Post-Traumatic Stress Disorder (PTSD) and TBI

Kyle Haggerty, Ph.D.

Learning Objects• What is Brain Injury• What is PTSD• Statistics• What to Rule Out• PTSD and TBI• Treatment• Case Study

What is Brain Injury

Traumatic Brain Injury

• Traumatic Brain Injury (TBI): cerebral damage that occurs after birth, and is not directly related to a developmental disorder or a progressive damaging of the brain. Traumatic brain injury refers to a specific form of acquired brain injury that is the result of a sudden trauma.

Physical CausesBruising/Bleeding, Tearing, Swelling, Open/Closed injuries

Common Symptoms

• Headaches• Memory Deficits • Word Finding Difficulty• Fatigue• Changes in Emotion• Changes in Sleep• Impulsiveness • Concentration

Memory• Immediate Memory

– Not a Common Complaint• Short Term Memory

– Most Common Deficit in TBI• Long Term Memory

– Missing details due to STM loss• Retrograde Amnesia

– Time before injury • Anterior grade Amnesia

– Immediate time following injury

Chronic Pain

• Headaches

• Spinal Cord Injuries

• Ineffectiveness of Pain Medication

Overload

• Brought on by large crowds, lots of noise, or information presented too quickly.– Inability to process external

environment– Fatigue – Rise in emotions

Emotions

• Emotions can become flat or amplified. – Lack of inhibition– Trouble analyzing social situations

• Difficulty with facial expression or tone of voice

Language/Word Finding

• Aphasia – Circumlocution– Hand Gestures– Tip of the tongue

• Common due to anatomy of skull

TBI and Mental Illness

• Prevalence rates for psychiatric disorders are high after TBI.– Depression rates have been

reported in 14 to 77% of patients– Substance abuse 5 to 28%– PTSD 3 to 27%– Other anxiety disorders 3 to 28%

What is PTSD

Overview• Posttraumatic stress disorder (PTSD) is an anxiety disorder that

a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror.

• The dominant features of posttraumatic stress disorder are emotional numbing (i.e., emotional nonresponsiveness), hyperarousal (e.g., irritability, on constant alert for danger), and reexperiencing of the trauma (e.g., flashbacks, intrusive emotions).

• PTSD is as an anxiety disorder. Anxiety disorders cover several different forms of abnormal, pathological anxiety, fears, phobias and nervous conditions that may come on suddenly or gradually over a period of several years, and may impair or prevent the pursuing of normal daily routines.

Diagnosis Criteria for PTSD• Criteria A

• 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

Continued

• Criteria 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 that symbolize or resemble an aspect of the event

Continued

• Criteria 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 or participation• Feeling detached or estranged

Continued Some More

• Criteria D• Persistent symptoms of increased arousal by 2 or more:

• Difficulty falling or staying asleep• Irritability or outbursts of anger• Difficulty concentrating• Hypervigilance• Exaggerated startle response

• Criteria E • Duration for more than 1 month

Statistics

Prevalence• The National Comorbidity Survey Replication

(NCS-R) estimated the lifetime prevalence of PTSD among adult Americans to be 6.8%

• Current past year PTSD prevalence was estimated at 3.5%

• The lifetime prevalence of PTSD among men was 3.6% and among women was 9.7%

• The twelve month prevalence was 1.8% among men and 5.2% among women

Veterans• The National Vietnam Veterans Readjustment Study (NVVRS)

conducted between November 1986 and February 1988, comprised interviews of 3,016 American Veterans selected to provide a representative sample of those who served in the armed forces during the Vietnam era

• The estimated lifetime prevalence of PTSD among these Veterans was 30.9% for men and 26.9% for women.

• Of Vietnam theater Veterans, 15.2% of males and 8.1% of females were currently diagnosed with PTSD at the time the study was conducted

• Recent conflicts• Prevalence of current PTSD was 13.8%

Caution• Since its inception PTSD has been embroiled in debate over

multiple issues• Major controversies about the diagnosis include the political

climate in which it was conceived (Herbert & Forman, 2005; McNally, 2004), the recent broadening of the definition of the traumatic event that is required to meet a diagnosis for PTSD, and that event’s questionable association with symptom manifestation

• Mol et al. (2005) found that PTSD symptoms were as commonly associated with life events such as an illness or problems at work as they were with events that meet Criterion A

• Terheggen, Stroebe, and Kleber (2001) reported that for Tibetans the most traumatic event was the witnessing of the destruction of religious signs

What to Rule OutSome of the disorders that must be ruled out when diagnosing PTSD include the following:

• Acute stress disorder (duration of up to 4 weeks)

• Adjustment disorder (less severe stressor or different symptom pattern)

• Mood disorder or other anxiety disorder (symptoms of avoidance, numbing, or hyperarousal are present before exposure to the stressor)

• Other disorders with intrusive thoughts or perceptual disturbances (obsessive compulsive disorder, schizophrenia, other psychotic disorder)

• Substance abuse or dependence disorder

• Chronic Personality Disorder

TBI and PTSD

Correlation Between PTSD and TBI

• Research suggests that PTSD is more likely following TBI• Incidence 13%-27%• Prevalence 3%-59%

(Bryant, 2000)

• Some researchers argued that PTSD following a head injury was not possible due to memory loss, but many of those hypotheses have not been supported by the data

Risk Factors for Developing PTSD Following a TBI

• Female• Avoidant • Lesions to the left temporal lobe• Pre-morbid depression or anxiety • Early symptoms of depression following the injury

Symptoms of TBI and PTSDPTSD Symptoms Mild TBI Symptoms

Memory Problems Memory Problems

Poor Concentration Poor Concentration

Depression Depression

Irritability Irritability

Sleep Difficulties Sleep Difficulties

Avoidance Headaches

Re-experiencing Symptoms Dizziness

Where Is the Difference?• All of the Criteria except for one are

frequently met by someone who suffered a significant head injury.• The exception is criteria B (Re-

experiencing the trauma)

PTSD

Cognitive Impairment

TBI

Treatment

Prolonged Exposure

• Treatment addresses two of the primary factors that maintain post-trauma symptoms: avoidance and unhelpful thoughts and beliefs

• Therapist explains that confrontation with distressing memories or situations:

• Facilitates emotional processing• Helps patient learn to better discriminate trauma reminders from the

trauma itself • Helps reduce excessive dear and gain realistic perspective on trauma• Reduces PTSD symptoms

• Two types of exposure: imaginal exposure and in vivo exposure

Continued

• Behavioral stress management is an important component of the therapy (e.g. breathing retraining)

• Construct In-Vivo Hierarchy

• Construct Imaginal Hierarchy

Other Treatments

• Cognitive Processing Therapy (CPT)

• Virtual Reality• Mindfulness • Preventive Treatment with

Benzodizapines

Case Study

Demographics

• 34 year old male• Married• Caucasian

Referring Question

• Was the patient experiencing post-concussive symptoms, or symptoms related to anxiety?

History• According to Mr.*****’s records, he enlisted in the Army in May

1995, and was active duty in the Army until 11/2005

• He did two tours in Afghanistan (11/2001 for six months, and 7/2003-4/2004)

• On 9/29/2004, the Veteran was exposed to a RPG explosion, in which he sustained hearing loss.

• Mr. ***** reports that he did not lose consciousness during the incident, but did notice a brief alteration in consciousness

• Following the injury he was able to return to his duties, and did not require hospitalization.

Continued• The Pt did report that he was in several fights during his time in the

military “where he was beat up.”

• Following his second deployment the Pt was diagnosed with PTSD.

• The Pt has been prescribed medication for the treatment of his PTSD (ongoing) (benzodiazepines)

Current Symptoms

• Mood

• The Pt reported that he was continuing to have difficulty leaving the house due to the anxiety he experienced

• He described experiencing significant symptoms of hypervigilance, which worsen when he was in a crowd.

• Due to these symptoms the Pt very rarely leaves his home, and has limited social contacts outside of his family.

Current Symptoms

• Attention/Memory

• Both the Pt and his wife reported that he was suffering from attention/memory deficits.

• He often forgot how to get to places while driving (such as the grocery store), and the birthdays of his children.

• The Pt reported that due to these symptoms, and because he would become distracted and engage in risky behaviors (e.g. inattentive lane changes, reported once beginning to take his seatbelt off and get out of a still moving vehicle), he no longer drove.

• The Pt reported fewer memory deficits when he remains in his home.

Current Symptoms• Headaches/Vestibular

• The Pt reported several physical symptoms, which included chronic headaches and dizzy spells.

• He did not identified any triggers to those symptoms, and felt they occurred somewhat randomly.

• Specifically, he did not feel the symptoms were related to bright lights, movement, noise, or posture (although the Pt did report that he found it difficult to tolerate background noise, which increased his agitation).

• The Pt had been treating his headaches with over the counter medication, which he used frequently, and may have been experiencing increased sensitivity to pain, due to his chronic use of the medication.

• He was prescribed topemax for his headaches, but reported a strong negative reaction where he “felt out of it,” and only took one dose of the medication.

Impressions

• The history provided by the Pt did not suggest that he had experienced significant post-concussive symptoms.

• The cognitive deficits the Pt reported suffering from appeared to be attention deficits, rather than impairments in primary memory.

• The level of psychological distress that he was reporting would be expected to produce this type of cognitive interference.

• While it was not possible to rule out the blast injury as a cause of the Pt’s symptoms, it appeared more likely that his severe PTSD symptoms were the cause of the cognitive symptoms.

Plan

• The Pt was encouraged to begin therapy with a provider who specializes in the treatment of PTSD.

• Prolonged exposure recommended as cognitive challenges could make cognitive based interventions less effective