PTSD and TBI: What are the Treatment
Katherine Porter, Ph.D.
VA Ann Arbor Healthcare System
• Thank you to collaborators that helped me with
this talk (Sheila Rauch, PhD; Erin Smith, PhD,
and Melody Powers, LMSW along with others).
• Some of the content and slides have been
borrowed from previous talks they have given
on this topic.
• What is PTSD
• PTSD and the courts/criminal behavior
• Data on TBI and comorbity
• Treatment planning with court order patients
• Evidence based care for PTSD
Response to Trauma and Stress
Following trauma many problems may occur and interact
• Requires:
– Event that threatened or caused death, physical injury,
threat to physical integrity.
– Responded with fear, helplessness, or horror
– Recently, this criteria has been removed, but is seen in most cases even
if they don’t use the words.
• Symptoms:
Reexperiencing of a specific event/s
Negative alterations in thoughts and mood
Alterations in arousal and reactivity
• Must impair function for at least one month
Normal Reaction vs. Pathology
• Most individuals exposed to traumatic situations, do not develop
• The manifestation of some symptoms during the first 30-90 days
after a traumatic experience is not uncommon and is generally part
of the normal stress response.
• However, a pattern of symptoms that begin to interfere with work,
home life or interpersonal relationships marks PTSD.
• Persistent symptoms that either do not improve or worsen, even if
considered normal initially, become problematic when they do not
remit over time.
Criminal Behavior and PTSD
• Symptoms of PTSD and comorbid disorders may
increase chance that a person may experience some
legal problems.
Anger and irritability
Hyperarousal/ perception of threat and danger
Feelings of disconnection/ isolation and lack of support
Intrusions, including flashbacks
• Majority of patients with PTSD do not have problems
with the law and are not violent.
Criminal Behavior and PTSD
• Data suggests that PTSD may be linked to
violence and aggression (e.g., Kulka et al.,1988;
Lasko et al., 1994; Orcutt et al., 2003).
– Substance use can increase risk
• Presence of PTSD does not suggest criminality
and criminal behavior does not mean that
symptoms are the cause of the behavior.
Anger & PTSD
• Elevated levels of anger often seen in trauma survivors and has been
shown to be related to severity of PTSD (e.g., Riggs et al., 1992).
• Anger is central feature in survival response
• Relationship between anger and PTSD stronger in military samples,
but not specific to it (e.g., Orth & Wieland, 2006)
• Anger levels decrease with treatment of PTSD even if it is not
directly targeted (Cahill et al., 2003; Stapleton et al., 2006)
Substance Use Disorders and PTSD
• Why the link between PTSD and substance use?
– High Risk Hypothesis
– Susceptibility Hypothesis
– Self-medication Hypothesis (most support)
Often conceptualized as avoidance in trauma focused therapy
• Data on prevalence varies, but it is estimated that:
– 20% seeking help for PTSD have a substance use disorder
– ~33% of veterans seeking help for SUD have PTSD.
– 30–59% of women with SUD have PTSD (Najavits,Weiss, & Shaw, 1997)
Traumatic Brain Injury (TBI)
• ~1.7 million people sustain a TBI annually
– Vast majority don’t require hospitalization
CDC (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and
• Symptoms and course can vary significantly
– Can include irritability, changes in mood, behavioral
• Many symptoms overlap with PTSD
Rates of mTBI and PTSD among OIF/OEF
Reported rates of both PTSD and mTBI vary
according to the study and may be
 TBI rates estimated at approaching 20% (Sayer et al., 2009)
The majority of these cases are in the mild range of
Evidence indicates that the majority of these cases resolve
within weeks or months
• Studies looking at rates of PTSD following TBI
vary considerably
– Depending on methods for diagnosing PTSD rates
reported between ~3-30% with interview and ~1859% with self-report (Gill et al., 2014).
• PTSD maybe less likely in cases with longer
periods of unconsciousness (Glaesser et al., 2004).
Assessment and Treatment with Court Ordered Patients
• Important to consider history of symptoms and behaviors
– Helps to reduce impact of secondary gain
– Provides information about potential function of behaviors
• Treatment plans should be symptom/diagnosis based
• Trauma focused therapies can be effective, but are only therapeutic
when patients are willing
– Education and rationale are provided to patient and they be strongly
encouraged, but not forced.
Assessment and Treatment with Court Ordered Patients
• PTSD therapies are short-term and involve work
outside of the therapy office
– Goal is to help person reconnect and engage in their life
– Important that they practice skills in their environment
• Consistent messages from team (treatment team
and courts) is important to help combat avoidance
PTSD Treatment
Clinical practice guidelines
Prolonged Exposure and Cognitive Processing Therapy
have been supported as first line treatments for PTSD
 VA/DOD PTSD Treatment guideline (VA/DOD, 2004, 2010)
 National Institute of Clinical Excellence (NICE, 2005)
 International Society of Traumatic Stress Studies (ISTSS, 2009)
 Institute of Medicine (IOM, 2007)
Selective Serotonin Reuptake Inhibitors(SSRIs) are also
supported first-line treatment- Zoloft and Paxil
Prolonged Exposure (PE)
Treatment Procedures
• Psychoeducation: Education about treatment and
common reactions to trauma; breathing training
• Repeated in vivo exposure
• Imaginal exposure
• Processing of the revisiting and in vivo exposure
PE Rationale
• Exposure:
– Challenges belief that anxiety lasts forever
– Challenges belief that memories, people, places,
and situations are dangerous
– Results in reduction of anxiety without engaging in
habitual avoidance behaviors
– Helps process traumatic experience(s)
– Enhances sense of control
Cognitive Processing Therapy (CPT)
Impact Statement
Trauma Account
Cognitive Challenge
– Identify stuck points
– Safety, trust, power/control, esteem,
CPT Rationale
o Trauma events change one’s perceptions about
the world, themselves, and other people
o “The world is dangerous”
o “It’s all my fault”
o Trauma victims with PTSD have a distorted sense
o Safety, Trust, Intimacy, Power/Control, Self-Esteem
o These distortions keep people stuck in their
PTSD symptoms and therefore must be modified
to accurately fit the context/reality of situations
Initial Data on Outcomes with PTSD/TBI
• Sripada et al., 2013
– Examined clinical sample from a VA clinic of PTSD
patient who received PE and data from a pilot study
– Compared outcomes of participants with and w/out a
history of mTBI
– Showed that PE was effective in reducing PTSD
symptoms and mTBI status did not impact efficacy.
The Good News:
• PTSD can be a chronic disorder, but with the right treatment
patients can get significantly better, including no longer meeting
criteria for the disorder post-treatment.
• For example, Rauch et al. (2009) found that 80 % of veterans
treated with Prolonged Exposure (PE) therapy achieved clinically
significant reductions in their PTSD symptoms and 50 % no longer
met criteria for PTSD.
• Data from VA roll out training of PE demonstrated that the
percentage of veterans screening positive dropped from 87.6%to
46.2% (Eftekhari et al., 2013).
The Good News:
• Monson et al. (2006) found that 40 % of a
veteran sample receiving Cognitive Processing
Therapy (CPT) did not meet criteria for PTSD
compared to 3 % for a wait-list control group.
• 50 % of the veterans receiving CPT had a
significant reduction in their symptoms,
compared to 10 % of the wait-list control group.
Cahill, S. P., Rauch, S. A.,Hembree, E. A.,&Foa, E. B. (2003). Effect of cognitive behavioral treatments for PTSD on anger.
Journal of Cognitive Psychotherapy, 17, 113–131.
CDC (2010). Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths.
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