TBI-PTSD G.I. Wilson 17 April 09 Version

1
TBI-PTSDG.I. Wilson17 April 09 Version
2
Outline

• Introduction 
• Background 
• Post Traumatic Stress Disorder (PTSD) and
  Traumatic Brain Injury (TBI) 1. What is
  TBI/mTBI?
• 2. What is PTSD3. Relationship Between PTSD
  and mTBI 
• Evidence Based Approaches for Treatment 
• Stigma, Institutional, Cultural Barriers  
• Forensics and PTSD
• Bringing The War Home With Them   

3
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?qc
achePlf-CqxwlbUJcism-southwestohio.org/Bringing
2520the2520War2520Home.docDrbartbillingsptsd
cd10hlenctclnkglusieUTF-8
4
Different Origins

• Although PTSD and TBI have different
  originsPTSD is caused by exposure to extreme
  stress, whereas TBI is caused by blast exposure
  or other head injurythey are closely related.
  People with TBI are more prone to PTSD, and many
  people with PTSD may have co-morbid undiagnosed
  mild TBI.

5
(No Transcript)
6
(No Transcript)
7
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

8
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.

9
TYPES OF HEAD INJURY

• Closed Head Injury
• Contusion/concussion
• Coup/Contre-Coup
• Cerebral edema
• Diffuse axonal injury
• Blast injury
• Open Head Injury

10
Concussion
11
Diffuse Axonal Injury
12
Coup-Contrecoup
13
Blast Injury
14
Open Head Penetrating
15
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

16
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

17
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.

18
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)

19
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 persons response involved intense fear,
  helplessness, or horror

20
(No Transcript)
21
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

22
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

23
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

24
PTSD Associated Features

• Feelings of depression
• Feelings of guilt related to the trauma
• Feelings of shame
• Thoughts of suicide
• Rate of suicide 6 times greater than individuals
  without PTSD
• Highest rates of suicide attempts of all the
  anxiety disorders
• Co-Morbidities Depression, Substance Abuse, Mood
  cycling, Panic and Anxiety Symptoms

25
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,

26
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

27
Patient Presentation mTBI-PTSD

• Cognitive complaints I have problems with
  short-term memory I cant 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 Hes 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

28
Clinical Presentation Overlapping Symptoms
TBI
PTSD
Poor Concentration Memory Impairment Insomnia
Depression Anxiety Irritability
Flashbacks
Headaches
Nightmares
Dizziness
29
Evidenced Based Treatment

• PTSD

• TBI

• 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

• 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).

30
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.

31
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.

32
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.

33
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)

34

• 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

35
Questions
36
Primary Sources

• Dewleen G. Baker MD
• http//www.idahotbi.org/Portals/_AgencySite/pdf/DG
  B_Part201_20PTSD-TBI.pdf
• Mary Lu MD and Adam Nelson
• http//www.biaoregon.org/docetc/conference/2009/PT
  SD20and20TBI20ML20and20AN.pdf
•  
• Charles W. Hoge, M.D
• www.roa.org/site/DocServer/RC_Conference-Mar23-200
  9-Short2.ppt?docID14321
•  
• Angela I Drake, Ph.D.
• http//www.usmc-mccs.org/cosc/conference/documents
  /Presentations/Tuesday201220Aug/Drake20-20PTSD
  20TBI.pdf
•  
• Stephen Jordan, PhD
• www.nasvh.org/confer_info/docs/Stephen-Jordan-Hand
  out-8-08.ppt  
• Jason Hawley MD
• crdamc.amedd.army.mil/behavh/resources/Traumatic2
  0Brain20Injury.ppt