… … mutually exclusive or two sides of the mutually exclusive or two sides of the same coin?same coin?

PTSD and MTBIPTSD and MTBIPTSD and MTBIPTSD and MTBI

OverviewOverviewI.I. Nature of ControversyNature of Controversy

II.II. TBI: Key ConsiderationsTBI: Key Considerations

III.III. PTSD: Key ConsiderationsPTSD: Key Considerations

IV.IV. Arguments against coexistenceArguments against coexistence

V.V. Resolution of argumentsResolution of arguments

VI.VI. Recommendations for assessmentRecommendations for assessment

Nature of ControversyNature of Controversy

II

““If the brain was so simple that we could If the brain was so simple that we could understand it, we would be so simple understand it, we would be so simple

that we couldn’t”that we couldn’t”

- Lyall Watson- Lyall Watson

old phenomenon… old phenomenon…

BackgroundBackground

WW IWW I

Shell-shockShell-shockSoldier’s HeartSoldier’s HeartRailway SpineRailway SpineBattle fatigueBattle fatigue OEF/OIFOEF/OIF

Traumatic Brain Traumatic Brain Injury (TBI)Injury (TBI)

VietnamVietnam

Posttraumatic Posttraumatic Stress Disorder Stress Disorder

(PTSD)(PTSD)

PTSD & TBIPTSD & TBI

Can they coexist?Can they coexist?

… … new contextnew context

Diagnostic ChallengesDiagnostic Challenges

• Sometimes we can’t rememberSometimes we can’t remember

• Sometimes we can’t forgetSometimes we can’t forget

• Human memory defined by “fragile power” Human memory defined by “fragile power” (Schacter)(Schacter)

• Brain Injury has dynamic courseBrain Injury has dynamic course

• Secondary gain & malingeringSecondary gain & malingering

• Approximately 15% of MTBI are unresolved Approximately 15% of MTBI are unresolved after 6-monthsafter 6-months

• Jumps to 32% if litigation is involvedJumps to 32% if litigation is involved

• Symptom overlap between TBI, PTSD, and Symptom overlap between TBI, PTSD, and Post Concussive Syndrome (PCS)Post Concussive Syndrome (PCS)

• Limbic system frequently damaged in TBILimbic system frequently damaged in TBI

Diagnostic ChallengesDiagnostic Challenges

SymptomSymptom

Posttraumatic Stress Posttraumatic Stress Disorder / Acute Stress Disorder / Acute Stress

DisorderDisorderTraumatic Brain Traumatic Brain

InjuryInjuryEmotional numbingEmotional numbing √√ √√

Reduced awarenessReduced awareness √√ √√

DepersonalizationDepersonalization √√ √√

DerealizationDerealization √√ √√

AmnesiaAmnesia √√ √√

Recurrent imagesRecurrent images √√ √√

NightmaresNightmares √√ NANA

Distress on remindersDistress on reminders √√ NANA

Avoid remindersAvoid reminders √√ NANA

Social detachmentSocial detachment √√ √√

Diminished interestDiminished interest √√ √√

Foreshortened futureForeshortened future √√ NANA

InsomniaInsomnia √√ √√

IrritabilityIrritability √√ √√

Concentration deficitsConcentration deficits √√ √√

HypervigilenceHypervigilence √√ NANA

Elevated startle responseElevated startle response √√ NANA

(Bryant, 2001)

TBI: Diagnostic Assessment – TBI: Diagnostic Assessment – Key ConsiderationsKey Considerations

IIII

Annual IncidenceAnnual IncidenceAnnual Incidence (cases)

1,500,000

176,000

11,000 43,600

10,400

MultipleSclerosisHIV/AIDS

Spinal CordInjuryBreast Cancer

TraumaticBrain Injury

Brain Injury Association of America

Causes of TBICauses of TBI

Leading Causes of TBI

Motor Vehicle

Accident50%

Falls21%

Assault12%

Sports10%Other

7%

Brain Injury Association of America

TBI RiskTBI Risk

• Males outnumber females 2:1Males outnumber females 2:1

• Ages 15-25 and 75+Ages 15-25 and 75+

• Substance abuseSubstance abuse

• Firearms useFirearms use

Combat TBI - PrevalenceCombat TBI - Prevalence

• 11,800 troops injured in IED attack11,800 troops injured in IED attack

• Thousands more within concussion Thousands more within concussion blast radiusblast radius

• As of Oct 31st 2006 only 1,652 soldiers As of Oct 31st 2006 only 1,652 soldiers and marines officially diagnosed with and marines officially diagnosed with TBITBI

Military Service & TBIMilitary Service & TBI

• Peacetime service = 7,000 hospital Peacetime service = 7,000 hospital admissions per year for TBIadmissions per year for TBI

• Combat theater TBI = 14-20% of Combat theater TBI = 14-20% of surviving casualtiessurviving casualties

• 2001 N = 1,361 veterans received VA 2001 N = 1,361 veterans received VA inpatient hospital care for TBIinpatient hospital care for TBI

Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)Motor ResponsesMotor Responses:: ScoreScore

Obeys CommandsObeys Commands 6 6Localizing responses to painLocalizing responses to pain 5 5Generalized withdrawal to painGeneralized withdrawal to pain 4 4Flexor posturing to painFlexor posturing to pain 3 3Extensor posturing to painExtensor posturing to pain 2 2No motor response to painNo motor response to pain 1 1

Verbal ResponsesVerbal Responses::OrientedOriented 5 5Confused conversationConfused conversation 4 4Inappropriate speechInappropriate speech 3 3Incomprehensible speechIncomprehensible speech 2 2No speechNo speech 1 1

Eye openingEye opening::Spontaneous eye openingSpontaneous eye opening 4 4Eye opening to speechEye opening to speech 3 3Eye opening to painEye opening to pain 2 2No eye openingNo eye opening 1 1

Glasgow Coma – LimitationsGlasgow Coma – Limitations

• Alcohol and drug useAlcohol and drug use

• Time: Injury Time: Injury Measurement Measurement

• Application beyond Emergency Application beyond Emergency Response (ER) personnelResponse (ER) personnel

Loss of Consciousness (LOC)Loss of Consciousness (LOC)

• Length of time patient is ‘non-responsive’.Length of time patient is ‘non-responsive’.

LimitationsLimitations

• Patient must have awareness of LOCPatient must have awareness of LOC• Reliance on witness/evaluator observationReliance on witness/evaluator observation

Posttraumatic Amnesia (PTA)Posttraumatic Amnesia (PTA)

• Length of time: Length of time:

consciousness consciousness memory for ongoing events memory for ongoing events

LimitationsLimitations

• Difficult to determine precise end-pointDifficult to determine precise end-point• Differentiation of PTA and LOCDifferentiation of PTA and LOC• Reliance on collateral reportingReliance on collateral reporting

Severity Grades of TBISeverity Grades of TBI

Mild (Grade 1)Mild (Grade 1) Moderate (Grade 2)Moderate (Grade 2) Severe (Grade 3 & 4)Severe (Grade 3 & 4)

Altered or LOC < 30 Altered or LOC < 30 minmin

&&

Normal CT &/or MRINormal CT &/or MRI

LOC < 6 hours LOC < 6 hours

&&

Abnormal CT &/or Abnormal CT &/or MRIMRI

LOC > 6 hoursLOC > 6 hours

&&

Abnormal CT &/or Abnormal CT &/or MRIMRI

GCS = 13-15GCS = 13-15 GCS = 9-12GCS = 9-12 GCS = < 9GCS = < 9

PTA < 24 hoursPTA < 24 hours PTA < 7 daysPTA < 7 days PTA > 7 daysPTA > 7 days

Diagnostic Criteria for Mild TBI Diagnostic Criteria for Mild TBI (MTBI)(MTBI)

1.1. Traumatically induced physiologic disruption of Traumatically induced physiologic disruption of brain function as indicated by at least one of the brain function as indicated by at least one of the following:following:

A.A. Any period of loss of consciousnessAny period of loss of consciousnessB.B. Any loss of memory for events immediately before or after Any loss of memory for events immediately before or after

accidentaccidentC.C. Any alteration in mental state at the time of the accidentAny alteration in mental state at the time of the accidentD.D. Focal neurologic deficits that may or may not be transientFocal neurologic deficits that may or may not be transient

2.2. Severity of the injury does not exceed:Severity of the injury does not exceed:

A.A. Loss of consciousness of 30 minLoss of consciousness of 30 minB.B. GCS score of 13-15 after 30 minGCS score of 13-15 after 30 minC.C. Posttraumatic amnesia of 24 hrsPosttraumatic amnesia of 24 hrs

American Congress of Rehabilitation Medicine

Pathophysiology of InjuryPathophysiology of Injury

Brain Injury Types:Brain Injury Types:

1.1. Focal (contusion, hematoma)Focal (contusion, hematoma)

2.2. Diffuse (diffuse axonal injury, DAI)Diffuse (diffuse axonal injury, DAI)• TBI may involve bothTBI may involve both• Focal damage = often visible CT or MRIFocal damage = often visible CT or MRI• Diffuse = difficult identification on CT or MRIDiffuse = difficult identification on CT or MRI

Diffuse Axonal Injury (DAI)Diffuse Axonal Injury (DAI)

• Results from Results from acceleration-acceleration-deceleration forcesdeceleration forces

• Axonal Axonal disconnection found disconnection found to occur to occur several several hours afterhours after injury injury

www.brainlaw.com

IIIIII

PTSD: Diagnostic Assessment – PTSD: Diagnostic Assessment – Key ConsiderationsKey Considerations

PTSD Diagnostic CriteriaPTSD Diagnostic Criteria

A.A. Exposure to traumatic event in which Exposure to traumatic event in which bothboth of of following present,following present,

(1) person experienced, witnessed, or was (1) person experienced, witnessed, or was confronted with an event or events that involved confronted with an event or events that involved actual or threatened death or serious injury, or a actual or threatened death or serious injury, or a threat to the physical integrity of self or others.threat to the physical integrity of self or others.

(2) person’s response involved intense fear, (2) person’s response involved intense fear, helplessness, or horror. helplessness, or horror.

Criterion B: Re-experiencingCriterion B: Re-experiencing

B.B. Traumatic event is persistently reexperienced in one (or Traumatic event is persistently reexperienced in one (or more) of the following ways:more) of the following ways:

(B1) recurrent & intrusive distressing recollections of the event, (B1) recurrent & intrusive distressing recollections of the event, including images, thoughts, or perceptionsincluding images, thoughts, or perceptions

(B2) recurrent distressing dreams of the event.(B2) recurrent distressing dreams of the event.

(B3) acting or feeling as if the event were recurring(B3) acting or feeling as if the event were recurring

(B4) intense psychological distress at exposure to internal or (B4) intense psychological distress at exposure to internal or external cues symbolic or representative of eventexternal cues symbolic or representative of event

(B5) physiological reactivity on exposure to internal or external (B5) physiological reactivity on exposure to internal or external cues symbolic or representative of eventcues symbolic or representative of event

Criterion C: Avoidance & Criterion C: Avoidance & Emotional NumbingEmotional Numbing

C. Persistent avoidance of stimuli associated with the trauma and C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), numbing of general responsiveness (not present before the trauma),

(C1) Efforts to avoid thoughts, feelings or conversations(C1) Efforts to avoid thoughts, feelings or conversations

(C2) Efforts to avoid activities, places, or people(C2) Efforts to avoid activities, places, or people

(C3) Inability to recall important aspect of trauma(C3) Inability to recall important aspect of trauma

(C4) Markedly diminished interest or participation in activities(C4) Markedly diminished interest or participation in activities

(C5) Feeling of detachment or estrangement from others(C5) Feeling of detachment or estrangement from others

(C6) Restricted range of affect(C6) Restricted range of affect

(C7) Sense of foreshortened future(C7) Sense of foreshortened future

Criterion D: HyperarousalCriterion D: Hyperarousal

D.D. Persistent symptoms of increased arousal (not Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or present before the trauma), as indicated by two (or more) of the following,more) of the following,

(D1) difficulty falling or staying asleep(D1) difficulty falling or staying asleep

(D2) irritability or outbursts of anger(D2) irritability or outbursts of anger

(D3) difficulty concentrating(D3) difficulty concentrating

(D4) hypervigilance(D4) hypervigilance

(D5) exaggerated startle response(D5) exaggerated startle response

Criterion E: DurationCriterion E: Duration

E.E. Duration of symptoms in Criteria B, C, D is more Duration of symptoms in Criteria B, C, D is more than 1 month.than 1 month.

Sub-types:Sub-types:

AcuteAcute: If duration of symptoms is less than 3 months: If duration of symptoms is less than 3 months

ChronicChronic: if duration of symptoms is 3 months or more: if duration of symptoms is 3 months or more

Delayed OnsetDelayed Onset: if onset of symptoms is at least 6 : if onset of symptoms is at least 6 months after the stressormonths after the stressor

Criterion F: Distress or Criterion F: Distress or ImpairmentImpairment

F. The disturbance causes clinically significant F. The disturbance causes clinically significant distress or impairment in distress or impairment in socialsocial, , occupationaloccupational, or , or other important areas of functioningother important areas of functioning

System Compromise in PTSDSystem Compromise in PTSD

• NeuropsychologicalNeuropsychological

• PsychophysiologicalPsychophysiological

• NeurobiologicalNeurobiological

NeurobiologicalNeurobiological– Cerebral-spinal fluid (CSF) cortisol abnormalities in PTSD Cerebral-spinal fluid (CSF) cortisol abnormalities in PTSD

patients 20+ years post-trauma (Baker)patients 20+ years post-trauma (Baker)

– Exposure to even mild stressors impairs PFC functioning Exposure to even mild stressors impairs PFC functioning (Arnsten, 1998)(Arnsten, 1998)

– Stress-induced PFC dysfunction related to high levels of Stress-induced PFC dysfunction related to high levels of Norepinephrine, protein kinase C (PKC), glucocorticoid Norepinephrine, protein kinase C (PKC), glucocorticoid (Lupien)(Lupien)

– Affective functioning strengthened in amygdala; less PFC, Affective functioning strengthened in amygdala; less PFC, more emotion-based behavior & thought (LeDoux)more emotion-based behavior & thought (LeDoux)

– Dendritic spine loss in PFC & hippocampus (Radley; Liston)Dendritic spine loss in PFC & hippocampus (Radley; Liston)

– Increased dendritic complexity in the amygdala (Mitra)Increased dendritic complexity in the amygdala (Mitra)

– Dysregulation of HPA axis in PTSD: cortisol, epinephrine, Dysregulation of HPA axis in PTSD: cortisol, epinephrine, norepinephrine, DHEA, GABA (Yehuda; Rassmussen; norepinephrine, DHEA, GABA (Yehuda; Rassmussen; Resick)Resick)

HPA AxisHPA Axis

PsychophysiologicalPsychophysiological

- Exaggerated startle; impaired pre-pulse inhibition Exaggerated startle; impaired pre-pulse inhibition (Orr; Pitman)(Orr; Pitman)

- Increased Galvonic Skin Response (nGSR) during Increased Galvonic Skin Response (nGSR) during thought suppression (Aikins & Johnson)thought suppression (Aikins & Johnson)

- High vagal tone, low heart-rate variability (Aikins)High vagal tone, low heart-rate variability (Aikins)

NeuropsychologicalNeuropsychological

- Impaired attention (sustained & divided), Impaired attention (sustained & divided), concentration (Vasterling)concentration (Vasterling)

- Working memory deficits (Vasterling)Working memory deficits (Vasterling)

- Logical memory deficits Logical memory deficits

- Heightened negative affect & confusionHeightened negative affect & confusion

- Source memory impairment (Johnson)Source memory impairment (Johnson)

- * Reaction time advantages (Vasterling)* Reaction time advantages (Vasterling)

Shin et al., Biological Psychiatry, 2001

PTSD & Emotion RegulationMedial Prefrontal Cortex (mPFC)

PTSD & Emotion RegulationMedial Prefrontal Cortex (mPFC)

IVIV

Arguments against TBI & PTSD Arguments against TBI & PTSD coexistencecoexistence

3 Arguments3 Arguments

• Disturbed consciousness (LOC or PTA) Disturbed consciousness (LOC or PTA) precludes “experiencing” or “witnessing” precludes “experiencing” or “witnessing” eventevent

• Disturbed consciousness prevents memory Disturbed consciousness prevents memory formation necessary for Criterion B (Re-formation necessary for Criterion B (Re-experiencing)experiencing)

• Posttraumatic Amnesia (PTA) is incompatible Posttraumatic Amnesia (PTA) is incompatible with Criterion C (Avoidance & Emotional with Criterion C (Avoidance & Emotional Numbing)Numbing)

Harvey, Brewin, Jones, & Kopelman, 2003

Do LOC & PTA preclude PTSD?Do LOC & PTA preclude PTSD?

VV

ResolutionResolution

Question: Why is fear stored indelibly?Question: Why is fear stored indelibly?

Hypothesis: If you forget what has Hypothesis: If you forget what has potential to harm you, your ability to potential to harm you, your ability to survive is compromisedsurvive is compromised

LeDouxLeDoux

• Declarative MemoryDeclarative Memory – Explicit memory for – Explicit memory for things and events (e.g. semantic and things and events (e.g. semantic and episodic)episodic)

• Non-Declarative MemoryNon-Declarative Memory – Implicit memory – Implicit memory for ‘how to do things’ (procedural) and for ‘how to do things’ (procedural) and conditioning (learned associations)conditioning (learned associations)

Multiple Memory SystemsMultiple Memory Systems

Differential Effects of Differential Effects of Overwhelming Overwhelming STRESSSTRESS

FacilitationFacilitation ImpairmentImpairment

Strengthening of Strengthening of implicit emotional implicit emotional

memorymemory

Loss of explicit memory Loss of explicit memory for emotional experiencesfor emotional experiences

Contextual ConditioningContextual Conditioning

• If ‘x’ then ‘y’ If ‘x’ then ‘y’

• Learning = ‘y’ is an extremely reliable Learning = ‘y’ is an extremely reliable predictor of ‘x’. predictor of ‘x’.

• If ‘s’ then not ‘q’ If ‘s’ then not ‘q’

• Learning = ‘s’ is an extremely reliable Learning = ‘s’ is an extremely reliable predictor of ‘q’predictor of ‘q’

Associative Learning (Conditioning)

TBI & PTSD: Resolution of TBI & PTSD: Resolution of CoexistenceCoexistence

• Encoding of memories is mediated via differential Encoding of memories is mediated via differential pathways (explicit vs. implicit)pathways (explicit vs. implicit)

• Emotional memories encoded through limbic Emotional memories encoded through limbic structures involved in conditioning (associative structures involved in conditioning (associative learning)learning)

• Trauma cues and contextual cues can be learned and Trauma cues and contextual cues can be learned and stored in memory w/o explicit awarenessstored in memory w/o explicit awareness

• Single-trial learning through implicit memory pathway Single-trial learning through implicit memory pathway is basis for post-trauma conditioned fear responsesis basis for post-trauma conditioned fear responses

VIVI

Recommendations for Recommendations for Forensic Assessment of Forensic Assessment of

PTSD & TBIPTSD & TBI

Elements of Forensic PTSD Elements of Forensic PTSD AssessmentAssessment

1.1. Comprehensive clinical examination: family, developmental history, Comprehensive clinical examination: family, developmental history, pre-event & post-event functioning.pre-event & post-event functioning.

2.2. Use of validated diagnostic interview specifically developed for the Use of validated diagnostic interview specifically developed for the assessment of PTSD symptoms and their impact on life/functioningassessment of PTSD symptoms and their impact on life/functioning

3.3. Use of structured diagnostic interview that provides an opportunity to Use of structured diagnostic interview that provides an opportunity to explore Axis I & Axis II disordersexplore Axis I & Axis II disorders

4.4. Use of general personality questionnaires measuring broad Use of general personality questionnaires measuring broad characteristics and response stylecharacteristics and response style

5.5. Measures of social-role & work functioningMeasures of social-role & work functioning

6.6. Assessment of malingering and feigned symptom or cognitive Assessment of malingering and feigned symptom or cognitive impairmentimpairment

7.7. Neuropsychological testing results.Neuropsychological testing results.

Keane et al, 2003

Clinician Administered PTSD Clinician Administered PTSD Scale (CAPS)Scale (CAPS)

• The ‘gold standard’ in The ‘gold standard’ in PTSD assessmentsPTSD assessments

• Structured (clinician Structured (clinician driven) interviewdriven) interview

• Accounts for both Accounts for both frequencyfrequency & & intensityintensity of symptomsof symptoms

What’s so special about What’s so special about ‘avoidance’?‘avoidance’?

• Most trauma survivors do not develop Most trauma survivors do not develop PTSDPTSD

• For significant portion of those with For significant portion of those with PTSD, the disorder remits over time.PTSD, the disorder remits over time.

chronic PTSD may represent a type of chronic PTSD may represent a type of vulnerability characterized by vulnerability characterized by maladaptive cognitive (avoidance) maladaptive cognitive (avoidance) process following extreme stressorsprocess following extreme stressors

Criterion C predicts PTSDCriterion C predicts PTSD

• OK City bombing (North et al., 2004)OK City bombing (North et al., 2004)

– Criterion C met = YES = 96% had PTSDCriterion C met = YES = 96% had PTSD

– Criterion B met = YES = 40% had PTSDCriterion B met = YES = 40% had PTSD– Criterion D met = YES = 39% had PTSDCriterion D met = YES = 39% had PTSD

Absence of Criterion CAbsence of Criterion C

• No-PTSD group:No-PTSD group:

– 2% met Criterion C criteria2% met Criterion C criteria

– 70% met Criterion B criteria70% met Criterion B criteria– 73% met Criterion D criteria73% met Criterion D criteria

ConclusionsConclusions

A.A. PTSD & TBI can coexistPTSD & TBI can coexist

B.B. Diagnostic precision requires Diagnostic precision requires multimodal approachmultimodal approach

C.C. PTSD & TBI are dynamic and each PTSD & TBI are dynamic and each influences presentation and course of influences presentation and course of the otherthe other

Conclusions (continued)Conclusions (continued)

D.D. Symptom overlap of PTSD & TBI Symptom overlap of PTSD & TBI indicate need for separate indicate need for separate psychological and psychological and neuropsychological evaluationsneuropsychological evaluations

E.E. Dynamic interaction of PTSD & TBI Dynamic interaction of PTSD & TBI suggest serial assessmentsuggest serial assessment

Thank youThank you

CONTACTCONTACT

Douglas Christian Johnson, Ph.D.Douglas Christian Johnson, Ph.D.

Email1: Email1: douglas.c.johnson@med.navy.milEmail2: Email2: douglascjohnson@ucsd.edu

Cell: (818)262-9533Cell: (818)262-9533