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Neuropsychiatric sequelae are common in combat veterans. Advances in personal protective body armor, armored vehicles, battlefield resuscitation, and the speed of evacuation to tertiary care have considerably improved the survivability of battlefield injuries, resulting in a greater awareness of the "silent wounds" associated with service in a combat zone. Although psychiatric and neurologic problems have been well documented in veterans of prior wars, the conflicts in Iraq and Afghanistan have been unique in terms of the level of commitment by the U.S. Department of Defense (DoD) and Department of Veterans Affairs (VA), Veterans Health Administration (VHA) to support research as the wars have unfolded, and to utilize that knowledge to guide population-level screening, evaluation, and treatment initiatives.


These conflicts, like previous ones, have produced hundreds of thousands of combat veterans, many of whom have received or will need care in government and civilian medical facilities. Studies have shown that service in the Iraq and Afghanistan theaters is associated with significantly elevated rates of mental disorders. Two conditions in particular have been labeled the signature injuries related to these wars: posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI)—also known as concussion. Although particular emphasis will be given in this chapter to PTSD and concussion/mTBI, it is important to understand that service in all wars is associated with a number of health concerns that coexist and overlap, and a multidisciplinary patient-centered approach to care is necessary.


Service members from the current decade of war have faced multiple deployments to two very different high-intensity combat theaters, and the cumulative strain has negatively impacted marriages, parenting, educational goals, and civilian occupations. The stresses of service in these conflicts have led to a significant increase in the rate of suicide in personnel from the two branches of service involved in the greatest level of ground combat (army, marines).


Service in a war-zone can involve extreme physical stress in austere environments, prolonged sleep deprivation, physical injury, exposure to highly life-threatening events and hazards such as explosive devices, sniper fire, ambushes, indirect fire from rockets and mortars, and chemical pollutants. Certain events such as loss of a close friend in combat, leave indelible scars. All of these experiences have additive effects on health, likely mediated through physiologic mechanisms involving dysregulation of neuroendocrine and autonomic nervous system (ANS) functions.


Veterans of virtually all wars have reported elevated rates of generalized and multisystem physical, cognitive, and psychological health concerns that often become the focus of treatment months or years after returning home. These multisystem health concerns include sleep disturbance, memory and concentration problems, headaches, musculoskeletal pain, gastrointestinal symptoms (including gastroesophageal reflux), residual effects of war-time injuries, fatigue, anger, hyperarousal symptoms, high blood pressure, rapid heart rate (sometimes associated with panic symptoms), sexual problems, and symptoms associated with PTSD and depression. In order to provide optimal care to veterans with these symptoms, it is important to understand how the symptoms interrelate, and to ...

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