Iatrogenic Risk in the Management of Mild Traumatic Brain Injury among Combat Veterans: A Case Illustration and Commentary

Abstract

The assessment of mild traumatic brain injury (mTBI) among combat veterans of the Iraq and Afghanistan wars is a major challenge. Recently, clinicians within the United States Veterans Administration Health System have expressed concern for potential iatrogenic disability related to outreach efforts to identify veterans with possible mTBI. We describe a veteran with a history of mTBI sustained during combat who underwent repeated examination for cognitive symptoms reportedly due to mTBI, and with variable descriptions of severe peri-trauma characteristics attributed to blast exposure over multiple assessments. Repeat neuropsychological (NP) testing indicated, in general, minimal cognitive impairment and probable invalid performance on testing (e.g., poor effort). The consensus conclusion of several NP examinations attributed his cognitive complaints to psychiatric disturbance, including posttraumatic stress disorder, rather than brain dysfunction. Despite this, the veteran’s treating medical practitioners continued to infer mTBI as a source for his cognitive complaints and self-reported disability. The repeated reassessment of cognitive function purportedly attributable to mTBI appeared to reinforce for the veteran an erroneous self-perception of permanent and severe brain damage, a process fostered by practitioner misunderstandings regarding the nature and trajectory of expected positive outcome from a single concussion. This case illustrates potential iatrogenic risk in encouraging an erroneous perception of being brain damaged among combat veterans with cognitive complaints. Common pitfalls in the misdirected clinical management of these veterans are explored.