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INTRODUCTION

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Neuropsychiatric sequelae are common in combat veterans. Advances in personal protective body armor, armored vehicles, battlefield resuscitation, and the speed of evacuation to tertiary care have considerably improved the survivability of battlefield injuries, resulting in a greater awareness of the “silent wounds” associated with service in a combat zone. Although psychiatric and neurologic problems have been well documented in veterans of prior wars, the conflicts in Iraq and Afghanistan that began after September 11, 2001, were unique in terms of the level of commitment by the U.S. Department of Defense (DoD) and Department of Veterans Affairs (VA), Veterans Health Administration (VHA) to support research as the wars unfolded and to use that knowledge to guide population-level screening, evaluation, and treatment initiatives.

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The Iraq and Afghanistan conflicts produced over 2.5 million combat veterans, many of whom have received or will need care in government and civilian medical facilities in the future. Studies clearly showed that service in the Iraq and Afghanistan theaters was associated with significantly elevated rates of mental disorders. Two conditions in particular have been labeled the signature injuries related to these wars: posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI)—also known as concussion. Although particular emphasis will be given in this chapter to PTSD and concussion/mTBI, it is important to understand that the neuropsychiatric sequelae of war are much broader than these two conditions. Wartime service is associated with a number of health concerns that coexist and overlap, and a multidisciplinary patient-centered approach to care is necessary.

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EPIDEMIOLOGY OF WAR-RELATED PSYCHOLOGICAL AND NEUROLOGIC CONDITIONS

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Service members involved in the Iraq and Afghanistan wars faced multiple deployments to two very different high-intensity combat theaters, and for many veterans, the cumulative strain negatively impacted health, marriages, parenting, educational goals, and civilian occupations. The stresses of service in these conflicts also led to a significant increase in rates of suicide in personnel from the two branches of service involved in the greatest level of ground combat (U.S. Army, Marines).

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Service in a war zone can involve extreme physical stress in austere environments, prolonged sleep deprivation, physical injury, exposure to highly life-threatening events, and hazards such as explosive devices, sniper fire, ambushes, indirect fire from rockets and mortars, and chemical pollutants. Certain events, such as loss of a close friend in combat, leave indelible scars. All of these experiences have additive effects on health, likely mediated through physiologic mechanisms involving dysregulation of neuroendocrine and autonomic nervous system (ANS) functions.

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Veterans of virtually all wars have reported elevated rates of generalized and multisystem physical, cognitive, and psychological health concerns that often become the focus of treatment months or years after returning home. These multisystem health concerns include sleep disturbance, memory and concentration problems, headaches, musculoskeletal pain, gastrointestinal symptoms (including gastroesophageal reflux), residual effects of wartime injuries, fatigue, anger, hyperarousal symptoms, high blood pressure, rapid heart rate (sometimes ...

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