**6. Traumatic brain injury**

Posttraumatic stress disorder has been regarded as a signature wound of the wars in Iraq and Afghanistan. Of equal importance is the fact that *traumatic brain injuries* have been called the other signature wound of the wars (National Council on Disability, 2009). This section will focus on traumatic brain injuries due the pronounced overlap of this medical condition with posttraumatic stress disorder in soldiers returning from Iraq and Afghanistan. During the current wars, it is believed that up to 23% of soldiers have obtained a traumatic brain injury during deployment (Terrio et. al., 2009). In addition, 5% to 7% of Operation Enduring Freedom and Operation Iraqi Freedom soldiers are thought to have a probable comorbidity of posttraumatic stress disorder and a traumatic brain injury (Carlson et. al., 2011). Hoge and colleagues (2008), using a sample of 2525 Army infantry soldiers, found that 43.9% of soldiers who had lost consciousness after experiencing trauma to the head met criteria for posttraumatic stress disorder three to four months after returning from Iraq. Furthermore, 27.3% of the soldiers who solely experienced altered consciousness following a trauma to the head also met criteria for posttraumatic stress disorder. Although this is a biased sample due to an Army infantry soldiers' disproportionately high levels of combat exposure, it highlights the clear overlap of posttraumatic stress disorder and traumatic brain injury.

A traumatic brain injury diagnosis is given when an individual experiences an external disturbance to the head, resulting in trauma to the brain, and causing a lack of consciousness or diminished cognitive capacity (Department of Defense, 2007). A traumatic brain injury diagnosis is categorized in terms of severity and labeled as mild, moderate, or severe. In 2009, of the soldiers diagnosed with a traumatic brain injury, 78.4% of the cases were classified as a mild traumatic brain injury (Levin, 2010). A mild traumatic brain injury is defined as experiencing trauma to the head that causes a loss of consciousness for less than 30 minutes and an alteration of consciousness or mental state and posttraumatic amnesia for less than 24 hours (Department of Defense, 2007).

Soldiers in the current war frequently come into contact with explosive devices and as a result can obtain a traumatic brain injury in three ways (Department of Defense, 2007). A

clinician also controls the smells that are emitted from the "olfaction box" which includes various scents such as: burning rubber, body odor, and gasoline. Since all of these stimuli are presented simultaneously, it increases the reality of the virtual environment (A. A.

Individuals undergoing treatment with the Virtual Iraq technology typically come in twice a week for 90 minutes over the course of five weeks (A. A. Rizzo, et al., 2008). The initial sessions are dedicated to identifying the details of the traumatic event and teaching the client stress management techniques such as deep breathing. They are also taught how to use the technology and to rate their distress so that it can be used as a reference throughout treatment. In a study on the efficacy of this treatment modality, Reger and Gahm (2008) found that patient's PTSD Checklist score decreased by approximately 50% post-treatment and they also showed a significant functional improvement. A major criticism of this type of therapy is the cost of the technology. Although this complaint is justified, virtual reality may

Posttraumatic stress disorder has been regarded as a signature wound of the wars in Iraq and Afghanistan. Of equal importance is the fact that *traumatic brain injuries* have been called the other signature wound of the wars (National Council on Disability, 2009). This section will focus on traumatic brain injuries due the pronounced overlap of this medical condition with posttraumatic stress disorder in soldiers returning from Iraq and Afghanistan. During the current wars, it is believed that up to 23% of soldiers have obtained a traumatic brain injury during deployment (Terrio et. al., 2009). In addition, 5% to 7% of Operation Enduring Freedom and Operation Iraqi Freedom soldiers are thought to have a probable comorbidity of posttraumatic stress disorder and a traumatic brain injury (Carlson et. al., 2011). Hoge and colleagues (2008), using a sample of 2525 Army infantry soldiers, found that 43.9% of soldiers who had lost consciousness after experiencing trauma to the head met criteria for posttraumatic stress disorder three to four months after returning from Iraq. Furthermore, 27.3% of the soldiers who solely experienced altered consciousness following a trauma to the head also met criteria for posttraumatic stress disorder. Although this is a biased sample due to an Army infantry soldiers' disproportionately high levels of combat exposure, it highlights the clear overlap of

A traumatic brain injury diagnosis is given when an individual experiences an external disturbance to the head, resulting in trauma to the brain, and causing a lack of consciousness or diminished cognitive capacity (Department of Defense, 2007). A traumatic brain injury diagnosis is categorized in terms of severity and labeled as mild, moderate, or severe. In 2009, of the soldiers diagnosed with a traumatic brain injury, 78.4% of the cases were classified as a mild traumatic brain injury (Levin, 2010). A mild traumatic brain injury is defined as experiencing trauma to the head that causes a loss of consciousness for less than 30 minutes and an alteration of consciousness or mental state and posttraumatic

Soldiers in the current war frequently come into contact with explosive devices and as a result can obtain a traumatic brain injury in three ways (Department of Defense, 2007). A

prove to be a very valuable tool for clinicians that can afford to use it.

posttraumatic stress disorder and traumatic brain injury.

amnesia for less than 24 hours (Department of Defense, 2007).

Rizzo, et al., 2010).

**6. Traumatic brain injury** 

soldier is said to have a *primary blast injury* when they were close enough to an explosion to experience the extreme changes in atmospheric pressure, otherwise known as a "blast wave." A blast wave can easily permeate a combat helmet and can ultimately cause trauma to the brain. A *secondary blast injury* can be obtained when a fragment from the explosion hits the soldier on the head hard enough to cause brain injury symptoms. This type of injury can be external but may also permeate the skull. Lastly, a soldier is said to have obtained a *tertiary blast injury* when an explosion causes the soldier to either be knocked to the floor or into something resulting in trauma to the head.

Despite the high comorbidity, researchers continue to struggle to detangle the overlap of symptoms between posttraumatic stress disorder and traumatic brain injury. The residual symptoms that one experiences as a result of a traumatic brain injury are called *postconcussive symptoms*. Many of the symptoms associated with posttraumatic stress disorder overlap with postconcussive symptomology, which include irritability, memory deficits, sleep problems, and difficulty focusing attention (Kennedy & Moore, 2010). Some of the symptoms that can often be unique to a traumatic brain injury diagnosis include balance problems, dizziness, and headaches (Kennedy & Moore, 2010).

Brenner and colleagues (2010) examined the unique contribution of posttraumatic stress disorder and traumatic brain injury to a sample of injured Army personnels' endorsement of postconcussive symptoms (headache, dizziness, memory problems, balance problems, irritability). They concluded that soldiers with either posttraumatic stress disorder or a traumatic brain injury endorsed more postconcussive symptoms than those without a diagnosis. Those with both posttraumatic stress disorder and a traumatic brain injury endorsed more symptom prevalence than those with a single diagnosis. Although it is noteworthy that a comorbid posttraumatic stress disorder and traumatic brain injury diagnosis can increase postconcussive symptomology, it is also important to recognize that the co-occurrence of either disorder can reciprocally exacerbate the other (King 2008).

Researchers have speculated that standard treatments for posttraumatic stress disorder could be less effective when a comorbid traumatic brain injury diagnosis exists (Bryant, 2001; Carlson et. al., 2011). This is solely speculation because there has been limited research to explore the efficacy of current treatments for those with this comorbidity. King (2008) suggests that early education about postconcussive symptomology and an explanation of the reciprocal relationship of the co-occurrence of posttraumatic stress disorder and traumatic brain injury can aid in proper detection and treatment. It is important for further research to explore the effectiveness of treatment for those with a comorbid diagnosis due to the high prevalence of soldiers who suffer from the co-occurring disorders. In addition, it is important for clinicians to be aware that the presence of a mild traumatic brain injury in a patient with posttraumatic stress disorder may make recovery from the posttraumatic stress disorder more challenging (Chard et. al., 2011).
