U.S. military health officials are using an ambiguous and unvalidated
method of identifying mild traumatic brain injuries among troops returning
from service in Iraq and Afghanistan, according to three Army medical
The Department of Defense now uses a brief checklist after the troops
return from the war zones to screen for medical consequences of deployment.
Only one question on the Post Deployment Health Assessment (PDHA) form asks
about possible traumatic brain injury (TBI).
The resulting information does not amount to a case definition because it
lacks three essential criteria for use months after injury: symptoms, time
course, and impairment, wrote Col. Charles Hoge, Col. Carl Castro, and Herb
Goldberg in the April 16 New England Journal of Medicine. Hoge is
director of the Division of Psychiatry and Behavioral Sciences at Walter Reed
Army Institute of Research in Silver Spring, Md., and Goldberg is a
communications specialist there. Castro is a psychologist and director of the
Military Operational Medicine Research Program at Fort Detrick,
Concussion or Mild TBI
Is Not Like More Severe Versions
Previously, other military health officials have stated that as many as
360,000 (20 percent) returning troops have experienced at least transitory
effects of blasts from improvised roadside bombs or other explosives, although
half of those cases resolve by the time of return to the United States
(Psychiatric News, April 3). The remaining cases may require further
treatment in primary or specialty care, either in the Department of Defense or
the Department of Veterans Affairs (VA) medical systems.
As they return home, service members are asked to recall if they were
exposed to a blast and if they were also "dazed or confused" at
the time, were unconscious for less than 30 minutes, or had posttraumatic
amnesia due to concussion or mild TBI.
"Positive responses to this single, unvalidated question have
accounted for two-thirds of all reported cases of concussion/mild TBI,"
they wrote. The current system may be inflating the number of cases.
"The issue is one of 'caseness,' how to define a person with mild TBI
or concussion," explained Castro, in an interview with Psychiatric
News. "For any symptom-based disorder or injury, a case is based on
five factors, each of which has to be independently validated: an event, the
reaction to the event, symptoms, impairment, and a time course."
The 360,000 figure is based on only two of those elements, the event and
the reaction, neither of which has been validated, said Castro. "So
they're saying, 'The soldier has been injured, but he has no
Furthermore, high rates of these symptoms occur in healthy populations, and"
postconcussion syndrome" appears after injuries to areas other
than the head. Validation of current case definition is poor, he said.
Terminology is fluid, but usually TBI refers to the injury itself, and
postconcussive syndrome applies to what follows the injury, said James Couch,
M.D., Ph.D., a professor of neurology at the University of Oklahoma Health
Sciences Center and a spokesperson for the American Academy of Neurology. Much
of the controversy comes from the fact that many symptoms associated with
concussion or mild TBI—such as headache, sleep disturbance,
irritability, dizziness, balance problems, fatigue, or poor
concentration—are not specific to head injury, he said.
"[C]linicians' attribution of such nonspecific symptoms to
concussion/mild TBI is subjective," but the present screening process
assumes that they are causally related, wrote Hoge and colleagues.
They are also concerned that the present approach encourages negative
expectations about recovery, complicated by possible secondary gain, and
"This is an excellent review of the clinically sensitive and
policy-relevant consequences of poorly defined diagnostic criteria for mild
traumatic brain injury," said Darrel Regier, M.D., M.P.H., director of
APA's Office of Research and the American Psychiatric Institute for Research
and Education. "There has been reluctance in the Department of Defense
to use the diagnosis of postconcussive syndrome simply because of the stigma
attached to this being a mental disorder—however transient—rather
than a neurological disorder."
Failure to address the consequences of the current concepts of mild TBI
could easily lead to expectations of permanent brain damage for those so
diagnosed, as happened with soldiers returning from World War I diagnosed with
shell shock, said Regier.
Hoge, Goldberg, and Castro have received a mixed response from higher ups
to their recommendations.
"Some are supportive, some want more debate and discussion,"
said Castro. "We want to keep the discussion going until we get the
right mixture of policies and procedures in place."
In response to the perspective in the New England Journal of
Medicine, the Pentagon unit charged with researching TBI acknowledged
that there was no clear standard of care for it in the early years of the two
current wars, but it has been collecting data to improve screening and
clinical practice, said Michael Kilpatrick, M.D., director of strategic
communications for the Military Health Service.
"Today DoD [Department of Defense] continues to analyze the data that
have been collected to make the best scientific changes to processes to
optimally identify, document, and treat mild TBI/concussion," said
Kilpatrick in a prepared statement. "The Hoge paper is the expression of
an opinion supporting this scientific process."
How DoD and the VA ultimately define mild TBI will have implications not
just for diagnosis but for treatment, compensation, and long-term care for
"The research of Hoge and colleagues has guided discussions of the
DSM-V trauma-related diagnostic criteria and has helped APA improve
the Defense Department's proposals to the Centers for Medicare and Medicaid
Services and the CDC's [Centers for Disease Control and Prevention's] National
Center for Health Statistics to revise the ICD-9-CM classification of
cognitive and behavioral consequences of concussion and TBI," said
Castro sees the paper by him and his colleagues as just one element of a
continuing debate aimed at getting the best possible solution for TBI issues
"Charles Hoge and I want every service member to return home and live
a happy and productive life," he said. "If any program, policy, or
procedure for which the scientific evidence is not appropriate hinders that,
then we need to speak out."
An abstract of "Care of War Veterans With Mild Traumatic Brain
Injury—Flawed Perspectives" is posted at<http://content.nejm.org/cgi/content/short/360/16/1588>.▪