When evaluating whether to grant veterans disability benefits for a traumatic brain injury (TBI), VA examiners tend to operate under the assumption that there is a direct correlation between how long the veteran was unconscious after their injury and the severity of the TBI. In reality, research suggests that a single concussion can cause lasting structural damage to the brain. A study published in the journal Radiology demonstrates that the brain undergoes a measurable loss of volume after a concussion. These volume changes are correlated with cognitive changes in memory, attention, and anxiety.
Changing Nature of Combat Injuries and TBI
The nature of military medical care and combat-related injury treatment has changed over time, due to multiple factors. Changes in combat arena weaponry, protective equipment, timing of evacuation into medical facilities, and advances in medical technology affect the nature of post-combat survivability for veterans. Soldiers with combat-related injuries that were previously fatal, are now getting more advanced medical care and receiving that care faster and in better-stabilized condition than in prior conflicts.
Consider all the injuries to military personnel during the Civil War that would not have been fatal if today’s medical science existed in the mid-1860s. According to the medical literature, among veterans from conflicts involving Afghanistan and Iraq, it is more common to have survivors of traumatic brain injury (TBI), and the wide range of medical problems associated with TBI, than in previous conflicts. The Department of Defense reports that in a tally from the years 2000 to 2017, approaching 400,000 military personnel were diagnosed with TBI. In fact, TBI was considered the “signature” injury for veterans from the Afghanistan and Iraq conflicts—although burn pit related illnesses may be eclipsing TBI.
The research results are interesting because mild traumatic brain injury or MTBI accounts for at least 75 percent of all traumatic brain injuries. This means that individuals suffering from what appear to be routine concussions may actually be suffering far more extensive structural brain damage than previously realized. Traumatic brain injury, even when mild, has a significant negative impact on recovering veterans. The term “mild” can be quite misleading and create difficulty for veterans trying to obtain benefits for real medical problems associated with “mild” TBI.
What determines whether a TBI is mild, moderate, or severe is also somewhat difficult to standardize. According to an in-depth review of the medical literature, TBI may be best rated using an assessment of the following factors: the score on the Glasgow Coma Scale, the presence/absence of loss of consciousness (LOC), the duration of LOC, and any abnormal brain imaging (whether CT scans or MRIs).
Rating TBI as “moderate” or “severe” is less challenging for medical professionals because the signs and symptoms are more graphic and obvious. Tragically, only a minority of veterans with this level of TBI return home and require immediate aggressive treatment.
Symptoms of TBI
The symptoms of a TBI include headaches, dizziness, memory loss, attention deficit, depression, and anxiety. Some of these symptoms can persist for months or years. The researchers found that even one year after a concussion, there was noticeable global and regional brain atrophy in a mild traumatic brain injury patient. The takeaway lesson from this is that a TBI does result in structural injury to the brain, even though it may not be seen on routine radiographs.
Traumatic brain injury, even when mild, has a significant negative impact on recovering veterans.
But when the criteria noted above are used to evaluate a veteran, a majority of veterans diagnosed with TBI are classified as “mild.” Specifically, a veteran can have no LOC and no abnormal imaging scans, yet still have a significant medical impact from a “mild” TBI. This is important to comprehend—because VA often denies TBI claims on the grounds that there is no radiographic proof or LOC.
A veteran should not be dissuaded from filing a claim for TBI just because he did not have LOC. While the residuals of mild TBI and related post-concussion syndrome may resolve, in some patients, they linger and cause long-term disability. This may be part of the medical reality of TBI injuries in veterans may be disregarded, misunderstood, or downplayed as they fight for the VA benefits they have earned from service.
The complexity of mild TBI cases cannot be overstated. First, the symptoms of mild TBI often overlap with other medical issues common in veterans, such as PTSD or depression, and can be difficult to distinguish. Complaints like headaches may be obvious, but less obvious symptoms such as irritability or difficulty concentrating are also correlated with mild TBI. To complicate things more, the medical literature indicates that veterans with TBI are at higher risk for developing PTSD and depression, which may be secondary to the TBI. These issues may be secondary to the TBI, but not fully manifest until months or even years later.
The complexity goes further when the medical literature reports that while the psychological issues of PTSD and depression related to combat are significant medical problems on their own, they are also related to veterans developing cardiovascular problems, obesity, high blood pressure, and abnormal cholesterol, which can lead to other health problems as well. The medical prognosis for a veteran who had a TBI is also influenced by what other medical problems they develop. A veteran suffering from a complex TBI situation needs an attorney advocate that has access to a highly qualified medical expert in order to assess the veteran’s medical records appropriately for issues involving TBI.
Traumatic brain injury has a complex landscape of related mental health problems and risk factors. TBI is regarded as a medical risk factor for tobacco use, alcohol misuse, and suicide. Even mild TBI has a considerable association with psychiatric problems, as noted in the medical literature.
According to the medical literature, a notable number of veterans with a history of TBI have major depression. Some studies show that more than half of the veterans in the VA system that have a diagnosis of TBI also have PTSD, which is closely associated with residual TBI symptoms. Sleep disturbances are a significant category of persistent long-term residual symptoms from TBI, and are sometimes missed as related to past in-service TBI. Sleep disturbances associated with TBI are varied, and include insomnia, excessive daytime sleepiness, nightmares, and broken sleep cycles According to the medical literature, insomnia may be more common in mild TBI than in more severe forms of TBI, and sleep disturbances may occur years after mild TBI. TBI is also associated with post-traumatic vertigo and dizziness.
In cases involving more than one TBI, it may be associated with changes in personality and behavior. Mild TBI is associated with double the risk for epileptic seizures for years after the TBI occurs. There are medical studies that show a higher risk of mortality in patients with a history of mild TBI, more than a decade after the mild TBI occurred!
There are many instances of cases where a veteran had TBI and also changes in personality and behavior.
Our client, Michael, illustrates how a veteran’s life can change following TBI. Michael suffered an in-service motor vehicle accident (MVA) and head trauma, which was well-documented in the record. Before the accident, Michael was an exemplary airman who performed his duties with aplomb. His performance reviews noted that he was recommended for a career in the Air Force. But after the accident, Michael manifested drastic changes in his personality, judgment, and mental and social functioning. The symptoms after the accident included substance misuse, which was not present at all prior to the head trauma. The conduct of Michael following the head injury was described in his service records as dependent, immature, impetuous, disorderly, and norm-violating. This stood in stark contrast with descriptions of him prior to the head trauma. Despite this evidence, the VA denied the claim on the grounds that Michael did not actually suffer a chronic injury to his brain. We hired several medical experts who properly understood that Michael exhibited classical symptoms of frontal lobe impairment directly attributable to the in-service MVA and head trauma.
Additionally, our medical experts further explained that Michael had a secondary psychological condition as a result of the physical trauma to the brain. They explained that reduced blood flow to the frontal lobe of the brain as a result of trauma is a well-known cause of depression. As such, our experts opined that Michael suffered from depression due to the in-service head trauma. After many years of appeal, we finally won service connection for Michael. If it was not for multiple medical experts that properly understood TBI, Michael may never have realized victory in his case. Another way of looking at Michael’s case, as it manifested to his friends and family, is that he had a trauma-induced personality change. This is how most family members experience a veteran’s TBI. It often comes across as if the veteran is a totally different person.
Secondary Issues Caused by TBI
Many issues may occur secondary to a TBI and would be considered service-related if the TBI was properly diagnosed—although the true TBI may not be recognized for what it is and “missed.” The medical issues, mental health problems, or sleep problems that occurred because of the TBI may also be “missed.” The medical literature shows that initial screening of veterans for mental health problems, shortly after a veteran’s return, will frequently miss many cases of mental health issues (“missed” diagnosis). Moreover, even if the TBI symptoms are discovered, properly characterized, and recorded in a medical exam, they may not be correctly found to be due to a TBI and may be misdiagnosed as something else (“misdiagnosis”). This creates many problems for veterans that are applying for benefits that are legitimately linked to TBI from their time in service.
In sum, veterans who seek assistance with their medical problems related to mild TBI need an informed advocate who can help them address these issues, along with skilled medical experts that have a thorough knowledge of the TBI medical literature. Good representation of the veteran’s claim for VA benefits can be tricky. For example, many veterans may be denied appropriate benefits if they do not have an obvious head injury associated with their TBI. However, the medical literature indicates that while TBI often occurs due to head injury from physical contact with shrapnel or explosive fragments, it also states that veterans can develop significant residuals from mild TBI without having any history of direct contact injury—or even LOC. This may seem to be a skeptical theory, often overlooked by the Board or Regional Office that may be deciding on the veteran’s benefits.
The Brain’s Anatomy and Head Trauma
Most laypeople know enough human anatomy to know the brain is seated within and protected by the skull. It would be easy and inaccurate to say that if the skull has not been fractured by a direct contact injury, the brain must be fine. The brain sits in liquid held around it by a membrane sac and the overlying skull. There is room for the brain tissue to move within the protective skull. Injury can occur if the brain is thrown against the skull with sufficient force. This may happen with a veteran exposed to a blast or explosion, a fall, or an MVA, without any object actually contacting the skull. Medical professionals categorize these kinds of brain injuries “coup/contrecoup” injuries that are caused by “acceleration/deceleration” of the brain within the skull. In these types of injuries, no direct contact with shrapnel or other objects is involved. Forces such as an explosive blast cause the brain to basically smash up against the back or front of the skull and cause TBI.
Injuries May Not Show Up on CT Scan
In addition to the damage done when the brain hits the skull, a second set of injuries occurs later, with the brain swelling or having chemical changes that affect the blood vessels. These types of changes caused by what is termed “secondary brain injury”, may or may not show up clearly as anatomical abnormalities on imaging such as CT scan or MRI. The problem here is a disturbance in normal brain function, not a change in the structure of the brain as it appears in a medical image. What is clear is that an evaluation of a veteran’s TBI requires more than simply looking at the initial event and what hit them in the head. Veterans deserve to be appropriately compensated for all the residuals of service-related TBI, even when there is no history of abnormal radiographic scans or direct hits to the head.
Our client William is an example of the gross inadequacy of the TBI evaluations many veterans receive, as well as the false belief by VA examiners and Regional Office raters, that a skull fracture is required for there to be a TBI. William suffered a blow to the head from a crowbar that required multiple sutures. When he came to us, he was already service-connected for the scars from this trauma - but not for the TBI or the psychiatric residuals. The records noted multiple lacerations and contusions on his head. A skull x-ray was negative for a skull fracture.
He had symptoms that included seeing flashing lights. The medical corps performed an eye exam, which was negative. Contrary to the medical standard of care, no brain scans were performed despite William being hit in the head and “seeing stars.” In fact, a tragic and grossly ridiculous aspect was that repeated eye exams were offered. Despite that, they continued to show that the issue was not with William’s eyes. Still, no further head imaging or brain scans were performed, as would have been appropriate. Yet, the VA based its denial of the TBI claim on the lack of a skull fracture. In fact, its own medical examiner gave the opinion that there was no TBI because of the absence of a skull fracture, and the examiner rendered this opinion in the face of an abundance of medical literature that indicates a skull fracture is not determinative of head trauma.
Again, to win William’s case, we hired a top-notch forensic medical expert with M.D. and Ph.D. degrees who was able to establish the indefensible position of the VA examiners and raters. Interestingly, the medical literature published by the VA itself contradicted their own position, which our experts brought to light. Finally, after years of appeal, the Board of Veterans Appeals finally granted William’s claim. William would not have been able to achieve this result without our assistance and our highly-qualified medical experts who understood TBI. The difference was our lawyers understood the medical issues surrounding TBI and were willing to spend their resources to hire such experts on behalf of William and others like him.
The 14 Most Common Reasons Why VA Denies TBI Cases
The bottom line is that veterans with service-related TBI are at high risk of missing out on benefits they should have been granted, when the following occur:
- The TBI occurs without loss of consciousness
- The TBI occurs without the direct impact of an object that hits the head and caused the head injury (acceleration/deceleration injuries)
- The TBI occurs with a closed head injury (skull is intact)
- The TBI occurred due to chemical disruption of brain function (secondary brain injury) without obvious structural changes to the brain (“normal” CT scans and MRIs)
- The TBI is not properly assessed or diagnosed in service when it occurs – missed diagnosis
- The symptoms of TBI are noticed and recorded in medical records, but they are confused with unrelated mental health problems - misdiagnosis
- The TBI is diagnosed with the category of “mild,” but the term “mild” traumatic brain injury is misunderstood and downplayed by VA adjudicators (it’s still a brain injury!)
- The TBI causes mental health problems that are not properly assessed as secondary to the TBI
- The TBI causes other medical problems such as cardiovascular issues that are not properly assessed as secondary to the TBI
- The medical/mental health problems secondary to TBI are there but missed specifically on the exam done upon leaving military service
- The medical or mental health problems secondary to TBI show up months or years after the TBI
- The medical or mental health problems secondary to TBI show up after active military service
- The TBI causes medical/psychiatric issues such as alcohol misuse, tobacco use, or suicidality that are not properly assessed as secondary to the TBI
- The TBI and secondary medical issues negatively affect the veteran’s overall medical prognosis, and this is not properly assessed, resulting in a lower overall rating for the veteran
There are many pitfalls related to veterans getting proper benefits for service-related brain injuries, especially with the most common “mild” TBI, that many veterans miss out on benefits they are entitled to. It takes a highly informed legal advocate with a strong team of knowledgeable medical experts to dissect the complexity of these cases, and properly defend veterans’ rights and benefits. With the proper analysis and logical breakdown, backed by strong references to current medical standards, many of these cases can be turned around to the veteran’s benefit and changed into successful compensation for veterans and their families.
The practical effects of the medical literature are that traumatic brain injuries can cause significant problems years later, even though there may not be any routine clinical imaging to support it. We have a client who suffered a traumatic brain injury during his time in the service (car accident where his head went through the front windshield), and he developed a psychotic disorder roughly 20 years after the injury. So, we know that there can often be a lag time between when the TBI occurs and when serious problems develop. In addition, we have veteran clients who had multiple traumatic brain injuries in service and then later became delusional. The scary thing is that their delusional disorder did not manifest until several years after their TBI. How many psychiatric disability cases exist today as a result of a head injury that happened many years ago? In short, anybody suffering from serious psychiatric problems, such as psychotic and delusional disorders, should carefully consider whether they suffered a TBI during service.
Accordingly, the connection between the TBI and later psychosis is often missed because of the time delay between the injury and symptoms of long-term damage. Certainly, it is a standard operating procedure for VA raters to deny claims when there is a lengthy hiatus between the events of service and the onset of a diagnosis or symptoms in the years following service. But in light of the research regarding a structural injury to the brain following traumatic brain injury, VA adjudicators must be more cautious about rejecting claims for veterans’ disability benefits associated with TBI.
Finally, VA disability advocates must look very carefully to determine if the structural injury to the brain has occurred after a TBI because injury to the brain can result in a whole host of problems, including mood disorders and neuroendocrine problems.
Case Study (TBI and Neuroendocrine Dysfunction “NED”)
In this case, our client, Daisy, served in the military in the early 1980s. While on active duty, she was involved in a motor vehicle accident. She was a passenger in a bus that collided with a tractor-trailer. She suffered head injuries as well as injuries to her back and lower extremities. The injuries put her in the hospital for about a week following the accident. She then developed classical signs of neuroendocrine dysfunction or “NED,” and we contended that the development of NED was due to the TBI.
Neuroendocrine dysfunction or NED refers to a variety of conditions caused by imbalances in the body's hormone production that are directly related to the brain. The extent of those conditions will be varied depending on the patient. In this particular case, they included diabetes, hypertension, polycystic ovarian syndrome, hypertension, morbid obesity, and hypercoagulability disorder. In addition, our client contracted dysmetabolic syndrome.
Further complicating this client’s presentation is that about 24 years after the motor vehicle accident in service, she was diagnosed with multiple sclerosis or MS. The symptoms of her MS included optic neuritis, right-sided weakness, and paresthesias. But most important from our perspective in trying to service connect her MS was the vague symptoms reported in her medical records from service. But in retrospect, they seemed more like harbingers of the earliest symptoms of MS. Of significance was the fact that two years before her official diagnosis with MS, she experienced visual symptoms, and those symptoms eventually led to the definitive diagnosis. But she did experience many other symptoms intermittently when she was on active duty, and they were recorded in her medical records.
What’s also interesting about this is that she had a CT scan of her brain during service, which showed no abnormalities. This was a key factor in why the VA denied her claim. They looked at the normal CT scan as being determinative of the lack of a neurological disorder like MS. However; the VA did not realize that the CT scan is not the radiographic imaging of choice. At the time our client had her accident, there was no such thing as an MRI machine, which would be the radiographic technique of choice when assessing the presence of MS. However, at the time, CT could only rule out other possible abnormalities.
But turning to the neuroendocrine dysfunction, we were able to ascertain the onset of this condition during her military service. For instance, shortly after the accident, things changed for her drastically. In short, she experienced a dramatic negative transformation in her health. She developed hypertension, morbid obesity, diabetes mellitus, hyperlipidemia, endometriosis, deep vein thrombosis, and polycystic ovarian syndrome (PCOS). These were all endocrine-oriented conditions caused by hormonal disruptions. Her other impairments included lumbar Spondylosis and chronic headaches.
Being located on the underside of the frontal lobe of the brain, the pituitary gland is connected to the hypothalamus, and that is the primary link between the nervous system and the entire endocrine system. Hence, it is the regulator of the hormonal functions of the entire body. Approximately 15% of patients with TBI experience persistent symptoms, and 15% of those develop neuroendocrine dysfunction. Therefore, brain trauma associated with shearing forces can interfere with the normal production and regulation of hormones produced by the hypothalamus and the pituitary gland. The most common hormonal deregulations and deficiencies include thyroid, growth hormone, gonadal, adrenal, and prolactin.
As a result, these disruptions can cause a broad range of manifestations. In this case, our client entered military service at a height of five foot 9 inches and a weight that ranged from 140 to 150 pounds. By most measures, she appeared fit and capable of military service. Then, she suffered the motor vehicle accident in service where she injured her head. What follows next in her medical records is an onset of morbid obesity, diabetes, hypertension, and hyperlipidemia. Just two years after the motor vehicle accident, her weight had increased to 174 pounds. By the time she was diagnosed with MS, she weighed as much as 335 pounds.
In addition, while still on active duty, she developed gynecological issues, including irregular menstrual cycles, intermittent bleeding, and endometriosis. This eventually resulted in her having to have a partial hysterectomy, and pathological reports showed the presence of multiple ovarian cysts--several of which exceeded the diameter of two inches. Therefore, she met the criteria for polycystic ovarian syndrome.
Our client's life was transformed in a drastically negative way as a result of the head trauma in service. She suffered no skull fracture and no loss of consciousness. But the trauma had damaged the pituitary-hypothalamus axis in her body resulting in drastic hormonal changes that led to morbid obesity, diabetes, gynecological problems, and multiple sclerosis.
The VA continued to deny her claim on the grounds that there was a normal CT scan of the brain during service. The VA and its examiners never comprehended or even considered the possibility of NED. In order to win this case, we had to retain the services of a very skilled forensic neurologist who was able to carefully review the entirety of her medical records and service personnel file. He was able to conclude that her records indicated the presence of neuroendocrine dysfunction, which could be traced back to the TBI.
As a result of our skilled advocacy and the assistance of a forensic neurologist, we were ultimately able to prevail in this client’s case. As a result, we obtained her a 100% service connection and retroactive pay of around $250,000.
When a Psychiatric Claim Hinges on a TBI
Sometimes a claim starts out as a claim for service connection for a psychiatric disorder, and then the key piece of evidence that results in getting the claim granted is a TBI. The best way to illustrate this point is to give you an example from one of our actual case files. We had a client, Tom, who claimed that he had PTSD from a very elaborate covert mission in Vietnam. However, his service records indicated that he was a cook on board a Naval vessel and never set foot on the land mass of Vietnam. His story read like a Hollywood screenplay. And in fact, we noticed that his story started to appear after 1979, which was the year the motion picture Apocalypse Now was released. His story began to take on an uncanny resemblance to the screenplay of that motion picture.
In speaking with our client, he was funeral serious about the events that he described. His sincerity was so profound that I was left with the distinct feeling that this man really believed the story he was telling. His demeanor and the other factors about his presentation all indicated to me that this was a deeply held belief. But I could not reconcile the objective facts of the case with his story. Our client was severely disabled, and unable to work. His psychiatric condition was completely consuming his life, making him incapable of doing anything productive.
I knew that winning the claim for PTSD was completely out of the question. There was simply no way the VA was ever going to believe his story. So we began digging deeper into the medical files. In barely legible handwriting, we discovered an entry in his service medical records that notated a head trauma. We then began to wonder whether a psychosis or a delusional disorder can result from head trauma. So, we had our client examined by a forensic psychiatrist who, in fact, did diagnose him with delusional disorder, and he did relate that delusional disorder to the head trauma in service. We then recharacterized the claim from one involving PTSD to a psychiatric disorder involving delusional disorder.
Under CAVC case law, a claim for one mental disability also includes claims for other mental disabilities. The theory behind that holding is that veterans are lay people, and they make claims based upon the symptoms they are experiencing, and they are not considered competent to narrow the universe of possible diagnoses.
Our forensic psychiatrist then rendered the conclusion that the veteran had a TBI during service, which caused a delusional disorder. The delusional disorder, in turn, is what caused the veteran to actually believe he was living the story of the motion picture Apocalypse Now.
So, in this particular case, a claim for a psychiatric disability ended up being won because of our careful review of the record and our discovery of a traumatic brain injury. Further, our understanding of TBI and its wide-ranging residuals alerted us to the reality that his delusions may be related to the head trauma. The forensic psychiatrist that we hired confirmed our belief, which resulted in a grant of service connection and a retroactive award that exceeded $250,000 in retroactive pay.
Whenever a traumatic brain injury is involved, and the VA has denied the claim, it is highly advisable that a disabled veteran consults with an experienced veteran’s disability attorney to have his case properly evaluated. The range of possible symptoms is wide and can range from depression and anxiety to psychosis and personality changes, to even neuro-degenerative conditions like MS or neuroendocrine dysfunction. So, even if there was no skull fracture or LOC and even if VA is saying the TBI was only mild, there may still be an avenue to winning service connection.
There can often be a lengthy hiatus between when the TBI occurred and when the condition manifested. As a result, sometimes proving service connection can be difficult and almost impossible without the assistance of a skilled attorney and a team of forensic medical experts.