TBI and Empathy in Combat Veterans: Iraq and Afghanistan

Background and Definitions

Traumatic brain injuries (TBI) are caused by sudden trauma to the head that damages the brain. The injury can result from sudden blunt force to the head or penetration of the brain by an object. Symptoms range from mild to severe, depending on the extent of the injury. Loss of consciousness for seconds to minutes can occur when trauma is present, as documented in studies of soldiers from the Iraq War.

Symptoms of mild TBI include headache, confusion, feeling "dazed," lightheadedness, dizziness, blurred or tired vision, "seeing stars," ringing in the ears, bad taste in the mouth, fatigue, changes in sleep patterns, behavioral or mood changes, and difficulty with memory, concentration, attention, or thinking. Moderate to severe TBI symptoms include all the symptoms of mild TBI, plus persistent headaches that worsen, repeated vomiting and nausea, convulsions, seizures, inability to awaken from sleep, dilation of one or both pupils, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation.

Medical attention for moderate to severe TBI is crucial to prevent additional brain damage. Moderate to severe TBI patients require recovery time, which can include rehabilitation programs involving physical therapy, occupational therapy, speech and language therapy, medicine, psychology and psychiatry, and social support. Long-term problems associated with TBI include Alzheimer's disease, dementia—particularly common in boxers—and post-traumatic dementia. People with traumatic brain injuries may experience significant personality changes that affect their daily lives.

In neurology literature, empathy is defined into three categories: cognitive empathy (knowing what another is feeling), emotional empathy (feeling what another is feeling), and compassionate empathy (responding compassionately to another's distress). Being aware of one's emotions allows individuals to reflect on them. According to Decety and Jackson (2006), individuals who can regulate their emotions are more likely to feel empathy for others and act in morally desirable ways.

The first study, "Outcome after traumatic brain injury: Pathway analysis of contributions from premorbid, injury severity, and recovery variables," examined by Novack et al. (2008), investigated the relationship of premorbid variables, injury severity, and cognitive and functional status to outcome one year after TBI. The study aimed to assess the viability of multivariate path analysis in understanding these relationships.

Literature Review: Two Key Studies

The study's procedure was based on hospital patients admitted to the neurointensive care unit who had experienced TBI. The findings emphasized the need for researchers to be cautious when examining the relationship of individual variables to outcome. Using only a handful of variables or one element of TBI may reveal "a relationship that would not fare well in a multivariate study." For example, the relationship between injury severity and outcome would likely appear greater if other variables that could affect outcome were not considered. As the authors note, "This misunderstanding might lead to inappropriate emphasis on some aspects of TBI recovery, while overlooking more informative factors in recovery."

Overall, the cognitive issues reported by subjects were similar to findings in other studies, particularly in Levin et al. (1990), where deficits in memory function and mental processing speed were clearly present. However, this study had distinct characteristics. Looking at Functional Independence Measure (FIM) scores during rehabilitation, the sample appeared more impaired than samples in other literature, specifically Cifu et al. (1997) and Harrison-Felix et al. (1996). Outcomes at the 6- and 12-month marks, measured by the Disability Rating Scale and Community Integration Questionnaire, were not as positive as reported in other studies. Only 17.8 percent had the possibility of returning to work (22.1 percent for those employed before injury), compared with other studies reporting 20 to 35 percent return-to-work rates for severe TBI cases in the same period.

This study demonstrated that while the sample was similar to that in other categories—such as Corrigan et al. (1998), Dikmen et al. (1994), and Gollaher et al. (1998)—the level of impairment was much more severe, as illustrated by lower FIM scores during rehabilitation and an overall less successful outcome.

The second study, published in The New England Journal of Medicine, was titled "Mild traumatic brain injury in U.S. soldiers returning from Iraq" (Hoge et al., 2008). This study emphasized the importance of understanding potential long-term effects of mild TBI or concussion from blast explosions in U.S. soldiers returning from Iraq. The study noted that "the epidemiology of combat-related mild traumatic brain injury is poorly understood." With better protective gear, a higher percentage of soldiers survive injuries that would have resulted in death in previous wars.

Head and neck injuries, including severe brain trauma, have been reported in one quarter of service members evacuated from Iraq and Afghanistan. Concern has emerged about possible long-term effects of mild TBI, characterized by brief loss of consciousness or altered mental status, from deployment-related injuries, particularly those resulting from proximity to explosions. Traumatic brain injury has been labeled a signature injury of the wars in Iraq and Afghanistan.

The study surveyed 2,525 U.S. Army infantry soldiers approximately 3 to 4 months after their return from a one-year deployment in Iraq. Valid clinical instruments were used to compare soldiers who reported mild TBI (defined as injury resulting in loss of consciousness or altered mental status such as confusion) with soldiers who reported other injuries.

In 2006, Hoge et al. (2008) conducted an anonymous survey of 2,714 soldiers from two U.S. Army combat infantry brigades—one active and one reserve component—three to four months after returning from a year-long deployment in Iraq. Both units experienced intense combat. The 3-to-4-month interval was chosen to reduce recall bias and because it is appropriate for determining persistent post-concussive symptoms. Of the 4,618 soldiers in the two brigades, 2,714 (59 percent) completed a questionnaire asking whether they had been injured during deployment by an explosion or blast, bullet, shrapnel, fall, motor vehicle accident, or other injury.

TBI in a soldier was defined by three criteria: (1) the person was knocked out and lost consciousness; (2) the person felt dazed or confused; or (3) the person did not remember the injury. If any of these applied, the soldier was labeled as having mild TBI. The questions were based on definitions from the Centers for Disease Control and Prevention and the World Health Organization, adapted by the Defense and Veterans Brain Injury Center working group for military use. The loss-of-consciousness question was examined separately from the others to determine whether it was a stronger predictor than the "altered mental status" questions, with results then combined for overall analysis. Soldiers reporting no altered mental status or loss of consciousness served as the reference group for all analyses.

Mild TBI was significantly correlated with psychiatric symptoms, especially post-traumatic stress disorder (PTSD), and this correlation remained significant after combat experiences were controlled for. Over 40 percent of soldiers with injuries linked to loss of consciousness met the criteria for PTSD. This demonstrates that a history of mild TBI in combat—especially when associated with loss of consciousness—mirrors exposure to a life-threatening situation and increases the likelihood of PTSD.

The study of soldiers returning from Iraq is particularly important. Although it used a nonrandom sample from two brigades, it is representative of soldiers in ground units in Iraq. The most significant finding is the strong association between mild TBI and PTSD. More than 40 percent of soldiers with injuries involving loss of consciousness met PTSD criteria. Strong associations were also found between mild TBI, PTSD, depression, and physical health symptoms in combat soldiers, indicating a need to refocus primary care attention on these populations.

Research Hypothesis and Rationale

Both studies introduced important findings regarding TBI. The first study, however, presented some contradicting outcomes that were difficult to interpret. The second study on Iraqi War veterans identified important correlations between mental disorders and TBI. This research could prove valuable in treating war veterans and warrants further investigation to better understand the direct links between TBI and PTSD, depression, anxiety, and other conditions.

The hypothesis is that there is a higher percentage of behavioral and emotional symptoms in soldiers who return from Operation Iraqi Freedom and Operation Enduring Freedom with a TBI diagnosis. The research will specifically examine the degree of empathy that patients have and how well they are able to exhibit or recognize empathy in others. Emotional problems are more difficult to detect than cognitive deficits, meaning they may go longer without treatment, potentially leading to permanent personality changes.

TBI is often difficult to recognize for doctors, patients, and families. After an injury, speech can be limited and nonsensical, but expressive aphasia often resolves once the brain's swelling decreases. Emotional problems, however, may not be recognized immediately. Family members may not notice changes such as lack of warmth or emotional responsiveness until long after the initial injury, often attributing these changes to stress. Because emotion-processing areas of the brain, like the frontal cortex, are particularly susceptible to damage in TBI due to their location at the front of the brain, this area of research requires focused study. If left untreated, these patients may not recover fully, and their quality of life will suffer significantly.

Conclusion

For individuals with TBI and other cognitive disorders, a loss in the ability to feel and recognize empathy is a research need directly related to the distress caused by exposure to high-risk war situations. Further investigation of this relationship will improve treatment outcomes for affected veterans.