Traumatic Brain Injury
and Post Traumatic
Stress Disorder
Meredith Melinder, Ph.D.
Polytrauma/TBI Clinic
Psychologist/Neuropsychologist
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?
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
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
What a Head Injury May Look
Like
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
Brain Damage
• Outcome depends on:
– Cause of the damage
– Area(s) of the brain damaged
– Extent/Severity of the damage
How to Determine Level of TBI
Glasgow Coma Scale
1
2
3
4
5
6
Eyes
Does not
open eyes
Opens eyes in
response to
painful stimuli
Opens eyes
in
response to
voice
Opens eyes
spontaneousl
y
N/A
N/A
Verbal
Makes no
sounds
Incomprehensible
sounds
Utters
inappropriate
words
Confused,
disoriented
Oriented,
converses
normally
N/A
Motor
Makes no
movements
Extension to
painful stimuli
Abnormal
flexion to
painful stimuli
Flexion /
Withdrawal to
painful stimuli
Localized
pain
stimuli
Obeys
commands
Potential Acute TBI Symptoms
Somatic Symptoms
Headache
Fatigue
Light/noise sensitivity
Sleep disturbance
Dizziness
Nausea/vomiting
Vision problems
Transient neurologic
problems
Seizures
Balance problems
Behavioral/Emotional
Depression
Anxiety
Agitation
Irritability
Impulsivity
Aggression
Cognitive Symptoms
Decreased Attention
Decreased Memory
Decreased New Learning
Decreased Processing Speed
Decreased Executive functions
Decreased Awareness
VA/DOD EBP Guideline, 2009
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
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.
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.
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
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.
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.
Expected Cognitive Outcomes
after TBI
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)
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
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
• 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.
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
Persistent Post-Concussive
Syndrome and Post
Traumatic Stress Disorder
PPCS
BOTH
PTSD
-Headache
-Light/Noise sensitivity
-Dizziness
-Memory problems
-Depression
-Anxiety
-Agitation
-Irritability
-Impulsivity
-Aggression
-Sleep problems
-Decreased Concentration
-Intrusive Symptoms
-Avoidance
-Increased arousal
-Negative Cognitions
-Depression
-Depression
-Anxiety
-Anxiety
- Agitation
-Agitation
-Irritability
-Irritability
-Impulsivity
-Impulsivity
-Aggression
-Aggression
-Sleep problems
-Sleep problems
-Decreased Concentration -Decreased Concentration
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.
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.
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
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)
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
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.
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
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, 200204.
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