CONCUSSION involves a bang on the head followed by unconsciousness or giddiness then a few days of headache and nausea. At least that is the usual understanding.
But on the battlefield it has come to mean something altogether more sinister: a blast-induced brain injury with a catalogue of symptoms such as fatigue, irritability and insomnia (see 鈥淏rain shock鈥�).
The US military claims 1 in 5 of its soldiers are returning from Iraq and Afghanistan debilitated by such symptoms, which it claims are due to mild traumatic brain injury (mTBI), as concussion is also known, and has launched screening programmes. Veterans groups have even warned of an epidemic.
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It seems plausible that mTBI is responsible for this apparent surge in battlefield illness: homemade roadside bombs are one of the greatest dangers coalition troops face in Iraq and Afghanistan, and most soldiers now survive such explosions thanks to their modern body armour.
Yet recent studies into the epidemiology of mTBI suggest that the symptoms soldiers are reporting derive not from head injury but mostly from psychological illness such as post-traumatic stress disorder (PTSD). In other words, they are triggered largely by the ghastly experience of being on a battlefield.
The distinction is important. Physicians can provide soldiers with more effective treatment if they know what caused their symptoms. And a false diagnosis could well exacerbate the problem: telling patients what is wrong with them can influence how they respond to treatment. That means if soldiers think their distress is due to an enduring brain injury they are likely to take longer to recover.
Inevitably, some people will rush to dismiss the suffering of returning soldiers as 鈥渁ll in the head鈥� and by implication less deserving of help. Governments have been as guilty as anyone of reinforcing the idea that psychologically based illness is less of a priority: most have justified withholding compensation for battlefield conditions such as Gulf war syndrome on the grounds that it has been hard to link them to physical causes.
Yet psychologically based pain can no longer be dismissed as malingering. The debilitating effects of battlefield stress have been well documented. Treatments for PTSD are well established, even though its precise diagnosis is controversial.
鈥淧sychologically based pain can no longer be dismissed as malingering鈥�
At least military doctors and researchers seem to agree on one thing 鈥� that the symptoms reported by veterans of Iraq and Afghanistan are real. It follows that they deserve plenty of support, even if the source of their suffering is still open to debate.