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TBI & PTSD 2008

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

Health & Medicine
1 of 58
… mutually exclusive or two sides of the same coin? PTSD and MTBI
Overview ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],I
[object Object],[object Object]
old phenomenon…
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?
… new context
Diagnostic Challenges ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],Diagnostic Challenges
(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
[object Object],II
Annual Incidence Brain Injury Association of America
Causes of TBI Brain Injury Association of America
TBI Risk ,[object Object],[object Object],[object Object],[object Object]
Combat TBI - Prevalence ,[object Object],[object Object],[object Object]
Military Service & TBI ,[object Object],[object Object],[object Object]
Glasgow Coma Scale (GCS) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Glasgow Coma – Limitations ,[object Object],[object Object],[object Object]
Loss of Consciousness (LOC) ,[object Object],[object Object],[object Object],[object Object]
Posttraumatic Amnesia (PTA) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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)
Diagnostic Criteria for Mild TBI (MTBI) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],American Congress of Rehabilitation Medicine
Pathophysiology of Injury ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diffuse Axonal Injury (DAI) ,[object Object],[object Object],www.brainlaw.com
III ,[object Object]
PTSD Diagnostic Criteria ,[object Object],[object Object],[object Object]
Criterion B: Re-experiencing ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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
Criterion D: Hyperarousal ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Criterion E: Duration ,[object Object],[object Object],[object Object],[object Object],[object Object]
Criterion F: Distress or Impairment ,[object Object]
System Compromise in PTSD ,[object Object],[object Object],[object Object]
Neurobiological ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
HPA Axis
Psychophysiological ,[object Object],[object Object],[object Object]
 
Neuropsychological ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
PTSD & Emotion Regulation Medial Prefrontal Cortex (mPFC) Shin et al., Biological Psychiatry, 2001
IV ,[object Object]
3 Arguments ,[object Object],[object Object],[object Object],Harvey, Brewin, Jones, & Kopelman, 2003
Do LOC & PTA preclude PTSD?
V Resolution ,[object Object],[object Object],LeDoux
[object Object],[object Object],Multiple Memory Systems
 
Differential Effects of Overwhelming STRESS Facilitation Impairment Strengthening of implicit emotional memory Loss of explicit memory for emotional experiences
Contextual Conditioning ,[object Object],[object Object],[object Object],[object Object]
Associative Learning (Conditioning)
TBI & PTSD: Resolution of Coexistence ,[object Object],[object Object],[object Object],[object Object]
VI ,[object Object]
Elements of Forensic PTSD Assessment ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Keane et al, 2003
Clinician Administered PTSD Scale (CAPS) ,[object Object],[object Object],[object Object]
What’s so special about ‘avoidance’? ,[object Object],[object Object],[object Object]
Criterion C predicts PTSD ,[object Object],[object Object],[object Object],[object Object]
Absence of Criterion C ,[object Object],[object Object],[object Object],[object Object]
Conclusions ,[object Object],[object Object],[object Object]
Conclusions (continued) ,[object Object],[object Object]
Thank you ,[object Object],[object Object],[object Object],[object Object],[object Object]

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TBI & PTSD 2008

  • 1. … mutually exclusive or two sides of the same coin? PTSD and MTBI
  • 2.
  • 3.
  • 4.
  • 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. … new context
  • 8.
  • 9.
  • 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.
  • 12. Annual Incidence Brain Injury Association of America
  • 13. Causes of TBI Brain Injury Association of America
  • 14.
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  • 20.
  • 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.
  • 23.
  • 24.
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  • 27.
  • 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.
  • 30.
  • 31.
  • 32.
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  • 36.  
  • 37.
  • 38.  
  • 39. PTSD & Emotion Regulation Medial Prefrontal Cortex (mPFC) Shin et al., Biological Psychiatry, 2001
  • 40.
  • 41.
  • 42. Do LOC & PTA preclude PTSD?
  • 43.
  • 44.
  • 45.  
  • 46. Differential Effects of Overwhelming STRESS Facilitation Impairment Strengthening of implicit emotional memory Loss of explicit memory for emotional experiences
  • 47.
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  • 58.