Download TITLE: Co-occurrence of mTBI, PTSD in Role Transitioning for

TITLE: Evaluating Evidence for the Treatment of Co-occurrence of PTSD amd mTBI
in Role Transitioning for Veterans: Case Study Approach
AUTHOR NAMES: AUTHOR 1, M.Sc.OT, OT Reg. (Ont.) 1,3 AUTHOR 2, M.Sc.OT,
O.T. 2,3
AUTHOR AFFILIATIONS:
1
Author 1 is a private practice occupational therapist in Toronto, Ontario.
2 Author
2 is an occupational therapist and PhD student at the University of Alberta, Dept. of Pediatrics,
Faculty of Medicine & Dentistry, in Edmonton, Alberta. (Address: Autism Research Centre, Glenrose
Rehab Hospital – E209, 10239 – 111 Ave, Edmonton AB)
3
This work was completed as part of coursework for University of Toronto’s Master of Science in
Occupational Therapy program. (Address: Dept of OS & OT, University of Toronto, 160 – 500 University
Ave, Toronto ON)
CORRESPONDING AUTHOR EMAIL ADDRESS: [email protected]
ABSTRACT
The application of cognitive strategies as part of role transitioning for this population
subset has been understudied; the primary purpose of this paper is to draw conclusions
based on available literature to inform current rehabilitation practice in mental health and
future areas of research. We will evaluate the efficacy of cognitive strategy to support
role transitions in post-tramatic stress disorder (PTSD) with co-occurrence mild traumatic
brain injury (mTBI) for veterans using a case-study approach. Although typical
interventions for these separate conditions are based on a variety of theoretical
underpinnings, they can work together harmoniously with a complex and co-morbid
population.
KEYWORDS: Rehabilitation, evidence evaluation, co-morbid, PTSD, mTBI, veteran
MANUSCRIPT TEXT:
This paper is informed by case of Bobby Wu (BW), a returning Canadian Military
soldier concurrently experiencing mild traumatic brain injury (mTBI) and posttraumatic
stress disorder (PTSD). BW was referred to a small team of occupational therapists who
work within a multidisciplinary rehabilitation team in a Veterans Clinic, specifically
designed for returning soldiers and military service members. The aim of a
multidisciplinary rehabilitation team is to support the reintegration of soldiers returning
from war into society and to address physical, cognitive, and psychosocial dysfunction
that may be evident after traumatic war experiences. Occupational therapist’s are
invaluable rehabilitation practitioners on the multidisciplinary team as their scope of
practice addresses return of physical, cognitive, and psychosocial functioning, and
specifically enabling individuals to return to previous life roles and previously enjoyed
occupations.
BW sustained a mTBI while deployed overseas and during intake other issues
became apparent that were impeding his occupational performance specifically PTSD. In
addition, Bobby questions his role as a “good father” and “loving husband” since
returning home to civilian life. Management has agreed to allow the scope of the initial
referral to be expanded and with Bobby’s consent the occupational therapist’s decide to
concurrently address mTBI, PTSD, and role transition difficulties. The question raised is
regarding the potential contraindications for best practices when addressing these issues
concurrently.
Although we have framed this paper within the context of a case study, Canada’s
military force is currently deployed in several international conflicts including
Afghanistan, Democratic Republic of Congo, Darfur, South Sudan and the boarder
between Israel and Syria.1 Soldiers returning from duty may face a multitude of physical
and psychological challenges, potentially in combination. As rehabilitation professionals,
we must consider the appropriateness and potential contraindications of treating comorbidities concurrently (mTBI and PTSD) to promote re-engagement of BW’s roles as
husband and father, including the evidence that supports or refutes such an approach.
Prior to investigating the evidence about the co-occurrence of mTBI, PTSD and
role transitioning, our assumption was that there might be contraindications between
therapies. Our clinical reasoning questioned the efficacy of using already impaired
cognitive processes due to mTBI to rehabilitate co-occurring psychological dysfunction
(PTSD) and its relationship to successful role transitioning. Therefore, this paper outlines
the process of enabling occupation from a multi-faceted evidence-informed clinical
perspective.
Background
A head injury is considered to be a mild traumatic brain injury (mTBI) when: a
person experiences a loss of consciousness for less than thirty minutes, an altered state of
consciousness for up to 24 hours, or posttraumatic amnesia of one day or less.2 Initial
symptoms include: headache, dizziness, nausea and vomiting, sleep disturbances,
sensitivity to noise and light, slowed thinking and reaction time, memory impairments,
irritability, depression, and visual changes.3 Individuals who sustain a mTBI can present
with symptoms at the time of the incident or days to weeks after the traumatic event.1
BW is experiencing both attention and concentration deficits weeks after the injury
occurred. In most cases, symptoms resolve within three months of injury, however 1030% of people with mTBI experience symptoms that persist and can affect resumption of
life roles and occupations.1
Posttraumatic stress disorder (PTSD) is a debilitating anxiety disorder that may
cause a person a significant distress and often goes undiagnosed.4 As defined in the
Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revised
(DSM-IV-TR),5 our client experiences PTSD as he was exposed to repeated traumatic
events as part of his job as a soldier as well as recurrent distressing dreams and
dissociative reactions (flashbacks) in which he feels the event is re-occurring. He also
experiences difficulty concentrating on tasks. As well, BW has persistent internal stimuli
(i.e. thoughts and feelings) that are constantly arousing the recollection of these traumatic
events. This has lasted over one month and has severely impaired his occupational and
social functioning.
For men, the types of trauma most commonly associated with PTSD are exposure
to military combat and witnessing a person being badly injured or killed.4 Evidence
shows that 11.3% of soldiers returning from Afghanistan experience PTSD.6 Keeping in
mind the high prevalence of soldiers who experience PTSD and research stating that
PTSD often goes undiagnosed, occupational therapists (OTs) can play a critical role in
detecting symptoms of PTSD in military service men. In general, understanding the
process and risk factors associated with combat stress relating to mental health is
important in rehabilitating psychological distress.7 Early intervention is important to
consider as the research shows that continued mental health concerns, such as PTSD,
continue to manifest today for soldiers who have served in World War 1, World War 2,
the Korean War and the Vietnam War. 7
Considering the transitioning needs of military men returning to Canada after
deployment is crucial to the treatment plan for BW. Re-integration is defined as “the
process of personal transitioning back into personal and organizational roles and society
after having been deployed.”8 Transitions can be associated with increased stress due to
the process of re-adjusting to an environment that is no longer familiar. BW is
experiencing difficulties with role transitioning after deployment, specifically his role as
husband and father.
Methods
We have conducted a preliminary literature search for “combat stress”+
“occupational therapy” + “transition” since 2009. After feedback from course instructors,
we conducted a second literature search for “combat stress”+ “mild traumatic brain
injury” since 2009 in Medline, CINHAL and Scopus. From this we found approximately
22 relevant articles, mostly situated within an American military context. Even though
much of the research comes from the American rehabilitation perspective, we believe that
there are clinical implications that can inform our own Canadian military service men’s
re-integration into society. To understand the perspective of returning soldiers such as
BW, we visited several online forums for individuals with PTSD and trauma experiences.
In addition, we read through several online newspaper articles and editorials to guide our
understanding of current national and international events. From the University of
Toronto’s Gerstein library, we located a comprehensive resource entitled “Effective
Treatments for PTSD” which provided an evidence-based clinical perspective on PTSD.
Intervention for Mild Traumatic Brain Injury
The high incidence of mTBI in military service men can be attributed to the
consequences of blasts or explosions caused by explosive devices placed on the roadside
or hidden in buildings.9 Evidence for primary blast effects (effects of the blast “wave”
itself) on the central nervous system is limited and is currently being investigated through
research.10 However, preliminary research suggests that there are a number of specific
characteristics associated with a blast induced brain injury including high rates of sensory
impairment, pain issues, and polytrauma.10 These characteristics differ from more
commonly associated brain injuries due to motor vehicle accidents or falls in a civilian
population.10 BW’s most concerning symptom is his inability to attend to tasks and
maintain his concentration.
Aspects of a comprehensive mTBI intervention plan for military service men
returning from the war include client education, and cognitive rehabilitation approaches
depending on the symptoms present.1 Education includes providing individuals with both
verbal and written education about mTBI and its associated symptoms. Anxiety may be
reduced after reassuring clients that their symptoms will most likely resolve over a period
of weeks to months.1112 The premise of client education assumes that if a client
understands the symptoms related to mTBI they are less likely to overreact to them.11 In a
study exploring the impact of patient education for patients with mTBI, it was concluded
that patients who reviewed and discussed extensive written instructions about mTBI with
their therapists before leaving the hospital reported considerably shorter symptom
duration and fewer symptoms altogether than those receiving routine discharge
information.13
Military men with mTBI can often experience impairments in both attention and
concentration up to three months after the incident, which is consistent with BW’s
symptoms.14 Interventions at the cognitive level introduce compensatory strategy training
for individuals with mTBI to aid with their everyday life functioning as the symptoms of
mTBI resolve.1 Attentional strategies may include teaching the client to complete a single
task at one time, removing visual or auditory distractions in the environment, performing
difficult tasks in the morning when the person is more alert, pacing, planning breaks, and
monitoring self-fatigue and attention levels.1 For example, the use of a timer is
recommended to encourage using planned breaks throughout activities.1 Knowing BW’s
most salient mTBI symptoms are attending to and concentrating on tasks, we continue to
question the feasibility of introducing PTSD interventions that may require these
cognitive processes.
Intervention for Posttraumatic Stress Disorder
While being cognisant of BW’s mTBI symptoms, we are going to concurrently
explore best practice interventions for PTSD as part of a multi-faceted intervention plan.
The efficacy of various types of cognitive behavioural therapy (CBT) treatments have
been studied specifically for chronic PTSD related to victims of war and combat trauma.
Examples of CBT based therapies include group therapy specifically for military service
men and exposure therapy.
Group therapy is one of the most common treatment modalities for PTSD.15 Each
group therapy program varies on several dimensions including goals and objectives,
theoretical rationales and strategies, structure of the group (open or closed), frequency
and length of sessions and duration of treatment.15 Group therapy for PTSD offers an
environment where interpersonal skills can be practiced and where people can restore a
sense of safety, trust, self-esteem, and intimacy with others and can decrease the sense of
isolation and alienation.15
The effectiveness of a 12 week group therapy program offering 10 hours of
therapy per week for 46 male veterans with PTSD and substance abuse was studied.16
The treatment included mainly cognitive behavioral skills training, trauma processing,
and peer support. Significant decreases in PTSD and addiction severity were identified at
both 6 month and 12-month follow-ups.16
Exposure therapy (ET) is a collective term to describe prolonged exposure to
anxiety provoking stimuli without relaxation or other anxiety reducing methods including
flooding, imaginal, invivo, and directed.17 The first step of ET begins with the
development of a client rated anxiety hierarchy.17 With some forms of ET, treatment
sessions begin with exposure to the highest rated item on the hierarchy, while others
begin with items rated as moderately anxiety provoking.17 Evidence suggests that by
confronting frightening yet safe stimuli and by continuing to expose oneself to fighting
stimuli, anxiety diminishes over time which leads to a decrease in the escape and
avoidance behaviors maintained via negative reinforcement.18
The physiological responses to combat memories in Vietnam veterans
experiencing PTSD and treated with ET were studied.19 The treatment group received ET
over 12-14 sessions of 50 minutes each while the control group received treatment as
usual.19 At follow-up the ET group had decreased physiological responses to exposure
scenes and showed improvement on community adjustment measures of anxiety,
depression, alienation, vigor and confidence in skills when compared to the control
group.19 ET over standard psychotherapeutic and pharmacologic approaches for the
treatment of PTSD in combat veterans through a randomized control trial have been
demonstrated to be effective.20 The treatment consisted of once or twice weekly ET, up
to 14 sessions that were 90-minutes in duration in addition to regular weekly individual
60-minute therapy sessions plus 120-minute weekly group therapy sessions.20 The
intervention group was superior to the control group on measures of anxiety; sleep
disturbances, nightmares, and subject anxiety during behavioral avoidance tasks and
treatment gains were maintained up to three months post treatment.20 A limitation of this
study was its small sample size.
Also studied were the effects of implosive ET on the symptoms of PTSD in
Vietnam combat veterans through a randomized control trial.21 The intervention group
received 14-16 sessions of ET, while the control group was assigned to a waiting list.21
When compared to the waiting list control, veterans receiving ET showed significant
improvement across many of the psychometric measures and the therapist ratings of
psychopathology.21 Changes were noted in the re-experiencing dimension of PTSD,
anxiety, and depression for the treatment group, however treatment did not seem to
influence the numbing and social avoidance aspects of PTSD.21 The authors conclude by
outlining the need for additional social skills training interventions directed at improving
social competence in interpersonal relationships.21 Overall, this research informs the
inclusion of ET in BW’s treatment plan given the above-mentioned benefits such as
symptom reduction and remediating the underlying PTSD. The research however, does
not directly indicate that either mTBI and/or PTSD interventions remediate or promote
role transition to civilian life. This is a self-identified area of concern for BW as he wants
to re-adjust to previous family roles and we will therefore review the evidence to support
BW in his role transition.
Intervention for Role Transition
Re-integration is a process in which military service men transition back into
personal, organizational, and societal roles after having been deployed to war.8 At a
mesosystem level, the effects of a poor re-integration to civilian life is not solely
experienced by the returning soldier but also by their family members who can
experience increased stress, disruption and negativity.22 For BW, there are several severe
consequences associated with poor community adjustment that has lasting effects on his
self-identity and family relationships. A group-based transitional program for eighteen
soldiers who were experiencing various degrees of trauma exposure related to their
deployment was evaluated.23 This program was called the Veterans Transition Program
(VTP) and was evaluated using quantitative and qualitative measures that explored
change in PTSD symptoms, depression and self-esteem. As part of the program, two
sessions encouraged participants to bring family to the program and participate in family
awareness evenings about PTSD. A critique of VTP is the authors did not evaluate a
change of the primary targeted outcome of transitions, but only some aspects of it such as
self-esteem. Only during qualitative interviews were family roles touched upon, with the
majority of the participants reporting an increase in partner intimacy.23
The essential need for returning soldiers to talk to each other as a means of
support for re-integration builds upon the concept of group therapy using CBT
approaches.22 Similar it explores the need for group therapy composed strictly of military
men as part of the decompression process of returning home related to role transition.22
This is consistent with the evidence reported in group therapy, in that clients who identify
with group members similar to themselves gain a greater sense of security and safety
within the group, which allows for therapeutic group progression. In addition,
participants valued group members only consisting of military personnel who “have
actually been there”23 increasing group trust and cohesiveness.
Consolidation of Evidence
Existing evidence-based interventions need to be modified to meet the needs of
individuals who have sustained an mTBI, experiencing PTSD and working towards role
transition from soldier to civilian life. A challenge of working with co-morbid
populations is that the symptoms attributed to any one diagnosis may overlap with
another.24 From a treatment perspective, this means that the alleviation of one symptom
may not be due to treatment intervention, but rather part of the natural spontaneous
recovery process; therefore detecting and evaluation change may be difficult. The
intersection of these issues and challenges requires special consideration of how to best
utilize cognitive rehabilitation for mTBI in conjunction with psychological interventions
for PTSD. Recent literature acknowledges that little is known about the effectiveness of
cognitive strategies for returning soldiers with co-morbidities such as mTBI and PTSD.24
Evidence informed treatments for PTSD, such as CBT, are argued to rely on intact
cognitive processes such as concentration, memory, and executive function.24 Therefore,
some literature questions if an impaired cognitive resource (such as attention) could have
negative implications for a client’s ability to use CBT effectively to address PTSD as part
of coping for role transition24, which paralleled our initial concerns with providing
treatment for our client.
At the present time, there is no research to show that CBT interventions (such
as group therapy and ET) for PTSD are contraindicated for a person with a diagnosis of
mTBI.24 Similarly, interventions for co-morbid mTBI and PTSD populations were found
not to be contraindicated.25 However, a modified CBT instructional approach using
additional resources (such as video-taping for feedback) was utilized. Military service
men exposed to combat deployment stressors, including physical injuries (i.e. mTBI) and
psychological trauma (i.e. PTSD), describe challenges when re-integrating into personal
and professional roles.8
Many service men that are diagnosed with PTSD experience social adjustment
problems including high rates of divorce, poor work histories, alcohol and substance
abuse, and difficulties in interpersonal relationships.26,27 Understanding the above
mentioned challenges and risk factors, the goal of VTP was to reduce combat related
trauma symptoms (PTSD) to promote improved internal coping skills ultimately leading
to successful transition back to roles in civilian life.23 A limitation of this study was that
that authors failed to disclose participant history of possible co-morbidities such as
mTBI. Interestingly, there is a study that argues that mTBI and CBT approaches are not
contraindicated for PTSD but rather CBT may contribute to mTBI remediation.28 Based
on our clinical reasoning and understanding of metacognitive processes, we can
appreciate this finding and its potential benefit for this client population.
All above-mentioned studies would benefit from further validation and
exploration within this population and the inclusion of a standardized occupational
performance measure (i.e. Canadian Occupational Performance Measure)29 to evaluate
related occupational performance issues, such as role transitioning. Role transitioning
itself is an under researched area related to military personnel although it is a common
experience for the returning soldier and their family. The potential for OTs to work
within and generate evidence for role transitioning for military personnel within Canada
provides tremendous opportunities as an emerging field.
Based on our critical analysis of all evidence we feel confident integrating
PTSD interventions with non-resolved mTBI symptoms. As consciously competent
practitioners we will monitor and evaluate a multifaceted intervention for BW including:
1) education and compensatory strategies to address attention deficits due to mTBI, 2)
enrolment in a minimum 12 week closed CBT group (including ET) for military service
men that includes family sessions, and 3) using CBT approaches directed to role
transitioning with ongoing peer support.
Conclusion
Overall, the critical appraisal and integration of current evidence demonstrates
that these interventions, although based on a variety of theoretical underpinnings, can
work together harmoniously with a complex and co-morbid population. As with any new
and emerging field, further research to inform clinical practice would be beneficial for the
client and health care professionals.
ACKNOWLEDGEMENTS: The authors thank Lynn Cockburn and Deidre Dawson,
course instructors in the Dept. of Occupational Science & Occupational Therapy, for their
feedback and guidance in the preparation of this manuscript.
CONFLICTS OF INTEREST: Authors report no conflicts of interest.
SUPPORTING INFORMATION: None.
REFERENCES:
Current Operations of Canadian Expeditionary Force Command. (2012, December
11). Retrieved January 12, 2013, from http://www.cjoc-coic.forces.gc.ca/exp/cur-acteng.asp
1
Radomski MV, Davidson L, Voydetich D, Erickson MW. Occupational therapy for
service members with mild traumatic brain injury. American Journal of Occupational
Therapy. 2009 Oct;63(5):646–655.
2
Carroll LJ, Cassidy JD, Holm L, Kraus J, Coronado VG. Methodological issues and
research recommendations for mild traumatic brain injury: The WHO Collaborative
Center Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitative Medicine.
2004 Feb;43:113–125.
3
Grinage BD. Diagnosis and management of post traumatic stress disorder. American
Family Physician. 2003 Dec;68(12):2401-2408.
4
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders fourth edition, text revised. Washington:DC, 2000
5
Hoge CW, McGurk D, Thomas JL, Cox A L, Engel CC, Castro CA. Mild traumatic
brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine. 2008
Jan;358:453-463.
6
Edge HJM, Ivey GW. Mediation of cognitive appraisal on combat exposure and
psychological distress. Military Psychology. 2012 Jan;24(1):71-85.
7
Currie SL, Day A, Kelloway K. Bringing the troops back home: Modeling the
postemployment reintegration experience. Journal of Occupational Health Psychology.
2011 Jan;16(1):38-47.
8
Warden D. Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma
Rehabilitation. 2006 Sep; 21(5):398–402.
9
French LM. Military traumatic brain injury: An examination of important differences.
Annals of the New York Academy of Sciences. 2010 Oct;1208:38-45.
10
Ponsford J. Rehabilitation interventions after mild head injury. Current Opinion in
Neurology. 2005 Dec;18(6):692–697.
11
Ponsford J, Willmott C, Rothwell A, Cameron P, Kelly AM, Nelms R, et al. Impact of
early intervention on outcome following head injury in adults. Journal of Neurology,
Neurosurgery, and Psychiatry. 2002; 73:330–332.
12
Mittenberg W, Tremont G, Zielinski RE, Fichera S, Rayls KR. Cognitive behavioral
prevention of post concussion syndrome. Archives of Clinical Neuropsychology.
1996;11(2):139–145.
13
Mittenberg W, Strauman S. Diagnosis of mild head injury and the postconcussion
syndrome. Journal of Head Trauma Rehabilitation. 2000 Apr;15:783–791.
14
Shea MT, McDevitt-Murphy M, Ready DJ, Schnurr PP. (2009). Group therapy. In: Foa
EB, Keane TM, Friedman MJ, Cohen JA, editors. Effective treatments for PTSD:
Practice guidelines from the international society for traumatic stress studies. New York:
The Guildford Press; 2009. p. 306-326.
15
Donovan B, Padin-Rivera E, Kowaliw S. “Transcend”: Initial outcomes form a
posttraumatic stress disorder substance abuse treatment program. Journal of Traumatic
Stress. 2001 Oct;14(4):757-772.
16
Cahill SP, Rothbaum BO, Resick PA, Follette VM. Cognitive-behavioural therapy for
adults. In: Foa EB, Keane TM, Friedman MJ, Cohen JA, editors. Effective treatments for
17
PTSD: Practice guidelines from the international society for traumatic stress. New York:
The Guildford Press; 2009. p.139-222.
18
Mowrer OA. Learning theory and behaviour. New York: Wiley;1960.
Boudewyns PA, Hyer L. Physiological response to combat memories and preliminary
treatment outcome in Vietnam veteran PTSD patients treated with direct therapeutic
exposure. Behavior Therapy. 1990;21:63-67.
19
Cooper NA, Clum GA. Imaginable flooding as a supplementary treatment for PTSD in
combat veterans: A controlled study. Behavior Therapy.1989;20:381-391.
20
Keane TM, Fairbank JA, Caddell JM, Zimfring RT. Implosive (flooding) therapy
reduces symptoms of PTSD in Vietnam combat veterans. Behavior Therapy. 1989 Dec;
20:245-260.
21
Sorsdahl MN. Re-entry and transition factors for returning Canadian Forces military
members from overseas deployments [doctor’s thesis]. [Vancouver BC]: The University
of British Columbia; 2010.
22
Westwood MJ, McLean H, Cave D, Borgen W, Slakov P. Coming home: A groupbased approach assisting military veterans in transitions. The Journal for Specialists in
Group Work. 2010 Mar;33(1):44-68.
23
Otis JD, McGlinchey R, Vasterling JJ, Kerns RD. Complicating factors associated with
mild traumatic brain injury: Impact on pain and posttraumatic stress disorder treatment.
Journal of Clinical Psychology in Medical Settings. 2011 Jun;18(2):145-154.
24
Chard KM, Schumm JA, McIlvain S, Bailey G, Parkinson RB. Examining the
effectiveness of CPT-C in a residential program for Veterans with PTSD and TBI. Paper
presented at the ITSTSS 26th Annual Meeting; 2010; Montreal, Quebec, Canada.
25
Carroll EM, Rueger DB, Foy DW, Danahoe CP. Vietnam combat veterans with
posttraumatic stress disorder: Analysis of marital and cohabiting adjustment. Journal of
Abnormal Psychology. 1985 Aug;94(3):329-337.
26
Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, Weiss
DS, Grady DA. Trauma and the Vietnam War generation: Report of findings from the
national Vietnam veterans readjusted study. New York: Brunner/Mazel;1990.
27
Soo C, Tate R. Psychological treatment for anxiety in people with TBI. Cochrane
Database of Systematic Reviews. 2007 Jul;18(3): CS005239
28
29 Law
M, Baptiste S, Carswell A, McColl M, Polatajko H, Pollock N. Canadian
Occupational Performance Measure (4th ed). Ottawa, ON: CAOT Publications ACE;
2005.