All wars since the invention of explosives have presented an identical problem for providers. How can you tell the difference between symptoms caused by combat or operational trauma and concussion? World War I (WWI) provides us our most representative example in the complicated differentiation between shell shock (a psychological disorder) and shell concussion (a neurological disorder). In modern parlance we use the terms combat stress (or posttraumatic stress disorder) and concussion. The problem of differentiation remains the same; only the names have changed.
But WWI was over 100 years ago. Are we any further now in being able to make a differential diagnosis? Astonishingly no. Neither combat stress nor concussion have any definitive diagnostic test and there is a substantial overlap in the symptoms of both. After many years of study, researchers have come to understand that the neuroanatomical constructs involved in both combat stress and concussion have substantial commonality, and so it makes sense that the symptoms are highly similar as well. In looking at the list of possible symptoms, it is easy to understand why both mental health care providers and patients may be at a loss.
Post-concussive and combat stress symptoms can include:
So, now what?
While diagnostically the two problems are very difficult to parse out (and it is common for a person to experience sequelae of both simultaneously), conveniently some of the early intervention techniques and treatment options are exactly the same. What I’m saying is that it might not be that important for a mental health provider to know which it is (if it is only one) or which one is exerting the largest influence to be effective in helping a service member achieve symptom resolution.
While the literature continues to develop, the following are some empirically validated recommendations which hold true to both conditions:
1. In the acute period following a concussion, the individual, pertinent family members and members of the chain of command need education on such topics as what symptoms to expect, how these symptoms may impact other injuries, how long they are likely to last, and the understanding that they are anticipated to resolve. This type of early intervention is also indicated in potentially traumatic events in which concussion is not a factor.
2. Social support impacts recovery. In the case of concussion, it is highly impactful when medical staff reach out to individuals in the days and weeks following the event to provide support, track recovery, assist in the graded return to normal activities, and reiterate the normalcy of symptoms and expectation of recovery. Early intervention in combat stress also focuses strongly on peer, leadership and medical/mental health staff support.
3. In a minority of concussion cases, symptoms become prolonged and cognitive behavioral therapy (CBT) is indicated. Therapy for a neurological disorder? Yes. CBT decreases both anxiety and depressive symptoms which perpetuate chronic concussion symptoms and helps to address other comorbid problems such as sleep difficulty and pain, teaches the individual to attribute ongoing symptoms to the most probable causes, teaches the individual to identify thoughts and behaviors which influence the symptoms, and helps the individual focus on a return to a normal activity level. While addressing the cognitions and behaviors that may be prolonging recovery from a concussion, therapy can simultaneously address symptoms which are present or chronic because of combat or operational stress.
In short, the exact origin of any given symptom when treating concussion and combat stress does not seem to be the most important aspect of treating these two conditions simultaneously, rather it is the treatment that is the key.
Find valuable tools for clinical providers who work with patients who have experienced concussion and information and resources for Brain Injury Awareness Month in March from the Defense and Veterans Brain Injury Center.
Find evidence-based guidelines for treating patients with concussion in the VA/DoD Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury (mTBI)
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.