men and women who have returned from conflicts in Iraq and Afghanistan.
Only recently have researchers gained an understanding of how closely post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are overlapping in post-9/11 veterans, many of whom were exposed repeatedly to high-impact explosions, roadside bombs and mortar attacks.
“Many of the people who came out of the current wars do have both,” said Matthew Friedman, a psychiatrist who is director of the Department of Veterans Affairs National Center for PTSD. “If you think about it, if you’ve been exposed to a situation where there’s a blast that’s sufficient to produce a concussive injury to you, maybe to kill or maim many of your colleagues, well, that certainly qualifies as psychological trauma as well.
“It shouldn’t be surprising that so many of the people that we’re seeing, particularly given the nature of the current wars, do suffer from both,” Friedman said in a phone interview.
PTSD is a collection of severe anxiety symptoms that can occur after exposure to psychological trauma, such as witnessing deaths and suffering injuries in modern warfare. TBIs and concussions are physical injuries that can be caused by explosions in combat, according to experts.
PTSD and TBI are “the two most prolific wounds coming out of the war,” said retired Gen. Peter Chiarelli, the former vice chief of staff of the U.S. Army and now CEO of One Mind, a research and advocacy nonprofit for mental health and brain diseases.
“The brain is a tremendously complicated organ,” Chiarelli said in a phone interview. “Most people don’t understand or don’t believe this. They think that there’s something the matter with this generation, that they have such a high rate of post-traumatic stress.”
Chiarelli felt a personal obligation to address these conditions in young veterans, because of what he saw as an unsuccessful attempt to stop the seeming epidemic of PTSD and TBI in troops when he was the Army’s vice chief of staff, he said.
“I have to be considered a horrible failure in my ability to get a handle on this problem,” Chiarelli said, pointing out how the number of injured troops with a 30 percent disability had increased dramatically during his tenure from 2008 to 2012.
Nearly 130,000 troops since 2001 have been diagnosed with PTSD, according to the Office of the U.S. Army Surgeon General. That number may be even higher for post-9/11 veterans, because many are not diagnosed until years after they are discharged from service.
“I’m embarrassed to say, I spent two tours in Iraq and Afghanistan, and I had no idea what traumatic brain injury and post-traumatic stress were,” Chiarelli said. “I began the process of learning.”
Advances in medical care might also be why blast injury victims are more likely to survive with traumatic brain injury. However, the overlap between PTSD and TBI is much deeper than overlapping traumas to the brain, said David Cifu, national director of the VA’s Physical Medicine and Rehabilitation Services.
Either trauma might affect how the brain recovers from injuries — psychological or physical, Cifu said.
“It could be that you don’t get the normal recovery of a concussion,” he said. “We don’t see that rapid recovery, that full recovery, in the face of some of the physiologic changes that occur as a result of acute stress” that marks PTSD.
PTSD causes physical alterations in brain makeup and structure, Cifu said, and those alterations can damage the same pathways that are interrupted by TBI.
“When you put those two things together,” he said, “neither may recover in the typical way that it does, with or without therapy.”
This has much to do with where such traumas affect the brain, Friedman said. These include the frontal region, which contains the “executive center” of rational decision-making and action, and the temporal lobes, which process sensory information and emotional memory.
“The brain structures most often affected by a blast injury are also the brain areas that we know are disregulated by PTSD,” he said. “We’re going to see abnormalities in certain important brain structures in the frontal and temporal areas, and we’re going to see changes in neurocircuitry in terms of how the brain processes information.”
Such changes in information processing make recovery from PTSD and TBI more challenging, Friedman said. “So what we have are two different mechanisms with overlapping pathological consequences.”
But overlap between PTSD and TBI is not new, Cifu said.
“This has been around for thousands of years,” he said. “It’s been documented in every war, and even in non-combat situations where there have been traumatic brain injuries.”
Before the 20th century, the condition was considered a moral deficit, akin to cowardliness in the face of combat. The official, medical diagnosis of PTSD was not formulated until the 1980s, but many researchers believe that evidence of it can be found in past conflicts by examining historical documents.
Evidence of PTSD can even be traced back to the earliest known literature, "The Epic of Gilgamesh," a tale from ancient Mesopotamia that follows the exploits of a Sumerian demigod. In 1992 research by James Boehnlein and John Kinzie, PTSD can be seen in Gilgamesh’s behavior after seeing his friend, Enkidu, killed in battle. The account of his symptoms — emotional numbing and intrusive memories of his friend’s death — are evidence that even the ancient Mesopotamians experienced what may have been combat-related PTSD.
Later in history, medical doctors began recognizing symptoms of what may correspond to the modern definition of PTSD in soldiers returning from combat. These early diagnoses were vague and highly subjective. In the 19th century, physicians used such terms as “exhaustion” and “soldier’s heart” to describe traumatized individuals.
By World War I, the combination of heavy-artillery barrages and traumatic combat experiences led physicians to devise the term “shell shock.” Sufferers often experienced many symptoms of PTSD, such as intense anxiety, exaggerated “startle” reflexes and emotional numbing.
This was also one of many conflicts in the 20th century in which the combination of high explosives and traumatic situations could have caused both TBI and combat-related PTSD.
Cifu offered a dramatic historical perspective.
“War is hell,” he said. “War causes brain injuries and trauma and stress, forever and ever, and it always will.”
While such injuries might have existed in veterans of all wars throughout history, ideas about how to treat them have changed dramatically.
Many combat veterans faced stigma and severe punishment for their anxiety and depression, which often were attributed to cowardice.
American Revolutionary War soldiers often were treated brutally for what is now considered a medical condition, Maj. Karen Baker wrote in a 2011 monograph for the School of Advanced Military Studies at Fort Leavenworth, Kan.
“Punishment for mental health problems and desertion was harsh,” she wrote, “and included flogging, running the gantlet, tar-and-feathering, and [being locked in] shackles.”
The term post-traumatic stress disorder was not defined until 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The formulation of this diagnosis was in response to the overwhelming number of Vietnam War veterans who had suffered combat-related trauma.
By the time of the Iraq and Afghanistan wars, a combination of media attention and rapidly advancing medical science led to some of the newest ideas on how to approach veterans who have PTSD and TBI.
As physicians have come to better understand this relationship and how it affects combat veterans’ recovery, new research fields are opening. Medical imaging advances that allow researchers to look inside patients’ brains are the focus of intense interest, Cifu said.
“There’s got to be 50 centers (nationally), if not more, doing specific research looking at existing imaging techniques that have been slightly modified,” he said. “The BRAIN Initiative that’s come out of the Obama administration, with partnerships with the NFL and GE (General Electric), are all very focused on ways to visualize these abnormalities.”
The BRAIN Initiative, for Brain Research through Advancing Innovative Neurotechnologies, was announced by President Barack Obama in April. The project will spend more than $100 million on research for brain diseases such as Alzheimer’s, epilepsy and TBI.
However, physicians such as Cifu who treat PTSD and TBI, question whether the money could be better spent.
“I would say that, while it’s nice to be able to visualize (brain disorders), and that’s exciting, I would rather see those funds put into ways of objectifying findings and a way forward to treatment,” Cifu said. “I’m happy that research is occurring, but I’d rather it be put into fixing people, rather than just imaging them.”
“I don’t need to see an X-ray to know these people have problems,” he said.
During his time as vice chief of staff, Chiarelli approached TBI first, because newer imaging techniques, such as positron emission tomography (PET), were available. That allowed researchers to capture an image of the brain from the inside. That image could be used to persuade soldiers to seek treatment.
“People don’t want to go in and get help,” Chiarelli said. “But with positron emission tomography, and being able to show a soldier what your brain looks like when it’s concussed — that has a huge impact.”
Chiarelli reported relative success preventing TBI, but was disappointed in efforts to address PTSD, he said.
“We made less progress with post-traumatic stress, because we don’t have good diagnostics for post-traumatic stress,” he said. “It’s caused a tremendous amount of problems.”
Research surrounding PTSD is either incomplete, or might not be relevant to soldiers who have experienced combat situations.
“Most of the work that has been done on post-traumatic stress has not been done on soldiers,” Chiarelli said.
Cifu’s own work has focused on combining medical disciplines to better treat veterans who have mental health and brain-injury conditions. Cifu works with a team of professionals who take care of soldiers’ “PTSD, their alcohol issues, their pain, whatever their secondary conditions or primary conditions are,” he said.
Understanding the overlap between PTSD and TBI can help physicians design treatment plans.
“You don’t treat these patients serially,” he said. “You don’t take care of their brain injury, wait three months, and then take of their PTSD.”
