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Traumatic Brain Injury: Signature Wound, Silent Epidemic in Returning Military

July 6, 2010

I have been working with Mark, an Army officer who has been diagnosed with posttraumatic stress disorder [PTSD], for almost six months now. In addition to medical intervention including medications for anxiety, Mark has been making good progress through a combination of somatic therapy, art therapy, mindfulness approaches, and stress reduction. However, Mark continued to have problems with language and cognition; in contrast, his ability to recognize the onset of stress reactions and reduce hyperarousal steadily improved. My concern led Mark and I to sit down with his doctor at our local clinic and revisit his symptoms and injuries sustained from his tour of duty in Iraq. After a number of tests, his doctor concluded that Mark had an undiagnosed mild traumatic brain injury [TBI], possibly due from a jolt to his head as a result of a bomb blast a week before his return to the US. In fact, Mark did not recall an injury since he had no visible head injury and only recently remembered that there he had been a block away from the bomb blast that likely caused some post-traumatic amnesia and a mild TBI.

We are now adjusting Mark’s psychosocial program to address TBI, in addition to PTSD and anxiety. For Mark, just having been identified has relieved the stress of his symptoms and his treatment can be redirected to focus on returning his cognitive functions to normalcy through rehabilitative efforts, including art therapy, occupational therapy, and other methods. Fortunately, much of the sensory intervention involved in treating his PTSD and anxiety issues were helpful in addressing TBI. Mark is lucky in that he is already in recovery from his TBI and is expected to have no long-term affects from his head injury;

As trauma specialists and mental health professionals, we generally focus on psychological symptoms our clients present and particularly stress reactions and posttraumatic stress in particular. However, when working with survivors of traumatic events who may have been exposed to head injuries, I learned from Mark that I have to take a broader perspective on what may be causing distressful reactions and lack of progress. We now know that returning military are not only susceptible to PTSD, but also TBI, a condition that often goes undiagnosed for days, weeks, or months.

A TBI is most often defined as a blow or shock to the head or a penetrating head injury that disrupts the function of the brain. TBI has been named one of war’s “signature wounds;” it can be caused by shock waves from bombs, a hit to the head, or a jolt that affects the brain. There may be no visible scars, but lasting cognitive and physical harm may be extensive. In contrast to a missing limb or spinal injury, TBIs are not visible, but still of great concern in the overall treatment of trauma to mind and body. Here are some facts about TBI:

  • Not all blows to the head result in a TBI;
  • Concussions are a type of TBI and are also known as closed head injuries.
  • TBIs can be mild, moderate, or severe, depending on the impact on consciousness and duration of amnesia or other symptoms, post-trauma;
  • TBI symptoms may occur immediately after an event or may appear days or weeks after an injury;
  • TBIs may affect thinking, sensing, motor skills, and emotions; their psychosocial impact can appear similar to emotional disorders such as PTSD;
  • In military, blast injuries are a significant cause of TBIs.

Hundreds of thousands of service members are believed to have suffered TBIs during their service in Afghanistan and Iraq, and many go undiagnosed, suffering the “invisible wounds” of war without explanation. The military is currently addressing TBI and the Pentagon recently opened a new 72,000 square foot facility for TBI research. The intent is to keep a comprehensive database that will follow US troops from the war zone through post-deployment, recording all personnel who are exposed to bomb blasts or similar trauma. Ideally, these individuals will be continuously monitored for developing symptoms weeks and months after exposure to injury.

As with PTSD, returning military with TBIs may have personality changes that impact family members, including their children. Imagine the stress a spouse and children experience when a husband, wife, “daddy” or “mommy” comes home with invisible scars that have altered behavior and interpersonal actions. According to my client Mark, his family might have been able adapt to broken leg or back injury more easily than to his personality changes. He feels fortunate that he and his family are getting the help they need in terms of his TBI and posttraumatic stress; he believes that his children are doing better than others under similar circumstances because they are receiving support and counseling at their schools and that he has benefited from medical and psychosocial care.

Finally, while the focus of this article is on TBI in returning military, let’s not forget that we may see undiagnosed brain injury in anyone, including children. Child and adolescent athletes often sustain a blow to the head, but may not be evaluated for TBI; meanwhile, these youngsters may show signs of cognitive and emotional problems for days and weeks after an incident. Their symptoms, too, may be identified as psychological when, in fact, an undiagnosed head injury is the main cause of behavioral changes and cognitive challenges.

There are a large number of great websites on the topic of TBI and the military; here is a short list of resources to get you started:

Traumatic Brain Injury in Theater: When Blasts Damage the Brain. This website provides a visual overview of various head injuries sustained in battle.

National Public Radio on Traumatic Brain Injury. Listen to an interesting podcast and read extensive coverage of TBI in returning military.

In Their Boots: A Documentary on Soldiers with Traumatic Brain Injury. Watch first person film accounts highlighting the challenges of TBI.

Making Art After Trauma. Listen to a short podcast, see a slide shows, and read about art and art therapy in the recovery process of Bret Hart, with commentary from Dr. Kathleen Bell.

Be well,

Cathy Malchiodi, PhD, LPAT, LPCC

And remember on July 13th, 2010, National Institute for Trauma and Loss in Children will welcome military personnel and their families to the Annual TLC Practitioners’ Assembly at Macomb ISD Education Center, Clinton Township, Michigan. For more information, click here. We hope to see you there!

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Become a Fan of the National Institute for Trauma and Loss in Children– join our Facebook Fan Page today!

3 Comments leave one →
  1. Lisa Burns, PhD permalink
    July 7, 2010 3:51 am


    I found this article interesting and informative, thanks! I have been working for about four months with a young woman recovering from past sexual trauma and recent meth addiction and domestic abuse, the latter involving routine battering, especially about the head. It was very difficult to tell whether her symptoms of cognitive fuzziness , irritability, and lack of focus were due to the drug withdrawal or to the (probably repeated) head injuries. She actually developed head tremors as well for a period of time in early treatment, and her physician was hard pressed to say whether it was temporary nerve damage from the toxins in her body or a result of her physical abuse. I can report that she is doing extremely well now with few physical symptoms, no tremors and is regaining her spirit and independence from all the harmful things she once sought refuge in. Art therapy was truly valuable in identifying the state of her self image and moving her toward healing.

  2. October 19, 2010 12:23 am

    Great article! It’s always very heartening when folks in healthcare recognize and respond to TBI as part of the overall picture of recovery. Thanks very much for writing about this and raising awareness.

    It’s very important.

    Be well


  3. Vicky Marimuther permalink
    April 19, 2011 10:25 pm

    Dear Cathy,

    I found this article informative as it portrays what Mark, the army officer had to deal with as well as the rehab and the help given. I am doing my PhD on mild traumatic brain injury amongst British service personnel returning from Iraq and Afghanistan. One of the studies explores public understanding of mild traumamtic brain injury amongst service personnel. I am about to send posters requesting participation for this study and was wondering if I could get permission from you to use the image of the brain and solder that you have in the article. Please let me know if it would be permissible to use the image.


    Best wishes,

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