Traumatic brain injury (TBI)—or in this case, Iranian Ballistic missile-related traumatic brain injury—can cause a host of symptoms, from relatively mild to life-changing. Symptoms such as cognitive dysfunction, dizziness, and chronic headaches occur far more frequently among military personnel with mild traumatic brain injury than in those without such injuries. Those with traumatic brain injury are also much more likely to experience significant emotional issues and serious sleep disorders.

The Defense Health Agency’s Hearing Center of Excellence assessed a battery of neurological tests used in the diagnosis of mild traumatic brain injury. The issue was studied between 2014 and 2017 at the Naval Medical Center in San Diego, California, and the Washington Madigan Army Medical Center at Joint Base Lewis-McChord. The goal of the study was to determine Oculomotor, Vestibular, and Reaction Time Response following a traumatic brain injury event.

According to the CDC, a traumatic brain injury is any “disruption in the normal function of the brain,” causes by a bump, blow or jolt to the head or by a penetrating head injury. TBI severity ranges from mild (concussion) to severe, with mild traumatic brain injury being the most common brain injury affecting military personnel. Troops can experience symptoms of a concussion, a “sub-concussion” that causes no symptoms, and symptoms associated with IED or other explosive devices.

Concussion vs. Sub-Concussion Impact - A concussion is a hit to the brain that causes symptoms to appear fairly quickly, as the brain is shaken violently enough that some brain cells will be damaged, failing to continue to work properly. A sub-concussive impact is any impact below that threshold where the brain is shaken—but not violently enough to cause fairly immediate symptoms.

While it might sound like a sub-concussion is not all that serious, in fact, sub-concussive impacts can add up to brain damage. Soldiers, like professional athletes, are likely to take “hits” to the body on a regular basis that “shake” the brain. Scientists have learned that these sub-concussive impacts, over time, can lead to the following:

• Suppression of brain function;
• Worsening memory and ability to pay attention to tasks, and
• Behavior and mood problems later in life.

In short, these sub-concussive “hits” damage the connections in the brain, making it more difficult for the different areas of the brain to properly communicate. It is likely that a significant percentage of soldiers have experienced these sub-concussive hits and will experience difficulties later in life.

Some of the troops injured in the Al Asad Airbase Ballistic Missile Attack may have experienced these sub-concussive events, while more experienced mild, moderate, or even severe traumatic brain injury. While there were blast injuries that were tended to immediately after the ballistic missile attack, the primary injuries were Iranian ballistic missile-related traumatic brain injury for those in the immediate vicinity. 

Symptoms of Minor TBI - Some of the symptoms of a minor concussion include the following:

• Headaches—sometimes chronic—are one of the most common symptoms following a traumatic brain injury, with more than 30 percent of those suffering a traumatic brain injury having chronic, sometimes severe headaches for years after the initial injury. Chronic headaches can make it very difficult to continue regular daily activities, making it more difficult to concentrate and remember. When an area of the brain becomes hypersensitive following a traumatic brain injury, migraine headaches can occur. A migraine can cause sensitivity to light or sound, a dull, throbbing sensation, nausea or vomiting, and pain level generally rated as moderate to severe. Other types of headaches experienced following a TBI include tension headaches, cervicogenic headaches (usually following some level of injury to the muscles and soft tissues in the back of the head and neck), or rebound headaches that are actually caused by the medications used to treat other types of headaches. If a TBI-induced headache worsens over time, there is an increase in nausea and/or vomiting, arm or leg weakness occurs, problems speaking occurs, or there is increasing sleepiness with the headache, this is definitely cause for concern.
• Nausea is another common symptom of traumatic brain injury. Nausea can be short-term, associated with mild TBI (acute concussion), or could be situational or persistent even after recovery from the initial injury. While chronic nausea is fairly rare following a minor TBI, it is normal to be nauseous for days, or possibly even weeks, after the initial brain injury. There is typically inflammation and microstructural damage to the brain following a TBI that interferes with the communication channels in the brain, causing overload. These less efficient pathways between the brain cells cause many symptoms, including nausea. If those communication pathways don’t fully heal after the initial injury, nausea can persist.
• Dizziness and vertigo are commonly seen in those with mild traumatic brain injury, with up to 80 percent of those suffering a TBI reporting vertigo that lasts a week or more. Post-concussive dizziness can persist for weeks or months after the injury, with one out of five individuals suffering from a minor TBI reporting dizziness and vertigo for 2-5 years after the initial injury. Dizziness and vertigo following a TBI have been linked to work-related disability, psychological distress, and prolonged recovery duration, specifically dizziness that stems from a blast-induced injury among military members.  
• Confusion is very common in those with TBI, particularly those individuals who lose consciousness, even for a brief period of time. Doctors often term this “post-traumatic amnesia,” because it can include a loss of memory skills disorientation. Problems with attention span can be caused by the TBI-associated confusion, and the confusion can, in turn, lead to altered activity levels, delusions, hallucinations, and mood swings. In one study detailed by the Brain Injury Association of America, about 69 percent of individuals with TBI experienced some level of confusion, and about 71 percent of those largely recovered within 43 days, while the remainder suffered episodes of confusion (minor to severe) for months or years after.  
• Changes in mood and behavior are yet additional hallmarks of traumatic brain injury. A concussion can affect the brain long after it has healed from the initial injury; since the way we process and understand information can change as a result of the injury, it should come as no surprise that our emotions can also be altered. Social anxiety, or feelings of depression, irritability, anger, general anxiety, feelings of hopelessness, restlessness, decreased energy, difficulty sleeping, mood swings, or feelings of being overwhelmed can all result from a minor TBI. For many, it can seem as though they are a completely different person, but in truth, the individual’s personality is simply buried under the weight of TBI symptoms. Many mood and behavior changes can be managed when the overall TBI treatment is correct.

Chronic Traumatic Encephalopathy - Above the level of a minor traumatic brain injury is Chronic Traumatic Encephalopathy which is a progressive brain disease associated with repeated TBIs, including concussions. Military personnel and athletes who play contact sports are at the greatest risk of CTE due to repeated “hits” to the head (or to the body, which in turn, jolt the brain). All of the symptoms associated with minor traumatic brain injury or concussion can be seen with CTE, along with much more serious symptoms, including:

• Suicidal thoughts among U.S. Veterans of the wars in Iraq and Afghanistan were studied to determine the incidence of suicide and suicidal thoughts following missile blasts. The study did find a correlation between CTE and suicidal thoughts, as well as actual suicide attempts.
• Substance abuse among military members with CTE is more common; the confusion, lack of impulse control, disorientation, and headaches caused by multiple traumatic brain injuries can lead to first-time drug use in an effort to feel “normal” again. If the individual likes how the drug makes him or her feel, it can be difficult to stop. Many injured military individuals use drugs in an attempt to self-medicate the emotional and psychological issues resulting from repeated trauma to the brain.
• Chronic depression has long been believed to be a common symptom of TBI, but among those with repeated head impacts—like those in our military troops—there can be difficulties with depression and cognitive functioning years, or even decades, later. While depression symptoms increased with a history of TBI alone, the highest level of depression symptoms was seen among those with repeated head impacts, particularly those who lost consciousness for any length of time.
• Brain fog is also seen among military members with CTE and is well-known as being one of the most common symptoms of a concussion. Brain fog can include trouble concentrating, difficulty learning or remembering new information, or an overall “slowness” in thinking. For some, brain fog occurs immediately following a traumatic brain injury or concussion. For others, it can occur weeks—or even months—later as the brain attempts to adapt to the dysfunction resulting from the concussion. Brain fog can come and go for some, while for others it remains constant.