There appears to be a common misconception among soldiers/veterans, the news media, and some healthcare providers that exposure to a blast event means that a person sustained a TBI. When working with patients and families, this misconception should be corrected. Exposure can mean multiple things. One soldier may see a Humvee three vehicles in front of his going over an exploding roadside bomb, but not experience any direct or indirect physical effect of the explosion. Another soldier could be in the first Humvee under which the bomb exploded and sustain a broken leg and ruptured tympanic membrane from the force of the blast, and be knocked unconscious for several minutes. While the first soldier did not experience a TBI, the second did.

Additionally, misattribution of symptoms to a residual TBI when such symptoms are secondary to stress, chronic sleep deprivation, PTSD or other mental health condition, could iatrogenically reinforce the misconception that these symptoms are permanent. Even if it is likely that a mild TBI did occur, reassurance and education about expected full recovery is crucial to minimizing any adverse iatrogenic effects. Clinicians, patients, and their families alike should be educated that symptoms frequently attributed to TBI may be due to factors other than TBI, particularly long after the TBI occurred.

Finally, with recent media attention on multiple concussions in the sports arena, and their purported association with dementia, suicide, and other adverse long-term outcomes, it is understandable that both patients and providers may have a more catastrophic reaction to a diagnosis of mild TBI than perhaps may be warranted. Providing education about typical recovery patterns following a mild TBI is crucial.

There is a growing body of literature that demonstrates the role of expectation in both cognitive performance and rate of symptom complaint. Mittenberg et al. [36] demonstrated that control subjects asked to imagine symptoms following a head injury reported very similar symptom profiles to individuals who had experienced a mild TBI. Findings also indicated that those with mild TBI underestimated their premorbid problems while reporting post-injury problem severity at levels consistent with “expected post-mild TBI levels” reported by control subjects. If there is an expectation of post-injury problems, then in at least a minority of individuals, such symptoms are more likely to occur. In addition, since virtually everyone with a mild TBI experiences acute symptoms for minutes to hours (e.g., initial confusion, perhaps a new onset headache, dizziness, and difficulty with focused and sustained attention), the mere presence of these symptoms can reinforce preexisting expectations and beliefs. In contrast, if there is no expectation of ongoing symptoms, as is the general case in sports-related mild TBI, then there are few or no ongoing symptoms reported [86, 87]. Both brain dysfunction and expectation likely play independent and interactive causative roles [88].

As discussed above, early post-TBI psychoeducational intervention is important in reducing post-injury anxiety, setting appropriate and realistic expectations for recovery, and enhancing the normal recovery process. This psychoeducational intervention should include providing information regarding the nature and incidence of expected symptoms, normalizing these initial symptoms as an expected part of the recovery process, providing a cognitive-behavioral model for understanding symptoms (e.g., worse with stress or poor sleep, or if emotionally upset), offering specific techniques for reducing symptoms, and providing instructions for gradual resumption of premorbid activities. If patients “expect” to get better and “understand” that initial symptoms are normal and not indicative of a significant problem, then they have a better recovery. In contrast, if patients believe that a symptom is a sign of a worsening or significant neurological problem, then their outcome is far worse. Expectation management is key, utilizing appropriate support, education, early symptom management, and a clear and consistent positive message of recovery over time. The “Home Depot” home improvement stores slogan of “You can do it, we can help” provides a model. The message to patients in the acute setting should be:

Your body will recover with rest and time; and if you need help managing or minimizing your symptoms, we can help. Don’t overdo it too quickly. An initial period of rest and time for recovery are key. You should be back to normal soon if you allow for healing.

As healthcare providers, we need to be very careful that we do not send a mixed or contradictory message to our patients. We cannot say on the one hand that individuals with a mild TBI/concussion should have some initial symptoms but that they should gradually diminish over a few days and be back to normal within weeks, while on the other hand we refer them to multiple providers for numerous tests and procedures. A patient’s rational internal response to such a situation might be: “If I should get better no matter what happens, then why are you sending me for all these appointments and tests? You must really think that something serious is wrong with me, despite your superficially reassuring statements.”

Often possible mild TBI events are unwitnessed, and clinicians are left to rely on the self-report of patients. Patients typically cannot accurately report if they sustained a LOC. They are likely to erroneously attribute a period of posttraumatic amnesia (PTA) to LOC, but may also erroneously deny LOC because they have some memories for being at the scene. Assessment of amnesia can pose similar challenges. A patient’s self-report of PTA, for instance, can be hampered by issues such as psychogenic amnesia, severe physical pain/injuries, intoxication at the time of injury, and medication administered by emergency medical personnel [89]. The criterion of alteration in mental status is particularly challenging to determine. This is especially true for OEF/OIF veteran patients, as their suspected concussions often occurred within the context of emotionally intense and adrenalin laden combat situations or following blast exposure. In such instances, it is challenging for the clinician to differentiate whether the veteran was disoriented or confused as a result of an intense emotional reaction, adrenalin surge, pain from musculoskeletal injuries, or an actual concussion [90].

One of the primary goals of the clinical interview is to recreate the injury event based upon all available information. Given that a diagnosis of concussion is made on the basis of acute injury characteristics, a detailed clinical interview (in conjunction with collateral interview sources and medical record review, if available) has been identified as the “gold standard” for mild TBI diagnosis [11, 90]. When assessing for LOC, the National Academy of Neuropsychology (NAN) Education Paper [89] recommends that clinicians ask patients whether anyone told them they were unconscious or saw them lose consciousness, as opposed to directly asking whether they experienced a LOC per se. However, patients may need to be given an “operational definition” of LOC—“Did any observer indicate that you were unresponsive at the scene, lying or sitting there with your eyes closed and not responding in any way?” For assessment of amnesia, it is important to distinguish between what patients have been told or pieced together about the event versus what they actually remember. Asking very specific questions, such as what is the last thing remembered before the event and what is the first memory after the event can help make this determination. Having patients describe the time periods surrounding the event (before, during, and after) in a free-flowing minute-by-minute manner should be encouraged. Confusion and disorientation can be assessed by establishing a timeline of the accident followed by a clinical determination of whether any confusion and disorientation was a direct result of the neurological insult. Specific queries about the patient’s emotional response (e.g., “Were you scared?”) can be helpful in differentiating psychological confusion versus physiological confusion.

The present authors, along with a number of other clinician investigators advocate for the use of a structured or semi-structured interview to assess for a concussion history. For example, Corrigan and Bogner [91] published the Ohio State University TBI Identification Method (OSU TBI-ID), which is a structured interview designed to retrospectively identify a history of TBI through self- or proxy-reports. The OSU TBI-ID first elicits recall of all injuries that received medical attention (or warranted medical attention) and then concentrates on those that involved trauma to the head or high-velocity forces. Next, these incidents are further probed for any alterations in consciousness. Lastly, the three most severe injuries are focused upon to assess the onset and course of any post-TBI symptoms and to evaluate for any functional consequences as a result of TBI. The OSU TBI-ID has been found to be a reliable and valid method of assessing lifetime history of TBI [91, 92].

In contrast to the OSU TBI-ID, which explicitly and directly asks about loss or alternation of consciousness, Vanderploeg, Groer, & Belanger [93] assembled a national panel of TBI experts to develop the “VA TBI Identification Clinical Interview” as a semi-structured interview approach that avoids “leading questions.” This was designed specifically to assess deployment-related TBIs in the post-deployment VA healthcare system months to years following the potential TBI. To minimize reporting bias veterans are not told that the interview is attempting to determine whether or not they sustained a TBI. Rather, patients are first told that the examiner is interested in understanding the effect of “physical forces” on them. Then, they are asked about the “physically most powerful event” they experienced, such as motor vehicle accidents, getting knocked in the head or to the ground, feeling a shock wave, or being hit by debris during an explosion. The interview process is designed to obtain a patient’s story while carefully paying attention for information that is consistent with the natural history of TBI. The interview consists of three parts: Part A: Series of open-ended questions (and follow-up probes) to facilitate the patient’s freely-told, spontaneous description of the event and any new onset symptoms or problems; Part B: Form for recording the patient’s spontaneously reported information from the Part A semi-structured interview; and Part C: Questions and recording form for confirming information acquired during Part A and recorded on the Part B form. Part C is the first time that direct and closed-ended questions are asked of the patient, but it simply confirms what was reported spontaneously. The interview process and recording form assists the interviewer determine: (a) whether or TBI occurred, (b) the severity of that TBI, (c) immediate symptoms, (d) course of symptoms, and (e) total number of TBIs that occurred. The accompanying Manual provides information on how to conduct the interview, and provides clear and unambiguous information regarding the nature and diagnostic criteria of TBI (particularly mild TBI), its severity, and its natural course. Preliminary work has demonstrated good inter-rater reliability of this interview tool [94].

The “VA TBI Identification Clinical Interview” [93] also assists the clinician in determining the onset and course of symptoms. Current symptoms reported months to years following a concussion in military theater or elsewhere can only be considered postconcussion symptoms (or persistent postconcussion symptoms) if they began at the time of the concussion (within the first 24–72 h) and continued without ever completely remitting to the present time. Evidence suggests that acutely experienced symptoms are inconsistently reported over time [64]. Even persistent symptoms should decrease over time and may disappear for a day or so, but if an increased level of physical or cognitive activity immediately re-activates the identical symptom it can still be considered a postconcussion symptom. However, if a symptom (e.g., headache or dizziness) remits and does not re-emerge until a week or more later, that “re-emerged symptom” should be thought of as a new symptom with a different etiology. It should not be considered a postconcussion symptom. Then the cause of this new, but similar symptom, must be determined and treated accordingly.

The acute psychoeducational message as outlined above will not work without modification in the chronic setting where a service member or veteran presents with multiple symptoms (e.g., headache, insomnia, irritability, anxious or sad mood, concentration problems, and memory difficulties) many months or even a year or more following a deployment-related mild TBI. Providers cannot say “your symptoms should resolve within days to weeks” without losing all credibility. The symptoms are experienced as having lasted for months, and frequently are presumed by the service member/veteran to have been caused by the TBI event. The psychoeducational message must be modified accordingly, and put into terms and a context that the service member/veteran will understand and accept. Veterans should be assured that the ongoing course of symptoms is understandable in light of their having been exposed to a high stress environment for many months. It is not reasonable to expect one’s stress response and symptoms to abate rapidly. Furthermore, common post-deployment stressors should be identified and moderated if possible, including help in re-adjustment to civilian life and re-negotiating relationships with family, friends, and partners. Veterans should be made aware that while it is true that they may have sustained a concussion in theater, most of the symptoms they continue to experience are common symptoms of general stress that are unlikely to be linked with remote concussion history. An initial message such as the following, presented in a calm and empathetic manner, may be an appropriate modification of the empirically supported acute intervention for patients in the more chronic stages:

Of course you are experiencing a variety of symptoms that don’t seem to go away. You have been in a high stress environment for a long time. Many of the symptoms that occur following a concussion are the same type of symptoms associated with prolonged exposure to high levels of stress. You also are trying to re-adjust to civilian life. Your symptoms and experiences are normal reactions to abnormal conditions. Stress related to deployment (even with no physical injury to the brain at all) has been shown to adversely affect one’s ability to pay attention and remember information. Whether your current symptoms are due to concussion, prolonged stress, re-adjustment issues, or a combination of these factors, they will improve as your stress levels go down and you re-adjust to post-deployment life. However, it took you awhile to get to this point – a year or longer. Your body is not going to re-adjust over night. It won’t even happen in a week or two.

Let’s monitor your symptoms, and see if they improve. There are things we can do if any particular symptom remains problematic. The important thing to do now is to re-engage in civilian life, try to get caught up on your sleep, and engage in enjoyable social activities with your family and friends. Don’t overdo it too quickly, and don’t expect improvement over night. This will take a little time. If you continue to experience problems, let us know what they are and we will work together to resolve them.

Current care should focus on a combination of diagnostic-based treatment and symptom reduction, with an emphasis on reducing functional disability and re-engagement in positive life experiences. Patient–provider interactions centered on determining specific etiologies for each of multiple symptoms should be de-emphasized. For those with co-occurring mild TBI and PTSD and/or depression, providers should determine the most appropriate sequence of treatment that needs to be implemented. An OEF/OIF veteran with severe symptoms of PTSD may not be appropriate for TBI rehabilitation services such as cognitive compensatory techniques, and hence may first benefit from stabilization of emotional problems secondary to PTSD or other mental health conditions.

To address residual symptoms, regardless of etiology, a sequential clinical approach has been suggested by Terrio and colleagues [3] and is encouraged by the current authors. The initial step of treatment is providing service members/veterans and their family members with the expectation for recovery and simultaneously addressing any psychiatric symptoms (e.g., depression) first, regardless of origin. The next step includes attending to somatic complaints (e.g., headaches) and self-care routines (e.g., sleep). Interventions focused on cognitive symptoms (e.g., memory loss) are not generally initiated until the initial two steps are sufficiently addressed, if cognitive symptoms have not resolved by then. Educating service members/veterans and their family members about the potential interplay between symptoms and the importance of monitoring symptoms and recommended interventions is inherent to the process. This approach is consistent with recently released mild TBI clinical practice guidelines [95]. Ultimately, this strategy is aimed at helping military personnel and veterans maintain or return to their social roles, thereby facilitating resilience. This treatment approach supports recovery, promotes health behaviors, and enhances resiliency. Utilizing this orientation, struggles related to getting better, frequently referred to as “secondary gain,” would be addressed in treatment as barriers to recovery.

Mr. Smith was exposed to an improvised explosive device (IED) blast while driving a large truck in Iraq which, as a result, reportedly flipped several times. As is typical in most of these combat-related situations, no medical records were available from medics at the site. Also typical was that without an extensive period of coma, information regarding acute Glasgow Coma Score, length of loss or alternation of consciousness, and duration of post-event confusion were not available from medical records. Mr. Smith remembers driving and remembers bits and pieces of his medical evacuation. He was able to report details surrounding the roll-over of the truck. He recalled wearing a seatbelt but he struck his head against the side of the vehicle. He did not think that he lost consciousness initially but was unable to provide the same level of detail on events following the crash. He reported a distinct memory, once he was being evacuated, of having a strange feeling of not knowing his whereabouts, followed by severe pain and an awareness that he was bleeding. He remembered being put in a helicopter, as well as portions of his 3-day stay at Landstuhl Regional Medical Center in Germany for acute medical care. He had bilateral internal fixation for his fractured hips at Walter Reed Army Medical Center (WRMC) and reported participating in physical rehabilitation there for 13 months. He also worked as an intern for the Department of Labor while residing at WRMC.

Comment and discussion: This report of events is typical of a deployment-related injury being evaluated within the VA. Given the lack of gold standard for determining a history of TBI, as discussed in this chapter, the current “gold standard” is to elicit history from the patient in an open-ended manner [93] and determine, to the extent possible, if there was a force to the head and if there were gaps in the patient’s recollection that might be consistent with a loss or alteration of consciousness. In this case, it seems likely that the patient sustained a mild TBI given that he struck his head and given the apparent gaps in his ability to provide details following his injury. However, as is typical, this report may be confounded by both emotional and bodily injury. The stress and shock associated with such an event can potentially cause “gaps” in memory, as could significant blood loss. In this case, the fact that he was able to successfully work during his acute rehabilitation suggests that anything more severe than a mild TBI is quite unlikely.

Mr. Smith reported significant difficulty with concentration, both in the classroom and at his job. He also complained of frequent headaches and back pain, as well as difficulty sleeping, typically getting 3 or 4 h of sleep per night. He reported that his headaches and cognitive problems were getting worse.

Mr. Smith had a high school education with no history of learning or attention problems. He performed infantry duties in the military with no difficulties or disciplinary action, and he reported that he received good reviews in his current job as a counselor at a Vet Center despite his perception that he was not performing to his full potential. He had been working there for about a year. He was collecting a service connected disability for his hip injury. At the time of the evaluation he was taking two classes and earning A’s in both courses. He had a 5-year-old son from a previous marriage. He reported that his girlfriend of 3 years just broke up with him the week of the evaluation. He reported feeling depressed with decreased appetite and anhedonia. He reported having suicidal and homicidal thoughts in the past, but denies any currently. He denied any significant medical problems prior to this injury. He had left wrist surgery as a child. At the time of the evaluation he was being prescribed hydrocodone, Tylenol and trazodone. A recent MRI of the brain was read as normal.

Behavioral observations: Mr. Smith arrived on time for his appointment, ambulating with a cane. He appeared very tired initially but aroused considerably as the session progressed. He was fully oriented, with fluent and articulate speech. He provided a detailed, logical, and coherent history that was consistent with existing medical records. He complained of concentration problems which he believed were due to his head injury sustained approximately 3 years earlier.

He walked slowly using a cane and complained of back pain. He described his mood as “down.” His affect was flat and depressed, and he reported being quite tearful. When questioned about psychological symptoms in an open-ended manner, he reported multiple symptoms consistent with depression including sadness, feelings of emptiness, anhedonia, early morning awakening, social withdrawal, and fatigue.

Premorbid estimation: Mr. Smith denied any difficulty obtaining his high school diploma and reportedly earned A’s and B’s. His predicted Full Scale IQ score, based on word reading (WTAR) [96] and demographic data, was 102 (with a possible range of 84–120 based on a 95 % confidence interval).

Validity concerns: Mr. Smith’s performance during the neuropsychological evaluation was generally inconsistent with his current level of functioning. Specifically, he scored in the impaired range within every cognitive domain despite his ability to function independently, successfully hold down a job, and earn A grades in coursework. Results of symptom validity tests (SVTs) are shown in Table 2. Mr. Smith recalled only 4 digits forward and 2 digits backward (Digit Span 1st percentile; RDS = 5) [97]. Mr. Smith failed the Medical Symptom Validity Test (MSVT) [98] as well as the Rey 15 Item Test with Recognition [99]. Despite these failing scores on symptom validity measures, he scored within normal limits on several cognitive measures. Taken together, these findings were interpreted as reflecting variable effort or engagement in the evaluation process.