Shell Shock and Mild Traumatic Brain Injury: A Historical Review

King's Centre for Military Health Research, Weston Education Centre, 10 Cutcombe Rd., London SE5 9RJ, UK.
American Journal of Psychiatry (Impact Factor: 12.3). 12/2007; 164(11):1641-5. DOI: 10.1176/appi.ajp.2007.07071180
Source: PubMed


Mild traumatic brain injury is now claimed to be the signature injury of the Iraq and Afghanistan conflicts. During World War I, shell shock came to occupy a similar position of prominence, and postconcussional syndrome assumed some importance in World War II. In this article, the nature of shell shock, its clinical presentation, the military context, hypotheses of causation, and issues of management are explored to discover whether there are contemporary relevancies to the current issue of mild traumatic brain injury. When shell shock was first postulated, it was assumed to be the product of a head injury or toxic exposure. However, subsequent clinical studies suggested that this view was too simplistic, and explanations soon oscillated between the strictly organic and the psychological as well as the behavioral. Despite a vigorous debate, physicians failed to identify or confirm characteristic distinctions. The experiences of the armed forces of both the United States and the United Kingdom during World Wars I and II led to two conclusions: that there were dangers in labeling anything as a unique "signature" injury and that disorders that cross any divide between physical and psychological require a nuanced view of their interpretation and treatment. These findings suggest that the hard-won lessons of shell shock continue to have relevance today.

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Available from: Simon Wessely, Dec 30, 2013
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    • "Mild traumatic brain injury (mTBI) has emerged as an important concern in the US military, and has become the “signature injury” of the Iraq and Afghanistan conflicts (Jones, Fear, & Wessely, 2007). An overall mTBI prevalence of 15% was found in a large survey of US combat infantry personnel deployed to Iraq (Hoge et al., 2008), whilst the prevalence in injured personnel returning from Iraq or Afghanistan who had been exposed to a blast was 40% (Okie, 2005). "
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    ABSTRACT: A substantial amount of research has been conducted into the mental health of the UK military in recent years. This article summarises the results of the various studies and offers possible explanations for differences in findings between the UK and other allied nations. Post-traumatic stress disorder (PTSD) rates are perhaps surprisingly low amongst British forces, with prevalence rates of around 4% in personnel who have deployed, rising to 6% in combat troops, despite the high tempo of operations in recent years. The rates in personnel currently on operations are consistently lower than these. Explanations for the lower PTSD prevalence in British troops include variations in combat exposures, demographic differences, higher leader to enlisted soldier ratios, shorter operational tour lengths and differences in access to long-term health care between countries. Delayed-onset PTSD was recently found to be more common than previously supposed, accounting for nearly half of all PTSD cases; however, many of these had sub-syndromal PTSD predating the onset of the full disorder. Rates of common mental health disorders in UK troops are similar or higher to those of the general population, and overall operational deployments are not associated with an increase in mental health problems in UK regular forces. However, there does appear to be a correlation between both deployment and increased alcohol misuse and post-deployment violence in combat troops. Unlike for regular forces, there is an overall association between deployment and mental health problems in Reservists. There have been growing concerns regarding mild traumatic brain injury, though this appears to be low in British troops with an overall prevalence of 4.4% in comparison with 15% in the US military. The current strategies for detection and treatment of mental health problems in British forces are also described. The stance of the UK military is that psychological welfare of troops is primarily a chain of command responsibility, aided by medical advice when necessary, and to this end uses third location decompression, stress briefings, and Trauma Risk Management approaches. Outpatient treatment is provided by Field Mental Health Teams and military Departments of Community Mental Health, whilst inpatient care is given in specific NHS hospitals.
    European Journal of Psychotraumatology 08/2014; 5. DOI:10.3402/ejpt.v5.23617 · 2.40 Impact Factor
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    • "Blast-induced brain injury has been of longstanding interest in military head trauma (Jones et al., 2007). Recently, there has been renewed interest in blast related traumatic brain injury (TBI) because of the frequency of blast injury in the conflicts in Iraq and Afghanistan (Elder et al., 2010). "
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    ABSTRACT: Blast-induced traumatic brain injury (TBI) has been a major cause of morbidity and mortality in the conflicts in Iraq and Afghanistan. How the primary blast wave affects the brain is not well understood. In particular, it is unclear whether blast injures the brain through mechanisms similar to those found in non-blast closed impact injuries (nbTBI). The β-amyloid (Aβ) peptide associated with the development of Alzheimer's disease is elevated acutely following TBI in humans as well as in experimental animal models of nbTBI. We examined levels of brain Aβ following experimental blast injury using enzyme-linked immunosorbent assays for Aβ 40 and 42. In both rat and mouse models of blast injury, rather than being increased, endogenous rodent brain Aβ levels were decreased acutely following injury. Levels of the amyloid precursor protein (APP) were increased following blast exposure although there was no evidence of axonal pathology based on APP immunohistochemical staining. Unlike the findings in nbTBI animal models, levels of the β-secretase, β-site APP cleaving enzyme 1, and the γ-secretase component presenilin-1 were unchanged following blast exposure. These studies have implications for understanding the nature of blast injury to the brain. They also suggest that strategies aimed at lowering Aβ production may not be effective for treating acute blast injury to the brain.
    Frontiers in Neurology 12/2012; 3:177. DOI:10.3389/fneur.2012.00177
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    • "Albeit some authors still dispute their legitimacy, regarding them exclusively as a culture-bound syndrome that flourished in the 1800s (Pope et al., 2007), dissociative (psychogenic) amnesic disorders have been linked to psychological trauma or stress in a variety of cultures (Thom and Fenton, 1920; Kiersch, 1962; Spiegel and Cardena, 1991; Draijer and Langeland, 1999; Xiao et al., 2006; Jones et al., 2007; Seligman and Kirmayer, 2008). As Goldsmith et al. (2009) remarked, Pliny the Elder (23–79 A.D.) already had talked about " fright " as being one of the causes of partial or total memory " loss. "
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    ABSTRACT: Remembering the past is a core feature of human beings, enabling them to maintain a sense of wholeness and identity and preparing them for the demands of the future. Forgetting operates in a dynamic neural connection with remembering, allowing the elimination of unnecessary or irrelevant information overload and decreasing interference. Stress and traumatic experiences could affect this connection, resulting in memory disturbances, such as functional amnesia. An overview of clinical, epidemiological, neuropsychological, and neurobiological aspects of functional amnesia is presented, by preponderantly resorting to own data from patients with functional amnesia. Patients were investigated medically, neuropsychologically, and neuroradiologically. A detailed report of a new case is included to illustrate the challenges posed by making an accurate differential diagnosis of functional amnesia, a condition that may encroach on the boundaries between psychiatry and neurology. Several mechanisms may play a role in "forgetting" in functional amnesia, such as retrieval impairments, consolidating defects, motivated forgetting, deficits in binding and reassembling details of the past, deficits in establishing a first person autonoetic connection with personal events, and loss of information. In a substantial number of patients, we observed a synchronization abnormality between a frontal lobe system, important for autonoetic consciousness, and a temporo-amygdalar system, important for evaluation and emotions, which provides empirical support for an underlying mechanism of dissociation (a failure of integration between cognition and emotion). This observation suggests a mnestic blockade in functional amnesia that is triggered by psychological or environmental stress and is underpinned by a stress hormone mediated synchronization abnormality during retrieval between processing of affect-laden events and fact-processing.
    Frontiers in Psychology 11/2012; 3:403. DOI:10.3389/fpsyg.2012.00403 · 2.80 Impact Factor
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