The OIF/OEF Cocktail: Shell Shock or mTBI and PTSD

I am often frustrated when people mistake mTBI and PTSD because they can be so different. Admittedly PTSD is the hardest thing I face from day to day, but that is because of mTBI. Anatomically speaking PTSD is the over stimulation or use of the Hypothalmic Pituitary Adrenal (HPA) Axis. There is no simple way to describe neurology, but I will do my best at explaining my experiences in relation to my limited understanding of brain anatomy. The HPA is a apart of the limbic system which is one of the oldest traits in the human body. Our dogs and horses are some of the best aids to PTSD because we share this structure even if our cortex functioning is very different. The HPA and limbic system creates a stress response by emitting the chemical cortisol (often called adrenaline) which gives you energy (anger), pulls the blood out of your extremities in preference to organs (you will simply feel tingling or numbness in your limbs), and activates a larger part of your brain making you hyperaware. Think of the golden hour a casualty has to get into surgery, and to get fresh blood and coagulants before they start to crash. That is the final aspect of the limbic system's response to stress: the crash that inevitably comes after your body works at such high levels. That feeling of extreme fatigue and the inability to sleep is a direct result of cortisol, and also why battle fatigue was one of the first terms for PTSD.

PTSD is the persistence of this complex stress response into non dangerous situations. This interplay works with the cortex because the limbic system will provide the stressors to your consciousness so that you can more quickly respond to similar situations in the future. The HPA cortex relationship is a two way loop that can be instinctually triggered, by the older limbic system or by the cortex's memory of previously stressful events. I can see the way that anatomy and social construction works together in my memory of soldiers saying that sooner or later we are going to jump when a car back fires just like all these other guys, already favoring the stress responses of previous groups of veterans through a learned behavior, as well as reflexive reactions to triggers common to the tactics of insurgents in Iraq and Afghanistan. I was blown up in a stairwell so I hyperventilate in stairwells to this day. The anatomy of stress, the events themselves and the way that others have responded socially all effect the way we experience danger as well as the way we choose to process our memory.

But this is a post about mTBI and PTSD. How does this matter?

mTBI is actually a lot less complicated neurological than PTSD, though the experience is incredibly complicated, the concussive nature of high explosives as well as hitting ones head generally damages the brain and most effects the frontal cortex. The brain's protective coating is damaged by concussion and the cortex gets slammed into your skull. This generally erodes your whole brain functioning, but has one set of symptoms that makes PTSD a lot harder to manage. Cortex injuries limit a person's impulse control, and when a person has been exposed to serious life or death situations they are more likely to have a cortex that always fires up the limbic system's response to any stressor. Hence why for me the graduate seminar table and public speaking will often trigger panic attacks. Also the anger I felt in battle is worse because my cortex is not as capable as it was prior to concussions or repeated exposures to explosions. Everything is worse because you have eroded impulse control and every part yourb rain as a system is not your own. Your body is literally not yours to control. The WWI and WWII crack ups were not solely PTSD, but also damage to the cortex from shelling, because as Jonathan Shay as observed, PTSD is actually useful in combat. You always want to fight or fly, but you fight better as a unit so your trained to stick to the plan, that is until blasts and concussions add to this mix and make it harder to control the stress impulse.

You crash because we are only designed to go that hard in brief instances: the golden hour. You become depressed because you are exceeding the capability of human anatomy, and because you are losing control of your impulses. Worse cortisol damages the conscious memory when it is overused and the center of your brain that is self aware is consistently damaged. Kurt Vonnegut referred to scouts, himself included, as people that were controlled by their spinal column, shared location with the limbic system, because he understood the human brain in a profoundly human and intellectual fashion, but when the cortex is damaged it is nearly impossible to stop this life or death impulsivity.

I can remember my first nightmare and flashback like it was yesterday. I had just shot an RPG gunner in Mosul, I had a flashback that day and a nightmare that night. I knew it was PTS and I didn't care, I managed it and was upfront with the Physician Assistant about it. It was war, of course it was going to be terrible, but it was important for me to continue to do my part. However, when I got a concussion I could no longer see what was going on as natural and I got way to stuck in my limbic system. Everything was extreme and everything remains life or death because no matter how smart I can make myself my cortex doesn't have the impulse control that I once had. I can know something, but not feel something, because the emotional stress response is more powerful than my ability to control that impulse. I perform amazing feats because I am running on an extreme and then I crash because I am going way to hard all the time. I know this, but it is almost impossible to control the powerful impulse. I just hope I never lose the ultimate battle to the natural and constant ups and downs that come with the OIF/OEF cocktail.

Congressionally Mandated Longitudinal Research on Traumatic Brain Injury

To improve our understanding of TBI in a military cohort by developing a data repository that contains clinical interview, neurobehavioral, neurocognitive, neuroimaging, blood specimen, and sensory/motor data on service members who were injured since October 2001 during deployment to OIF/OEF.

Exploring the Natural History of Traumatic Brain Injury Within a Military Cohort – A Longitudinal Database and Blood Banking Study

Congressionally Mandated Study on Caregivers for Veterans with TBI

If you are a caregiver of a service member or veteran who served in OIF/OEF and returned with a moderate or severe TBI, you may be eligible to participate in a study requested by Congress. If you or someone you know may be interested, please call 1-855-821-1469 or email caregiver.study@dvbic.org.

Caring for Caregivers

Remembering The Boston Marathon Attack: There Were More Heroes than Villains Today

A Veteran from TRWB using his shirt as a bandage

It is often assumed that the memory of an event is solely based on what actually happened, rather than a process that occurs overtime and through a purposeful process. Like many other veterans, this day was harder for me because all the images of carnage conjured up memories of similar tragedies. I have been watching the images and has sent me back to the aftermaths of suicide bomber attacks on civilians. That is my weight to bear and is less important than trying to make sense of days like today. All of the television footage of the explosions do not hold a candle to what was actually experienced.

With the shock-wave of high explosives sensations of heat and concussion hit you before your brain can process the image. So the television cameras are less of  an expression of the actual experience, instead, they provide an illusion of clarity. When you see people still running forward its because their brains haven't even put two and two together yet. It is worse for the injured because they are physically affected by the injuries prior to even full rationalization of what is happening.

When you come to a location after a bombing, people have almost no understanding of their injuries. The adrenaline of the attack will cover up the pain, but there is still such a look of terror. I was just standing here and there was this loud noise, heat, pain, and I am now on the ground. The emotional shock of the event almost overpowers the physical aspects until the chemical groups that manage adrenaline fade away. Medical professionals call this the golden hour. Shell Shock was the moniker of the First World War because it speaks to the confusion and chaos that goes on in the brain in the wake of explosions like today's. These chemicals often damage memory and will always make these memories difficult without the tragic nature of their content.

Watching the images of people on the ground just looking around aimlessly illustrates how the events are much more chaotic for people present. The capturing of multiple still images does very little to capture it. Just think of the smell of it. You never forget those smells and anything that reminds me of the smell of burning flesh make me sick for weeks.

Despite the horror and misery that these poor runners and bystanders absorbed today, no justice for the terrorist(s) who did this will make it right. The important part of the narrative that will diminish over time is the human capacity for compassion illustrated by this tragedy. It is important that we remember the good that was demonstrated today. Watch the video. One person or a small group of people did this, but before the smoke cleared people were running to help. You could see some bleeding themselves and doing all they could to save others.

That doesn't make everything better, but when things like this happen it is important to note that when one or maybe ten people conspire to do something this terrible, hundreds of people will rush into that danger to help others. There is no divorcing today's attack from the tragic impact it has made on the lives of the injured, but it is another reminder that their will always be many more people rushing to help. Some people have no problem doing terrible things to innocent people, but more people will fight to help the injured. In senseless tragedies we see the worst of a few people, but the best of so many more. It doesn't make the suffering from today's events any less acute, but it does speak to the human spirit and how we can stand in the face of tragedy. In the coming weeks we are going to be bombarded with what went wrong today, and I am sure there may be some finite oversights that could have prevented this. However, there were many more good people stepping up as heroes than there were terrorists using the misery of the innocent to draw attention to their cause. We would be wise not to forget this hard earned fact, that many more first responders and bystanders did all they could to save lives today.

Impairment Honesty Without Sacrificing Goals

By Joseph Miller


It takes a couple of years to realize that the people who you surround yourself with will never truly understand the daily and constant battles that a veteran suffering from PTSD and mTBI go through. I have simply stopped trying to communicate these problems with my peers or even my friends and family. It is not because I am ashamed, though I certainly have been ashamed in the past, but more that people do not really want to understand how hard the little things in life have become. As a student in graduate program at a research university I doubt significantly that any of my colleagues regularly meet with neuropsychologists or speech therapist to manage their calendar and appointments. I doubt that they have trouble knowing what day of the week it is or can be thrown it days of painful migraines by getting a bump on the head or by whatever stimulus throws you into another round of painful memories. They often do not understand why you put yourself through the rigors of graduate school when your subsistence is provided by other means, and would not likely put themselves through the same challenges were they in the same position. If I did not constantly remind myself that my friends who have died do not have the opportunity to come home and find a way to continue supporting their communities then I would have quit a long time ago.

As scholar my research is on PTSD during the U.S. early national period will certainly be the focus of my future contributions, but I would rather provide some stark and unapologetic honesty about my own struggles following three tours of duty in Iraq. When I began to write my Master’s Thesis I recognized how writing about violence was a triggering my PTSD and I began to do what veterans do when they are reminded of their own traumatic experiences. At first when I wrote about violence I avoided it by putting anything I could in front of it in my schedule. Once I recognized it I used alcohol to help me face it. Though this is what got my drafts finished they were terrible and by engaging in this negative behavior they became difficult emotionally. Proofreading became a challenge, and worse they required a great deal of editing because I needed to self medicate to even finish them. This process has taken about a year and a half longer than it should have because I was not prepared for what research on warfare would do to me emotionally.

But this is not a cautionary tale; rather it is actually about growth. Like many students working on a Thesis I had a few unanswered questions that did not directly relate to the project. I had been researching military officers serving the revolutionary period since I was in high school and I began to realize that they were often “invalided” by unexplainable conditions. I was studying the Battle of Detroit and one of my sources had detailed descriptions about a fever called “ague.” I had PTSD for a long time and when I went back to Iraq the third time I had TBI and pretty severe PTSD. I was sick for the first two months and at times bedridden. I felt fevered and I constantly threw up, but when seen by doctors I had no discernible illness. Like my somatic expressions of a psychological disorder I realized that all the bouts of ague came after traumatic events and could also have been expressions of PTSD.

This realization did not provide enough material to prove that there was PTSD, and I will not get into my methodology, but it does illustrate how I have learned to use the terrible experiences and difficulties I face everyday as a worthwhile perspective to analyze warfare affect on the individual. PTSD casts a strange kind of amnesia about war because it causes those most affected by it to do everything in their power to avoid reminders of traumatic experiences. So my perspective despite the pain it has caused me in the past (I certainly no longer use alcohol to get through a project) is a useful to provide a better understanding of war as a source of emotional trauma. It has led me to look to different sources and to follow the lives of soldiers after the wars were over. It has become apparent that many suffered from the same sort of odd illnesses suffered by then men in my Master’s thesis. This work will be a significant contribution to the field of history. This realization could not have occurred if I had not conducted by research at the time that I was most impaired by PTSD. It may have delayed my Thesis, but it has helped me uncover something much more important about how war has affected the lives of American veterans from the very beginning of U.S. history. For others struggling with invisible illnesses you are not the first ones, and your generation is not weaker than the preceding veterans. Your impairments are significant and challenging, but they can also become a source of strength and an incredibly valuable perspective.


Joseph Miller  in 2003 commissioned as an Infantry officer and assigned to the 82nd Airborne Division. Deployed three times to Iraq in support of national elections and as an Iraqi Army adviser during the 2007 surge. During his second rotation he was injured by an IED. His awards include the Bronze Star Medal, Combat Infantryman’s Badge, Iraqi Campaign medal with three service stars, Senior Parachutist Badge, and Ranger Tab. Recently named 2011 Army ROTC Instructor of the Year and is completing his Master’s degree in Canadian/American History at the University of Maine.

Rules for Combat PTSD Change within the VA Today

Obama Chronicles writes,

In the weekly address, President Obama outlined how his administration is making it easier for veterans with Post Traumatic Stress Disorder to receive the benefits they need. These new changes in the Department of Veterans Affairs take effect today.

We Combat PTSD Veterans, had to ‘prove’ we were in combat, even though I was awarded the Combat Infantry Badge (CIB). I applied 7 times over 15 years before I was diagnosed and starting receiving care and treatment.

Dear Deadly Duo PTSD and TBI

An open letter to PTSD and his evil henchman TBI.

Dear Deadly Duo,

You consider yourselves formidable foes, but I am not scared of you. A pair of cowardly trolls is all you are, and if I could find the bridge beneath which you cower, I would rain down deadly mortars akin to those you send to torture my husband in his nightly dreams, entombing you both in the rubble. But for now I will content myself with stabbing your effigy with venomous fervor, wishing you a slow and painful death or a quick and fiery one, I don't care, I'll take whatever I can get so long as the outcome is your ultimate demise.

And do you have nothing better to do with your spare time than sit around creating disturbingly twisted storyboards, planning out frame by frame the hellish nightmares you have in store for my husband each night? Do you enjoy watching him pass out on the couch, drunk, at 3am 'cause he can't face what you have in store for him when he climbs into bed? If you thought you were the only ones with warped minds, I have a suggestion for a new scene, it shows TBI rolling up one of those drawings into a tight tube and cramming it up PTSD's ass!

Oh Wizard of PTSD, why do you insist on using your evil black magic to transport my husband back to Iraq with cruel and realistic flashbacks. I cannot reach him when you do that, dangling him within my grasp but out of my reach is nothing short of mental abuse. If you're looking for something to abuse I suggest you lock yourself in a closet and abuse your d**k! That is of course if you can find it, and if you can't, I'm sure your boyfriend TBI knows exactly where it is seeing how it has his name tattooed on it and all.

And speaking of TBI, I thank you for the gift of patience although I expect to have several years tacked on to both mine and my husband's lives for all those times he's sat on the couch in suspended animation during his 50-yard-stare episodes. And for all those times I have sat by his side waiting for him to free himself from a bout of stammering before he can start a sentence or engaged in a conversation twice as long as it needed to be as it was peppered with ums and uhs. And for robing him of his career twenty years before he was due to retire for which I should be sending you an invoice by the way. But what's the point? You are the poorest of the poor, and have no worth from which to pay him.

I should thank you also for teaching me how to survey my surroundings in order to forewarn my husband of potential triggers. And for showing me and the kids how to conduct ourselves in a calm and quiet manner so as not to startle him. My hope however PTSD, is that while you're setting one of the booby traps that triggers his anxiety, it will detonate in your face. And don't count on TBI to save you, he doesn't remember anything he learned about first aid, he'd be too confused and disoriented in a stressful situation such as that. Chances are you'd bleed out before help arrived, that is with any luck.

You think you hold all the cards, that all the power is in your hands. It is true that one of you alone could inflict enough damage to do the job quite nicely but still insist on tag teaming without having the decency to play by the rules while one of you waits outside the ropes. I call bullshit on that, two against one are unfair odds, but it's not two against one, I am right by his side to defend and fight back. Deadly duo? I think not. Go crawl back under that bridge from whence you came and hide like the cowards you are. As for me, I'll never stop hunting you down, mortars at the ready.

Review of Auditory Dysfunction in Traumatic Brain Injury

The article was informative with regards to giving a clearer picture of the growing population of veterans with hearing loss attributed to their military service. The report found that admissions for traumatic brain injury (TBI) increased 47% since the beginning of Operation Iraqi Freedom (OIF). A subgroup of blast related (BR) veterans were reported as having 62% hearing loss and 38% of this group with tinnitus. The authors indicated a gap in screening services for veterans as they had inadequate training for the management of tinnitus. The article was well organized and concise in that it gave specific representations of populations and subpopulations. The article does recognize some limitations to the service streams within the Veterans Administration (VA), but falls short in fully recognizing and advocating for the veteran.

One possibility as to the articles soft stance on identifying problems and barriers to care, it appears the target audience was for the VA. Hence, while identifying some issues with assessment and services the full exposure and extent of problems in the continuum of care and the bureaucratic entanglements might impede funding for further research monies for the authors. The article quickly lists the figures for comparisons and draws conclusions delineated from two groups. Forty months before the beginning (group I) of OIF and forty months after (group II), the two groups were compared, and found that group II had a significant amount of younger veterans with BR-TBI and hearing loss. This matter of younger veterans with TBI and hearing loss marks a significant change in the topology and identity of a growing population of veterans who have limited resources for an ever growing pool of patients.

The authors dance around the problems and charging forward with a battlement of statistics and cross analytics encompasses the VA’s endless studying the problem without addressing the quandary. More proof that was suspected and witnessed and now corroborated. Endless speculation as to the causes and no end in sight to the ramblings of those that need “proof positive” before treatment remedies can begin to trickle down to the masses of veterans needing services. A social work perspective and holistic approach would begin to recognize the problem and begin effect treatments in conjunction with research for improving modalities while building on the clients strengths. The most significant piece of information revealed in this endeavor is the low statistical and counter-intuitive expectation in the rupture of the tympanic membrane in percussion blast waves. Even more interesting, this information only covered less than half of a paragraph in the results section and missing in the discussion section.

As far as helping the social worker, this article does little to add to the discussion in helping the veterans. Except that it might add to the growing avalanche of data that the government requires before allocating funding for services and care for the veteran.

Lew, H. L., Jerger, J. F., Guillory, S. B., and Henry, J. A. (2007). Auditory dysfunction in traumatic brain injury. Journal of Rehabilitation Research and Development, 44(7), 921-928.