Traumatic brain injury (TBI) has been called the "signature injury" of the Iraq war.
Most commonly, the injuries are caused by improvised explosive devices, or IEDs, the makeshift bombs insurgents frequently use to attack U.S. forces.
Even if soldiers are not directly hit, the shockwaves of these explosions can violently shake their brains or send shrapnel into their helmets. The result is often an injury that's much like a boxer hit with a knock-out punch.
Thanks to excellent medical care and advanced body armor, service members are surviving injuries that would have killed them in previous wars. But with that survival often comes brain damage, a decrease in cognitive abilities and a lessening of emotional self-regulation.
Psychologists, particularly neuropsychologists, are stepping in to assess the damage, help patients learn new strategies to compensate while their brains recover, and raise public awareness of the increasing number of servicemen and women with TBIs. In fact, 1,977 service members were treated for them at Defense and Veterans Brain Injury Center (DVBIC) sites from January 2003 to February 2007.
"We're going to have a large population of individuals with significant brain impairment who are going to have difficulty navigating through everyday life," says William Perry, PhD, president of the National Academy of Neuropsychology (NAN).
Within the military, stepped-up efforts are under way to detect service members who have sustained a TBI, with intensified screening efforts at military hospitals and at bases back in the United States. Organizations outside of the military are stepping up efforts too: In November at its annual conference, NAN will recognize the educational efforts of ABC journalist Bob Woodruff, severely injured by a roadside bomb in Iraq. Along with his wife, Lee, Woodruff wrote a book about his rehabilitation experiences.
To help catch service members who might be suffering the lingering effects of an untreated TBI after they leave the military, the Department of Veterans Affairs started screening all Operation Iraqi Freedom or Operation EnduringFreedom veterans who visit a VA facility for TBI as of April 2, 2007.
After answering a series of screening questions, veterans will be referred to a recently organized network of VA facilities for follow-up treatment from teams of TBI specialists, if needed.
By July, the VA will start three additional residential community re-entry programs, capable of treating between eight and 12 patients at a time, to help ease veterans and active-duty service members with TBI back into civilian or military life.
While Perry points that neuropsychologists are centrally involved in the effort to assess and treat service members with TBIs and help them-and their family members-cope with and adjust to the cognitive and emotional difficulties inflicted by a TBI, he stresses that psychology as a whole will be helping people deal with the aftereffects of a TBI for decades to come.
"We don't know how this is going to manifest two or three decades from now...So, I think it's a wakeup call to [psychologists] that you're going to be seeing these folks," he says.
Looking for signs of TBI
Some surveys indicate that between 10 and 20 percent of soldiers returning from deployments might have suffered a mild TBI.
Given the number of soldiers and Marines who went to Afghanistan as part of OEF since 2001 or OIF since 2003, thousands more could be at risk for a TBI's lingering effects.
Responding to concerns about whether TBIs are being adequately screened in the Army's medical system, Army Surgeon General Lt. Gen. Kevin C. Kiley formed a traumatic brain injury task force in January. Kiley resigned in March after news of poor conditions for wounded service members at Walter Reed Army Medical Center in Washington, D.C., broke.
Among the leading neuropsychologists tackling the problem is Lt. Col. Gary Southwell, PhD, an Army neuropsychologist at Landstuhl Regional Medical Center in Germany, which treats all service members wounded in Iraq and Afghanistan who are evacuated for further medical treatment. Every month, about 700 service members, mostly soldiers and Marines, come through Landstuhl, where they are screened for TBI symptoms.
"It's certainly become an increasing concern during this war, as we realize that people may have been exposed to conditions in which they might have received a TBI without really being aware of it," Southwell says.
If a service member has TBI warning signs, Southwell and his staff administer the Military Acute Concussion Evaluation (MACE), a cognitive evaluation tool first fielded in August 2006.
The brain injury center developed the five-minute evaluation to accommodate medical personnel in Iraq and Afghanistan who need to quickly assess head injuries during, for example, a street fight, says Kathy Helmick, manager of the Office of Clinical Standards for the DVBIC.
MACE's first section consists of a series of questions seeking details on what happened, including whether or not the person can remember events immediately before or after the incident, whether they experienced an alteration of consciousness, and other symptoms.
The second section is an examination drawn from the Standardized Assessment of Concussion, an evaluation developed by Michael McCrea, PhD, of Waukesha Memorial Hospital.
Helmick credits McCrae and neuropsychologists Jeffrey Barth, PhD, Louis French, PsyD, and Angie Drake, PhD, for their assistance in developing the MACE.
Besides being employed at hospitals such as Landstuhl, Army medics, Navy corpsmen, physicians' assistants, nurses and doctors in Iraq and Afghanistan have all been trained in how to use the MACE.
"We needed to get it down to the masses, so we could help the most people," Helmick says.
At Landstuhl, service members who score below a cutoff point on the MACE are referred for more neurocognitive assessment and treatment at one of the designated medical centers such as Walter Reed or Brooke Army Medical Center in San Antonio once they reach the United States.
In March, of the 240 inpatient service members interviewed at Landstuhl, 80 screened positive for TBI symptoms and were administered the MACE.
After being stabilized at Landstuhl, the next stop for many service members who need more medical evaluation, assessment and treatment for a TBI is often Walter Reed.
At Walter Reed, Louis French, PsyD, serves as the clinical chief for DVBIC. A joint activity of the Department of Defense and the Department of Veterans Affairs, DVBIC runs eight U.S. treatment and research sites dedicated to researching and improving treatment of TBI.
Assessing whether a patient has suffered TBI can be challenging, given that the severely wounded patients are often dealing with the disorienting effects of intense pain, extended sleep deprivation, and an abrupt separation from their unit and the "hypervigilance" needed to function in a combat zone.
"It's not a trivial thing, for somebody to go from a place where people are trying to kill you every day, to a safe place...and for your mind to turn that off is not a simple thing," French says.
Challenges of rehabilitation
For patients who need more rehabilitation than Walter Reed can provide, the next stage of treatment is a VA hospital, particularly one of four "polytrauma centers" established by the VA in response to the new patterns of injuries caused by blasts. The VA's centers collaborate with the brain injury centers.
At one of those, the James A. Haley Veterans Hospital in Tampa, Fla., for example, a team led by neuropsychologist Rodney Vanderploeg, PhD, works with patients on compensation strategies for memory loss, such as writing down the day's schedule in a three-ring binder.
"If you can't remember it, [our goal is to] teach you ways you can organize yourself so you can accomplish the things you need to," saysVanderploeg, clinical director for the brain injury program.
Patients with a moderate to severe TBI might need physical therapy to learn such basic skills as how to get up in the morning and put their clothes on or how to walk smoothly again, Vanderploeg says.
Motivation can also be a challenge, especially as patients become more aware of their impaired cognitive functioning. That's when anger and depression can set in, as patients start to understand the scope of the challenge they face, he says.
"People can get so overwhelmed by that, that they refuse to get out of bed," he says.
Many patients must also cope with post-traumatic stress disorder (PTSD), in addition to a TBI. Some remember coming back to consciousness when they were injured, seeing their friends wounded and dying, and being unable to help.
Dealing with a patient who already has a decreased ability to cope and concentrate because of PTSD- combined with the cognitive difficulties of a TBI-isn't something psychologists often encounter in the civilian world, he says.
"Treating that in the course of acute rehabilitation is a real challenge for the whole clinical team, and that's a new challenge for psychology," Vanderploeg says.
Back into the community
After treatment at a hospital such as Walter Reed and a VA facility, two longer-term DVBIC programs aim to return service members back toactive duty-or, if that's not possible, a productive civilian life.
At Virginia NeuroCare, in Charlottesville, Va., up to eight patients live in a group home called Grove House, a two-story, wood-framed house in a quiet hillside neighborhood.
While Virginia NeuroCare was started in 1996, a second residential program for service members, Laurel Highlands Neuro-Rehabilitation Center in Johnstown, Pa., was set up in 2005 by George Zitnay, PhD.
Jeffrey Barth, PhD, a neuropsychologist at the University of Virginia and Virginia NeuroCare's senior scientist, relies on neurocognitive evaluations to gauge each person's strengths and weaknesses, and other tests to measure evels of depression and other emotional stressors, he says.
Patients work with speech psychologists, as well as physical and occupational therapists. During the day, patients have individual and group therapy, and chances to work at the facility's used book store in town, prepare lunches at the Salvation Army Center or work in several other settings to ease their entry back into work. Patients who are functioning better get back into uniform and work at the Judge Advocate General school, the training site for military lawyers.
Supervised by staff, they cook meals together and do handy-man work around the house and yard. On their own time, they take trips together to shopping malls or see a movie as a group.
From the time a person sustains a TBI, there's a two-year window of natural healing that takes place, when rehabilitation needs to be intense and focused for the best results, Barth says.
"Our rehabilitation task is to get them back to the level they were prior to the injury, or as close as possible, but with some we can't, so we're trying to make them functional enough to fit back into their communities," Barth says.