Stress Injury
TBI and PTSD have been called the invisible wounds of war mainly because there are minimal physical deformities or obvious scars. These wounds are far from invisible, if one knows where to look. The evidence of the wounds is found in diminished quality of life, impaired occupational functioning, loss of family integrity, and myriad physical and cognitive impairments. These invisible wounds can impact the context of care. Combat deployments are associated with increased risk of posttraumatic stress disorder, depression, suicide, substance abuse, and eating disorders that impact between 12% and 23% of those deployed (Wells et al., 2011). Prevalence rates of mental disorder diagnoses do not capture the broader range of mental health impact that is associated with the military occupation that includes combat deployments; non-combat and humanitarian operations; family separation for training; and international peace keeping roles and reintegration challenges for service members, their families, and military communities. The broader context of behavioral health impact associated with military service can include stress reactions such as impaired sleep, cognitive functions, and relationships; and drug use (SAMSHA, 2012).
To address broader issues of behavioral health impact versus focusing on impairment, the military services developed various programs that focused on stress injury and resilience. These programs were consistent with individual military branch culture. Initially, stress injuries were referred to as combat and operational stress reactions (COSR) or injuries (COSI). Part of the goal to shift the discourse toward injury was to decrease diagnostic stigma, while increasing recognition that stress injuries were similar to physical injuries in needing immediate care to reduce risk of further harm. Nurses working with service members, veterans, and families need to listen for and be ready to use the concept of stress injury. Stress injuries are defined as:
More severe and persistent distress or loss of functioning caused by disruptions to the integrity of the brain, mind, or spirit after exposure to overwhelming stressors. Stress injuries are invisible, but literal, wounds caused by stress, but, like more visible physical wounds, they usually heal, especially if given proper care (Figley & Nash, 2007; USMC & USN, 2010, p. 1–3).