characteristics of mild traumatic brain injury and persistent symptoms

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.

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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%)


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


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


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)


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


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

characteristics of mild traumatic brain injury and persistent symptoms

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