Combat Related Suicide Requires a Comprehensive Evaluation Study

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.