Sgt. Raleigh Heekin of Colorado was driving a Humvee through the winding streets of a small village in Anbar Province, Iraq, last fall when his vehicle hit an improvised explosive device (IED). Heekin lost consciousness for several minutes; when he awoke, he found himself in the middle of a nightmare.

Sgt. Heekin was the only one alive in the vehicle. One of his best friends-the company medic-was sitting next to him, the lower half of his body missing. Outside of the Humvee, another soldier lay dead against the front grill of the truck.

When I met Sgt. Heekin, he was lying on a gurney in a military hospital in Iraq. As he relayed his harrowing story, the telltale signs of a blast-related brain injury emerged. He recounted details of the event out of sequence. Trying to answer questions, he stalled as if the words were there, but he couldn't verbalize them.

Working to save his life, surgeons repaired Sgt. Heekin's mangled leg, and prepared him for the long flight to Germany, where he was stabilized and flown back to the States. At Walter Reed Army Medical Center in Washington, DC, Sgt. Heekin was administered the Military Acute Concussion Evaluation, a 15-minute neuropsychological evaluation that measures the potential and severity of a brain injury.

Doctors never informed Sgt. Heekin of the results, but advised him that he probably suffered from post-traumatic stress disorder (PTSD) from witnessing the horrific deaths of his friends.

During his recuperation, Sgt. Heekin grew labile and moody. He couldn't sleep through the night. It wasn't until he returned home, however, that Sgt. Heekin would see the harsher effects of his injury.

Co-occurring Conditions

The Department of Defense reports that since the global war on terror began, more than 25,000 members of the military have been wounded in action-and more than 20,000 have been diagnosed with PTSD. While the Department of Veterans Affairs has received criticism recently for the mental health treatment of veterans, the widespread impact of brain injury and PTSD is just beginning to be felt in the private sector.

As a brain injury case manager for the Neurologic Rehabilitation Institute at Brookhaven Hospital in Tulsa, OK, I've received a number of calls from veterans seeking help outside the VA system. Like Sgt. Heekin, they report changes in their abilities and cognition. They're unable to concentrate like before, or have trouble remembering routine tasks. They can't sleep through the night. In severe cases, they've started drinking heavily, and their spouses have reported abuse.

It's often easier for clinicians working with mild traumatic brain injuries (MTBIs) to identify the hallmark characteristics of PTSD. With an MTBI, a person can describe problems and symptoms with greater acuity, and generally has working insight into the condition.

On the other hand, people with a moderate to severe brain injury may manifest cognitive and behavioral problems that make identifying and treating co-occurring PTSD difficult. Many characteristics of PTSD mirror the cognitive and behavioral issues a person with a brain injury may experience.

A Perfect Storm

In veterans, the source of the trauma often involves recurring experiences of wartime trauma, or of the emergency lifesaving care they underwent. A military member's post-traumatic amnesia may alter an accurate depiction of the event, yet the incident may live on as a vivid memory, complete with physiological and emotional responses.

Along with re-experiencing the traumatic event comes a state of hyperarousal, which keeps the person linked to internal or external stimuli. Even the most ordinary occurrences-flickering lights, slammed doors, television noise-can trigger upsetting memories.

In a sense, the victim becomes stuck in a loop, re-experiencing the trauma and its disconcerting emotions.

Soon, he begins to suffer the secondary effects of a mental disorder. Social withdrawal, disconnection and irritability often plague PTSD survivors. Victims struggle to make sense of their trauma, and simultaneously grapple with controlling emotions.

From studying veterans of the conflicts in Vietnam, Iraq and Afghanistan, we've learned about the enormous burden of survivor guilt and, for some, the omnipresent thoughts of suicide and increased risk of substance abuse.

PTSD, coupled with TBI, represents a type of "perfect storm"?cognitive, psychological and behavioral factors can blend together, intensify and cause significant upheaval in the lives of the victim and the people around him.

TBI and PTSD in Rehab

At our facility we see many patients struggling with brain injury and PTSD. Often, the condition is manifested by uncontrolled rage attacks, or an addiction to the numbing effects of drugs and alcohol.

Sam, a 56-year-old shopkeeper who was beaten during a robbery at his store, speaks candidly of his all-consuming rage toward his assailant. It became so powerful that he couldn't stand being around other people, and often retreated to his apartment with blinding headaches that lasted for days. He'd immerse himself in alcohol and misuse prescribed medications to numb the pain.

With intense counseling and substance abuse treatment, Sam was able to move forward with cognitive rehabilitation, and gradually returned to independence.

He hopes to get married someday, though he's still concerned about his memory loss and inability to control his anger. Sam's recovery is an up-and-down journey that likely requires several more years of outpatient counseling and medical support.

With more soldiers returning from Iraq and Afghanistan with brain injuries and PTSD, the need for programs capable of treating the psychological wounds associated with these conditions assumes critical importance.

The potential for PTSD exists at all levels of brain injury, and can take many forms. PTSD may pose an additional barrier to any cognitive, behavioral and psychological recovery. It may hide within the intricacies of cognitive problems, and it may be the trigger behind a sudden loss of behavioral control.

Whatever form it takes, PTSD must be included in the scope of a TBI rehab program?and not be left to psychological support following rehab. There's value in providing people with coexisting TBI and PTSD with a fully integrated program, merging the worlds of brain injury rehabilitation with the services required for the treatment of PTSD.

Coming Home

When I last spoke with Sgt. Heekin, he'd been living at home for several months. His wife says he's emotionally distant, distracted and inattentive. When a driver cut him off in traffic, he chased the car for miles and accosted the vehicle with his cane.

Though the Heekins' house was once a place for the neighborhood kids to congregate and play basketball, Sgt. Heekin now withraws into the garage. Once, his daughter crawled onto his lap, giggling-Sgt. Heekin stood up and left the room. He's easily overwhelmed by loud noises and bright lights.

Sgt. Heekin has yet to receive any brain injury rehabilitation from the VA-his leg always gets more medical attention than his head. As he begins to navigate the demands of supporting his family and continuing his military career, he will likely turn to a local health service for support.

Like many injured soldiers, Sgt. Heekin may initially present with complaints of the physical injury to his leg. He may even downplay or deny any lingering effects from a head injury.

It's the charge of rehab clinicians to establish a dialogue, to ask questions about a soldier's experiences and find out if he sustained injuries in close proximity to a blast. By paying attention to the effects we can't see with our eyes, clinicians are in a position to repay a small part of the high price these veterans have paid to their country.

Michael Mason is a brain injury case manager at the Neurologic Rehabilitation Institute at Brookhaven Hospital in Tulsa, OK. His book, Head Cases: Stories of Brain Injury and its Aftermath, will be released in April 2008. He can be reached at www.michaelpaulmason.com.