TBI & PTSD 2008


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Mild Traumatic Brain Injury and PTSD: Mutually Exclusive or Two Sides of the Same Coin

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  • TBI & PTSD 2008

    1. 1. … mutually exclusive or two sides of the same coin? PTSD and MTBI
    2. 2. Overview <ul><li>Nature of Controversy </li></ul><ul><li>TBI: Key Considerations </li></ul><ul><li>PTSD: Key Considerations </li></ul><ul><li>Arguments against coexistence </li></ul><ul><li>Resolution of arguments </li></ul><ul><li>Recommendations for assessment </li></ul>
    3. 3. <ul><li>Nature of Controversy </li></ul>I
    4. 4. <ul><li>“ If the brain was so simple that we could understand it, we would be so simple that we couldn’t” </li></ul><ul><li>- Lyall Watson </li></ul>
    5. 5. old phenomenon…
    6. 6. Background WW I Shell-shock Soldier’s Heart Railway Spine Battle fatigue OEF/OIF Traumatic Brain Injury (TBI) Vietnam Posttraumatic Stress Disorder (PTSD) PTSD & TBI Can they coexist?
    7. 7. … new context
    8. 8. Diagnostic Challenges <ul><li>Sometimes we can’t remember </li></ul><ul><li>Sometimes we can’t forget </li></ul><ul><li>Human memory defined by “fragile power” (Schacter) </li></ul><ul><li>Brain Injury has dynamic course </li></ul><ul><li>Secondary gain & malingering </li></ul>
    9. 9. <ul><li>Approximately 15% of MTBI are unresolved after 6-months </li></ul><ul><li>Jumps to 32% if litigation is involved </li></ul><ul><li>Symptom overlap between TBI, PTSD, and Post Concussive Syndrome (PCS) </li></ul><ul><li>Limbic system frequently damaged in TBI </li></ul>Diagnostic Challenges
    10. 10. (Bryant, 2001) NA √ Elevated startle response NA √ Hypervigilence √ √ Concentration deficits √ √ Irritability √ √ Insomnia NA √ Foreshortened future √ √ Diminished interest √ √ Social detachment NA √ Avoid reminders NA √ Distress on reminders NA √ Nightmares √ √ Recurrent images √ √ Amnesia √ √ Derealization √ √ Depersonalization √ √ Reduced awareness √ √ Emotional numbing Traumatic Brain Injury Posttraumatic Stress Disorder / Acute Stress Disorder Symptom
    11. 11. <ul><li>TBI: Diagnostic Assessment – Key Considerations </li></ul>II
    12. 12. Annual Incidence Brain Injury Association of America
    13. 13. Causes of TBI Brain Injury Association of America
    14. 14. TBI Risk <ul><li>Males outnumber females 2:1 </li></ul><ul><li>Ages 15-25 and 75+ </li></ul><ul><li>Substance abuse </li></ul><ul><li>Firearms use </li></ul>
    15. 15. Combat TBI - Prevalence <ul><li>11,800 troops injured in IED attack </li></ul><ul><li>Thousands more within concussion blast radius </li></ul><ul><li>As of Oct 31st 2006 only 1,652 soldiers and marines officially diagnosed with TBI </li></ul>
    16. 16. Military Service & TBI <ul><li>Peacetime service = 7,000 hospital admissions per year for TBI </li></ul><ul><li>Combat theater TBI = 14-20% of surviving casualties </li></ul><ul><li>2001 N = 1,361 veterans received VA inpatient hospital care for TBI </li></ul>
    17. 17. Glasgow Coma Scale (GCS) <ul><li>Motor Responses : Score </li></ul><ul><li>Obeys Commands 6 </li></ul><ul><li>Localizing responses to pain 5 </li></ul><ul><li>Generalized withdrawal to pain 4 </li></ul><ul><li>Flexor posturing to pain 3 </li></ul><ul><li>Extensor posturing to pain 2 </li></ul><ul><li>No motor response to pain 1 </li></ul><ul><li>Verbal Responses : </li></ul><ul><li>Oriented 5 </li></ul><ul><li>Confused conversation 4 </li></ul><ul><li>Inappropriate speech 3 </li></ul><ul><li>Incomprehensible speech 2 </li></ul><ul><li>No speech 1 </li></ul><ul><li>Eye opening : </li></ul><ul><li>Spontaneous eye opening 4 </li></ul><ul><li>Eye opening to speech 3 </li></ul><ul><li>Eye opening to pain 2 </li></ul><ul><li>No eye opening 1 </li></ul>
    18. 18. Glasgow Coma – Limitations <ul><li>Alcohol and drug use </li></ul><ul><li>Time: Injury  Measurement </li></ul><ul><li>Application beyond Emergency Response (ER) personnel </li></ul>
    19. 19. Loss of Consciousness (LOC) <ul><li>Length of time patient is ‘non-responsive’. </li></ul><ul><li>Limitations </li></ul><ul><li>Patient must have awareness of LOC </li></ul><ul><li>Reliance on witness/evaluator observation </li></ul>
    20. 20. Posttraumatic Amnesia (PTA) <ul><li>Length of time: </li></ul><ul><li>consciousness  memory for ongoing events </li></ul><ul><li>Limitations </li></ul><ul><li>Difficult to determine precise end-point </li></ul><ul><li>Differentiation of PTA and LOC </li></ul><ul><li>Reliance on collateral reporting </li></ul>
    21. 21. Severity Grades of TBI PTA > 7 days PTA < 7 days PTA < 24 hours GCS = < 9 GCS = 9-12 GCS = 13-15 LOC > 6 hours & Abnormal CT &/or MRI LOC < 6 hours & Abnormal CT &/or MRI Altered or LOC < 30 min & Normal CT &/or MRI Severe (Grade 3 & 4) Moderate (Grade 2) Mild (Grade 1)
    22. 22. Diagnostic Criteria for Mild TBI (MTBI) <ul><li>Traumatically induced physiologic disruption of brain function as indicated by at least one of the following: </li></ul><ul><ul><li>Any period of loss of consciousness </li></ul></ul><ul><ul><li>Any loss of memory for events immediately before or after accident </li></ul></ul><ul><ul><li>Any alteration in mental state at the time of the accident </li></ul></ul><ul><ul><li>Focal neurologic deficits that may or may not be transient </li></ul></ul><ul><li>Severity of the injury does not exceed: </li></ul><ul><ul><li>Loss of consciousness of 30 min </li></ul></ul><ul><ul><li>GCS score of 13-15 after 30 min </li></ul></ul><ul><ul><li>Posttraumatic amnesia of 24 hrs </li></ul></ul>American Congress of Rehabilitation Medicine
    23. 23. Pathophysiology of Injury <ul><li>Brain Injury Types: </li></ul><ul><li>Focal (contusion, hematoma) </li></ul><ul><li>Diffuse (diffuse axonal injury, DAI) </li></ul><ul><li>TBI may involve both </li></ul><ul><li>Focal damage = often visible CT or MRI </li></ul><ul><li>Diffuse = difficult identification on CT or MRI </li></ul>
    24. 24. Diffuse Axonal Injury (DAI) <ul><li>Results from acceleration-deceleration forces </li></ul><ul><li>Axonal disconnection found to occur several hours after injury </li></ul>www.brainlaw.com
    25. 25. III <ul><li>PTSD: Diagnostic Assessment – Key Considerations </li></ul>
    26. 26. PTSD Diagnostic Criteria <ul><li>Exposure to traumatic event in which both of following present, </li></ul><ul><li>(1) person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. </li></ul><ul><li>(2) person’s response involved intense fear, helplessness, or horror. </li></ul>
    27. 27. Criterion B: Re-experiencing <ul><li>Traumatic event is persistently reexperienced in one (or more) of the following ways: </li></ul><ul><li>(B1) recurrent & intrusive distressing recollections of the event, including images, thoughts, or perceptions </li></ul><ul><li>(B2) recurrent distressing dreams of the event. </li></ul><ul><li>(B3) acting or feeling as if the event were recurring </li></ul><ul><li>(B4) intense psychological distress at exposure to internal or external cues symbolic or representative of event </li></ul><ul><li>(B5) physiological reactivity on exposure to internal or external cues symbolic or representative of event </li></ul>
    28. 28. Criterion C: Avoidance & Emotional Numbing C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), (C1) Efforts to avoid thoughts, feelings or conversations (C2) Efforts to avoid activities, places, or people (C3) Inability to recall important aspect of trauma (C4) Markedly diminished interest or participation in activities (C5) Feeling of detachment or estrangement from others (C6) Restricted range of affect (C7) Sense of foreshortened future
    29. 29. Criterion D: Hyperarousal <ul><li>Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following, </li></ul><ul><li>(D1) difficulty falling or staying asleep </li></ul><ul><li>(D2) irritability or outbursts of anger </li></ul><ul><li>(D3) difficulty concentrating </li></ul><ul><li>(D4) hypervigilance </li></ul><ul><li>(D5) exaggerated startle response </li></ul>
    30. 30. Criterion E: Duration <ul><li>Duration of symptoms in Criteria B, C, D is more than 1 month. </li></ul><ul><li>Sub-types: </li></ul><ul><li>Acute : If duration of symptoms is less than 3 months </li></ul><ul><li>Chronic : if duration of symptoms is 3 months or more </li></ul><ul><li>Delayed Onset : if onset of symptoms is at least 6 months after the stressor </li></ul>
    31. 31. Criterion F: Distress or Impairment <ul><li>F. The disturbance causes clinically significant distress or impairment in social , occupational , or other important areas of functioning </li></ul>
    32. 32. System Compromise in PTSD <ul><li>Neuropsychological </li></ul><ul><li>Psychophysiological </li></ul><ul><li>Neurobiological </li></ul>
    33. 33. Neurobiological <ul><ul><li>Cerebral-spinal fluid (CSF) cortisol abnormalities in PTSD patients 20+ years post-trauma (Baker) </li></ul></ul><ul><ul><li>Exposure to even mild stressors impairs PFC functioning (Arnsten, 1998) </li></ul></ul><ul><ul><li>Stress-induced PFC dysfunction related to high levels of Norepinephrine, protein kinase C (PKC), glucocorticoid (Lupien) </li></ul></ul><ul><ul><li>Affective functioning strengthened in amygdala; less PFC, more emotion-based behavior & thought (LeDoux) </li></ul></ul><ul><ul><li>Dendritic spine loss in PFC & hippocampus (Radley; Liston) </li></ul></ul><ul><ul><li>Increased dendritic complexity in the amygdala (Mitra) </li></ul></ul><ul><ul><li>Dysregulation of HPA axis in PTSD: cortisol, epinephrine, norepinephrine, DHEA, GABA (Yehuda; Rassmussen; Resick) </li></ul></ul>
    34. 34. HPA Axis
    35. 35. Psychophysiological <ul><li>Exaggerated startle; impaired pre-pulse inhibition (Orr; Pitman) </li></ul><ul><li>Increased Galvonic Skin Response (nGSR) during thought suppression (Aikins & Johnson) </li></ul><ul><li>High vagal tone, low heart-rate variability (Aikins) </li></ul>
    36. 37. Neuropsychological <ul><li>Impaired attention (sustained & divided), concentration (Vasterling) </li></ul><ul><li>Working memory deficits (Vasterling) </li></ul><ul><li>Logical memory deficits </li></ul><ul><li>Heightened negative affect & confusion </li></ul><ul><li>Source memory impairment (Johnson) </li></ul><ul><li>* Reaction time advantages (Vasterling) </li></ul>
    37. 39. PTSD & Emotion Regulation Medial Prefrontal Cortex (mPFC) Shin et al., Biological Psychiatry, 2001
    38. 40. IV <ul><li>Arguments against TBI & PTSD coexistence </li></ul>
    39. 41. 3 Arguments <ul><li>Disturbed consciousness (LOC or PTA) precludes “experiencing” or “witnessing” event </li></ul><ul><li>Disturbed consciousness prevents memory formation necessary for Criterion B (Re-experiencing) </li></ul><ul><li>Posttraumatic Amnesia (PTA) is incompatible with Criterion C (Avoidance & Emotional Numbing) </li></ul>Harvey, Brewin, Jones, & Kopelman, 2003
    40. 42. Do LOC & PTA preclude PTSD?
    41. 43. V Resolution <ul><li>Question: Why is fear stored indelibly? </li></ul><ul><li>Hypothesis: If you forget what has potential to harm you, your ability to survive is compromised </li></ul>LeDoux
    42. 44. <ul><li>Declarative Memory – Explicit memory for things and events (e.g. semantic and episodic) </li></ul><ul><li>Non-Declarative Memory – Implicit memory for ‘how to do things’ (procedural) and conditioning (learned associations) </li></ul>Multiple Memory Systems
    43. 46. Differential Effects of Overwhelming STRESS Facilitation Impairment Strengthening of implicit emotional memory Loss of explicit memory for emotional experiences
    44. 47. Contextual Conditioning <ul><li>If ‘x’ then ‘y’ </li></ul><ul><li>Learning = ‘y’ is an extremely reliable predictor of ‘x’. </li></ul><ul><li>If ‘s’ then not ‘q’ </li></ul><ul><li>Learning = ‘s’ is an extremely reliable predictor of ‘q’ </li></ul>
    45. 48. Associative Learning (Conditioning)
    46. 49. TBI & PTSD: Resolution of Coexistence <ul><li>Encoding of memories is mediated via differential pathways (explicit vs. implicit) </li></ul><ul><li>Emotional memories encoded through limbic structures involved in conditioning (associative learning) </li></ul><ul><li>Trauma cues and contextual cues can be learned and stored in memory w/o explicit awareness </li></ul><ul><li>Single-trial learning through implicit memory pathway is basis for post-trauma conditioned fear responses </li></ul>
    47. 50. VI <ul><li>Recommendations for Forensic Assessment of PTSD & TBI </li></ul>
    48. 51. Elements of Forensic PTSD Assessment <ul><li>Comprehensive clinical examination: family, developmental history, pre-event & post-event functioning. </li></ul><ul><li>Use of validated diagnostic interview specifically developed for the assessment of PTSD symptoms and their impact on life/functioning </li></ul><ul><li>Use of structured diagnostic interview that provides an opportunity to explore Axis I & Axis II disorders </li></ul><ul><li>Use of general personality questionnaires measuring broad characteristics and response style </li></ul><ul><li>Measures of social-role & work functioning </li></ul><ul><li>Assessment of malingering and feigned symptom or cognitive impairment </li></ul><ul><li>Neuropsychological testing results. </li></ul>Keane et al, 2003
    49. 52. Clinician Administered PTSD Scale (CAPS) <ul><li>The ‘gold standard’ in PTSD assessments </li></ul><ul><li>Structured (clinician driven) interview </li></ul><ul><li>Accounts for both frequency & intensity of symptoms </li></ul>
    50. 53. What’s so special about ‘avoidance’? <ul><li>Most trauma survivors do not develop PTSD </li></ul><ul><li>For significant portion of those with PTSD, the disorder remits over time. </li></ul><ul><li> chronic PTSD may represent a type of vulnerability characterized by maladaptive cognitive (avoidance) process following extreme stressors </li></ul>
    51. 54. Criterion C predicts PTSD <ul><li>OK City bombing (North et al., 2004) </li></ul><ul><ul><li>Criterion C met = YES = 96% had PTSD </li></ul></ul><ul><ul><li>Criterion B met = YES = 40% had PTSD </li></ul></ul><ul><ul><li>Criterion D met = YES = 39% had PTSD </li></ul></ul>
    52. 55. Absence of Criterion C <ul><li>No-PTSD group: </li></ul><ul><ul><li>2% met Criterion C criteria </li></ul></ul><ul><ul><li>70% met Criterion B criteria </li></ul></ul><ul><ul><li>73% met Criterion D criteria </li></ul></ul>
    53. 56. Conclusions <ul><li>PTSD & TBI can coexist </li></ul><ul><li>Diagnostic precision requires multimodal approach </li></ul><ul><li>PTSD & TBI are dynamic and each influences presentation and course of the other </li></ul>
    54. 57. Conclusions (continued) <ul><li>Symptom overlap of PTSD & TBI indicate need for separate psychological and neuropsychological evaluations </li></ul><ul><li>Dynamic interaction of PTSD & TBI suggest serial assessment </li></ul>
    55. 58. Thank you <ul><li>CONTACT </li></ul><ul><li>Douglas Christian Johnson, Ph.D. </li></ul><ul><li>Email1: [email_address] </li></ul><ul><li>Email2: [email_address] </li></ul><ul><li>Cell: (818)262-9533 </li></ul>