Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Returning Iraq and Afghanistan War Veterans: Implications for Assessment and Diagnosis

Article excerpt

Mild traumatic brain injury (MTBI) is a physical injury to the brain caused by blows or jolts to the head. It is a common battlefield injury for U.S. service members involved in the Iraq and Afghanistan wars, with as much as 20% of soldiers having had an MTBI (Traumatic Brain Injury [TBI] Task Force, 2008). The number of veterans with this injury will increase as the wars continue, and because soldiers have families, the ripple effect will be monumental as health care professionals struggle to provide medical and mental health care along with other types of support (Keltner & Cooke, 2007).

Posttraumatic stress disorder (PTSD) frequently co-occurs with MTBI in combat soldiers returning from Iraq and Afghanistan, so much so that together they have been referred to as "signature injuries" (Department of Defense [DOD] Task Force on Mental Health, 2007, p. ES-1) of the current conflict. As such, in 2007, the President's Commission on Care for America's Returning Wounded Soldiers strongly recommended that the DOD and the Department of Veterans Affairs rapidly improve prevention, diagnosis, and treatment of both PTSD and MTBI. In the meantime, military personnel's problems related to MTBI and PTSD often go undetected while they are in the service (Colarusso, 2007; Levin, 2007); thus, combat veterans will seek care at nonmilitary settings (e.g., community mental health centers, family medical practices, substance abuse treatment facilities) weeks or months after the original primary injury. Few civilian mental health professionals have graduate training or experience with MTBI (Lung, 2007) or can differentiate MTBI from PTSD. A review of the major counseling journals (i.e., Journal of Counseling & Development, Journal of Mental Health Counseling, Counselor Education and Supervision, Journal of Addictions and Offender Counseling, and Rehabilitation Counseling Journal) from 1994 to present revealed that only five articles existed on TBI and none existed regarding co-occurring PTSD and MTBI.

The purpose of this article is to provide information to professional counselors about MTBI and PTSD in returning combat soldiers. The article (a) defines MTBI and its resulting symptoms, (b) describes PTSD and MTBI in combat soldiers, and (c) provides implications for assessment and diagnosis.


MTBI--often described as "shell shock" or "getting your bell rung"--is the most common type of TBI, making up 75% of all brain injuries (Centers for Disease Control and Prevention [CDC], 2003). The primary criterion of all TBIs, regardless of severity, is trauma preceding injury (Petchprapai & Winkelman, 2007). Brain injuries may be "open," involving penetration of the brain, or "closed," without a penetrating wound. MTBI is more frequently caused by closed head wounds and is considered the least serious form of TBI (CDC, 2003).

The majority of MTBIs acquired during combat in the current wars are closed brain injuries caused by exposure to a blast from improvised explosive devices, the makeshift bombs insurgents frequently use to attack U.S. forces (Okie, 2005; Warden, 2006). Damage to the brain can occur from the impact of the blast waves themselves, the force of an object from the blast, or the impact of the brain striking the inner walls of the skull. In previous wars, soldiers were less likely to survive blast injuries; however, in the current conflicts, advances in body armor have resulted in more soldiers surviving injuries from explosions and blasts (Okie, 2005; Warden, 2006). Kevlar helmets, specifically, have reduced the frequency of penetrating head injuries; however, the helmets and armor cannot completely protect the face, head, and neck, nor do they prevent closed brain injuries often produced by blasts (Lew, Poole, Alvarez, & Moore, 2005). Thus, although advanced body armor has led to a reduction in the mortality of soldiers, it has resulted in increased closed brain injuries and MTBIs. …


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