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Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Abby Carter & Elana Newman, Ph.D. The University of Tulsa

December 10, 2014

Learning Objectives

•  Describe the interaction of PTSD and mild traumatic brain injury and its diagnostic presentation.

•  Identify the clinical need to distinguish between these disorders.

•  Detail strategies that can be used to evaluate these conditions.

Mild neurocognitive disorder due to traumatic brain injury

The criteria are met for mild neurocognitive disorder. A. Evidence of a TBI—i.e., an impact to the head or other

mechanisms of rapid movement or displacement of the brain within the skull, with 1+:

1. Loss of consciousness.

2. Posttraumatic amnesia.

3. Disorientation and confusion.

4. Neurological signs

B. Neurocognitive disorder presents immediately after the TBI (or immediately after recovery of consciousness) and persists past the acute post-injury period.

(APA, 2013)

TBI Classification

(APA, 2013)

Severity GCS LOC PTA

Mild 13-15 <30 mins. <24 hours

Moderate 9-12 30 mins. – 24 hours

24 hours – 7 days

Severe 3-8 >24 hours >7 days GCS = Glascow Coma Scale LOC = Loss of consciousness PTA = Posttraumatic amnesia

mTBI is prevalent

•  The recent wars in Iraq and Afghanistan have led to increased attention towards mTBI (Vasterling et al., 2012)

•  mTBI is the most frequent TBI among both civilians & OEF/OIF soldiers & veterans (Carlson et al., 2011)

•  Possible causes of mTBI: •  Combat •  Blast •  Motor vehicle

accident •  Sexual assault

•  Non-sexual assault •  Domestic violence •  Contact sports •  Work injury •  Traumatic falls

mTBI and PTSD are highly comorbid

•  37- 44% of OEF/OIF veterans with mTBI have comorbid PTSD (Hoge et al., 2008; Tanielian & Jaycox, 2008)

•  PTSD more likely to develop following injury resulting in mTBI vs. non-TBI (Bryant et al., 2009)

•  mTBI as a risk factor for PTSD (Bryant et al., 2009)

•  Both may result from the same event (Carlson et al., 2010; Vasterling et al., 2012)

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Course of recovery from mTBI

•  Immediately following injury = Symptoms most severe

•  Days – weeks following injury = Substantial improvements

•  Complete resolution expected by 3-months post-injury

•  Not all who experience an mTBI will develop postconcussive syndrome or mild neurocognitive disorder

•  BUT…A history of repeated mTBIs may result in more persistent symptoms

(APA, 2013; Vasterling et al., 2012)

PTSD •  Symptoms of

intrusion (nightmares, flashbacks) •  Avoidance •  Guilt •  Shame

mTBI •  Headache •  Sensitivity to light •  Nausea •  Vision problems •  Dizziness •  Poor coordination/

balance •  Memory deficits

•  Depression •  Anhedonia •  Anxiety •  Hyperarousal •  Sensitivity to noise •  Irritability •  Anger •  Impulsivity •  Trouble

concentrating/attention problems •  Fatigue •  Sleep disturbances/

insomnia

(APA, 2013; Carlson et al., 2010; Stein & McAllister, 2009; Vasterling et al., 2012)

Differential Diagnosis

•  Use careful questioning & structured diagnostic interviews

•  Look for symptoms unique to each condition

•  Consider symptom onset

•  Difficult to disentangle symptoms when: •  Both conditions are present

•  Onset coincides

•  Course is similar (e.g., delayed onset)

•  Remember other co-occuring conditions are also prevalent •  E.g., TBI increases risk of depression

(Carlson et al., 2010; Stein & McAllister, 2009; Vasterling et al., 2012)

mTBI may interfere with treatment of PTSD

•  Poor outcomes with structural brain abnormalities

•  Cognitive deficits may exacerbate symptoms

•  Greater symptom severity due to cumulative effect of overlapping symptoms

•  Deficits in inhibition and flexibility may hinder cognitive interventions •  Targeting distorted thinking

•  Inhibiting maladaptive thoughts

•  Sufficient flexibility necessary to re-appraise

(Carlson et al., 2010; Stein & McAllister, 2009; Vasterling et al., 2012)

PTSD may interfere with recovery from mTBI

•  Post-concussive symptoms tend to become worse with co-occurring PTSD

•  Stress hormones from PTSD may impede brain repair

•  Longer course of recovery

(Vasterling et al., 2012)

Complications for Assessment

•  Diagnosis for neurocognitive disorder needs standardizes assessments of cognitive function

•  Not much help for differential diagnosis

•  Neurological problems and psychological problems tend to show similar deficits •  Attention/concentration •  Working memory •  Memory encoding •  Executive functioning •  Information processing speed

•  Deficits are not etiologically specific

(Vasterling et al., 2012; Vasterling & Lippa, 2014)

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Best use of assessment

•  Neuropsychological testing may provide objective, performance based indicators

•  Ancillary measures of recovery

•  Formulating treatment plan

•  Monitoring progress

•  Rule out other conditions

(Vasterling et al., 2012)

Treatment recommendations

•  Multidisciplinary approach (Vasterling et al., 2012)

•  Psychoeducation (Basso & Newman, 2000)

•  Mneumonic tools to accommodate for cognitive difficulties (Basso & Newman, 2000)

•  Research support for cognitive-behavioral interventions •  Effectiveness for reducing symptoms and preventing onset of PTSD in patients

with Acute Stress Disorder and mTBI (Bryant et al. 2003)

•  Cognitive Processing Therapy effective for PTSD in veteran sample with history of mTBI (Chard et al., 2011; Davis et al., 2013)

Conclusions

•  Assessment and treatment of co-occurring PTSD and mTBI presents a variety of challenges to the clinician.

•  The diagnostic presentation is complex due to considerable symptom overlap and interaction.

•  Distinguishing between the two conditions is necessary for determining the best treatment approach.

Questions?

References American Psychiatric Association. (2013). Diagnostic and statistical manual for mental disorders (5th ed.) Washington, DC: author.

Basso, M.R., Newman, E. (2000). A primer of closed head injury sequelae in post-traumatic stress disorder. Journal of Personal and Interpersonal Loss, 5, 125-147.

Bryant, R. A., Creamer, M., O’Donnell, M. Silove, D., Clark, R., & McFarlane, A. C. (2009). Post-traumatic amnesia and the nature of post-traumatic stress disorder after mild traumatic brain injury. Journal of the International Neuropsychological Society, 15, 862-867. doi: 10.1017/S1355617709990671 

Bryant, R. A., Moulds, M., Guthrie, R., Nixon, R. D. (2003). Treating acute stress disorder following mild traumatic brain injury. American Journal of Psychiatry, 160(3), 585 – 587.

Carlson, K. F., Kehle, S. M., Meis, L. A., Greer, N., MacDonald, R., Rutks, I., Sayer, N. A., Dobscha, S. K., & Wilt, T. J. (2011). Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: A systematic review of the evidence. Journal of Head Trauma and Rehabilitation, 26 (2), 103-115. doi: 10.1097/HTR.0b013e3181e50ef1

Chard, K. M., Schumm, J. A., McIlvain, S. M., Bailey, G. W., & Parkinson, R. (2011). Exploring the efficacy of a residential treatment program incorporating cognitive processing therapy for veterans with PTSD and traumatic brain injury. Journal of Traumatic Stress, 24, 347-351. doi:10.1002/jts.20644

Davis, J.J., Walter, K.H., Chard, K.M., Parkinson, R.B., & Houston, W.S. (2013). Treatment adherence in cognitive processing therapy for combat-related PTSD with history of mild TBI. Rehabilitation Psychology, 58(1), 36-42. doi: 10.1037/a0031525

 

References (cont.)

Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L., Engel, C. C., & Castro, C. A. (2008). Mild traumatic brain injury in U.S. Soldiers returning from Iraq. New England Journal of Medicine, 358, 453 – 463. Stein, M. B., & McAllister, T. W. (2009). Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury. American Journal of Psychiatry, 166 (7), 768-776. Tanielian, T., & Jaycox, L. H., eds. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation; 2008. Vasterling, J. J., Bryant, R. A., & Keane, T. M. (Eds.). (2012). PTSD and Mild Traumatic Brain Injury. New York: Guilford Press.   Vasterling, J. J., & Lippa, S. (2014). Neurocognitive alterations associated with PTSD: Neuropsychological deficits, information-processing biases, and implications for mild traumatic brain injury. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.). Handbook of PTSD: Science and practice (2nd ed.). New York: Guilford Press.