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

TBI-PTSD G.I. Wilson 17 April 09 Version . Outline. Introduction  Background  Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI)  1. What is TBI/mTBI? 2. What is PTSD 3. Relationship Between PTSD and mTBI  Evidence Based Approaches for Treatment 

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

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  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?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

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

  5. 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

  6. 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.

  7. TYPES OF HEAD INJURY • Closed Head Injury • Contusion/concussion • Coup/Contre-Coup • Cerebral edema • Diffuse axonal injury • Blast injury • Open Head Injury

  8. Concussion

  9. Diffuse Axonal Injury

  10. Coup-Contrecoup

  11. Blast Injury

  12. Open Head –Penetrating

  13. 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

  14. 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

  15. Ringing in the ears. Bad taste in the mouth. Fatigue. Lethargy. Sleep pattern changes. Behavioural/mood changes. Trouble with memory, concentration, attention, or thinking. 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.

  16. 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)

  17. 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 person’s response involved intense fear, helplessness, or horror

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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,

  23. 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

  24. Patient Presentation: mTBI-PTSD • Cognitive complaints: “I have problems with short-term memory” “I can’t 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: “He’s 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

  25. Clinical Presentation Overlapping Symptoms TBI PTSD Poor Concentration Memory Impairment Insomnia Depression Anxiety Irritability Flashbacks Headaches Nightmares Dizziness

  26. Evidenced Based Treatment PTSD TBI 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 practiceguidelines that address treatment of mild TBI (US Government Accountability Office Feb 2008). • 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

  27. 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.

  28. 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.

  29. 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.

  30. 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)

  31. 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

  32. Questions

  33. Primary Sources Dewleen G. Baker MD http://www.idahotbi.org/Portals/_AgencySite/pdf/DGB_Part%201_%20PTSD-TBI.pdf Mary Lu MD and Adam Nelson http://www.biaoregon.org/docetc/conference/2009/PTSD%20and%20TBI%20ML%20and%20AN.pdf Charles W. Hoge, M.D www.roa.org/site/DocServer/RC_Conference-Mar23-2009-Short2.ppt?docID=14321 Angela I Drake, Ph.D. http://www.usmc-mccs.org/cosc/conference/documents/Presentations/Tuesday%2012%20Aug/Drake%20-%20PTSD%20TBI.pdf Stephen Jordan, PhD www.nasvh.org/confer_info/docs/Stephen-Jordan-Handout-8-08.ppt   Jason Hawley MD crdamc.amedd.army.mil/behavh/resources/Traumatic%20Brain%20Injury.ppt

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