TBI-PTSDTBI-PTSDG.I. WilsonG.I. Wilson

17 April 09 Version 17 April 09 Version

OutlineOutline Introduction Introduction  Background Background  Post Traumatic Stress Disorder (PTSD) and Post Traumatic Stress Disorder (PTSD) and

Traumatic Brain Injury (TBI) Traumatic Brain Injury (TBI) 1. What is TBI/mTBI? 1. What is TBI/mTBI?

2. What is PTSD2. What is PTSD3. Relationship Between PTSD and mTBI 3. Relationship Between PTSD and mTBI 

Evidence Based Approaches for Treatment Evidence Based Approaches for Treatment  Stigma, Institutional, Cultural Barriers  Stigma, Institutional, Cultural Barriers   Forensics and PTSDForensics and PTSD Bringing The War Home With Them  Bringing The War Home With Them  

  

Dr Bart Billings, a psychologist Dr Bart Billings, a psychologist and retired colonel, predicts the and retired colonel, predicts the mental wounds from PTSD and mental wounds from PTSD and traumatic brain injury will cost traumatic brain injury will cost the country the country "a couple hundred "a couple hundred billion dollars a year in care" billion dollars a year in care" for for many years. many years.

http://209.85.173.132/search?q=cache:Plf-CqxwlbUJ:cism-southwestohio.org/Bringing%2520the%2520Warhttp://209.85.173.132/search?q=cache:Plf-CqxwlbUJ:cism-southwestohio.org/Bringing%2520the%2520War%2520Home.doc+Dr+bart+billings+ptsd&cd=10&hl=en&ct=clnk&gl=us&ie=UTF-8%2520Home.doc+Dr+bart+billings+ptsd&cd=10&hl=en&ct=clnk&gl=us&ie=UTF-8

Couple of Hundred BillionCouple of Hundred Billion

Different OriginsDifferent Origins

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

What is Traumatic Brain Injury?What is Traumatic Brain Injury? Insult to brain caused by external physical forceInsult to brain caused by external physical force Produces diminished or altered state of Produces diminished or altered state of

consciousnessconsciousness Dazed, and confused for several minutesDazed, and confused for several minutes ““Knocked out”/rendered unconscious and/orKnocked out”/rendered unconscious and/or With memory gaps for some or all of the With memory gaps for some or all of the

immediateimmediate Can result in impairments in physical , cognitive, Can result in impairments in physical , cognitive,

behavioral, and/or emotional functioningbehavioral, and/or emotional functioning

What is Traumatic Brain Injury?What is Traumatic Brain Injury?

Occurs when a sudden trauma causes Occurs when a sudden trauma causes damage to the brain.damage to the brain.

Closed Head InjuryClosed Head Injury: Occurs when the : Occurs when the head suddenly hits an object or when an head suddenly hits an object or when an external force damages brain tissue. external force damages brain tissue.

Open Head InjuryOpen Head Injury: Occurs when an object : Occurs when an object pierces the skull and enters the brain.pierces the skull and enters the brain.

Symptoms: Mild, Moderate, Severe.Symptoms: Mild, Moderate, Severe.

TYPES OF HEAD INJURYTYPES OF HEAD INJURY

Closed Head InjuryClosed Head Injury Contusion/concussionContusion/concussion Coup/Contre-CoupCoup/Contre-Coup Cerebral edemaCerebral edema Diffuse axonal injuryDiffuse axonal injury Blast injuryBlast injury

Open Head InjuryOpen Head Injury

ConcussionConcussion

Diffuse Axonal InjuryDiffuse Axonal Injury

Coup-ContrecoupCoup-Contrecoup

Blast InjuryBlast Injury

Open Head –Penetrating

Associated Symptoms of TBIAssociated Symptoms of TBI

CognitiveCognitive Memory deficits, poor concentration, thinking Memory deficits, poor concentration, thinking

challengeschallenges

Emotional –BehavioralEmotional –Behavioral Depression, anxiety, irritability, mood swings, Depression, anxiety, irritability, mood swings,

impulsivity, apathy, agitation, aggressionimpulsivity, apathy, agitation, aggression

PhysicalPhysical Headache, dizziness, fatigue, noise/light Headache, dizziness, fatigue, noise/light

intolerance, sleep disturbanceintolerance, sleep disturbance

Mild TBI (mTBI)Mild TBI (mTBI)

There is no symptom that is unique to There is no symptom that is unique to or diagnostic of mTBIor diagnostic of mTBI

Many post concussion symptoms Many post concussion symptoms occur in normal healthy individualsoccur in normal healthy individuals

All symptoms/problems overlap with All symptoms/problems overlap with one or more other conditionsone or more other conditions

– – PTSD, depression, anxiety, chronic pain, PTSD, depression, anxiety, chronic pain, somatoform disorder, chronic health somatoform disorder, chronic health conditionsconditions

Mild TBI (mTBI) SymptomsMild TBI (mTBI) Symptoms

Headache.Headache. Confusion.Confusion. Light-headednessLight-headedness Dizziness.Dizziness. A person with mTBI may A person with mTBI may

remain conscious or remain conscious or may experience a loss may experience a loss of consciousness for a of consciousness for a few seconds or minutes.few seconds or minutes.

Blurred vision.Blurred vision. Tired eyes.Tired eyes.

Ringing in the ears.Ringing in the ears. Bad taste in the mouth.Bad taste in the mouth. Fatigue.Fatigue. Lethargy.Lethargy. Sleep pattern changes.Sleep pattern changes. Behavioural/mood Behavioural/mood

changes.changes. Trouble with memory, Trouble with memory,

concentration, concentration, attention, or thinking.attention, or thinking.

There are 2 types:

Acute PTSD1-3 mo

Chronic PTSD3 mo +

----------------------------------------- (Acute Stress Disorder occurs within 4 wks of stress event, lasts from 2 days to 4 wks)

What is PTSD?

Diagnostic Criteria for PTSD Diagnostic Criteria for PTSD (DSM IV TR)(DSM IV TR)

A. Exposed to traumatic eventA. Exposed to traumatic event

– – The person experienced, witnessed, or The person experienced, witnessed, or was confronted with an event involving was confronted with an event involving actual or threatened death, serious injury actual or threatened death, serious injury or a threat to physical integrity of self or or a threat to physical integrity of self or othersothers

– – The person’s response involved The person’s response involved intense intense fear, helplessness, or horrorfear, helplessness, or horror

Diagnostic Criteria for PTSD Diagnostic Criteria for PTSD

B. The traumatic event is B. The traumatic event is re-experiencedre-experienced in in

one or more of the following waysone or more of the following ways

– – RecurrentRecurrent images, thoughts or perceptions images, thoughts or perceptions

– – RecurrentRecurrent distressing dreams of the event distressing dreams of the event

– – Acting or feeling as if the Acting or feeling as if the event was event was recurringrecurring

– – Intense psychological distress OR Intense psychological distress OR physiologic reactivity at exposure to cues physiologic reactivity at exposure to cues

Diagnostic Criteria for PTSD Diagnostic Criteria for PTSD

C. Persistent avoidance of stimuli associated C. Persistent avoidance of stimuli associated with trauma and numbing as indicated by 3 with trauma and numbing as indicated by 3 or more:or more:

– – Avoiding thoughts, feelings, or discussion, Avoiding thoughts, feelings, or discussion, activities, places or people that bring back activities, places or people that bring back recollections; sense of foreshortened futurerecollections; sense of foreshortened future

– – Inability to recall; restricted affectInability to recall; restricted affect

– – Diminished interest Diminished interest

– – Feeling detached or estrangedFeeling detached or estranged

Diagnostic Criteria for PTSDDiagnostic Criteria for PTSD

D. Persistent symptoms of increased D. Persistent symptoms of increased arousal by 2 or more:arousal by 2 or more:– – Difficulty falling or staying asleepDifficulty falling or staying asleep

– – Irritability or outbursts of angerIrritability or outbursts of anger

– – Difficulty concentratingDifficulty concentrating

– – Hyper-vigilanceHyper-vigilance

– – Exaggerated startle responseExaggerated startle response

E. Duration for more than 1 monthE. Duration for more than 1 month

PTSD Associated FeaturesPTSD Associated Features Feelings of depressionFeelings of depression Feelings of guilt related to the traumaFeelings of guilt related to the trauma Feelings of shameFeelings of shame Thoughts of suicideThoughts of suicide

o Rate of suicide 6 times greater than Rate of suicide 6 times greater than individuals without PTSDindividuals without PTSD

o Highest rates of suicide attempts of all the Highest rates of suicide attempts of all the anxiety disordersanxiety disorders

Co-Morbidities: Depression, Substance Abuse, Co-Morbidities: Depression, Substance Abuse, Mood cycling, Panic and Anxiety SymptomsMood cycling, Panic and Anxiety Symptoms

PTSD and TBI/mTBIPTSD and TBI/mTBI PTSD is an anxiety disorder (psychological)PTSD is an anxiety disorder (psychological) TBI is a well defined injury recognized in the TBI is a well defined injury recognized in the

literature (physical) literature (physical) Literature Literature indicates personnel with mTBI indicates personnel with mTBI

likely to have symptoms suggestive of PTSDlikely to have symptoms suggestive of PTSD Neuropsychiatry Review (Mar 08) notes Neuropsychiatry Review (Mar 08) notes mTBI mTBI

among US soldiers leads to PTSD and among US soldiers leads to PTSD and physical health problemsphysical health problems

Mood symptoms are very common in Mood symptoms are very common in personnel with TBIpersonnel with TBI

Irritability, sleep disturbance, depression, Irritability, sleep disturbance, depression,

PTSD & Suicide PTSD & Suicide

““People with a diagnosis of PTSD are People with a diagnosis of PTSD are also at greater risk to attempt suicide.” also at greater risk to attempt suicide.”

Among people who have had a Among people who have had a diagnosis of PTSD at some point in their diagnosis of PTSD at some point in their lifetime, approximately 27% have also lifetime, approximately 27% have also attempted suicide.” attempted suicide.”

Tull, 2008, p. 1Tull, 2008, p. 1

Cognitive complaints: Cognitive complaints: “I have problems with short-term “I have problems with short-term memory” “I can’t concentrate” memory” “I can’t concentrate”

Looks good on neuro-psych testing/examLooks good on neuro-psych testing/exam Mild impairments in attention and information processingMild impairments in attention and information processing

Pain & somatic complaints: headaches, neck, back, Pain & somatic complaints: headaches, neck, back, jointsjoints

Disrupted sleep, fatigueDisrupted sleep, fatigue Wife: Wife: “He’s not the same, forgets things, flies off the “He’s not the same, forgets things, flies off the

handle, something is definitely wrong with him. You handle, something is definitely wrong with him. You need to fix him.” need to fix him.”

Financial, housing, transportation, legal stressorsFinancial, housing, transportation, legal stressors Employment issuesEmployment issues Missed appointmentsMissed appointments

Patient Presentation: mTBI-PTSDPatient Presentation: mTBI-PTSD

Clinical Presentation Overlapping Symptoms Clinical Presentation Overlapping Symptoms

Poor Concentration

Memory Impairment

Insomnia

Depression

Anxiety

Irritability

Flashbacks

Nightmares

PTSD

Dizziness

TBI

Headaches

Evidenced Based TreatmentEvidenced Based TreatmentPTSDPTSD

Cognitive Therapy Cognitive Therapy Exposure Therapy Exposure Therapy Stress Inoculation Testing Stress Inoculation Testing Eye Movement Eye Movement

Desensitization and Desensitization and Reprocessing Reprocessing

Imagery Rehearsal Therapy Imagery Rehearsal Therapy Psychodynamic Therapy Psychodynamic Therapy Group Therapy Group Therapy

PharmacotherapyPharmacotherapy Selective serotonin reuptake Selective serotonin reuptake

inhibitors (SSRIs) inhibitors (SSRIs) Monoamine oxidase inhibitors Monoamine oxidase inhibitors

TBITBI

Treatment for individuals who Treatment for individuals who have TBI includes rest, have TBI includes rest, prevention of further head prevention of further head trauma, management of existing trauma, management of existing symptoms, and education about symptoms, and education about mild TBI symptoms. mild TBI symptoms.

Unfortunately there are no Unfortunately there are no evidence-based clinical practiceevidence-based clinical practice guidelinesguidelines that address that address treatment of mild TBI (US treatment of mild TBI (US Government Accountability Government Accountability Office Feb 2008). Office Feb 2008).

Evidenced Based Treatment Evidenced Based Treatment and Co-Morbidityand Co-Morbidity

Currently “no empirically validated therapies Currently “no empirically validated therapies exist to treat co-morbid PTSD, depression, exist to treat co-morbid PTSD, depression, and post concussive disorders, which may be and post concussive disorders, which may be confounded by self-medicated alcohol confounded by self-medicated alcohol misuse, abuse, or dependence.”.misuse, abuse, or dependence.”.

Journal of Rehabilitation Research and Development, Lew et al., 2008 Vol.Journal of Rehabilitation Research and Development, Lew et al., 2008 Vol.

45 Number 3 p. xi — xvi. 45 Number 3 p. xi — xvi.

Veterans Affected By 3 Types of StigmaVeterans Affected By 3 Types of Stigma

Public stigmaPublic stigma: The notion that a veteran would be perceived as : The notion that a veteran would be perceived as weak, treated differently, or blamed for their problem if he or weak, treated differently, or blamed for their problem if he or she sought help. she sought help.

Self StigmaSelf Stigma: The individual may feel weak, ashamed and : The individual may feel weak, ashamed and embarrassed. embarrassed.

Structural StigmaStructural Stigma: Many service members believe their military : Many service members believe their military careers will suffer if they seek psychological services. careers will suffer if they seek psychological services. Although the level of fear may be out of proportion to the risk, Although the level of fear may be out of proportion to the risk, the military has institutional policies and practices that restrict the military has institutional policies and practices that restrict opportunities for service members who reveal that they have a opportunities for service members who reveal that they have a psychological health issue by seeking mental health services.psychological health issue by seeking mental health services.

Cultural FactorsCultural Factors Despite high rates of PTSD, African Despite high rates of PTSD, African

American, Latino, Asian, and Native American, Latino, Asian, and Native American veterans are less likely to use American veterans are less likely to use mental health services. mental health services.

This is due, in part, to increased stigma, This is due, in part, to increased stigma, absence of culturally competent mental absence of culturally competent mental health providers, and lack of linguistically health providers, and lack of linguistically accessible information for family members accessible information for family members with limited English proficiency who are with limited English proficiency who are providing support for the veteran. providing support for the veteran.

Forensics and PTSDForensics and PTSD

Simon has observed that Simon has observed that "no diagnosis in American "no diagnosis in American psychiatry has had such a profound influence on psychiatry has had such a profound influence on civil and criminal law"civil and criminal law" (Simon, 1995a, p. xv). (Simon, 1995a, p. xv).

In part, this is because PTSD seems easy to In part, this is because PTSD seems easy to understand. understand. It is one of only a few mental disorders It is one of only a few mental disorders for which the psychiatric Diagnostic and Statistical for which the psychiatric Diagnostic and Statistical Manual (DSM) describes a known causeManual (DSM) describes a known cause. In contrast, . In contrast, for example, a diagnosis of depression opens the for example, a diagnosis of depression opens the issue of causation to many factors other than the issue of causation to many factors other than the stated cause of action” (Sparr 2007)stated cause of action” (Sparr 2007)

Bringing The War Home With ThemBringing The War Home With Them

"Combat trauma is different from other kinds of trauma because "Combat trauma is different from other kinds of trauma because the horror of war – the trauma-inducing murderousness of it – the horror of war – the trauma-inducing murderousness of it – is inextricably linked with sacrifice, courage, honor, pride, and is inextricably linked with sacrifice, courage, honor, pride, and patriotism. patriotism.

And the trauma occurs in the context of profound personal And the trauma occurs in the context of profound personal loyalty. Some personnel will never experience bonds as loyalty. Some personnel will never experience bonds as intense as those formed with buddies fighting or dying beside intense as those formed with buddies fighting or dying beside them in desperation of battle or the confines of an exploding them in desperation of battle or the confines of an exploding Humvee.Humvee.

No other trauma is so intermingled with our deepest values and No other trauma is so intermingled with our deepest values and strongest fears of overwhelming loss. Is it any wonder that strongest fears of overwhelming loss. Is it any wonder that they have a hard time letting go?“they have a hard time letting go?“

www.legion.org/documents/ppt/ptsd_tbi.pptwww.legion.org/documents/ppt/ptsd_tbi.ppt

QuestionsQuestions

Primary Sources Primary Sources Dewleen G. Baker MDDewleen G. Baker MD

http://www.idahotbi.org/Portals/_AgencySite/pdf/DGB_Part%201_%20PTSD-TBI.pdfhttp://www.idahotbi.org/Portals/_AgencySite/pdf/DGB_Part%201_%20PTSD-TBI.pdf

Mary Lu MD and Adam NelsonMary Lu MD and Adam Nelson

http://www.biaoregon.org/docetc/conference/2009/PTSD%20and%20TBI%20ML%20andhttp://www.biaoregon.org/docetc/conference/2009/PTSD%20and%20TBI%20ML%20and%20AN.pdf%20AN.pdf

  

Charles W. Hoge, M.DCharles W. Hoge, M.D

www.roa.org/site/DocServer/RC_Conference-Mar23-2009-Short2.ppt?docID=14321 www.roa.org/site/DocServer/RC_Conference-Mar23-2009-Short2.ppt?docID=14321

  

Angela I Drake, Ph.D.Angela I Drake, Ph.D.

http://www.usmc-mccs.org/cosc/conference/documents/Presentations/Tuesdayhttp://www.usmc-mccs.org/cosc/conference/documents/Presentations/Tuesday%2012%20Aug/Drake%20-%20PTSD%20TBI.pdf%2012%20Aug/Drake%20-%20PTSD%20TBI.pdf

  

Stephen Jordan, PhDStephen Jordan, PhD

www.nasvh.org/confer_info/docs/Stephen-Jordan-Handout-8-08.ppt   www.nasvh.org/confer_info/docs/Stephen-Jordan-Handout-8-08.ppt  

Jason Hawley MDJason Hawley MD

crdamc.amedd.army.mil/behavh/resources/Traumatic%20Brain%20Injury.pptcrdamc.amedd.army.mil/behavh/resources/Traumatic%20Brain%20Injury.ppt