Traumatic Brain Injury Traumatic Brain Injury and Post Traumatic and Post Traumatic

Stress Disorder Stress Disorder

Meredith Melinder, Ph.D.Meredith Melinder, Ph.D.

Polytrauma/TBI Clinic Polytrauma/TBI Clinic Psychologist/NeuropsychologistPsychologist/Neuropsychologist

Presentation ObjectivesPresentation Objectives1) Definition of Traumatic Brain Injury (TBI)1) Definition of Traumatic Brain Injury (TBI)

2) Criteria by which brain injury severity is rated2) Criteria by which brain injury severity is rated

3) Expected recovery for individuals diagnosed with 3) Expected recovery for individuals diagnosed with TBITBI

4) Definition of Post Traumatic Stress Disorder 4) Definition of Post Traumatic Stress Disorder (PTSD)(PTSD)

5) Criteria by which PTSD is diagnosed5) Criteria by which PTSD is diagnosed

6) Examining the overlap between TBI and PTSD6) Examining the overlap between TBI and PTSD

7) What do we expect in terms of recovery for 7) What do we expect in terms of recovery for PTSD?PTSD?

8) How may symptoms interfere in an academic 8) How may symptoms interfere in an academic setting? What can you do?setting? What can you do?

TBI and MilitaryTBI and Military• It is estimated that 22% of all combat injuries from It is estimated that 22% of all combat injuries from

OIF/OEF/OND conflicts are brain injuries, compared to OIF/OEF/OND conflicts are brain injuries, compared to 12%12% of Vietnam related combat casualties.of Vietnam related combat casualties.

• The primary causes of TBI in Veterans of Iraq and The primary causes of TBI in Veterans of Iraq and Afghanistan are blasts, blast related motor vehicle Afghanistan are blasts, blast related motor vehicle accidents, MVAs, and gunshot wounds. accidents, MVAs, and gunshot wounds.

• The co morbidity of PTSD, history of mild TBI, chronic The co morbidity of PTSD, history of mild TBI, chronic pain and substance abuse is common and may pain and substance abuse is common and may complicate recovery from any single diagnosis. complicate recovery from any single diagnosis.

• People with previous brain injuries may find that it takes People with previous brain injuries may find that it takes longer to recover from their current injury. longer to recover from their current injury.

Source: DOD and Veterans Brain Injury CenterSource: DOD and Veterans Brain Injury Center

Definition of TBIDefinition of TBI

““A traumatically induced structural injury A traumatically induced structural injury and/or a physiological disruption of and/or a physiological disruption of brain function as a result of an external brain function as a result of an external force that is manifested by at least one force that is manifested by at least one of the following…”of the following…” Alteration in mental state or LOCAlteration in mental state or LOC Amnesia for the event (before or after)Amnesia for the event (before or after) A focal neurological deficit A focal neurological deficit

VA/DOD EBP Guideline, 2009VA/DOD EBP Guideline, 2009

What a Head Injury May Look What a Head Injury May Look LikeLike

Brain DamageBrain Damage

• Congenital versus Congenital versus AcquiredAcquired • Congenital – Present at the time of birthCongenital – Present at the time of birth• Acquired brain injury – Occurs after birth; Not Acquired brain injury – Occurs after birth; Not

the result of genetic disorder or birth traumathe result of genetic disorder or birth trauma

• Atraumatic versus Atraumatic versus TraumaticTraumatic• Atraumatic – Damage progress over timeAtraumatic – Damage progress over time• Traumatic – Caused by an outside force that Traumatic – Caused by an outside force that

impacts the head hard enough to cause impacts the head hard enough to cause damage to the braindamage to the brain

Brain DamageBrain Damage

• Outcome depends on:Outcome depends on:

– – Cause of the damageCause of the damage

– – Area(s) of the brain damagedArea(s) of the brain damaged

– – Extent/Severity of the damageExtent/Severity of the damage

How to Determine Level of TBIHow to Determine Level of TBI

Glasgow Coma ScaleGlasgow Coma Scale

1 2 3 4 5 6

Eyes Does not open eyes

Opens eyes in response to painful stimuli

Opens eyes in response to voice

Opens eyes spontaneously

N/A N/A

Verbal Makes no sounds

Incomprehensible sounds

Utters inappropriate words

Confused, disoriented

Oriented, converses normally

N/A

Motor Makes no movements

Extension to painful stimuli

Abnormal flexion to painful stimuli

Flexion / Withdrawal to painful stimuli

Localized pain stimuli

Obeys commands

Potential Acute TBI SymptomsPotential Acute TBI Symptoms

Somatic SymptomsSomatic Symptoms Behavioral/EmotionalBehavioral/Emotional Cognitive Symptoms Cognitive Symptoms

HeadacheHeadache DepressionDepression Decreased Attention Decreased Attention

FatigueFatigue AnxietyAnxiety Decreased Memory Decreased Memory

Light/noise sensitivityLight/noise sensitivity AgitationAgitation Decreased New Learning Decreased New Learning

Sleep disturbanceSleep disturbance IrritabilityIrritability Decreased Processing Decreased Processing SpeedSpeed

DizzinessDizziness ImpulsivityImpulsivity Decreased Executive Decreased Executive functionsfunctions

Nausea/vomitingNausea/vomiting AggressionAggression Decreased Awareness Decreased Awareness

Vision problemsVision problems

Transient neurologic Transient neurologic

problemsproblems

SeizuresSeizures

Balance problemsBalance problemsVA/DOD EBP Guideline, 2009VA/DOD EBP Guideline, 2009

Expected OutcomesExpected Outcomes• Brain Injury is NOT a progressive diseaseBrain Injury is NOT a progressive disease• The effects of a TBI are most significant immediately The effects of a TBI are most significant immediately

following injury. Worsening symptoms over time are following injury. Worsening symptoms over time are not TBI relatednot TBI related

• In most cases, rapid improvement is seen over the In most cases, rapid improvement is seen over the days and weeks following injurydays and weeks following injury

Prognosis: Prognosis: Concussion/Mild TBIConcussion/Mild TBI

• Approximately 80% of TBI cases are MildApproximately 80% of TBI cases are Mild• Rapid improvement is seen within 3 weeks. Rapid improvement is seen within 3 weeks. • Most people return to normal functioning within 3 Most people return to normal functioning within 3

months. months. • Most people recover without any formal Most people recover without any formal

treatment. treatment. • Approximately 10%-15% of patients may Approximately 10%-15% of patients may

develop chronic post concussive symptoms.develop chronic post concussive symptoms.

Persistent Post Concussion Persistent Post Concussion Syndrome (PPCS)Syndrome (PPCS)

• Post concussion syndrome is when symptoms Post concussion syndrome is when symptoms continue for more than three months after the continue for more than three months after the injury.injury.

• As many of the symptoms in PCS are common As many of the symptoms in PCS are common to, or exacerbated by, other disorders, there is a to, or exacerbated by, other disorders, there is a risk of misdiagnosis.risk of misdiagnosis.

• There is NO treatment for PCS itself. Symptoms There is NO treatment for PCS itself. Symptoms can be treated. can be treated.

Lack of Specificity of PPCSLack of Specificity of PPCS• Postconcussion-like symptoms are endorsed by Postconcussion-like symptoms are endorsed by

depressed individuals (Iverson, 2006)depressed individuals (Iverson, 2006)• Postconcussion-like symptoms are endorsed in Postconcussion-like symptoms are endorsed in

healthy individuals (Iverson & Lang, 2003)healthy individuals (Iverson & Lang, 2003)• Also, endorsed by college students, chronic pain Also, endorsed by college students, chronic pain

patients, and personal injury claimantspatients, and personal injury claimants• Reattribution of normal symptoms to TBI (Mittenberg Reattribution of normal symptoms to TBI (Mittenberg

et al., 1992)et al., 1992)• Research has examined why some individuals Research has examined why some individuals

continue to experience symptoms. Theories include continue to experience symptoms. Theories include personality factors, substance abuse, monetary personality factors, substance abuse, monetary compensation. Not related to positive imagingcompensation. Not related to positive imaging

Prognosis:Prognosis:Moderate TBIModerate TBI

• Over 90% are able to live independently. Over 90% are able to live independently. • Some individuals may require assistance Some individuals may require assistance

with employment, financial management, and with employment, financial management, and physical abilities. physical abilities.

• Many people can learn to compensate for Many people can learn to compensate for their deficits.their deficits.

Prognosis:Prognosis:Severe TBISevere TBI

• Improvement may occur more slowly. Improvement may occur more slowly. • Intensive rehab is recommended.Intensive rehab is recommended.• Change will occur most rapidly in the first six Change will occur most rapidly in the first six

months and will be expected through the first months and will be expected through the first to two years.to two years.

• Potentially need a caregiver. Potentially need a caregiver. • Possible permanent disabilities. Possible permanent disabilities.

Expected Cognitive Outcomes Expected Cognitive Outcomes after TBIafter TBI

Definition of Posttraumatic Definition of Posttraumatic Stress DisorderStress Disorder

• PTSD is diagnosed after a person PTSD is diagnosed after a person develops characteristic symptoms develops characteristic symptoms following exposure to one or more following exposure to one or more traumatic events. traumatic events.

• Symptoms include Symptoms include • Intrusive symptoms (e.g., unwanted Intrusive symptoms (e.g., unwanted

memories, dreams, flashbacks)memories, dreams, flashbacks)• Avoidance symptoms (e.g., memories, place, Avoidance symptoms (e.g., memories, place,

people, activities)people, activities)

PTSD symptoms continuedPTSD symptoms continued

• Negative alterations in cognitions and Negative alterations in cognitions and mood (e.g., exaggerated negative beliefs, mood (e.g., exaggerated negative beliefs, decreased interest, guilt, shame)decreased interest, guilt, shame)

• Alterations in arousal (e.g., irritable Alterations in arousal (e.g., irritable behavior, hypervigilance, exaggerated behavior, hypervigilance, exaggerated startle, problems with sleep and startle, problems with sleep and concentration)concentration)

• Symptoms need to last more than a monthSymptoms need to last more than a month• Symptoms cause impairment in social, Symptoms cause impairment in social,

occupational or other areas of functioningoccupational or other areas of functioning

PrevalencePrevalence• Projected lifetime risk for PTSD in general Projected lifetime risk for PTSD in general

population is approximately 8.7%population is approximately 8.7%• Rates of PTSD are higher among those whose Rates of PTSD are higher among those whose

vocation increases the risk of traumatic vocation increases the risk of traumatic exposure (e.g., police, firefighters, combat exposure (e.g., police, firefighters, combat veterans)veterans)

• Different numbers have been referenced for Different numbers have been referenced for those deployed to Operation Enduring those deployed to Operation Enduring Freedom and Operation Iraqi Freedom Freedom and Operation Iraqi Freedom prevalence.prevalence.

Source National Center for PTSD and DSM 5Source National Center for PTSD and DSM 5

• Of 496,800 veterans treated by VHA between 2004 and 2009, Veterans with a diagnosis of PTSD (but not TBI) accounted for 21 percent (103,500) of the total.

• Those with a diagnosis of TBI (but not PTSD) accounted for 2 percent (8,700).

• Veterans with diagnoses of both PTSD and TBI accounted for about 5 percent (26,600).

• Post-deployment rates of PTSD for non-infantry units is 3% and 13-19% in infantry units.

Sources: Congressional Budget Office and Kok et al.Sources: Congressional Budget Office and Kok et al.

Treatment for PTSDTreatment for PTSD• Many people naturally recover after Many people naturally recover after

experiencing trauma, and they therefore experiencing trauma, and they therefore do not have a diagnosis of PTSD. do not have a diagnosis of PTSD.

• However, if someone does have clinically However, if someone does have clinically significant symptoms interfering in their significant symptoms interfering in their life there are effective treatments.life there are effective treatments.• Cognitive Processing TherapyCognitive Processing Therapy• Prolonged Exposure TherapyProlonged Exposure Therapy• Medication OptionsMedication Options

Persistent Post-Concussive Persistent Post-Concussive Syndrome and Post Syndrome and Post

Traumatic Stress DisorderTraumatic Stress DisorderPPCSPPCS BOTH BOTH PTSDPTSD

--HeadacheHeadache --Intrusive SymptomsIntrusive Symptoms

--Light/Noise sensitivityLight/Noise sensitivity --AvoidanceAvoidance

--DizzinessDizziness --Increased arousalIncreased arousal

--Memory problemsMemory problems --Negative CognitionsNegative Cognitions

-Depression-Depression -Depression-Depression -Depression-Depression

-Anxiety -Anxiety -Anxiety -Anxiety -Anxiety -Anxiety

-Agitation-Agitation - Agitation- Agitation -Agitation-Agitation

-Irritability-Irritability -Irritability-Irritability -Irritability-Irritability

-Impulsivity-Impulsivity -Impulsivity-Impulsivity -Impulsivity-Impulsivity

-Aggression-Aggression -Aggression-Aggression -Aggression-Aggression

-Sleep problems-Sleep problems -Sleep problems -Sleep problems -Sleep problems -Sleep problems

-Decreased Concentration -Decreased Concentration -Decreased Concentration -Decreased Concentration -Decreased Concentration-Decreased Concentration

Impact on Academic FunctioningImpact on Academic Functioning• Overall we expect people to be getting better Overall we expect people to be getting better

with time.with time.• Residual effects of a moderate or severe TBI can Residual effects of a moderate or severe TBI can

interfere with cognitive functioning.interfere with cognitive functioning.• Ongoing PPCS symptoms can interfere with Ongoing PPCS symptoms can interfere with

cognitive functioning.cognitive functioning.• Mental health symptoms can interfere with Mental health symptoms can interfere with

cognitive functioning. cognitive functioning. • And decreased cognitive functioning can And decreased cognitive functioning can

interfere with academic functioning and interfere with academic functioning and performance.performance.

However, most reports of However, most reports of cognitive problems are normalcognitive problems are normal

• Responsibility versus structure relationshipResponsibility versus structure relationship

• Everyday memory/cognitive failuresEveryday memory/cognitive failures Noticed initially, then more frequently noticedNoticed initially, then more frequently noticed Compounded by stress, misuse of Compounded by stress, misuse of

substances, mental health diagnoses, etc.substances, mental health diagnoses, etc.

Reasonable AccommodationsReasonable Accommodations• A neuropsychological assessment can help A neuropsychological assessment can help

determine if the person has a diagnosable determine if the person has a diagnosable problem with learning, memory, attention, etc.problem with learning, memory, attention, etc.

• A neuropsychologist can make specific A neuropsychologist can make specific recommendations about accommodations to recommendations about accommodations to help.help.• Quiet testing environmentQuiet testing environment• TutoringTutoring• Getting lecture notes ahead of timeGetting lecture notes ahead of time

• If people are distractible, they should sit in the If people are distractible, they should sit in the front of the classroomfront of the classroom

What can I do?What can I do?• If you are working with someone who reports If you are working with someone who reports

attention or memory problems:attention or memory problems:• Write things down (bullet points)Write things down (bullet points)• Talk slowlyTalk slowly• Ask them to repeat back what they heard so you Ask them to repeat back what they heard so you

can correct misunderstandingscan correct misunderstandings• Allow them the opportunity to ask questionsAllow them the opportunity to ask questions• Provide a phone number should they think of Provide a phone number should they think of

questions later (suggest they program it into their questions later (suggest they program it into their phone, or give business card stapled to paper with phone, or give business card stapled to paper with notes)notes)

Where can a Veteran go for Where can a Veteran go for help?help?

• Enroll in VAEnroll in VA Can Google for local VA locationCan Google for local VA location Report to local VA Eligibility OfficeReport to local VA Eligibility Office Submit copy of DD214 Submit copy of DD214 Schedule Primary Care AppointmentSchedule Primary Care Appointment Primary Care can referral to specialty Primary Care can referral to specialty

departments such as TBI Clinic, departments such as TBI Clinic, Neuropsychology Clinic, Mental Health Clinic Neuropsychology Clinic, Mental Health Clinic for further evaluation and treatment needsfor further evaluation and treatment needs

ConclusionsConclusions• TBI is a one-time diagnosis, not an ongoing diagnosis; TBI is a one-time diagnosis, not an ongoing diagnosis;

“a history of TBI” not “I have TBI”.“a history of TBI” not “I have TBI”.• TBI symptoms should improve over time, and with TBI symptoms should improve over time, and with

treatment if necessary.treatment if necessary.• PTSD symptoms should improve over time and with PTSD symptoms should improve over time and with

treatment if necessary.treatment if necessary.• Ongoing symptoms may interfere with school but Ongoing symptoms may interfere with school but

difficulty in school is not necessarily due to these difficulty in school is not necessarily due to these symptoms/diagnoses (also likely are stress, lack of symptoms/diagnoses (also likely are stress, lack of sleep, everyday memory/attention failures, etc.). sleep, everyday memory/attention failures, etc.).

• With support, students should be able to be successful With support, students should be able to be successful which will build confidence.which will build confidence.

VA and Polytrauma Network VA and Polytrauma Network EvaluationsEvaluations

• Nationwide Population:Nationwide Population: Since April 2007, our country has screened Since April 2007, our country has screened

over over 768,744768,744 OIF/OEF/OND veterans for OIF/OEF/OND veterans for possible TBI. possible TBI. ((76.2%76.2% screened negative for TBI). screened negative for TBI).

Approximately Approximately 108,807108,807 completed detailed completed detailed evaluation.evaluation.

57.5%57.5% confirmed TBI diagnosis confirmed TBI diagnosis 42.5% 42.5% TBI diagnosis ruled outTBI diagnosis ruled out

SourcesSourcesAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.Congress of the United States Congressional Budget Office: The Veterans Health Administration’s Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans. February 2012Hoge, C.W., Castro, C.A., Messer, S. C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004) Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. New England Journal of Medicine, 351, 13-22.Howe, L.L.S. (2009). Giving Context to Post-Deployment Post-Concussive Like Symptoms: Blast-Related Potential Mild Traumatic Brain Injury and Comorbidities. The Clinical Neuropsychologist, 23, 1315-1337.

Iverson, G.L. (2006). Complicated vs uncomplicated mild traumatic brain injury: acute neuropsychological outcome. Brain Injury, 20, 1335-1344.

Iverson G.L., & Lang, R.T. (2003) Examination of “postconcussion-like” symptoms in a healthy sample. Applied Neuropsychologist, 10, 137-44.

Kok, B.C., Herrell, R.K., Thomas, J.L., & Hoge, C.W. (2012). Posttraumatic Stress Disorder Assoiciated With Combat Service In Iraq or Afghanistan: Reconciling Prevalence Differences Between Studies. The Journal of Nervous and Mental Disease, 200, 444-450.Mittenberg, W., DiGuilio, D.V., Perrin S., & Bass, A.E. (1992). Symptoms following mild head injury; Expectation as aetiology. Journal of Neurology, Neurosurgery and Psychiatry, 55, 200-204.Vasterling, J.J. & Sullivan K.D. (2009). Mild traumatic brain injury and posttraumatic stress disorder in returning veterans: Perspectives from cognitive neuroscience. Clinical Psychology Review, 29, 674-684.VA/DOD EBP Guideline, 2009http://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asphttp://bianj.org/Websites/bianj/images/persistentpostconcussivesyndrome.pdf