On May 20, 2004, Jerry Pendergrass’s convoy was ambushed. The National Guard sergeant was standing outside his Humvee when a rocket-propelled grenade landed a few feet behind him and exploded, launching him 15 feet in the air. A few moments later, Pendergrass found himself lying on the ground, shrapnel lodged in his leg and his helmet several yards away. He was conscious but unsure of where he was, classic signs of concussion. Another member of his unit pulled him behind the protective barrier of the disabled Humvee, where they awaited evacuation to a medical checkpoint in a secure zone down the road.
Pendergrass soon returned to duty, ignoring the persistent headaches and the sleep, memory, and balance problems that plagued him after the blast. When his tour was up and he returned home to North Carolina, he took prescription painkillers and drank, trying to wash away both his memories of war and the reality of his health problems. It wasn’t until he began a second tour–and was evacuated two months later for spinal damage linked to the earlier blast–that he realized the full extent of his injuries. He was diagnosed with both mild traumatic brain injury and post-traumatic stress disorder (PTSD)–a condition, first defined in Vietnam veterans, that can develop after exposure to a terrifying event. “Big bangs scare the living fart out of me,” says Pendergrass, in a conference room at the Lakeview Virginia NeuroCare center in Charlottesville, VA. He seems startled by even small noises, jumping as a nearby copy machine is jostled into action.
Pendergrass has spent the last three months at NeuroCare, which is partnered with the Defense and Veterans Brain Injury Center. The small in-patient clinic, with an adjacent residence for patients, offers intensive therapy and is staffed by occupational and physical therapists, speech and language therapists, and clinical psychologists. Pendergrass is getting psychological counseling for PTSD and rehabilitation for his brain injury.
He expects to return home soon, but his recovery is complicated by his dual diagnosis. In blast-injured soldiers, PTSD and mild brain injury often occur together. The two conditions also share symptoms–including depression, memory and attention deficits, sleep problems, and emotional disturbances–and research suggests that they can aggravate each other. A 1998 study of veterans with PTSD found that those exposed to blasts were more likely to have lingering attention deficits and abnormal brain activity that persisted long after the injury. And a study published earlier this year in the New England Journal of Medicine found that the 15 percent of soldiers who reported having suffered concussions had a much greater risk of developing PTSD: 44 percent of soldiers who had lost consciousness on the battlefield met criteria for PTSD, compared with 16 percent of those in the same brigades who suffered other injuries.
However, the two conditions can have different prognoses. While PTSD is a serious anxiety disorder, it can often be treated effectively with psychological and drug therapies. Patients with moderate to severe TBI have a far grimmer prognosis. Even people with concussions, who often get better on their own, can have enduring damage: symptoms that linger more than six months may be permanent. No drug treatments have proved effective for curing long-term symptoms, and other therapies are limited. For the most part, patients are simply taught new strategies for dealing with their impairments, such as carrying notepads to help them remember important tasks or designating specific spots for their keys.
Determining the true extent of the Iraq War’s brain-injury epidemic will require sorting out whether individual patients’ persistent symptoms are caused primarily by PTSD or by physical trauma. Statistical analysis from the New England Journal of Medicine study found that lasting symptoms could be attributed largely to PTSD and depression rather than to brain injuries themselves. But the conclusion is controversial. “I think that’s minimizing the potential effects of concussion in this equation,” says Barth, the University of Virginia neuropsychologist.