PTSD and Traumatic Brain Injury: Trauma Inside Out
Posted by dlende on September 22, 2009
Jake was fond of saying that even though he had become dumber, he wasn’t quite dumb enough. He knew that the improvised explosive device (IED) in Iraq had mangled his body, brain and self.
Jake (a pseudonym) lost 30 IQ points due to Traumatic Brain Injury (TBI) from that IED blast. According to the military, he was still smart enough to function and hold down a job, so they didn’t plan to include TBI in his disability rating.
He fought them on this, just as he fought them on the decision not to amputate his leg. After countless surgeries and rehabilitation techniques, his leg was almost useless, allowing him maybe 30 minutes of use before it started rebelling against its reconstructed form. The pain that caused was excruciating; he simply couldn’t use it more.
Eventually Jake won his battle to lose his leg. It was the best thing that happened to him during the year I got to know him while doing my dissertation fieldwork at Walter Reed Army Medical Center in Washington, D.C. (yes, that Walter Reed).
Dealing with, or writing about, TBI is rarely as clear as an amputation. The same is true of TBI’s nearly constant companion, Post Traumatic Stress Disorder (PTSD). TBI and PTSD are not injuries that you can see, unlike a lost leg. Despite the high numbers of TBI and PTSD cases from Iraq and Afghanistan, the relationship of these conditions to more obvious forms of combat trauma remains a fraught one: Witness the debate about PTSD and the Purple Heart.
Most people think that the Purple Heart, that most iconic of military honors, is awarded to American military members injured in combat. As with most issues military, it is not quite that simple.
In 2008, after months of consultation, the decision was made not to award the Purple Heart to those suffering from PTSD because, in part, the medal “recognizes those individuals wounded to a degree that requires treatment by a medical officer, in action with the enemy or as the result of enemy action where the intended effect of a specific enemy action is to kill or injure the service member.” PTSD doesn’t count.
Though the decision was officially framed in rather bureaucratic terms, the debate which surrounded it raises much deeper issues about the nature of trauma. Thinking through these issues has led me to think about the Cartesian split between the (internal) mind and the (external) body and the nature of trauma inside and out.
From one perspective, TBI is trauma itself. It is the physical result of the brain being banged around inside the skull or otherwise damaged. But its symptoms – being ‘dumb’, acting out, short term memory loss – are the kinds of things we normally associate with an interior self.
To complicate matters further, in the soldiers I worked with, TBI was accompanied by visible injuries, sometimes to the head, sustained during the same event. Jake, for example, had nearly his whole scalp peeled from his skull along with his helmet. But this actually had nothing to do with his TBI, which was caused by the force of the IED blast itself.
This gives TBI a slightly strange status on the physical-mental continuum that you can see in things like the RAND study on Invisible Wounds which consistently pairs mental health issues and TBI, thus linking them together while still setting TBI apart. So does all of this make TBI any more or less bodily? Any more or less interior?
PTSD, on the other hand, is the reaction to trauma. It is linked to the memory of, and psychological response to, a physical event or threatened physical event. This would seem to put it squarely on the mental end of the continuum. Yet most recent innovations in the treatment of PTSD have focused on the bio-chemistry and physicality of the brain.
Such a ‘physical’ approach has its benefits. For example, most of the soldiers I worked with were highly resistant to talk and other ‘interior’ kinds of therapy while they relished the idea of treatments which work on the mind through the body. Medication does that, but so do things like Virtual Reality Exposure therapy. (For more background on the causes and treatments for PTSD in soldiers, see Erin Finley’s terrific posts here and here).
And while we tend to think of PTSD as a psychological reaction to a particular traumatic event, in my fieldwork it was more often the result of a whole slew of experiences which had very much to do with the body, sights, sounds, smells, and corporeal feelings of discomfort, pain, heat, exhaustion, sleeplessness. These same bodily sensations constitute in part the experience of PTSD, meaning that while diagnoses or theorizations of PTSD may focus on the mind, the subjective experience of it is very much in the body.
Even when we recognize that the mind and the body are connected, as we do in the realms of psychopharmacology, most people generally subordinate one to the other and deny their unity. We do that by relying on Cartesian dualism, by splitting the self into body and mind and then mapping the two parts onto the outside and inside. By marking the bodily self as the province of medicine and the mind as the province of psychiatry, we deny a more complete understanding of the subjective experience of trauma.
Jake’s amputated leg, his short term memory loss, his insomnia, his problems with linear thought, his 30 missing IQ points, his headaches, these are all part of his transformed self and way of being in the world. Though it may be required, in certain clinical settings, to typologize these pieces of him, to call them symptoms and assign them to various qualitative and quantitative categories, as anthropologists we are relatively free of these paradigmatic constraints. Our discipline is essentially an empathetic one and when working with people who have endured certain kinds of trauma, we ought to do our best to maintain the integrity of their experience. After all, haven’t they been ripped apart enough?
Zoë H. Wool is a doctoral candidate in anthropology at the University of Toronto. You can reach her at firstname.lastname@example.org