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'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.

• 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

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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