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 consider the possibility that there may be underlying combat-related physiologic effects.
The overlapping and multisystem health symptoms reported by warriors from every generation have been given different labels, and have led to debates among medical professionals as to whether these are mediated primarily by physical or psychological causes. For example, World War I produced extensive debate about whether "shell shock," diagnosed in more than 80,000 British soldiers, was neurologic ("commotional" from the brain being shaken in the skull by concussive blasts) or psychological ("emotional" or "neurasthenia") in origin. World War II veterans were said to suffer from "battle fatigue," Korean war veterans developed "combat stress reactions," and Vietnam veterans developed the "post-Vietnam syndrome." The role of environmental exposure (e.g., agent orange) and psychological causes (alcohol addiction, drug addiction, and PTSD) continue to be debated.
Gulf War I led to extensive debates as to whether Gulf War syndrome, also known as multisystem illness, was best explained by environmental exposures (e.g., oil fires, depleted uranium, nerve gas, multiple vaccinations) or the psychological stress of deployment to a war zone where there was anticipation of high casualty rates from chemical and biologic weapons and stressful training exercises involving the use of impermeable full-body protective uniforms (made from rubber, vinyl, charcoal impregnated polyurethane, and other materials) in desert conditions under extreme temperatures. Although no clinical syndrome was ever definitively confirmed among the nearly 1 million service members who deployed in 1990–1991, studies consistently found that military personnel who served in the Gulf experienced elevations in generalized symptoms across all health domains (e.g. physical, cognitive, neurologic, psychological) compared with service members who deployed elsewhere or did not deploy. In addition, there is good evidence that deployment to the Persian Gulf region during this period was associated with subsequent development of PTSD; other psychiatric disorders including generalized anxiety disorder, depression, and substance abuse, particularly alcohol abuse (Chap. 392); functional gastrointestinal symptoms such as irritable bowel syndrome (Chap. 296); and chronic fatigue syndrome (Chap. 389).
The conflicts in Iraq and Afghanistan have led to similar debates as to whether postwar symptoms such as headaches, irritability, sleep disturbance, dizziness, and concentration problems are best attributed to concussion/mTBI or to PTSD. Several studies have shown that either PTSD or depression explains the majority of the postdeployment "postconcussive" symptoms attributed to concussion/mTBI, a finding not well received by some experts in traumatic brain injury (TBI) but consistent with civilian studies on risk factors for developing persistent symptoms after concussion. As in past wars, it has taken years to understand how PTSD and concussion/mTBI interrelate with other deployment-related health concerns, and the implications for designing effective evaluation and treatment strategies.
Veterans understandably may become angry at the suggestion that their postwar health concerns are stress-related or psychological, and thus it is necessary for primary care professionals to be sensitive to this concern.