Posttraumatic Stress Disorder
and Traumatic Brain Injury:
The Similarities and
Differences
Brian A. Boatwright, Psy.D.
Neuropsychologist
Director of the Neurological Rehabilitation
Institute at Brookhaven Hospital
Objectives
Compare PTSD and TBI noting the
similarities and differences
Review basic neuroanatomy associated
with PTSD and TBI
Learn important interview questions and
considerations when working with
TBI/PTSD population
Discuss options for patients’ continuity of
care
Objectives
Increase awareness of formal assessment
Clinical case examples
The Similarities
PTSD Cognitive
Complaints
–
–
–
–
Attention
Working memory
Memory
Slower mental
processing speed
TBI Cognitive
Complaints (Varies
according to injury)
–
–
–
–
Attention
Working memory
Memory
Slower mental
processing speed
The Similarities
PTSD
Affective/Personality
–
–
–
–
Traumatic event
Sleep disturbance
Hypervigilance
Alteration in mood
(irritability, affective
flattening, depressed
mood)
– Paranoia
– Anxiety
– Substance Abuse
TBI Affective/Personality
–
–
–
–
Traumatic event
Sleep disturbance
Hypervigilance
Alteration in mood
(irritabilty, affective
flattening, depressed
mood)
– Paranoia
– Anxiety
– Substance Abuse
Neuroanatomy Review
Neuropsychological Domains
Acquired Knowledge
Attention & Memory
Language
Visual Spatial
Motor & Sensory Perceptual
Reasoning & Problem Solving
Executive Functions
– Planning
– Processing Speed
– Cognitive Flexibility
Personality
Social Cognition
Motivation / Response Bias
TBI and Neuropsychology
Performance IQ loss is generally greater
than Verbal IQ loss.
Deficits may be seen in any number of
domains, dependent on lesion location.
Memory is the most prominently effected
neuropsychological function but will also see
marked impairment in executive functioning.
Greatest improvement seen shortly postinjury but may be two years and beyond.
Basic Neuroanatomy and
Functional Localization
Frontal Lobes
– Attention
– Planning
– Sequencing
– Organization
– Mental Flexibility
– Problem Solving
– Impulse Control
– Aspects of Memory (Executive Memory)
Temporal Lobes (Hippocampus,
Amygdala, Basal Ganglia)
– Sound recognition and processing
– Comprehension and production of speech
– Aspects of memory
Parietal Lobes
– Integration of sensory information from the
body
– Contains primary sensory cortex
– Proprioception
– Spatial Functioning
– Visuoconstruction
– Aspects of memory
Occipital Lobe
– Primary Visual Cortex
Cerebellum
– Balance
– Movement
– Coordination
– Some aspects of attention/executive
functioning, frontal connections
PTSD and Cognition
Attention and Memory common complaints
Some confounding variables-Most research in
PTSD involves veterans with comorbid
psychiatric diagnoses
Alcohol abuse-Right hemisphere more
vulnerable?
Samuelson, et al. (2009) – lower scores on
working memory and verbal memory
(Contextually based)
Samuelson, K.W., Metzler, T.J., Rothlind, J., Choucroun, G., Neylan, T.C., Lenoci, M., Henn-Haase, L.,
Weiner, M.W., & Marmar, C.R. (2006). Neuropsychological functioning in posttraumatic stress
disorder and alcohol abuse. Neuropsychology, 20, 716-726.
Studies show decreased hippocampal
volume in those with chronic PTSD
Verbal memory-increased intrusion errors
Mental flexibility
Perseverative errors
Visuospatial deficits (Alcohol abuse-right
hemisphere)
Chicken or the Egg???
Differences in cognitive functioning prior to
trauma
Lower cognitive capacity risk factor for
PTSD?
Premorbid dysexecutive functioning
Less able to shift thoughts
Become stuck in behavior patterns
Gilbertson, M.W., Gurvits, T.V., Lasko, N.B., Paulus, L.A., Williston, S.K., Pitman, R.K., & Orr, S.P.
(2006). Neurocognitive function in monozygotic twins discordant for combat exposure:
Relationship to posttraumatic stress disorder. Journal of Abnormal Psychology, 115, 484-495.
Additional Neural Considerations
Studies using provocation techniques elicit
increased amygdala and lower frontal
cortical activation
Hypothesis-Verbal contextual abilities help
one integrate the traumatic memory in
one’s past
Dorefl, D., Werner, A., Schaefer, M., & Karl, A. (2010). Pilot neuroimaging study in civilian trauma
survivors episodic recognition memory, hippocampal volume, and posttraumatic stress disorder
symptom severity. Journal of Psychology, 218, 128-134.
The Clinical Interview-Areas of
Focus
Background information (education,
psychiatric, medical, family history, etc.)
Inform patient that the interview will be
detailed and may be difficult at times
Obtain specific information about the event
When?
Where? (Nearby, something you heard)
What happened? (Blown off feet, ran over
IED, learned that peer was killed)
Be specific with timeline
Were you knocked out?
What’s the last thing you remember before
the accident?
What’s the first thing you remember once
you regained awareness of your
surroundings?
Ex Post Facto
What problems have you had since the event?
Memory
– What are you having trouble remembering? (Names,
routes, written information, oral information, object
locations)
– When does it happen?
– How often do you forget this information?
– Is it more difficult at certain times? (When stressed,
just after panic attack, when around certain objects,
places, etc.)
If you stop and think about it, does the
answer or information usually come to
you?
Substance use?
Complaints about attention/concentration
– What situations are most problematic?
– Do you notice any specific topics that cause
you difficulty focusing?
– Substance use?
Other problems or concerns
– Language changes
– Personality changes
– Relationships (Importance of collateral
informant)
What do I do???!!!
If not clear PTSD only or suspect
combination of PTSD/TBI-Refer for
neuropsychological evaluation
Look at timeline of TBI-Function at time of
injury and post-injury
Problems with return to work?
Complaints from coworkers/supervisors?
Secondary Gains
Neuropsychological Evaluation
Full review of records (MRI, CT, additional
documentation)
Neurobehavioral Status Examination
Collateral Interview
Objective Testing
Effort
Premorbid Estimate of Ability
Current Ability (IQ)
Academic
Motor Functioning
Memory
Executive Functioning
Language
Personality/Psychopathology
Outcome of Evaluation
Final report back to provider
Refer for psychotherapy/counseling
If TBI, repeat neurocognitive evaluation
Timeline of improvement of functioning
post-TBI
Early treatment for PTSD (research shows
hippocampal volume decrease in chronic
patients)
Cognitive rehabilitation
Case Example
The patient is a 28-year-old, Caucasian,
married, male who returned from
Afghanistan three months ago. He has two
children who are ages 4 and 5. The patient
was referred to you by his primary care
physician who suspects posttraumatic
stress disorder and wants your
professional opinion. While in Afghanistan,
he was nearby a mortar explosion that
knocked him against a wall.
“I am not like I was before going off to
war.”
“My family tells me that I’m difficult to be
around.”
“I am having trouble at work. I can’t do my
job like I used to.”
“My friends don’t come around.”
“My friends, that are still coming around,
tell me I’m different.”
“I can’t go places where there’s a bunch of
people.”
“I’m having trouble driving.”
“Reading is more difficult.”
“I just can’t watch t.v.”
The patient’s wife reports, “My husband
stays away from the rest of the family. It’s
like having a stranger in the house.”
The patient’s wife reports, “He doesn’t
help with cooking and keeping up with
things around the house anymore.”
The patient’s wife reports, “My husband
forgot to pick up the kids from school.”
The patient’s wife reports, “His boss called
me and said he’s different at work.”