I first met Alma Hall at a Wounded Warrior Wives’
retreat in El Paso. As fate would have
it, she was my roommate for the weekend, and we quickly found we had many
things in common. Both of our husbands
served as combat medics in the Army, both had similar struggles with PTSD, but
then she began talking about his traumatic brain injuries and how it had
affected him and their daily lives. He
had memory problems, and she had to be the one to remind him when to take his
medications and sometimes even when to bathe.
Their latest battle had been with brushing his teeth. She would ask him if he had brushed his
teeth, and even after pausing for a moment to think long and hard, he could not
remember. Using a play out of the
Parenting 101 book, she would check his toothbrush—dry.
She confessed she was nervous to be away from him
for the weekend because he relied on her memory to compensate for his own. Even though he had good friends who were
going to be checking in and spending time with him while she was away, she was
as anxious as a new parent leaving a newborn with a babysitter for the first
time.
Between sessions, Alma, like many other wives, could
be found in the hallway, cell phone to her ear, calling to make sure nothing
had fallen apart and to remind him to brush his teeth. On the last day, breakfast moved straight
into another class, and she wasn’t able to call as early as she had
wanted. She quickly slipped out, and
when she returned, she was wiping tears from her eyes. Concerned, many of us asked what was
wrong. She began to beam with tears of
joy streaming down her cheeks. “He
remembered to brush his teeth,” she announced proudly. And the room erupted with cheers.
TRAUMATIC BRAIN INJURY
PTSD isn’t the only “invisible injury” that our troops
deal with when they return home from war.
Traumatic brain injury (TBI) has also become a signature wound of the
war on terror, and like PTSD, sometimes symptoms do not arise, or are not
noticed, right away. PTSD and TBI share
many common symptoms, so there can be confusion as to which one is causing the
problems, and can sometimes cause a TBI diagnosis to be missed altogether. What’s worse is when differing symptoms of
both begin to compound and even clash, causing new and worsening problems. Just like not every soldier has PTSD, not
every soldier with PTSD has a TBI, but knowing can make a world of difference
in the treatment of both.
WHAT IS TBI?
“Why do you look inside a carton of eggs before you
buy it? Because even though the outside
of the carton may seem perfectly normal and intact, one of the eggs inside may
be cracked. The same holds true for
TBI. Your Veteran’s head may show no
signs of being injured, but the inside, his or her brain, may in fact be
damaged.” –Brannan Vines,
FamilyOfaVet.com
A traumatic brain injury occurs when an outside
force (trauma) injures the brain. This
can happen with a blow to the head in sports, falls, and other physical contact
with a hard object. It can happen when
nothing directly hits the skull, like sudden acceleration or deceleration in a
car crash. TBIs can also be the result
of a blast, such as those experienced in Iraq and Afghanistan from improvised
explosive devices. In addition to the
blast possibly causing the warrior to be thrown down or hit their head, the
shock waves themselves can cause irreversible damage.
Some may ask why there seem to be more cases of TBI
in today’s military than in previous conflicts.
Why wasn’t brain injury more common in other conflicts? The two easiest answers are advances in armor
and the increased use of explosives by the enemy. Technology has brought military armor a long
way, and warriors are surviving many injuries that would have been fatal in the
past. IEDs and suicide bombers have been
the weapons of choice for terrorists who seek to inflict major damage to a
large number of people. Veteran
advocates estimate that 10-20% of Iraq veterans, or 150,000-300,000 service
members have some level of TBI.
In the TBI tip card from Lash & Associates
Publishing, Harvey E. Jacobs, Ph. D. and Flora M. Hammond, M.D. explain the
types of brain injuries, causes, symptoms, and how to recognize traumatic brain
injury.
“The causes and effects of a traumatic brain injury
vary with each person. The location and
size of the blow or impact determine what parts of the brain are injured. No two traumatic brain injuries are alike…
Most commonly, the person does not lose consciousness when a brain injury
occurs. These are called mild brain
injuries, but they can cause many difficulties that are not necessarily
mild. The person may feel dazed or just
a little confused for a brief time and then return to work or usual
activities. Problems may develop
later. Sometimes people wrongly assume
the effects of a brain injury are caused by something else such as combat
fatigue, illness, stress, or nerves.”
Another strike against warriors who received a TBI
in a warzone is the lack of rest that is crucial to recovery after a brain
injury. When an athlete sustains a
concussion, the doctor will typically order rest so the brain has time to heal
and recover. This is not an option for
warriors who are still in an extremely stressful environment with a mission to
accomplish. Repeated blasts and
injuries, often before the previous injury has healed with very little rest in
between, can compound to make very serious changes to the way the brain
functions.
“Injury on the football field can be devastating,
but after the concussion, people aren’t trying to kill you,” says Dr. Shane
McNamee from the Richmond VA. “People
aren’t shooting at you. You’re not
seeing your loved ones, your brothers, maimed and killed in front of you. You’re not then pressed out the next day, to
go back out and do it again, and again, and again.”
In recent years, the military has also begun to
notice the increased risks for concussions and multiple TBIs. In 2011, PBS ran a series called “Where
Soldiers Come From”. In the episode on TBI,
they talked about changes the military has made to stop warriors from suffering
multiple concussions.
“The Pentagon recently released a new policy for the
treatment of TBI, which includes a mandatory 24-hour rest period after a blast
and a complete neurological assessment for anyone who’s had three or more
concussions. The United States Congress
has mandated that military and veterans’ hospitals screen all service members
returning from combat assignments. Yet
even when TBI is properly diagnosed, it is difficult to treat properly. Often a soldier does not realize he or she has
suffered a concussion—symptoms may first surface months or years later.”
SIMILARITIES TO PTSD
Some warriors who return home with PTSD often don’t
realize they could have a TBI because some of the symptoms overlap. Difficulty with short-term memory could be
written off as cognitive problems from PTSD and lack of sleep. Substance abuse can be suggested as the
warrior trying to avoid, but instead could mean that the area of the brain
regulating impulse control and judgment have been compromised. Some studies also suggest that having a TBI
increases the risk for PTSD in service members.
Marilyn Lash has over 35 years’ experience working
with persons with disabilities and is a respected key-note speaker on the topic
of brain injuries. She has spoken at
many wounded warrior wives retreats, including the El Paso retreat mentioned
earlier. She says the five areas that
she most often hears about being common in both PTSD and TBI are cognition,
depression, anxiety, insomnia, and fatigue.
When asked if there was one area that seemed more common in veterans
with PTSD and TBI, she said it would probably be those in terms of thinking,
such as memory changes, organizing, problem-solving, and other executive
skills.
SYMPTOMS
TBI symptoms can be broken down into four
categories: Physical, Cognitive, Communication, and Emotions and
Behaviors. Again, every TBI is
different, and symptoms are usually a result of what part of the brain was
injured. Some people may have several different symptoms while others only have
a few. These are just general lists of
possible symptoms.
Physical:
headaches; seizures; nausea; weakness/paralysis; balance; clumsiness; changes
to vision, hearing, smell, taste, or appetite; sensory sensitivity (sensitive
to light, sound, smells, etc.); fatigue; sleep disorders.
Cognitive:
amnesia; memory problems; slowed processing; organization and planning; poor
judgment; inability to multitask; poor initiation; confusion; easily
distracted; repetitive thoughts and comments; impulsive.
Communication: slurred speech; word finding (trouble finding the right word- “it’s
right on the tip of my tongue!”); not on topic; trouble listening; dominates
conversation; problems with reading and writing; change in rate of speech
(usually slower); repetitive storytelling; literal; comprehension problems.
Emotions & Behaviors: anxiety; depression; self-centered; short temper;
frustrated; inappropriate crying or laughing; mood swings; rigid or stubborn;
dependent; personality change; disinhibited.
If you or a veteran you know has been exposed to
blasts, has had a head injury, or has had repeated concussions while serving
overseas and you have noticed any of the above changes, then it’s time to be
checked for a TBI.
LIVING WITH TBI
It was after the El Paso retreat that I began to
reassess my husband’s behaviors and symptoms.
I knew he had been in multiple blasts and had lots of hard landings that
made him “see stars” when he jumped out of planes with the 82nd
Airborne. He had a lot of the symptoms
that were common to TBI but not PTSD. We
were both more than shocked to find when he asked to be tested at the VA for
TBI that it was actually already in his medical record. They knew very early on what we did not know:
that TBI had caused significant changes to the way he functioned each day.
Alma Hall picked up on signs that something was not
right immediately, even from another continent.
Her husband, Russ, called her after his vehicle took a direct hit from
an IED and flipped over. He wanted to
let her know that he was okay, but she could tell something was off.
“He kept repeating himself over and over again, and
he was speaking very slowly,” she said.
“It just didn’t sound right.”
His fellow combat medics showed concern, but as
senior medic, he waved them off saying he was fine. He completed his tour and returned home in
December 2007. It was then that Alma
really began seeing the red flags that he was not “fine”.
“It was pretty obvious,” said Alma. “He had developed a stutter, he would repeat
things within a few minutes of each other, he had horrible migraines, and he
would constantly lose his train of thought.”
Russ has since had two years of occupational therapy
to help with the cognitive issues as well as two and a half years of speech
therapy. While it’s not a permanent fix,
they did teach him tools and coping skills to make living with a TBI
easier. She still has to remind him to
take his meds, guide him through the steps for everyday tasks, and yes, sometimes
still remind him to brush his teeth, so it’s easy to see why something so small
would be such a big celebration when he remembered without prompting.
Still, just as with PTSD, there are good days, and
there are bad days.
“If he is extremely tired, has had very little
sleep, or has migraines, the first thing I notice is his speech is wonky,” said
Alma. “He’ll start throwing out words
that don’t pertain to anything about what he is saying. His short-term memory loss is also ten times
worse.”
Sometimes it’s hard to explain these symptoms to
others, especially civilian wives. I’ve
spoken to many wounded warrior wives who are frustrated when they try to
describe what it’s like, only to have someone say, “Oh, that’s just a man for
you. They don’t listen, and they never
remember.”
I’m sure everyone has had those moments when you
walk into a room and forget what you went in there for in the first place. That’s common, but much, MUCH more frequent,
and sometimes on a much larger scale.
There have been times my own husband has gone to Amarillo, only to hit
I-40 and think, “What was I coming to town for?” He confessed to me that there had been times
that he simply drove around town for hours, hoping to see something that would
spark his memory.
We also have the same conversations over and over,
sometimes in the same 10-minute time frame because they don’t remember having
it the first time. The times when there
is disagreement over who said what and when are daily. Getting flustered and giving him a hard time
about not remembering something I said or asked
him to do doesn’t help, so we chalk it up as a “TBI moment” and move
forward. Just as I have learned not to
take it personally when he forgets, he has learned not to take it personally
when I remind him ten times a day about an upcoming appointment or something he
needs to do.
“The best advice I can give is to be patient,” said
Alma, a sentiment that echoed from every PTSD/TBI group I posed the question
to.
LONG-TERM EFFECTS
Multiple studies have found an increased risk for
Alzheimer’s in people with TBI. Moderate
and severe TBIs (respectively) are associated with a 2.3 and 4.5 times
increased risk for Alzheimer’s. If you
were to look at some of the early warning signs of Alzheimer’s, you would see
that most of those symptoms listed are also symptoms of TBI. Knowing you have a TBI, learning ways to
cope, and always being aware of any changes or worsening symptoms are the best
way to detect problems later on.
There
have also been studies that suggest people with TBIs have a higher rate of
suicide. Add that to the higher rate
because of PTSD, and it can be a scary situation for the veteran who has
both. It has also gotten attention from
outside the military. Athletes,
particularly football players who take hard hits for a living, are showing
their vulnerability as well. The NFL has
been in the spotlight as some of its former players have committed suicide the
past few years with some experts theorizing a link between suicide and brain
injuries. Junior Seau, NFL linebacker,
took his own life this year, and preceded by Dave Duerson who left a note
asking for his brain to be sent to the “NFL brain bank” for study. This fall, the U.S. Army and NFL publicly
announced that they would be teaming up to spread awareness and pioneer
research on TBI.
There
seems to be new research coming out every day about TBI and its effect on the
military and athletes. Technology is
beginning to catch up, bringing new imaging machines and therapies, but they
are still out of reach for many veterans, especially in rural areas. Many of the first troops who returned home
from Iraq and Afghanistan did not have the information on TBI that has become
more common and readily available. Many
who separated before 2008 were not tested for TBI or may have had symptoms that
began to manifest years later. And just
like PTSD, it’s created another group of disabled veterans with invisible
wounds who struggle every day with a public that doesn’t understand.
YOU ARE
NOT ALONE.
Marie Rowland is a neuroscientist, writer, and patient advocate. She
founded EmpowermentAlly to help promote patient empowerment in people
who have mental illness or a brain injury.