1. Characteristics of Mild Traumatic Brain Injury and Persistent Symptoms

2. 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

3. Points to be Covered  Mild traumatic brain injury (MTBI)  Postconcussion Syndrome (PCS)  Posttraumatic Stress Disorder (PTSD)  Other explanations for persistent complaints following MTBI

4. 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

5. Symptoms Reported Following MTBI  Physical  Headaches  Dizziness  Sensitivity to light or noise  Impairments in vision and hearing  Problems with balance  Fatigue

6. Symptoms Reported Following MTBI  Cognitive  Impaired memory  Concentration  Word finding difficulty  Slowed overall processing  Impaired organizational and problem solving skills

7. Symptoms Reported Following MTBI  Behavioral  Difficulty being around people  Personality changes  Irritability, frustration, “short-fuse”

8. 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%)

9. 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

10. 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

11. 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)

12. 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)

13. 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

14. 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

15. Postconcussion Syndrome DSM-IV Research Criteria  3 or more sxs occur shortly after the trauma and persist for at least 3 months –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

16. Etiology of Postconcussion Syndrome  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)

17. 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

18. 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

19. 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

20. 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  5 th most common psychiatric disorder (5% of Americans)  20 years after Vietnam, 15% of combat veterans still have PTSD (National Vietnam Veteran Readjustment Study, 1990)

21. 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

22. Symptoms of PTSD  Emotional –Irritability –Mood swings –Increased Aggression –Withdrawal/Avoidance Cognitive –Forgetfulness –Attentional Problems –Concentration  Physical –Difficulty sleeping –Over arousal

23. Overlap Symptoms of MTBI & PTSD  Concentration  Memory deficits  Sleep problems  Irritability/anger/increased aggression  Withdrawal

24. 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

25. 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?

26. TBI PTSD Chronic Pain Medication Substance Alcohol Abuse

27. Possible explanations for Persistent PCS  PTSD overlay  Goal oriented behavior: “Patient role”  Somatoform disorder  Factitious disorder  Malingering

28. 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)

29. 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

30. 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

31. 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.

32. 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

33. 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.

34. Malingering vs. Factitious Disorder Malingering Factitious Disorder VolitionalVolitional Conscious Goals Unconscious Goals Self Controlled Compulsively Driven May Be Adaptive Psychopathological Avoids Risky/Painful Procedures Eagerly Undergoes Such Procedures Avoids Self Harm May Inflict Personal Injury

35. 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

36. Characteristics of Individuals Seeking Secondary Gain Unconscious (e.g. Somatoform, Factitious) (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 Usually rejects such an offer Enjoys visiting the doctor Dislikes Submits to treatment Avoids treatment

37. 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)

38. 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

39. 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