Combat Trauma, Traumatic Brain Injury & Addictive Disorders
Combat Trauma, Traumatic Brain Injury, & Addictive Disorders
Larry L. Ashley, Ed.S., LCADC, CPGC & Karmen K. Boehlke, M.S. provide an fascinating insight into the experiences of American veterans returning from recent conflicts in Iraq and Afghanistan.
Whether anticipating, engaging in, or experiencing the aftermath of battle, historical accounts indicate that war has always had severe psychological impacts on soldiers in immediate and enduring ways. For example, three thousand years ago, an Egyptian combat veteran named Hori wrote about the feelings he experienced before going into battle: â€śYou determine to go forwardâ€¦Shuddering seizes you, the hair on your head stands on end, your soul lies in your hand.â€ť Herodotus, the Greek historian, writing of the battle of Marathon in 490 B.C., cited an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier â€śwas wounded in no part of his body.â€ť In a different account referencing the battle of Thermopylae Pass in 480 B.C., Herodotus wrote of another soldier, Aristodemus, who was so shaken by battle that he was nicknamed â€śthe Trembler.â€ť Aristodemus later hanged himself in shame (Bentley, 2005; p. 1).
Employing the term â€śNostalgiaâ€ť in 1678, Swiss military physicians were among the first to identify and name the constellation of symptoms that comprised acute combat reactions (Bentley, 2005). Since then, the moniker has undergone several revisions. Transitioning from â€śsoldierâ€™s heartâ€ť during the Civil War, to â€śshell shockâ€ť during World War I, to â€ścombat exhaustionâ€ť or â€ścombat fatigueâ€ť during World War II and the Korean War (Hunter, 2009) to â€ścombat stress reactionâ€ť during the Vietnam War (Johnson, 2010), posttraumatic stress disorder (PTSD), as it is currently classified today, officially debuted in 1980 when it was included in the in third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). Symptoms of PTSD include sleep disorders, avoidance, numbing, detachment, re-experiencing, hyper-arousal, and hyper-vigilance (Reckess, Chen, & Vasterling, 2012).
While epidemiological data suggest that the majority of adults (69%-90%) have experienced at least one potentially traumatic event (Dedert et al., 2009), PTSD rates are more than twice as high in veterans than civilians (Back et al., 2014). According to a reexamination of the National Vietnam Veterans Readjustment Study, approximately 19% of male Vietnam theatre veterans developed PTSD (Dohrenwend et al., 2006). Hoge et al. (2004) found PTSD rates in veterans returning from the Iraq and Afghanistan wars to range between 11% and 17%.
Traumatic brain injury (TBI) often occurs during some type of trauma, such as an accident, blast, or a fall. A disruption of normal brain function occurs when the skull is struck, suddenly thrust out of position, penetrated or struck by blast pressure waves. While the initial trauma tears, shears, or destroys brain tissue, the effects from the incipient wound may cause a second injury cascade in the brain resulting in edema, internal bleeding, and oxygen deprivation. Symptoms associated with TBI, many of which overlap with the common reactions following trauma, occur in the physical, cognitive, and affective domains and range from headaches to memory problems to changes in mood and personality (Center for Substance Abuse Treatment, 2010).
The conflicts in Iraq and Afghanistan (OIF/OEF) have resulted in increased numbers of veterans presenting with TBI. While 12% of the combat wounds incurred during the Vietnam War were related to TBI, the Department of Defense and the Defense and Veteranâ€™s Brain Injury Center estimate that 22% of all OIF/OEF combat wounds are brain injuries. Additionally, symptomatology in veterans appears to extend beyond what is experienced in the civilian population. Studies show that most veterans who experience a TBI will suffer symptoms 18-24 months following the initial injury (U.S. Department of Veterans Affairs, 2014).
While the stresses of military service, combat, and reintegration have the potential to place individuals at an elevated risk for experiencing PTSD and TBI, these variables have also been identified as risk factors associated with the development of other emotional and behavioral disorders, including depression, generalized anxiety disorder, and addictive disorders (Biddle et al., 2005). The rates of PTSD among individuals presenting for substance use disorder (SUD) treatment have been reported to fall between 30-59% (Stewart et al., 2000). According to the National Research Council (1996), individuals presenting with trauma histories are 1.5 to 5.5 times more likely to abuse chemical substances than those without a trauma history. To complicate matters further, as many as 82% of individuals presenting with a comorbid PTSD-SUD diagnosis experience additional non-substance use Axis I disorders (Cacciola et al., 2001).
Current prevalence rates of SUDs in veterans aged 18-53 is nearly five times that of the general population (SAMHSA, 2007). The most commonly abused drug among active duty military and veterans is alcohol. Approximately 27% of Army soldiers were found to meet criteria for referral to treatment when screened within 3-4 months after returning home from service in Iraq (NIDA, 2011).
There is also evidence indicating that prescription drug misuse rates in the military also exceed civilian rates. The Department of Defense (2009) reported an 11.7% prescription drug abuse rate among military personnel compared to that of 4.4% in the civilian population. Not only are the abuse rates higher in the military, they are also escalating at a more rapid pace: statistics indicate that prescription misuse by military personnel doubled from 2002 to 2005, and then nearly tripled between 2005 and 2008 (NIDA, 2011).
Additionally, differences exist between the military population and the general population with respect to gambling. According to the National Council on Problem Gambling, anywhere between 1 to 3 percent of the general population experience a gambling problem within a given year. However, 10 percent of veterans utilizing VA treatment services have been diagnosed with a gambling disorder (Hall, 2013).
In general, comorbid disorders tend to complicate treatment. Comorbidity is associated with increased symptom severity and poorer treatment outcomes (Brown & Wolfe, 1994). Individuals presenting with comorbid disorders tend to experience more psychiatric symptoms and interpersonal distress than clients presenting with either a PTSD or SUD disorder alone (Najavits et al., 1998). Additionally, individuals diagnosed with comorbid PTSD-SUD tend to relapse sooner (Brown, Stout, & Mueller, 1996) and engage in more frequent inpatient treatments than individuals presenting with an SUD alone (Brown, Recupero, & Stout, 1995).
Moreover, military personnel face unique factors that may interfere with treatment-seeking endeavors. Concerns related to the potential stigma attached to utilizing mental health services appears to be disproportionately high in the military population compared to that found in the civilian population. A particular concern relates to how a soldier will be perceived by his/her peers and leadership. There is also concern that treatment-seeking may prove harmful to career aspirations or result in disciplinary actions (Hoge et al., 2004).
Despite advances in classification, recognition, and public awareness, misunderstanding and denial continue to exist regarding the lingering effects of combat trauma. A particularly poignant portrayal of denial was demonstrated a number of years ago by the actor George C. Scott wherein he played the role of General Patton in the movie Patton. In one scene, Patton visited an aid station behind front lines and came upon a soldier sitting on the edge of his hospital bed. Seeing no visible signs of wounds, Patton asked, â€śWhatâ€™s wrong with you, son?â€ť Uncertain how to respond and awed by the presence of the general, the soldier simply stammered. Impatient, Patton raised his voice and repeated the question. Informed by the attending nurse that the soldier was suffering from combat fatigue, Patton became incensed, launched into a litany of obscenities, disparaged the soldier, and called him a coward. Before storming out of the aid station, Patton hit the soldier with his gloves (Johnson, 2010).
The tirade cost Patton his command. However, the scene illustrates a lingering attitude: If there is no blood, there is no harm. And, while helmets and body armor can provide some protection against penetrating head injury, the psyche remains vulnerable to the invisible wounds that result from combat (Johnson, 2010).
Veterans are exceptionally susceptible to experiencing PTSD and TBI. As a consequence, especially if left untreated, some will become homeless; others may engage in domestic violence and criminal behaviors that will result in subsequent incarceration. Many will develop other debilitating psychological problems as a result of their struggles with PTSD, including depression, anxiety, and addictive disorders; tragically, some will see suicide as the only way to escape their pain (Hurley, 2010). There is little doubt that the current rate of mental health problems amongst military personnel and veterans present enormous economic challenges to both the U.S. militaryâ€™s medical system and the communities into which soldiers reintegrate upon return from combat. However, those bearing the preponderance of the painful costs associated with war are the soldiers and their families who live first-hand with the psychological wounds of battle (Hurley, 2010). And, while the needs of veterans are complex and the systems though which they receive care can be complex, services must promote the care, healing, and recovery of afflicted members of the veteran population. The health and the well-being of our veterans depend on it, as do the health and well-being of our nation.
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