Post-traumatic stress disorder (PTSD) has become the most prevalent medical diagnosis of this century and among veterans of past wars, some of whom were originally classified as suffering from shell shock, war neurosis, soldier’s heart, effort syndrome, battle exhaustion, combat fatigue, acute stress disorder – and, unofficially, in the first half of the 20th century, cowardice. As such, it sometimes led to execution during World War I and dishonorable discharge and loss of veteran’s benefits during World War II.
Serious research and the designation of PTSD as a combat injury really began when it was first listed in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DMS-III) (1980), but it has become the subject of a wide range of proposed causes, interactions with other neural functions, and treatments – some contradictory, many controversial.
PTSD and TBI often are linked with each other and with other combat injuries; as such, they are referred to as “polytrauma” – two or more injuries to organs or parts of the body that create potentially life-threatening injuries and/or disruption to physical, mental, and psychological functioning.
Traumatic brain injury (TBI) is considered one of the “signature” injuries of the past 13 years of combat in Southwest Asia, but veterans from previous eras also are now being reviewed for possible TBI as knowledge about it continues to grow. Basically, TBI can be caused by anything from a bump on the head to the severe concussive force of a nearby explosion. According to a Congressional Research Service report on military casualties from the Gulf War, the Department of Defense (DOD) categorizes TBI cases as mild, moderate, severe, or penetrating:
- Mild TBI is characterized by a confused or disoriented state lasting less than 24 hours, loss of consciousness for up to 30 minutes, memory loss lasting less than 24 hours, and structural brain imaging that yields normal results.
- Moderate TBI is characterized by a confused or disoriented state that lasts more than 24 hours, loss of consciousness for more than 30 minutes – but less than 24 hours – memory loss lasting greater than 24 hours but less than seven days, and structural brain imaging yielding normal or abnormal results.
- Severe TBI is characterized by a confused or disoriented state that lasts more than 24 hours, loss of consciousness for more than 24 hours, memory loss for more than seven days, and structural brain imaging yielding normal or abnormal results.
- Penetrating TBI is one in which the dura mater – the outer layer of the system of membranes enveloping the central nervous system – is penetrated; penetrating injuries can be caused by high-velocity projectiles or objects of lower velocity, such as knives or bone fragments from a skull fracture that are driven into the brain.
PTSD and TBI often are linked with each other and with other combat injuries; as such, they are referred to as “polytrauma” – two or more injuries to organs or parts of the body that create potentially life-threatening injuries and/or disruption to physical, mental, and psychological functioning. According to a 2013 report published by the National Institutes of Health (NIH):
“Prior studies have identified TBI, PTSD and pain to be the major comorbid [one or more disorders or diseases co-occurring with a primary disease or disorder] elements most frequently seen in those previously deployed to Iraq and Afghanistan who return with polytrauma. This constellation of comorbidities has been referred to as the ‘polytrauma triad.’ Investigators have noted that among [service members] treated at an in-patient polytrauma rehabilitation unit within the VA [Department of Veterans Affairs], 80-to-93 percent were diagnosed with TBI, 81-to-96 percent with pain, and 44-to-52.6 percent with a mental health disorder.
“Those with deployment-related difficulties from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND – U.S. military operations in Iraq after September 2010) receiving care in VA outpatient polytrauma programs were diagnosed with three or more post-concussive (TBI) symptoms 67-to-97 percent of the time, complained of persistent pain issues 82-to-97 percent of the time and were diagnosed with PTSD 68-to-71 percent of the time.”