President Kenneth Haapala called the 2,233rd meeting to order at 8:21 pm February 8, 2008 in the Powell Auditorium of the Cosmos Club. The minutes of the 2,232nd meeting were read and approved.
Mr. Haapala introduced the speaker of the evening, Mr. Charles W. Hoge, who spoke on the topic, “Epidemiology of PTSD and Mild Traumatic Brain Injury (mTBI) among Soldiers Returning from Iraq.” Mr. Hoge leads a psychiatric research program at Walter Reed Army Institute of Research focused on mitigating the mental health impact of the wars in Iraq and Afghanistan.
Mr. Hoge said he would deal first with the epidemiology and then mild traumatic brain injury. This latter term, he said, is an oxymoron — brain injury is never mild.
What the “health” is epidemiology, Mr. Hoge asked. It is the study of the distribution and determinants of diseases in specified populations.
He reviewed the basic principles in epidemiology used to infer causation, which Mr. Haapala had also mentioned in introducing Mr. Hoge. These principles were expressed in 1965 by Austin Hill in the course of his debates with Ronald Fisher about the effect of smoking on lung cancer. These principles are:
PTSD (post-traumatic stress disorder) “came into existence,” he said, in the early 80's, when the disease was observed among Viet Nam veterans. The disease is caused by a traumatic event involving threatened or actual death or serious injury to self or others and presents as a response of intense fear, helplessness, or horror. The symptoms are severe or interfere with functioning. They may include nightmares, flashbacks, and int rusive memories, difficulty sleeping, concentration problems, emotional detachment, and others.
The disease is strongly associated with trauma although only about 30% of soldiers most exposed to trauma develop the symptoms. It is found in multiple populations. It only follows, never precedes, trauma and is related to both the severity and frequency of trauma. Being wounded in combat is followed by PTSD more than twice as often as combat without being wounded. Interventions, both drug and behavioral therapy, do relieve symptoms somewhat.
There has been considerable work since the start of the war on the availability of help for affected soldiers. Stigma has been a major concern because it often prevents treatment. Despite the efforts, stigma remains pervasive. Effort now goes to better educating leaders, family members, and medical personnel regarding psychological health. Nevertheless, 50 - 65% of soldiers strongly agree that accepting mental health care would cause them to be seen as weak, cause their leaders to treat them differently, harm their careers, and the like.
He showed a diagram of a human brain showing that the limbic system, sometimes called the reptilian brain, is a center for survival related emotions and responses, fear, rage, flight, and fight. He showed a series of pictures taken in Iraq that illustrated plenty of reasons for stress and trauma.
Alcohol overuse and abuse increase substantially after deployment, as does physical aggression. A number of other measures of poor health also relate to PTSD. He noted that passing out with alcohol is not actually sleep; it has a very different architecture, so alcohol may be aggravating the problem.
Someone asked if anything in the limbic system predicts who develops PTSD. No, Mr. Hoge said, but we do know that those who have had traumatic experiences as children do have higher risk. Even the first sergeants and staff sergeants cannot predict who will get it.
Then he turned to the “signature” disorder of this war, mild traumatic brain injury. mTBI is a loss of consciousness of 30 minutes or less or transient memory loss. Unconscious of more than 30 minutes is called moderate traumatic brain injury. At 30 minutes, you can see the pathology in brain. With mild TBI, you can’t see it. There is no relationship of the symptomology with the injury. In mild TBI, the axons are twisted or pulled, but not sheared. These definitions are not tight. They depend on self-reports, and the self reporters don’t seem confident of their reports.
Some victims go back to normal and some don’t. They continue to have headaches, difficulty concentrating, and related symptoms. Indications are that these are generalized injury responses.
The only effective treatment for mTBI is information to normalize the victim’s behavior. Convincing them they will get better leads them to get better.
Finally he said that none of the standards for causative inference are met by mTBI.
During the question - answer session, someone asked about football injuries and PTSD. Football injuries do not lead to PTSD, but car accidents do. In this context, he said that litigation is the strongest indicator of mTBI symptoms.
He was asked, “Is there any way of predicting the magnitude of the problem when this war is over?” He responded that the hope is that, since we have better treatment and more victims are getting in earlier for treatment, it will be moderate.
“What has been done to mitigate the effect of stigma?” he was asked. Mental health care has been increased and mental health screening has been increased. Also, soldiers are being taught that they have to be tactically aware while in combat, but at home that will be a symptom.
“Why was PTSD not reported in earlier wars?” Actually, something was reported after all wars. “Shell shock” and terms like it were used for the syndrome.
After the address, Mr Haapala presented to Mr. Hoge a commemorative plaque and welcomed Mr. Hoge to membership in the Society. He exacted a princely sum from nonmembers of the Cosmos Club who parked in the Club lots and referred these people to the Society’s new treasurer, Boris Comiceau. He made a pitch for support. He directed folks considering membership to Bob Hershey, who wielded his trusty trifold brochure. He announced the next meeting. Finally, at 9:45 pm, he adjourned the 2233rd meeting to the social hour.
Ronald O. Hietala,
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