Conceptual and Practical Overlap: Mild Traumatic Brain Injury, PTSD , and Pain

1. Conceptual and Practical Overlap: Mild Traumatic Brain Injury, PTSD, and Pain Rodney D. Vanderploeg, Ph.D., ABPP-CN James A. Haley Veterans Hospital, Tampa, FL Associate Professor of Psychology & Psychiatry, University of South Florida

2. Disclaimer The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Veterans Affairs

3. Mild Traumatic Brain Injury (mild TBI)

4. Hoge et al. NEJM Jan. 2008 • Survey data on 2714 OIF veterans (59% survey completion rate) • 4.9% reported a mild TBI w/ LOC • 10.3% reported a mild TBI w/ AOC • 17.2% reported some other type of injury 15.2%

5. Hoge NEJM Jan. 2008 study (cont.) • mTBI was strongly associated with PTSD and with Depression, so . . . • Does mTBI cause PTSD & Depression or increase the risk of developing them?

6. Hoge NEJM Jan. 2008 study (cont.) • Multiple physical, cognitive, and behavioral symptoms were compared across groups: • Various pains, dizziness/balance problems, shortness of breath, heart pounding, bowel problems, fatigue, sleep disturbance, ringing in the ears • Memory problems, concentration problems • Irritability

7. Hoge NEJM Jan. 2008 study (results) • Returning soldiers who suffered a concussion have a higher number of somatic and postconcussive symptoms than soldiers with other injuries • However, after adjusting for demographic factors, and current PTSD and Depression, mild TBI was no longer associated with these symptoms, except for headache

8. % w % w AOC LOC n = 124 n = 260 (17.7% to 32.2%) (5.9% to 8.3%)

9. + PTSD Re-experiencing Arousal Sensitive to noise Concentration Insomnia Irritability Avoidance Social withdrawal Memory gaps Apathy ? Mild TBI Residual Headaches Dizziness Difficulty with decisions Memory Problems Mental slowness Concentration Appetite changes Fatigue Sadness + Depression

11. Odds-Ratios for Presence of the Postconcussion Symptom Complex (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)  15.7% increase  12.5% increase

12. Odds-Ratios for Various Physical/NeurologicalPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

13. % w % w AOC LOC n = 124 n = 260 (17.7% to 32.2%) (5.9% to 8.3%)

14. Mild TBI Current Symptoms PTSD Possible Mediation Effects PTSD Hoge’s proposed mechanism Current Symptoms Mild TBI Tested in the Vietnam Experience Data Set

15. mTBI and PTSD Effects on PCS:No Mediation Effect - Independent & Additive mTBI Group MVA Injury 27% PTSD Effect 15% mTBI Effect

16. Does Having a mTBI Influence the Course of PTSD? 20.7%

17. What about non-physical outcomes? Vietnam Experience Study Data (continued)

18. Odds-Ratios for Various Cognitive/NeuropsychologicalPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

19. Odds-Ratios for Various Emotional/PsychologicalPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

20. Odds-Ratios for Various OtherNeurological Signs During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

21. This is fine for group data, but what about at the patient level?Can we tell what symptoms (or how much of a symptom) is due to what comorbid condition?

22. PTSD Substance Use Disorder Physical Injuries Mild TBI Anxiety Depression Pain

23. Apples Psychiatric Diagnosis(PTSD) Pears Remote Historical Event (mTBI) Symptom (Pain) Oranges

24. Patterns of Symptom Overlap in mTBI and PTSD: Implications for Assessment and Treatment

25. Palo Alto PNS Clinic – Mild TBI Group Symptom % of Patients Sleep Disturbances 84 Irritability 84 Attention/Concentration Problems 79 Memory Problems 76 Mood Swings 76 Anxiety 74 Headaches 71 Light/Noise Sensitivity 69 Depression 66 Visual Disturbances 66 Tinnitus 58 Excessive Fatigue 58 Balance Problems 42 Dizziness 40 Lew et al., 2007

26. WRAMC NSI Data:mTBI (n = 115) Moderate to Very Severe Sx

27. Early on while still at WRAMC:mTBI Symptom Overlap • Anxiety appears to be the significant contributor to other Symptoms

28. Boston PNS NSI Data:mTBI (n = 200) Moderate to Very Severe Sx

29. Several Months Later:mTBI Symptom Overlap • Initial Anxiety fades into a more chronic depression and sleep problem pattern and • Sleep problems& Depression appear to become the significant contributors to other Symptoms

30. Boston PNS NSI Data:(PTSD excluded)mTBI (n = 64) Moderate to Very Severe Sx

31. Several Months Later:mTBI Symptom Overlap • When those with comorbid PTSD are removed from the sample: • Again initial Anxiety fades into a more chronic Depression but • Headache pain in interaction with Sleep Problems become significant contributors to other symptoms following mTBI

32. Vietnam Experience StudymTBI (n = 278) Moderate to Very Severe Sx

33. Vietnam Experience StudyPTSD (n = 249) Moderate to Very Severe Sx

34. mTBI Symptom Overlap:Changes Over Time • Early: • Anxiety appears to be the significant contributor to other Symptoms • Several Months Later: • Depression & Sleep problems (in PTSD/mTBI) • Depression, Headaches & Sleep problems (in mTBI alone) become the significant contributors to other Symptoms • Years Later: • Emotional Contributors fade, while chronic Sleep Problems& Irritability together become the significant contributors to other Symptoms

35. Ft. Carson: Post-Deployment Data (n = 907) Terrio et al., JHTR, 2009; 24, 14-23.

36. Currently Symptomatic: Onset of Symptoms (n = 844) Terrio et al., JHTR, 2009; 24, 14-23. Terrio et al., JHTR, 2009; 24, 14-23.

38. COGNITIVE ISSUES IRRITABILITY / IMPULSIVITY SELF-CARE ROUTINES* SOMATIC COMPLAINTS EDUCATION: Expectation of Recovery TBI Step-Care Treatment Model† BEHAVIORAL HEALTH ISSUES †Begin each encounter at the bottom of the pyramid and progress upward * Includes SLEEP HYGIENE, diet, exercise, and avoiding further TBI Terrio 2009

39. VA/DoD Mild TBI Clinical Practice Guidelines(April 2009) http://www.healthquality.va.gov/Rehabilitation_of_Concussion_mTBI.asp

40. Research Questions • Is Hoge correct? Is treating these conditions or the “P3+ Complex” (mTBI, PTSD, Pain, etc.) in specialty clinics a less than optimal approach? • Are we bringing excessive attention to and over-pathologizing expected post-deployment adjustment issues; thereby reinforcing them and making them worse or delaying recovery?

41. Hoge et al. Conclusions

42. Research Questions • Are patients more likely to seek help in one type of setting versus another? • Mental Health (general) • Mental Health (specific): PTSD • TBI/Polytrauma (physical/neurological problem; not mental health problem) • Primary Care Clinic (general) • Primary Care Clinic (OIF/OEF specific)

43. Research Questions • Do patients’ assumptions or expectations regarding cause, treatment, and recovery differ across these different medical settings? • Is so, do these assumptions and expectations affect recovery trajectories?

44. Possible Research Study • Identical teams, Identical programs • PTSD setting • TBI/Polytrauma setting (PNS) • Primary Care (OIF/OEF clinic) setting • Assess pre-treatment beliefs, assumptions, and expectations • See if recovery outcomes differ • Across settings • Based on patient beliefs, assumptions, and expectations