New research findings indicate that some post-traumatic stress disorder cases may actually be the result of traumatic brain injury.

“We talk about PTSD being a psychiatric problem – how people respond to the horrors of war,” Dr. Daniel Perl told the New York Times. “But at least in some cases, no – their brain has been damaged.”

If these findings hold up – and they come from a very small study – it would indicate three similar but distinct forms of PTSD.

The first, of course, is the traditional PTSD, a form of persistent hyperarousal which begins when a soldier struggles to survive as others are trying to kill him, but which fails to lessen after he returns home amidst relative safety.

The second is what I call the wounded soul syndrome. It’s not about the fear of what others are trying to do to you, but the opposite: a sense of guilt over what you have done to your enemies (or failed to do for your friends).

Now Perl, a neuropathologist, has examined the brains of eight former soldiers who experienced concussive TBI and discovered that all had a distinct pattern of astrogial scarring which he believes could account for their neurological and psychiatric symptoms.

The implications are large because it suggests that some forms of PTSD may actually be the results of physical injury.

Perl and his colleagues at the Uniformed Services University of the Health Sciences in Bethesda, Md., examined the brains post-mortem of three military personnel exposed to acute blasts who died days or months after their injuries and five others with chronic blast exposure who died several months to years later.

All had a unique pattern of damage to the brain involving scarring in parts of the brain crucial for emotional and cognitive function, memory, sleep. That scarring was found in the subpial gilal plate, penetrating cortical blood vessels, grey-white matter junctions and structures lining the ventricals.

Perl compared their brains with 13 others – men with impact TBI such as found in athletes, opiate use or healthy controls – and found no indication of scarring.

“We believe this is the brain attempting to repair the damage produced during the exposure to the blast,” Perl told MedPage Today. “This pattern of scarring is exactly what biophysicists who study the effects of a blast wave on a biological structure would have predicted for the brain.”

And this scarring differs from brain injuries caused by impact TBI, the kind of injury seen among football players and boxers.  Blast TBI occurs when an explosion creates a wave of compressed air, traveling faster than the speed of sound, that inflicts intense pressure on the body, including the brain.

“It interacts with whatever it happens upon, including the service members who are standing in the range of the explosion,” Perl was quoted as saying. “”Others have shown that a blast wave can penetrate the skull and can be measured inside an intact skull. So it makes sense that it may damage the brain.”

Soldiers suffering from blast TBI often develop persistent neurological and psychiatric symptoms, including PTSD, headaches, sleep disturbance, and memory problems.

Perl’s study raises the possibility that better head protection for active-duty soldiers could deflect away some of the blast wave’s most damaging aspects. Dr. Ralph DePalma, a special operations officer in the office of research and development at the VA, told the New York Times that the prospect of better protection could be “the most important aspect of this paper.”

He added that soldiers should not assume they will automatically be damaged by blast waves. Genetics are believed to protect some combat soldiers against PTSD, so damage varies from individual to individual.

In the future, researchers will continue to study how the magnitude of a blast leads to scarring, how clinical damage might correlate to various behavioral and neurologic areas, and whether there is a way to determine these kinds of damages in living service members.

“Our study makes an important contribution in terms of understanding the nature of what a blast does to the brain,” Perl told MedPage Today. “But we need a great deal more work to better understand it.”

The New York Times Magazine summed it up best: “If Perl’s discovery is confirmed by other scientists – and if one of blast’s short-term signatures is indeed a pattern of scarring in the brain – then the implications for the military and for society at large could be vast. Much of what has passed for emotional trauma may be reinterpreted and many veterans may step forward to demand recognition of an injury that cannot be definitively diagnosed until after death. There will be calls for more research, for drug trials, for better helmets and for expanded vet care. But these palliatives are unlikely to erase the crude message that lurks, unavoidable, behind Perl’s discovery: Modern warfare destroys your brain.”