Download Traumatic_Brain_Injury

Characteristics of Mild Traumatic
Brain Injury and Persistent
Symptoms
Disclaimer
The views expressed in this presentation
are those of the authors and do not
reflect the official policy of the
Department of the Navy, Department of
the Army, Department of Defense, or
the U.S. Government.
2
Points to be Covered
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Mild traumatic brain injury (MTBI)
Postconcussion Syndrome (PCS)
Posttraumatic Stress Disorder (PTSD)
Other explanations for persistent complaints
following MTBI
Pathophysiology of MTBI
 A “neurometabolic cascade” leaves the
brain in a state of neurophysiologic disarray
during the acute phase after injury
 Functional neuroimaging studies in animals
and humans have demonstrated the brain’s
return to normal neurophysiologic
functioning within days to weeks
 MTBI is a transient process followed by
spontaneous recovery
Symptoms Reported Following
MTBI
 Physical
Headaches
Dizziness
Sensitivity to light or noise
Impairments in vision and hearing
Problems with balance
Fatigue
Symptoms Reported Following
MTBI
 Cognitive
Impaired memory
Concentration
Word finding difficulty
Slowed overall processing
Impaired organizational and problem solving
skills
Symptoms Reported Following
MTBI
 Behavioral
Difficulty being around people
Personality changes
Irritability, frustration, “short-fuse”
Functional Outcome after
MTBI (Civilian Population)
 Most severe sxs are evident within minutes
of injury
 There is measurable improvement within
hours of injury
 A combination of physical and cognitive sxs
is most common
 Recovery occurs over 7-10 days in an
overwhelming majority (80-90%)
Functional Outcome after
MTBI (Civilian Population)
 Memory is the most susceptible to change
after MTBI, but shows recovery within days
 Headache is the symptom that tends to
linger the longest and be most problematic
in terms of clinical management
 Delayed sx onset is rare
 Sxs persisting beyond the expected
recovery are often attributable to non-injury
related factors
Functional Outcome after
MTBI (Civilian Population)
 In moderate and severe TBI, acute injury
severity (as measured by LOC, PTA, and
GCS) is the single strongest predictor of
functional outcome.
 In the MTBI population injury-related factors
have not been found to be powerful
predictors of outcome or persistent
postconcussion symptoms
Functional Outcome after
MTBI (Civilian Population)
 Non-injury factors are more commonly
predictive of potential for poor outcome:
Preexisting medical or psychological problems
High levels of psychosocial stress at time of
injury
Poor social support systems
Alcohol and drug use
Litigation (motivational factors)
Clinical Presentation of MTBI
(Concussion) due to Blast Exposure
 Often no LOC or brief LOC (<5 minutes)
 “Alteration in consciousness” (dazed,
confused, temporarily disorientated)
 No Posttraumatic Amnesia, or PTA of short
duration
PTA = the last event recalled before the injury
(retrograde amnesia) & the first event recalled
after the injury (anterograde amnesia)
Medical Management of
MTBI
 A recent systematic review of treatments for
mild TBI (Cooper, 2005, Brain Injury)
Medication
Cognitive rehabilitation
Educational intervention
 Strongest evidence is in support of the
effectiveness of early patient education
 Provide expectation for recovery
Postconcussion Syndrome
DSM-IV Research Criteria
 History of head trauma that has caused
significant cerebral concussion (includes
LOC, PTA, and less commonly
posttraumatic onset of seizures)
 Evidence from neuropsychological testing or
quantified cognitive assessment of difficulty
in attention or memory
Postconcussion Syndrome
DSM-IV Research Criteria
 3 or more sxs occur shortly after the trauma
and persist for at least 3 months
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Becoming easily fatigued
Disordered sleep
Headache
Vertigo or dizziness
Irritability or aggression on little or no provocation
Anxiety, depression, or affective instability
Changes in personality (e.g. social or sexual
inappropriateness)
– Apathy or lack of spontaneity
Etiology of Postconcussion Syndrome
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Debate: neurological damage vs. transient
physiological disturbance with the
symptoms maintained by psychological
distress.
Explanations for PCS
1) Chronic or residual CNS damage
2) Secondary gain
3) Emotional response to the trauma or an
overlay of posttraumatic stress disorder
Rimel, Giordani, Barth, Boll, & Jane (1981)
Nonspecificity of PCS
 Studies have shown the level of sx
endorsement reported by TBI patients and
controls is similar
– Chronic pain population
– Fibromyalgia patients
– Psychiatric patients
– Normal controls
– Iverson & Lange (2003) found PCS sxs are not
unique to MTBI, and are highly correlated with
depressive symptoms
Gordon, Haddad, Brown,
Hibbard, and Sliwinski (2000)
 Examined a large sample:
– Individuals with mild, moderate, and severe TBI
– HIV-positive patients
– Patients with spinal cord injury
– Patient s/p liver transplant
– Nonaffected controls
Gordon, Haddad, Brown,
Hibbard, and Sliwinski (2000)
 MTBI patients reported significantly more
sxs than the other groups including those
with moderate and severe TBI
 Only MTBI patients reported cognitive
impairments
Posttraumatic Stress Disorder
Definition and History
 An Anxiety Disorder
 PTSD is unique among psychiatric disorders in
that the symptoms are directly linked to a
traumatic event
 5th most common psychiatric disorder (5% of
Americans)
 20 years after Vietnam, 15% of combat veterans
still have PTSD (National Vietnam Veteran Readjustment Study,
1990)
Posttraumatic Stress Disorder
 Characterized by reexperiencing symptoms,
avoidance behaviors, and elevated arousal
 To meet diagnostic criteria:
– The symptoms must cause marked impairment
in functioning
– Symptoms persist for at least one month
following the trauma
Symptoms of PTSD
 Emotional
– Irritability
– Mood swings
– Increased Aggression
– Withdrawal/Avoidance
Cognitive
– Forgetfulness
– Attentional Problems
– Concentration
 Physical
– Difficulty sleeping
– Over arousal
Overlap Symptoms of MTBI & PTSD
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Concentration
Memory deficits
Sleep problems
Irritability/anger/increased aggression
Withdrawal
Differentiating MTBI in the
OIF/OEF Population
 Obtain brain injury history
– Type of injury (e.g. blast exposure, penetrating
vs. nonpenetrating, etc.)
– LOC, PTA, neuroimaging
– Assess for postconcussion symptoms
– Effects of sedating medication
– Time since injury
Differentiating MTBI in the OIF/OEF
Population
 Obtain combat/trauma history
– number of deployments, combat duties
 Assess “arousal” vs. “depressive” symptoms
 Clinical judgment
– Blast exposure w/o LOC, PTA, or medical
treatment
– Completed tour of duty
– Reports symptoms 1 year later
 PTSD or MTBI?
PTSD
TBI
Substance
Chronic
Alcohol
Abuse
Medication
Pain
Possible explanations for
Persistent PCS
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PTSD overlay
Goal oriented behavior: “Patient role”
Somatoform disorder
Factitious disorder
Malingering
Somatoform Disorder
DSM-IV Criteria
 A history of many physical complaints
before age 30 that occurs over several
years and results in seeking treatment
 Reports of significant social, occupational,
or other functional impairment
 Sxs from 4 separate areas must be
experienced (pain, gastrointestinal, sexual,
& pseudoneurological)
Somatoform Disorder
DSM-IV Criteria
 “Appropriate investigation” must reveal no
specific medical condition that would explain
the sxs
 The sxs are not produced intentionally, as to
distinguish them from factitious disorders
and malingering
Criticisms of the Diagnostic
Criteria for Somatoform Disorder
 Restrictive criteria made the conditions
appear to be rare
 Medically unexplained symptoms (1980’s)
captures a sizable population with
somatoform issues, despite not meeting the
formal diagnostic criteria
Factitious Disorder
DSM-IV Criteria
 Intentional production or feigning of physical
or psychological signs or symptoms
 The motivation for the behavior is to assume
the sick role
 External incentives for the behavior such as
economic gain or avoiding legal
responsibility, as in malingering, are absent.
Malingering
 “The intentional production of false or
grossly exaggerated physical or
psychological symptoms, motivated by
external incentives such as avoiding military
duty, avoiding work, obtaining financial
compensation, evading criminal prosecution,
or obtaining drugs.”
DSM IV
Forms of Malingering
 Feigning
– Never any symptoms
– Symptoms existed but resolved
 Exaggeration
– A disability would be advantageous.
– Complaints of distress that appear to exceed
what the injury or illness would be expected to
cause, signal the possibility of malingering.
Malingering vs. Factitious Disorder
Malingering
Factitious Disorder
Volitional
Volitional
Conscious Goals
Unconscious Goals
Self Controlled
Compulsively Driven
May Be Adaptive
Psychopathological
Avoids Risky/Painful
Procedures
Avoids Self Harm
Eagerly Undergoes Such
Procedures
May Inflict Personal Injury
Characteristics of Individuals
Seeking Secondary Gain
Unconscious
(e.g. Somatoform, Factitious)
Intentional
(e.g. Malingering)
Cooperative, pleasant
Guarded, hostile
Good rapport
Poor rapport
Dependent, naive
Manipulative
Disability payments reinforce
dependency and self -doubt
Disability payments
encourage further
manipulation
Gaps in history
Few gaps
Personality testing reveals
neurotic conflicts
May reveal antisocial
personality traits
Characteristics of Individuals
Seeking Secondary Gain
Unconscious
(e.g. Somatoform, Factitious)
Intentional
(e.g. Malingering)
Difficulty performing
responsibilities
Same
Difficulty with leisure activities
Leisure functioning intact
Performs poorly in each
setting
Performs poorly when being
observed
History of responsibility
Variable
Will accept offer to work in
non-impaired activities
Enjoys visiting the doctor
Usually rejects such an offer
Submits to treatment
Avoids treatment
Dislikes
Management of Persistent
Symptoms
 Patients with medically unexplained
symptoms often encounter treatment
providers who are dismissive or
disrespectful
– Results in “doctor shopping”
 As clinicians we have the opportunity to take
a more tolerant approach to dealing with
interpersonal limitations (e.g. poor coping,
faulty beliefs)
Management of Persistent
Symptoms
 Our goal is to encourage appropriate
interventions to break the cycle
– Discuss referrals to psychiatry in the context of
“mind-body” connections
– When asked: doctor, do you think it is all in my
head, answer yes! Because the brain interprets
symptoms
Management of Persistent
Symptoms
 Treatment interventions
– Cognitive behavioral therapy (CBT) to reframe
faulty beliefs
– Treatment should focus on determining the
meaning of the symptoms to the patient
– Education is important in the acute and chronic
phases of symptom presentation