An ASU doctoral student and associate professor is shining a new light on the world of brain injuries and cognition in veterans returning to civilian and academic life, emphasizing shortcomings in treatment and diagnosis of cognitive issues in multiple stages of military healthcare.
"My focus is on a number of different service-related conditions — mostly mild traumatic brain injuries (MTBI) and post-traumatic stress disorder (PTSD) and how they affect vets entering civilian life," said Karen Gallagher, who is working toward a Ph.D in speech and hearing science. Gallagher herself is a veteran of the First Gulf War, and she received a Pat Tillman Scholarship this year to further her research.
"Cognitive demands for vets entering college are especially high," she said.
These cognitive issues are especially problematic upon activation of a veteran's G.I. Bill.
"Many vets activate their G.I. Bill immediately after exiting," Gallagher said. "But, if they're not ready to integrate, they can burn through those credits before earning a degree."
Gallagher's Research and Scholarship
Veterans who sustained a TBI while serving may have trouble with complicated memory recollection, concentration, shortened attention spans and chronic headaches, among other symptoms. Coupling these issues with the hypervigilance, anxiety, depression and even violence associated with PTSD compounds difficulties with civilian life.
The problem is worsened by inconsistent treatment of brain injuries by military and VA doctors, Gallagher said. Soldiers may not seek treatment for cognitive difficulties or a suspected concussion if the soldier next to them has shrapnel wounds, for example.
"And, there's questionable followthrough in post-deployment testing," Gallagher said. "The VA was never really set up to deal with young people who are otherwise healthy. They're running to catch up at this point. A lot of vets come into my research looking for help where the VA couldn't."
Gallagher said she's found that veterans with long-term difficulties stemming from brain injuries didn't receive a proper diagnosis because medical testing didn't always account for frenetic environments encountered in civilian and academic life.
"If you take a veteran who says they have a history of concussions, and you give them a test in a sterile environment, you're not going to see the difficulties that would appear in a classroom environment," she said.
To account for that, Gallagher tests long-term, episodic memory, akin to what might be needed to pass an exam. She will tell her subjects a story and ask them to repeat it immediately in as much detail as possible. Most can do that without a problem. However, a half-hour later, she'll ask the veteran to repeat the same story, and those with an MTBI tend to encounter serious difficulties.
She said veterans with no history of brain injury also self-cue when recalling the story — meaning that they recall context from the first time they heard it to guide themselves toward repeating the story. However, those with an MTBI do not.
"We want to put together a battery of cognitive tests and tasks that are easily deliverable," Gallagher said. "We're piloting a cognitive coaching program for vets who are going to be first-time freshmen as well."
Doing so would make identification of TBI's easier and more consistent, and would combat feelings of overmedication some vets who come to her have.
Gallagher receives support for her research through the Pat Tillman Foundation, which awards scholarships to service members and veterans in higher education.
"We have a highly selective screening process," said Killjan "Kill" Anderson, an Air Force veteran and COO of the Foundation. "Thousands applied this year, and we picked 60. We look for veterans and their spouses who have a proven track record of success. Above all, we look for a call to serve."
He said there is a need for Gallagher's research and agrees that there may be issues in reporting brain injuries in the service.
"It's like being on any team," he said. "There is a pressure to be at your best and to contribute as much as possible. You may not feel well, but you don't want to let down your team, especially in a combat theater. Asking for help is a sign of strength, but it's hard. People don't want to be seen as holding back the team, or as weak."
Reforming Cognitive Science at the VA
"The TBI clinic is one of the busiest clinics we have," said Dr. Patricio Reyes, director of the Traumatic Brain Injury and Alzheimer's Disease & Cognitive Disorders clinics at Phoenix Veterans Affairs Medical Center.
Reyes has a long history with neurosurgery and neuropathology, as an academic, researcher and provider. He came to the VA in 2014 to reform neuropathology at the center and help reduce wait times after the Veterans Health Administration scandal the same year.
He said the first step in treating a veteran who believes they have a TBI is a clinical assessment.
"I want to document any history of a TBI," Reyes said. "TBIs in returning veterans from Iraq or Afghanistan are most often due to IED explosions. It's a different type of TBI — the physical factors are different, the circumstances are different, as are the linear and angular forces. You have exposure to intense heat, dust, chemicals, things like that."
Doctors too often search only for explicit brain injuries when diagnosing cognitive issues, when devices like IEDs can cause systemic health problems just as detrimental to cognition, such as high or low blood pressure, difficulty breathing and sleeping, lack of oxygen to the brain and so on, Reyes said.
"Most cases go unreported because only the serious ones go to the hospital," he said.
From the field, brain injuries are hard to diagnose. Soldiers who might be concussed may have trouble answering whether or not they fell unconscious, or for how long they were dazed.
"If you are dazed, you don't think about it," Reyes said. "You just grab your rifle and start firing again."
Reyes would examine a patient physically, neurologically and cognitively. Depending on the severity, he might refer a patient for neuropsychological evaluation. However, he said many doctors don't understand that cognitive issues may be chemical, rather than structural, so an MRI may not pick up any abnormalities.
Then, he would administer an assessment for PTSD and depression.
"They have hypervigilance," he said. "They don't want to be in crowds. They don't go to movies, or malls. They have nightmares and insomnia. We lose 20-22 vets per day to suicide. You try to ask them about weapons in their home, but many get defensive."
Reyes agrees with Gallagher's research — many veterans use up their G.I. Bill benefits with no degree because they cannot concentrate in class.
"Sometimes, other doctors tell me that everything is normal," he said. "But normal is relative — normal to what? Normal for people who didn't go to war?"
Reyes said part of his reformation of cognitive health at the VA has been recognizing that the symptoms of TBIs and PTSD cannot always be seen in a lab, and they should not always be treated with drugs.
"We need to educate physicians and providers about the complex manifestations of a TBI," he said. "Many patients come with sleep apnea. They stop breathing while they sleep. So, the brain lacks oxygen, and we don't measure heat exposure. Brain function depends on enzyme activity, and the enzymes must be activated within a certain temperature range."
Treating a veteran's family and social circle can be as important as treating the veteran himself, Reyes said. Veterans with TBIs and PTSD can have trouble forming relationships, they can become abusive, placing significant stress on their families.
"I once had a 21-year-old patient who was divorced three times," he said.
The solution, Reyes said, is providing both traditional and untraditional care. Medicines for these types of illnesses only treat the symptoms – anti-depressants, anti-psychotics, sleep aids and so on, and for a veteran with memory issues, it can be easy to overdose.
Some of the most effective treatments involve cognitive training and therapy. He said a group of 14 veterans who went on a fishing trip came back feeling much better than medicines ever accomplished.
The key is neuroplasticity: the process of the brain creating new neural pathways as it adapts to different needs and stimuli. The concept has been around since the 1890s but is only just being used in therapy.
Reyes said cognitive exercises are often much more effective than anything else, and they address more than the symptoms.
"But I can't prescribe that," he said. "I have to poison them with medicines. Medicine is for sale. I'm ashamed to charge."
Reach the reporter at Arren.Kimbel-Sannit@asu.edu or follow @akimbelsannit on Twitter.