Stewar E — Modern Warfare Destroys Brains

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N AT I O N A L S E C U R I T Y F E L L O W S P R O G R A M

Modern Warfare
Destroys Brains
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury Warren Stewart Kevin M. Trujillo

PA P E R
J U LY 2 0 2 0

About the Authors
Colonel Warren Stewart holds a doctorate in nursing practice (DNP) from Duke University. Warren is board certified as an Acute Care Nurse Practitioner and Critical Care Clinical Nurse Specialist with over 22 years of trauma experience to include multiple deployments in support of combat operations. Warren currently serves as the Assistant Deputy for Medical Affairs for the Assistant Secretary of the Army, Manpower & Reserve Affairs.
Lieutenant Colonel Kevin Trujillo has over 20 years in the US Army and over 16 years serving in Special Forces and Ranger assignments holding key leadership positions from Detachment Commander through Joint Task Force Commander. He has extensive combat experience due to numerous deployments to Iraq and Afghanistan and was recently selected to command a US Army Special Forces Group.

Both authors pledged to donate their brains to the Center for Neuroscience and Regenerative Medicine Brain Donation Awareness Program. For information how to donate your brain for research: https://www.researchbraininjury.org/registry/

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Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

Acknowledgements
A special thanks to the following individuals who provided their guidance and insights with our research:
Dr. Daniel P. Perl, Professor of Pathology, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine, and Director, Neuropathology Core Center for Neurosciences and Regenerative Medicine;
Ms. Stacey Gentile, Neuropathology Core Project Manager for the Henry F.
Jackson Foundation; Ms. Jane Horton, Senior Advisor (USD P&R); Home Base BG Jack Hammond (USA-Ret.), Executive Director; CSM Bill Davidson (USA-Ret.) Director of Peer Outreach and Support; Dr. Alex Balbir, Director Independence Services, Wounded Warrior Project; Mr. Frank Larkin, former SEAL, father of Ryan Larkin, advocate for brain health awareness and for permission to include some of his policy recommendations; Dr.
B Christopher Frueh, Department of Psychiatry and Behavioral Sciences, University of Texas Health Sciences Center; Ms. Terri Tanielian, Senior Behavioral Scientist, Rand Corporation; COL Mark Mitchell (USARet.), Former Principal Deputy Assistant Secretary of Defense for Special Operations/Low-Intensity Conflict; Dr. Chris Nowinski, co-founder and CEO, Concussion Legacy Foundation; Ms. Kathy M Lee, Special Assistant to Deputy Assistant Secretary of Defense for Health Readiness Policy & Oversight; VADM Szymanski, Deputy Commander US Special Operations Command; Ms. Kat Deary, USSOCOM Command Surgeon’s Office; MG William Rapp (USA- Ret.) Harvard Fellows Director and Military Lecturer Belfer Center, Harvard Kennedy School and the countless Gold Star Spouses who provided their personal stories and for those who gave their lives in defense of our country.

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Table of Contents
Executive Summary............................................................................1 1. Introduction .....................................................................................................................2 2. “Operator Syndrome”................................................................... 7 Post-Traumatic Stress Disorder.................................................................... 10 Traumatic Brain Injury and the Scope of the Problem............................... 14 Interrelated Conditions of “Operator Syndrome” ..................................... 19 Endocrine Dysfunction....................................................................................................... 19 Sleep Disturbance and Sleep Apnea................................................................................ 20 Depression and Suicide...................................................................................................... 21

Remaining Components of the “Operator Syndrome”...............................22 National Security Implications.....................................................................23

3. Blast Related Traumatic Brain Injury......................................... 25 Effects of Repeated Blast Exposures...........................................................28 Differences Between CTE and IAS.............................................................. 30

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Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

4. Humanizing the Impacts............................................................. 32 The Costs........................................................................................................35

5. Current USSOCOM and DOD Efforts to Address Warfighter Brain Health................................................................................. 37 Department of Defense Efforts—USD for Personnel and Readiness....... 38

6. Policy Recommendations........................................................... 41 Technology..................................................................................................... 41 Research ....................................................................................................... 42 Policy.............................................................................................................. 44 Education....................................................................................................... 46

7. Conclusion....................................................................................48 Bibliography......................................................................................50

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Glossary
bTBI

Blast related traumatic brain injury/Blast wave traumatic brain injury

CTE

Chronic traumatic encephalopathy

DOD

Department of Defense

IAS

Interface Astroglial Scarring

mTBI

mild traumatic brain injury

PTSD

Post-Traumatic Stress Disorder

SO

Special Operator

SOF

Special Operations Forces

TBI

Traumatic Brain Injury

USSOCOM

United States Special Operations Command

blast related traumatic brain injury: traumatic brain injury caused by an explosion or blast that can be more complex compared with a TBI from other causes blast wave: complex pressure wave generated by an explosion, an instantaneous rise in atmospheric pressure that is much higher than normal for humans to withstand.
comorbidities: the simultaneous presence of 2+ morbid conditions or diseases in the same Pt, which may complicate a Pt’s overall health or treatment plan chronic traumatic encephalopathy: a neurodegenerative disease caused by repeated head injuries interface astroglial scarring: distinct and previously undescribed pattern of scarring at boundaries between brain parenchyma and fluids, and at junctions between grey and white matter.
posttraumatic stress disorder: a psychological reaction occurring after experiencing a highly stressing event (such as wartime combat, physical violence, or a natural disaster) that is usually characterized by depression, anxiety, flashbacks, recurrent nightmares, and avoidance of reminders of the event.
traumatic brain injury: A traumatically induced structural injury or physiological disruption of brain function, as the result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event: Any alteration in mental status (e.g., confusion, disorientation, slowed thinking, etc.). Any loss of memory for events immediately before or after the injury.
Any period of loss of or a decreased level of consciousness, observed or self-reported.

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Rangers from 75th Ranger Regiment train on the 120mm Mortar System.
US Army Photo / Spc. Garrett Shreffler

Executive Summary
“Operator Syndrome,” especially blast TBI (bTBI) and PTSD, are destroying the lives of special operators at an alarming rate. For the purposes of this paper, operators are Green Berets, SEALs, MARSOC Raiders, Combat Controllers, Pararescue, Explosive Ordnance Disposal Technicians, Special Mission Units or those that may accompany special operations forces regularly in training or on missions. The USSOCOM must continue to aggressively address bTBI. The authors acknowledge that the Nation and the command have invested heavily in developing strategies to address this issue; however, thus far, the efforts seem disjointed and have failed to mitigate the impact on special operators. These well-intentioned programs, policies, and research efforts are not making it to the team rooms or the ready rooms of our Ranger Platoons, Green Beret “A-Teams,” SEAL Platoons, Marine Special Operations Teams or other special mission units. There is no time to waste—senior leaders, policy makers and researchers must translate the current knowledge into actionable programs. There is no doubt that if provided the right tools, equipment and education, the senior non-commissioned officers will undoubtedly alter training protocols, inform their teammates and force positive change.
This paper has two primary objectives. First, it will support the argument that blast related TBI is uniquely different from the more recognized brain injury known as chronic traumatic encephalopathy (CTE) injury associated with impact trauma and therefore requires a different approach to both diagnosis and treatment. Second, it will provide recommendations for mitigating the effects of bTBI on the readiness and long-term health of special operators.
Key recommendations will include identifying blast pressure thresholds, developing imaging technology, and blood markers to diagnose bTBI. It calls for the DoD to institute and sustain “baseline” health surveillance to detect patterns of injury and health distress early, promote awareness for the Center for Neuroscience and Regenerative Medicine Brain Donation Awareness Program, and to establish an active Cross-Functional Brain Consortium. An additional recommendation will include changes to training plans that continue to prepare operators for combat but reduce their exposure to blast trauma.
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1. Introduction
SOF Truth #1:
“Humans are More Important Than Hardware”1 Due to the nature of the current global counter-terrorism and partnership efforts, the men and women of the United States Special Operations Command (USSOCOM) have been disproportionately exposed to direct combat and high-risk training compared to their conventional force counterparts.2 As a clear example of the high operational tempo, the number of countries where special operations forces (SOF) deployed increased from “60 countries in 2009 to over 147 in 2015.”3 These forces continue to conduct a wide range of SOF missions to include foreign internal defense and direct action raids in support of the counterterror fight. Owing to their relatively small footprint and ability to operate within “ungoverned spaces,”4 SOF will continue to be employed across the globe, all while retooling for the near-peer competitor fight. The recent USSOCOM cultural and ethics review revealed a “mission accomplishment” culture that sacrificed leader development and created significant stress on the force.5 The study uncovered an ethos unwilling to say “no” to employment, regardless of its impact on the force, which created a high demand for SOF, exposing a large number of special operators to both physical and psychological injuries.6 Suicide rates continue to rise among Special Operations Service members.
New, emerging scientific evidence is increasingly illuminating the connection between traumatic brain injury and the increased risk for suicide.7 The Department of Defense, the Veterans Affairs Administration and several

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1

“SOF Truths,” accessed January 27, 2020, https://www.socom.mil/about/sof-truths.

2

Daniel Byman and Ian A. Merritt, “The New American Way of War: Special Operations Forces in the War on Terrorism,” The Washington Quarterly 41, no. 2 (April 3, 2018): 79–93, https://doi.org/10.10 80/0163660X.2018.1484226.

3

Byman and Merritt.

4

Byman and Merritt.

5

John Friberg, “USSOCOM Comprehensive Review of Culture and Ethics,” SOF News (blog), January 29, 2020, https://sof.news/ussocom/ussocom-sof-culture-ethics-report-2020/.

6

Friberg.

7

Lisa A. Brenner et al., “Suicidality and Veterans with a History of Traumatic Brain Injury: Precipitants Events, Protective Factors, and Prevention Strategies,” Rehabilitation Psychology 54, no. 4 (November 2009): 390–97, https://doi.org/10.1037/a0017802.

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

private foundations are expending tremendous resources to research and develop means to combat this growing epidemic. Despite the multitude of efforts, we continue to lose many Service members to suicide, which is having significant, strategic impacts on our national security.
This high stress, physically demanding profession has created a “cascade of medical, emotional, and social problems…” that have proven difficult to manage.8 Christopher Frueh et al. utilizes the term “Operator Syndrome” to describe the “constellation of medical and behavioral healthcare issues that include traumatic brain injury (TBI), endocrine dysfunction, sleep disturbance, obstructive sleep apnea, chronic joint/back pain, orthopedic problems and headaches. Additional problems included in the syndrome involve substance abuse, depression and suicide, posttraumatic stress disorder (PTSD), anger and stress reactivity. Finally, operators suffer from high rates of marital, family, and community dysfunction, experience problems with sexual health and intimacy, suffer from memory, concentration and cognitive impairments, and have diminished vestibular function and vision problems.”9 The first SOF truth states that “Humans are More Important than Hardware,”10 and General James McConville, the Army’s 40th Chief of Staff, has been clear that his number one priority is people. He argues that for the Army to win in war, it must ensure that Soldiers receive the best possible leadership, training and equipment.11 Providing for the safety and health of special operators and their Families is fundamental to any “people-centric” philosophy. Additionally, the cornerstone of mission command is trust between the Commander and his/her subordinates.12 To maintain that trust, leaders must make every effort to protect the health of their charges and, if injured, ensure they receive the most exceptional care

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B. Christopher Frueh et al., “‘Operator Syndrome’: A Unique Constellation of Medical and Behavioral Health-Care Needs of Military Special Operation Forces,” International Journal of Psychiatry in Medicine, February 13, 2020, 91217420906659, https://doi.org/10.1177/0091217420906659.

9

Frueh et al.

10

“SOF Truths.”

11

“New Chief of Staff: Taking Care of People Key to Winning the Fight,” www.army.mil, accessed October 26, 2019, https://www.army.mil/article/225377/new_chief_of_staff_taking_care_of_people_key_to_winning_the_fight.

12

“Adrp6_0.Pdf,” accessed October 26, 2019, https://fas.org/irp/doddir/army/adrp6_0.pdf.

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possible. If people are genuinely the “most important weapon system,”13 then military medicine and other vital stakeholders must first acknowledge and be willing to address the constellation of issues associated with “Operator Syndrome.” Due to the limited scope and length of this paper, the authors will focus on blast-related traumatic brain injury due to the high number of operators impacted, because TBI is central to “Operator Syndrome,” and finally because TBI is widely considered the “signature injury” of the current war on terror.14 Traumatic brain injury is defined by the Center for Disease Control as a “disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head or a penetrating head injury.”15 TBI has significant long-term effects on the patient that include impaired cognition, chronic pain, and increased risk for suicide.16 Fortunately, most TBI (i.e. mTBI) patients recover in a reasonable amount of time. However, there are many with protracted recoveries for various reasons and risk factors.17 Because of the scope and complexity of diagnosing and treating TBI, there must be a coordinated effort across multiple government departments and agencies, civilian medical and research institutions, and non-profit organizations. A failure to address this emerging crisis in a timely manner threatens national security for various reasons outlined herein are three of the most important. First, service members are willing to put themselves in harm’s way because they have faith that they will receive the highest quality of care if wounded — military medicine’s inability to provide solutions to this issue jeopardizes that commitment. Second, if TBI remains in the

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13

“40th Chief of Staff of the Army Initial Message to the Army Team,” www.army.mil, accessed October 23, 2019, https://www.army.mil/article/225605/40th_chief_of_staff_of_the_army_initial_message_to_the_army_team.

14

Christine L. Mac Donald et al., “Prospectively Assessed Clinical Outcomes in Concussive Blast vs Nonblast Traumatic Brain Injury among Evacuated US Military Personnel,” JAMA Neurology 71, no. 8 (August 2014): 994–1002, https://doi.org/10.1001/jamaneurol.2014.1114.

15

“Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel,” n.d.

16

Maya Troyanskaya et al., “Combat Exposure, PTSD Symptoms, and Cognition Following Blast-Related Traumatic Brain Injury in OEF/OIF/OND Service Members and Veterans,” Military Medicine 180, no. 3 (March 2015): 285–89, https://doi.org/10.7205/MILMED-D-14-00256.

17

Amanda R. Rabinowitz et al., “Prevalence and Predictors of Poor Recovery from Mild Traumatic Brain Injury,” Journal of Neurotrauma 32, no. 19 (October 1, 2015): 1488–96, https://doi.
org/10.1089/neu.2014.3555.

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

public consciousness, it will continue to impact the ability of the services, and in return, the USSOCOM to recruit and retain the best quality force.
Most importantly, the inability to correctly prevent, diagnose, and treat TBI will leave the thousands affected to suffer without optimized care. To humanize this issue, according to the New York Times, 100% of the Special Operators that committed suicide in 2014 had previously sought treatment for TBI.18 “Operator Syndrome,” especially bTBI and PTSD, are destroying the lives of special operators.19 The USSOCOM must continue to aggressively address blast TBI as well as mental health. The authors acknowledge that the Nation and the command have invested heavily in developing strategies to address this issue; however, thus far, the efforts seem disjointed and have failed to mitigate the impact on special operators. These well-intentioned programs, policies, and research efforts are not making it to the team rooms or the ready rooms of our Green Beret “A-Teams,” SEAL Platoons, Ranger Platoons, Marine Special Operations Teams or other special mission units. There is no time to waste -- senior leaders, policy makers and researchers must translate the current knowledge into actionable programs.
There is no doubt that if provided the right tools, equipment and education, the senior non-commissioned officers will undoubtedly alter training protocols, inform their teammates and force positive change.
This paper has two primary objectives. First, it will argue that blast related TBI is uniquely different from the more recognized brain injury known as chronic traumatic encephalopathy (CTE) injury associated with impact trauma and therefore requires a different approach to both diagnosis and treatment. Second, it will provide recommendations for mitigating the effects of bTBI on the readiness and long-term health of special operators.
Key recommendations will include identifying blast pressure thresholds, developing imaging technology, and blood markers to diagnose bTBI. It calls for the DoD to institute and sustain “baseline” health surveillance to 18

Thom Shanker and Richard A. Oppel Jr, “War’s Elite Tough Guys, Hesitant to Seek Healing,” The New York Times, June 5, 2014, sec. U.S., https://www.nytimes.com/2014/06/06/us/politics/wars-elitetough-guys-hesitant-to-seek-healing.html.

19

Robert F. Worth, “What If PTSD Is More Physical than Psychological?,” The New York Times Magazine, June 10, 2016, https://nytimes.ms/1TYYp6U.

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detect patterns of injury and health distress early, promote the Center for Neuroscience and Regenerative Medicine Brain Repository, and to establish a Cross-Functional Brain Consortium. An additional recommendation will include changes to training plans that continue to prepare operators for combat but reduce their exposure to blast trauma. This potentially controversial recommendation is in response to reports that as high as 85% of operators experience TBI from training alone.20 The authors will focus on special operations forces because they are disproportionally exposed to multiple risk factors during training and combat deployments, and due to its service-like authorities, USSOCOM is uniquely postured to tackle this problem aggressively. The recommendations will be relevant to joint and conventional force commanders - particularly those exposed to repeated concussive blast events such as AC-130 Gunship aerial gunners, US Navy Gunner’s mates, armor crewman, artillerymen, explosive ordnance disposal technicians, and engineers as exposure to repeated concussive blasts permeate all services.
This paper will explore the constellation of conditions identified in the “Operator Syndrome” framework, focusing on blast TBI, PTSD and suicide. Next, the authors will describe the difference between CTE and blast wave TBI and explore the current evidence on the prevention and treatment of blast-related traumatic brain injury. Additionally, the paper will describe ongoing efforts within the USSOCOM, the DoD and other public and private organizations that promote awareness of care to operators impacted by these difficult to treat conditions. Finally, the authors will provide clear, concise recommendations for policymakers and commanders within the special operations community that will improve operator health and unit readiness.

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Frueh et al., “Operator Syndrome.”

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

2. “Operator Syndrome”
“I have seen boys like these, younger than these, their arms torn out, their legs ripped off. But there is nothin’ like the sight of an amputated spirit. There is… no prosthetic for that.” Lt. Col Frank Slade, portrayed by Al Pacino in the movie Scent of a Woman To best understand the complexity of the problem facing SOF, it is essential to spend some time discussing the “Operator Syndrome,” and the physical and psychological injuries that can mask the diagnosis of TBI and complicate its treatment. While the link between the injuries is still not fully understood, medical providers and commanders should maintain a high degree of humility and circumspection when caring for special operators with bTBI.
The landmark 2008 RAND publication Invisible Wounds of War21 described three medical conditions that often go undiagnosed and, therefore, untreated in many veterans of the wars in Iraq and Afghanistan:
post-traumatic stress disorder, major depressive disorder, and traumatic brain injury.22 This critical work served as a call to action for the United States Congress,23 the Department of Defense, medical professionals, and other vital stakeholders that resulted in improvements in awareness, diagnosis, and treatment of these insidious conditions.24 Unfortunately, these 21

Terri Tanielian, Lisa H. Jaycox, David M. Adamson, et al., “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery,” Product Page, 2008, https://www.rand.org/pubs/monographs/MG720.html.

22

Tanielian, Jaycox, Adamson, et al.; Rachel P. Chase and Remington L. Nevin, “Population Estimates of Undocumented Incident Traumatic Brain Injuries among Combat-Deployed US Military Personnel,” The Journal of Head Trauma Rehabilitation 30, no. 1 (February 2015): E57-64, https://doi.
org/10.1097/HTR.0000000000000061.

23

“Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel.”

24

Ralph G. DePalma and Stuart W. Hoffman, “Combat Blast Related Traumatic Brain Injury (TBI):
Decade of Recognition; Promise of Progress,” Behavioural Brain Research 340 (15 2018): 102–5, https://doi.org/10.1016/j.bbr.2016.08.036; Committee on the Assessment of Ongoing Efforts in the Treatment of Posttraumatic Stress Disorder, Board on the Health of Select Populations, and Institute of Medicine, Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations:
Final Assessment (Washington (DC): National Academies Press (US), 2014), http://www.ncbi.nlm.
nih.gov/books/NBK224878/.

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efforts failed to produce significant progress in either the number of troops impacted by TBI or its morbidity.25 The impacts of these injuries are far-reaching and affect not only the individual but their social support system26 and the readiness of their unit. The negative consequences include impaired cognition, suicidal ideation, alcohol and opiate dependence, family dysfunction, chronic pain, and decreased quality of life.27 The degradation of unit readiness can be attributed to the loss of person-hours, disruption of close-knit teams and a strain on resources to include funding, medical support, training time and commanders’ priorities.28 As described earlier, Frueh et al. recently published an article describing a cluster of definitive signs and symptoms within the SOF community, using the term “Operator Syndrome.” Frueh and his colleagues developed a schematic model to illustrate the interrelated factors that lead to diminished functioning.29 (See Figure 1)

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25

Kimberly A. Hepner et al., “Delivering Clinical Practice Guideline-Concordant Care for PTSD and Major Depression in Military Treatment Facilities,” Rand Health Quarterly 7, no. 3 (April 2018):
3; Daniel K. Schneider et al., “Current State of Concussion Prevention Strategies: A Systematic Review and Meta-Analysis of Prospective, Controlled Studies,” British Journal of Sports Medicine 51, no. 20 (October 2017): 1473–82, https://doi.org/10.1136/bjsports-2015-095645; Terri Tanielian et al., “Barriers to Engaging Service Members in Mental Health Care Within the U.S. Military Health System,” Psychiatric Services (Washington, D.C.) 67, no. 7 (01 2016): 718–27, https://doi.
org/10.1176/appi.ps.201500237.

26

Terri Tanielian et al., “Military Caregivers: Cornerstones of Support for Our Nation’s Wounded, Ill, and Injured Veterans,” Rand Health Quarterly 3, no. 1 (2013): 3; Joan M. Griffin et al., “The Invisible Side of War: Families Caring for US Service Members with Traumatic Brain Injuries and Polytrauma,” The Journal of Head Trauma Rehabilitation 27, no. 1 (February 2012): 3–13, https://doi.
org/10.1097/HTR.0b013e3182274260.

27

Kevin J. Heltemes et al., “Blast-Related Mild Traumatic Brain Injury Is Associated with a Decline in Self-Rated Health amongst US Military Personnel,” Injury 43, no. 12 (December 2012): 1990–95, https://doi.org/10.1016/j.injury.2011.07.021; Yelena Bogdanova and Mieke Verfaellie, “Cognitive Sequelae of Blast-Induced Traumatic Brain Injury: Recovery and Rehabilitation,” Neuropsychology Review 22, no. 1 (March 2012): 4–20, https://doi.org/10.1007/s11065-012-9192-3; Maya Troyanskaya et al., “Combat Exposure, PTSD Symptoms, and Cognition Following Blast-Related Traumatic Brain Injury in OEF/OIF/OND Service Members and Veterans,” Military Medicine 180, no. 3 (March 2015):
285–89, https://doi.org/10.7205/MILMED-D-14-00256; Sara Dolan et al., “Neuropsychological Sequelae of PTSD and TBI Following War Deployment Among OEF/OIF Veterans,” Neuropsychology Review 22, no. 1 (March 2012): 21–34, https://doi.org/10.1007/s11065-012-9190-5.

28

Tanielian, Jaycox, Adamson, et al., “Invisible Wounds of War,” 2008; Suzanne McGarity et al., “Community Reintegration Problems Among Veterans and Active Duty Service Members With Traumatic Brain Injury,” The Journal of Head Trauma Rehabilitation 32, no. 1 (February 2017): 34, https://doi.
org/10.1097/HTR.0000000000000242.

29

Frueh et al., “Operator Syndrome.”

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

Figure 1:

Schematic of the “Operator Syndrome” and its Impact on the Operator.30

30

Frueh et al.

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Post-Traumatic Stress Disorder
Understanding PTSD and its impact on special operations forces and their support systems, is vital for a few reasons. First, the risk for PTSD increases with the severity, duration, and recurring exposure to combat31, all of which place SOF in a higher risk group than their conventional counterparts.
Second, PTSD has a significant impact on the individual, including interpersonal problems, physical health comorbidities and, most concerning, is strongly associated with suicide.32 The physical comorbidities include alcohol dependence, major depressive disorder, and illicit drug use.
Interestingly, PTSD is linked to “…joint disease, cardiological conditions, and metabolic disease.”33 Importantly for this paper, PTSD is closely associated with mTBI. According to Carlson et al., up to 39% of TBI patients also have PTSD.34 Awareness of the TBI/PTSD relationship is key to understanding those suffering from this dual diagnosis.
Post-Traumatic Stress Disorder entered the Nations’ consciousness following the Vietnam War, but has been described throughout the history of warfare. Literature from prior wars applied terms like “soldier’s heart,” “shell shock,” and “battle fatigue,”35 to describe a psychiatric disorder caused by exposure to a traumatic event such as combat. For the diagnosis of PTSD, the patient must be exposed either directly or indirectly to a traumatic experience, then exhibit symptoms for a minimum of 30 days.
The symptoms can present immediately or, in many cases, weeks to months

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31

Rajeev Ramchand et al., “Prevalence Of, Risk Factors For, and Consequences of Posttraumatic Stress Disorder and Other Mental Health Problems in Military Populations Deployed to Iraq and Afghanistan:,” Product Page, 2015, https://www.rand.org/pubs/external_publications/EP50677.
html.

32

Ramchand et al.

33

Rajeev Ramchand et al., “Prevalence Of, Risk Factors For, and Consequences of Posttraumatic Stress Disorder and Other Mental Health Problems in Military Populations Deployed to Iraq and Afghanistan:,” Product Page, 2015, https://www.rand.org/pubs/external_publications/EP50677.
html.

34

Jitender Sareen, “Posttraumatic Stress Disorder in Adults: Impact, Comorbidity, Risk Factors, and Treatment,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 59, no. 9 (September 2014): 460–67, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168808/.

35

“What Is PTSD?,” accessed February 8, 2020, https://www.psychiatry.org/patients-families/ptsd/ what-is-ptsd.

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

following the event. The symptoms fall into four different categories and can vary in severity.36 1.

“Intrusive thoughts such as repeated, involuntary memories;
distressing dreams; or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.”37

2. “Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that bring on distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.”38 3. “Negative thoughts and feelings may include ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); ongoing fear, horror, anger, guilt or shame; much less interest in activities previously enjoyed; or feeling detached or estranged from others.”39 4. “Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being easily startled; or having problems concentrating or sleeping.”40 Recent studies estimate rates as high as 15-20% of combat veterans from the wars in Iraq and Afghanistan screen positive for PTSD.41 Identifying prevention, screening and treatment options for PTSD has been a significant focus of the VA/DoD and their civilian behavioral health counterparts since it was officially recognized in the 1970s by the American Psychiatric 36

Wei Qi, Martin Gevonden, and Arieh Shalev, “Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions,” Current Psychiatry Reports 18 (2016), https://doi.
org/10.1007/s11920-015-0655-0.

37

“What Is PTSD?”

38

“What Is PTSD?”

39

“What Is PTSD?”

40

“What Is PTSD?”

41

Ramchand et al., “Prevalence Of, Risk Factors For, and Consequences of Posttraumatic Stress Disorder and Other Mental Health Problems in Military Populations Deployed to Iraq and Afghanistan,” 2015; Terri Tanielian, Lisa H. Jaycox, David M. Adamson, et al., “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery,” Product Page, 2008, https://www.rand.org/pubs/monographs/MG720.html.

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Association.42 A brief discussion of those efforts can assist with providing context to the authors’ recommendations later in the paper.
While many risk factors for PTSD have been described, there is currently no individualized risk prediction available. Risk factors include gender, age, genetics, type of traumatic exposure and intensity. Other factors include past psychiatric history, family history and education level. Special operators are exposed to some risk factors to include intense and repeated combat, potential genetic factors, and previously undiagnosed behavioral health issues. They have an inherent advantage pre-exposure due to their age, physical fitness, higher problem-solving ability and lower emotional reactivity related to most demographic groups studied.43 Because all operators have some level of risk in the development of PTSD, systematic screening should occur post-exposure, or at a minimum post-deployment and then months later due to the frequent late onset of PTSD. Screening within the DoD is accomplished through the Post Deployment Health Assessment (PDHA), the Post Deployment Health Reassessment (PDHRA) and the annual Physical Health Assessment (PHA). The PDHA and PDHRA utilize a shortened PTSD screening tool that appears to identify those with potential PTSD accurately; however, RAND researchers warn that the screening tools are not entirely validated for this specific population and more research is required.44 There is evidence that prevention strategies can be helpful in particular patient populations, but generalizable treatment options have proven difficult. According to a literature review by Qi et al., there are “two primary goals for early interventions: to mitigate the development of early symptoms, and to increase the likelihood of remission in those who develop symptoms.”45 Mitigation is accomplished through “…attempts to reduce the stressfulness of the traumatic event (e.g., ‘stress management,’

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42

Miriam Reisman, “PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next,” Pharmacy and Therapeutics 41, no. 10 (October 2016): 623–34, https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5047000/.

43

Qi, Gevonden, and Shalev, “Prevention of Post-Traumatic Stress Disorder After Trauma.”

44

Terri Tanielian, Lisa H. Jaycox, Terry L. Schell, et al., “Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries,” Product Page, 2008, https:// www.rand.org/pubs/monographs/MG720z1.html.

45

Qi, Gevonden, and Shalev, “Prevention of Post-Traumatic Stress Disorder After Trauma.”

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

‘need-based assistance’), and interventions meant to reduce participants’ initial responses to the event or its encoding in memory…”46 Behavioral health providers commonly utilize psychological debriefing and cognitive behavioral therapy to target psychosocial factors. Psychological debriefing has fallen out of favor, but when used attempts to reduce the impact of PTSD through the processing of the emotional impact of trauma immediately following a traumatic experience.47 Cognitive Behavioral Therapy “challenges the patient’s beliefs about the meaning and current implication of the trauma and is offered individually or in a small group.48 Patients that respond to this therapy seldom relapse but continue to be at risk if exposed to new trauma.49 The methods utilized to address the neurobiological mechanisms include the use of medications and the use of fear conditioning and neurobehavioral training. According to a 2014 Cochrane review, hydrocortisone is moderately supported by evidence to provide benefit to trauma survivors that were not previously being treated for psychiatric conditions.
Unfortunately, the analysis failed to confirm the efficacy of other promising drugs that include morphine, propranolol, oxytocin and gabapentin.
Additionally, benzodiazepines were found to increase the effects of PTSD and are currently discouraged in the treatment of PTSD.50 PTSD with TBI is challenging to treat; however, the USSOCOM is moving in the right direction by employing individualized treatment plans. The use of multidisciplinary teams provides the best chance for success in treatment. Future efforts must include the reduction of the stigma associated with seeking behavioral health care, further exploration of pharmacological options, and the continued emphasis on screening for PTSD with any diagnosis of TBI.

46

Qi, Gevonden, and Shalev.

47

Qi, Gevonden, and Shalev.

48

Qi, Gevonden, and Shalev.

49

Qi, Gevonden, and Shalev.

50

Qi, Gevonden, and Shalev.

Belfer Center for Science and International Affairs | Harvard Kennedy School

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Traumatic Brain Injury and
the Scope of the Problem The Assistant Secretary of Defense defines traumatic Brain Injury (TBI) as:
A traumatically induced structural injury or physiological disruption of brain function, as the result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event:
Any alteration in mental status (e.g., confusion, disorientation, slowed thinking, etc.). Any loss of memory for events immediately before or after the injury. Any period of loss of or a decreased level of consciousness, observed or self-reported.51 Traumatic brain injury has three categories: mild, moderate and severe.
All three have specific diagnostic criteria that are outside of the scope of this paper. Because mTBI is the most common and most likely to go undiagnosed or undertreated, it is worth noting its characteristics and common signs and symptoms. The term mild TBI is interchangeable with a concussion and received increased attention due to its impact on athletes, especially professional football players. Because this type of brain injury does not present in radiographic studies, and there is not currently a reliable laboratory test to confirm, diagnosis requires a detailed physical examination and a comprehensive patient history that includes a traumatic event involving the head that results in a loss of consciousness for less than 30 minutes, and return to baseline cognition in under 24 hours.52 Mild TBI can occur from exposure to blunt trauma (car accident, fall), or blast trauma (Improvised Explosive Device (IED), breaching charges),

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51

“Assistant Secretary of Defense. Traumatic Brain Injury: Updated Definition and Reporting. Washington,DC: Department of Defense; 2015. - Google Search,” accessed October 26, 2019, https:// www.google.com/search?q=Assistant+Secretary+of+Defense.+Traumatic+brain+injury%3A+Updated+definition+and+reporting.+Washington%2CDC%3A+Department+of+Defense%3B+2015.&oq=Assistant+Secretary+of+Defense.+Traumatic+brain+injury%3A+Updated+definition+and+reporting.+Washington%2CDC%3A+Department+of+Defense%3B+2015.&aqs=chrome..69i57.2316j0j8.

52

Ralph G. DePalma, “Combat TBI: History, Epidemiology, and Injury Modes,” in Brain Neurotrauma:
Molecular, Neuropsychological, and Rehabilitation Aspects, ed. Firas H. Kobeissy, Frontiers in Neuroengineering (Boca Raton (FL): CRC Press/Taylor & Francis, 2015), http://www.ncbi.nlm.nih.gov/ books/NBK299230/.

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

or a combination of the two.53 Due to its insidious nature, mTBI often is undiagnosed and untreated. Even when discovered, treating the associated symptoms is often a challenge.
It is important to note that mTBI related to blast wave exposure can occur without loss of consciousness and can occur in common military tasks to include demolition training, firing large caliber weapons, and being in proximity to other explosive events. Furthermore, bTBI creates Interface Astroglial Scarring (IAS) which is a “distinct and previously undescribed pattern of scarring at boundaries between brain parenchyma and fluids, and at junctions between grey and white matter.”54 This will be discussed in more detail shortly.
The most troubling chronic symptoms of mTBI include headache, sleep disorder, decreased cognition, depression, suicidal ideation, post-traumatic stress disorder, dizziness and tinnitus.55 These symptoms can exacerbate or cause even more problematic issues that include alcohol and opiate abuse, behavioral problems that impact work performance, family dysfunction and, in extreme cases, actual suicide.56 According to the RAND Corporation, 20% of veterans from the wars in Iraq and Afghanistan suffer from traumatic brain injury.57 A review of the Defense and Veterans Brain Injury Center Clinical Tracking Form by Licona et al. found that over 80% of combat zone TBI was related to blast trauma.58 Although traumatic brain injury has been a focus of significant 53

Nathaniel W. Nelson et al., “Blast-Related Mild Traumatic Brain Injury: Neuropsychological Evaluation and Findings,” in Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects, ed. Firas H. Kobeissy, Frontiers in Neuroengineering (Boca Raton (FL): CRC Press/Taylor & Francis, 2015), http://www.ncbi.nlm.nih.gov/books/NBK299235/.

54

Sharon Baughman Shively et al., “Characterisation of Interface Astroglial Scarring in the Human Brain after Blast Exposure: A Post-Mortem Case Series,” The Lancet. Neurology 15, no. 9 (2016):
944–53, https://doi.org/10.1016/S1474-4422(16)30057-6.

55

Jennifer J. Vasterling et al., “Neuropsychological Outcomes of Mild Traumatic Brain Injury, Post-Traumatic Stress Disorder and Depression in Iraq-Deployed US Army Soldiers,” The British Journal of Psychiatry: The Journal of Mental Science 201, no. 3 (September 2012): 186–92, https:// doi.org/10.1192/bjp.bp.111.096461.

56

Terri Tanielian, Lisa H. Jaycox, Terry L. Schell, et al., “Invisible Wounds of War: Summary and Recommendations for Addressing Psychological and Cognitive Injuries,” Product Page, 2008, https:// www.rand.org/pubs/monographs/MG720z1.html.

57

Tanielian, Jaycox, Schell, et al.

58

Nytzia E. Licona et al., “Prospective Tracking and Analysis of Traumatic Brain Injury in Veterans and Military Personnel,” Archives of Physical Medicine and Rehabilitation 98, no. 2 (February 2017):
391–94, https://doi.org/10.1016/j.apmr.2016.09.131.

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research and effort, solutions for prevention, diagnosis, and treatment remain elusive. Despite changes in protective equipment (ballistic helmets, armored vehicles), mandated use of TBI screening tools, and mandatory rest periods following TBI exposure, the number of those affected remains alarmingly high. According to the Center for Disease Control, from 2000 through 2011, 235,046 service members (or 4.2% of the 5,603,720 who served in the Army, Air Force, Navy, and Marine Corps) were diagnosed with a TBI.59 Incredibly, 33,149 U.S. military personnel were diagnosed with a TBI in 2011 alone.60 Most recently, the Senior Enlisted Leader to the Joint Chiefs of Staff stated that 413,858 service members had sustained a TBI since 2000.61 There are several contributing factors to the increased prevalence of TBI during the current war on terror. First, the improvements in body armor, combat casualty care, and armored vehicle design resulted in casualties surviving traumatic events that would have otherwise killed them in prior conflicts.62 Second, the nature of the threat, especially the use of improvised explosive devices have increased the exposure to brain injury.63 Finally, repeated deployments for many service members, particularly those in combat arms specialties, added to the accumulative effects of blast exposure, both in training and in actual combat.
The DoD mandated screening for all personnel exposed to a potentially concussive event. Department of Defense Instruction 6490.11 defines those that require testing to be any member that is involved in a vehicle blast event, collision or rollover, present within 50 meters of a blast (inside or outside), suffers a direct blow to the head or witnessed a loss of consciousness, and finally, exposed to more than one blast event. The DOD

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59

“Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel.”

60

“Report to Congress on Traumatic Brain Injury in the United States: Understanding the Public Health Problem among Current and Former Military Personnel.”

61

Ramon Colon, “Senior Enlisted Advisor to the Chairman,” FaceBook, March 20, 2020, https://www.
facebook.com/SEAC.JCS/.

62

DePalma and Hoffman, “Combat Blast Related Traumatic Brain Injury (TBI).”

63

Christine L. Mac Donald et al., “Detection of Blast-Related Traumatic Brain Injury in U.S. Military Personnel,” The New England Journal of Medicine 364, no. 22 (June 2, 2011): 2091–2100, https:// doi.org/10.1056/NEJMoa1008069.

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

instruction includes mandatory rest periods following any event and reporting of screening results.64 The DoD developed a TBI screening tool to help medical providers treat patients that have been exposed to a potentially concussive event. The Military Acute Concussion Evaluation 2 is an evidence-based instrument that provides an easy to administer, standardized tool that augments the provider’s clinical judgment and the use of the Concussion Management Tool (CMT) to best manage mTBI.65 The CMT provides treatment recommendations from the initial presentation up to seven days post-injury. The tool includes recommendations on follow-on screening, rest, sleep hygiene, headache management, referral criteria, return-to-duty criteria and other management options.66 The DoD/Veterans Administration Clinical Guidelines provides clinicians with an evidence-based recommendation for the acute and long-term care of mTBI patients. Current treatment options for mTBI focus on symptom management and do not address the structural changes that occur with brain injury, especially blast-related changes.
Thus far, developing a cure for the sequela of mTBI has proven elusive. Still, research continues in a wide range of areas that include preventative equipment, therapeutic and treatment options, and biomarkers for the detection of mTBI. Devices like jugular vein compression collars have shown the potential to reduce the impact of the blast wave on the brain. The collar has been tested in civilian Special Weapons and Tactics (SWAT) teams during explosive breaching training and showed promise in reducing injury.67 Additionally, Magnetic Resonance Therapy is already being tested within the USSOCOM and is a non-invasive brain stimulation process that utilizes Magnetic Resonance Imagining machines. The therapy has shown 64

“Fact Sheets,” DVBIC, September 14, 2015, https://dvbic.dcoe.mil/fact-sheets.

65

“Military Acute Concussion Evaluation 2 (MACE 2),” DVBIC, August 27, 2018, https://dvbic.dcoe.
mil/material/military-acute-concussion-evaluation-2-mace-2.

66

“Concussion Management Tool,” DVBIC, October 31, 2017, https://dvbic.dcoe.mil/material/concussion-management-tool.

67

Scott Bonnette et al., “A Jugular Vein Compression Collar Prevents Alterations of Endogenous Electrocortical Dynamics Following Blast Exposure during Special Weapons and Tactical (SWAT) Breacher Training,” Experimental Brain Research 236, no. 10 (October 2018): 2691–2701, https:// doi.org/10.1007/s00221-018-5328-x; Ming Gu et al., “Protection against Blast-Induced Traumatic Brain Injury by Increase in Brain Volume,” BioMed Research International 2017 (2017): 2075463, https://doi.org/10.1155/2017/2075463.

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potential in improving cognitive function in TBI patients.68 Most importantly, USSOCOM must continue to research point of injury and acute treatment options that can mitigate the impact of mTBI. One potential therapeutic tool is the use of Magnesium (Mg2+) in some combination to protect brain function. Adenosine, lidocaine and Mg2+ resuscitation has great potential in both hemorrhagic trauma and TBI but requires further investigation.69 While a recent study70 failed to show that the administration of Mg2+ alone improves outcomes, this neuroprotective agent still holds possibilities and should be investigated further. Finally, the diagnosis of mTBI relies on clinical exam, but there is hope that someday biomarkers could confirm the presence of TBI or serve to screen those that have subclinical signs and symptoms that are missed during physical exams.71

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68

Si A. Lee and Myoung-Kwon Kim, “Effect of Low Frequency Repetitive Transcranial Magnetic Stimulation on Depression and Cognition of Patients with Traumatic Brain Injury: A Randomized Controlled Trial,” Medical Science Monitor : International Medical Journal of Experimental and Clinical Research 24 (December 4, 2018): 8789–94, https://doi.org/10.12659/MSM.911385; Iuri Santana Neville et al., “Repetitive Transcranial Magnetic Stimulation (RTMS) for the Cognitive Rehabilitation of Traumatic Brain Injury (TBI) Victims: Study Protocol for a Randomized Controlled Trial,” Trials 16 (October 5, 2015), https://doi.org/10.1186/s13063-015-0944-2; Arnold Toth, “Magnetic Resonance Imaging Application in the Area of Mild and Acute Traumatic Brain Injury: Implications for Diagnostic Markers?,” in Brain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects, ed.
Firas H. Kobeissy, Frontiers in Neuroengineering (Boca Raton (FL): CRC Press/Taylor & Francis, 2015), http://www.ncbi.nlm.nih.gov/books/NBK299202/.

69

Hayley L. Letson and Geoffrey P. Dobson, “Adenosine, Lidocaine, and Mg2+ (ALM) Resuscitation Fluid Protects against Experimental Traumatic Brain Injury,” The Journal of Trauma and Acute Care Surgery 84, no. 6 (2018): 908–16, https://doi.org/10.1097/TA.0000000000001874.

70

Nancy R. Temkin et al., “Magnesium Sulfate for Neuroprotection after Traumatic Brain Injury: A Randomised Controlled Trial,” The Lancet. Neurology 6, no. 1 (January 2007): 29–38, https://doi.
org/10.1016/S1474-4422(06)70630-5.

71

Tor Ingebrigtsen and Bertil Romner, “Biochemical Serum Markers for Brain Damage: A Short Review with Emphasis on Clinical Utility in Mild Head Injury,” Restorative Neurology and Neuroscience 21, no. 3,4 (January 1, 2003): 171–76, https://content.iospress.com/articles/restorative-neurology-and-neuroscience/rnn00236?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Restorative_Neurology_and_Neuroscience_TrendMD_1&origin=32511c9b9969d834c3d35830fea57b29.

Modern Warfare Destroys Brains:
Creating Awareness and Educating the Force on the Effects of Blast Traumatic Brain Injury

Interrelated Conditions of
“Operator Syndrome” Understanding the interlinked conditions associated with the “Operator Syndrome” will help to formulate potential treatment plans. Traumatic brain injury appears to be central to the syndrome and any holistic care plan must address the entire syndrome.72 A brief description of the remaining conditions will illustrate the complexity of the problem facing the operator, their caregivers, and medical providers.

Endocrine Dysfunction
Traumatic brain injury, and especially bTBI, is known to cause endocrine dysfunction. Over 33% of bTBI patients will suffer from neuroendocrine alterations that can lead to psychiatric disorders.73 Brain trauma disrupts the hypothalamic-pituitary-adrenal axis, which is responsible for homeostasis, stress responses, energy metabolism, and neuropsychiatric function.74 The impact on the special operator is multifaceted and can compound PTSD, anxiety, and depression. Because the axis plays a significant role in the stress response, disruption can alter the release of cortisol and norepinephrine that leads to insomnia and sleep disruption, while lowering the body’s immune response.
Additionally, TBI can create hypogonadism, which can lower testosterone levels, resulting in chronic fatigue and can mimic depression.75 Studies have found that special operators, regardless of TBI, have lower than

72

Frueh et al., “Operator Syndrome.”

73

Ashley L. Russell et al., “Differential Responses of the HPA Axis to Mild Blast Traumatic Brain Injury in Male and Female Mice,” Endocrinology 159, no. 6 (01 2018): 2363–75, https://doi.org/10.1210/ en.2018-00203.

74

Sharon DeMorrow, “Role of the Hypothalamic–Pituitary–Adrenal Axis in Health and Disease,” International Journal of Molecular Sciences 19, no. 4 (March 26, 2018), https://doi.org/10.3390/ ijms19040986; Walter L. Miller, “The Hypothalamic-Pituitary-Adrenal Axis: A Brief History,” Hormone Research in Paediatrics 89, no. 4 (2018): 212–23, https://doi.org/10.1159/000487755.

75

Züleyha Karaca et al., “GH and Pituitary Hormone Alterations After Traumatic Brain Injury,” Progress in Molecular Biology and Translational Science 138 (2016): 167–91, https://doi.org/10.1016/ bs.pmbts.2015.10.010; Andrew E. Jensen et al., “Hormonal Balance and Nutritional Intake in Elite Tactical Athletes,” Steroids 152 (2019): 108504, https://doi.org/10.1016/j.steroids.2019.108504.

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normal testosterone levels.76 The only way to diagnose hormonal imbalances is through lab testing. It is recommended that all operators receive lab tests on a routine basis.77

Sleep Disturbance and Sleep Apnea
As mentioned above, bTBI is implicated in the disruption of endocrine function, which can cause sleep disturbances. As many of 30%-70% of TBI patients suffer from disruptions in sleep cycles,78 and 24% of TBI patients are diagnosed with sleep apnea.79 Regardless of TBI, special operators are high-risk for sleep disruptions, especially when coupled with other co-occurring conditions. The frequent use of “reverse cycle” work schedules while deployed, emotional stress, chronic pain, and high levels of substance abuse all contribute to suboptimal sleep patterns. According to Frueh et al., “sleep disturbance is nearly universal in special operators which can lead to irritability, cognitive impairment, memory loss, impulsivity, poor concentration, depression and even paranoia.”80 In addition to the above issues, insufficient sleep can contribute to heart disease, Type-2 diabetes and obesity.81 Obstructive sleep apnea alone can cause significant medical problems that include high blood pressure, stroke, heart failure, headaches and reduces cognitive function in TBI patients.82

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76

Jon K. Linderman, Reginald O’Hara, and Jason Ordway, “Effect of Special Operations Training on Testosterone, Lean Body Mass, and Strength and the Potential for Therapeutic Testosterone Replacement: A Review of the Literature,” Journal of Special Operations Medicine: A Peer Reviewed Journal for SOF Medical Professionals 20, no. 1 (2020): 94–100.

77

Frueh et al., “Operator Syndrome.”

78

Christian R. Baumann et al., “Sleep-Wake Disturbances 6 Months after Traumatic Brain Injury: A Prospective Study,” Brain: A Journal of Neurology 130, no. Pt 7 (July 2007): 1873–83, https://doi.
org/10.1093/brain/awm109.

79

Richard J. Castriotta and Jayasimha N. Murthy, “Sleep Disorders in Patients with Traumatic Brain Injury: A Review,” CNS Drugs 25, no. 3 (March 2011): 175–85, https://doi.org/10.2165/11584870000000000-00000.

80

Frueh et al., “Operator Syndrome.”

81

Sang Jun Yoon et al., “Systemic and Local Metabolic Alterations in Sleep-Deprivation-Induced Stress: A Multiplatform Mass-Spectrometry-Based Lipidomics and Metabolomics Approach,” Journal of Proteome Research 18, no. 9 (September 6, 2019): 3295–3304, https://doi.org/10.1021/ acs.jproteome.9b00234; Nadir M. Balba et al., “Increased Sleep Disturbances and Pain in Veterans With Comorbid Traumatic Brain Injury and Posttraumatic Stress Disorder,” Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine 14, no. 11 (15 2018): 1865–78, https://doi.org/10.5664/jcsm.7482.

82

Mieke Verfaellie et al., “Self-Reported Sleep Disturbance Mediates the Relationship Be