September 12, 2012 Blog The Invisible Yet Overshadowing Effects of Posttraumatic Stress

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Jack Tsai, PhD

VA New England Mental Illness Research, Education, and Clinical Center and Yale University School of Medicine, West Haven, Connecticut


Combat-related concussion, or what is more commonly termed mild traumatic brain injury (mTBI), has become a hot topic of widespread concern in both research and clinical settings. Among soldiers who have returned from conflicts in Iraq and Afghanistan, mTBI has become a “signature” injury.

But, of course, mTBI isn’t the only problem that soldiers serving in Iraq and Afghanistan have returned with. There are other “invisible wounds of war,” as Tanielian and Jaycox called them, the most common being posttraumatic stress disorder (PTSD).

The concordance of mTBI and PTSD is high. If you are injured during combat, it is likely that the event was psychologically traumatic in some way. In fact, the diagnosis of PTSD requires that the person experienced some risk of death or serious injury to self or others, or some event that involved intense fear, horror, or helplessness.

What is important to recognize is that symptoms of PTSD and mTBI can be remarkably similar. Thus, we see not only a great likelihood of them co-occurring but also a great overlap in their clinical presentations. What my colleagues and I found in our study, and others have found in a few previous studies, is that PTSD symptoms, not mTBI symptoms, largely explain the decreased health-related quality of life of veterans who served in Iraq and Afghanistan. Thus, presumably, a focus on treatment of PTSD instead of mTBI may improve the health and quality of life of these veterans.

The Department of Veterans Affairs has dramatically ramped up efforts to provide PTSD treatment and engage veterans who need treatment. However, stigma remains a significant barrier for veterans who need PTSD treatment. So, there may be a bit of a dilemma here. Whereas mTBI may be viewed by veterans as a physical condition that is more acceptable (ie, less stigmatized) to seek treatment for, research shows that their PTSD symptoms are often what is actually negatively affecting their quality of life. Perhaps providing integrated treatment of mTBI and PTSD would be both acceptable and helpful to veterans.

I don’t mean to downplay the potentially debilitating effects of mTBI, which is associated with various physical, cognitive, and emotional impairments and certainly deserves clinical attention and treatment. But, instead, I wanted to point out that PTSD symptoms often co-occur with mTBI and that PTSD symptoms can be more impairing to health-related quality of life than mTBI symptoms among those who have both. The treatment of mTBI should not be overshadowed by the effects of untreated PTSD.

Financial disclosure:Dr Tsai had no relevant personal financial relationships to report.​

Category: PTSD , Veteran
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11 thoughts on “ Blog The Invisible Yet Overshadowing Effects of Posttraumatic Stress

  1. We had a very effective psychiatric MASH in the Korean War. GIs who showed signs went there post haste and got the treatment needed. The same early diagnosis and treatment are needed, Waiting to the end of the tour allows depression to supervene and that is permanent.
  2. My name is Dr. Eliahu Halpern. I am an M.D., Psychiatrist. I am a department chief in a Psychiatric Hospital. I have served in the Israeli army thru several wars, including on battlefields and I have been treating PTSD victims, both army vets and civilians. I myself have suffered from some symptoms (intrusions and hyperarousal) for some years and dealt with them by becoming an workoholic. I usually nudge the afflicted to occupy themselves and to talk about the symptoms instead of acting them out. Alas, I believe the social stigma will always prevail over common sense, and I am pessimistic about changing that. One problem is that the patients live in a private hell that affects, sometimes severely, their entourage.

  3. WFSM is using High-resolution, Relational, Resonance-based Electroencephalic Mirroring (HIRREMâ„¢) as an intervention for brain energy imbalances. In their open label clinical trial, 13 subjects were treated with PTSD (and some TBI as well) with extremely encouraging results. Doctor Charles Tegeler, Neurologist, is Principal Investigator.
  4. After working for two years and 300 transports on the Stanford Life Flight helicopter I developed symptoms similar to combat veterans PTSD in severity. Ironically, I served as the attending physician in charge of the Persian Gulf, Agent Orange, Ionizing Radiation Registry for the Palo Alto Veterans Administation Health Care System and was active during the 30 year anniversary of the Viet Nam Tet Offensive. It has become cliche to call PTSD an “invisible” disorder. It is not! Patients with severe PTSD have disturbances in affect and autonomic hyperarousal that make them easy to spot to any expert. Symptoms of autonomic hyperarousal like hypervigilance, psychomotor agitation and intermittent explosive disorder are not subtle. I was afflicted with night terrors and ballistic outbursts that were seizure like and frightening to people around me. Many of these symptoms can be controlled by relatively low doses of beta blockers and do not require the use of sedative hypnotics.
  5. I am a retired family physician and volunteer for wounded warrior sports programs. As in my practice, I am concerned about the veterans who do NOT participate in the many recreational activities offered. I am quite sure that PTSD and mTBI contibute to much of the limitation of social activities in OIF-OEF veterans. The most that PCPs can offer to veterans with these conditions is to refer them either to an already overtaxed VA or MHS behaviioral health faciity or to TriCare participating mental health professionals in the civilian community. I can prescribe BB, prazosin, SSRIs, but I am concerned that I am at best putting a band-aid on an infected wound. I have nothing to offer someone with mTBI except Tylenol and a referral. I think somatic therapies for both of these conditions should be a high priority. Right now the only thing I have to offer is accupuncture and VA does not pay for that with TriCare.
  6. my wife and her mother are both survivors of war and torture and both suffer from PTSD. Being Asian may or maynot have anything to do with their tx but they tried everything on both of them , beta blockers, ssri’s, atypical antipsychotics and they both had severe reactions to them all. The irony is that when they were put on benzos my mother in law only responded to diazepam 2mg q/id and my wife had a CNS reaction to that and developed ulcers and was subsequently placed on Librax which worked for her. Sometimes when the condition is permanent the tx must be also. I have noted when explaining to my patients that this disorder is like being an insulin dependent diabetic, and we don’t call them addicts. So don’t rule out benzodiazipines as most do just because of the possible addiction when the benefit of a better life may await them.
  7. One problem I have noticed over the years is that military members are relunctant to share their experiences. When they finally agree to do so, they begin to share with someone not experienced enough or who claims “is out of their scope”. It’s hard enough to start to tell your “story” once, but to feel forced to tell it again to someone else (maybe even more times) becomes more and more unlikely. Like Bert indicated, we have to seize the opportunity to treat these individuals effectively the first time we meet them and not try to pass them off to someone else.
  8. I am familiar with the excellent and often ground-breaking work at the West Haven VA, having worked with the VAs’ home care and hospice program while I was Clinical Manager of the Branford (New Haven area) home care office of the CT Hospice. You and your colleagues are to be commended. However, I must agree that interventions post-tours in our several war zones are too late, therefore must play a potentially lethal game of catch-up. I am of the Vietnam War generation and saw two friends die by their hand(s) after “coming home.” One hung himself in the shower room IN the LA area’s dedicated psychiatric hospital. I further agree that PTSD and mTBI are not “invisible injuries.” I am aware of innovative re-entry programs in the Boston area, I believe. Waiting for “bad behaviors” to surface is cruel, and hardly what our heroes deserve.
  9. Thank you all for your comments. I agree that greater efforts to intervene immediately after trauma would be useful. There is also work being done to investigate how to prevent the negative effects of trauma through fostering resilience, i.e., preparing soldiers for trauma before they experience it. One of the difficulties with providing interventions immediately after trauma is that there can be a delayed response. PTSD symptoms may not occur until months after the trauma, and the effects of mTBI are not really known until months after the trauma as well (i.e., the persistent postconcussive symptoms). Certainly, more work needs to be done examining ways to accurately predict who will be more likely to experience problems after trauma so that these individuals can be targeted for early intervention.

    Labeling PTSD and mTBI as “invisible injuries”, although technically untrue, was a way to bring attention to what was a relatively unaddressed problem.

  10. Freud solved the problem of PTSD by inventing the Oedipus Complex turning the blame on the patient rather than counter transfer.
    the problem GIs face is not going to be solved any time soon by changes in policy. women and men who’ve been raped and victims of car crashes all get the same “get over it” and “you should have been more careful.” and for exactly the same reason why Freud turned to mythology. BTW Claude Levi Strauss does a nice analysis of Oedipus which includes Freud’s as one variant of the myth. it relates to survivor guilt if i recall.
    BUT one of freud’s victims became one of Europe’s leading women’s rights activists early in the 20th century by rejecting his analysis as the psychobabble it was and found empowerment in activism.
    there really is no other cure of PTSD than turning the lemons into lemonade and staring a profitable lemonaide business. A lot of outstanding psychiatric therapists in the trauma field have PTSD and they made a good career of it.
    no DoD or government policy changes will do nearly as much for Trauma patients than their own natural healing processes. McCain used his PTSD to become a senator. got himself well married.
    you cannot ask anyone to share their trauma when by definition they cannot feel safe doing that. but rape survivors do share and by sharing for others find themselves empowered. incorporate the military tradition of helping others to empower military whose PTSD threatens them professionally to help others likewise under that veil of threat. vets with PTSD and trauma likewise can get greater sense of safety and security by helping others worse off than themselves.
    this may not be how the AMA views medicine. It was founded to prevent lay involvement in treatment of illness. but PTSD is partly a social not merely a medical condition. Support of community and the lack of a support network are key factors in PTSD. so a social lay community based political [‘n the sense that all families have power issues] therapy is one place where PTSD survivors can find a purpose and a meaning in their wounds. and pride. serving the community is a real source of pride, and motivates a lot more than any pill does. pride in service changes the trauma victim into a person of substance worth and puropose.

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