Transcript Traumatic Brain Injury Evaluation and Management of Soldiers

TBI-PTSD
G.I. Wilson
17 April 09 Version
Outline







Introduction
Background
Post Traumatic Stress Disorder (PTSD) and
Traumatic Brain Injury (TBI)
1. What is TBI/mTBI?
2. What is PTSD
3. Relationship Between PTSD and mTBI
Evidence Based Approaches for Treatment
Stigma, Institutional, Cultural Barriers
Forensics and PTSD
Bringing The War Home With Them
Couple of Hundred Billion
Dr Bart Billings, a psychologist
and retired colonel, predicts the
mental wounds from PTSD and
traumatic brain injury will cost
the country "a couple hundred
billion dollars a year in care" for
many years.
http://209.85.173.132/search?q=cache:Plf-CqxwlbUJ:cismsouthwestohio.org/Bringing%2520the%2520War%2520Home.doc+Dr+bart+billings+ptsd&cd=10&hl=en&ct=cln
k&gl=us&ie=UTF-8
Different Origins
Although PTSD and TBI have different
origins—PTSD is caused by exposure
to extreme stress, whereas TBI is
caused by blast exposure or other head
injury—they are closely related. People
with TBI are more prone to PTSD, and
many people with PTSD may have comorbid undiagnosed mild TBI.
What is Traumatic Brain Injury?



Insult to brain caused by external physical force
Produces diminished or altered state of
consciousness
 Dazed, and confused for several minutes
 “Knocked out”/rendered unconscious and/or
 With memory gaps for some or all of the
immediate
Can result in impairments in physical , cognitive,
behavioral, and/or emotional functioning
What is Traumatic Brain Injury?




Occurs when a sudden trauma causes
damage to the brain.
Closed Head Injury: Occurs when the
head suddenly hits an object or when an
external force damages brain tissue.
Open Head Injury: Occurs when an
object pierces the skull and enters the
brain.
Symptoms: Mild, Moderate, Severe.
TYPES OF HEAD INJURY

Closed Head Injury
Contusion/concussion
 Coup/Contre-Coup
 Cerebral edema
 Diffuse axonal injury
 Blast injury


Open Head Injury
Concussion
Diffuse Axonal Injury
Coup-Contrecoup
Blast Injury
Open Head –Penetrating
Associated Symptoms of TBI

Cognitive


Memory deficits, poor concentration, thinking
challenges
Emotional –Behavioral


Depression, anxiety, irritability, mood swings,
impulsivity, apathy, agitation, aggression
Physical

Headache, dizziness, fatigue, noise/light
intolerance, sleep disturbance
Mild TBI (mTBI)



There is no symptom that is unique to
or diagnostic of mTBI
Many post concussion symptoms
occur in normal healthy individuals
All symptoms/problems overlap with
one or more other conditions
– PTSD, depression, anxiety, chronic pain,
somatoform disorder, chronic health
conditions
Mild TBI (mTBI) Symptoms







Headache.
Confusion.
Light-headedness
Dizziness.
A person with mTBI
may remain conscious
or may experience a
loss of consciousness
for a few seconds or
minutes.
Blurred vision.
Tired eyes.







Ringing in the ears.
Bad taste in the mouth.
Fatigue.
Lethargy.
Sleep pattern changes.
Behavioural/mood
changes.
Trouble with memory,
concentration,
attention, or thinking.
What is PTSD?
There are 2 types:
 Acute PTSD
1-3 mo
 Chronic PTSD
3 mo +
----------------------------------------(Acute Stress Disorder occurs within 4 wks
of stress event, lasts from 2 days to 4 wks)
Diagnostic Criteria for PTSD
(DSM IV TR)
A. Exposed to traumatic event
– The person experienced, witnessed, or
was confronted with an event involving
actual or threatened death, serious injury
or a threat to physical integrity of self or
others
– The person’s response involved intense
fear, helplessness, or horror
Diagnostic Criteria for PTSD
B. The traumatic event is re-experienced in
one or more of the following ways
– Recurrent images, thoughts or
perceptions
– Recurrent distressing dreams of the event
– Acting or feeling as if the event was
recurring
– Intense psychological distress OR
physiologic reactivity at exposure to cues
Diagnostic Criteria for PTSD
C. Persistent avoidance of stimuli associated
with trauma and numbing as indicated by 3
or more:
– Avoiding thoughts, feelings, or discussion,
activities, places or people that bring back
recollections; sense of foreshortened future
– Inability to recall; restricted affect
– Diminished interest
– Feeling detached or estranged
Diagnostic Criteria for PTSD
D. Persistent symptoms of increased
arousal by 2 or more:
– Difficulty falling or staying asleep
– Irritability or outbursts of anger
– Difficulty concentrating
– Hyper-vigilance
– Exaggerated startle response
E. Duration for more than 1 month
PTSD Associated Features





Feelings of depression
Feelings of guilt related to the trauma
Feelings of shame
Thoughts of suicide
o Rate of suicide 6 times greater than
individuals without PTSD
o Highest rates of suicide attempts of all the
anxiety disorders
Co-Morbidities: Depression, Substance
Abuse, Mood cycling, Panic and Anxiety
Symptoms
PTSD and TBI/mTBI






PTSD is an anxiety disorder (psychological)
TBI is a well defined injury recognized in the
literature (physical)
Literature indicates personnel with mTBI
likely to have symptoms suggestive of PTSD
Neuropsychiatry Review (Mar 08) notes mTBI
among US soldiers leads to PTSD and
physical health problems
Mood symptoms are very common in
personnel with TBI
Irritability, sleep disturbance, depression,
PTSD & Suicide

“People with a diagnosis of PTSD are
also at greater risk to attempt suicide.”

Among people who have had a
diagnosis of PTSD at some point in
their lifetime, approximately 27% have
also attempted suicide.”
Tull, 2008, p. 1
Patient Presentation: mTBI-PTSD


Cognitive complaints: “I have problems with short-term
memory” “I can’t concentrate”
Looks good on neuro-psych testing/exam







Mild impairments in attention and information processing
Pain & somatic complaints: headaches, neck, back,
joints
Disrupted sleep, fatigue
Wife: “He’s not the same, forgets things, flies off the
handle, something is definitely wrong with him. You need
to fix him.”
Financial, housing, transportation, legal stressors
Employment issues
Missed appointments
Clinical Presentation Overlapping Symptoms
TBI
PTSD
Poor
Concentration
Flashbacks
Nightmares
Memory
Impairment
Headaches
Insomnia
Depression
Anxiety
Irritability
Dizziness
Evidenced Based Treatment
PTSD

Cognitive Therapy
Exposure Therapy
Stress Inoculation Testing
Eye Movement
Desensitization and
Reprocessing
Imagery Rehearsal Therapy
Psychodynamic Therapy
Group Therapy

Pharmacotherapy








Selective serotonin reuptake
inhibitors (SSRIs)
Monoamine oxidase inhibitors
TBI

Treatment for individuals who
have TBI includes rest,
prevention of further head
trauma, management of existing
symptoms, and education about
mild TBI symptoms.

Unfortunately there are no
evidence-based clinical practice
guidelines that address
treatment of mild TBI (US
Government Accountability
Office Feb 2008).
Evidenced Based Treatment
and Co-Morbidity

Currently “no empirically validated therapies
exist to treat co-morbid PTSD, depression,
and post concussive disorders, which may be
confounded by self-medicated alcohol
misuse, abuse, or dependence.”.
Journal of Rehabilitation Research and Development, Lew et al., 2008 Vol.
45 Number 3 p. xi — xvi.
Veterans Affected By 3 Types of Stigma

Public stigma: The notion that a veteran would be perceived as
weak, treated differently, or blamed for their problem if he or
she sought help.

Self Stigma: The individual may feel weak, ashamed and
embarrassed.

Structural Stigma: Many service members believe their military
careers will suffer if they seek psychological services.
Although the level of fear may be out of proportion to the risk,
the military has institutional policies and practices that restrict
opportunities for service members who reveal that they have a
psychological health issue by seeking mental health services.
Cultural Factors

Despite high rates of PTSD, African
American, Latino, Asian, and Native
American veterans are less likely to use
mental health services.

This is due, in part, to increased stigma,
absence of culturally competent mental
health providers, and lack of linguistically
accessible information for family members
with limited English proficiency who are
providing support for the veteran.
Forensics and PTSD

Simon has observed that "no diagnosis in American
psychiatry has had such a profound influence on
civil and criminal law" (Simon, 1995a, p. xv).

In part, this is because PTSD seems easy to
understand. It is one of only a few mental disorders
for which the psychiatric Diagnostic and Statistical
Manual (DSM) describes a known cause. In contrast,
for example, a diagnosis of depression opens the
issue of causation to many factors other than the
stated cause of action” (Sparr 2007)
Bringing The War Home With Them
"Combat trauma is different from other kinds of trauma because
the horror of war – the trauma-inducing murderousness of it –
is inextricably linked with sacrifice, courage, honor, pride, and
patriotism.
And the trauma occurs in the context of profound personal
loyalty. Some personnel will never experience bonds as
intense as those formed with buddies fighting or dying beside
them in desperation of battle or the confines of an exploding
Humvee.
No other trauma is so intermingled with our deepest values and
strongest fears of overwhelming loss. Is it any wonder that
they have a hard time letting go?“
www.legion.org/documents/ppt/ptsd_tbi.ppt
Questions
Primary Sources
Dewleen G. Baker MD
http://www.idahotbi.org/Portals/_AgencySite/pdf/DGB_Part%201_%20PTSD-TBI.pdf
Mary Lu MD and Adam Nelson
http://www.biaoregon.org/docetc/conference/2009/PTSD%20and%20TBI%20ML%20and%20A
N.pdf
Charles W. Hoge, M.D
www.roa.org/site/DocServer/RC_Conference-Mar23-2009-Short2.ppt?docID=14321
Angela I Drake, Ph.D.
http://www.usmcmccs.org/cosc/conference/documents/Presentations/Tuesday%2012%20Aug/Drake%20%20PTSD%20TBI.pdf
Stephen Jordan, PhD
www.nasvh.org/confer_info/docs/Stephen-Jordan-Handout-8-08.ppt
Jason Hawley MD
crdamc.amedd.army.mil/behavh/resources/Traumatic%20Brain%20Injury.ppt