By Noëlle Bernard
In early March, Staff Sergeant Robert Bales was accused of committing the most heinous U.S. war crimes in the deacde-long Afghanistan war. Bales was charged with 17 counts of murder for killing 17 civilians in the Kandahar Province located in southern Afghanistan. Currently, speculations are circulating regarding Staff Sgt. Bales’ sanity. Many critics are blaming the rampage on an undiagnosed case of post-traumatic stress disorder (PTSD) or a side effect of traumatic brain injury (TBI). At this time, Bales’ full diagnosis is under investigation, but a general understanding of PTSD and TBI is warranted.
Both medical conditions affect the U.S. military at high frequencies. From 2000 to 2011, traumatic brain injury has affected roughly 230,000 military personnel, according to the Department of Defense. Likewise, 10 to 18 percent of Iraq and Afghanistan war veterans are likely to have post-traumatic stress disorder, according to the Department of Veterans Affairs.
PTSD is a psychological condition that occurs after an individual is indirectly or directly exposed to a traumatic event, such as war, assault or a disaster, according the American Psychiatric Association’s DSM-IV. Following a trauma it is normal to experience levels of stress, but once the stress-induced symptomatic distress and functional impairment starts disrupting daily life, the possibility that this is due to PTSD needs to be considered, said Dr. Matthew Friedman, executive director of the National Center for PTSD.
“If you can’t shake [a trauma] off in one way or another or if it really gets in the way of your capacity to function, to have loving relationships, and to have a fulfilling life, then we’re starting to get in the clinical realm and possibly, a psychiatric diagnosis,” Friedman said.
According to Friedman, one of the major misconceptions surrounding PTSD is that it affects anyone exposed to a trauma.
“Although over half of Americans have been exposed to a traumatic event, less than 10 percent develop PTSD,” Friedman said. “So it’s a minority that develops PTSD.”
An individual cannot be diagnosed with the condition until a month has elapsed following the trauma. This is due to “the fact that most people are resilient and able to cope with the psychological aftermath of trauma,” said Friedman.
“We humans are able to absorb a great deal of emotional shock and most people can regroup in a month’s time,” Friedman said. “That doesn’t mean that all their symptoms are going to disappear but that they no longer will exceed a clinical threshold.”
Another misconception about PTSD is that the condition is untreatable. According to Friedman, there are powerful psychotherapy treatments and effective medications available for PTSD patients. Individuals suffering from PTSD may experience flashbacks, nightmares, anger, restlessness and other symptoms associated with the four major symptoms: re-experiencing the event, avoiding thoughts of the event, emotional numbing and feeling hyper-alert.
Moreover, research has shown indications of a connection between the symptoms of PTSD and TBI. When a traumatic brain injury occurs the brain is more susceptible to anxiety disorders such as PTSD, said Dr. David Cifu, national director for physical medicine and rehabilitation programming in the Department of Veterans Affairs.
“The brain is very sensitized—the deeper limbic structures of the brain, specifically the amygdala and the hippocampus, are the main areas,” Cifu said. “These limbic structures are often damaged in a brain injury and when they’re damaged the perception of an event like trauma can be amplified.”
According to the Veteran: 2000 Census Brief, there is a population of nearly 27 million veterans. More than 230,000 service members have been diagnosed with brain injuries since 2000, many as a result of the Afghanistan and Iraq Wars. Based on recently published VA research, nearly 90 percent of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans with TBI have also been diagnosed with a mental health condition, with PTSD being the most common, said Cifu.
A TBI is the same as a concussion and may vary in severity. There are three classifications of brain injury severity: severe, moderate and mild. In the military community and civilian population, the most prevalent brain injuries are classified as mild traumatic brain injuries (mTBI), according to the National Center for PTSD. The most common symptoms of mTBI are dizziness, insomnia, impaired memory and lower sensitivity to light and sound.
“If unconscious for more than 30 minutes and up to six hours it’s called moderate, and more than 6-24 [hours] is severe,” Cifu said. “But over 90 to 95 percent of war injuries are mild traumatic brain injuries where there’s a very brief loss or alteration of consciousness.”
Just like PTSD, there are several misconceptions surrounding TBI. According to Cifu there are two main misconceptions that confuse the general public. A false assumption is that TBI worsens over time.
“A brain injury is an event that occurs at a specific time,” Cifu said. “It occurred when the blast exploded or the Humvee was jolted or crashed. We do not expect any worsening or new problems to occur after the first 48 to 72 hours of care. Most often, we see rapid recovery over the next weeks to months to a point where the vast majority of people who have a brain injury can return to totally normal lives.”
The second major assumption stems from Hollywood’s portrayal of brain injuries, which are usually incorrect.
“They’re going to have difficulty remembering something they were just told at first but over time that’s going to get better,” Cifu said. “Even the people with the most severe injuries will recover to the point that they have long-term memories intact.”
Over the course of the wars in Iraq and Afghanistan there has been an increase in TBIs. Some reasons are due to technological advances in weaponry, such as HMMWVs (Humvees) built to withstand IED blasts and the quality of body armor and helmets, which have allowed more servicemen to return to the battlefield than during past wars.
“The survivability for these conflicts is markedly increased over prior wars, to about 95 percent of injuries,” Cifu said. “It does allow service members to return to the battlefield and potentially get reinjured. High TBI rates are due to the enhanced use of IEDs and the need for service members to be deployed on foot in rugged terrain. War is a dangerous activity and the enemy is getting better and better at hurting troops.”
Consequently, the Army experiences 67 percent of PTSD cases, the Air Force has nine percent, the Navy 11 percent, and the Marines have 13 percent, according to the U.S. Army Office of the Surgeon General. Those percentages are proportionate to the size of each branch. But U.S. Marine Corps proportionately experiences the most cases of PTSD and TBI cases due to the nature of their missions, said Cifu.
Meanwhile, the Department of Veterans Affairs faces several challenges in regards to ensuring all veterans and active duty servicemen receive the necessary diagnosis. In the military community there is a stigma associated with individuals being treated for a mental health condition, said Friedman.
“In the military culture I think this gets magnified because you’re now seen as not having the right stuff,” Friedman said. “[They might say], ‘People in my unit won’t think as much of me, my commanding officer won’t trust me as much, it might get in the way of my chances for promotion if I want to have a career in the military.’”
Likewise, there is a crisis of underreporting of TBI by returning and active troops.
“Unfortunately 45 percent of the of the service members who leave the service don’t even come to The VA [The Department of Veterans Affairs] for care so we haven’t screened them,” Cifu said. “The bad news is that it can be a challenge if the person never tells you they had a problem or if you as a clinician have never seen it.”
To combat these issues, the Department of Veterans Affairs and the military have improved its methods for early detections, on-site evaluations and recuperation, and the transference of mental health to primary care.
“Every person who comes into the VA for the first time and for five years in [the service] is screened automatically for PTSD, depression, substance use disorder, and traumatic brain injury,” Friedman said. “At the front door we’re trying to identify people who are at risk.”
Moreover, the Department of Veterans Affairs is trying to reach out to the younger generation of veterans and active soldiers by utilizing social media, such as Facebook and Twitter.
As with any other medical condition, not all PTSD or TBI cases are curable, but lifelong care is promised for patients and families.
My job is to take care of people with brain injuries for the rest of their lives,” Cifu said. “The VA has taken it from a process where you know you were lucky if you got diagnosed, to the point now where there’s a comprehensive system in place that you can be plugged into. If you’re not back to normal, there are people here to help care for you, help you get a job, and help your family.”