Bogus Identification of Mild Traumatic Brain Injury by Military in Iraq Vets

This week in the New England Journal of Medicine there is an article by military researcher Charles Hoge and colleagues about a topic that has been dear to me heart for some time now. Namely the bogus mis-identification of “mild traumatic brain injury (TBI)” in returning Iraq vets which has resulted in a screening criteria so loose that it applies to almost everyone. There is also an interesting back story in USA Today about how we got into such a pathetic state of affairs in the first place.

I work in an assessment clinic for returning Iraq vets at the Atlanta Ga VA, and I see people all the time who get labelled as mild TBI with little or no evidence that anything ever happened to their brains. The current classification states that mild TBI can be seen in any loss of consciousness of less than 30 minutes without evidence of gross head injury based on imaging or neurological exam. The problem is that the loss of consciousness can be as brief as a few seconds. Also, any change is consciousness can count, even just being dazed or momentarily confused or disoriented.

Iraq soldiers can't have pets, but they can assign them to combat duties. This is Fathead, one of the cats at Habbaniya assigned to keep the mouse population under control.

Most soldiers are driving around Iraq in armor plated vehicles like Humvees which are vulnerable to getting blown up by roadside remotely detonated bombs called Improvised Explosive Devices (IEDs). It is not uncommon for soldiers to get blown up at least once during their tour in Iraq. However, vecause of the nature of the armor protecting their vehicles as well as their persons, the most comment effect is a moment of confusion or disorientation that occurs during the “manic minute” when they establish their positions after getting blown up.

As the authors point out, this momentary confusion or disorientation or any other mental confusion attributable to the “fog of war” can result in soldiers being classified as having a mild TBI. This has led to the unfortunate situation where as many as one third of returning Iraq veterans are being labelled as having mild TBI, mostly incorrectly. In addition, as previous articles from these researchers have found, much of the pathology in those labelled as mild TBI is attributable to PTSD more than any specific head injury.

With sudden acceleration or deceleration of the head one can develop shear injuries, where the brain keeps moving in the skull after the head has stopped. This can be associated with damage to myelin and other problems that are not seen as gross damage on MRI, as would be seen if, for instance, an object penetrated the brain. However animal studies show that these kinds of injuries are associated with loss of consciousness of ten minutes or greater, which is nowhere near what is seen in the vast majority of those currently classified as mild TBI.

In the back story of how the military started screening in this way, several psychiatrists advised them, which led to the current screening protocol. There was also a great deal of worry in the Congress and in the popular sentiment about the dangers of a new generation of soldiers suffering from TBI and/or PTSD, which led to efforts by public officials to force the military to “do something”. Now the same psychiatrics who advocated the current screening criteria are saying that to not identify these people threatens to create a group of people with neurological problems down the road, like the current football players who develop chronic neurological problems following repeated concussions.

John Corrigan MD, an Ohio State University psychiatrist and researcher, was involved in giving the recommendations to the military on the guidelines on screening for mild TBI. Dr. David Hovda, director of the Brain Injury Research Center at UCLA, said that Iraq vets could meet the same fate as NFL football players who develop chronic neurological problems from repeated concussions.

But this misguided comparison is simply silly. The NFL football players have had multiple concussions with lengthy periods of loss of consciousness of 20 or 30 minutes or more. This simply cannot be compared to the brief confusion most soldiers experience after an IED explosion.