Traumatic Brain Injury
“We are facing a massive mental health problem as a result of our wars in Iraq and Afghanistan. As a country, we have not responded adequately to this problem. Unless we act urgently and wisely, we’ll be dealing with an epidemic of service-related psychological wounds for years to come.”
–Bobby Muller, President Veterans For America
David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles (UCLA), calls traumatic brain injury (TBI) the “silent epidemic.” It is the most common cause of death for U.S. adults under the age of 45, deadlier than AIDS, Multiple Sclerosis, spinal cord injury and breast cancer combined. It strikes down 1.6 million Americans a year. And while TBI may be a quiet wound, its consequences for victims, family, friends and co-workers can be catastrophic.
Adding to that 1.6 million figure are two wars whose signature injury are blast-induced head wounds. A recent study by the General Accounting Office found that, “Traumatic brain injury has emerged as the leading injury among U.S. forces serving in Afghanistan and Iraq.”
According to a Walter Reed Hospital study, “closed brain” injuries—injuries with no visible marks—outnumber “penetrating brain injuries” seven to one. Other researchers put the ratio much higher.
“We are looking at a very frightening situation,” says Dr. Judith Landau,psychiatrist and president of Linking Human Systems in Boulder, Colorado, who works with vets and their families.
And yet, according to Dr. Michael Weiner, professor of medicine, radiology, psychiatry and neurology at the University of California at San Francisco (UCSF) and director of the Center for Imaging of Neurodegenerative Disease at the Veteran’s Administration Medical Center,
“There is a lot more that we don’t know about it [TBI], than we do.”
For starters it’s hard to spot. “Our scans show nothing,” says Weiner.
TBI is a slippery beast, or “murky” as Weiner puts it. It can cause symptoms ranging from depression and uncontrollable rages to irritable bowels and emotional disengagement. It can suddenly appear long after the incident that caused it, and it is difficult and complex to treat.
While medicine is beginning to understand more about the kind of TBI generated by car accidents, falls, or sports injuries, no one is quite sure exactly what causes the TBI generated by roadside bombs in Iraq and Afghanistan. “It is a complicated injury to the most complicated part of the body,” says Dr. Alisa Gean, chief of Neuroradiology at San Francisco General Hospital, who has worked with wounded soldiers at the U.S. Army’s Regional Medical Center at Landstuhl, Germany.
Whatever the causes, the constellation of symptoms that TBI induces include short term memory loss, stomach, chest, back and head pain, dizziness, racing pulse, constipation, diarrhea, sexual dysfunction, insomnia, inability to concentrate, damage to hearing and vision, personality changes, and Post Traumatic Stress Disorder (PTSD).
Indeed, part of the problem in identifying TBI is that its symptoms are so similar to PTSD.
A recent study of veterans returning from Iraq and Afghanistan found that the severity of those symptoms was greatly affected by how serious the incident that caused the TBI was: whether the victim was knocked unconsciousness, or was simply dazed and confused, inwhat is called an “altered state.” A U.S. military study notes, “Injuries associated with the loss of consciousness carried a much greater risk of health problems than did injuries associated with altered mental states.”
The Pentagon says about 20,000 GIs have returned with TBI, but most experts say the figure is much higher. U.S. Rep. Bill Pascrell (D-NJ), founder of the Congressional Brain Injury Task Force, says the figure could be as high as 150,000.
TBI is hardy new. Some 5.3 million people in the country are currently hospitalized or in residential facilities because of it. And its consequences surround us.
For instance, researchers have found a relationship between TBI and problems like addiction and homelessness. “Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure,” says Wayne A. Gordon, director of the Brain Injury Research Center at Mt. Sinai School of Medicine.
One Mt. Sinai study of 100 homeless men in New York found that 80 of them had suffered brain trauma, much of it from child abuse. A similar study of 5,000 homeless people in New Haven, Conn.., discovered that those who had suffered a blow that knocked them unconscious or into an altered statewere twice as likely to have alcohol and drug problems and to be depressed. It also found higher rates of suicide attempts, panic attacks, and obsessive-compulsive disorder.
A Canadian study indicates that a blow powerful enough to cause unconsciousness causes a loss of brain tissue. “There is more damage and it is more widespread that we had expected,” Brian Levine of the University of Toronto’s Rotman Research Institute told the Toronto Star.
Levine says the cell loss appears to be in the brain’s white matter that is essential to communication. Even a small loss in this region of the brain, “Will have a quite large effect on behavior,” he says.
If its effects are dramatic, its profile has been modest until recently. Gean says she has been “carrying a torch” on civilian TBI for over 20 years—she is the author of what is considered the standard textbook on imaging TBI—but the subject has “escaped the radar of funding.” People worry about whether they are going to get breast cancer or AIDS, but “people don’t think they are going to get TBI,” she says.
Afghanistan and Iraq have changed all that. “The wars have caused people to come around to acknowledge the psychological aspects of TBI,” says Gean, and she credits ABC’s Bob Woodruff for helping to bring the subject before the public.
Woodruff was seriously wounded in the head by a roadside bomb in Iraq and his struggle to return to work was covered extensively by the news organization. Woodruff has since done a number of reports on soldiers suffering from TBI
Gean says there are many similarities between civilian TBIs and those inflicted in combat; “Penetrating injuries are penetrating injuries. They are seen everyday in gang warfare,” she says, although in Iran and Afghanistan the projectiles may be “nuts, bolts and pieces of car fenders” rather than bullets.
But there are also major differences. “Combat trauma is trauma on steroids,” she says, “It is truly polytraumatic.” When she talks about seeing soldiers with burns, open wounds, multiple amputations and TBI at Landstuhl. At one point she stops, remembering looking at one mutilated 20-year old. “I will never forget those injuries,” she says quietly.
While there is general agreement in the field about what causes TBI in impact injuries like an auto accident or a sports concussion, there is no such agreement when it comes to how massive explosions affect the brain.
Most researchers assume the damage comes from a violent shaking of the head. “These brains are rattled like a yolk in an egg,” says Jessica Martinez, an occupational therapist at Scripps Memorial Hospital in Encinitas, Ca.
However, P. Stephen Macedo, a doctor formerly with the VA, told the Toronto Starthat when the force of an explosion “moves through the brain, it seems to cause little gas bubbles to form. When they pop, it leaves a cavity. So you are littering people’s brains with these little holes.”
U.S. physician Susan Okie thinks that the combination of a blast wave followed by a sudden drop in pressure is the culprit.
Psychiatrist Evan Kanter of the University of Washington argues that explosions disconnect the amygdala, or emotional part of the brain, from the frontal lobes, which control planning and decision-making.
And Dr. Ibolja Cernak of Johns Hopkins postulates that blast waves generate powerful vibrations of major blood vessels in the chest and abdomen, which transfer that energy to areas deep in the brain, such as the hippocampus. Cernak says the damage eventually leads to premature aging of the brain.
A recent Army study downplayed the seriousness of mild TBI (MTBI), suggesting that the health problems associated with MTBI were largely a result of PTSD and depression.
But a careful reading of the study reveals that researchers failed to directly link PTSD to MTBIand that “These data should not be construed as suggesting that mild traumatic brain injury is not a serious medical concern.” Solders who suffer MTBI, especially those knocked unconscious or who experience it multiple times, “were at a very high risk for physical and mental health problems.”
UCLA’s Hovda even questions the term “mild.” He says, “I don’t know what makes it ‘mild,’ because it can evolve into anxiety disorders, personality changes, and depression.”
Besides the acute symptoms of TBI, there is a tapestry of psychological syndromes that victims can suffer. “Even mild brain trauma shakes up the entire body,” says Dr. Landau. “Many doctors and therapists just don’t see this.”
One problem, says Landau, is that MTBI can produce such a wide variety of systems, from disrupting the female hormone system to irritable bowels.
One of the major effects of TBI is what Landau calls the development of “identity ambiguity: people who were decisive become indecisive. People who were charming become withdrawn. They may have trouble reading. They may fly into rages.”
Landau says this can be devastating for those around TBI sufferers. “The family is excited that this young person is coming home [from the war] with no major injuries. They left as a good son, a good father, and a good husband. Suddenly they start hitting their children, can’t have sex, start drinking too much, talking too loud.”
Mary Watson, RN, DSM, a psychiatric nurse at a Cleveland VA hospital, says TBI sufferers can “seem to be perfectly normal and then spontaneously become confused and irritated, suddenly set off by something in their surroundings, and start yelling and cussing.”
Pennsylvania Psychologist Barry Jacobs, author of “Emotional Guide for Caregivers,” says TBI victims may lose their ability to empathize with others. “It is like a stranger has suddenly shown up.”
Jacobs says he is particularly concerned about MTBI. “Mild injuries are most at risk,” he says, “because the symptoms are subtle and may not be recognized as neurological. But while the symptoms may be subtle, the consequences for family, friends and coworkers “may be severe,” he says.
According to Landau, “There is a 70 percent chance that relationships will break down after TBI.”
Treating TBI is tricky, not just because it can be both subtle and stubborn, but because military culture resists admitting to problems. A Pentagon study found that 60 percent of the soldiers who suffered from the symptoms of TBI refused to seek help because they felt their unit leaders would treat them differently. Some 55 percent refused help because they thought they would be seen as weak or would lose the trust of their fellow soldiers. A number feared that reporting the symptoms of TBI could prevent them from getting jobs as police and firemen once they left the military.
“Vets don’t tell the truth,” says Hovda. “They say, ‘I’m fine, I can go back into battle.” The result, however, is that TBI victims may be exposed to further damage before they can heal. “MTBI is a biochemical event,” says Hovda, that creates a crisis for the brain. During this crisis, “the brain is vulnerable to another incident. A second incident during this phase is likely to have more severe repercussions.”
The Center for the Study of Retired Athletes found that three or more concussions meant that athletes were three times as likely to have “significant memory problems” and five times as likely to suffer from depression or develop an Alzheimer’s-like syndrome called Chronic Traumatic Encephalopathy.
Whether it is sports or war, the more one is exposed to trauma, the worse the damage.
Multiple tours and longer deployments mean soldiers are exposed to more explosions. “The multiple nature of it is unprecedented. People just get blasted and blasted and blasted,” says Maj. Connie Johnmeyer of the 332nd Medical Group, a unit that deals with psychological problems.
But with a major shortage of troops, the pressure is to get lightly wounded soldiers back into battle. Out of the 1.6 million who served in both wars, some 525,000 troops have had more than two combat tours, 70,000 have served three, and 20,000 have done five or more.
When soldiers are first wounded, says Gean, “The acute care [at Landstuhl and Walter Reed] is truly world class,” far better than most people could get in the U.S., bar a few trauma centers. But she thinks that the TBI problem “is larger than we think,” and she worries about “what happens after” they leave.
The worry is well placed. Soldiers return to find that there are few psychological resources for them, and virtually no individual therapy. “There are two things going on regarding vets,” says Col. (ret) Will Wilson, chair of the American Psychological Association’s Division 19 (Military Psychology). “One, there are not enough care providers available, and two, there are not enough people focusing on the problem outside of the military.”
The Department of Defense’s (DOD) Task Force on Mental Health concluded that “The psychological health needs of service members, their families, and their survivors are daunting and growing.” And yet the military has lost 22 percent of its psychologists in the past several years, most from burnout.
At Walter Reed, soldiers with PTSD outnumber amputees 43 to 1, but the hospital has no PTSD center. “TBI can be missed,” says Watson. “People demonstrating psychological problems can be sent to the general psych unit where they are locked up.”
Soldiers are also routinely treated with medications rather than therapy. A study by Veterans for America found that some soldiers were taking 20 different medications at once, some of which canceled others out.
Soldiers also have difficulty finding therapists because the VA pays below-market rates, and even cut those reimbursements 6.4 percent in 2007. The result is that some 30 percent of psychologists are unwilling to take on military patients. For regular soldiers, one 45-minute session once a month is not uncommon, and they may be treated by a different health professional each time.
This situation may be worse for the National Guard and the Reserves, who make up almost 50 percent of the troops deployed in both wars and who, according to the Veterans for America study, “are experiencing rates of mental health problems 44 percent higher than their active duty counterparts.” Health care for such troops may be inferior to that offered to full-time regulars.
The problem is broader than psychological services. A Harvard study found that 1.8 million vets under 65 have no health care or access to the VA. “Most uninsured veterans are low-to-middle income workers who may be too poor to afford private coverage but are not poor enough to qualify for Medicaid or free VA care,” the study found.
“The insurance situation is horrible,” says Landau.
Therapists like Landau and Jacobs point out that while TBI may affect an individual, its consequences ripple out to a much wider audience.
“You have to mobilize their [TBI sufferers] support system,” says Landau. Educating a TBI sufferer’s family is essential and “very possible to do.” But many in the military are not trained in skills like family therapy.
Watson agrees about the importance of working with families, but points out “that in many cases there is no core family” and TBI sufferers are on their own.
As grim as the current situation looks, most health professionals say there is hope for many TBI sufferers.
Gean says that when she was in school, conventional wisdom was that damaged brains couldn’t heal. “But we now know that the brain can heal. It has an intrinsic plasticity that allows it to recover, and this is particularly true for the young brain.”
On the psychological side, while recovering from TBI may take a long time—Landau says sometimes from five to 10 years—if the proper care is given, recovery is possible. Jacobs agrees the recovery period may be extensive, but, “things do get better over time.”
Rehabilitation, however, is expensive, and it is by no means clear how many victims there are. Between TBI and the kind of damage that substance abuse inflicts, Landau guesses that “40 percent of the returning vets will have physical and psychological difficulties.”
No one has put a final figure on what that will cost, but $14 billion over the next 20 years is not out of the question.
Right now the resources don’t meet the demand. “Currently the VA system cannot manage patients with TBI,” says Dr. Heekin Chee of Boston’s Spaulding Rehabilitation Hospital. Jacobs agrees: “The infrastructure that exists is not going to be able to cope.”
UCSF researcher Weiner ticks off what he sees as at least some of the solutions: “First, everyone of these people has to have access to quality clinical care, and physicians need to get educated about this syndrome. Second, we have to create a national database on this so we can figure out what is going on, and what we can learn from clinical treatment. Third, there needs to be a lot more organized research on these people.”
Weiner says the federal government has made $300 million available for research, “Which sounds like a lot of money, but really isn’t.”
Following the revelations of inadequate medical care at Walter Reed, Congress has gotten more involved in the issue.
Last July Congress passed the Wounded Warrior Bill (S 1606) to improve care for troops and veterans, and the House Energy and Commerce Committee just passed a reauthorization of Traumatic Brain Injury Act (HR 1418) to support research and rehabilitation for TBI sufferers.
Rep. Pascrell led the push for the bill. “This is not just for the military,” says Pascrell’s Communication’s Director, Caley Gray, but for TBI sufferers nationwide.
It has taken a war to put the issue of TBI on the nation’s health agenda, but the cost of that awareness in blood, flesh, and decimated relationships is high. Even if the war ends soon, there will be hundreds of thousands of soldiers and veterans who will bear the burden of TBI. Sorting out how to deal with it may well test the nation’s mettle far more than the conflicts that produced the damage.
For Gean, who has seen some of that wreckage first hand, the solution is clear: “We have to do something for these soldiers.”