Transcript TBI

Understanding Mild TBI and Mental Health
Concerns in military service members after
deployment
Presented by:
Lori Terryberry-Spohr, Ph.D., ABPP-CN
Madonna Rehabilitation Hospital
Brain Injury Program Manager
OBJECTIVES
• TBI in a combat environment/
Understanding blast related exposures
and injuries
• Understanding the similarities and
distinctions between the symptoms of
TBI and PTSD
Military and TBI
• Since October 2001, approximately 2.3 Million
US troops have been deployed to OEF and OIF
in Afghanistan and Iraq
• The impact of traumatic brain injury is felt
within each branch of the service
This Time Is Different
• 12% of deployed military are women
• 50% of deployed military are National Guard/Reserve
• Frequent re-deployment is new with this war (about 50%
of those serving have been deployed more than once)
• The level of communication between military service
members and those at home is dramatically increased
– Home front stress is cited as the #1 issue addressed by
mental health providers in theater
• Military personnel are going in and out of both the DoD
and VA systems because of going on and off duty
Slide provided by Marilyn Lash, Lash and
Associates Publishing
OEF/OIF: A New Type of War
Key Iraq wound: Brain trauma
by Gregg Zoroya
USA TODAY
March 2005
“A growing number of U.S. troops whose body armor
helped them survive bomb and rocket attacks are suffering
brain damage as a result of the blasts. It's a type of injury
some military doctors say has become the signature wound
of the Iraq war.”
• Current conflicts in Iraq and Afghanistan are
characterized by exposure to explosive blasts and
associated concussions / traumatic brain injury.
• Reasons for an increased rate of identified mild
brain injuries/concussions include:
– (1) increased awareness of traumatic brain injury
– (2) improved body armor and survivability
– (3) better systems for identification of TBI
Military and TBI
• 44% of US service members returning from
Afghanistan and Iraq reported some type of
difficulties following return from deployment
with many individuals reporting more than one
health condition
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TBI (19-23 percent)
PTSD (4-20 percent)
Depression (5-37 percent)
Alcohol Abuse (5-39 percent)
• (Institutes of Medicine, 2013)
Causes of Blast Injury
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Improvised explosive devices (IEDs)
Suicide bombers
Land mines
Mortar rounds
Rocket propelled grenades
Symptoms of Mild Traumatic
Brain Injury
• Physical
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Emotional
Headache
Dizziness
Balance problems
Nausea/Vomiting
Fatigue
Visual Disturbances
Sensitivity to
Light/Noise
Ringing in the ears
Alteration of taste or
smell
Weakness in one side
of the body
Seizures
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Cognitive
Anxiety
Depression
Irritability
Mood lability
Denial
Inappropriate behavior
Self-centeredness
Sexual dysfunction
Social isolation
• Slowed processing
• Decreased attention
• Poor Concentration
• Memory Problems
• Verbal dysfluency
• Word-finding
• Abstract reasoning
• Problems planning
• Poor judgment
• Perceptual problems
Course of Recovery
of mild TBI
–General Population
• Mild TBI symptoms are usually temporary
• Most resolve within a few weeks
• Persistent symptoms can be exacerbated
or maintained by other non-injury factors
• Multiple injuries (3+) are a risk factor for
prolonged recovery and long-term
symptoms
Course of Recovery
• Returning Service Members
– Mild TBI is strongly associated with PTSD and
physical health problems
– PTSD and depression appear to be mediators of
the relationship between MTBI and physical
health problems (Hoge et al, 2008)
– Blast injured personnel may experience greater
symptoms of PTSD
Course of Recovery
• Although there is no strong evidence that sequelae
of blast-related mild TBI are different from other mild
TBI, there are other factors that make the veteran
population unique and must be considered
– Conditions of deployment
– Post-Injury recovery variables
– Multi-system trauma
– Additional Exposures
Blast Injury
Are blast related MTBIs different than other MTBIs?
Can we apply current models to blasts?
– Limited studies on effects of primary blast waves
on human brain
– Pathophysiology of primary blast injuries may differ
from other mechanisms
– Current evidence does not suggest difference in clinical
outcomes
Course of recovery of
Symptoms after MTBI
• A small percentage will have persistent symptoms
– Prevalence of persistent symptoms varies from 7-33%
(Alexander, 1995; Binder et al., 1997; Iverson, 2005;
– Rimel et al., 1981)
• Repeat concussions lead to increased morbidity (Collins,
et al, Neurosurgery 2002)
– We do not know yet how this applies to repeat blast injury
• Educational interventions are effective in reducing
symptoms (Ponsford, et al. 2002)
Consequences of TBI
 Although TBI may result in physical impairment,
the most problematic consequences involve the
individual’s cognitive, behavioral and emotional
functioning.
 Negatively impact the rehabilitation process,
relationships, community reintegration, and return to
work
 These consequences are the most distressing to
family members/caregivers/society
Unresolving Cognitive Complaints
• Studies suggest that a small percentage of patients will
experience ongoing difficulties following a mTBI
• Current research suggests this may be related to untreated
comorbidities including vestibular disorders, visual processing
issues, cervicogenic headaches or psychological issues such as
anxiety or depression
• Recent research at MRH suggests that successful headache
management is one of the biggest predictors of return to
work
• If symptoms do not resolve in a timely manner,
multidisciplinary assessment and treatment is warranted to
determine what other factors may be contributing and their
appropriate treatment
General Treatments for TBI
• Education and support for the patient and family
– Written & verbal Patient Information
– Websites / resources www.biausa.org; www.dvbic.org
• Symptom Management/Meds
• Rest/Graded Return to duty
• Therapies and/or Rehab
• Prevention
Combat Stress and Mental Health
When a veteran returns from combat…
• Healthy Adjustment?
• Psychiatric Condition?
• Mild TBI?
• Combination of the Above?
Healthy Adjustment
• There are a range of normal, healthy reactions
to returning to home including:
– Excitement
– Relief
– Tension
– Stress
– Concern
– Combat Stress Reaction
• (National Center for PTSD)
Some Symptoms thought may continue or
exacerbate and cause significant interference with
daily living
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Post Concussion Symptoms/mild TBI
Anger or Aggressive Behavior
Depression
Suicidal Thoughts
Self-blame, Guilt and Shame
Alcohol and/or Drug Abuse
Post-Traumatic Stress Disorder
“The Silent Epidemic”
“The Invisible Wounds of War”
• Stress, depression, and TBI are invisible to the
eye
• They can often go undetected, unrecognized,
unnoticed
• They can affect mood, thought, and behavior
Post Traumatic Stress Disorder
• Known about for thousands of years but called by
different names
– WWIShell Shock
– WWII Combat Fatigue
– Post-Vietnam PTSD
• Many not diagnosed—only 40% of Veterans utilize
the VA system and many do not disclose their
veteran status unless asked
PTSD Diagnostic Criteria
• Exposure to a traumatic event in which both are present
– Experienced, witnessed, or confronted with event(s) that involved
actual or threatened death or serious injury to self or others
– Responded with intense fear, helplessness, or horror
• 3 Symptom Clusters
– Re-experiencing (e.g., recurrent intrusive images/thoughts)
– Avoidance & Emotional numbing (e.g., markedly diminished
participation in significant activities; feeling emotionally detached
from others)
– Arousal (e.g., difficulty sleeping; irritability; difficulty concentrating)
PTSD Diagnostic Criteria
• Symptoms present for more than 1 month
• Symptoms cause clinically significant distress or
impairment in social, occupational or other
important areas of functioning
• Symptoms can VARY in terms of Intensity and
Duration
What’s Unique about PTSD?
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Unwanted repeated memories of event
Flashbacks and blackouts
Avoidance of people, places, sights or sounds
Feelings detachment and emotional numbness
Shame about what happened and was done
Survivor guilt with loss of friends or comrades
Hypervigilance or constant alertness for threats
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Can PTSD and TBI coexist?
• Studies suggest that PTSD following TBI does occur,
but may be modified by the brain injury
• Intrusive memories are less common in individuals
who had a TBI and when they are present, are highly
predictive of PTSD
• PTSD is more likely in mild TBI than severe TBI
(Bombardier, C., et al. 2006. J Neuropsychiatry Clin Neurosci:
Posttraumatic Stress Disorder Symptoms During the First Six Months After
Traumatic Brain Injury: 18: 4: 501-508.)
It’s Complicated…
• Post Concussive symptoms are NOT specific to
concussion
• Diagnostic Overlap complicates diagnostic efforts
• Diagnostic Overlap also complicates research efforts
• Increases the need for an Interdisciplinary Approach
to assessment, treatment and rehabilitation
Overlap of PTSD &TBI Symptoms
PTSD
Flashbacks
Nightmares
Hypervigilance
Increased startle response
TBI
Cognition
Depression
Anxiety
Insomnia
Fatigue
Substance use
Headache
Nausea
Vertigo
Vision problems
Sensitivity to light or noise
Source: David E. Ross, M.D., Director, Virginia Institute of Neuropsychiatry, Clinical Assistant
Professor, Virginia Commonwealth University
How Does TBI and PTSD Overlap?
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Memory
Slowed processing
Organization
Planning
Poor judgment
Inability to multitask
Poor initiation
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
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Confusion
Easily distracted
Problem solving
Anger, irritability
Substance use
Anxiety
Insomnia
Fatigue
On the Homefront
What’s does TBI and/or PTSD look like at home?
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Why does he…
Why won’t he…
When will he…
How can he…
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Confabulation
Why does he say things that aren’t true?
Lying is deliberate deception and distortion of
truth.
Confabulation is compensation for short
circuited memory; believes is truth based on
faulty memory.
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Memory
Why can’t he remember?
Short term vs. long-term memory
Types of memory
episodic
events by time and place; what did yesterday
procedural
motor movement; riding bike, using computer
semantic
facts learned; phone #s, state capitals
retrograde
events before injury; wedding, graduation
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Initiation or Self-Starting
Why does he lie around all day?
Is it laziness, boredom,
depression or lack of initiation
“not motivated”
“doesn’t care”
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Distractibility
Why does he get so distracted?
• Jumps from one thing to another
• Can’t multitask
• Doesn’t finish anything
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Social Conversataions
Why does he interrupt conversations, go off on
tangents?
• Looks like
– Rudeness
– Uninterested
– Not in “sync”
• Memory and processing issue
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Self-centered
Does he say such hurtful things
• Egocentric
• Lack of empathy
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
What’s Different
with TBI and PTSD?
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Amnesia
• TBI
Loss of memory
»before = retrograde amnesia
»after = anterograde amnesia
LOC time determines label of severity of TBI
• PTSD Intrusive memories
flashbacks
blackouts
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Sleep
• TBI
Trouble falling asleep, staying asleep, or
waking early
Normal sleep patterns disrupted
• PTSD Hypervigilance
Nightmares and Flashbacks
Nightsweats
Sleep apnea
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Isolation
• TBI
Wants social contact
Misses friends, coworkers, peers
• PTSD
Self imposed isolation
Trigger avoidance
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Emotions
• TBI
Emotional lability
Tears to laughter
Mood swings
Intense emotions
• PTSD Emotional shutdown; numbness,
Feeling dead inside, little joy in life;
Loss of intimacy
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Anger
• TBIFrontal lobe syndrome
More irritable, quick temper, explosive
Stimuli overload
• PTSD Increased physical aggression
Danger of weapons
Overwhelming and persistent anger
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Sex and Sexuality
• TBI
Pituitary gland changes
Physical pain and positioning
Loss of interest
Faulty filter; disinhibited
• PTSD
Avoidance or constant demands;
Loss of intimacy
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Depression
• TBI
Most common psychiatric diagnosis
– close to 50%; higher with more severe
• PTSD Mild TBI most common and depression
second most common diagnosis after PTSD in
OEF and OIF veterans
– Stigma of mental health care for depression among
military
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Anxiety
TBI
Doesn’t get big picture
Disregards consequences of actions;
Compulsive rituals
PTSD
Overwhelming panic and anxiety.
Triggers or free floating anxiety
Cascade on thinking, reasoning, actions
Compulsive calling or messaging
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Trauma Talk
• TBI
Repetitive history of injury; TMI;
any willing listener
• PTSD Avoidance and reluctance to talk about
combat and trauma, poetry
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Substance Use
• TBI Highs quicker and more intense.
Increases risks of seizures
Slows reactions, affects cognition, alters judgment
Interacts with medications
Increases risk for another brain injury.
PTSD Self-medicating with alcohol and drugs.
Vets drink more heavily and binge more often.
Used to cope with and dull symptoms of PTSD and
depression, but creates further problems with
memory, thinking and behavior.
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Suicide
• TBI
• PTSD
Unusual in civilians with TBI.
Rising rates with OEF and OIF.
Guns weapon of choice.
Increased risk
with TBI, PTSD, chronic pain, depression
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Acceptance and Recovery –
is it possible?
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Moving forward not looking back
Rebalancing priorities
Finding peace
Changing expectations
Finding meaning in survival
Reshaping the future
Slide content provided by Marilyn Lash,
Lash and Associates Publishing
Questions