Due to the increasing efficacy of protective equipment (e.g., Kevlar body armor and helmets), an increasing number of service members are surviving combat-related injuries (Taber & Hurley, 2010). However, these survivors often have other injuries that would have resulted in death in previous theaters (Owens et al, 2008). The most visible of these injuries are the loss of limbs (though the increasing sophistication of prosthetics has made these injuries difficult to discern). Conversely, several combat veterans sustain a Traumatic Brain Injury (TBI): what is often referred to as the “signature wound” of OIF/OEF.
Estimated percentages of OIF/OEF veterans diagnosed with TBI vary widely. Furthermore, these estimates do not account for veterans that were never formally evaluated, or who had the effects of a concussion that did not raise to the threshold of a TBI. However, study of a Brigade Combat Team found that 22.8% of the soldiers returning from Iraq were identified as having sustained a TBI, and 7.5% of those soldiers continued to experience three or more TBI symptoms following deployment (Terrio et al, 2009).
Veterans with TBI often have associated psychological difficulties that bring them in for therapy. Alternatively, the effects of TBI can impact relationships, leading the veteran’s partner to seek therapy either individually or through family therapy. For these reasons it is beneficial for marital and family therapists to have a rudimentary understanding of the causes and manifestations of TBI, and how it affects both individuals and families.
Service members deployed to combat theaters experience several events that contribute to TBI, primarily from various types of explosions (Owens et al, 2008; Taber & Hurley, 2010). The frequency of these explosions can range up to several times per week. Service members on patrol can experience the impact of an Improvised Explosive Device (IED) exploding near their convoy. Artillery shells can detonate in close proximity to a service member. Rocket propelled grenades (RPGs) can hit a service member’s vehicle. One study found the most common cause of TBI was IED explosions, accounting for slightly over half of all TBI (Galarneau et al, 2008). Although service members wear protective headgear, the shock alone from one of these explosions can cause a concussion. Moreover, a nearby explosion can knock a service member to the ground or into a wall, impacting the head and insulting the brain. Although most of these incidents are more likely to result in a concussion, the accumulation of concussions or a significant impact can result in a TBI.
A service member is considered to have a TBI when there is a significant external force disrupting the brain’s functioning. The blast from an explosion creates a sudden increase in air pressure that is immediately followed by a sudden decrease in air pressure, resulting in intense wind that can damage the brain (Okie, 2005). The blast wave or projectiles from an explosion can similarly damage the brain (Jackson, Hamilton, & Tupler, 2008). The disruption in brain functioning can be evidenced through a loss of or alteration in consciousness, skull fracture, loss of memory, neurological deficits, or an intracranial lesion (Galarneau et al, 2008; Taber & Hurley, 2010).
Impact of a TBI
The impact that a TBI has on a veteran can vary depending on the location of the impact, the severity of the impact, as well as the age and general health of the individual (Galarneau et al, 2008). Even mild Traumatic Brain Injury can lead to several neurological symptoms.
Traumatic Brain Injuries are most understandably associated with cognitive symptoms. Typical among these symptoms are difficulty with attention and concentration, which could cause the veteran to appear to “space out” or appear “not there.” This is associated with difficulty with short-term memory and working memory resulting in the veteran frequently forgetting things and having difficulty performing mental manipulations of information. The veteran with a TBI could also experience difficulty with judgment and planning, leading to difficulty organizing his or her day or implementing the most efficient way of organizing tasks.
Veterans with a TBI are also noted to experience several somatic symptoms. These symptoms include dizziness or sensitivity to light and noise, which can cause the veteran to want to sit down or not want to go certain places. Frequent or chronic headaches are also common with TBI. Additionally, TBI can contribute to insomnia and fatigue that might affect the veteran’s motivation and energy levels.
Perhaps the more difficult symptoms associated with a TBI to fully appreciate are the emotional symptoms. Most notably, TBI can be associated with irritability and difficulty with impulse control that can lead the veteran to become easily angered and aggressive toward others. Anxiety is also seen in TBI, contributing to a veteran to not wanting to go to certain public areas.
Although research has shown that irritability and memory difficulty were found to be the most persistent symptoms over time (Terrio et al, 2009), any of these symptoms could cause distress in the veteran’s family or marital dynamics.
How to help
If there is concern that the veteran sustained a TBI it is important for the veteran to be formally assessed. Such an assessment could not only determine the presence and severity of a TBI, but can also provide treatment recommendations specific to the individual veteran. Providing the veteran and family members with information related to TBI will help normalize the veteran’s behaviors, and provide some understanding for the cause of the behaviors. It is also important to empathize with both the veteran and family members over the frustration from the veteran’s diminished cognitive abilities, and resultant change in self-identify. The veteran could also be encouraged to get in contact with agencies, such as the VFW of the American Legion, that might have support groups.
Carlo A. Giacomoni, PsyD, ABPP specializes forensic evaluations, and has a particular interest in working with combat veterans.
Galarneau, M. R., Woodruff, S. I., Dye, J. L., Mohrle, C. R., & Wade, A. L. (2008). Traumatic brain injury during Operation Iraqi Freedom: Findings from the United States Navy-Marine Corps Combat Trauma Registry. Journal of Neurosurgery, 108, 950-957.
Jackson, G. L., Hamilton, N. S, & Tupler, L. A. (2008). Detecting traumatic brain injury among veterans of operations enduring and Iraqi freedom. North Carolina Medical Journal, 69, 43-47.
Okie, S. (2005). Traumatic brain injury in the war zone. New England Journal of Medicine, 352, 2043-2047.
Owens, B. D., Kragh, J. F., Wenke, J. C., Macaitis, J., Wade, C. E., & Holcomb, J. B. (2008). Combat Wounds in Operation Iraqi Freedom and Operation Enduring Freedom. Journal of Trauma, 64, 295-299
Taber, K. H., Hurley, R. A. (2010). OEF/OIF deployment-related traumatic brain injury. PTSD Research Quarterly, 21(1), 1-7
Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K., et al. (2009). Traumatic brain injury screening: Preliminary findings in a US Army brigade combat team. Journal of Head Trauma Rehabilitation, 24, 14-23.