Review: Managing Posttraumatic Stress Disorder in Combat Veterans with Comorbid Traumatic Brain Injury

Article excerpt

INTRODUCTION

The improvised explosive device (IED) is one of the most commonly encountered weapons in Operations Iraqi Freedom and Enduring Freedom (OIF/OEF), and its battlefield use creates serious risk for physical injury or death [1-3]. The IED threat, together with blunt trauma head injury mechanisms, has altered recent approaches to combat veteran ** mental health care by highlighting the topic of traumatic brain injury (TBI), and in particular mild TBI (mTBI). For the mental health clinician, the IED threat is another wartime event that can lead to posttraumatic stress disorder (PTSD), and proper management of the veteran population exposed to IEDs requires the clinician to consider both psychiatric disorders and the possibility of a comorbid mTBI.

Casualties from explosions are a significant cause of morbidity among OIF/OEF veterans. IEDs and explosions from other ordnance accounted for nearly 80 percent of all casualties reported to a military trauma registry from October 2001 through January 2005 [4], and relative to previous military actions, casualties from Afghanistan and Iraq received proportionally more face, head, and neck injuries [2]. There are no direct comparisons of TBI prevalence across military conflicts in the 20th century. As a proxy for relative risk for TBI across different military conflicts, Owens et al. studied the anatomic location of combat wounds in World War II, the conflicts in Korea and Vietnam, and OIF/OEF [4]. They found a statistically significant difference, because 30 percent of OIF/OEF combat wounds involved the head and neck compared with 16 percent in the Vietnam war and 21 percent in both the Korean war and World War II.

As in prior military conflicts, improved combat medical care leads to an increased need for postwar rehabilitation of injuries. Among veterans of the present conflicts, the incidence of TBI is higher than it was in prior conflicts, perhaps because of blast injuries. The Department of Defense (DOD) and Department of Veterans Affairs (VA) mental health communities face a difficult clinical challenge in the diagnosis and management of psychiatric sequelae of war when the veteran was exposed to explosions: determining whether the presenting symptoms are best explained by PTSD or another psychiatric diagnosis, residual symptoms of mTBI, or both a psychiatric diagnosis and mTBI. This article addresses the diagnosis and treatment of PTSD among combat veterans with a particular focus on comorbid mTBI and the most recent version of the VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress [5].

The military and VA healthcare systems are familiar with the high prevalence rate of PTSD among combat veterans. Among OIF/OEF veterans who sought treatment at a VA healthcare facility, the PTSD prevalence is 13 to 21 percent [6-7]. The range of wartime traumatic events that can lead to PTSD must now include the dangers posed by exploding IEDs. To the practicing mental health clinician, it should be clear how an exploding IED could cause PTSD, but the patient's symptoms could also be caused by mTBI. Cognitive complaints can accompany the clinical presentation of PTSD, typically a subjective decline in short-term memory that can result from diminished concentration. However, if a comorbid TBI is present, memory could be affected directly. Two reports suggest blast-related TBI as a risk factor for memory impairments [8-9], although another study of combat veterans with blast-related mTBI found no memory changes compared with a control group [10]. However, mTBI from blunt trauma is not known to adversely affect memory, but moderate to severe TBI from blunt trauma can cause memory impairments [11-12].

The possible presence of mTBI in the combat veteran causes additional diagnostic and management complications. TBI is associated with neuropsychiatric sequelae such as depression, mania, or psychosis [13]; substance use disorders [14]; and medical problems including sleep disorders [15-16], chronic pain [17], and endocrine deficiencies [18-19]. …