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
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
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
- Visual disturbances
- Memory loss (especially short term memory)
- Poor attention and concentration
- Sleep disturbances
- Dizziness and loss of balance
- Feelings of depression
- Suicidal thoughts
Other Symptoms Associated with Mild
- 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:
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
Physical Therapist: Provides specific therapy
and help for balance and hearing problems.
Psychiatrist: Provides medications to relieve
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
For more information on TBI and PTSD:
Comorbid TBI and PTSD Conditions
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