The Nation struggles to help a deluge of veterans suffering post-traumatic stress and traumatic brain injury.

Ten years of combat in Iraq and Afghanistan under the constant threat of ambush, sniper attack and improvised explosive devices (IEDs) have created an epidemic of hidden wounds among American service members, particularly Army and Marine Corps ground troops and the Sailors and Airmen who support them in the field. Although these invisible wounds would appear less severe than the amputations inflicted by the IEDs, they affect many more service members and can have as much impact on the casualty’s future as the loss of limbs.

The most common of these unseen injuries is the psychological damage inflicted by exposure to acute danger or tragedy, known as post-traumatic stress, or PTS. But despite

better-armored vehicles, the proliferation of powerful IEDs has caused a jump in the more harmful traumatic brain injury, or TBI.

The alarming increase in these invisible but very real wounds, and protests from Congress, veterans’ organizations and military family members, have resulted in a torrent of additional resources, research and new programs seeking to prevent or minimize their effects and to treat those injured by what are being called the “signature wounds” of the war on terror.

Efforts to deal with PTS include pre-deployment training to reduce the psychological impact of traumatic events in combat; mental health providers embedded in combat units or located in close-by care centers; more screening for symptoms in theater and at home; and better care for those affected.

For TBI, research is being pressed to improve helmets and vehicles to reduce the shock of explosions. Command directives have been issued to instill greater sensitivity to the effects of concussions and to require steps to prevent re-injury before the brain has had time to heal.

Research also is being pursued on many fronts for improved ways to treat the more than 750,000 service members affected by psychological and physical trauma. That stunningly high number, which grows every day U.S. troops are engaged in Iraq and Afghanistan, have forced unprecedented attention on what is a very old problem.

Old as war itself

PTS has been around probably since man first engaged in organized combat. It was reflected in characters in Sophocles’ ancient Greek dramas. In World War I it was known as shell shock, and in World War II, Korea and Vietnam as combat fatigue or battle fatigue.

One of the major problems in dealing with PTS has been the tendency of leaders to dismiss its seriousness, and of troops to refuse to report the symptoms for fear of appearing weak or harming their careers. A notorious example of that first factor occurred in 1943 when Army Lieutenant General George S. Patton slapped two soldiers he found suffering from psychological breakdown in aid stations in Sicily.

Indicating how that has changed, several top leaders, including Marine Corps Commandant General James Amos, reject the word “disorder,” calling PTS an injury that must be treated.

In a concerted effort to eliminate the stigma that can thwart treatment of PTS, “one of our focuses on the Navy side is to change the culture,” which includes the Marine Corps, said Navy Capt. Richard Bergthold, a leader in the attack on PTS and TBI at the Navy Bureau of Medicine and Surgery in Washington. That effort involves guidelines and training that “goes out to the most senior line officers down to the most junior leaders.”

In addition, Capt. Bergthold said, directives have been issued to help commanders in Iraq and Afghanistan follow new guidelines intended to reduce the effects of PTS and TBI.

PTS can occur when a severe threat or a shocking event is seared into a person’s memory and recurs later in flashbacks or nightmares, or causes other psychological or physical reactions. It can reduce situational awareness in combat or cause detachment in social settings.

TBI occurs when brain tissue is damaged due to a physical blow to the skull, the supersonic shock wave from an explosion or by a penetrating wound.

Studies by several institutions estimate that up to 500,000 military personnel have suffered from PTS and about 270,000 from TBI in the 10 years of war in Iraq and Afghanistan.

But some researchers insist the military “chronically underestimates” the number of TBI cases, due to policy, culture and imperfect detection measures.

Government doctors involved in the fight against PTS and TBI acknowledge that military medicine is scrambling to close the gaps in knowledge, resources and policies for countering the hidden injuries. But they insist progress is being made, under orders from the highest levels of the military and civilian leadership. “We’ve come a very long way,” Capt. Bergthold said, citing the changes since he first arrived at BuMed in 2006.

Making slow progress

Asked if the military is getting better at dealing with the hidden wounds, Navy Capt. Paul Hammer said: “The short answer is yes. We’re making progress. The more difficult answer is: I wish we were making more rapid progress. We have learned a lot over the last decade about both of these conditions, and we continue to learn a lot. We’ve invested an enormous amount in efforts and in research in order to understand these conditions better.”

It’s a challenge to get what they have learned implemented into the system “so what we do is common everywhere, is uniform throughout the system,” he said. Promoting standardization of practice is a major part of Capt. Hammer’s job as director of the Defense Center of Excellence for Psychological Health and TBI, which he said, “is basically the integrator of information” on those injuries for the military.

The goal, he said, is to promote “the translation of research into practical clinical guidelines,” and to ensure that the best practices get widely disseminated.

Capt. Hammer’s organization itself is evidence of the progress. But it is only one of the new or revitalized establishments focusing on PTS and TBI, including his previous unit, the Naval Center for Combat and Operational Stress Control at the Naval Medical Center, San Diego.

Another indicator of progress is the increasingly interservice attack on psychological injuries, Capt. Bergthold said. “Never before, to my knowledge, has the Navy worked so closely with the other services … to provide a coordinated response” to PTS by attacking it “before, during and after deployment,” he said.