By Marilyn Lash, M.S.W.
Lash and Associates Publishing/Training, Inc.

Signs of stress and PTSD in the military 

As service members and veterans come home from Iraq and Afghanistan, many have psychological issues related to traumatic stress and post traumatic stress disorder (PTSD).  

• More than 90% of soldiers and Marines returning from Iraq reported stressors of…
  • roadside bombs
  • length of deployment
  • handling human remains
  • killing an enemy
  • seeing dead or injured comrades
  • being unable to stop a violent situation. 
• 30% of troops returning home from Iraq reported some type of mental health problem, including
  • anxiety
  • depression http://www.lapublishing.com/depression–brain-injury-family/
  • nightmares
  • anger
  • difficulty concentrating. 
• 15-17% of troops returning from Iraq in 2004 experienced acute stress or post traumatic stress disorder (PTSD).  http://www.lapublishing.com/PTSD-blast-brain-injury/

The stigma of mental health

Mental health treatment has always been carried more stigma or “baggage” than treatment for physical conditions in the U.S.  Common misperceptions in the general population are that seeking therapy, counseling or even medication for emotional help is a sign of weakness.  Even most private health insurers have strict limits on the scope and number of mental health services allowed.  There is a general belief among the public that those who seek mental health treatment are unstable, disturbed, and mentally ill.  This stereotype leads to patterns of avoidance by friends, neighbors and coworkers.  It contributes to denial by individuals and delays seeking treatment.   

This stigma makes it even more difficult for soldiers and service members to ask for help in a military culture that stresses being strong and avoiding signs of vulnerability or weakness. 

PTSD screening in the military

 The military has made a serious effort to address psychological issues among troops.  Despite this, there is still a lag of soldiers actually seeking help.  Before returning to their home stations, all soldiers undergo mandatory psychological and medical screening.  Based on the results of the psychological questionnaire to assess PTSD, depression and alcohol abuse, soldiers may be required to have an interview with a mental health professional.  Those who indicate medical symptoms are referred to medical professionals. 

Soldiers are more reluctant to report psychological problems, especially when returning with their units.  The findings are striking… 

• Only 38-45% of troops newly diagnosed with mental health problems were interested in receiving help.
• Fear of stigmatization and concern about barriers to getting psychological help was twice as likely among troops who scored positively compared to those who did not.
• Only 23-40% of troops who reported interest in seeking help during the previous year had actually received professional treatment.

Beliefs about mental health and mental illness

Beliefs that psychological distress is a sign of weakness are also linked to the perception that individuals are responsible for their problems.  There is a common belief among civilians and service members that individuals should be able to control their psychological symptoms through choice, determination, and sheer will power. 

Consequently, it is easy to see why service members fear exclusion by comrades if they report symptoms of PTSD or other emotional distress.  Seeking treatment may be avoided or delayed due to apprehension about its stigma and reactions of comrades. 

Interventions for reducing stigma in the military 

Organizational policies and programs directly impact whether service members seek mental health support.  Concerns about losing a job or security clearance are barriers to seeking mental health treatment.  Anonymity and confidentiality are other concerns reported by soldiers. 

Leaders and supervisors have a critical role in identifying and helping soldiers receive mental health support and treatment.  If leaders emphasize the importance of early mental health treatment, service members are more likely to seek help because it has less negative associations.  Leaders are instrumental for creating a climate where mental health problems such as PTSD are recognized and early treatment encouraged and supported.

References:

Greene-Shortridge, TM, Britt, TW, and Castro, CA. (2007). The Stigma of Mental Health Problems in the Military. Military Medicine, 172, 2:157.

For more information, see:

Understanding the Effects of Brain Injury, Blast Injury, Concussion and PTSD

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

Healing Together

By Suzanne Phillips, Psy.D and Dianne Kane, D.S.W.

Book for couples coping with effects of trauma and post-traumatic stress disorder (PTSD) from war, brain injury, violence, accidents, crime or health problems.

By Katherine H. Taber, Ph.D. and Robin A. Hurley, M.D.

More veterans have brain injuries and concussions

Brain injuries are becoming increasingly more common with changes in modern warfare. Returning combat veterans may not know they have suffered such a wound. That is why VA doctors want returning soldiers and their families to have this information.

If the head is hit or shaken severely, a “concussion” or “closed head injury” can result. Many types of forces can cause a brain injury. Examples include being hit on the head, being near an explosion, and being in a motor vehicle accident. A brain injury can happen in the absence of any external injury. However, it is important to remember that presence of external injury does not mean the brain has been injured.

Concussion is seldom life threatening, so doctors often use the term “mild” when the person is only dazed or confused or loses consciousness for a short time. However, concussion can result in serious symptoms. People who survive multiple concussions may have more serious problems. Here are some of the more common symptoms of brain injury.

Common symptoms of brain injury concussion

• “I just don’t feel like myself.”
• Feeling light-headed or dizzy
• Difficulty organizing daily tasks
• Blurred vision or ringing in the ears
• Feeling sad, anxious or listless
• Easily irritated or angered
• Feeling tired all the time
• Trouble with memory, attention or concentration
• More sensitive to sounds, lights or distractions
• Impaired decision making or problem solving
• Difficulty inhibiting behavior – impulsive
• Slowed thinking, moving, speaking or reading
• Easily confused, feeling easily overwhelmed
• Change in sleep – much more or much less
• Change in sexual interest or behavior
• People who have had a concussion may say that they are “fine” although their behavior or personality has changed. Changes such as these in a family member or friend suggest the need for medical help.

Recovery following brain injury

Some symptoms may be present immediately. Others may appear much later. People experience brain injuries differently. Speed of recovery varies from person to person. Most people with mild brain injuries recover fully, but it can take time. Here are some things that can be done to promote healing, and to make symptoms easier to manage.

Promote healing and manage symptoms of concussion

Things that can help

• Get plenty of rest and sleep
• Increase activity slowly
• Carry a notebook – write things down if you have trouble remembering
• Establish a regular daily routine to structure activities
• Do only one thing at a time if you are easily distracted – turn off the TV or radio while you work
• Check with someone you trust when making decisions

Things that can hurt

• Avoid activities that could lead to another brain injury – examples include contact sports, motorcycles, skiing
• Avoid alcohol as it may slow healing of the injury
• Avoid caffeine or “energy enhancing” products as they may increase symptoms – check the labels on cough, cold, and allergy medicines
• Avoid excessive use of over-the-counter sleeping aids – they can slow thinking and memory
• In general, recovery is slower in older persons. People with a previous brain injury may find that it takes longer to recover from their current injury. Some symptoms can last for days, weeks, or longer. Talk to your health care provider about any troubling symptoms or problems.

Katherine Taber, Ph.D. and Robin Hurley, M.D. are at the Mid-Atlantic Mental Illness Research, Education and Clinical Center located at the W.G. “Bill” Hefner VA Medical Center in Salisbury, NC.

For more information on blast injuries and concussion, see the manual:

Understanding the Effects of Concussion, Blast and Brain Injuries:

Blast injury, PTSD and brain injury guide for families and caregivers on the consequences of concussion in veterans. Used by many VA Hospitals and Army Medical Facilities.

By Carolyn Rocchio

Mild brain injury is a real problem for families

Many service members and veterans have returned from war with undiagnosed mild brain injuries or concussion.  Greater emphasis is now being placed on case management and coordination of services for service members and veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom after sustaining traumatic brain injury in response to the July 12, 2006 report from the Department of Veterans Affairs Office of Inspector General (1). This need was reinforced by testimony before the House Veteran’s Affairs Subcommittee on September 28, 2006 with the presentation of alarming data about the large numbers of blast injuries resulting in changes in neurosensory deficits (2).

Traumatic brain injury has become the “signature” injury of Operation Enduring Freedom and Operation Iraqi Freedom. As of January 2006, the Department of Defense reported more than 11,852 returning wounded had exposure to blast injuries (2). It is reasonable to conclude that many additional service members/veterans who have been exposed to blasts without bodily injury are later experiencing classic signs of mild brain injury.

Mild brain injury is a significant problem in the general population in this country as well. According to data from the Centers for Disease Control and Prevention 1.1 million Americans are seen annually in emergency departments with mild brain injury and countless numbers are never screened or diagnosed.(3)

Coming home isn’t always easy

Many service members/veterans return home with the expectation that their lives will resume as they were prior to deployment. Such is not the case for many who have been exposed to blasts. Without information and resources to guide and support the service member/veteran and family, a “mild” brain injury can take a serious toll on the family. It is critical that service members/veterans be screened for a mild brain injury when exposed to blast injury and given appropriate follow up and treatment. Equally important is educating the family members who will ultimately become the support team once the veteran completes treatment. Families must be made aware of the nature and consequences of mild brain injury and provided with tools to provide support in the months and possibly years to follow.

Social workers should be aware of informational resources to assist families being seen in VA facilities, both inpatient and outpatient. Many educational resources and publications exist to educate families. In turn, families must be taught how to access community resources and be prepared for changes and characteristics common to mild brain injury. Some of the more common characteristics that may be present on discharge or develop later include:

• headache
• fatigue
• dizziness
• memory problems
• sleep disorders
• problems concentrating
• ringing in ears
• irritability
• visual changes
• sexual dysfunction
• sensitivity to light, sound and odors

Even though some or many of the characteristics above may exist, the overall appearance of the individual can still be unchanged unless there are other physical injuries. This appearance of well-being can be misleading for family members, friends, and others. Even the service member/veteran is not always aware of the less visible cognitive changes. This can lead to frustration when the family is not patient and supportive.

A mild brain injury can be tricky to diagnose

Mild brain injury is often difficult to diagnose as changes in brain structure are seldom captured by CT or MRI scanning. This lack of physical evidence of an injury can result in labeling the individual as “faking” or malingering, when in fact there have been molecular changes in the brain that affect how the individual thinks and acts. A neuropsychological assessment is the key piece of information that can explain how the injury has affected the individual’s functional capabilities. Ideally the service member/veteran, family members and the neuropsychologist should meet to discuss the findings and establish ways the family can support and promote emotional well being of the service member/veteran and other family members.

All members of the family undergo a difficult adjustment once the service member/veteran returns home. There may have been many role reversals with family members assuming new responsibilities while the service member was deployed. After a brief honeymoon period, when everyone is delighted that the service member has returned, things can go down hill very rapidly. This can happen when others see the subtle changes, but do not understand the cause. At this point, it is not uncommon for the service member/veteran to develop a secondary emotional response to these changes. This can create new problems, that without professional intervention, may escalate into family dysfunction and even violent behaviors. This secondary emotional response often becomes even more disabling than the original insult when support is not available. This can lead to a psychiatric referral that further exacerbates this issue. Persons with mild brain injury often describe themselves as feeling “crazy” because they do not understand the changes they are experiencing.

Risks at home

Families need to be extremely vigilant when there are small children in the home. Irritability and impaired behavioral control can result in children becoming the target of the service member/veteran’s temper when seemingly minor interactions become emotionally charged. Older children may need help understanding why the parent who was once loving and supportive becomes moody and irritable for no apparent reason.

Trying to return to work can be fraught with problems. While the initial return to a job may be met with exhilaration and a sense of camaraderie with old colleagues, problems may surface over time. The service member/veteran may find things that were once easy are now far more difficult. The pace of work is slower. Fatigue is a major factor. Interaction with coworkers can become argumentative and problematic.

Seizure activity can develop some months or even years after a blow to the head. Often these seizures are not convulsive, but more likely to be partial complex temporal lobe seizures which manifest as a change in behavior. The service member/veteran may complain about foul odors, become more sensitive to light or sound, pace the floor and even have hallucinations. Any symptoms should be reported with a follow up evaluation to determine if seizure activity is present.

What can be done to lessen these problems?

Structure is important for reestablishing a daily routine. Military personnel have one advantage in that they are very disciplined and used to taking orders from others. Until the routine is going smoothly at home, the spouse, parent or significant other may need to be the authority figure and help set up a structure. It is not uncommon for a brain injury to affect a person’s ability to initiate a daily routine. This can be particularly difficult when moving from the highly structured military regime back to a more relaxed home setting.

Some helpful strategies for family caregivers include:

• Use day planners, post it notes, and written lists to minimize problems related to memory loss.
• Use watches with alarms, egg timers or electronic timers to keep track of time related tasks.
• Organize all possessions, shelves, drawers, etc with everything in an assigned place to prevent the frustration of locating lost or misplaced items.
• Build in time for relaxation, meditation and/or yoga and Tai Chi to reduce stress.
• Encourage social interaction, but make sure all friends, families and others are aware of the service member/veteran’s persistent problems and ways to interact more successfully.
• Find support groups. The assurance of others with similar residual affects of mild brain injury can be extremely important. Some VA centers with brain injury programs sponsor such groups. Information about community based support groups for individuals with brain injuries and their families can be obtained by contacting the Brain Injury Association of America at 800-444-6443 for referral to the group nearest the family.
• Plan time each day for rest or a nap to offset the effects of long term fatigue. Many will experience disrupted sleep and may require medication to insure restful sleep occurs.
• Model calm when things become emotionally charged. In the event that violence is an issue, make sure family members leave the area to avoid being injured until calm is restored.
• Seek professional help from a person familiar with mild brain injury in planning the work environment to ensure a successful return to work.
• Ask about the use of alcohol and nonprescription drugs before discharge. Alcohol and street drugs can have negative effects when medications are prescribed for conditions such as seizures. In general, any use of alcohol has an exaggerated affect on a person with brain injury. Use of alcohol and other substances is best reinforced if guidance is provided in discharge summaries so family members can rely on professional direction in written form.
• Ask about driving safety due to changes in perception, judgment, visual, and attention deficits. Driving should not be resumed until the service member/veteran is evaluated by a Certified Driving Educator, where emphasis is more on cognitive functions than the mechanical ability to operate a vehicle.

Summary

Mild brain injury can create significant disruption in the lives of the person with the injury as well as members of the family. To insure a more successful recovery, it is critical that there be a thorough assessment to determine what areas of the brain have been injured and the effects on everyday functioning. Additionally, once cognitive deficits have been identified, it is important that strategies to compensate for these deficits be developed. Lastly, family education and resources must be provided. A well informed and supportive family is the major component of successful community reentry.

References:

 (1) Health Status of and Services for Operation Enduring Freedom, Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation. Report Number 05-01818-165. VA Office Office of Inspector General. Washington, DC , July 12, 2006.

(2) Zamperi, Thomas. Chrm. Director Government Relations, The Blind Veterans Association. Testimony: The House Veterans Affairs Subcommittee. September 28, 2006.

(3) Langlois J, Rutland-Brown W, Thomas K. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004.

Recommendation reading

Mild Traumatic Brain Injury Workbook

By Douglas J. Mason, Psy.D

Workbook for adults, veterans and families on mild traumatic brain injury and concussion symptoms with strategies and exercises for improving attention, memory and executive functions.

Brain LASH

By Gail Denton, Ph.D.

Book helps adults and families understand mild brain injury symptoms with strategies for physical, cognitive and emotional changes after concussion.