Articles Posted in Psychological Injuries

If the march of history has shown us anything, it is that technological advances are often the result of armed conflict. We have seen that in striking detail in the Iraq and Afghanistan conflicts. One of the most unfortunate consequences of these conflicts is that they have dramatically highlighted the armed services’ inability to effectively screen and treat traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) in returning soldiers. Another consequence is that the fact that soldiers have suffered TBI and PTSD in ever increasing numbers has forced research forward concerning these intractable disorders. In recent weeks, several articles of note crossed our desks here at the Alaska Personal Injury Law Group.

The Government Accounting Office (GAO) just released a report that underscored the Dept. of Veteran’s Affairs’ (VA) continuing inability to identify and provide services to affected veterans. This is true despite a pledge by the VA Secretary, Jim Nicholson, last April to promote new screenings for brain injury and a personal promise to see the changes through. The GAO reviewed nine VA medical centers, and found that there were problems in securing follow-up appointments after the veterans initially tested positive under the VA’s TBI screening tool. Two of the medical centers did not follow the screening tools protocol because they failed to use the symptom checklist, which they said was because they didn’t know the checklist existed or because they had inadequate staffing. The GAO also identified poor rural access to services resulting in a 50% decrease in the ability to provide care. It is estimated that as many as 20% of US combat troops who fought in Iraq and Afghanistan are believed to leave with signs of TBI.

At the end of January, the New England Journal of Medicine published a study submitted by specialists at the Walter Reed Army Institute of Research that added further to the controversy about how veterans should be screened and treated upon their return. Studying outcomes for over 2500 soldiers, the researchers found that soldiers with mild traumatic brain injury, particularly those who had suffered loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and post-concussive symptoms than were soldiers with other injuries. After the data was adjusted, the researchers concluded that mild traumatic brain injury with loss of consciousness was strongly associated with PTSD and depression. Over 43% of soldiers reporting TBI with loss of consciousness met criteria for PTSD, compared with 27% of those with the lesser brain injury from an altered mental status following their injury. TBI with loss of consciousness was also significantly associated with major depression. The difficulties the soldiers faced may therefore be more attributable to the result of intense psychiatric reactions to battlefield events, rather than a structural injury to the brain. This may be good news in that there are treatments for PTSD and depression, and very few medical treatments available to those who have suffered a structural injury to the brain.

Depression is often one of the difficult conditions clients of the Alaska Personal Injury Law Group face following traumatic brain injury (TBI). Depression is suffered by about 5% of the general population, but over 40% of those recoverying from head trauma can suffer from depression. Until now, it has been difficult to understand how depression and TBI are linked, although that association has long been known.

Studying athletes who suffered concussions, the researchers at the Montreal Neurological Institute of McGill University have shown the neurological basis for depression in a study published this week in the Archives of General Psychiatry. They studied 40 concussion victims against healthy subjects and found through the use of functional magnetic resonance imaging (fMRI) that the same areas of the brain were affected in both the athletes and those patients with major depression. Abnormal neural activity was found in the dorsolateral prefrontal cortex and striatum, as well as attenuated deactivation in the medial and temporal regions. Gray matter loss was also confirmed using Voxel based morphometry (VBM), a neuroimaging analysis technique that analyzes focal differences in brain volume.

This type of medical advance in imaging will help clients and care providers better understand why depressed mood is occurring after someone has had a traumatic brain injury. Ultimately, it is hoped that such imaging will lead to better diagnosis and treatment for those who suffer the devastating consequences of traumatic brain injury.

The Alaska Personal Injury Law Group often handles cases involving traumatic brain injuries(TBI). With severe brain injuries, the impairments suffered by the client are usually unmistakable to the client’s care providers and neurological experts testifying on their behalf. With “mild” brain injuries-although there is no such thing as a “mild” brain injury when it happens to you-the impairments are more nuanced and difficult to determine with standard neuroimaging or routine neurological and neuropsychological testing. Often clinicians have concluded that no impairments have occurred simply because there was minimal or no loss of consciousness reported when the brain injury was sustained. Now, advances in neurological imaging are establishing what we have already found to be true in our practice-cognitive impairments can occur even with minimal or no loss of consciousness.

In a study published in the October issue of the journal Brain, researchers at the University of Illinois’ Chicago College of Medicine report that diffusion tensor imaging (DTI) can identify structural changes in the brain’s white matter-which is particularly vulnerable to injury-even in patients identified as having minimal or no loss of consciousness. They studied 37 TBI patients with both diffusion tensor imaging and neuropsychological testing to evaluate memory, attention, and executive function. All the patients were at least six months post-injury, and most were highly functioning, i.e., in school or working at the time of evaluation. The structural white matter changes found by DTI correlated to cognitive deficits that were observable.

The researchers were also able to determine axonal damage-a tearing of the axons that allow one neuron to communicate with another-occurring the brain’s white matter. This differs from injury to the myelin, which is the protective sheath around the axons. Injury to the myelin can interrupt the signals between the brain and other parts of the body. The study showed that all severities of brain injury, even those typically viewed as “mild,” caused some degree of axonal damage, while myelin damage was only apparent in moderate to severe TBI.

One of the unfortunate consequences of the current conflicts in Iraq and Afghanistan is that veterans are returning with traumatic brain injuries and psychological injuries in such numbers that it is forcing the military and America to learn more about the devastating consequences of these injuries.

The New York Times today reported that PTSD has been linked to more than 120 murders committed by returning veterans. The study was conducted based on examining news reports, and is not a study based on scientific data. The New York Times’ study showed an 89% increase in such episodes, from 184 cases to 349 cases, since the conflict in Afghanistan began in 2001. While the Pentagon questioned the methodology of the study, the newspaper said its study was conservative. “This reporting most likely uncovered only the minimum number of such cases, given that not all killings, especially in big cities and on military bases, are reported publicly or in detail.” The Pentagon does not track this type of data regarding its veterans.

The victims were mostly known to the veterans involved, including spouses, girlfiiends, children and family members, but their victims were also strangers. Unfortunately, the soldiers themselves became victims. Thirteen of the veterans took their own lives after the killings, and two more were fatally shot by the police. Several more attempted suicide or expressed a death wish.