Traumatic Brain Injury and Post Traumatic Stress Disorder

1. Traumatic Brain Injury and Post Traumatic Stress Disorder Meredith Melinder, Ph.D. Polytrauma/TBI Clinic Psychologist/Neuropsychologist

2. Presentation Objectives 1) Definition of Traumatic Brain Injury (TBI) 2) Criteria by which brain injury severity is rated 3) Expected recovery for individuals diagnosed with TBI 4) Definition of Post Traumatic Stress Disorder (PTSD) 5) Criteria by which PTSD is diagnosed 6) Examining the overlap between TBI and PTSD 7) What do we expect in terms of recovery for PTSD? 8) How may symptoms interfere in an academic setting? What can you do?

3. TBI and Military • It is estimated that 22% of all combat injuries from OIF/OEF/OND conflicts are brain injuries, compared to 12%of Vietnam related combat casualties. • The primary causes of TBI in Veterans of Iraq and Afghanistan are blasts, blast related motor vehicle accidents, MVAs, and gunshot wounds. • The co morbidity of PTSD, history of mild TBI, chronic pain and substance abuse is common and may complicate recovery from any single diagnosis. • People with previous brain injuries may find that it takes longer to recover from their current injury. Source: DOD and Veterans Brain Injury Center

4. Definition of TBI “A traumatically induced structural injury and/or a physiological disruption of brain function as a result of an external force that is manifested by at least one of the following…” • Alteration in mental state or LOC • Amnesia for the event (before or after) • A focal neurological deficit VA/DOD EBP Guideline, 2009

5. What a Head Injury May Look Like

6. Brain Damage • Congenital versus Acquired • Congenital – Present at the time of birth • Acquired brain injury – Occurs after birth; Not the result of genetic disorder or birth trauma • Atraumatic versus Traumatic • Atraumatic– Damage progress over time • Traumatic – Caused by an outside force that impacts the head hard enough to cause damage to the brain

7. Brain Damage • Outcome depends on: – Cause of the damage – Area(s) of the brain damaged – Extent/Severity of the damage

8. How to Determine Level of TBI

9. Glasgow Coma Scale

10. Potential Acute TBI Symptoms Somatic Symptoms Behavioral/Emotional Cognitive Symptoms Headache Depression Decreased Attention Fatigue Anxiety Decreased Memory Light/noise sensitivity Agitation Decreased New Learning Sleep disturbance Irritability Decreased Processing Speed Dizziness Impulsivity Decreased Executive functions Nausea/vomiting Aggression Decreased Awareness Vision problems Transient neurologic problems Seizures Balance problems VA/DOD EBP Guideline, 2009

11. Expected Outcomes • Brain Injury is NOT a progressive disease • The effects of a TBI are most significant immediately following injury. Worsening symptoms over time are not TBI related • In most cases, rapid improvement is seen over the days and weeks following injury

12. Prognosis: Concussion/Mild TBI • Approximately 80% of TBI cases are Mild • Rapid improvement is seen within 3 weeks. • Most people return to normal functioning within 3 months. • Most people recover without any formal treatment. • Approximately 10%-15% of patients may develop chronic post concussive symptoms.

13. Persistent Post Concussion Syndrome (PPCS) • Post concussion syndrome is when symptoms continue for more than three months after the injury. • As many of the symptoms in PCS are common to, or exacerbated by, other disorders, there is a risk of misdiagnosis. • There is NO treatment for PCS itself. Symptoms can be treated.

14. Lack of Specificity of PPCS • Postconcussion-like symptoms are endorsed by depressed individuals (Iverson, 2006) • Postconcussion-like symptoms are endorsed in healthy individuals (Iverson & Lang, 2003) • Also, endorsed by college students, chronic pain patients, and personal injury claimants • Reattribution of normal symptoms to TBI (Mittenberg et al., 1992) • Research has examined why some individuals continue to experience symptoms. Theories include personality factors, substance abuse, monetary compensation. Not related to positive imaging

15. Prognosis:Moderate TBI • Over 90% are able to live independently. • Some individuals may require assistance with employment, financial management, and physical abilities. • Many people can learn to compensate for their deficits.

16. Prognosis:Severe TBI • Improvement may occur more slowly. • Intensive rehab is recommended. • Change will occur most rapidly in the first six months and will be expected through the first to two years. • Potentially need a caregiver. • Possible permanent disabilities.

17. Expected Cognitive Outcomes after TBI

18. Definition of Posttraumatic Stress Disorder • PTSD is diagnosed after a person develops characteristic symptoms following exposure to one or more traumatic events. • Symptoms include • Intrusive symptoms (e.g., unwanted memories, dreams, flashbacks) • Avoidance symptoms (e.g., memories, place, people, activities)

19. PTSD symptoms continued • Negative alterations in cognitions and mood (e.g., exaggerated negative beliefs, decreased interest, guilt, shame) • Alterations in arousal (e.g., irritable behavior, hypervigilance, exaggerated startle, problems with sleep and concentration) • Symptoms need to last more than a month • Symptoms cause impairment in social, occupational or other areas of functioning

20. Prevalence • Projected lifetime risk for PTSD in general population is approximately 8.7% • Rates of PTSD are higher among those whose vocation increases the risk of traumatic exposure (e.g., police, firefighters, combat veterans) • Different numbers have been referenced for those deployed to Operation Enduring Freedom and Operation Iraqi Freedom prevalence. Source National Center for PTSD and DSM 5

21. 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.

22. Treatment for PTSD • Many people naturally recover after experiencing trauma, and they therefore do not have a diagnosis of PTSD. • However, if someone does have clinically significant symptoms interfering in their life there are effective treatments. • Cognitive Processing Therapy • Prolonged Exposure Therapy • Medication Options

23. Persistent Post-Concussive Syndrome and Post Traumatic Stress Disorder PPCSBOTH PTSD -Headache -Intrusive Symptoms -Light/Noise sensitivity -Avoidance -Dizziness -Increased arousal -Memory problems -Negative Cognitions -Depression -Depression -Depression -Anxiety -Anxiety -Anxiety -Agitation - Agitation -Agitation -Irritability -Irritability -Irritability -Impulsivity -Impulsivity -Impulsivity -Aggression -Aggression -Aggression -Sleep problems -Sleep problems -Sleep problems -Decreased Concentration -Decreased Concentration -Decreased Concentration

24. Impact on Academic Functioning • Overall we expect people to be getting better with time. • Residual effects of a moderate or severe TBI can interfere with cognitive functioning. • Ongoing PPCS symptoms can interfere with cognitive functioning. • Mental health symptoms can interfere with cognitive functioning. • And decreased cognitive functioning can interfere with academic functioning and performance.

25. However, most reports of cognitive problems are normal • Responsibility versus structure relationship • Everyday memory/cognitive failures • Noticed initially, then more frequently noticed • Compounded by stress, misuse of substances, mental health diagnoses, etc.

26. Reasonable Accommodations • A neuropsychological assessment can help determine if the person has a diagnosable problem with learning, memory, attention, etc. • A neuropsychologist can make specific recommendations about accommodations to help. • Quiet testing environment • Tutoring • Getting lecture notes ahead of time • If people are distractible, they should sit in the front of the classroom

27. What can I do? • If you are working with someone who reports attention or memory problems: • Write things down (bullet points) • Talk slowly • Ask them to repeat back what they heard so you can correct misunderstandings • Allow them the opportunity to ask questions • Provide a phone number should they think of questions later (suggest they program it into their phone, or give business card stapled to paper with notes)

28. Where can a Veteran go for help? • Enroll in VA • Can Google for local VA location • Report to local VA Eligibility Office • Submit copy of DD214 • Schedule Primary Care Appointment • Primary Care can referral to specialty departments such as TBI Clinic, Neuropsychology Clinic, Mental Health Clinic for further evaluation and treatment needs

29. Conclusions • TBI is a one-time diagnosis, not an ongoing diagnosis; “a history of TBI” not “I have TBI”. • TBI symptoms should improve over time, and with treatment if necessary. • PTSD symptoms should improve over time and with treatment if necessary. • Ongoing symptoms may interfere with school but difficulty in school is not necessarily due to these symptoms/diagnoses (also likely are stress, lack of sleep, everyday memory/attention failures, etc.). • With support, students should be able to be successful which will build confidence.

30. VA and Polytrauma Network Evaluations • Nationwide Population: • Since April 2007, our country has screened over 768,744 OIF/OEF/OND veterans for possible TBI. (76.2% screened negative for TBI). • Approximately 108,807 completed detailed evaluation. • 57.5% confirmed TBI diagnosis • 42.5% TBI diagnosis ruled out

31. Sources • American 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 2012 • Hoge, 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, 2009 • http://www.ptsd.va.gov/professional/PTSD-overview/epidemiological-facts-ptsd.asp • http://bianj.org/Websites/bianj/images/persistentpostconcussivesyndrome.pdf