Jonathan Silver '75

Orli Etingin, MD

In the foreword to the second edition of Textbook of Traumatic Brain Injury, Bob and Lee Woodruff write about the devastating turn their lives took when Bob was gravely injured by a bomb blast while covering the Iraq War for ABC's World News Tonight.

"Severe TBI [traumatic brain injury] is obvious," they write. "But many brain injuries are hidden. Once the person heals on the outside, the damage remains on the inside, which is why the brain injured are often referred to as the 'walking wounded.' "

Jonathan M. Silver, one of three editors of the Textbook of Traumatic Brain Injury, has seen his share of TBI patients. A clinical professor of psychiatry at New York University School of Medicine and past president and fellow of the American Neuropsychiatric Association, Silver first became interested in the effects of brain injuries as a medical student. "I was drawn to learning more about the psychiatric manifestation of neurological disorders," he says. His residency at Columbia University with Stuart Yudofsky—now the D.C. and Irene Ellwood Professor and chair of the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine—introduced Silver to the field of neuropsychiatry, which deals with the treatment of mood and behavioral changes associated with brain disorders and injuries.

"Each year, more than 3 million people in the U.S. sustain a traumatic brain injury," says Silver. "These people often experience emotional, cognitive, and personality changes, such as increased aggression or irritability. While most TBIs are 'mild,' regardless of the severity, in many ways it is a hidden injury. Someone who experiences a TBI appears 'normal'—their sensory and motor functions are fine—but there are many consequences of TBI that often go unrecognized or untreated."

Since the first edition of the Textbook was published in 2005, Silver says, there has been growing awareness and research about TBI. The wars in Iraq and Afghanistan have resulted in thousands of soldiers returning to the U.S. with significant brain injuries often compounded by conditions such as post-traumatic stress disorder. "Individuals are now surviving injuries that would have previously been fatal," says Silver.

There also has been increased scrutiny of the long-term effect of brain injuries from sports such as football, ice hockey, and boxing, as well as growing evidence that mild concussions from automobile wrecks or accidental falls need to be taken more seriously than they have been.

Silver, who is a member of Duke's Kenan Institute for Ethics advisory board, says he is also intrigued by the ethical questions that arise when considering the dangerous impact of TBI on popular pastimes and leisure pursuits. "Can you make a sport safe? Should you?" he says. "Some people think that if football players didn't wear helmets or padding, the incidence of TBIs would go down, since players wouldn't be hitting each other so hard."

Ethical musings aside, Silver, who lives in New York, says that treating patients who have sustained brain injuries has made him wary of potentially dangerous activities, such as bike riding, and even using cell phones or texting while crossing the street. "The best treatment for traumatic brain injury is prevention," he says. "I've seen too many brain injuries to take unnecessary risks."

—Bridget Booher