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Article Excerpt
In 2002 and 2003, the George W. Bush Administration stressed that Iraq posed a danger to the safety and security of the United States through the fear that Iraq was developing an arsenal of chemical, biological, and nuclear weapons. The United States and its allies subsequently invaded Iraq in March 2003 and this conflict, commonly referred to as the "Iraq War," continues into its sixth year (Wong, 2008).
The United States has incurred massive human and financial expenditures through its involvement in Iraq. It is estimated that total spending on the Iraq war will cost the United States up to $3 trillion to fund current military operations along with the expenses of paying the long-term disability costs of injured military personnel, death benefits sent to the families of those killed in Iraq, and interest fees paid by the United States Treasury to borrow money to fund current expenditures (Bilmes & Stiglitz, 2008). More importantly, as of October 4, 2008, a total of 4,169 United States military service members have lost their lives in this conflict (U.S. Department of Defense, 2008). Further, the organization "Iraq Body Count" estimates that through mid October 2008, 88,373 to 96,466 Iraq citizens have been killed since the March 2003 invasion (Iraq Body Count, 2008).
The American public as well as rehabilitation professionals are increasingly developing awareness of these realities. In addition to television programs, newspaper stories, and radio shows, an especially effective source of awareness are first-hand accounts of the horrors and aftermaths of combat chronicled in such books as In An Instant: A Family's Journey of Love and Healing (Woodruff & Woodruff, 2007) and Rule Number Two." Lessons I Learned in a Combat Hospital (Kraft, 2007). Such accounts educate readers that those who are fighting in Iraq face the significant potential of incurring a chronic disability or illness. Two of the most common chronic conditions now experienced are traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD).
TBI and PTSD are commonly referred to as the "signature" injuries of military personnel serving in the Iraq War (Fairweather & Garcia, 2007). The need to develop and facilitate specialized care and rehabilitative services for veterans impacted by this modern disability is of paramount importance. An estimated 22% of all Operation Iraqi and Enduring Freedom (OIF/OEF) combat injuries involve some form of brain damage (Summerall, 2008). Also, the California Community Foundation (2008) estimates one in five service members who engaged in OIF/OEF military operations develop PTSD or major depression.
The unique nature of how military personnel incur combatrelated injuries presents the emergence of a new disability for rehabilitation counselors and other health professionals to confront. Many combat-injured military personnel are returning from the Iraqi conflict with the simultaneous onset of both TBI and PTSD. Volatile combat conditions, which frequently entail the infliction of blast-related polytrauma, increase military personnel's likelihood to experience both conditions (Kennedy et al., 2007). Living with both disabilities presents a unique array of challenges that is distinct from singularly living with either TBI or PTSD.
The purpose of this article is to help prepare rehabilitation counselors and other professionals to address the unique needs of this emerging client population for vocational rehabilitation, independent living, and family support. Specifically, we will provide (a) an overview of the injury sequelae of TBI and PTSD, (b) the challenges in living with TBI combined with PTSD, and (c) available interventions and support services.
An Overview of the Injury Sequelae of TBI and PTSD
With over 1.6 million military personnel deployed in coordination with Operations Iraqi and Enduring Freedom (California Community Foundation, 2008), and close to 30,000 troops wounded in action (Defense Link, 2008) the need for optimal, specialized rehabilitation services for veterans impacted by the combination of TBI and PTSD is imperative. Multiple, lengthy deployments to harsh venues of battle have subsequently created a unique set of stresses for numerous active duty, Reservists, and National Guard members and their families.
Blast injuries from improvised explosive devices (IED) in the Iraq War are the most frequent causal agent of combat casualties (Levin, 2008). The consequences of IED caused blasts include primary, secondary, tertiary (Taber, Warden, & Hurley, 2006; Warden, 2006), and quaternary injuries (DePalma, Burris, Champion, & Hodgson, 2005). Primary injuries refer to the effects of the wave-induced changes in atmospheric pressure following the blast, resulting in possible damage to body parts with air-fluid interfaces, such as lungs, the bowels, and the middle ear. Secondary injuries refer to damage caused by objects put into motion following the blast and then hitting people. Tertiary injuries result from persons hitting an object or the ground following the blast. Quaternary injuries refer to complications or worsening of existing conditions. Quaternary injuries are caused by toxic inhalation, burns (chemical or thermal), exposure to radiation, asphyxiation (includes carbon monoxide and cyanide after incomplete material combustion, and breathing in dust from coal or asbestos; DePalma et al., p. 1338). One example of how quaternary injuries are caused occurs when IEDs are constructed with ball bearings coated with various poisons (M. McDonough, personal communication, March 18, 2008).
The National Center on Posttraumatic Stress Disorder estimates that 60-80% of solders who experience an lED attack blast also acquire a TBI (Summerall, 2008). Warden (2006) noted that blast-related secondary and tertiary injuries result in TBI much like this injury occurs in the civilian world through such causes as falls and motor vehicle accidents. However, the connection between primary injuries and TBI is much less clear.
TBI is characterized by trauma to the head, resulting in concussive, or closed, and penetrating injuries (Defense and Veterans Brain Injury Center, 2007). Ranging in severity from mild to severe, symptoms related to TBI comprise cognitive, somatic and behavioral problems, including concentration, attention, and memory setbacks, sleep dysfunction, headache, anxiety, depression, and irritability (Degeneffe, 2001). Persons with TBI...
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