Sunday 11 November marks Remembrance Day: a day to commemorate the efforts, achievements and sacrifices that were made in past wars and military conflicts since the onset of the First World War.
This year Remembrance Day takes on an added significance, as 2018 marks 100 years since the end of the First World War, one of the most significant conflicts of the 20th century.
The First World War is infamous for the number of lives it cost; however it also generated some extraordinary developments in medicine and technology. As these advancements in battlefield medicine and technology have continued over the years, an unprecedented percentage of service personnel are now surviving combat injuries that would have previously been fatal.
If you consider the types of injuries a member of the Armed Forces may suffer, it is likely that you would think of blast injuries and amputations, gunshot or shrapnel wounds or open wounds and fractures.
But what about the injuries that cannot be seen? Those with invisible injuries, such as psychological or brain injuries?
Traumatic brain injuries
A Traumatic Brain Injury (TBI) is a form of acquired brain injury and occurs when a sudden trauma causes damage to the brain. A TBI may happen from a blow or jolt to the head or an object penetrating the brain. These are highly prevalent injuries acquired by personnel in a military setting due to the risks of undertaking combat roles.
TBIs vary in severity; from mild to moderate to severe and while physical disabilities are more easily apparent, a large majority of individuals with a brain injury have ‘hidden’ disabilities which affect memory, judgement, behaviour and other higher functions.
A mild TBI, which includes concussion, is the most common traumatic brain injury affecting service personnel. It is also however, the most difficult to diagnose and the least well understood. Undoubtedly, the ‘invisible’ nature of a mild TBI, notably the lack of any external physical evidence of damage to the head or brain, has been a major factor contributing to the impression of inconsequentiality. In addition, other more serious injuries may have occurred and if an injury has been caused by a traumatic event, such as a blast, the symptoms may be attributed to a stress reaction or even post traumatic stress disorder (PTSD).
The effects of a mild TBI can be very subtle and are often not obvious to others. However, even seemingly minor problems can significantly affect people’s lives and those of their loved ones and it is recognised that some mild TBIs have persistent, and sometimes progressive, long-term debilitating effects.
Studies have shown that the age of dementia onset is lowered for those with a history of a TBI (Barnes 2014. Li, 2016) and whilst the risk of developing dementia may be age-specific, a mild TBI is enough to raise the risk in people over the age of 65. (Gardner, 2014)
The presence of a mild TBI can cause the following symptoms: loss of consciousness, disorientation, confusion or post traumatic amnesia. For some, the consequences of such an injury can be serious and long-lasting, with changes in mood and behaviour, such as irritability, aggression, depression and memory loss.
Brain injury is often associated with greater mental health problems, higher rates of depression or mood disorder and there is a clear link between a mild TBI and psychological and behavioural changes. This poses another challenge given the large numbers of service personnel and military veterans who develop mental health difficulties.
PTSD and TBI often co-exist, particularly within a military setting, because brain injuries are often sustained in traumatic experiences and many researchers have drawn parallels between the discussion surrounding mild TBI, and that of ‘shell-shock’ from the First World War.
Several studies have reported associations between TBI and PTSD, and TBIs sustained during deployment have been found to be significant predictors of developing PTSD.
The suffering veterans bear can be heavy. More die from suicides because of psychological and emotional trauma than are killed in combat. Ministry of Defence figures show 400 ex military personnel killed themselves between 1995 and 2014.
Thousands of servicemen from the First World War suffered with severe mental health problems yet received little or no sympathy. Today, attitudes to mental health are changing and the taboo of PTSD is being broken. However many service personnel still find it difficult to access support for mental health difficulties, only seeking help when they reach crisis point.
The impact of a failure to identify invisible injuries
There is a compelling case for the need for further research to disentangle the symptoms of mild TBI and PTSD as well as the need for an appreciation that invisible injuries can be just as hard to cope with as physical ones.
The strong association between TBI and mental health indicates the importance of thorough screening and assessment of both serving personnel and military veterans who report either such symptoms, in order to ensure that the most effective treatments are given.
In a small minority of cases, mild TBIs can develop into more serious, long-lasting difficulties and there is a need for clarity regarding the diagnosis of mild TBI, especially when in the context of psychological distress.
Suffering from invisible injuries is undoubtedly challenging. These chronic conditions can have life-long consequences and if incorrectly diagnosed, the correct treatment will not be provided which can have devastating consequences.