Download Brain Injury Rehabilitation Increasing Community Participation

Post-Traumatic Stress Disorder
(PTSD) and TBI
Kyle Haggerty, Ph.D.
Learning Objects
•
•
•
•
•
•
•
What is Brain Injury
What is PTSD
Statistics
What to Rule Out
PTSD and TBI
Treatment
Case Study
What is Brain Injury
Traumatic Brain Injury
• Traumatic Brain Injury (TBI): cerebral damage that
occurs after birth, and is not directly related to a
developmental disorder or a progressive damaging of the
brain. Traumatic brain injury refers to a specific form of
acquired brain injury that is the result of a sudden trauma.
Physical Causes
Bruising/Bleeding, Tearing, Swelling, Open/Closed injuries
Common Symptoms
•
•
•
•
•
•
•
•
Headaches
Memory Deficits
Word Finding Difficulty
Fatigue
Changes in Emotion
Changes in Sleep
Impulsiveness
Concentration
Memory
• Immediate Memory
– Not a Common Complaint
• Short Term Memory
– Most Common Deficit in TBI
• Long Term Memory
– Missing details due to STM loss
• Retrograde Amnesia
– Time before injury
• Anterior grade Amnesia
– Immediate time following injury
Chronic Pain
• Headaches
• Spinal Cord Injuries
• Ineffectiveness of Pain Medication
Overload
• Brought on by large crowds, lots of noise,
or information presented too quickly.
– Inability to process external environment
– Fatigue
– Rise in emotions
Emotions
• Emotions can become flat or amplified.
– Lack of inhibition
– Trouble analyzing social situations
• Difficulty with facial expression or tone of voice
Language/Word Finding
• Aphasia
– Circumlocution
– Hand Gestures
– Tip of the tongue
• Common due to anatomy of skull
TBI and Mental Illness
• Prevalence rates for psychiatric disorders
are high after TBI.
– Depression rates have been reported in 14 to
77% of patients
– Substance abuse 5 to 28%
– PTSD 3 to 27%
– Other anxiety disorders 3 to 28%
What is PTSD
Overview
•
Posttraumatic stress disorder (PTSD) is an anxiety disorder that
a person may develop after experiencing or witnessing an
extreme, overwhelming traumatic event during which they felt
intense fear, helplessness, or horror.
•
The dominant features of posttraumatic stress disorder are
emotional numbing (i.e., emotional nonresponsiveness),
hyperarousal (e.g., irritability, on constant alert for danger), and
reexperiencing of the trauma (e.g., flashbacks, intrusive
emotions).
•
PTSD is as an anxiety disorder. Anxiety disorders cover several
different forms of abnormal, pathological anxiety, fears, phobias
and nervous conditions that may come on suddenly or gradually
over a period of several years, and may impair or prevent the
pursuing of normal daily routines.
Diagnosis Criteria for PTSD
• Criteria A
• The person experienced, witnessed, or was confronted with an event
involving actual or threatened death, serious injury or a threat to physical
integrity of self or others
• The person’s response involved intense fear, helplessness or horror
Continued
• Criteria B
• The traumatic event is re-experienced in one or more of the following
ways
• Recurrent images, thoughts or perceptions
• Recurrent distressing dreams of the event
• Acting or feeling as if the event was recurring
• Intense psychological distress OR physiologic reactivity at exposure
to cues that symbolize or resemble an aspect of the event
Continued
• Criteria C
• Persistent avoidance of stimuli associated with trauma and numbing as
indicated by 3 or more:
• Avoiding thoughts, feelings, or discussion, activities, places or people
that bring back recollections; sense of foreshortened future
• Inability to recall; restricted affect
• Diminished interest or participation
• Feeling detached or estranged
Continued Some More
• Criteria D
• Persistent symptoms of increased arousal by 2 or more:
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response
• Criteria E
• Duration for more than 1 month
Statistics
Prevalence
• The National Comorbidity Survey Replication
(NCS-R) estimated the lifetime prevalence of
PTSD among adult Americans to be 6.8%
• Current past year PTSD prevalence was
estimated at 3.5%
• The lifetime prevalence of PTSD among
men was 3.6% and among women was
9.7%
• The twelve month prevalence was 1.8%
among men and 5.2% among women
Veterans
•
The National Vietnam Veterans Readjustment Study (NVVRS)
conducted between November 1986 and February 1988,
comprised interviews of 3,016 American Veterans selected to
provide a representative sample of those who served in the armed
forces during the Vietnam era
• The estimated lifetime prevalence of PTSD among these
Veterans was 30.9% for men and 26.9% for women.
• Of Vietnam theater Veterans, 15.2% of males and 8.1% of
females were currently diagnosed with PTSD at the time the
study was conducted
•
Recent conflicts
• Prevalence of current PTSD was 13.8%
Caution
•
Since its inception PTSD has been embroiled in debate over
multiple issues
• Major controversies about the diagnosis include the political
climate in which it was conceived (Herbert & Forman, 2005;
McNally, 2004), the recent broadening of the definition of the
traumatic event that is required to meet a diagnosis for PTSD,
and that event’s questionable association with symptom
manifestation
•
Mol et al. (2005) found that PTSD symptoms were as commonly
associated with life events such as an illness or problems at work
as they were with events that meet Criterion A
•
Terheggen, Stroebe, and Kleber (2001) reported that for Tibetans
the most traumatic event was the witnessing of the destruction of
religious signs
What to Rule Out
Some of the disorders that must be ruled out when diagnosing PTSD
include the following:
•
Acute stress disorder (duration of up to 4 weeks)
•
Adjustment disorder (less severe stressor or different symptom
pattern)
•
Mood disorder or other anxiety disorder (symptoms of
avoidance, numbing, or hyperarousal are present before
exposure to the stressor)
•
Other disorders with intrusive thoughts or perceptual
disturbances (obsessive compulsive disorder, schizophrenia,
other psychotic disorder)
•
Substance abuse or dependence disorder
•
Chronic Personality Disorder
TBI and PTSD
Correlation Between PTSD
and TBI
•
Research suggests that PTSD is more likely following TBI
• Incidence 13%-27%
• Prevalence 3%-59%
(Bryant, 2000)
•
Some researchers argued that PTSD following a head injury was not possible
due to memory loss, but many of those hypotheses have not been supported
by the data
Risk Factors for Developing
PTSD Following a TBI
•
•
•
•
•
Female
Avoidant
Lesions to the left temporal lobe
Pre-morbid depression or anxiety
Early symptoms of depression following the injury
Symptoms of TBI and PTSD
PTSD Symptoms
Mild TBI Symptoms
Memory Problems
Memory Problems
Poor Concentration
Poor Concentration
Depression
Depression
Irritability
Irritability
Sleep Difficulties
Sleep Difficulties
Avoidance
Headaches
Re-experiencing Symptoms
Dizziness
Where Is the Difference?
• All of the Criteria except for one are frequently
met by someone who suffered a significant head
injury.
• The exception is criteria B (Re-experiencing the
trauma)
PTSD
Cognitive
Impairment
TBI
Treatment
Prolonged Exposure
•
Treatment addresses two of the primary factors that maintain post-trauma
symptoms: avoidance and unhelpful thoughts and beliefs
•
Therapist explains that confrontation with distressing memories or situations:
•
•
•
•
•
Facilitates emotional processing
Helps patient learn to better discriminate trauma reminders from the trauma itself
Helps reduce excessive dear and gain realistic perspective on trauma
Reduces PTSD symptoms
Two types of exposure: imaginal exposure and in vivo exposure
Continued
• Behavioral stress management is an important component of the therapy
(e.g. breathing retraining)
• Construct In-Vivo Hierarchy
• Construct Imaginal Hierarchy
Other Treatments
•
•
•
•
Cognitive Processing Therapy (CPT)
Virtual Reality
Mindfulness
Preventive Treatment with Benzodizapines
Case Study
Demographics
• 34 year old male
• Married
• Caucasian
Referring Question
• Was the patient experiencing postconcussive symptoms, or symptoms related
to anxiety?
History
•
According to Mr.*****’s records, he enlisted in the Army in May
1995, and was active duty in the Army until 11/2005
•
He did two tours in Afghanistan (11/2001 for six months, and
7/2003-4/2004)
•
On 9/29/2004, the Veteran was exposed to a RPG explosion, in
which he sustained hearing loss.
•
Mr. ***** reports that he did not lose consciousness during the
incident, but did notice a brief alteration in consciousness
•
Following the injury he was able to return to his duties, and did not
require hospitalization.
Continued
•
The Pt did report that he was in several fights during his time in the
military “where he was beat up.”
•
Following his second deployment the Pt was diagnosed with PTSD.
•
The Pt has been prescribed medication for the treatment of his
PTSD (ongoing) (benzodiazepines)
Current Symptoms
•
Mood
•
The Pt reported that he was continuing to have difficulty
leaving the house due to the anxiety he experienced
•
He described experiencing significant symptoms of
hypervigilance, which worsen when he was in a crowd.
•
Due to these symptoms the Pt very rarely leaves his home,
and has limited social contacts outside of his family.
Current Symptoms
•
Attention/Memory
•
Both the Pt and his wife reported that he was suffering from
attention/memory deficits.
•
He often forgot how to get to places while driving (such as the
grocery store), and the birthdays of his children.
•
The Pt reported that due to these symptoms, and because he
would become distracted and engage in risky behaviors (e.g.
inattentive lane changes, reported once beginning to take his
seatbelt off and get out of a still moving vehicle), he no longer
drove.
•
The Pt reported fewer memory deficits when he remains in his
home.
Current Symptoms
•
Headaches/Vestibular
•
The Pt reported several physical symptoms, which included
chronic headaches and dizzy spells.
• He did not identified any triggers to those symptoms, and
felt they occurred somewhat randomly.
• Specifically, he did not feel the symptoms were related to
bright lights, movement, noise, or posture (although the
Pt did report that he found it difficult to tolerate
background noise, which increased his agitation).
•
The Pt had been treating his headaches with over the counter
medication, which he used frequently, and may have been
experiencing increased sensitivity to pain, due to his chronic
use of the medication.
• He was prescribed topemax for his headaches, but
reported a strong negative reaction where he “felt out of
it,” and only took one dose of the medication.
Impressions
•
The history provided by the Pt did not suggest that he had
experienced significant post-concussive symptoms.
•
The cognitive deficits the Pt reported suffering from appeared to be
attention deficits, rather than impairments in primary memory.
•
The level of psychological distress that he was reporting would be
expected to produce this type of cognitive interference.
•
While it was not possible to rule out the blast injury as a cause of
the Pt’s symptoms, it appeared more likely that his severe PTSD
symptoms were the cause of the cognitive symptoms.
Plan
•
The Pt was encouraged to begin therapy with a provider who
specializes in the treatment of PTSD.
•
Prolonged exposure recommended as cognitive challenges
could make cognitive based interventions less effective