Traumatic Brain Injury and Post Traumatic Stress Disorder

1
Traumatic Brain Injury and Post Traumatic Stress
Disorder

• Meredith Melinder, Ph.D.
• Polytrauma/TBI Clinic Psychologist/Neuropsychologi
  st

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Presentation Objectives

• 1) Definition of Traumatic Brain Injury (TBI)
• 2) Criteria by which brain injury severity is
  rated
• 3) Expected recovery for individuals diagnosed
  with TBI
• 4) Definition of Post Traumatic Stress Disorder
  (PTSD)
• 5) Criteria by which PTSD is diagnosed
• 6) Examining the overlap between TBI and PTSD
• 7) What do we expect in terms of recovery for
  PTSD?
• 8) How may symptoms interfere in an academic
  setting? What can you do?

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TBI and Military

• It is estimated that 22 of all combat injuries
  from OIF/OEF/OND conflicts are brain injuries,
  compared to 12 of Vietnam related combat
  casualties.
• The primary causes of TBI in Veterans of Iraq and
  Afghanistan are blasts, blast related motor
  vehicle accidents, MVAs, and gunshot wounds.
• The co morbidity of PTSD, history of mild TBI,
  chronic pain and substance abuse is common and
  may complicate recovery from any single
  diagnosis.
• People with previous brain injuries may find that
  it takes longer to recover from their current
  injury.
• Source DOD and Veterans Brain Injury Center

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Definition of TBI

• A traumatically induced structural injury and/or
  a physiological disruption of brain function as a
  result of an external force that is manifested by
  at least one of the following
• Alteration in mental state or LOC
• Amnesia for the event (before or after)
• A focal neurological deficit
• VA/DOD EBP Guideline, 2009

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What a Head Injury May Look Like
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Brain Damage

• Congenital versus Acquired
• Congenital Present at the time of birth
• Acquired brain injury Occurs after birth Not
  the result of genetic disorder or birth trauma
• Atraumatic versus Traumatic
• Atraumatic Damage progress over time
• Traumatic Caused by an outside force that
  impacts the head hard enough to cause damage to
  the brain

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Brain Damage

• Outcome depends on
• Cause of the damage
• Area(s) of the brain damaged
• Extent/Severity of the damage

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How to Determine Level of TBI
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Glasgow Coma Scale
1 2 3 4 5 6
Eyes Does not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A N/A
Verbal Makes no sounds Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally N/A
Motor Makes no movements Extension to painful stimuli Abnormal flexion to painful stimuli Flexion / Withdrawal to painful stimuli Localized pain stimuli Obeys commands
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Potential Acute TBI Symptoms

• Somatic Symptoms Behavioral/Emotional Cognitive
  Symptoms
• Headache Depression Decreased Attention
• Fatigue Anxiety Decreased Memory
• Light/noise sensitivity Agitation Decreased
  New Learning
• Sleep disturbance Irritability Decreased
  Processing Speed
• Dizziness Impulsivity Decreased Executive
  functions
• Nausea/vomiting Aggression Decreased Awareness
• Vision problems
• Transient neurologic
• problems
• Seizures
• Balance problems
• VA/DOD EBP Guideline, 2009

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Expected Outcomes

• Brain Injury is NOT a progressive disease
• The effects of a TBI are most significant
  immediately following injury. Worsening symptoms
  over time are not TBI related
• In most cases, rapid improvement is seen over the
  days and weeks following injury

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Prognosis Concussion/Mild TBI

• Approximately 80 of TBI cases are Mild
• Rapid improvement is seen within 3 weeks.
• Most people return to normal functioning within 3
  months.
• Most people recover without any formal treatment.
  
• Approximately 10-15 of patients may develop
  chronic post concussive symptoms.

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Persistent Post Concussion Syndrome (PPCS)

• Post concussion syndrome is when symptoms
  continue for more than three months after the
  injury.
• As many of the symptoms in PCS are common to, or
  exacerbated by, other disorders, there is a risk
  of misdiagnosis.
• There is NO treatment for PCS itself. Symptoms
  can be treated.

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Lack of Specificity of PPCS

• Postconcussion-like symptoms are endorsed by
  depressed individuals (Iverson, 2006)
• Postconcussion-like symptoms are endorsed in
  healthy individuals (Iverson Lang, 2003)
• Also, endorsed by college students, chronic pain
  patients, and personal injury claimants
• Reattribution of normal symptoms to TBI
  (Mittenberg et al., 1992)
• Research has examined why some individuals
  continue to experience symptoms. Theories include
  personality factors, substance abuse, monetary
  compensation. Not related to positive imaging

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PrognosisModerate TBI

• Over 90 are able to live independently.
• Some individuals may require assistance with
  employment, financial management, and physical
  abilities.
• Many people can learn to compensate for their
  deficits.

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PrognosisSevere TBI

• Improvement may occur more slowly.
• Intensive rehab is recommended.
• Change will occur most rapidly in the first six
  months and will be expected through the first to
  two years.
• Potentially need a caregiver.
• Possible permanent disabilities.

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Expected Cognitive Outcomes after TBI
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Definition of Posttraumatic Stress Disorder

• PTSD is diagnosed after a person develops
  characteristic symptoms following exposure to one
  or more traumatic events.
• Symptoms include
• Intrusive symptoms (e.g., unwanted memories,
  dreams, flashbacks)
• Avoidance symptoms (e.g., memories, place,
  people, activities)

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PTSD symptoms continued

• Negative alterations in cognitions and mood
  (e.g., exaggerated negative beliefs, decreased
  interest, guilt, shame)
• Alterations in arousal (e.g., irritable behavior,
  hypervigilance, exaggerated startle, problems
  with sleep and concentration)
• Symptoms need to last more than a month
• Symptoms cause impairment in social, occupational
  or other areas of functioning

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Prevalence

• Projected lifetime risk for PTSD in general
  population is approximately 8.7
• Rates of PTSD are higher among those whose
  vocation increases the risk of traumatic exposure
  (e.g., police, firefighters, combat veterans)
• Different numbers have been referenced for those
  deployed to Operation Enduring Freedom and
  Operation Iraqi Freedom prevalence.
• Source National Center for PTSD and DSM 5

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• Of 496,800 veterans treated by VHA between 2004
  and 2009, Veterans with a diagnosis of PTSD (but
  not TBI) accounted for 21 percent (103,500) of
  the total.
• Those with a diagnosis of TBI (but not PTSD)
  accounted for 2 percent (8,700).
• Veterans with diagnoses of both PTSD and TBI
  accounted for about 5 percent (26,600).
• Post-deployment rates of PTSD for non-infantry
  units is 3 and 13-19 in infantry units.
• Sources Congressional Budget Office and Kok et
  al.

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Treatment for PTSD

• Many people naturally recover after experiencing
  trauma, and they therefore do not have a
  diagnosis of PTSD.
• However, if someone does have clinically
  significant symptoms interfering in their life
  there are effective treatments.
• Cognitive Processing Therapy
• Prolonged Exposure Therapy
• Medication Options

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Persistent Post-Concussive Syndrome and Post
Traumatic Stress Disorder

• PPCS BOTH PTSD
• -Headache -Intrusive Symptoms
• -Light/Noise sensitivity -Avoidance
• -Dizziness -Increased arousal
• -Memory problems -Negative Cognitions
• -Depression -Depression -Depression
• -Anxiety -Anxiety -Anxiety
• -Agitation - Agitation -Agitation
• -Irritability -Irritability -Irritability
• -Impulsivity -Impulsivity -Impulsivity
• -Aggression -Aggression -Aggression
• -Sleep problems -Sleep problems -Sleep
  problems
• -Decreased Concentration -Decreased
  Concentration -Decreased Concentration

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Impact on Academic Functioning

• Overall we expect people to be getting better
  with time.
• Residual effects of a moderate or severe TBI can
  interfere with cognitive functioning.
• Ongoing PPCS symptoms can interfere with
  cognitive functioning.
• Mental health symptoms can interfere with
  cognitive functioning.
• And decreased cognitive functioning can interfere
  with academic functioning and performance.

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However, most reports of cognitive problems are
normal

• Responsibility versus structure relationship
• Everyday memory/cognitive failures
• Noticed initially, then more frequently noticed
• Compounded by stress, misuse of substances,
  mental health diagnoses, etc.

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Reasonable Accommodations

• A neuropsychological assessment can help
  determine if the person has a diagnosable problem
  with learning, memory, attention, etc.
• A neuropsychologist can make specific
  recommendations about accommodations to help.
• Quiet testing environment
• Tutoring
• Getting lecture notes ahead of time
• If people are distractible, they should sit in
  the front of the classroom

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What can I do?

• If you are working with someone who reports
  attention or memory problems
• Write things down (bullet points)
• Talk slowly
• Ask them to repeat back what they heard so you
  can correct misunderstandings
• Allow them the opportunity to ask questions
• Provide a phone number should they think of
  questions later (suggest they program it into
  their phone, or give business card stapled to
  paper with notes)

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Where can a Veteran go for help?

• Enroll in VA
• Can Google for local VA location
• Report to local VA Eligibility Office
• Submit copy of DD214
• Schedule Primary Care Appointment
• Primary Care can referral to specialty
  departments such as TBI Clinic, Neuropsychology
  Clinic, Mental Health Clinic for further
  evaluation and treatment needs

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Conclusions

• TBI is a one-time diagnosis, not an ongoing
  diagnosis a history of TBI not I have TBI.
• TBI symptoms should improve over time, and with
  treatment if necessary.
• PTSD symptoms should improve over time and with
  treatment if necessary.
• Ongoing symptoms may interfere with school but
  difficulty in school is not necessarily due to
  these symptoms/diagnoses (also likely are stress,
  lack of sleep, everyday memory/attention
  failures, etc.).
• With support, students should be able to be
  successful which will build confidence.

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VA and Polytrauma Network Evaluations

• Nationwide Population
• Since April 2007, our country has screened over
  768,744 OIF/OEF/OND veterans for possible TBI.
  (76.2 screened negative for TBI).
• Approximately 108,807 completed detailed
  evaluation.
• 57.5 confirmed TBI diagnosis
• 42.5 TBI diagnosis ruled out

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Sources

• American Psychiatric Association. (2013).
  Diagnostic and statistical manual of mental
  disorders (5th ed.). Arlington, VA American
  Psychiatric Publishing.
• Congress of the United States Congressional
  Budget Office The Veterans Health
  Administrations Treatment of PTSD and Traumatic
  Brain Injury Among Recent Combat Veterans.
  February 2012
• Hoge, C.W., Castro, C.A., Messer, S. C., McGurk,
  D., Cotting, D.I., Koffman, R.L. (2004) Combat
  Duty in Iraq and Afghanistan, Mental Health
  Problems, and Barriers to Care. New England
  Journal of Medicine, 351, 13-22.
• Howe, L.L.S. (2009). Giving Context to
  Post-Deployment Post-Concussive Like Symptoms
  Blast-Related Potential Mild Traumatic Brain
  Injury and Comorbidities. The Clinical
  Neuropsychologist, 23, 1315-1337.
• Iverson, G.L. (2006). Complicated vs
  uncomplicated mild traumatic brain injury acute
  neuropsychological outcome. Brain Injury, 20,
  1335-1344.
• Iverson G.L., Lang, R.T. (2003) Examination of
  postconcussion-like symptoms in a healthy
  sample. Applied Neuropsychologist, 10, 137-44.
• Kok, B.C., Herrell, R.K., Thomas, J.L., Hoge,
  C.W. (2012). Posttraumatic Stress Disorder
  Assoiciated With Combat Service In Iraq or
  Afghanistan Reconciling Prevalence Differences
  Between Studies. The Journal of Nervous and
  Mental Disease, 200, 444-450.
• Mittenberg, W., DiGuilio, D.V., Perrin S.,
  Bass, A.E. (1992). Symptoms following mild head
  injury Expectation as aetiology. Journal of
  Neurology, Neurosurgery and Psychiatry, 55,
  200-204.
• Vasterling, J.J. Sullivan K.D. (2009). Mild
  traumatic brain injury and posttraumatic stress
  disorder in returning veterans Perspectives from
  cognitive neuroscience. Clinical Psychology
  Review, 29, 674-684.
• VA/DOD EBP Guideline, 2009
• http//www.ptsd.va.gov/professional/PTSD-overview/
  epidemiological-facts-ptsd.asp
• http//bianj.org/Websites/bianj/images/persistentp
  ostconcussivesyndrome.pdf