WASHINGTON—Mild traumatic brain injuries are being overdiagnosed in returning troops, according to a study by Army TBI researchers in the April 16, 2009, issue of the New England Journal of Medicine. In the article titled “Care of War Veterans with Mild Traumatic Brain Injury--Flawed Perspectives,” the authors make the case that flawed questions on the post-deployment screening form have led to incorrect diagnoses of mild TBI in returning troops. The consequences of these mistaken diagnoses are that some servicemembers are receiving inappropriate treatment while underlying conditions such as depression, post-traumatic stress disorder or substance abuse are being neglected, according to the article.

“The questions that are being asked lack validity and are very imperfect and very inaccurate. What is happening with the way the questions are structured is that post-war symptoms that are very common— that soldiers experience frequently after combat and coming back from war—the questions are structured in such a way that those symptoms are attributed to TBI,” according to Col. Charles Hoge, M.D., director of the division of psychiatry and neuroscience at the Walter Reed Army Institute of Research and one of the authors of the article.

One of the questions that the authors pointed to as problematic in post-deployment screening is one that asks servicemembers to recall whether they were “dazed” or “confused” at the time of an injury or blast experience. Positive responses to this question have accounted for two-thirds of all reported cases of mild TBI, but the study authors note that an alteration of consciousness in combat can result form other normal responses to “injury, acute stress, dissociation, sleep deprivation, syncope or the confusion of war.”

Asking someone months after their injury whether they were dazed and confused at their time of injury is too “nonspecific,” Dr. Hoge said. “Being dazed or confused at the time of any injury is a common experience. It is so nonspecific that it is not a good screening question for traumatic brain injury, especially when it is applied months or even years after servicemembers come home,” he said in an interview.

The responses troops give on the post-deployment health screening are the basis of a 2008 Rand Corp. finding that more than 300,000 U.S. servicemembers have suffered TBI during the wars in Iraq and Afghanistan. Dr. Hoge contends that it is “really impossible to say” what the prevalence of mild TBI is among servicemembers.

Diagnosing Mild TBI

The article is not suggesting that concussion is “not an important problem,” according to its authors. “Concussion is an important problem, and we’ve shown, and others have shown, that soldiers who have experienced concussions on the battlefield, where they lost consciousness in particular, are at higher risk for a variety of health concerns when they come home,” Dr. Hoge said.

The authors recommend enhancing the screening questions by asking more specific questions about all injuries; a recommendation that, Dr. Hoge points out, is supported by the Army’s Surgeon General Lt. Gen. Eric Schoomaker, MC, USA. “The goal is to improve it, not to eliminate TBI screening, but to improve the screening for all injuries, including traumatic brain injury,” Dr. Hoge said.

In addition, the authors are calling for the development of a more solid definition of mild TBI. There are plans to have the Defense Health Board look at that question, Dr. Hoge said.

The article also proposes that widespread use of the terms “mild TBI,” “signature injury,” “invisible wound” and “silent epidemic,” as well as patient-education materials that combine mild TBI with more serious types of TBI, are detrimental to the recovery of injured servicemembers. “If they have had a moderate or severe TBI they need to be educated about a moderate or severe TBI and what can be done and what the rehabilitation strategies are,” Dr. Hoge said. “If they have a concussion and they are having post-concussive symptoms that may be related to that concussion, they need an entirely different education material. Just lumping them together, putting them all together, is not a good strategy.”

Col. Carl Castro, Ph.D., director of the Military Operational Medicine Research Program at Fort Detrick in Maryland and another of the study’s authors, acknowledged that their findings may generate some controversy, particularly for those who have developed the policies on how the military screens and defines mild TBI. “I think it’s safe to say that people who were on these expert consensus panels are not as happy with the recommendations,” Dr. Castro said.