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TBI and its links to PTSD Symtoms

Purple Hearts: A Cold-Blooded Decision

Conn Hallinan | January 28, 2009

Editor: John Feffer

Foreign Policy In Focus

Behind the recent Pentagon decision to deny Purple Heart medals to soldiers suffering from Post Traumatic Stress Disorder (PTSD) is a cold-blooded calculation: It saves money.

The official rationale for refusing to honor what is widely considered the “signature wound” of the wars in Iraq and Afghanistan is that PTSD, according to Pentagon spokeswoman Eileen Lainez, is “an anxiety disorder caused by experiencing or witnessing a traumatic event,” not “a wound intentionally caused by the enemy.”

But a recent study by the Rand Corporation found that up to 320,000 vets returning from the two conflicts suffer from Mild Traumatic Brain Injury (MTBI), a condition whose symptoms are almost indistinguishable from PTSD. Virtually all MTBI injuries are the result of roadside bombs, also known as improvised explosive devices (IEDs).
What is MTBI?

MTBI is a slippery beast. Its symptoms range from depression and uncontrolled rages to digestive problems, emotional disengagement, blinding headaches, memory loss, and sexual dysfunction. MTBI is also associated with higher suicide rates.

“It is a complicated injury to the most complicated part of the body,” says Dr. Alisa Glean, a chief of neuroradiology at San Francisco General Hospital and author of the standard text for imaging MTBI, who has been working with wounded soldiers at the Army’s Regional Medical Center at Landstuhl, Germany.

MTBI doesn’t show up on CAT scans, and its symptoms may not manifest themselves for several months or even years. There isn’t even full agreement on exactly what causes it. Some researchers think it’s just a concussion on steroids. But others point to injured tissue deep in the brain, which can’t be explained by a simple concussion hypothesis.

Whatever its origins, the consequences for sufferers can be catastrophic.

One of the major effects of MTBI is what Dr. Judith Landau, a psychiatrist who works with veterans’ families, calls “identity ambiguity: people who were decisive become indecisive. People who were charming become withdrawn.” She sees soldiers who “left as a good son, a good father, and a good husband” suddenly “start hitting their children, can’t have sex, start drinking too much, talking too loud.”

Like a stone thrown into a pond, this behavior ripples out to family, friends, and coworkers. “There is a 70% chance that relationships will break down” after a person suffers from MTBI, says Landau.

It’s possible to recover from MTBI, but the process may be long — sometimes from five to 10 years, according to Landau — and expensive. Some estimates reach at least $14 billion over the next 20 years.
Cold-Hearted Denial

Purple Heart awardees are entitled to enhanced benefits, including exemptions from co-payments for hospital and outpatient care. They are also fast-tracked for getting appointments for medical care and psychological services.

Soldiers come home to few psychological services and virtually no individual therapy. It isn’t uncommon to wait several months to see a therapist, and then only once a month. MTBI sufferers may see as many as seven different therapists.

The military has made little effort to deal with MTBI and PTSD. Soldiers suffering from PTSD outnumber amputees at Walter Reed Hospital 43 to 1, but there is no PTSD center. After diagnosis, sufferers usually go to the hospital’s psych division, where they are housed with bipolar and schizophrenic patients and tanked up with drugs. A study by Veterans for America (VFA) found that some soldiers were taking up to 20 different medications at once, some of which canceled out others.

The military has lost 22% of its psychologists over the past several years, mostly to burn-out. Soldiers have difficulty finding private therapists because the Department of Veterans Affairs pays below market rates and even cut those reimbursements in 2007. About 30% of private psychologists won’t take on military patients because they can’t afford to. The situation is worse for the National Guard and Reserves, who make up almost 50% of the troops deployed in both wars and who, according to VFA, “are experiencing rates of mental health problems 44% higher than their active duty counterparts.” Health care for such troops is generally inferior — and more expensive — than that offered full-time regulars.

Many soldiers are also reluctant to report their symptoms because they are afraid it will keep them from getting a promotion or landing a job once they leave the military. Only 53% of those diagnosed with MTBI sought help and, according to the Rand Study, “roughly one-half got minimally adequate care.”

Worse, solders who report behavioral difficulties may find themselves discharged from the service, with the consequent loss of medical care. They may even be billed for their recruitment bonus.

PTSD and MTBI both result from deployment in combat zones. Large numbers of these soldiers were exposed to IEDs — the number-one cause of death and injury in Iraq and Afghanistan — but many didn’t suffer visible injuries. To make “shedding blood” the only criterion for being awarded a Purple Heart (and the benefits that go with it) is to deny the nature of the wars the United States is currently fighting.
Time for a Change

In contrast, the Canadian military awards a Sacrifice Medal to those who have suffered “mental disorders that are, based on a review by a qualified mental healthcare practitioner, directly attributable to a hostile or perceived hostile action.”

A recent editorial in the Globe and Mail charged that the Pentagon’s decision applies “19th century medical standards to what constitutes injury,” and that the ruling “will further stigmatize mental illness and fails a group of veterans whose sacrifices can be every bit as great as those with physical injuries.”

In his recent testimony before the Senate Committee on Veterans’ Affairs, the new director of the Department of Veteran Affairs, Gen. Eric Shinseki (Ret.), promised to care for wounded veterans “bearing scars of battle, some visible and many others invisible,” and to “treat our veterans with dignity and respect.”

These are fine words, but so far the military has stubbornly resisted treating these so-called “unseen damage” injuries that Iraq and Afghanistan is inflicting on U.S. soldiers. “Many soldiers and veterans are waiting months, often years, for mental healthcare and disability benefits,” says Veterans for Common Sense director Paul Sullivan.

Fewer than half of those Iraq and Afghanistan vets diagnosed with PTSD or MTBI have received disability benefits. One Veterans Affairs psychologist in Texas even urged VA staff to “refrain from giving a PTSD diagnosis” and consider instead “a diagnosis of adjustment disorder.” PTSD sufferers receive up to $2,527 a month, adjustment disorders significantly less.

Terri Tanielian, the co-leader of the Rand Corporation study, says, “There is a major health crisis facing those men and women who have served our nation in Iraq and Afghanistan. Unless they receive appropriate and effective care for these mental health conditions, there will be long-term consequences for them and for the nation. Unfortunately, we found there are many barriers preventing them from getting the high-quality treatment they need.”

The major barrier is pentagon-shaped. And the bottom line is that, given a choice between buying fancy weapons systems and taking care of soldiers damaged by war, the military will always choose the former over the latter.

NY Times

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Published: January 7, 2009

The Pentagon has decided that it will not award the Purple Heart, the hallowed medal given to those wounded or killed by enemy action, to war veterans who suffer from post-traumatic stress disorder because it is not a physical wound.

Chris Ramirez for The New York Times

The Purple Heart will be given for physical wounds only.

Readers’ Comments

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The decision, made public on Tuesday, for now ends the hope of Iraq and Afghanistan veterans who have the condition and believed that the Purple Hearts could honor their sacrifice and help remove some of the stigma associated with the condition.

The disorder, which may go unrecognized for months or years, can include recurring nightmares, uncontrolled rage and, sometimes, severe depression and suicide. Soldiers grappling with PTSD are often unable to hold down jobs.

In May, Defense Secretary Robert M. Gates said awarding Purple Hearts to such service members was “clearly something that needs to be looked at,” after he toured a mental health center at Fort Bliss, Tex.

But a Pentagon advisory group decided against the award because, it said, the condition had not been intentionally caused by enemy action, like a bomb or bullet, and because it remained difficult to diagnose and quantify.

“Historically, the Purple Heart has never been awarded for mental disorders or psychological conditions resulting from witnessing or experiencing traumatic combat events,” said Eileen Lainez, a Pentagon spokeswoman. “Current medical knowledge and technologies do not establish PTSD as objectively and routinely as would be required for this award at this time.”

One in five service members, or at least 300,000, suffer from post-traumatic stress disorder or major depression, according to a Rand Corporation study in 2008.

For some soldiers suffering from the disorder, the historical distinction between blood and no blood in an injury fails to recognize the depths of their mental scars. A modern war — one fought without safe havens and with the benefit of improved armor — calls for a new definition of injuries, some veterans say.

Kevin Owsley, 47, who served in the Ohio National Guard in 2004 as a gunner on a Humvee and who is being treated for PTSD and traumatic brain injury, said he disagreed with the Pentagon’s ruling.

Unable to hold a job, Mr. Owsley supports his family on disability payments. This week he told his Veterans Affairs doctor he was fighting back suicidal impulses, something he has struggled with since his return. “You relive it every night and every day,” he said. “You dream about it. You can see it, taste it, see people getting killed constantly over and over.”

“It is a soldier’s injury,” he said, angrily, in a telephone interview on Wednesday.

But many soldiers do not feel that way. In online debates and interviews they expressed concern that the Purple Heart would be awarded to soldiers who faked symptoms to avoid combat or receive a higher disability rating from the Department of Veterans Affairs.

“I’m glad they finally got something right,” said Jeremy Rausch, an Army staff sergeant who saw some of the Iraq War’s fiercest fighting in Adhamiya in 2006 and 2007. “PTSD can be serious, but there is absolutely no way to prove that someone truly is suffering from it or faking it.”

The Purple Heart in its modern form was established by Gen. Douglas MacArthur in 1932. Some 1.7 million service members have received the medal, and, as of last August, 2,743 service members who served in Afghanistan and 33,923 who fought in Iraq had received the award.

The medal entitles veterans to enhanced benefits, including exemptions from co-payments for veterans hospital and outpatient care and gives them higher priority in scheduling appointments.

The Pentagon left open the possibility that it could revisit the issue.

But a Pentagon-supported service group, the Military Order of the Purple Heart, has strongly opposed expanding the definition to include psychological symptoms, saying it would “debase” the honor.

“Would you award it to anyone who suffered the effects of chemicals or for other diseases and illnesses?” John E. Bircher III, director of public relations for the group, said Wednesday. “How far do you want to take it?”

Post-traumatic stress disorder was first identified during the Vietnam War and has gradually been accepted as a serious psychological problem for some who experience violence and fear.

Dr. Barbara V. Romberg, a psychologist in Bethesda, Md., and founder of Give an Hour, which offers mental health services to troops and their families, said that she and many other psychologists believed the discussion of Purple Hearts had brought more attention to post-traumatic stress disorder and the seriousness of psychological wounds suffered on the battlefield.

“We’re working to normalize post-traumatic stress as an understandable human consequence of war that can result in very serious damage to some people’s lives, and they deserve honoring for that,” she said.

“But I don’t want to be so quick to condemn the decision,” she added.

Many have post-traumatic stress, but only some develop a serious lasting disorder; in both cases, she said, “people deserve to be honored in some way for the injury they received in combat.”

After years of criticism for ignoring the problem, the Defense Department and the Veterans Administration have bolstered their capacity to diagnose and treat PTSD, and those with serious cases may receive substantial disability benefits. Some of those suffering from severe traumatic brain injuries qualify for a Purple Heart because they required medical treatment.

But in its decision not to extend Purple Hearts to PTSD sufferers, first reported Tuesday by Stars and Stripes, the Pentagon said part of the problem stemmed from the difficulty in objectively diagnosing the disorder.

That decision was made in November. It was not clear why the Pentagon did not announce the decision then.

There have been recent changes in awarding Purple Hearts. The criteria was expanded in 2008 to include all prisoners of war who died in captivity, including those who were tortured. “There were wounds there,” Mr. Bircher said.

“You have to had shed blood by an instrument of war at the hands of the enemy of the United States,” he said. “Shedding blood is the objective.”


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