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Deployment-Related Traumatic Brain Injury and Co-Occurring Conditions
A Course for Civilian Health Care Providers from BrainLineMilitary.org
Stress is a normal reaction in combat situations. Keep in mind that for service members injured by an improvised explosive device (IED), not only was the blast a horrific and stressful event in and of itself, but it may have killed or injured close comrades.
John Rigg, an M.D. and rehabilitation specialist, discusses battlefield stress:
VIDEO: Stress, Not Craziness
Stress, Not Craziness
"One of the most important things that I tell the soldiers is they're not crazy. They're having a normal reaction to an abnormal situation "
PTS and TBI
Concussion frequently co-occurs with PTS (post-traumatic stress) in this population.
So when evaluating a patient for concussion, consider the possibility that your patient may have PTS, or PTS and concussion. If your patient has PTS (with or without concussion), making the diagnosis is valuable because evidence-based treatments are available.
Here is a brief overview of post-traumatic stress treatments from the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury.
The signs and symptoms of concussion and PTS overlap considerably, so use the graphic below to learn the symptoms that can help you discriminate between concussion and post-traumatic stress for patients who have only one or the other. A printable version of this graphic is available for download here.
Reference: Stein MB, McCallister TW (2009). Exploring the convergence of post-traumatic stress disorder and mild traumatic brain injury. Am J Psychiatry; 166:766-776.
Regardless of the cause of the symptoms, treating the symptoms themselves is the right approach.
Many returning service members will experience post-traumatic stress (PTS) without necessarily meeting the diagnostic criteria for post-traumatic stress disorder (PTSD), which is discussed below.
Read the following brief article which outlines ways to manage any kind of post-combat stress:
Stress weighing you down? Learn some easy ways to manage stress related to TBI.
Among men and women who served in Iraq and Afghanistan, Post-Traumatic Stress Disorder is common and can occur with or without a concussion. To merit a diagnosis of PTSD, a service member must have experienced not only a horrific, stressful, traumatic event, but also must re-experience that trauma persistently, avoid reminders of the event (certain places or objects, for example), and display increased arousal. With PTSD, these symptoms persist longer than a month and interfere materially with the service member's life. Neuropsychologist Cynthia Boyd describes a corpsman with multiple blast exposures who re-experiences a trauma in a manner consistent with PTSD:
VIDEO: Life After Five Deployments and TBI
Life After Five Deployments and TBI
"He thought they were under fire. He went in a full on flashback "
PTSD symptoms that emerge after a concussion can be treated with various types of therapy and/or medication. Therapies that have been found effective in the treatment of PTSD include exposure therapy, cognitive therapy, anxiety management and eye movement desensitization and processing (EMDR). Some service members find one type more effective than others, whereas, a combined approach may be more beneficial. Effective medications for PTSD may include tricyclic antidepressants (TCAs), Monoamine Oxidase Inhibitors (MAOIs), Selective serotonin reuptake inhibitors (SSRIs), mood stabilizers and/or anti-anxiety agents. Providers often individualize treatment based on the service member's needs, preferences, tolerance and reaction. A concussion may increase the challenge of managing multiple medications and possible side effects so, if possible, first consider non-pharmacological interventions.
For an overview of PTSD treatment methods, read this short article:
Learn about treatments for PTSD.
Remember that it's more important to treat symptoms of stress than to spend time and resources trying to decide whether someone meets the diagnostic criteria for PTSD.