Keywords: traumatic brain injury (TBI), military, blast injury, concussion, neurocognitive functioning, rehabilitation, quality of life (QOL)
This paper reviews the major findings and controversies relevant to military-related Traumatic Brain Injury (TBI) from various disciplines (mainly psychology, medicine, and neuroscience). The aim is to aid readers in examining the topic from a multidisciplinary perspective that takes into consideration the interconnection of the various domains of functioning affected by a military TBI in order to better understand the complicated challenges faced by military personnel who are returning to our communities with such injuries. I will begin by briefly defining TBI and explaining how a TBI may occur, followed by a review of studies regarding biopsychosocial outcomes that represent the most commonly noted changes, complications, and challenges an individual with a military TBI may face. Then, the implications of the research are presented, the connections that can be made between them, and the new directions the research community should pursue in order to further our understanding of the military TBIs on all levels of functioning and from injury to outcome.
The impact of military traumatic brain injuries (TBIs) has grown to become so great that it is now considered one of the prominent signature war wounds of the Global War on Terror and Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) (Moore & Jaffee, 2010). Thus, it is important for the public, families of service members, and the clinicians and health professionals who will be working closely with soldiers and veterans who return to their communities with a TBI, to understand just what a TBI is, how it will impact the individual in various domains of their life, and what factors influence the progress of TBI from injury to long-term outcomes.
The recent increase in combat-related military TBIs has been attributed to the nuances that set OEF and OIF apart from previous conflicts, mainly an increase in the frequency of attacks involving explosions and bomb blasts and advances in body armor worn by military personnel (Jett, 2010; Jones, Young, & Leppma, 2010; Warden, 2006). The changing nature of combat has resulted in a war with significantly higher risk for closed head injury and a much higher likelihood that military personnel will survive injuries that would, in past wars, have been fatal (Moore & Jaffee, 2010; Taber, Warden, & Hurley, 2006). Furthermore, the increased use of improvised explosive devices (IED) has introduced an element of injury besides blunt-force trauma as a mechanism for brain damage: injury directly due to the blast pressure wave following explosions, the effects of which are not well understood (Moore & Jaffee, 2010; Rosenfeld & Ford, 2010; Taber et al., 2006). From the years 2000 to 2010, the United States Armed Forces reported a cumulative total of 202,281 cases of Traumatic Brain Injury (TBI) (Defense and Veterans Brain Injury Center, 2011). These numbers, however, may be a gross underestimation of the true scope of the problem, as it has been estimated that about 57 percent of military TBIs go unreported and unevaluated (Tanielian & Jaycox, 2008). With an approximated 1.64 million U.S. military personnel having been deployed to OEF/OIF (Tanielian & Jaycox, 2008) and a recent report that an estimated 78 percent of injuries at second echelon treatment sites were the result of blast attacks (Owens et al., 2008), it is clear that the impact of combat and blast related TBI on U.S. military personnel, veterans, and their families is a significant one.
The behavior and cognition of an individual exists within an ecosystem that provides a dynamic and reciprocal interaction. Thus, understanding the potential a TBI may have to change the life of a service member and designing methods of effective treatment, education, and support requires looking not only at changes in physiology or psychology in isolation but must include an understanding of the changes that may occur at all levels of human functioning, from biochemical to social interactions. The ultimate goal of this paper is to create a comprehensive, multidisciplinary, and holistic lens with which readers unfamiliar with the topic can understand one of the signature war wounds of our time and readers familiar with TBI can use to generate new research questions regarding how to improve the lives of soldiers and veterans with TBI.
What is a Traumatic Brain Injury?
The Department of Defense defines TBI as a “traumatically induced structural injury and/or physiological disruption of brain function as the result of an external force . . .” (French & Parkinson, 2008). First and foremost, a TBI begins with physical injury to and changes of the brain. In the context of military service and combat, such an injury is also typically accompanied by extreme psychological stress and often emotional trauma. If individuals survive the injury, they must often contend with changes in their cognitive and physical abilities that may result in challenges to their autonomy and functioning, which alter their interactions with others, their perception of themselves, and quality of life. In short, a TBI, especially one acquired in a combat setting, is a dynamic injury with far-reaching consequences moderated by many factors internal and external to the patient.
Severity of injury is determined through the use of the Glasgow Coma Scale (GCS), the duration of posttraumatic amnesia (PTA), and the length of time of loss of consciousness (LOC) or alteration of consciousness (AOC) (Jaffee et al., 2009). Mild TBI patients do not typically experience long-term impairment in functioning, although up to a third of individuals with mild TBI (mTBI) have been noted to develop persistent physical, cognitive, and emotional symptoms, a condition known as postconcussion syndrome (PCS)(Jones et al., 2010; McCrea et al., 2008). Although the majority of TBIs are classified as mild, moderate and severe injuries do occur in the military population serving in OEF/OIF and thus will be included in this review (Defense and Veterans Brain Injury Center, 2011).
In the combat zone, the primary mechanisms of injury are due to explosive weaponry common to the theaters of war in Iraq and Afghanistan (Owens et al., 2008). The impact of the primary blast wave from an explosion can cause acceleration/deceleration of the head and induce stress and shear injuries in brain tissue, especially in tissues of different densities (Cheng et al., 2010; Jaffee et al., 2009; Rosenfeld & Ford, 2010). Overall, the topic of the damage in the brain that may or may not be caused in a primary blast is not well understood (Taber et al., 2006). Although blast trauma is the most common injury among military personnel in OEF/OIF, blast injuries can also result in secondary and tertiary injuries, such as being struck in the head by objects set in motion by blast that are similar to non-blast TBI mechanisms (Luethcke, Bryan, Morrow, & Isler, 2011). Therefore, literature regarding what is known of TBI in the civilian population due to non-blast related mechanisms (e.g., assault, falls, motor vehicle accidents, sports concussion) are included in this review, in addition to studies specific to the context of combat and blast-related TBI. Recent studies comparing the cognitive and psychological outcomes in blast-related versus non-blast TBI have not found substantial evidence to suggest that there is a major difference in the two mechanisms of injury in terms of outcomes, although further investigation is warranted (Belanger, Kretzmer, Yoash-Gantz, Pickett, & Tupler, 2009; Luethcke et al., 2011).
The short and long-term response of an individual to TBI is affected by a number of complicated factors that makes each injury unique. Such factors that influence the outcome of the injury include premorbid psychological factors, history of injury, individual physiology, such as genetics, the type and mechanism of injury, the context of the injury, psychological stress, and the immediate and long-term care of the individual (Halbauer et al., 2009). Each soldier can emerge from combat with different patterns of damage and care. As a result, discussion of TBI-related sequelae is complicated, but this paper will attempt to summarize the most common symptoms that are known to occur in patients with TBI.
Some cognitive dysfunctions that occur in the aftermath of a TBI include changes in memory, attention, language, facial affect recognition, visuospatial cognition, and executive function, the severity and endurance of which appear to be dependent on the nature and severity of injury (Halbauer et al., 2009). The most frequent dysfunctions following TBI are related to memory (Warden, 2006). Because memory is involved in a vast majority of cognitive functions, the ecological significance of such deficits in memory range from the ability of the individual to remember everyday tasks and appointments to learning new skills and relearning lost abilities (Halbauer et al., 2009). Each component of cognitive processing is not only important for the tasks related to recovery, such as remembering appointments and effectively communicating with health professionals during the treatment process, but also affect tasks necessary for maintaining and improving one’s quality of life, such as functioning optimally in the classroom or the workplace. Detecting the presence of diffuse axonal injury following TBI is important because the presence of such damage is associated with persistent cognitive impairment (Scheid, Preul, Gruber, Wiggins, & von Crammon, 2003). Kinnunen et al. (2010) used Diffusion Tensor Imaging (DTI) to examine whether differences in white matter structure in post-acute and chronic patients with TBI of varying severities can be detected and found that specific patterns of white matter abnormalities could be linked with distinct cognitive symptoms, most notably processing speed, memory, and executive function.
An important consequence of cognitive dysfunction in individuals with TBI concerns recovery of competency and medical decision-making capacity (MDC). In a study by Dreer, DeVivo, Novack, Krzywanski, and Marson (2008) investigating the neurocognitive predictors of MDC in severe TBI and healthy adults, baseline performance of short-term verbal memory was found to have a strong relationship with impairments in capacity to consent during initial hospitalization and that 6 months after baseline testing, measures of executive functioning and working memory were stronger predictors of improved capacity. Although the sample was small, the study suggested the role of cognitive measures in neuropsychological batteries in aiding clinicians in understanding MDC in their patients and highlighted an ecological role of cognitive functioning vital to proper patient care.
Communication difficulties also arise in TBI, with damage to regions affiliated with the function of language processes. Such damage may foster the production of aphasia, leading to deficits in naming objects, fluency of speech, comprehension, and repetition (Halbauer et al., 2009). Damage to language areas affect communication and thus also bring about challenges in social functioning, such as an inability to express oneself effectively or comprehend the intent of other speakers (Halbauer et al., 2009), resulting in poor social relationships and inappropriate behavior (Pagulayan, Temkin, Machamer, & Dikmen, 2006; Rolls, Hornak, Wade, & McGrath, 1994; Teasdale & Engberg, 2005). The behavioral outcome of TBI patients with changes in empathy are often characterized as ego-centric, demonstrating a poor awareness of the feelings of others, and a self-centered attitude that is neglectful of individuals the patient tended to have warm interactions with pre-injury (Wood & Williams, 2008). Such changes in ability to empathize may have detrimental effects on the social support network of patients, a factor that will be discussed later in this paper as vital to improving quality of life and preventing suicide in veterans with TBI.
Veterans with TBI are noted in the literature as being at risk for several neurobehavioral disorders, such as major depression (MD), post-traumatic stress disorder (PTSD), and changes in affect, agitation, and aggression (Halbauer et al., 2009; van Reekum, Cohen, and Wong, 2000). PTSD, the other signature injury of OEF/OIF, has been noted to frequently co-occur with mTBI (Jones et al., 2010), a finding not at all surprising when one considers that combat zones are the setting not only for blast attacks but for situations that induce experiences of extreme fear, stress, and vulnerability (Kennedy et al., 2007). The comorbidity of PTSD and mTBI, however, presents several problems in accurate assessment and diagnosis. Jones, Young, and Leppma (2010) present arguments for several of these clinical challenges, including the misattribution of symptoms of mTBI to PTSD and vice versa and the gradual manifestation of symptoms in both conditions that increases the likelihood that one or both will go unrecognized by health professionals.
Major depressive disorder (MDD) or major depression (MD) is another significant neurobehavioral disorder of great concern to scientists and clinicians who work with patients with TBI, particularly because of the increased risk of suicide in patients who have depression (Halbauer et al., 2009) and the impact of MD on psychosocial functioning in the workplace and in interpersonal relationships (Hoge et al., 2008). Physical health outcomes are strongly correlated with PTSD and depression, and the strong and complex interaction between PTSD, depression, mTBI, and PCS suggests that further research is needed on depression and TBI to develop better strategies for primary care and intervention for veterans and soldiers at risk for TBI (Hoge et al., 2008). Like PTSD and many other conditions associated with TBI, the current level of understanding regarding the link between MD and TBI is meager but what is clear is that TBI seems to increase the risk of individuals for developing MD (Matthews et al., 2011; van Reekum et al., 2000). Although it cannot be concluded based on current data that TBI is causally associated with the development of depression, possible mechanisms for such a relationship include the potential damage and shearing of the axons of serotonergic and norepinephrine neurons during TBI, thus disrupting or altering the neurobiology of systems that have been found to be relevant in the development of depression (Halbauer et al., 2009).
The capacity for a TBI to alter personality is supported not only by recent studies (Tate, 2003) but is also found in well-known historical examples, such as the infamous incident of the brain injury of the American railway worker Phineas Gage, who is often described as having been a conscientious and responsible leader pre-injury and an impulsive, aggressive social pariah after a heavy iron rod pierced his skull and destroyed parts of his frontal lobes (Larson and Buss, 2010). The case of Phineas Gage is informative, and personality change is widely accepted as a frequent consequence of TBIs that are on the more severe end of the injury spectrum (Tate, 2003), but the majority of cases of TBI in the military are mild and involve closed head injuries (Defense and Veterans Brain Injury Center, 2011). It is important to realize, however, that there have been reports in civilian literature of personality change in association with milder and closed head injuries (Levin & Kraus, 1994), that penetrating head wounds and severe TBIs do occur in combat, and although these soldiers and veterans might be the minority of TBI cases, the impact a severe TBI can have on such an individual is great and deserves the attention of researchers and clinicians as much as sequelae associated with milder injuries have received. Sergeant First Class (SFC) B from the case illustrations of French and Parkinson (2008), for example, was diagnosed with personality change due to TBI, which manifested as unstable mood and increases in aggression, irritability, and impulsivity after shrapnel penetrated his right frontal lobe. These changes made his ability to resume functioning in a military environment difficult, and despite reporting that he could not imagine himself in any other role besides that of a soldier, (SFC) B was eventually discharged from the military on the grounds of his TBI and related psychiatric changes (French & Parkinson, 2008).
Because a TBI, especially in the context of combat, is also confounded with other factors that can contribute to these neurobehavioral disorders (stress and emotional trauma), it cannot be assumed that a direct causal relationship exists between organic brain damage and behavioral changes. Further research is clearly needed in deciding whether or not TBI can directly cause psychiatric disorders, but if such a relationship does exist, several biological mechanisms are proposed. TBI in general tends to produce diffuse axonal injury as well as discrete damage (Warriner & Velikonja, 2006), and just as neuroanatomical changes in structures involved in cognitive processes alter cognitive functioning, changes in behavior and affect are likely to have neuroanatomical correlates as well. Damage to brain tissues and metabolic changes in response to injury can alter regions of the brain involved in regulation of mood, emotion, and behavior, such as the frontal or temporal lobes (Warriner &Velikonja, 2006; van Reekum et al., 2000).
Although there is still little consensus as to what one can expect in terms of long-term damage, disruptions, and outcomes, there is little doubt that TBI, especially in the context of a combat zone, will change an individual for life. Although understanding the physiological and neurobehavioral aspects of TBI are important, there should also be focus given to the psychosocial factors that contribute to outcomes and quality of life for veterans and soldiers with TBI. Studies of brain injury in the civilian context have revealed several important psychosocial and emotional elements in optimizing quality of life for patients after TBI, including coping styles (Wolters, Stapert, Brands, & Van Heugten, 2010) and spirituality (Matheis, Tulsky, & Matheis, 2006 ; Schultz, Tallman, & Altmaier, 2010).
Studies report that how patients cope with the negative outcomes of their trauma influences the process by which such individuals adapt (Finset & Andersson, 2000). Recent research on patients with brain injury found that coping style was an important factor related to quality of life, that it changed over time in relation to cognitive rehabilitation, and that most patients demonstrated adjustments in their coping styles in a maladaptive direction (Wolters et al., 2010). This particular study found that increases in active problem-focused coping and decreases in passive emotion-focused coping predicted higher quality of life over time, but the participants in the Wolters et al. (2010) study showed the opposite pattern with the passage of time. It has been proposed that this may occur because as rehabilitation continues and time passes, patients embrace the notions that some of the problems caused by their injury will persist, that nothing they can do will solve these issues, and that they will never regain the level of functioning they possessed before the injury (Kendall & Terry, 1996 as cited in Wolters et al., 2010). This theory may be particularly significant for participants with more severe forms of TBI who may experience damage that does not heal and results in persistent symptoms. This research highlights the importance of teaching, encouraging helpful coping strategies, and providing resources that encourage adaptive coping as part of rehabilitation for soldiers and veterans with TBI.
Spinal cord injury patients share many qualities that TBI patients may endure, including functional impairments that are persistent, impair social and occupational functioning, and reduce independence (Matheis et al., 2006). A study investigating how spiritual-based coping relates to quality of life (QOL) after spinal cord injury in 75 participants may be an enlightening source for understanding the role spirituality may play in TBI QOL (Matheis et al., 2006). The main findings of Matheis et al. (2006) seem to indicate that spirituality serves to mediate a more positive outlook and acceptance of life changes that occurred due to the injury, and this could serve as a useful strategy for improving patient outlook and QOL in veterans with TBI who will not experience a full recovery of functioning and must learn to adapt to their change in abilities.
A topic of particular significance for veterans with TBI is suicidality. Brenner, Homaifar, Adler, Wolfman, and Kemp (2009) cited data suggesting that veterans and individuals with TBI are both populations identified as being at increased risk for suicidal behaviors (Kaplan, Huguet, MacFarland, & Newsom , 2007; Simpson & Tate, 2007), and male veterans have been found to be twice as likely as non-veterans to die by suicide (Kaplan et al., 2007). Reports suggested that risk factors for suicide in TBI patients include substance misuse and comorbid emotional and psychiatric disturbances (Teasdale & Engberg, 2005; Simpson & Tate, 2005). Protective factors included social support, a sense of purpose and hopefulness, religiosity or spirituality, and mental health treatment. In terms of social support, the participants of the Brennar et al. (2009) reported that veterans expressed the importance of family, friends, and pets in providing them with emotional support as well as granting them a sense of purpose. The importance of having a job, hobby, or volunteering position that established a sense of purpose was protective against feelings of uselessness; cognitive rehabilitation is even more important when one considers the importance of cognitive functioning involved in the ability of a veteran to secure employment. Religion and spirituality was reported as serving either to aid veterans in finding purpose and meaning or in providing a social network. Veterans reported that psychiatric medication and the relationships with clinicians and hospital staff was protective as a resource to turn to when suicidal thoughts occurred. Considering the possibility of neurobehavioral disturbances in TBI, discussed earlier in this paper, that involve social cognition, personality, and affect, which may adversely affect social networks, veterans with TBIs that result in a pattern of symptoms that will put strains on their ability to utilize protective social resources could be at even higher risk for suicide.
The lack of understanding surrounding military TBIs, and TBI in general, raises the concern that soldiers and veterans who are currently living with TBI (and the deployed warriors in OEF/OIF who are at high risk for TBI) will be harmed by the high possibility that TBI and associated conditions will be overlooked or misdiagnosed and improper and ineffective care may be given. A lack of understanding and awareness of the capacity for combat-related neurotruama to have the potential to be debilitating has already led to barriers in service members seeking care; Jett (2010) argued that the absence of external signs of trauma in most cases of military TBI means that service members may be reluctant to report their possible head injury or to associate their symptoms with blast exposure, and those that do may not have their invisible injury taken seriously. Studies of blast injury have suggested a frequency of missed TBIs in the care of both civilian and military victims (Bochicchio et al., 2008; Tanielian & Jaycox, 2008). It was proposed that this may be due to measures of TBI that lack the necessary sensitivity to detect all possible cases and that initial assessment may miss the injury, as TBI is a dynamic injury process and symptoms may take time to develop (Bochicchio et al., 2008). Because blast- related TBI is often sustained under stressful circumstances, whether it is a hostile attack in the battlefield or criminal bombing in the civilian setting, there is also difficulty in differentiating between symptoms due to blast-related TBI and those due to severe stress and emotional shock (Rosenfeld & Ford, 2010). Unique to the combat environment are the pressures and chaos following blast attacks that may make it difficult for adequate assessment and care to take place immediately post-injury (Jaffee et al., 2009). It is also possible that the individual lacks awareness of their emotional and cognitive disturbances in the wake of TBI, focusing instead on physical symptoms (McCrea et al., 2008).
Because treatment of TBI often includes treatment of emotional and neurobehavioral disorders (Halbauer et al., 2009; Jett, 2010), another barrier to treatment lies in the still lingering stigma among military personnel concerning treatment for mental-health problems (Jett, 2010). A study of TBI in a U.S. Army Brigade Combat Team (Terrio et al., 2009) suggested that, for career soldiers, pressures such as a desire to return to duty or leave the military might impact self-report of symptoms and TBI-related events. These stigmas and challenges in the awareness of the full spectrum of TBI and willingness of soldiers to report mTBI are important to address, not only for accurate assessment in the clinical setting but because the various symptoms that may arise after TBI can affect reaction time and decision making in the combat zone, potentially putting the lives and mission of the individual and her or his comrades at risk (McCrae et al., 2008; Jaffee et al., 2009). Furthermore, the prevalence of blast attacks in OEF/OIF puts any individual on the front lines at risk for multiple blast exposures, and sports concussion literature notes the danger in repeated concussion over a lifetime, with recent studies finding evidence of cognitive impairment and dementia in older athletes who experience mild repetitive TBI (Dekosky, Ikonomovic, & Gandy, 2010).
The association of TBI with cognitive and neurobehavioral impairments that in turn play a role in quality of life, suicide, health and psychosocial functioning as discussed in this paper, and the unfortunate outcomes discussed above that are rooted in an overall lack of coherent knowledge about military TBIs, demonstrate the vital need for research and education on this topic on all levels of analysis—from the intracellular to the social environment of the patient and from injury to outcome. Perspectives from medicine and neuroscience can not only elucidate the physical mechanisms of injury within the brain and therapeutic techniques that can assist at the molecular and cellular level, but such research can also lend credibility to the invisible injury as the public becomes more aware of the very real impact of the entire spectrum of TBIs. The soldiers and veterans who survive to live with TBIs will be even better served if advances in research are also made in disciplines that investigate the psychosocial functioning, mental health, and non-physical factors that can improve rehabilitation and well-being.
Some general suggestions for future direction include improving the research on personality and TBI by making use of the current ongoing deployments of military service members to OEF/OIF. Baseline testing could correct for any errors that likely occur in the use of retrospective self-reports in investigations of personality in TBI. Many personality studies rely on retrospective ratings of personality from patients and those close to patients before TBI in order to assess if changes occur post-TBI (Rush et al., 2006). Perhaps soldiers with no history of head trauma who will be deployed to OEF/OIF with units heading for zones of conflict with a high likelihood of exposure to blast attacks can take a series of tests which include several measures of personality commonly used in TBI research, such as a version of the Eysenck Personality Questionnaire (Rush et al., 2006). The current data on the incidence of blast attacks and TBI cited in this paper suggest that it would be highly probable that a proportion of each of the units being tested will have had some kind of exposure to blast that would make them likely candidates for TBI. Post-injury questionnaires for both suspected and diagnosed TBIs should be compared with the previous measures of pre-injury personality and might add to the body of knowledge on the role of premorbid traits in post-TBI personality and adjustment (Tate, 1998, 2003).
A final suggestion concerns how to optimize the use of available treatments and rehabilitative resources by veterans with TBI. Although there is a need to research and develop drugs, assessments, and therapies for TBI and associated conditions in medicine and neuroscience, the number of soldiers with a TBI will only grow with each passing year. As this review has illustrated, the current system of diagnosis and treatment is riddled with flaws and uncertainty, but it is far better for those with a TBI to utilize their health resources than for any patient to face the symptoms and complications of a TBI alone and without education or support from health professionals. Research should be conducted to learn more about the factors that promote recovery, treatment compliance, and utilization of health resources in order for the military and Veterans Affairs (VA) health systems to create a system of health and education that promotes positive health behaviors. Self-efficacy is a notable factor shown to predict positive changes and maintenance of health behaviors (Strecher, McEvoy, Becker, & Rosenstock, 1986). Older veterans who scored low on self-efficacy had higher odds of pain-related disability (Barry, Guo, Kerns, Duong, & Reid, 2003). What role does self-efficacy play in health behaviors relevant to military TBIs, and how do soldiers and veterans with TBI compare with other soldiers and veterans with non-TBI injuries in self-efficacy? Does TBI result in poorer ratings in self-efficacy due to the nature of its associated sequelae, or is injury in the combat zone sufficient for poorer outcomes in self-efficacy and therefore health behaviors? These suggestions for future direction in TBI research that are specific to the military and combat context are meant to contribute to the multidisciplinary, integrated approach to understanding and treating military TBIs. The ultimate goal of such research is to provide patients, soldiers, health professionals, and the communities to which soldiers will come home with the appropriate knowledge and tools necessary to optimize the rehabilitation process of TBI. Hopefully, such a holistic approach will impact veterans and soldiers in a positive manner, helping to lessen the impact of such a life-changing event on all levels of functioning.
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