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Characteristics of Mild Traumatic Brain Injury and Persistent
Symptoms
DisclaimerDisclaimer
The views expressed in this presentation The views expressed in this presentation are those of the authors and do not are those of the authors and do not
reflect the official policy of the reflect the official policy of the Department of the Navy, Department of Department of the Navy, Department of
the Army, Department of Defense, or the Army, Department of Defense, or the U.S. Government. the U.S. Government.
2
Points to be CoveredPoints to be Covered
Mild traumatic brain injury (MTBI)Mild traumatic brain injury (MTBI) Postconcussion Syndrome (PCS)Postconcussion Syndrome (PCS) Posttraumatic Stress Disorder (PTSD)Posttraumatic Stress Disorder (PTSD) Other explanations for persistent complaints Other explanations for persistent complaints
following MTBIfollowing MTBI
Pathophysiology of MTBIPathophysiology of MTBI
A “neurometabolic cascade” leaves the A “neurometabolic cascade” leaves the brain in a state of neurophysiologic disarray brain in a state of neurophysiologic disarray during the acute phase after injuryduring the acute phase after injury
Functional neuroimaging studies in animals Functional neuroimaging studies in animals and humans have demonstrated the brain’s and humans have demonstrated the brain’s return to normal neurophysiologic return to normal neurophysiologic functioning within days to weeksfunctioning within days to weeks
MTBI is a transient process followed by MTBI is a transient process followed by spontaneous recoveryspontaneous recovery
Symptoms Reported Following Symptoms Reported Following MTBIMTBI
PhysicalPhysical Headaches Headaches DizzinessDizziness Sensitivity to light or noiseSensitivity to light or noise Impairments in vision and hearingImpairments in vision and hearing Problems with balance Problems with balance FatigueFatigue
Symptoms Reported Following Symptoms Reported Following MTBI MTBI
CognitiveCognitive Impaired memory Impaired memory ConcentrationConcentration Word finding difficultyWord finding difficulty Slowed overall processingSlowed overall processing Impaired organizational and problem solving Impaired organizational and problem solving
skillsskills
Symptoms Reported Following Symptoms Reported Following MTBIMTBI
BehavioralBehavioral Difficulty being around peopleDifficulty being around people Personality changesPersonality changes Irritability, frustration, “short-fuse”Irritability, frustration, “short-fuse”
Functional Outcome after Functional Outcome after MTBI (Civilian Population)MTBI (Civilian Population)
Most severe sxs are evident within minutes Most severe sxs are evident within minutes of injuryof injury
There is measurable improvement within There is measurable improvement within hours of injuryhours of injury
A combination of physical and cognitive sxs A combination of physical and cognitive sxs is most commonis most common
Recovery occurs over 7-10 days in an Recovery occurs over 7-10 days in an overwhelming majority (80-90%)overwhelming majority (80-90%)
Functional Outcome after Functional Outcome after MTBI (Civilian Population)MTBI (Civilian Population)
Memory is the most susceptible to change Memory is the most susceptible to change after MTBI, but shows recovery within daysafter MTBI, but shows recovery within days
Headache is the symptom that tends to Headache is the symptom that tends to linger the longest and be most problematic linger the longest and be most problematic in terms of clinical managementin terms of clinical management
Delayed sx onset is rareDelayed sx onset is rare Sxs persisting beyond the expected Sxs persisting beyond the expected
recovery are often attributable to non-injury recovery are often attributable to non-injury related factorsrelated factors
Functional Outcome after Functional Outcome after MTBI (Civilian Population)MTBI (Civilian Population)
In moderate and severe TBI, acute injury In moderate and severe TBI, acute injury severity (as measured by LOC, PTA, and severity (as measured by LOC, PTA, and GCS) is the single strongest predictor of GCS) is the single strongest predictor of functional outcome.functional outcome.
In the MTBI population injury-related factors In the MTBI population injury-related factors have not been found to be powerful have not been found to be powerful predictors of outcome or persistent predictors of outcome or persistent postconcussion symptoms postconcussion symptoms
Functional Outcome after Functional Outcome after MTBI (Civilian Population)MTBI (Civilian Population)
Non-injury factors are more commonly Non-injury factors are more commonly predictive of potential for poor outcome:predictive of potential for poor outcome: Preexisting medical or psychological problemsPreexisting medical or psychological problems High levels of psychosocial stress at time of High levels of psychosocial stress at time of
injuryinjury Poor social support systemsPoor social support systems Alcohol and drug useAlcohol and drug use Litigation (motivational factors)Litigation (motivational factors)
Clinical Presentation of MTBI Clinical Presentation of MTBI (Concussion) due to Blast Exposure(Concussion) due to Blast Exposure
Often no LOC or brief LOC (<5 minutes)Often no LOC or brief LOC (<5 minutes) ““Alteration in consciousness” (dazed, Alteration in consciousness” (dazed,
confused, temporarily disorientated)confused, temporarily disorientated) No Posttraumatic Amnesia, or PTA of short No Posttraumatic Amnesia, or PTA of short
durationduration PTA = the last event recalled before the injury PTA = the last event recalled before the injury
(retrograde amnesia) & the first event recalled (retrograde amnesia) & the first event recalled after the injury (anterograde amnesia)after the injury (anterograde amnesia)
Medical Management of Medical Management of MTBIMTBI
A recent systematic review of treatments for A recent systematic review of treatments for mild TBI (Cooper, 2005, Brain Injury)mild TBI (Cooper, 2005, Brain Injury) Medication Medication Cognitive rehabilitationCognitive rehabilitation Educational interventionEducational intervention
Strongest evidence is in support of the Strongest evidence is in support of the effectiveness of early patient educationeffectiveness of early patient education
Provide expectation for recoveryProvide expectation for recovery
Postconcussion SyndromePostconcussion SyndromeDSM-IV Research CriteriaDSM-IV Research Criteria
History of head trauma that has caused History of head trauma that has caused significant cerebral concussion (includes significant cerebral concussion (includes LOC, PTA, and less commonly LOC, PTA, and less commonly posttraumatic onset of seizures)posttraumatic onset of seizures)
Evidence from neuropsychological testing or Evidence from neuropsychological testing or quantified cognitive assessment of difficulty quantified cognitive assessment of difficulty in attention or memoryin attention or memory
Postconcussion SyndromePostconcussion SyndromeDSM-IV Research CriteriaDSM-IV Research Criteria
3 or more sxs occur shortly after the trauma 3 or more sxs occur shortly after the trauma and persist for at least 3 monthsand persist for at least 3 months– Becoming easily fatiguedBecoming easily fatigued– Disordered sleepDisordered sleep– HeadacheHeadache– Vertigo or dizzinessVertigo or dizziness– Irritability or aggression on little or no provocationIrritability or aggression on little or no provocation– Anxiety, depression, or affective instabilityAnxiety, depression, or affective instability– Changes in personality (e.g. social or sexual Changes in personality (e.g. social or sexual
inappropriateness)inappropriateness)– Apathy or lack of spontaneityApathy or lack of spontaneity
Etiology of Postconcussion SyndromeEtiology of Postconcussion Syndrome
Debate: neurological damage vs. transient Debate: neurological damage vs. transient physiological disturbance with the physiological disturbance with the symptoms symptoms maintainedmaintained by psychological by psychological distress.distress.
Explanations for PCSExplanations for PCS 1)1) Chronic or residual CNS damageChronic or residual CNS damage2)2) Secondary gainSecondary gain3)3) Emotional response to the trauma or an Emotional response to the trauma or an
overlay of posttraumatic stress disorderoverlay of posttraumatic stress disorderRimel, Giordani, Barth, Boll, & Jane (1981)Rimel, Giordani, Barth, Boll, & Jane (1981)
Nonspecificity of PCSNonspecificity of PCS
Studies have shown the level of sx Studies have shown the level of sx endorsement reported by TBI patients and endorsement reported by TBI patients and controls is similarcontrols is similar– Chronic pain populationChronic pain population– Fibromyalgia patientsFibromyalgia patients– Psychiatric patientsPsychiatric patients– Normal controlsNormal controls– Iverson & Lange (2003) found PCS sxs are not Iverson & Lange (2003) found PCS sxs are not
unique to MTBI, and are highly correlated with unique to MTBI, and are highly correlated with depressive symptomsdepressive symptoms
Gordon, Haddad, Brown, Gordon, Haddad, Brown, Hibbard, and Sliwinski (2000)Hibbard, and Sliwinski (2000)
Examined a large sample:Examined a large sample:– Individuals with mild, moderate, and severe TBIIndividuals with mild, moderate, and severe TBI– HIV-positive patientsHIV-positive patients– Patients with spinal cord injuryPatients with spinal cord injury– Patient s/p liver transplantPatient s/p liver transplant– Nonaffected controlsNonaffected controls
Gordon, Haddad, Brown, Gordon, Haddad, Brown, Hibbard, and Sliwinski (2000)Hibbard, and Sliwinski (2000)
MTBI patients reported significantly more MTBI patients reported significantly more sxs than the other groups including those sxs than the other groups including those with moderate and severe TBIwith moderate and severe TBI
Only MTBI patients reported cognitive Only MTBI patients reported cognitive impairmentsimpairments
Posttraumatic Stress DisorderPosttraumatic Stress DisorderDefinition and HistoryDefinition and History
An Anxiety DisorderAn Anxiety Disorder PTSD is unique among psychiatric disorders in PTSD is unique among psychiatric disorders in
that the symptoms are directly linked to a that the symptoms are directly linked to a traumatic eventtraumatic event
55thth most common psychiatric disorder (5% of most common psychiatric disorder (5% of Americans)Americans)
20 years after Vietnam, 15% of combat veterans 20 years after Vietnam, 15% of combat veterans still have PTSD still have PTSD (National Vietnam Veteran Readjustment Study, (National Vietnam Veteran Readjustment Study, 1990) 1990)
Posttraumatic Stress DisorderPosttraumatic Stress Disorder
Characterized by reexperiencing symptoms, Characterized by reexperiencing symptoms, avoidance behaviors, and elevated arousalavoidance behaviors, and elevated arousal
To meet diagnostic criteria:To meet diagnostic criteria:– The symptoms must cause marked impairment The symptoms must cause marked impairment
in functioningin functioning– Symptoms persist for at least one month Symptoms persist for at least one month
following the traumafollowing the trauma
Symptoms of PTSDSymptoms of PTSD
EmotionalEmotional– IrritabilityIrritability– Mood swingsMood swings– Increased AggressionIncreased Aggression– Withdrawal/AvoidanceWithdrawal/Avoidance
CognitiveCognitive– ForgetfulnessForgetfulness– Attentional ProblemsAttentional Problems– ConcentrationConcentration
PhysicalPhysical– Difficulty sleepingDifficulty sleeping– Over arousalOver arousal
Overlap Symptoms of MTBI & PTSDOverlap Symptoms of MTBI & PTSD
ConcentrationConcentration Memory deficitsMemory deficits Sleep problemsSleep problems Irritability/anger/increased aggressionIrritability/anger/increased aggression WithdrawalWithdrawal
Differentiating MTBI in the Differentiating MTBI in the OIF/OEF PopulationOIF/OEF Population
Obtain brain injury historyObtain brain injury history– Type of injury (e.g. blast exposure, penetrating Type of injury (e.g. blast exposure, penetrating
vs. nonpenetrating, etc.)vs. nonpenetrating, etc.)– LOC, PTA, neuroimagingLOC, PTA, neuroimaging– Assess for postconcussion symptomsAssess for postconcussion symptoms– Effects of sedating medicationEffects of sedating medication– Time since injuryTime since injury
Differentiating MTBI in the OIF/OEF Differentiating MTBI in the OIF/OEF PopulationPopulation
Obtain combat/trauma historyObtain combat/trauma history– number of deployments, combat dutiesnumber of deployments, combat duties
Assess “arousal” vs. “depressive” symptomsAssess “arousal” vs. “depressive” symptoms Clinical judgment Clinical judgment
– Blast exposure w/o LOC, PTA, or medical Blast exposure w/o LOC, PTA, or medical treatmenttreatment
– Completed tour of duty Completed tour of duty – Reports symptoms 1 year laterReports symptoms 1 year later
PTSD or MTBI?PTSD or MTBI?
TBI PTSD
Chronic
Pain
Medication
Substance
Alcohol
Abuse
Possible explanations for Possible explanations for Persistent PCSPersistent PCS
PTSD overlayPTSD overlay Goal oriented behavior: “Patient role”Goal oriented behavior: “Patient role” Somatoform disorderSomatoform disorder Factitious disorderFactitious disorder MalingeringMalingering
Somatoform DisorderSomatoform DisorderDSM-IV CriteriaDSM-IV Criteria
A history of many physical complaints A history of many physical complaints before age 30 that occurs over several before age 30 that occurs over several years and results in seeking treatmentyears and results in seeking treatment
Reports of significant social, occupational, Reports of significant social, occupational, or other functional impairmentor other functional impairment
Sxs from 4 separate areas must be Sxs from 4 separate areas must be experienced (pain, gastrointestinal, sexual, experienced (pain, gastrointestinal, sexual, & pseudoneurological)& pseudoneurological)
Somatoform DisorderSomatoform DisorderDSM-IV CriteriaDSM-IV Criteria
““Appropriate investigation” must reveal no Appropriate investigation” must reveal no specific medical condition that would explain specific medical condition that would explain the sxsthe sxs
The sxs are not produced intentionally, as to The sxs are not produced intentionally, as to distinguish them from factitious disorders distinguish them from factitious disorders and malingeringand malingering
Criticisms of the Diagnostic Criticisms of the Diagnostic Criteria for Somatoform DisorderCriteria for Somatoform Disorder
Restrictive criteria made the conditions Restrictive criteria made the conditions appear to be rareappear to be rare
Medically unexplained symptomsMedically unexplained symptoms (1980’s) (1980’s) captures a sizable population with captures a sizable population with somatoform issues, despite not meeting the somatoform issues, despite not meeting the formal diagnostic criteriaformal diagnostic criteria
Factitious DisorderFactitious DisorderDSM-IV CriteriaDSM-IV Criteria
Intentional production or feigning of physical Intentional production or feigning of physical or psychological signs or symptomsor psychological signs or symptoms
The motivation for the behavior is to assume The motivation for the behavior is to assume the sick rolethe sick role
External incentives for the behavior such as External incentives for the behavior such as economic gain or avoiding legal economic gain or avoiding legal responsibility, as in malingering, responsibility, as in malingering, are absentare absent..
MalingeringMalingering
““The intentional production of false or The intentional production of false or grossly exaggerated physical or grossly exaggerated physical or psychological symptoms, motivated by psychological symptoms, motivated by external incentives such as avoiding military external incentives such as avoiding military duty, avoiding work, obtaining financial duty, avoiding work, obtaining financial compensation, evading criminal prosecution, compensation, evading criminal prosecution, or obtaining drugs.”or obtaining drugs.”
DSM IVDSM IV
Forms of MalingeringForms of Malingering
FeigningFeigning– Never any symptomsNever any symptoms– Symptoms existed but resolvedSymptoms existed but resolved
ExaggerationExaggeration– A disability would be advantageous.A disability would be advantageous.– Complaints of distress that appear to exceed Complaints of distress that appear to exceed
what the injury or illness would be expected to what the injury or illness would be expected to cause, signal the cause, signal the possibilitypossibility of malingering. of malingering.
Malingering vs. Factitious DisorderMalingering vs. Factitious Disorder
MalingeringMalingering Factitious DisorderFactitious Disorder
VolitionalVolitional VolitionalVolitional
Conscious GoalsConscious Goals Unconscious GoalsUnconscious Goals
Self ControlledSelf Controlled Compulsively DrivenCompulsively Driven
May Be AdaptiveMay Be Adaptive PsychopathologicalPsychopathological
Avoids Risky/Painful Avoids Risky/Painful ProceduresProcedures
Eagerly Undergoes Such Eagerly Undergoes Such ProceduresProcedures
Avoids Self HarmAvoids Self Harm May Inflict Personal InjuryMay Inflict Personal Injury
Characteristics of Individuals Characteristics of Individuals Seeking Secondary GainSeeking Secondary Gain
Unconscious Unconscious
(e.g. Somatoform, Factitious)(e.g. Somatoform, Factitious)
IntentionalIntentional
(e.g. Malingering)(e.g. Malingering)
Cooperative, pleasantCooperative, pleasant Guarded, hostileGuarded, hostile
Good rapportGood rapport Poor rapportPoor rapport
Dependent, naiveDependent, naive ManipulativeManipulative
Disability payments reinforce Disability payments reinforce dependency and self -doubtdependency and self -doubt
Disability payments Disability payments encourage further encourage further
manipulationmanipulation
Gaps in historyGaps in history Few gapsFew gaps
Personality testing reveals Personality testing reveals neurotic conflictsneurotic conflicts
May reveal antisocial May reveal antisocial personality traitspersonality traits
Characteristics of Individuals Characteristics of Individuals Seeking Secondary GainSeeking Secondary Gain
UnconsciousUnconscious
(e.g. Somatoform, Factitious)(e.g. Somatoform, Factitious)
IntentionalIntentional
(e.g. Malingering)(e.g. Malingering)
Difficulty performing Difficulty performing responsibilitiesresponsibilities
SameSame
Difficulty with leisure activitiesDifficulty with leisure activities Leisure functioning intactLeisure functioning intact
Performs poorly in each Performs poorly in each settingsetting
Performs poorly when being Performs poorly when being observedobserved
History of responsibilityHistory of responsibility VariableVariable
Will accept offer to work in Will accept offer to work in non-impaired activitiesnon-impaired activities
Usually rejects such an offerUsually rejects such an offer
Enjoys visiting the doctorEnjoys visiting the doctor DislikesDislikes
Submits to treatmentSubmits to treatment Avoids treatmentAvoids treatment
Management of Persistent Management of Persistent SymptomsSymptoms
Patients with Patients with medically unexplained medically unexplained symptoms symptoms often encounter treatment often encounter treatment providers who are dismissive or providers who are dismissive or disrespectfuldisrespectful– Results in “doctor shopping”Results in “doctor shopping”
As clinicians we have the opportunity to take As clinicians we have the opportunity to take a more tolerant approach to dealing with a more tolerant approach to dealing with interpersonal limitations (e.g. poor coping, interpersonal limitations (e.g. poor coping, faulty beliefs)faulty beliefs)
Management of Persistent Management of Persistent SymptomsSymptoms
Our goal is to encourage appropriate Our goal is to encourage appropriate interventions to break the cycleinterventions to break the cycle– Discuss referrals to psychiatry in the context of Discuss referrals to psychiatry in the context of
“mind-body” connections“mind-body” connections– When asked: doctor, do you think it is all in my When asked: doctor, do you think it is all in my
head, answer yes! Because the brain interprets head, answer yes! Because the brain interprets symptomssymptoms
Management of Persistent Management of Persistent SymptomsSymptoms
Treatment interventionsTreatment interventions– Cognitive behavioral therapy (CBT) to reframe Cognitive behavioral therapy (CBT) to reframe
faulty beliefsfaulty beliefs– Treatment should focus on determining the Treatment should focus on determining the
meaningmeaning of the symptoms to the patient of the symptoms to the patient– Education is important in the acute and chronic Education is important in the acute and chronic
phases of symptom presentationphases of symptom presentation