PTSD and TBI Comorbities - Relationships of Suicide for Returned Combat Veterans

Running head: PTSD AND TBI COMORBIDITIES 1
PTSD and TBI Comorbidities:
Understanding the Relationship Between These Disorders and the Suicide Rate Amongst
Returned Combat Veterans
Charles Mayer
University of San Francisco

PTSD AND TBI COMORBIDITIES 2
Throughout the past twelve years in America's involvement in conflicts across the globe,
troubling new problems are being faced by the soldiers who return home from deployments.
With the advancement in body armor, many of the injuries that would have been considered fatal
in the past are now saving more lives than ever. However, this advancement in armor and rapid
trauma treatment on the battlefields are leading to a new generation of disorders. Of these
disorders, there are two common diagnoses wounded soldiers return with: Post Traumatic Stress
Disorder (PTSD) and Traumatic Brain Injury (TBI). PTSD and TBI have been clinically
diagnosed more than any other disorder since 2001. Since these are relatively new diagnoses due
to the nature of modern warfare trauma, little is known as to accurate measuring instruments,
correlations with suicidal ideations, and other neurological disorders. The concussive blasts
from roadside bombs and suicide bombers are now being absorbed in the areas not protected by
the body armor, the limbs, and the head. The head trauma and emotional injuries that may be
associated with being involved in violent combat have now been categorized into two distinct
diagnoses. Some level of a TBI is often associated with neurological symptoms, such as
anterograde or retrograde amnesia. TBI is defined by the Diagnostic and Statistical Manual for
Mental Disorders DSM-IV-TR (2000) 4th ed., text rev. as an injury which causes specific
impairments in the ability to concentrate, processing speed, impulsivity, and mood swings. A
TBI is a history of head trauma that stems from a concussion. It is important to note that a TBI
has different levels of severity, with a mild Traumatic Brain Injury (mTBI) being the least
affected and most common diagnosis, and a severe Traumatic Brain Injury (sTBI) being the most
affected and least diagnosed trauma wound. According to the DSM-IV-TR (2000) 4th ed., text
rev., Post Traumatic Stress Disorder (PTSD) is a disorder which manifests in different severities
of mental processing: extreme alertness, nightmares, flashbacks of wartime scenarios, and other

psychological manifestations. PTSD results from exposure to "an extreme traumatic stressor
involving direct personal experience of an event that involves actual or threatened death or
serious injury". Being diagnosed with one of these disorders, or a combination of the two, may
greatly increase the risk of suicide and suicidal ideations among returning soldiers. The impacts
of these disorders are everywhere, as over 2,000,000 American soldiers have served in combat
the past decade. The majority of these diagnoses have occurred within the past decade,
coinciding with American conflicts in Iraq and Afghanistan (Morisette et al., 2001, p. 340).
These disorders can affect quality of life greatly, such that many turn to suicide to quiet the
emotional distress that is commonly associated with a TBI and/or PTSD. This review intends to
gather accurate diagnostic rates of these two disorders. Ultimately, with a better understanding
of these disorders, efforts can be made to diagnose these disorders to provide quicker treatment.
It is important to note that these studies all attempt to determine diagnoses of mental disorders
and suicide in a nonexperimental setting. The history of military personnel being subjected to
experimental research has been long and dubious, therefore no experimental research into
determining mental disorders and suicide are conducted with soldiers for the purpose of
determining the relationship between PTSD, TBI, and suicide.
The DSM-IV-TR (2000) 4th ed., text rev. defines PTSD as having numerous symptom
criterion. These symptoms include initially having "a stressor, intrusive recollection,
avoiding/numbing, hyper-arousal, duration, and functional significance." It only takes a
diagnosis of having several of these categories to be fully diagnosed with PTSD. According to
the DSM-IV-TR (2000) 4th ed., text rev., a TBI is a history of head trauma directly relating from
a concussive blast absorbed in combat. It is important to note that not all cases of PTSD and TBI
are directly related to military service, but the majority of these cases in the past decade are from

soldiers returning home from a war zone. Having a diagnosis of one, or both, dramatically
increased the risk of depression, and in the most severe cases, suicide. Since the majority of
people in the armed forces are male, the majority of the subjects in research are predominantly
male as well. There are difficulties, however, in determining the rates of soldiers with TBI, since
the nature of TBI is made more difficult to discern because of the nonspecific nature of post-
concussive symptoms (PCS) (Morisette et al., 2011, p. 340).
Research conducted by Hoge et al. (2008) directly looked at the relationship in a mTBI
within returning soldiers from combat. Since this is a nonexperimental study, it is important to
note the aim of this study. The purpose was to determine statistical significance between soldiers
who were diagnosed with PTSD and TBI. A total of 2,525 soldiers were surveyed 3-4 months
directly after a one-year long deployment to Iraq. A total of 124 (4.9%) were diagnosed with
loss of conscious (LOC) injuries, 260 (10.3%) with altered mental status, and 435 (17.2%) with
other injuries during deployment (Hoge et al., 2008, p. 453). A large percentage of these
soldiers, 43.9%, met the clinical criteria to be diagnosed with PTSD as well. The results indicate
that there is a very strong association between mTBI and PTSD in soldiers three to four months
post-deployment, since there were many overlapping symptoms. Initially, 2,714 soldiers
properly completed the questionnaire developed by the Walter Reed Army Institute of Research.
The dependent variable was measured in symptoms of post-concussive symptoms or PTSD that
were measured by the nine-question depression-assessment module of the Patient Health
Questionnaire (Hoge et al., 2011, p. 455). The independent variables were the life stressors and
experiences each individual underwent during military service, amount of time spent overseas,
and more specifically amount of combat exposure. The PTSD subjects had to meet the DSM-IV-
TR (2000) criteria, which is a mixture of testing positive for avoidance, arousal, and avoidance

symptoms. Statistical multivariate analysis tests were utilized with the use of multiple logistic
regression, as it was deemed to be the most effective to properly measure validity. Chi-Squared
testing and Analysis of Variance (ANOVA) were also conducted, and it is the aggregate of these
measures which make the research conducted by Hoge et al. (2008) a landmark study. Ninety-
five percent of the subjects were male, since an Infantry Brigade was assessed (at the time of the
study, Infantry was an all-male military occupational speciality). Of these, the majority were
Caucasian. This may be a possible area of bias, since infantry units tend to have more Caucasian
soldiers (Hoge et al., 2008, p. 455). Overall, 43.9% of soldiers who experiences a LOC also met
PTSD criteria (p<001). The two major factors for PTSD diagnosis was level of combat intensity,
and loss of consciousness. Injuries that were diagnosed as having an altered mental state and
high level of combat intensity were statistically significantly associated with PTSD (p=.002) but
not depression (Hoge et al., 2008, p. 458). One of the more difficult areas of research lies within
determining if certain factors are causes or correlations, and although research has not proved a
causal relationship, the correlations between the two are not disputed. Some potential areas of
bias in this study were similar to other studies. It was found very difficult due to the nature of
military movement to keep track of the soldiers at different time intervals. Also, soldiers who
were away for training on a survey day or at medical appointments were not assessed. It is these
soldiers who are at medical appointments that may need to be more thoroughly researched, since
PTSD and TBI have a direct impact on physical symptoms, including back pain, sleep
disturbance, memory problems, and emotional distress (Hoge et al., 2008, p. 460-461). As with
almost all large scale military trials, the main limitation is relying on the accuracy of self-
reported data, where recall bias may be an issue. This limitation occurs in nearly every large-
scale clinical trial.

Recent research has been conducted to more properly determine the relationships
between PTSD, TBI, and suicidal ideations. In a smaller-scale experimental study conducted by
Morisette et al. (2011), 213 veterans who had recently returned home from combat overseas were
tested to assess the relationships between PTSD, TBI, and Post-Concussive Symptoms (PCS).
Participants were given questionnaires, and were divided into either one or two different clinical
studies. Excluding factors for this process were soldiers who were diagnosed as being bipolar,
currently at risk to themselves or others, or started taking medications for their symptoms during
the previous three months (Morisette et al., 2011, p. 344). There is possible bias on relying
solely on questionnaires, but due to the nature of the military work schedule there is no other
effective way. The study determined that 47.0% of the first group screened positive for TBI and
44.4% screened positive in the second group, so determining the validity of the screenings both
groups were collapsed into one large group. Eighty seven percent of the population group was
male, which can be attributed to the nature of the military being male dominant.
These veterans were tested for a possible TBI or PTSD disorder using the Brief
Traumatic Brain Injury Screen (BTBIS), the PTSD Checklist-Military Version (PCL-M), or two
other similar and known measures to ensure validity. These test measures are the dependent
variables. This study was unique in that it had a more controlled access of the soldiers than most
larger-scale studies. Partial disaggregation was utilized to ensure the accuracy of these models
was most appropriate for a smaller sample size (Morisette et al., 2011, pp. 368-369). The scores
of the PTSD subjects were remarkably similar to the TBI subjects, and often overlapped. This
overlapping of symptoms is now associated with depression and suicidal ideations amongst war
veterans, as well as other physical symptoms.

In an attempt to view current data in a different way, research by Brenner et al. (2008)
utilizes data known about PTSD and TBI and qualitatively assessed these in relation to suicidal
ideations and suicides in the military. A total of 65.1% of OIF soldiers and 46% of OEF soldiers
reported a positive history of association with combat (Brenner et al., 2008, p. 212; Hoge et al.,
2008, pp. 456-457) up to the year 2008. In this study, three aspects of questioning were
involved. These constructs were perceived burdensomeness by the soldiers, reaction to acute or
chronic pain, and a feeling of a failure to belong and reintegrate (Brenner et al., 2008, p. 213).
This relatively small scale study is included to offer a qualitative construct of suicide in veterans
and how PTSD and TBI affects emotional stability. A sample of 16 OIF/OEF veterans were
chosen who had significant combat experience, with the majority coming from the Army (12).
All were either diagnosed with PTSD, TBI, or a combination. Nine were aged 18-24, and six
were 40 or older. The questions that were posited to the soldiers all revolved around the three
themes listed above. After the initial interviews were taken, four other team members
independently reviewed and coded each transcript to track universal themes and ideas. After a
further in-depth examination of the interviews, the researchers concluded that the point of
saturation had been reached and that no new ideas were being shown. The independent variable
was each individual experience unique to the soldier in regards to suicidal ideation. Common
themes were those of the perceived notion that "in the military I was always told to 'man up'...so
I really try to shut it out or not to let them see me" (Brenner et al., 2008, p. 217). Similarly, a
notion of being desensitized to emotional experiences of combat has made it particularly difficult
to adapt back into society, causing emotional distancing. A feeling of normalcy was not felt, as
typical reactions would be that they are not living, just existing. Additional burdens were placed
on the soldiers when they exited the military, as many felt that they had lost their identity, and

now had no way to support their family and felt like a failure. This was especially exacerbated
when the soldiers were involuntarily discharged due to medical reasons (Brenner et al., 2008, p.
218). Lastly, the theme of failed belongingness is explored. Many of the veterans stated that
post military, they had no one to share their common bond with. There is a strong theme of
connectivity and emotional health. This can also be stated as a fundamental failure to
emotionally connect with others outside the military after time served, and lacking a shared
experience that is so common to positive mental health. According to the modules determined
by Brenner et al. (2008), suicide risks are the highest when there is a conjunction of the two
groups of burdensomeness and failed belonging.
As a result of this study, certain coping strategies were theorized to combat each one of
the three modules. Mindfulness based therapy is attempting to teach people how to feel their
thoughts in a way which is analytical, cognitive, and nonjudgmental. In regards to
burdensomeness, it is stressed that certain veterans may need to receive vocational support, to
help create their identity. The perceived therapy for the feeling of failed belongingness is a
socially appropriate interaction therapy, such as couples counseling, Battle-minded Training
offered by Walter Reed (which specifically is aimed at the transition from service-member to
civilian), and other mixes of civilian-military therapy. It is stated that if tests were available to
accurately neurologically test for PTSD and TBI, therapeutic intervention could be given much
sooner and save potential lives (Brenner et al., 2008, p. 223). The researchers individually
checked the data for thoroughness, and multiple times with a random team member. The
qualitative measure was based on the Interpersonal-Psychology Theory of Suicide Risk, which is
a common and valid measurement for analysis in this field. Such flaws in this research study
would be the small sample-size used. Since the saturation point had been reached, the validity

measure was not affected. These same themes are being currently researched to help prevent
suicide in military members who suffer from one or more disorders.
There is also the issue of barriers to healthcare, especially the stigma of asking for help in
the military. Combined with a lack of proper diagnosis, stigma and perceived malingering can
lead soldiers to not ask for help. New research into the area of perceived stigma and other
barriers to healthcare were conducted by Wright et al. (2009). A sample size of 680 soldiers
from differing units were chosen three months after their return from overseas combat. The main
initiative of this research was to determine perceptions of leader behaviors and unit cohesion,
and the perceived stigma to access healthcare (Wright et al., 2009, p. 108). Data was collected
to determine the soldiers perception of unit cohesion in predicting barriers to care. As this is
another study relying on nonexperimental methods, the aim of this research must be understood.
Using standardized testing methods, the relationship between perceived stigma to receive mental
health was looked at in a leadership context. Specifically, the Patient Health Questionnaire
(PHQ) was utilized as well as the 13-item Depression and Anxiety Scale (Wright et al., 2009, p.
112). Also utilized was the 17-item PCL, which is clinically valid. The majority of the subjects
(431) had been in the military five years or less, were between the ages of 20-24 (39.2%), male
(82.6%), and Caucasian (56.1%). This is typical with other demographics coming from a
combined arms unit in the military (Hoge et al., 2008; Morisette et al., 2011). Reliability
analyses were carried out periodically throughout each different criteria in this experiment,
ranging from twelve different factors. It was determined that officer leadership is appropriate for
determining adequate reliability within individual units, as with each unit there is a different and
unique style of leadership (Wright et al., 2009, p. 114). In accordance with the correlations
among the main variables (N=591), four different predictors of stigma were tested. Ratings of

unit leadership, perception on combat cohesion, interaction between soldiers and leaders, and
mental health analyses were tested (Wright et al., 2009, p. 115). The interactions show that the
lowest scores of stigma and barriers to care were the unit where the officer participation was the
highest and perceived unit cohesion was the best (p<.01). It is the inverse relationship between
perceived leadership qualities and the stigma of receiving care that needs to be understood and
acted upon by the military. The results of this study were consistent with at least six other
similar studies conducted between 2001 and 2007 (Wright et al., 2009, p. 127).
Recent research has been conducted that also examines risk factors of suicides or suicide
attempts in the Army from 2001-2009 (Black, Gallaway, Bell, & Ritchie, 2011). The aim of this
study was to examine the soldiers already at risk to inversely determine what relationships
certain diagnoses maintained with suicide and suicidal ideations. The list of stressors for suicide
include socio-cultural and military risk factors, psychological risk factors, suicide event
characteristics, and stress load (Black et al., 2011, pp. 436-437). A total number of 874 Army
suicide cases were analyzed from information selected from the Army Behavioral Health
Integrated Data Environment (ABHIDE) from 2001-2009. Each individual stress factors was
identified individually, such as looking at the diagnosis of mental health disorders and examining
the levels of combat exposed to the soldiers. From the year 2001 to 2009, suicide rates have
more than doubled to a level of 22 per 100,000 (Black et al., 2011, p. 437). In 2001, there were
52 Army suicides, and in 2009 there were 162. This trend existed in all components of the
Army, including National Guard and Reserve forces. As of 2008, U.S. military deaths have
increased at a much higher rate than civilian deaths. Civilian suicide rates have maintained
relative stability in the past decade, fluctuating from 18.0 to 18.5 deaths per 100,000 per year. It
is noted that with the current operations tempo the U.S. Army has sustained, often this means

individual soldiers will deploy overseas to combat two or three times in a period of five years.
This is a commonly held belief as to why the suicide numbers have exponentially increased
(Black et al., 2011, p. 438).
It is important to note that although other stressors were examined in detail, for the
purpose of this review only the psychological factors will be reported. Fifty four percent of
suicides did not have any diagnosis of mental disorders, whereas 46% had received one mental
health diagnosis, and 31% had received multiple diagnoses. These results are remarkably
consistent with Hoge et al. (2008). Deployment histories almost doubled the risk of suicide,
from 35.6% (non-deployed) to 64.4% (one or more deployments). In summation, risk factors for
soldiers diagnosed with a mental health disorder were up to 4.7 times higher than soldiers
without a diagnosis. Twenty five percent of all Army suicides had previously been diagnosed
with an adjustment disorder. This term is somewhat lacking since it is sometimes used by
clinicians as a safety diagnosis when they know something is wrong, but do not know what
(Black et al., 2011, p. 442). Reduction of mental healthcare stigma is noted as being a major
obstacle to accessing healthcare. This study was non-experimental, as it looked through
ABHIDE records at suicide rate in the Army alone. A major limitation of this study was that
there were no non-suicide control groups available to be analyzed. Therefore, only correlations
could be inferred. It was the intent of this review to examine the preeminent studies in each
factor, and compare them.
Brenner et al. (2011) conducted follow-up research to contextualize their previous
qualitative studies with a more in-depth quantitative study. This article is considered along with
Hoge et al. (2008), to be the most relied upon research method for determining PTSD, TBI, and
suicidal behaviors. The results show that PTSD, and subsequently a history with TBI was

associated with increased risk for suicide attempt (OR=2.8; 95% Cl: 1.5, 5.1) (Brenner et al.,
2011, p. 417). Examined for the first time were previous generational diagnoses of PTSD and
suicide rates among those veterans. Among Vietnam veterans, soldiers with PTSD were fifteen
times more likely to attempt suicide than those not diagnosed with the disorder. Soldiers
returning from Iraq and Afghanistan were over four times as likely to have suicidal ideations
than soldiers without diagnosed PTSD (Brenner et al., 2011, p. 417). Out of necessity this study
only concentrated on a military population, which examined 81 veterans with a history of suicide
attempts. Of these 81 soldiers who had received VA healthcare between 2004 and 2006, two
control patients were matched for each individual patient, stratified for age and gender
demographics. Medical records were looked over to ensure a lack of bias, to thoroughly show
that each veteran had attempted suicide and was involved in the healthcare system at the time. A
final reliability check of patient medical charts, including neurologic conditions and suicidal
ideations, was conducted by a final member of the research team.
Key words were entered for four separate disorders and symptoms. These four disorders
were PTSD, TBI, suicide, and neurologic disease. Included in the neurologic disease categories
were key words such as: Huntingtons, Parkinsons, and stroke. The overall methodologies
utilized were varied, as either Fisher's Exact or Chi-Squared tests were used where appropriate.
Patients who had been diagnosed with PTSD were 64% in the case group, and 42% in the control
group (Chi-Squared p=.001). These percentages are consistent with the previous Hoge et al.
(2008) study. The relationship between diagnosed TBI was not clear. Thirty percent of the case
group were diagnosed with a TBI, along with 29% of the control group (Chi-Squared p=.97).
Furthermore, dual-diagnosis of these two disorders was 22% in the case group and 16% of the
control group (Chi-Squared p=.21). Eighty three percent of the overall patients were male, as is

consistent with military service. It must be noted that TBI and neurologic disorders were not
individually significant to be associated with suicide attempts. Unlike the other disorders, PTSD
is a significant predictor of suicide attempts (p=.0008) (Brenner et al., 2011 p. 421). When TBI
and PTSD were examined together, PTSD was deemed significant whereas TBI was not.
Overall, patients diagnosed with PTSD were 2.8 times the odds of a suicide attempt versus
patients not diagnosed with PTSD. The odds of a dual-diagnosis of PTSD and TBI rose from 2.8
times (PTSD only) to 3.3 times as likely to attempt suicide as with those diagnosed with TBI
only.
Limitations of this study shared a similar theme as with most studies regarding veterans
(Brenner et al., 2011; Hoge et al., 2008). A major limitation involving all of the studies is the
reliance on retrospective data. This data is received often directly from the patient may change
from time, thereby affecting the reliability. Another major limitation that is common is the lack
of medical data to determine PTSD, TBI, and other related disorders. Too often clinicians
diagnose these disorders based off one thirty minute session with a patient. Since the diagnosis
is unique to each clinician, exact data has been difficult to ascertain.
The main strengths of these studies has been the increased awareness of mental disorders
in the past decade. Whereas little data had previously been collected targeting PTSD, TBI and
suicide, now there is an abundance. Still, this matters little unless the data is reliable and valid.
Studies conducted by Brenner et al. (2011) and Hoge et al., (2008) has helped ascertain reliable
data and information regarding these correlations. One of the major challenges with studying
suicide in veterans has been the retrospective nature of the disorders themselves. The diagnosis
now is made based upon medical records and cognitive behavioral health analysis of the
individual veteran. Of all the numerous data collected by researchers, studies conducted by

Brenner et al., (2011) and Hoge et al. (2008) are considered to be landmark studies based on their
validity and reliability. There are immediate practical applications that can be based upon
current research. Most importantly, now that more reliable data has been gathered to show
percentages of soldiers with PTSD or a TBI, these must be matched with some sort of reliable
biomarker. Whether these imaging techniques include an fMRI, CT scan, PET scan, or MEG
imaging, the data collected must be reliably applied to information gathered (Brenner et al.,
2011).
Another important practical application is lessoning the stigma of receiving mental
healthcare in the military. Now that there are statistics that draw strong correlations between unit
cohesion and leadership effectiveness, there needs to be a more intensive effort starting from the
top down in de-stigmatizing receiving mental healthcare (Wright et al., 2009, p. 127). Examples
of this are specifically diagnosing concussive blasts while on the battlefield instead of shrugging
it off, and seeking behavioral healthcare during and after redeployment. The perception that
seeking help for emotional trauma is associated with malingering must be redefined. With a
more intensive program that holds senior leaders accountable, many suicides can be prevented.
Areas of future research that should be addressed are the instrumentations of veterans studies
themselves. Instead of gathering retrospective data which relies upon possibly brain damaged
individuals to denote psychological or physical symptoms, there should be a larger scale
database share within the military which is more streamlined and universal (similar to the
ABHIDE but a result of cohesive confluence between all armed forces sectors). This
achievement concurrent with the existence of a reliable biomarker for mental disorders would
allow for these disorders to be diagnosed at the earliest stage, allowing therapeutic benefit to be
the greatest. The scale of the previous military program testing body armor designed to protect

physical characteristics must be applied now to protect mental disorders as well. The ultimate
goal of this area of research is to diagnose as early as possible, and with treatment, improve
quality of life. In an era where the United States loses more soldiers each year to suicide than to
enemy combat, this is more than an essential task. Perhaps with the emergence of more refined
neuroimaging techniques and with a dramatic de-stigmatization of mental health treatment in the
military, countless lives will be saved.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). doi:10.1176.appi.books.9780890423349
Black, S., Gallaway, M., Bell, M., & Ritchie, E. (2011). Prevalence and risk factors associated
with suicides of Army soldiers 2001-2009. Military Psychology, 23(4), 433-451.
doi:10.1037/h0094766
Brenner, L., Betthauser, L., Homaifar, B., Villarreal, E., Harwood, J., Staves, P., & Huggins, J.
(2011). Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history
among veterans receiving mental health services. Suicide and Life-Threatening Behavior,
41(1), 416-423. doi:10.1111/j.1943-278X.2011.00041.x
Brenner, L., Gutierrez, P., Cornette, M., Betthauser, L., Bahraini, N., & Staves, P. (2008). A
Qualitative study of potential suicide risk factors in returning combat veterans. Journal
of Mental Health Counseling, 30(3), 211-225.
Hoge, C., McGurk, D., Thomas, J., Cox, A., Engel, C., & Castro, C. (2008). Mild traumatic brain
injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine,
358(5), 453-463. doi:10.1056/NEJMoa072972
Morisette, S., Woodward, M., Kimbrel, N., Meyer, M., Dolan, S., & Gulliver, B. (2011).
Deployment-related TBI, persistent postconcussive symptoms, PTSD, and depression in
OEF/OIF veterans. American Journal of Rehabilitation Psychology, 56(4), 340-350.
doi:10.1037/a0025462

Wright, K., Cabrera, O., Bliese, P., Adler, A., Hoge, C., & Castro, C. (2009). Stigma and barriers
to care in soldiers postcombat. Psychological Services, 6(2), 108-124.
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