Brain Damage Blog - Attorney Gordon Johnson

Vietnam Remains Our Biggest Military Health Issue

2008-06-18T14:12:00.000-07:00

As we shift our focus of this blog to the emotional side of the synergistic neuropsychiatric disability that faces combat vets, I want to put the context of current soldier suicides and PTSD into perspective. This series of blogs began with my reaction to this news:

“The Associated Press announced that active duty military suicides hit its highest level on record in 2007, 119 soldiers dead. See the AP story at: http://hosted.ap.org/dynamic/stories/M/MILITARY_SUICIDES?SITE=CADIU&SECTION=HOME&TEMPLATE=DEFAULT “

My first reaction to that number when I read it was that there was something wrong with the record books, because I had remembered reading a number of references over the years about suicide in Vietnam veterans with numbers as high as 250,000 people. Well, the reason 119 is a “record” is the Pentagon didn’t start recording soldier suicides until around 1980 and that number is for active duty soldiers and doesn’t include vets.

Still, the overwhelming question that seems to being missed in the political debate and news coverage of 2008 is what about the Vietnam vets? As tragic as the Iraq and Afghanistan Wars have been, their footprint of death, disability and psychosis has yet to reach 10% of the magnitude of that of Vietnam. While Vietnam is now more than 30 years in our rear view mirrors, the primary group of soldiers it affected are from 55 to 70 years old. That is a serious public and military health issue for at least another generation.

$500 million dollars for TBI research for blast injuries in the so-called War on Terror is great – but what about Vietnam? The discovery of brain injury and brain damage in Iraq by the politicos and news media is truly wonderful. But Iraq is not the first war with blast injuries, not the first war where our soldiers suffered brain injury, not the first war where the soldier who returned home is a brittle, vulnerable shadow of the vibrant young man who left.

John McCain makes great political hay out of his Vietnam heroism as a prisoner of war. But how can McCain make those claims without looking back and recognizing that the United States mental health obligations to its Vets reaches back to Vietnam, Korea and even World War II survivors?

The issue of the brain injury disability and mental health of older Vets has countless sub-issues, but the most important for this blog is that brain injury and brain damage were not even considered in what we today call mild to moderate brain injury during Vietnam. Prior to 1990, there was little belief in the medical community that a brain injury that involved less than a five minute loss of consciousness was significant. Now we recognize, and have highly sophisticated neuroimaging and neuropsychological methodologies to confirm, that brain damage can occur without a loss of consciousness.

We often hear that our modern medical interventions result in more people surviving brain injury, because soldiers who would have died in Iraq or Afghanistan are now saved because of the rapid evac and treatment. That is true, but what is implicitly missing in such a statement is the clear fact that almost no one with a mild to moderate brain injury would die from it, regardless of whether they got prompt treatment. The realities of combat in Vietnam, and all wars that preceded it, is that a soldier on the front lines who gets knocked out, dazed or confused - is not likely to die from such injuries, unless he is killed by his inability to respond to the immediacy of the combat demands at the time.

Thus, there are probably far more vets with mild brain injuries in the Vietnam era than in the current generation of soldier and vets, but there are no medical records to document that they suffered such injuries. A soldier with a short-term confusion in that combat was likely expected to shrug it off and go back to fighting. Making matters worse, the complete catastrophe that is the Vietnam military health records makes it almost a certainty that documentation of brain injury is just not there. Further, the brain damage suffered in Vietnam is considerably broader than just brain injury because of the prevalence of Cerebral Malaria, which may have caused brain damage to hundreds of thousands of U.S. soldiers in Vietnam. See http://www.va.gov/OCA/testimony/hvac/16JY98NV.asp

Without the documentation of brain damage, what came out of Vietnam were hundreds of thousands of soldiers with clear cut neuropsychiatric symptoms in search of a diagnosis. The result: PTSD. PTSD is a Vietnam era syndrome of severe emotional problems, that are tied to some type of extreme emotional stressor, such as combat. But as with most “syndromes” the purity of its diagnostic criteria is lacking. The resulting over inclusive use of it in differential diagnosis of any emotional or neuropsychiatric symptom is staggering. At its threshold criteria, it requires life-threatening terror.

See http://en.wikipedia.org/wiki/PTSD which states the threshold requirement that "the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others." The second (A2) requires that "the person’s response involved intense fear, helplessness, or horror."

This sounds like combat, it does not sound like a rear end automobile collision. While some automobile or other accidents involve prolonged moments of terror, most do not. They are over within a few moments of beginning. I have experienced both kinds but my memory of the truly terrorizing accidents (and yes, I did have that realization that my life was about to end both times) ended abruptly at the moment of collision. Relatively few people who suffer concussions have clear enough memory of the event to be exposed to a pure PTSD terror. What most relate is a moment of surprise that an accident is about to happen and then a gap in memory.

In contrast - combat, rape, fires - involve prolonged exposure to truly terrorizing events. This is the type stressor that can actually make a hard wire change to the way the brain processes information. This is the type of stressor that can create haunting memories. This is the type of stressor that can create nightmares. Yet PTSD should never become a catchall for all emotional reactions to life changing events. The category for stressor has as its blue print combat. When there is no elongated exposure to terror, the focus should be on normal human emotional responses, not a psychiatric catchall.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447

Hysteria or Conversion Diagnosis Focuses on Perceived Character Flaws, not Relevant Injury Factors

2008-06-17T08:12:00.000-07:00

In understanding the stain that the “hysteria” diagnosis has left on our medical science, it is important to distinguish “hysteria” from PTSD. The modern term for hysteria (if there should even be a modern term for it) is “Conversion Disorder”. See DSM-IV 300.11. PTSD is an entirely different matter as it relates to the development of specific emotional problems, as a result of emotional trauma. In Conversion Disorder, the emotional issues of the patient (not traumatically induced symptoms) are converted into physical problems. In Myers’ case studies, he attributed the neurological symptoms of his soldiers to this type of “hysterical” conversion of emotional problems.

The DSM-IV criteria for Conversion Disorder, stresses the likelihood that the patient have a prior history of psychosis.

“A history of other unexplained somatic (especially conversion) or dissociative symptoms signifies a greater likelihood that an apparent conversion symptom is not due to a general medical condition, especially if criteria for Somatization Disorder have been met in the past.”

While such criteria were not formally laid out in his time, Myers seemed to sense the need to show that his soldiers were psychologically weak. With respect to Soldier #1, he said:

"Prior history. –He had been for two months in the Aisne district on the lines of communication, sleeping badly all that time owing to lumbar pains (and toothache during the first three weeks.) He had failed to pass a medical examination some time previously because of renal trouble (abnormal amount of albumin in water) until after a long period of treatment. He had had lumbar pains a few nights before coming to France.”

The significance of the reference to the lumbar pains, seems to be the implication that the emotional stress of coming combat had brought them on.

With respect to Soldier #2:

"As to his past history, he came out to the war on August 13th, and was in the last two days’ retreat at Mons and after at La Bassee. Has slept very badly since the start, often when billeted taking large doses of whisky to procure sleep. Has led a ‘fast' life and has had recent domestic worry.”

While he has no comment on the prior history of Soldier #3, he stresses the nervousness of the soldier in his narrative.

“A healthy looking man, well-nourished, but obviously in an extremely nervous condition. He complains that the slightest noise makes him start…. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach…. He complains that he gets very excited when anyone addresses him.”

The use of these implicit (without direct comment on their relevancy) comments by Myers is strongly reminiscent of the character assassination found in Defense neurological and neuropsychological opinions. No where does Myers say these symptoms are related to these character issues, just the “no comment seems necessary.”

While Myers wasn’t working with a formal diagnostic criteria for a “hysterical” diagnosis, the modern definition of Conversion Disorder does at a minimum require ruling out all medical explanations for the neurological symptoms.

“A diagnosis of Conversion Disorder should be made only after a thorough medical investigation has been performed to rule out an etiological neurological or general medical condition. Because a general medical etiology for many cases of apparent Conversion Disorder can take years to become evident, the diagnosis should be evaluated periodically.” DSM-IV, page 493.

Did Myers rule out all medical conditions for the neurological symptoms? Of course not. As discussed in the previous blogs, there are clear neurological, biomechanical and pathological explanations for the amnesia and the anosmia. Much is made by Myers of the partial visual complaints of these three soldiers. Yet other Cranial Nerve damage can account for many of these phenomenon, even without any damage to the eye, or the Optic Nerve. There are references to Soldier #3’s stomach complaints, but anyone acquainted with the vestibular system should recognize these symptoms as being explained by vertigo: “He appeared as if about to faint, and says that he felt cold and dizzy, and experienced “round and round movements of the stomach.” See http://vestibulardisorder.com Further, the reports of sweating and feeling like he is about to faint, is clearly explained by a condition called POTS (postural orthostatic tachycardia syndrome), which would also cause the vertigo. POTS, vertigo, cranial nerve damage - are all clear markers of traumatic brain injury.

The Character Assassination: Soldier #1 back pains prior to deployment; Soldier #2, heavy drinker with domestic problems. While there might be emotional explanations for increasing back pain under extreme stress, that isn’t the type of deep psychosis which would explain an extremely rare diagnosis of “hysteria.” As for his attacks on Soldier #2’s character, one must ask: How many soldiers are heavy drinkers? (Even our current Republican Nominee, John McCain has admitted to hell-raising during his 20’s.) What soldier doesn’t have some worry about his marriage, his family while deployed in a combat zone?

Sleep. Myers discusses sleep with each of his soldiers. But diagnosing hysteria versus organic injury to the brain and neurological system because of pre-morbid problems with sleep, makes as much sense as stating that these soldiers were carrying a gun at the time they were shelled. The soldier who sleeps well, like a soldier who doesn’t carry a gun, is not a oldier to fare well in combat. Combat requires hypervigilance. The soldier who sleeps soundly, especially in World War I, is the soldier who is in peril. One of the most cogent theories of PTSD is that it is a result not of the specific instances of emotional shock, but as a result of the constant need to be hyper-aware. It is the never sleeping well, the need to being always ready to reach for the gun, to leap for cover, that may be the hardest thing for the combat veteran to wind down from, post combat. It may be the inability to shut off the mechanism to never truly sleep, to dream, that causes the surrealistic elements of post combat stress.

Next: We will discuss the elements of PTSD, its roots in combat, and its questionable applicability to more routine civilian stressors. But before this commentary leaves Myers behind, I do want to stress one important point:

Myers was not wrong to factor in the terror at the time of the injury and the precedent emotional vulnerability of the patient. His mistake was to miss the clear organic evidence of brain trauma, brain damage. It may be the terror or the emotional makeup of these specific soldiers, made them more likely to be disabled by the blast injury that might not have disabled a stronger individual. But the diagnosis must begin with a full differential consideration of brain or neurological damage. Once brain damage has been identified, it is fully appropriate to incorporate the synergistic interplay of the vulnerability of each individual, the additive factors of the combat stress such individual was under, and the emotional impact of such injury, on that particular brain.

Myers may not have had all the tools of modern medicine available to him, but he did have the most important: history and examination. He took the history, seemingly quite accurately. He did the examination better than most modern doctors (especially with respect to the Olfactory Nerve). Where he failed, and perhaps because of British unwillingness to believe the brain could be so easily damaged, was in not believing the realness of his own findings. His soldiers couldn’t smell. They couldn’t remember. They had neurological explanations for the vast majority of their symptoms. Combat emotional stress could certainly explain the rest. Brain injury, by any other name, will still disable.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447

Understanding the Biomechanics of War Time Brain Injuries

2008-06-16T09:49:00.000-07:00

Previous blogs in this series have focused on the contrast between the quality of the meticulous description of history and symptoms by Charles Myers’ in his seminal 1915 Lancet paper on “Shell Shock” and his clearly flawed “comment” that these case studies were explained by hysteria. Yesterday’s blog focused on how he documented, but didn’t find significant the loss of taste and smell. This blog will focus on the biomechanical clues to the proper diagnosis, found in Myers’ detailed descriptions.

According to Myers’ Soldier#1 was injured when he was surrounded by exploding shells, while he was caught in barbed wire. Soldier #2 was injured when the trench that he was taking cover in was imploded by an exploding shell and Patient #3 was injured when he was knocked 15 feet off a pile of bricks, by another shell. What could clearly have accounted for Myers’ misdiagnosis in these three cases studies was absence of evidence of a clear blow to the head from a shell in any of the above case studies. As is shown by other British research at the time, the head injury focus was with soldiers who suffered skull facture.

It is now a known medical fact, that a direct blow to the head is not necessary for the brain to be injured in a traumatic event. Known mechanisms of brain damage could have occurred to all three of these soldiers. Those mechanisms include blast phenomenon, indirect blows to the head from either falls or flying objects, and acceleration/deceleration injuries.

Blast Injury. When an explosion occurs, shock waves are generated that can penetrate the human body. Such shock waves can directly injure the brain and/or force the brain into the skull, injuring the brain as a result of such collision. For an illustration of the force of a blast, see the below picture of the displacement occurring to a battleship when its guns are firing. Blast injury can injure, not just at the receiving end of the blast, but also at the firing end. One historic perspective of military medicine is that sailors who fired guns below deck, would over time show evidence of shell shock and dementia. See http://www.research.va.gov/news/features/blasts.cfm for research as to the direct effect of blast force waves on the brain. All three of Myers’ soldiers could have been injured by shock waves directly from the blast.

Indirect Blows to the Head. The perfect example of an indirect blow to the head in Myers story is Soldier #3 who was knocked down from a height of 15 feet by the force of the blast. In the fall, such soldier clearly could have hit his head. Similarly, at the time that Soldier #2’s trench imploded on him, he could have been either knocked to the ground (striking his head) or some portion of the trench, or some object within it, could have hit him the head. While there is no direct details of a fall or a flying object in Soldier #1’s case study, such could also have occurred. A fall - especially one propelled by a blast - is one of the clearest understood mechanisms of injury. Not only is the force of the body being rapidly transferred to the head at the time of the fall, but the brain bounces inside the skull in reaction of the striking of the head.

In a slightly different mechanism, the force of a flying object is transferred to the brain, through the mechanism of a force wave, when the head is hit by an object. There is no way a rational analysis of what happened to these three soldiers could have ruled out a mechanism of injury from an indirect blow to the head. Clearly, Myers’ didn’t believe that any such blows to the head were sufficient to leave any substantial injury to the brain.

Acceleration/Deceleration Injury to the Brain. Without a doubt, all three of these soldiers head and necks were exposed to severe whiplash forces. Even without a blow to the head, such forces would be sufficient to injure the brain. Such injury can occur through at least two mechanisms: the collision between the brain and the skull or through the mechanism of diffuse axonal injury.

In a whiplash mechanism, especially one where a soldier is knocked down or falls, the brain and skull are accelerated at different speeds. When such occurs, there is a collision between the brain and the skull. See

In a diffuse axonal injury, it is not just that the brain is moving at relatively different speeds than the skull, but that different layers of the brain, are moving at different speeds from each other. This occurs because all human acceleration is angular, not linear. This means that rather than going in a straight line, the brain matter rotates on the radius of a circle. Layers of the brain have different densities and different distances from the fulcrum of the acceleration. This means that there is significant torque between these different parts of the brain.

Axons are long are microscopically thin connective portions of neurons, that span across these different layers of density and rotations. At the points of the greatest internal differential acceleration, forces can be sufficient to begin to stretch and tear the axons. For more information on Diffuse axonal injury, see http://subtlebraininjury.com/

One side note, in addition to these three potential mechanisms of injury, Soldier #2 could have suffered a hypoxic injury as a result of being buried in the trench. Hypoxia is when the brain or other organ, doesn’t get enough oxygen or blood flow to sustain itself. It is possible he did not receive enough oxygen during such period, resulting in brain damage.

It is odd that Myers would not have appreciated the potential for injury in the fall mechanism, especially with Soldier #3. But he can certainly not be criticized for his failure to recognize the potential for other injuries occurring without a direct impact to the head. Yet that flaw, whether excusable or not, makes his conclusion with respect to hysteria, completely dismissible. It is essential that current brain injury diagnosis exercise any lingering use of the hysterical or conversion diagnosis.

In our next part, we will look at the emotional issues that existed both before and after the injuries to these soldiers, and the role the wrong diagnosis, over emphasized the role of pre-injury emotional factors.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

Loss of Smell was a Missed Sign of Brain Injury in World War I Shell Shock

2008-06-13T10:36:00.000-07:00

Previous blogs in this series have focused on the contrast between the quality of the meticulous description of history by Charles Myers’ in his seminal 1915 Lancet paper on “Shell Shock” and his clearly flawed comment that these case studies were explained by hysteria. See “A Contribution to the Study of Shell Shock” published in the British Medical Journal, the Lancet, on February 13, 1915.
Yesterday’s blog focused on how he documented, but didn’t find significant evidence of amnesia. This blog will focus on the loss of taste and smell.

As thoroughly as we have criticized Myers’ conclusions, we must applaud the thoroughness of his investigative skills. One of the great flaws of current neurological exams is the failure to test all cranial nerves. The words “Cranial Nerves II through XII are intact” are tantamount to misrepresentation by omission in brain injury diagnosis. What about Cranial Nerve I?

Well Myers, for all his failure to “get it”, tested Cranial Nerve I and tested it thoroughly. Cranial Nerve I is the olfactory nerve, the nerve which comprises most of the human sense of smell. If all neurologists would so diligently test Cranial Nerve I (and unlike Myers understand its significance) the quality of brain injury diagnosis would go up exponentially.

What is the relevance of the loss of smell to a diagnosis of brain injury? To fully appreciate this, it is necessary to understand the basic geography of the brain and the cranial nerves. The cranial nerves are generally the nerve groups which control the function of muscles, organs and feelings in the head (the cranium). For example, Cranial Nerve VII is needed to make a person smile. Cranial Nerve VIII is involved in balance and the vestibular system. Cranial Nerve I is the Olfactory Nerve, which is responsible for the sense of smell. For a full chart of the Cranial Nerves see: http://www.gwc.maricopa.edu/class/bio201/cn/cranial.htm

Unlike the other Cranial Nerves, which take a circuitous route into the brain through the brainstem, Cranial Nerve I goes directly from the nose into the brain. At the juncture between the Olfactory Nerve and the brain is something called the Olfactory Bulb. Immediately adjacent to the Olfactory bulb, on the surface of the brain, are some of the most sensitive and important functions of the lower frontal lobes. While losing the sense of smell does not mean that a person has brain damage, when the Olfactory Nerve is injured in a traumatic event, there is in most cases, correlative damage to the adjacent structures of the brain. That particular part of the brain is the orbital frontal lobe.

Thus, when Myers was meticulously documenting the loss of smell in his patients, he was not describing an anomaly, but very significant correlative damage to the part of the neurological system, immediately adjacent to some of the most sensitive and important parts of the brain. The predictive value of loss of smell to brain injury pathology is born out by substantial research that correlates disability to loss of smell. See Neuropsychological Significance of Anosmia following Traumatic Brain Injury
Journal of Head Trauma Rehabilitation. 14(6):581-587, December 1999.
Callahan, Charles D. PhD, ABPP; Hinkebein, Joseph PhD http://www.headtraumarehab.com/pt/re/jhtr/abstract.00001199-199912000-00006.htm;jsessionid=LNTQj0tnvkKKVQB1Z2yMGwZphHLhQh2Q21TSY4HLQnCw8pFLyTlS!435538499!181195629!8091!-1 and Varney NR, Pinkston JB, Wu JC. Quantitative PET findings in patients with posttraumatic anosmia. J Head Trauma Rehabil. 2001;16:253–259. Such correlation is stronger than almost any other marker of brain injury with the exception of amnesia.

The technical term for loss of smell is anosmia. As most neurologists do not test for loss of smell, it is often necessary to look for clues that anosmia occurred. The best clues to anosmia are typically changes in taste, eating habits and weight. Smell is a big part of how people taste, especially the subtle differences between foods. Post traumatic anosmia fundamentally changes how and what people taste. This can leave the marker of weight loss - or the more common - weight gain. Those with anosmia often increase the fat content and the spice content of their food, in order to have it taste more.

As discussed on our related blog, http://subtlebraininjury.blogspot.com King Henry the VIII’s remarkable gain in weight after his jousting injury (and significant loss of consciousness) is probably best explained by anosmia. His patterns of neurobehavioral changes after such injury clearly correlate to frontal lobe injury. See http://subtlebraininjury.blogspot.com/2008/06/henry-viii-and-brain-injury-behavior.html

While Myers’s case study does not include any longitudinal study of either change in weight or future employability of his subjects, research done long term with Vietnam vets, clearly documents those phenomenon. If an injured individual has a dramatic change in diet or weight post accident, brain injury must be considered to be part of the diagnostic differential.

Next: the biomechanical clues to brain injury in Myers case studies.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

Amnesia was a Missed Marker of Brain Injury in World War I Shell Shock

2008-06-12T07:43:00.000-07:00

In this series of blogs, we have been focusing on the synergistic interplay between the emotional problems related to combat stress and war-time brain injuries. The previous blog focused on Charles Myers' 1915 case studies of three British soldiers injured in World War I, and what we believe to be his failure to properly factor in amnesia, loss of smell (and taste) and the neuropathological and biomechanical explanations for brain injury. See “A Contribution to the Study of Shell Shock” published in the British Medical Journal, The Lancet, on February 13, 1915. Today, we will focus on the specifics of amnesia, with the next blog relating to loss of smell and the next, the likely neuropathology of these three injuries.

Amnesia in Myers’ patients. Myers seemed completely ignorant about the nature of amnesia and its correlative symptom of confabulation. Each of his patients had hallmark examples of post-traumatic amnesia. Soldier #1’s recollection of the ambulance ride is a classic: “He thinks he must have slept on the ambulance, as he remembers nothing.” How telling that Myers initialized those words in the original, as if it was evidence for what he said needed no comment, the similarity to “hysteria?”

Soldier #2’s narrative begins with the statement: “Can remember nothing until he found himself in a dressing station at a barn lying on straw.” According to Myers’ narrative, the soldier’s description of how he got hurt is clearly contradicted by uninjured eye-witnesses.

Soldier #3’s bizarre theory that he must have been knocked into a lake is a pure example of confabulation. The soldier admitted it was something he deduced, not something he actually remembered. Myers states: “He does not know how he got there or how he left the cellar, but he remembers being in another hospital before he was admitted here.” What other explanation is there for such statement other than amnesia?

While 1915 is nearly 100 years ago, it still seems odd that a combat physician would not realize the significance of amnesia with respect to a diagnosis of injury to the brain. As I have often commented - there is a collective wisdom passed down through the ages with respect to the symptoms of brain injury. The most understood of those symptoms is amnesia. See my essay: The Boy who Could Not Remember, taken from an Alaskan Indian myth.

Yet, Myers ignored that wisdom and the evidence in his own detailed case notes. The result: the wrong diagnosis. Could it be that with the other innovations of modern warfare having their genesis in World War I, the horror of supplanting thousands of years of human experience with the arrogance of a “modern” diagnosis, also arose?

What has been the impact of Myers getting it wrong on Western medical thought? That is hard to measure. But his sarcastic reference to the obvious hysteria diagnosis was published in the leading medical journal of its time, The Lancet. Over the next 75 years, the culprit of a false diagnosis of “hysteria” seeps into almost all neurological diagnosis. Only by focusing on the clear cut neuropathological clues found in Myers’ detailed case studies, can this stain on neurological diagnosis be removed.

Tomorrow: This series will continue with a focus on the significance of loss of smell and taste to a modern diagnosis of brain injury.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

Lancet Case Study of Three World War I Soldiers with Shell Shock

2008-06-11T07:18:00.000-07:00

As introduced in yesterday’s blog, Captain Charles Myers, a British Physician authored a significant case study of three wounded soldiers with shell shock in the Lancet, the publication of the British Medical Society. See C.S. Myers, “A Contribution to the Study of Shell Shock” The Lancet, on February 13, 1915 page 316-320.

Myers begins his discussion of the three cases by calling them “remarkably similar.” All three soldiers were

• Injured by a by shells bursting near them;
• Had sleep problems before their injuries,
• Had memory disturbances after their injuries;
• Had vision affected;
• Had disturbances of smell and taste.

And quite significantly to Myers, despite the proximity of the blasts, none had any significant disruption in hearing.

Soldier # 1:

Myers describes the first soldiers case as follows:

“During the (retreat) from this trench at 1:30 p.m., they were “found” by the German artillery. Up to that time he had not been feeling afraid; he had rather ‘been enjoying it’ and was in the best of spirits until the shells burst about him… He was trying to creep under wire entanglements when two or three shells burst near him. As he was struggling to disentangle himself from the wire, three more shells burst behind and one in front of him. After the shells had burst he succeeded in getting back under the wire entanglements. … Immediately after the shell burst in front of him his sight became blurred. It hurt his eyes, and they burned when closed. At the same moment he was seized with the shivering, and the cold sweat broke out especially around the loins “like a punch on the head, without any pain of it’. The shell in front cut his haversack clean away, bruised his side, and apparently it burned his little finger. …

“When he got to treatment… he was crying the whole time and worrying as to whether he was going blind. … At the dressing table station he was crying and shivering; he was taken thence to a hospital by horse ambulance… He thinks he must have slept on the ambulance, as he remembers nothing. (Emphasis in original.)

Three months post injury ‘says he has lost the sense of taste and smell since the shell’s burst around him.’

Woke up last night and found himself crying: ‘not thinking of anything in particular’.

Past history: He had been for two months in the Aisne district on the lines of communication, sleeping badly all the time owing to lumbar pain… He had failed to pass a medical examination some time previously because of renal trouble.

Soldier # 2:

Myers says of the second soldiers combat experience:

“The patient says he was buried for 18 hours owing to a shell bursting and ‘blowing in’ the trench in which he lay.”

This soldier also has lost his sense of smell and much of his sense of taste. While some “memory” of the events around the time of his injury returned, comparison to his later description of events was not consistent with what other soldiers who survived the battle remembered. While Myers seemed troubled by the conflict in these stories, it can clearly be explained by the brain injury symptom of “confabulation”.

Soldier # 3:

Myers detailed the history as follows:

The patient says was blown off a heap of bricks, 15 feet high, owing to a shell bursting close to him. Thinks he must have fallen into a pool of water, as he next remembers finding himself, about 3 p.m., the same afternoon in a cellar near a church with his clothes drenched. He does not know how he got there or how he left the cellar, but he remembers being in another hospital before he was admitted here.”

Myers details this soldier’s symptoms as follows:

“A healthy-looking man, well-nourished, but obviously in extreme nervous condition. He complains that the slightest noise makes him start. His legs feel weak and he has pain in the precordial region. His sight has been very much impaired since the shock. …

He has slept very little the last two nights. Hands tremulous. Knee jerks normal, but the first attempts to evoke them provoked a spasm of the calf muscles and a few general convulsive movements as the patient lay in bed. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint and says that he felt cold and dizzy, and experienced round and round movements of the stomach. … The slightest touch on the legs provoked well-marked spasm of the quadriceps muscles of the same thigh. Extensor muscles of the toes appeared to be in a state of clonic contraction.

Left nostril fails to detect smell of ether, peppermint, eucalyptus, ammonia, carbolic acid, or iodine tincture, all of which are at once recognized when placed beneath the right nostril. No signs of nasal obstruction. Taste: Only tastes very strong solutions of sugar, salt and acid…”

Conclusions. Myers, after discussing the three histories, ends his paper with this comment:

Comment on these cases seems superfluous. They appear to constitute a definite class among others arising from the effects of shell-shock. The shells in question appear to have burst with considerable noise, scattering much dust, but this was not attended by the production of odor. It is therefore difficult to understand why hearing should be (practically) unaffected and the dissociated “complex” be confined to the senses of sight, smell and taste (and to memory). The relation of these cases to those of “hysteria” appears fairly certain.

Thus, at a critical juncture in military medicine, with all the observational facts recorded to shift the focus to brain injury, the theory of hysterical illness raises its specter. That pattern gets repeated and becomes the cornerstone of far too much bad diagnosis - even to this day - at least in forensic neurological practice.

Myers’ choice of the word “hysteria”, is now replaced by the words “conversion disorder”. Myers might have been a pioneer - a leader in the field of military medicine in 1915 - yet his ignorance relative to what we know today about brain anatomy, is significant. The two most predictable markers of brain injury are loss of memory for events around the time of the injury (amnesia) and the loss of smell. He dismissed these findings. Further, he clearly lacked any basic understanding of the biomechanical forces which result in brain injury. While his ignorance is understandable, the ongoing use of these ridiculous psychiatric excuses for clear-cut neurological phenomenon, are not.

In the coming blogs, we will look at the clues to a proper diagnosis in these three cases histories: amnesia, loss of smell and the biomechanical and neuropathological explanations for brain injury.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

World War I Literature Shows the Reluctance to Identify Brain Injury in Shell Shock Soldiers

2008-06-10T08:08:00.000-07:00

I owe my perception of the World War I literature on Shell Shock to a good friend’s academic pursuit of such topic while at Yale. The below quotes are from a paper discussing the dichotic treatment of shell shock as an emotional/organic injury in the novel: Return of the Soldier, by Rebecca West. Quoting from Kara Harton’s paper:

Shell Shock in Rebecca West’s Return of the Soldier

Set in 1916 at the Baldry family estate outside London, Return of the Soldier is the fictional story of Chris Baldry, a veteran of The Great War, who is discharged from the military due to shell shock-induced amnesia. His only memories are expressed as flashbacks of his pre-war life.

The idea of shell shock is introduced in the novel before the main character actually appears. Kitty and Jenny are at Baldry Court, nostalgically reminiscing about the past, when Margaret arrives with news about Chris. She informs the women that Chris has experienced some sort of misfortune on the battlefield but is somewhat hesitant to reveal the details. When Kitty asks if he is wounded, Margaret responds with, “Yes . . . he’s wounded,” but soon corrects herself by explaining, “I don’t know how to put it, he’s not exactly wounded. A shell burst –.” “Concussion?” Kitty asks. Margaret clarifies that Chris has shell shock and is “not dangerously ill.” After her explanation, the women share an awkward silence; they are obviously uncomfortable, and it is clear that neither of them is certain of the implications of the news.

Just as the characters of Return of the Soldier are not quite sure how to classify this condition, most Europeans, including medical and psychological experts, were unsure of the exact cause and characteristics of shell shock. There was an extensive debate about whether the nature of the condition was physical or mental, and whether it could legitimately be classified as a “wound.” The inability to pinpoint Chris’s injury in the previous passage is an excellent illustration of this uncertainty. It is not a tangible injury, and no one can decide exactly how to refer to it. The women seem uncomfortable using the term “shell shock,” which shows their lack of familiarity and understanding of the condition.

In addition to providing an excellent illustration of the uncertainty with which people approached shell shock, Return of the Soldier also contains numerous examples of the way that this condition disrupted society during and after the War. After Chris’s return, Kitty wants their lives to return to normalcy because as members of the upper echelon of society, they both have important responsibilities and obligations to fulfill.

* * *

Jay Winter, a notable World War One historian, calls shell shock “a code to describe the shock of the war to the ruling elite, whose sons and apprentices, being groomed for war, were slaughtered in France and Flanders.” (Winter 10) In this war, unlike other wars, the higher a man’s socioeconomic status, the greater his chances of becoming a casualty. This fact was very real to the social elites, and the phenomenon of shell shock provided “a symbol . . . of the effect of the war on both their own social formation and British society as a whole, which many of them took to be interchangeable.” (10) Officers were expected to be shielded from the danger of emotional breakdown by their superior competence and judgment, their position of responsibility, and the need to set an example for their inferiors. The awareness that officers were more likely to become casualties (both due to shell shock and more conventional injuries) was an uncomfortable reality for society.

© Kara S. Harton, 2007 For the full paper, click here.

In following up on Kara Harton’s research, I found some of the published works of the British physician, Charles S. Myers. Tragically, Myers had immense difficulty overcoming his skepticism that an actual injury to the brain could have occurred without obvious head trauma, despite his focus on the “shell shock” events at the time of onset of the symptoms. While Myers did an excellent job in documenting diagnostic information from which a brain injury diagnosis could have been made, he sarcastically dismissed these cluster of symptoms as “hysterical” (psychiatric) in nature.

Tomorrow: A closer look at Myers' 1915 seminal paper on “A Contribution to the Study of Shell Shock” published in the British medical journal, The Lancet, on February 13, 1915.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

Shell Shock – Then and Now – Eliminating the Stigma and Labels Key to Treatment

2008-06-09T07:26:00.000-07:00

While this issue may in fact be prehistoric, the dilemma as to whether the radically different emotions and behaviors of the returning vet were the result of injury or psychic stress was an important theme of post World War I thought. World War I, like Vietnam, (and now our occupation of Iraq) was a war without decisive battles, where returning soldiers returned home with little thoughts of glory, and severe difficulty adapting to civilian life. As World War I and Vietnam were fought repeatedly over the same turf, there was little drama in the successes and failures in the field. There were no great battle movies like the Battle of the Bulge or Midway to come out of those conflicts. Instead, we got All Quiet on the Western Front, Apocalypse Now and The Deerhunter.

The literature of the time focused on the futility and horror of the conflict. It may be that such "treading water" kind of war results in either more psychic stress or more non-fatal closed head injury. It may be a combination of the two, but both wars resulted in a mushrooming of anti-war literature, focused on the ravages of such conflict on the minds of its veterans. In many ways, it is through listening to the voices of literature that so many diagnostic clues of what we would today diagnose as Post Concussion Syndrome, can be heard.

The literature after World War I as it pertained to "shell shock" reflected the struggle for society to accept that its brave soldiers could be "weak" enough to be haunted by the psychological horror of war. It is claimed that the British resisted such labels, instead looking for physical injuries which could explain the major change in the personality of its returning veterans.

"In order for the condition to seem more valid, the stigma of psychological disorder had to be surmounted – a significant obstacle to a society in which the mentally ill were considered outsiders. Therefore, it could not be attributed to fear or nervous breakdown due to the atrocities of war; medical experts had to assert that shell shock was caused by proximity to an exploding shell. "

See Kara S. Harton paper on The Return of the Soldier.

While French and German medical experts more easily accepted the psychological explanation, the British medical experts shifted the focus to the more tangible explanation that proximity to an exploding shell, explained the change. However, even the British fell far short of truly appreciating the brain injury that occurred as a result of those blast injuries. Tomorrow: A Closer Look at the British View of Combat Neuro-Trauma

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

The Nightmare of a Wartime Brain Injury

2008-06-08T16:52:00.000-07:00

Modern warfare has become such a nightmare, that when our soldiers come home from war with nightmares, we don’t even bother to consider whether those nightmares could be caused by injuries to their brains. The mind is the most complex thing studied by man, perhaps the least understood. The 20th century saw an explosion of theories and treatments to mend the broken psyche, yet very little increased understanding as to how vulnerable the organic components of the mind are. It is as if when our computer didn’t work after we dropped it, the only fix we considered was reloading the software, not an examination to see if any of the hardware had been damaged.

Brain injury and war have always gone hand in hand. Before there were arrows, bullets and bombs, there was the club. Before there was body armor and bulletproof vests, there was the helmet. No soldier goes to war without his helmet. Yet the helmet is primarily another carton, designed to protect the brain’s natural carton, the skull. Never have helmets eliminated all injury to the egg inside the carton. The skull may be intact, yet its ward the brain, severely injured.

What is perplexing is that when we look at the troubled soldier, we fail to evaluate how much of that trouble could have come from a scrambling of the egg. Each new war seems to come up with its new label for the psychiatric consequences of warfare. World War I had its “shell shock”, Vietnam its PTSD (post traumatic stress disorder.) There was a recognition as early as World War I that modern medicine was saving the lives of those with injured brains who might have died, yet little has been done to recognize that repairing the shell, does not restore its contents to their pre-war status.

2008 brings us to a crossroads in this dialectic. The Iraq war is one where brain injury is reaching center stage. IADs are more likely to kill and injure through concussion than through penetrating injuries. Faster, more advanced surgical and intervention techniques identify those most likely to suffer catastrophic outcomes. Yet as in real life situations, in warfare there is a 20 fold more likelihood to injure the brain in situations where the injury and its lasting effects are subtle. And because of the stressors of combat, there is little likelihood that acute triage and diagnosis is likely to occur. One does not med-evac the walking, talking soldier. A detailed analysis of amnesia is probably the only sensitive way to identify most lasting concussions, yet no one is going to bother to investigate for amnesia with someone who is not obviously confused.

The issue of the degree of brain damage in the undiagnosed vet is not a new topic for investigation. It was the topic of both medical study, as well as considerable literature after World War I. Immense contributions were made both based on acute studies and the development of surgical techniques during World War II and the Korean War. Vietnam had numerous studies, including the remarkable development of the PTSD diagnosis. Even brain damage from disease processes such as malaria, got some study after Vietnam. See http://www.va.gov/OCA/testimony/hvac/16JY98NV.asp. Further, longitudinal studies from throughout our 20th century wars, gave us a much more complete view of the long term affects of brain injury.

While just the changes in combat and war time triage would make this topic worthy of a reevaluation during this brain injury intensive Iraq War, there is perhaps a more compelling reason to revisit this topic:

Our understanding of the vulnerability of the brain to suffer permanent damage as a result of what typically would be labeled a concussion, has increased exponentially since the last time this country engaged in a sustained conflict. The principles of Diffuse Axonal Injury to the brain have been described and researched. See http://subtlebraininjury.com/biomechanics1.html. The perceived threshold of acute symptomotology requisite for a potentially permanent brain injury has been significantly lowered. See http://www.cdc.gov/ncipc/tbi/mtbi/mtbireport.pdf Quite significantly, neuro-imaging has developed to the point that at least the tip of the iceberg of neuropathology can be seen. http://neuro-imaging.com

Yet, this inquiry is not limited to helping Iraq war veterans but has a broader goal. It is our hope that if this commentary can impact the analysis and treatment of Iraq War nightmares, we might also gain an appreciation of one of the United States most troubled population subgroups: the Vietnam War vet.

Lastly, it is our hope that we might significantly advance our understanding of civilian brain injury. War, by necessity, becomes a laboratory to learn about brain injury. Much of what we have learned about brain injury was learned from military medicine. We must use the sacrifices of our soldiers to assist in civilian medicine.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447
©Attorney Gordon S. Johnson, Jr. 2008

Understanding Combat Related Suicide Requires a Comprehensive Evaluation of all that is Wrong Inside the Head

2008-06-07T15:59:00.000-07:00

The cause of suicide: “it’s all in the head.”

That cliché is said typically about psychological problems. But the brain injury community likes to twist this cliché, with a tone of irony, pointing out that a brain injury, is also “in the head.” While our psyche is in our head - our brain’s structures, our neurons, the center of our neurological systems, are there, too.

In 1980, the American Psychiatric Association formally recognized the diagnosis, Post Traumatic Stress Disorder, (PTSD) largely because of the increasing recognition of the clustering of emotional problems from Vietnam veterans. See the DSM-IV. Since then, PTSD has been the easy catch-all for emotional problems that someone who has been in combat, is suffering. Other generations had other labels - shell shock the most enduring. The problem with the historic combat stress diagnosis is that the organic component of the emotional symptoms experienced after combat has never been properly addressed.

I believe that to properly treat a neurological malfunction, it is necessary to fully understand the cause of the problem. If the emotional problems relate strictly to the emotional shock and stress of combat, then that would indicate a certain strategy to address those issues. If on the other hand, the emotional problems are secondary to organic injury to the brain, then different strategies may be necessary.

The May 19, 2008 New Yorker contains a fascinating article about the use of virtual reality therapies that are designed for the treatment of PTSD in Iraq War veterans. Click here for this article. What is ironic though is that while the story of soldier Lance Boyd’s combat stress is quite harrowing, the article and in all likelihood the military, have ignored one very important aspect of his neurological health: at the time he was wounded, he also suffered a concussion.

Depression comes in many forms, but for someone who has suffered a brain injury, that depression has multiple elements. As with anyone who is injured and/or disabled, there is a depression that relates to the loss of previous abilities, a reactive depression. With someone who has a brain injury, there also is the risk of an organic depression, specifically related to an injury to the mood centers of the brain. The brain’s mood is controlled by multiple areas of the brain, working together. If there is an injury to one or more of these centers, or the communication fibers that connect them, a very specific type of depression may exist. However, the emotional changes that can come from injury to other parts of the brain, can be even more pronounced.

Another major element in the depression mix is fatigue. I had once believed that depression causes fatigue. While it can, research indicates that the cause and effect is often reversed: fatigue causes depression. Perhaps one of the two or three most common symptoms of brain injury is fatigue. There are multiple reasons for this fatigue, but the two easiest to illustrate relate to:

1) Sleep problems, and
2) Over-attending fatigue.

1. Sleep. Organic injury to the brain can disrupt sleep, because it can interfere with the neurological triggers and mechanisms for sleep. Further, as will be discussed below, pain interferes with sleep.

2. Over-attending Fatigue. Virtually everyone with a persisting brain injury disability, has problems concentrating and multi-tasking. I have often illustrated this with analogizing it to a computer that is just about to crash. Picture how all of a computer's functions slow down as the computer's processor spinning out of control. Likewise, for a brain injured person, when every mental task requires activating more of the brain’s power than it did pre-injury, the brain’s mental energy is rapidly consumed. Another example: the difference between an easy two hour drive on an uncrowded expressway, versus the mental fatigue of driving in traffic, or in a storm. The easy drive may actually refresh, the traffic or storm situation will quickly exhaust. For the brain injured, mental processing of even simple tasks may involve a virtual traffic jam of thought inside the injured brain. The result, fatigue.

Another common denominator for depression and brain injury is pain. I once thought of brain injury as a cognitive disorder, with associated personality and fatigue-related symptoms. But each time I asked a group of brain injured survivors the question for the most common symptom, I got the same answer back: headache. Headache after brain injury can come in many forms, but migraine is present in at least half of my clients. Vertigo and neck pain also contribute significantly to headache in this population. The causes of headache are as multi-factorial and synergistic as depression, but the they all increase depression. Pain = depression. Pain = lack of sleep. Pain = disability.

Again from the New Yorker article of soldier Lance Boyd, who not only suffered a concussion, but other physical injuries:

“We had to crawl out of there,” said Boyd, who was hit with shrapnel and suffered a concussion, earning a Purple Heart. “That was my worst day.”

If all that the virtual reality does is address the emotional stress of being under fire and having a buddy killed, it is not likely to make a major dent in depression. If all of the factors at work aren't treated, the cure may work in a virtual world, but not in this one.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447

©Gordon S. Johnson, Jr. 2008

Suicide and Terror Continues for Our Iraq and Afghanistan Soldiers

2008-06-05T11:17:00.000-07:00

It was a confluence of many issues coming together at once last week, but the mental health of our Iraq and Afghanistan Veterans was all over the news. The Associated Press announced that active duty military suicides hit its highest level on record in 2007, 119 soldiers dead. See the AP story at: http://hosted.ap.org/dynamic/stories/M/MILITARY_SUICIDES?SITE=CADIU&SECTION=HOME&TEMPLATE=DEFAULT

With Memorial Day, this issue got more play than usual, including some very heart wrenching call ins from family members of some of the victims on NPR On Point with Tom Ashbrooke, week in the news. See http://www.onpointradio.org/shows/2008/05/20080530_a_main.asp The Suicide discussion begins in the last 10 minutes of the show.

To round out the issues, the beginning of the general election campaign between Barack Obama and John McCain has sharpened the focus on the Iraq war. This is especially true because of McCain standing with President George Bush against expanding veteran scholarship benefits. http://www.msnbc.msn.com/id/24805581/ McCain and Bush claim that the proposed scholarship plan for Vets would hurt the military because it would encourage soldiers to leave the service after only three years.

One of the most disturbing scandals of the Bush Administration has been their continuing shoddy treatment of both active duty troops and veteran benefits. But the issue of mental health is perhaps an area where the focus on what is wrong with our current treatment of soldiers and Vets comes into the clearest focus.

When the United States invaded Iraq, defeated the formal Iraqi military and deposed Saddam Hussein, the conflict there went from the type of job for which we trained our soldiers, defense and military conquests, to a police action, a war of occupation. The United States does not have in its DNA to be an occupying country. Occupying a country has been the role of the bad guys: the Germans in Europe during World War II, the Russians in Afghanistan. That is not what we are supposed to be doing, not what we train our soldiers to do, not what the 400 year immigration to the Free World has been about.

The mental health issues facing occupying troops will be different than those who are actively engaged in fighting a definable enemy, with clear cut battles, front lines. In Iraq, there is no definable battle, no tangible goals to achieve, just bullets flying and random roadside bombs. In the Onpoint Memorial Day Podcast, the story is told of Alissa Rubin’s (Deputy Baghdad Bureau Chief for the New York Times) ride in a military transport out of Iraq, with one sole coffin in the rear of the plane. http://www.onpointradio.org/shows/2008/05/20080526_a_main.asp The soldier in that coffin was killed by a roadside bomb while on his way to a memorial service for two other soldiers who were also killed by roadside bombs.

That type of ironic danger, the totally unpredictable moment when the world will go from calm to death, creates an emotional toll that can’t be overstated. These issues don’t just effect enlisted men, but also reach into the officer corps. The soldier suicide documented in the story from the June 4, issue of the Huntington Post was a major- a major who killed himself as he was set to deploy to his third tour in this amorphous combat zone the Bush Administration likes to call the War on Terror. Click here for the story of Major Lance Waldrof. http://www.huffingtonpost.com/greg-mitchell/another-shocking-vet-suic_b_105255.html

My brain injury advocacy began at a time when the Brain Injury Association was my beacon. I remember hours spent in committee meetings, debating the words of our Mission Statement for the Brain Injury Association of Wisconsin. The Brain Injury Association’s mission statement to this day contains these simple words:

Creating a better future through brain injury prevention, research, education and advocacy.

The path of advocacy begins with Prevention.

Death is part of a war. Combat related stress is part of war. Brain injury is part of war. PTSD and other emotional costs are part of war. The only way to eliminate these risks, is Peace. The time has come to prevent death, brain injury, combat stress and PTSD. The time has come to save our brave and capable troops from a war of occupation, a war that no American soldier should have ever been forced to fight. We are not fighting a War on Terror. We are simply terrorizing our bravest men.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447

Department of Defense Treated Brain Injured Vets Like Defense Lawyers Do

2008-05-21T10:47:00.000-07:00

I have always called it the Defense of Misdirection. This year, is an election year, and I have an easier term for people to understand: SPIN. Spin is what defense attorney's do. They spin everything, ignoring the obvious and coming up with some type of misdirection to disregard the diagnosis of treating doctors. The goal is to shift blame from everyone but the defendant who actually caused the injury by his/her/its wrongful conduct.

The favorite spin of defense attorneys is to blame it on pre-injury (pre-morbid is the medical term, meaning previously to the injury "mordibity") psychological problems. The Army now is using similar tactics. With insurance companies the motive is to build up the skepticism of the jury, to reduce the amount its insured is required to pay. With the Military, the motive is to find as many warm bodies as possible to send back into a combat zone, to keep the numbers up for the surge in Iraq. There might also be the motive to save billions in VA benefits, too.

An April 23, 2007 story in the Army Times details the way in which the Army is using so-called “personality disorders” and tactics typical of Defense lawyers to force soldiers to go back into combat, or deny them proper veterans medical and disability benefits. For the full story, click here: http://www.armytimes.com/news/2007/04/military_braininjury_thurman_070420w/

The insurance industry propaganda machine is always trying to stir up sentiment about frivolous lawsuits. What actually happens in the Courtroom is dramatically different.

Defense attorneys learn how to spin any disability into something where they can raise jurors skepticism. Defense attorneys hire doctors who know what is expected of them. Ridiculous, psychosomatic diagnosis not found in the real medical world since Freud, are reinvented.
(The actual condition of Conversion disorder is so rare, that only left-over Freudian influence in the psychiatric profession, keeps it in the DSM-IV.) Pre-morbid personality disorders are found even though the person was considered well adjusted and productive before they got hurt. Any emotional counseling around life’s normal challenges such as divorce or marital difficulties is turned into evidence of deep seeded psychosis.

Jurors often see the Defense doctors as equally credible to the plaintiffs treating doctors, for reasons that are hard to fathom. As the plaintiff has the “burden of proof”, any doubts are resolved in favor of the Spin Doctors. Often the most credible evidence is that of friends and co-workers, who tell of how normal and productive the plaintiff was before. Defense lawyers try to spin this, and apparently, so does the military. The Army Times story linked above, tells of a soldier who was claimed to have a personality disorder, even though it didn’t show itself until he returned from Iraq.
Edward Kaspar said he served as Town’s lieutenant and was a witness to the incident in which a rocket exploded above Town’s head in Iraq, causing his brain injury.
“I was pretty shocked to hear about his problems now,” Kaspar said by e-mail. “This personality disorder thing just doesn't make sense. I'm not a trained medical professional, but I can say that in the years he served as one of my soldiers, he definitely had it together. _ I relied on him to get the job done and he never failed me, both in peacetime and in war.”

Senators and Congressmen are calling for our wounded soldiers to get better treatment than this. While Bush and McCain are still fighting giving maximum benefits to Iraq Veterans, the political tide looks like by early next year, the laws will be improve. But changing the written rules won’t be enough. The culture of denial must be changed. Doctors, both civilian and military must start to believe that good, hard working people, are not malingers, just waiting for a chance for a free ride. People don’t choose the life of the disabled. They are disabled because their minds have been fundamentally changed by either trauma or extraordinary stress in a way, that has left them only a shadow of who they were. This is not a life of luxury, but a tragedy that deserves all of the assistance either our court system in the case of civilian injuries, or the VA system, in case of military injuries, can provide.

There can be no disagreement on this: forcing a soldier with a brain injury or PTSD to return to combat is unconscionable, not just because it is exposes that soldier to death and more disability, but because it exposes other soldiers to the same, because they will not be able to rely on that soldier.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447

NFL, War and Brain Injury, Part II

2008-05-16T07:35:00.000-07:00

Yesterday I commented on the intersection of news about Iraq War veterans and the death of an NFL player. Today, we focus more on the synergistic effect of the interplay between brain injury and emotional problems.

It was reported in the April 19, 2008 edition of the Science Daily that one in five Iraq and Afghanistan Veterans suffer from PTSD or major depression. In addition, 19% are reported to be suffering from the effects of brain injury.

Click here for the complete story: http://www.sciencedaily.com/releases/2008/04/080417112102.htm

According to this article:

Researchers surveyed 1,965 service members from 24 communities across the country to assess their exposure to traumatic events and possible brain injury while deployed, evaluate current symptoms of psychological illness, and gauge whether they have received care for combat-related problems.

The article said:

"There is a major health crisis facing those men and women who have served our nation in Iraq and Afghanistan," said Terri Tanielian, the project's co-leader and a researcher at RAND, a nonprofit research organization. "Unless they receive appropriate and effective care for these mental health conditions, there will be long-term consequences for them and for the nation. Unfortunately, we found there are many barriers preventing them from getting the high-quality treatment they need."

Odds are that they will get this attention. The recent federal funding has allocated large sums of money for TBI research and treatment from these two wars. Still, these numbers, if they are to be believed (i.e.,19% with TBI) mean that there are considerably more veterans involved the 20,000 or so that have been involved in recent studies. A 19% figure could push the number of vets with post concussional syndrome well into the hundreds of thousands. That would make even a half of billion dollars, seem inadequate.

Combat involves a synergistic (as defined yesterday) exposure to screwing up what makes the brain work. Not only are enemy attacks particularly bad for the organic matter inside the brain, but the constant vigilance and stress that which can occur, can create a more vulnerable brain to an “organic” injury. Prevalent throughout almost all neuropsychological literature is the challenge to distinguish between actual physical injury to brain tissue (organic injury) and the effect of emotional responses on the brain. There is no shortage of areas that the allocated research funds could be directed. Still, we believe that focusing on the synergistic effect and the vulnerabilities to injury of someone exposed to the stress of combat, should be near the forefront of priorities.

NFL, War and Brain Injury

2008-05-15T12:17:00.000-07:00

My internet news today had an intersecting of two recurring themes in the brain injury world, with that of an unexpected death of a former NFL player. The first theme is the difficulties retired NFL players have with disability. The second theme the degree of depression found in post Iraq war veterans. What does the death of Curtis Whitley have to do with the other two themes? Perhaps nothing, but even if this case doesn’t, other similar cases could. For the full story on the death of Curtis Whitely, click here.

Anyone who works in the field of brain injury, has often turned the old cliché about mental illness “Its all in the head” on itself, because of course, anything to do with the brain, is in the head. But, the extent of the interplay between emotional problems and brain injury is never, and I repeat never, fully appreciated. As I sit here and write this, I can’t fully appreciate this interplay, because it involves the area of human emotions and function, that we are only scratching the surface in our capacity to understand and have no clue as to how to measure.

Brain injury deficits and emotional deficits are synergistic, meaning the whole of the problems when you combine these two, is greater than the sum of the parts. From a recent deposition I took of a defense neuropsychologist:

Q If I were going to use the term "synergistic" to apply to the cumulative effect of all of these multifactorial aspects of an outcome, is that a reasonable word to use to describe it.
A Can you define how you're using synergistic?
Q Well, if synergistic means the total exceeds the sum of the parts, do you believe that post concussional deficits can be synergistic?
Q I'll add to that. Do you believe that the cumulative disability from post-concussional deficits can be synergistic?
A I believe -- I hope I'm answering this consistent with what you're asking -- but I believe that these factors can feed off of each other and result in a very complex, poor outcome.

With respect to Whitley, the 39 year old was found face down in a bathroom in Fort Stockton, Texas. The local sheriff said there was no indication of foul play, but the case is under investigation. That investigation will likely look at Whitley’s history of drug and/or alcohol abuse. What won’t be examined is how many concussions he had, how his dependencies on substances might have interplayed with those concussions and how his emotional vulnerabilities from the combination of the two contributed to the end of his NFL career and his premature death.

But perhaps, Iraq war veterans will have a better fate. A recent article in the Science Daily, promises more for them, and we will discuss such issues in our next blog. Click here for that story.

Attorney Gordon Johnson
http://subtlebraininjury.com
http://tbilaw.com
http://waiting.com
http://vestibulardisorder.com
http://youtube.com/profile?user=braininjuryattorney
g@gordonjohnson.com
800-992-9447

Wounded Troops and Partners: Supporting Intimate Relationships.

2008-05-13T10:40:00.000-07:00

From the Brain Injury Association of Wisconsin:

Dear Members and Donors:

The following conference offering was sent to us from the BIAA. We are forwarding to you for your information.

The Center of Excellence for Sexual Health invites you to join elected officials, public and private agency leaders, healthcare professionals, members of the armed services, veterans, and concerned civilians for a one-day conference, Wounded Troops and Partners: Supporting Intimate Relationships.

This conference seeks to:

Create visibility for the linkage of mental and physical disabilities like PTSD, traumatic brain injury, and serious burns with failed intimate relationships that contribute to higher suicide rates, divorce, and other problems
Strengthen specific initiatives around intimate relationships for person with service-related disabilities
Develop and expand enduring networks of people to serve these populations
This is your opportunity to contribute to a national dialogue on how U.S. agencies, healthcare providers, and communities can help wounded troops and their partners develop and maintain healthy intimate relationships.
You will hear first person experiences and receive briefings from leading experts on:

How healthy intimate relationships contribute to recovery from physical and mental trauma
How lack of a satisfying intimate relationship contributes to ongoing mental health problems and suicide
The special challenges and concerns of wounded women warriors
How intimate relationships help wounded spirits heal
The specific sexual health concerns of troops with disabilities
How addressing sexual health concerns strengthens marriages and other committed relationships
Featured speakers include Bob Dole, Dr. David Satcher, Dr. Richard Carmona, Dr. Margaret Giannini and Lee Woodruff.

Participate and send a strong message about the importance of wounded troops and their partners having access to the healthcare, counseling and resources
that they need to sustain intimate relationships that provide support and promote healing.

Please visit our conference website http://www.msm.edu/Centers_&_Institutes/CESH/Programs_&_Initiatives/Disabilities/Wounded_Troops_and_Partners/Wounded_Troops_&_Partners_Home.htm or contact our office for more information. There is no charge for registration. Lunch will be provided.

When
Wednesday, May 21, 2008 8:30 AM - 5:30 PM
Eastern Time Zone

Where
Henry J. Kaiser Family Foundation
Barbara Jordan Conference Center
1330 G Street, NW
Washington, DC 20005

Intimacy, sexuality, empathy are among the areas that brain injured survivors have some of their most significant problems. Lower frontal lobe damage is likely to contribute to these problems. Vets have the additional issues stemming from the overlay of combat related emotional issues.

We would encourage not only Vets and their loved ones to attend this conference, but anyone affected by brain injury.