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Screening for concussion/mTBI is now routine for veterans returning
from OIF and OEF. However, this is leading to concussion/mTBI being
underdiagnosed, overdiagnosed, and misdiagnosed because of the lack
of any definitive way to make the diagnosis so many months or years after
injury. Many warriors who had concussions during deployment have not
been evaluated or treated. More important, many warriors with serious
postwar symptoms, such as headaches, rage, memory problems, and sleep
disturbance, have been mistakenly told that their symptoms are due to
the lingering effects of a brain injury, when they're actually due to other reasons. Widespread screening for concussion/mTBI may actually be
causing warriors who are not brain-injured to believe that they are.

Some health professionals (and warriors) consider that it's better to
be diagnosed with a brain injury than with a mental disorder (PTSD), and
the mTBI label is sometimes being used instead of PTSD. This is problematic, since the treatments are completely different. Many warriors are
undergoing complex neuropsychological evaluations of memory, concentration, attention, and other cognitive abilities. However, these tests are
often inconclusive, even when baseline measures have been obtained for
comparison. Neuropsychological tests cannot distinguish concussion from
other potential causes of cognitive complaints, such as sleep disturbance,
coexisting medical problems, fatigue, anxiety, depression, or PTSD. The
physiological effects of PTSD have been shown in several studies to be a
much more likely cause of long-term concentration, attention, and memory problems after combat than concussion. Making an incorrect diagnosis can lead to the use of potentially harmful treatments or medicines that
have side effects.

Here are the key things you should know about treatment:

TREATMENT FOR CONCUSSION/mTBI

• The one treatment proven to be effective for concussion/mTBI
is rest immediately after the injury combined with education on
what to expect. Once weeks or months have passed after the injury,
treatment becomes focused on alleviating specific symptoms, such as
sleep difficulties, headaches, or cognitive problems.

• Many postwar symptoms, including those related to concussion/
mTBI, are interconnected. Problems with anger, sleep disturbance,
cognitive problems, being revved up physiologically, pain, and other
symptoms go hand in hand. For example, if you're experiencing
memory or concentration problems, the most important initial
treatment may be to ensure that there is good sleep and control
of physiological symptoms related to being revved up, irritable,
or angry. However, if headaches, nightmares, or pain are partially responsible for the sleep disturbance and irritability, these problems
may need to be addressed first.

• Although treatment is available for your postwar health concerns,
including those related to concussion, there are some caveats that
you should be aware of. Many war-related health problems, including
persistent ones after concussion, are probably best addressed initially
byyour primary care provider, who has the most experience in treating
a ,wide range of health concerns. That being said, sometimes primary
care providers don't have enough time during brief appointments to
address all concerns, and may be inclined to refer you to a specialist
for further evaluation or treatment. Some debilitating problemslike fatigue, cognitive problems, and pain-can be very difficult
to treat, and are best addressed through collaborative approaches
involving several professionals coordinated through primary care.
However, evaluation by specialists can be a double-edged sword.
Although specialists are skilled in the latest modalities of evaluation
and treatment for their particular area of expertise (which can be of
benefit to you), they often have little or no knowledge of effective
treatments from other fields of medicine that may be relevant for
the types of problems that you have. When the diagnosis is uncertain
or involves multiple potential causes, specialists are more inclined
than primary care professionals to attribute them to a disorder that
they have the most expertise in, which may not be the right answer.
Many specialists in concussion/mTBI have ignored evidence on
effective collaborative treatments based on lessons learned from
past wars and from studies conducted in primary care of how best
to treat overlapping conditions when symptoms have more than one
possible cause.

• Being referred to specialists for war-related symptoms can sometimes
feel like being thrown around like a Ping-Pong ball, which can
contribute to high distress, frustration, and worsening health
problems. When you visit multiple specialists, there is a higher
likelihood of being given several medicines that may not interact well
with each other. If you're on several medicines, you could be at risk for complications unless your primary care provider is coordinating
the care, monitoring the potential interactions, and isn't reluctant to
change medications recommended by specialists. This may be difficult
for your primary care provider to accomplish in the time allotted for
your care. Visiting different specialists can also consume a lot of your
time, which may affect your work or other aspects of your life.

• Sometimes the key to successful recovery is actually to do less.
There are no easy answers. This is a product of the system that
we operate in, and the only thing you can do is be aware that this
is going on and ask questions about your care at each step along
the way.

• There is no distinction between "psychological," "stress-related," and
"physical" symptoms related to war. All symptoms have a physical
and physiological basis involving neurological, endocrine, and other
systems in the body. They need to be addressed if they are causing
functional impairment sufficient to interfere with your life. All have
to be addressed simultaneously, which is why multidisciplinary and
collaborative care approaches involving primary care professionals
is so critical. There is no split between the body and mind. Medical
professionals need to learn how to communicate this better so
that warriors don't feel like their debilitating symptoms are being
dismissed as "stress" or "psychological" problems. In turn, warriors
can help by gently reminding the medical community to stop splitting
up symptoms into convenient groups and labels, stop arguing about
their causes, and focus on finding the best treatment approaches for
the full range of overlapping symptoms, regardless of their causes.

• Chapter 4 will present more discussion on the physiological
processes associated with war. Many of the exercises and skills in the
remainder of this book can be beneficial to your overall physical and
cognitive health by reducing the degree to which your body may be
physiologically revved up as a result of your wartime service.

• The VA has established regulations for disability concerning
problems associated with concussion/mTBI that do not appear to be based on validated medical criteria. However, this is not
necessarily bad for warriors. Because there is no definitive way to
prove that postwar cognitive problems or other symptoms (e.g.,
irritability, sleep disturbance, fatigue, dizziness, headaches, etc.)
are not due to concussion/mTBI, it would seem difficult to deny a
disability claim under the current regulations as long as there's a
history of concussion/mTBI during military service and a medical
provider who makes a determination that your current symptoms
might be related to this. However, don't consider yourself "braininjured" if you apply for a concussion/mTBI disability. Just because
you had a mild brain injury on the battlefield doesn't mean that
you're brain-injured now. What you're likely experiencing are the
expected physical, cognitive, or behavioral symptoms that warriors
have experienced after every war; concussion may have contributed,
but is probably not the only factor. The brain can heal even after
very serious injuries, and there are many things that can be done
to alleviate these concerns. It's important for your health to have a
good understanding of these issues and to have a positive outlook.
Positive expectations actually improve the physical health of the
body.

SUMMARY

In summary, don't get caught up in the mTBI versus PTSD debate. Recognize that combat in itself, as well as combat-related injuries of all types, can
lead to a variety of physical, behavioral, and cognitive reactions, and these
are closely connected to each other. There is no mind-body split, and all
postwar health concerns need to be addressed together. Have confidence
that there are many things that can be done to alleviate these reactions
to promote a healthy and fulfilling life despite injuries or other traumas
that you may have experienced during your service in the war zone. You
deserve to receive the very best care available.

I was less prepared returning home than when I deployed;
wooden was the word my wife used to describe me, reflecting the
emotion that I had maintained downrange, the "put your mind
on the tasks at hand and drive on" emotion, the "throw your shit
at your feet and buckle in" emotion, the emotion that is embodied in the moment when the convoy commander, who only seconds
before was joking around with the crew, gives the signal to move
out, that split-second switch on the faces of the whole team as we
move from lightheartedness to the business at hand, the business of
going "outside the wire, " the business of statistics, where no matter
how well you prepare, no matter how many good-luck charms you
carry, or how many people you have in your life to pray for you,
you are simply at the mercy of "Randome, " the goddess of surreal,
the feline beast that distorts time as it maims or kills in a slowmotion deafening wave.

MEDICAL OFFICER, POST-IRAQ

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