PTSD, TBI, or Both?
A changing brain science paradigm.
Posted Mar 20, 2020
The history of the diagnostic term post-traumatic stress disorder (PTSD) weaves back to the diagnoses of "shell shock" during World War I, and even earlier to the Napoleonic Wars and the American Civil War.
Dr. Charles Samuel Myers, a consulting psychologist and physician to the British Army during World War I, first coined the term "shell shock" to describe the neurobehavioral difficulties—including emotional and cognitive breakdown and problems with balance—that military physicians observed in soldiers incapacitated due to combat exposure. It is estimated that 80,000 British soldiers suffered from shell shock, and 100,000 German soldiers were treated for what was termed "hysteria" in military field hospitals during World War I.
Myers argued that the stress of war could cause a mental breakdown that had nothing to do with moral fiber or mental illness. He believed that the soldiers’ symptoms could be transient and were not due to defective genetics as some had hypothesized. His recommended treatment involved psychological support and rest. Myers’ approach was much more preferable to the firing squad at dawn that a number of suffering British soldiers tragically faced. He remains one of the unsung heroes of psychology from whose legacy we continue to benefit.
Anthony Babington’s book Shell-Shock: A History of the Changing Attitudes to War Neurosis described earlier terms for soldiers breaking down under the strain of combat conditions. Pre-World War I, the term "nostalgia" was commonly used as a diagnosis for soldiers becoming depressed from the harshness of the conditions to which they were exposed, in combination with obsessive idealized fantasies of the home lives they sacrificed when entering the military. The term "irritable heart" was also commonly used as a diagnosis for soldiers’ conditions.
Physician attitudes of that era ranged from contempt to curiosity for the soldiers who became incapacitated from combat. Conditions such as blindness and paralysis were documented in military medical records. These cases were difficult for physicians to understand as there was no apparent physical injury and the cases were indolent to recovery.
Babington writes about American military surgeons during the Civil War theorizing about the sudden development of battlefield paralysis. The battlefield surgeons believed that wind from a shell passing close to a soldier’s spine could cause paralysis in one or more of his limbs. They referred to this mechanism as windage.
Babington quotes a Union Army Surgeon, Huntington, who described the supposed pathogenesis of windage. Huntington stated, “It is now conceded by modern surgeons that, without the actual contact of the projectile, injuries can occur; on the other hand, it is admitted that slight contact from the grazing or brushing of a projectile, or the rolling motion of a cannonball over the surface of the body, may by the weight and momentum, aided by the elasticity of the skin, effect most serious results, while little or no external evidence of such contact is left,” (Babington, 1997).
Similar to the theory of windage, cases of what was termed "cerebrospinal shock" were reported during the Napoleonic Wars. Symptoms included tingling, twitching, and paralysis that resulted from the soldiers’ proximity to explosions, or exposure to the passage of a projectile in what was termed a wind contusion (Jones & Wessely, 2005).
More recent terms to describe groups of medically unexplained symptoms have been classified under War Syndromes or Post-Combat Disorders (Hyames, K.C., Wignall, F.S., and Rosewell, R., 1996). Such conditions include headaches, cardiac irregularities, blindness, amnesia, depression, anxiety, sleep disturbances, loss of appetite, paralysis, and nightmares.
It is only with the more recent wars in the Middle East that physicians and neuroscientists have begun to develop a greater understanding of the impact of the concussive forces from explosions on the nervous system. An interesting article by Chen and Huang (2011), describes the theoretical injury to the brain from explosion exposure due to rapid physical movement and displacement of blood from a blast overpressure wave.
According to Chen and Huang’s theory, a blood surge, due to elevated overall pressure in the ventral body cavity after torso exposure to the blast wave, may move through the blood vessels to the low-pressure cavity from the high ventral body cavity. This movement of blood dramatically increases cerebral perfusion pressure and causes damage to both tiny cerebral blood vessels and the blood-brain barrier. Thus, blood acts as a transmission medium to propagate a pressure wave to the brain. Brain injury then results due to a sudden fluctuation in perfusion pressure, and brain tissue is damaged due to a volumetric blood surge.
A controversy has arisen. Are the symptoms resulting from combat injuries diagnosed as post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), or both? Researchers are currently exploring the effects of concussive shock waves on the endocrine system and starting to implement possible treatment protocols. Their findings have demonstrated that hormonal treatments result in positive physical and mental health symptom improvements. Dr. Mark Gordon of Millennium Regenerative Centers is one such researcher who has been conducting cutting edge studies with hormone replacement and nutraceutical treatments that are showing encouraging results in reducing inflammation from injury pathogenesis (Gordon, 2018).
Over the past three decades, mental health clinicians have presumed that PTSD, war neurosis, or combat fatigue can only cause psychological symptoms. However, there is now an emerging understanding and increasing evidence to suggest that these conditions may also cause debilitating physiological changes. We are on the threshold of a more comprehensive neuroscientific understanding of how humans are damaged by the conditions of war and what can be done to heal their injuries.
Helping to broaden and encourage our understanding is Dr. Daniel Amen’s illuminating work with SPECT scans which produce neuroimaging to show blood flow patterns in the brain. The scans show areas of under- or overactivity in the brain. In PTSD, the brain scans show areas of overactivity. In TBI, the brain scans show areas of underactivity. Amen has found that there can also be both over- and underactivity in combined PTSD/TBI cases (Amen, 2017).
To date, the general mental health approach for psychological conditions like PTSD has been solely focused on treatments with psychotherapy or psychotropic medications—however, additional treatment protocols based in neuroendocrinology and neuropsychology may now offer vastly improved treatment results. It’s an exciting time of discovery that calls for embracing research findings and adapting new, interdisciplinary treatment protocols to help both injured soldiers and civilians suffering from PTSD and traumatic brain injury regain the quality of their lives. The practices of psychotherapy and psychiatry must become better integrated with neuroscience as a progressive, expanding paradigm of injury, inquiry, and recovery is upon us.
Amen, D. (2017, September, 2017). How to Know If You Are Suffering From PTSD. Retrieved
Babington, A. (1997). Shell-Shock: A History of the Changing Attitudes to War Neurosis.
Barnsley, England: Pen & Sword Books.
Chen, Y., Huang, W. (2011). Non-impact, blast induced mild TBI and PTD: Concepts and
Caveats. Brain Injury, 25 (7-8).641-50. DOI:10.3109/02699052.2011.580313.
Hyames, K.C., Wignall, F.S., Rosewell, R. (1996). War Syndromes and Their Evaluation: from
the U.S. Civil War to the Persian Gulf War. Ann Intern Med, 125 (5). 398-405.
Jones, E. & Wessely, S. (2005). Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf
War. Hove, England: Psychology Press