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TBI : The Invisible Injury for the Forgotten Generation

The last U.S. combat troops will leave Afghanistan in 2014, ending America’s longest war. The Iraq war ended in December in 2011, with an official flag-lowering ceremony in Baghdad, in which Defense Secretary Leon Panetta declared that a free, democratic Iraq was worth the sacrifice in American lives.

What about the sacrifices made by those who did not die?

What lingering injuries and disabilities will plague this generation of veterans?

And will we be able to even see them?

It’s easier to accept that an entire generation of soldiers is damaged when you can actually see the injuries on thousands of men and women around you. The cost of war surrounds us in our daily life.

In the Civil War, amputation was the lingering disability. Doctors sawed off injured feet, legs, hands and arms, to prevent the spread of infection and gangrene that they did not yet understand. Years later, when you saw a man with a missing limb, you knew where he’d been and what had happened to him.

In World War 1, soldiers met mustard gas. These gas attacks not only seared a man’s lungs, they could burn his face off. In the 1920‘s in Great Britain, there were tens of thousands of veterans with brutal facial injuries, and it was declared the “worst loss of all,” worse than any amputation, since it robbed the veteran of his identity and humanity. The first advances in plastic surgery happened because doctors created the first modern prosthetics to give these veterans their lives back.

In later wars, the injuries soldiers suffered became less apparent. The dioxin in Agent Orange, first sprayed in Vietnam 50 years ago, has injured hundreds of thousands of Americans. Yet, you cannot pick out the veteran disabled by Agent Orange from the crowd. This invisibility may be one reason why the Agent Orange Registry estimates there are still 500,000 disputed disability claims related to Agent Orange with the Veterans Administration.            

And what about our current generation of veterans?  There are over two million veterans from the Iraq and Afghanistan wars. What is their most common injury?

We have all heard of Post Traumatic Stress Disorder, or PTSD. You do a keyword search for PTSD on the Los Angeles Times website, and dozens of articles come up about the disorder.

Many feature articles have been written about veterans who can’t re-assimilate into American society. They may be overly anxious, easily frightened and quick to anger. They may have trouble holding jobs. They may be depressed, or feel an absence of emotion, so in order to feel anything they engage in risky behavior, like racing motorcycles at top speeds without a helmet, or they self-medicate with alcohol or drugs.

Consider my own Uncle Ian, my mother’s brother, from whom I get my middle name. Once he returned home after being injured, he seemed to make a miraculous recovery.

 However, his personality gradually changed. He became more of a thrill seeker. He often had accidents -- car accidents, work accidents, sporting accidents. He was kind and loving, but sometimes he was inexplicably quick to anger. After one argument he went out on his snowmobile on a frozen lake and was speeding so fast that he flipped it tail over end and it landed on him, crushing his pelvis. Another time, he was helping a friend build a house and he climbed far too high on the scaffolding without a safety harness. The scaffolding collapsed and he fell and shattered his leg. He suffered from depression and anxiety, and compounded with the pain from his injuries, he finally committed suicide.

 It wasn’t until I read about veterans with PTSD did I recognize his behavior and realize it had a name. The only problem is, my Uncle Ian never saw combat. He never even served in the Armed Forces. He had something else that often leads to PTSD. He had TBI, or Traumatic Brain Injury, from a snow sledding accident at age 15.

My mother’s family lived in cold Port Arthur, Ontario, Canada, a small town that grew into what is now called Thunder Bay. My uncle Ian was sledding on a steep and icy hill, when he climbed higher than the other boys for a more thrilling ride. His sled jumped the snow bank at the end of the run, and he flew into traffic. A car couldn’t stop in time, and its bumper slammed into his head. He was in a coma for over two weeks.

He made what seemed to be a miraculous recovery, and had no memory of the incident. His challenges didn’t start until months later, and I don’t think anyone ever linked his changed behavior as an adult to the TBI he suffered as a teenager.

 If he had lost a leg, or had his face burned off, we would have always remembered that he had been injured. The invisibility of his injury made forget that it was (I believe) the root cause of many of his problems. He did receive some rehab at the time, but once he appeared to speak and walk normally, everyone assumed that his recovery was complete. In fact, much more rehab probably needed to be done.            

New studies are showing that our newest disabled veterans are not just suffering from the “stress” of PTSD. In many cases -- perhaps in most cases -- they actually have an injury, like my uncle - TBI -- Traumatic Brain Injury. It’s the TBI that’s causing the stress problems, and the PTSD is the name we give what we see.

This, from both the Los Angeles Times (Dec. 3, 2013) the on-line University of California News Room (Dec. 11, 2013):

 In a novel study of U.S. Marines investigating the association between traumatic brain injury (TBI) and the risk of post-traumatic stress disorder (PTSD) over time, a team of scientists led by researchers from the Veterans Affairs San Diego Healthcare System and University of California, San Diego School of Medicine report that TBIs suffered during active-duty deployment to Iraq and Afghanistan were the greatest predictor for subsequent PTSD.

 What are the symptoms and behaviors of PTSD? vs TBI? Let’s compare and contrast. These are the symptoms of PTSD, taken from Maketheconnection.net, which is a PTSD support group:

1) Having nightmares, vivid memories, or flashbacks of the event that make you feel like it’s happening all over again.

2) Feeling emotionally cut off from others.

3) Feeling numb or losing interest in things you used to care about.

4) Becoming depressed.

5) Thinking that you are always in danger

6) Feeling anxious jittery, or irritated.

7) Experiencing a sense of panic that something bad is about to happen

8) Having difficulty sleeping.

9) Having trouble keeping your mind on one thing.

10) Having a hard time relating to and getting along with your spouse, family, or friends.

Now, here are some of the symptoms of general TBI -- and not TBI related to combat. These are general symptoms of Traumatic Brain Injury. Blows to the head from falls, car accidents, getting popped with a baseball or a bat, or getting multiple concussions playing football. It also can happen from a lack of oxygen, from asphyxiation during choking, and near drownings. These signs and symptoms may appear immediately, or weeks after the traumatic event. These are taken from the Mayo Clinic, at www.mayoclinic.com:

The signs and symptoms of mild to moderate traumatic brain injury may include:

11) Memory or concentration problems.

12) Mood changes or mood swings.

13) Feeling depressed or anxious.

14) Fatigue or drowsiness.

15) Difficulty sleeping.

16) Sleeping more than usual.

17) Agitation, combativeness or other unusual behavior.

What caused the TBI? While the Vietnam War had Agent Orange, the conflicts in Afghanistan and Iraq had the infamous Improvised Explosion Device, or IED, which caused 1/3 of all casualties in Iraq. Imagine explosions going off right next to your head, or the shock waves the rolls through an armored Humvee after it drives over a bomb. That sloshes the grey jello inside your skull that we call brain matter.

The numbers are still out, however, about how many veterans had bombs go off near their heads. I believe that the number may be very high, and that PTSD may turn out to be, in fact, a bi-product of TBI. Why is the distinction important? Because it changes our approach to how we view them, and how we treat them.

How do we handle a basketball player who endures a traumatic emotional event that prevents him from playing? We may send him to a psychiatrist or psychologist. We may even prescribe anti-depressants. We hope he overcomes his stress and gets back in the game as soon as possible. Ultimately, he is the one responsible for his recovery.

What if he is injured?  If he rips his Achilles tendon and he is weeping in pain, or is angry, we don’t call his tears an emotional problem. We see it an an injury first.            

One of the challenges of TBI is that it’s hard to know when a certain behavior is a  symptom. A person with TBI may lose memory and cognitive skills, but still insist they are “back to normal.” They may have trouble reading, and balancing a checkbook, yet not recognize the extent of their own problem.

Let’s mention just two parts of the brain, that  will create new and different  behaviors in people if they are damaged. The amygdala is an almond shaped organ near the front of the brain that processes memory and emotion. You could call it the “ fear center,” because it reminds you of what is terrifying and when you should fight or flee. The frontal lobes are where we process information and make the executive decisions to get through our day. They also help us to control our impulses.

Why is the veteran terrified when a car honks? It may not be just leftover stress he must work through. His damaged amygdala may be hypersensitive and recalling a minor stimulus as a terrible threat. What about the angry veteran who fights with his wife and then jumps on a motorcycle and tears off into traffic? He may need more than  counseling. He may have a frontal lobe injury that can’t process choice and conflict well, and he can’t control his impulses. If  it jumps to amygdala interprets an argument about the rent check as a life and death threat.

These same reactions can be created in the laboratory, with lab rats. In 2012, Dr. Maxine Reger from UCLA was able to create PTSD symptoms in rats by damaging their amygdalas by giving them concussions.

There are 2 million veterans from the Iraq and Afghan wars. Tens of thousands may have TBI and PTSD. How do we treat them?

We must convince them they are injured, and then test for what specific injuries they have. Once we know their injuries, we don’t force them to do what they cannot do, because that exacerbates the problem. Instead, you remember they are injured and develop compensatory strategies to get through life. After you have your compensatory strategies in place, then also work on a fixing the injury itself.

Consider the injured basketball player. You convince him to stop playing, even if he insists he can play through the pain. He gets tested. Is it a pull, or a ripped tendon? Once you know, you then give him compensatory strategies -- like crutches, or a bandage. Then you work on fixing the injury, with surgery and rehab.

Some brain injuries can’t be cured. If a section of the brain is gone, it’s gone and won’t come back, just like the basketball player who loses a foot.

But the brain can rewire itself. As long as we live and breathe, the brain can create new connections, at any age. Neuroplasticity -- the brains ability to adapt and change and rewire itself to face new challenges and stimulus -- is where the answer lies. Donald Hebb first said in 1949, that “cells that fire together, wire together.” 

There are exercises for kids with TBI, dyslexia, visual processing problems, even autism, and these exercises force the brain to operate globally to solve challenges that one section of the brain can’t handle.

For instance, when you are calling long distance, the phone connection will sometimes use three different satellites if it can’t make the connection with the satellite that is closest. The brain will work in the same way, if you encourage it to make the new roundabout connection.

One of the most famous rehab “work arounds” after brain trauma was with Congresswoman Gabrielle Giffords, as she was recovering from gunshot wounds to her brain. She couldn’t say her name -- but she could sing it. Music works a different part of the brain than speech, and she learned to speak again by running the connection through the music part of her brain.

There is another overall strategy for TBI and PTSD that is already working, and the Armed Forces have been using it for years -- Meditation. Some call it Transcendental Meditation, some call it by it’s new buzz word, “Mindfulness.”

Enter these keywords into any search engine, and see what pops up:

Meditation, TM, mindfulness, PTSD, TBI, Marines, Army.

Since 2010, the Marines and the Army have found that meditation works for their veterans with PTSD and TBI. Enter just the keywords “meditation” and “TBI” and there are just as many articles about how meditation works to help the brain rewire itself after any kind of TBI injury, not just those in combat.

 I worry that there will be a generation of injured veterans who are angry, depressed, and addicted, and we will dismiss them --There goes another angry vet speeding on a motorcycle after a bar fight because he doesn’t know the war is over.      

We have to recognize their changed behavior for what it actually is -- TBI which requires rehab work, and not just counseling and medication.

Rehab also costs, money, but it costs much less money in the long run because it doesn’t involve constant medical visits and medicine, and it can specific and targeted. And TBI will create much higher cost to society if it remains untreated.

RESOURCES:

For resources on how to recover and rehab after brain injury, check out the Brain Injury Association of California: http://biacal.org

The article about the rats is: "Concussive Brain Injury Enhances Fear Learning and Excitatory Processes in the Amygdala" by Maxine L. Reger, Andrew M. Poulos, Floyd Buen, Christopher C. Giza, David A. Hovda, and Michael S. Fanselow Biological Psychiatry, Volume 71, Issue 4 (February 15, 2012), published by Elsevier.

Amygdala:

An almond-shaped cluster of neurons in the limbic system thought to be involved in processing emotions and memory.

Frontal lobes:

Area of the brain made up by the front portions of right and left hemispheres of the cerebral cortex. These areas are involved in memory, planning, organization, language and impulse control. These areas also have been linked to personality.