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TBI & PTSD’S IMPACT ON RETURNING VETERANS

Tracy L. Thomas, Ph.D.Clinical Neuropsychologist

November 10, 2008

Objectives

Identifying Signs and Symptoms of TBI and PTSDCourse of TreatmentSuccess in TreatmentLong-Term Effects of TBI and PTSDInvolvement of Family and FriendsInvolvement in the Delivery SystemsQuestions and Answers

Identifying Signs and Symptoms of TBI

Giza, CC and Hovda, DA (2001). The Neurometabolic Cascade of Concussion. Journal of Athletic Training, 36(3); 228-235.

Identifying Signs and Symptoms of TBI

Physical SymptomsHeadaches (may get worse over time)WeaknessNumbnessDecreased coordinationVomitingLethargySlurred speechSeizures/ConvulsionsSleep pattern changesLoss of balanceBlurred vision/visual disturbanceLoss of sense of smell/tasteTinnitus (ringing in the ears)Sensitivity to noise or light

Identifying Signs and Symptoms of TBI (cont.)

Cognitive/Emotional SymptomsConfusionRestlessness/AgitationPersonality changesAttention/Concentration difficultiesWord finding difficultiesMemory difficultiesDecreased ability to plan/organizeHard time making decisionsSlow to respond or understand (processing speed)Reduced/Heightened libidoReduced motivation/initiationDepressionIrritabilityAnxiety/hypervigilance/exaggerated startle

Identifying Signs and Symptoms of TBI (cont.)

AssessmentNeuropsychological Assessment

Screening measures COGNISTAT

Takes 10-20 minutes to administer RBANS

Takes 15-30 minutes to administer

Full batteries Fixed

Can take up to 8-10 hours to administer Flexible

Can take 2-10 hours to administer

NeuroimagingComputed Tomography (CT) ScansMagnetic Resonance Imaging (MRI) ScansPositron Emission Tomography (PET) Scans

Neurological Exam

Identifying Signs and Symptoms of PTSD

Symptoms:Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DMS-IV) criteria:

A. Exposure to a traumatic event in which both were present:1. Experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others2. Response involved intense fear, helplessness, or horror

B. Reexperiencing1. Intrusive memories, including images, thoughts, or perceptions2. Nightmares3. Flashbacks4. Intense psychological distress upon exposure to internal /external trauma cues5. Physiological reactivity upon exposure to internal/external trauma cues

Identifying Signs and Symptoms of PTSD (cont.)

Symptoms:C. Avoidance/Numbing

1. Avoid thoughts, feelings, or conversations about trauma2. Avoid activities, places, or people associated with trauma3. Unable to recall important aspects of the trauma4. Diminished interest/participation in significant activities5. Feel detached/estranged from others6. Restricted range of affect7. Sense of foreshortened future

D. Arousal1. Sleep difficulties2. Irritability/Anger outbursts3. Concentration difficulties4. Hypervigilance5. Startle response

E. Duration of symptoms last for more than one month

F. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Identifying Signs and Symptoms of PTSD (cont.)

Assessment:Clinician Administered PTSD Scale (CAPS-IV)

30-item structured interview that corresponds to the DSM-IV criteria for PTSDCan be used to assess Current or Lifetime diagnosis of PTSDTakes 45-60 minutes to administer

Posttraumatic Stress Disorder Checklist (PCL)17-item self-report scale based on DSM-IV criteriaTakes 5-7 minutes to administer3 versions available

MilitaryCivilian“Specific Stressful Event”

PTSD Prevalence in Veterans

16.6% of soldiers from 4 Army combat infantry brigades surveyed 1 year after returning from deployment were diagnosed with PTSD (Hoge, et al., 2007)

PTSD prevalence increases with the presence of TBI (Hoge, et al., 2007 & Schneiderman, et al., 2008)

Injured active duty OIF personnel = 32%Uninjured active duty OIF personnel = 14%

Treatment for TBI

EducationCognitive RemediationSocial Skills TrainingRelaxationGroup TherapyFamily TherapyMedication

Treatment for TBIEducation

Providing education can lead to relief, as it validates the client’s experience and helps them realize that they are not “crazy.”Knowledge is Power – by recognizing your limitations you can learn to compensate for them or work around them

Example 1: By knowing that your memory is poor, you may learn to write down important information so it is not forgottenExample 2: Establish external organization. If you keep forgetting keys, wallet, etc. when leaving the house, put a stand by the front door where you put them immediately upon entering the home.

Treatment for TBI

Cognitive RemediationThe goals of cognitive remediation are to bolster specific cognitive capacities that are weak and also to teach compensatory strategies to work around limitationsTypically use a gradual increase in complexity, based upon the clients performance. Once they establish consistency at 80% or above, increase the complexity of the task.Areas of focus:

Attention/ConcentrationLanguageVisuospatial skillsMemoryOrganization/Planning

Treatment for TBI

Social Skills TrainingTBI can affect the natural “feedback loop” that allows us to assess and modify our social interactions with others.When this is “broken” people may talk too much (i.e., fail to take turns in conversation), impulsively state what’s on their mind even if it is not appropriate, or fail to recognize social cues (e.g., not recognizing that someone may be in a hurry when they are looking at their watch).

Treatment for TBIRelaxation

Biofeedback – this training allows clients to reestablish control over their arousal levels, as lowered frustration tolerance is often seen with TBI.

Group TherapyAt Rehab Without Walls we offer several groups.

Coping group – allows individuals an opportunity to share with and learn from others who have also suffered a brain insult.Stress Management Group – where clients learn about the physiological aspect of stress and practice relaxation techniques together.Memory Group – a didactic group that provides education regarding the cognitive, behavioral, and emotional sequelae of TBI. T’ai Chi Group – helps clients develop a nice balance between healing the mind and the body.

Treatment for TBI

Group Therapy (cont.)VA – offers a “Brain Booster” group, which provides veterans with education regarding the effects of TBI and homework assignments geared towards improving areas of cognitive limitation.Benefits of group therapy:

Accountability – feeling peer pressure to follow through with homework assignments Support – often times individuals with TBI feel that they are alone, that no one understands what they are going through, until they meet others with similar issues

Treatment for TBI

Family TherapyFamily/friends are also affected by TBI “Changes” are often noted in personality and behavior, which can confuse family/friends.Client is not “lazy” or “acting out”Education provides family/friends with relief and gives a sense of hopeKnowledge also makes them better supporters of the injured personImportant to help children understand changes seen in their parent as well

Treatment for TBIMedication

PsychostimulantsFor attention deficits and initiation difficultiesIncreases frontal lobe activity, which is an important area for attention processing (Perna & Bordini, 2001)

AntidepressantsDepression following TBI is common and can hinder recovery (Jorge et al., 2004)

Typically first choice is from the SSRI group

AnticonvulsantsApproximately 5-10% of TBI clients will develop new-onset seizures (Meythaler & Novack)

Typically given as a prophylactic to help prevent seizures after an injury The risk of seizures increases with severity of injuryThe risk is greatest the first two years and then gradually declines thereafter

Treatment for PTSD

Cognitive TherapyExposure TherapyEMDRRelaxationGroup TherapyFamily TherapyMedication

Treatment for PTSD

Cognitive Processing Therapy (CPT; Resick et al., 2007)

A manualized, 12-session, specific form of CBT for PTSDProvides both cognitive and exposure therapy elementsFocuses on a range of emotions, such as anxiety, shame, sadness, anger, etc.CPT has produced statistically significant improvements compared with Prolonged Exposure (PE) therapy in trauma-related guilt (Resick, et al., 2002)

CPT was found effective in treating military-related PTSD as well (Monson et al., 2006)

Treatment for PTSDCPT (cont.):

Session 1: Introduction and EducationPsychoeducation – PTSD symptoms are explainedHomework – Write an “Impact Statement” (the meaning of the traumatic event and beliefs as to why it happened)

Session 2: The Meaning of the EventRead “Impact Statement” – geared towards identifying problematic beliefs and cognitions (“stuck points”)Education – to identify the connection between events, thoughts, and feelingsHomework – Practice identifying connection between events, thoughts, and feelings


Session 3: Identification of Thoughts and FeelingsReview self-monitoring homeworkHomework – Write a detailed account of the most traumatic event and read it every day before Session 4

Session 4: Remembering the Traumatic EventRecall and better contextualize traumatic events and to experience the natural emotions that they may have suppressed following these eventsHomework – Rewrite the trauma account with more details and emotions and document current thoughts and beliefs as they write the account. Read daily before Session 5


Session 5: Second Trauma AccountRead second accountCognitive challenging using a Socratic style of questioningTeach clients to ask questions regarding their assumptions and self-statements in order to begin challenging them

Session 6-7: Challenging Questions & Patterns of Problematic Thinking

Education regarding using worksheets in day-to-day lives to challenge and modify maladaptive thoughts and beliefs related to traumatic experience

Treatment for PTSD

CPT (cont.):Session 8-12:

Overgeneralized beliefs in five areas (i.e., safety, trust, power/control, esteem, & intimacy) are challenged as they relate to self and others

Treatment for PTSD

Exposure Therapy (EP):A client is asked to vividly recount a traumatic event repeatedly until the client’s emotional response decreases and to gradually confront safe but fear-evoking trauma reminders.

If multiple traumas exist, focus upon the most distressing memory. Successfully processing the worst trauma usually generalizes to other memories.

Treatment for PTSD

Exposure Therapy (EP):Compared to Present Centered Therapy (PCT; focusing on today’s issues as manifested by having PTSD), EP was superior: (Schnurr, et al., 2007)

Lost Diagnosis

Total Remission

EP Women 41.0% 15.2%

PCT Women 27.8% 6.9%

Treatment for PTSD

Eye Movement Desensitization and Reprocessing (EMDR):

Developed by Francine Shapiro, Ph.D.It is an Information Processing Therapy

“When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. “ (Shapiro)

Treatment for PTSD

Eye Movement Desensitization and Reprocessing (EMDR):

It uses an 8 phase approachPhase 1: Client History & Treatment Planning

Identify possible targets for EMDR processing 3-pronged:

Recent distressing events Related historical incidents Development of skills/behaviors needed by client in future situations

Treatment for PTSDEye Movement Desensitization and Reprocessing (EMDR, cont.):

Phase 2: Client Preparation Teach self-soothing techniques (i.e., establish a “safe place” the client can return to during times of emotional distress) Client identifies type of bilateral attention process preferred to use (visual, auditory, or tactile) Client’s fears and concerns are addressed

Phase 3: Assessment Identify target incident State what picture represents the worst part of the experience Rate negative and positive cognitions Describe related body feelings


Phase 4: Desensitization Client focuses on bilateral stimulation while holding target event in mind Lasts 30 seconds to several minutes depending upon client’s response Clear the mind and allow whatever comes into awareness Repeat the procedure

Phase 5: Installation of Positive Cognition Determine validity of positive cognitionConduct bilateral attention until it is experienced as being totally valid


Phase 6: Body Scan Clients close their eyes and scan their body for tension or negative sensations Bilateral stimulation is conducted until negative sensations subside or a positive feeling is experienced

Phase 7: Closure Education is provided regarding experiences the client may have after the session, such as having new insights, vivid dreams, intrusive thoughts, etc. Client is to record and report these experiences during the next session

Treatment for PTSD

Eye Movement Desensitization and Reprocessing (EMDR, cont.):

Phase 8: Reevaluation Review the week, discussing any new sensations Review the client’s log Assess the previous session’s target in order to determine whether further desensitization work is needed

Treatment for PTSDRelaxation Therapy:

Progressive Muscle RelaxationSqueezing and releasing different muscle groups

Diaphragmatic BreathingBreathing into the belly rather than into the chest

Meditation

Aromatherapy

Massage

Treatment for PTSDGroup Therapy:

These groups provide mutual support from others who have experienced similar traumas and encourage the patient to begin confronting their traumas (Davidson & Neale, 1998).

Family Therapy:There are no research studies on the effectiveness of marital/family therapy for the treatment of PTSD. However, because of trauma's unique effects on interpersonal relatedness, clinical wisdom indicates that spouses and families be included in treatment of those with PTSD. Of note, marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been successfully (individually) rehabilitated.

Treatment for PTSDMedication:

SSRIs – research shows that these medications tend to decrease anxiety, depression, and panic. They may also reduce aggression, impulsivity, and suicidal thoughts.Types of SSRIs:

citalopram (Celexa)fluoxetine (Prozac)paroxetine (Paxil)sertraline (Zoloft)

Take 6-8 weeks to workMany do not get relief from the first prescription and will need to try another medicationA relapse is less likely to occur if prescribed for at least one year

Treatment for PTSDMedication:

Atypical antipsychoticsTypes of antipsychotics:

risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel)

Most useful for those with agitation, dissociation, hypervigilance, paranoia, or brief psychotic reactions

Mood stabilizersTypes of mood stabilizers:

lamotrigine (Lamictal) tiagabine (Gabitril)divalproex sodium (Depakote)

Treatment Success for TBI

A review of studies conducted in several countries, over 20 years, found early intervention involving education, reassurance, and reattribution of symptoms to benign causes to be effective (Mittenberg et al., 2001)

Long-term benefits have been found for symptomatology and quality of life after undergoing neuropsychological rehabilitation after a brain injury (Svendsen & Teasdale, 2006).

Treatment Success for PTSD

A meta-analysis on 61 treatment outcome trials for PTSD (Van Etton & Taylor, 1998) revealed:

Psychological therapies had a lower drop-out rates than pharmacotherapiesPsychological therapies were more effective in symptom reduction than pharmacotherapiesBoth therapies were more effective than controlsOf drug therapies, SSRIs and carbamazepine had the greatest effect sizesOf psychological therapies, behavior and EMDR were most effectiveSSRIs were more effective than any other therapy in treating depression

Long-Term Effects of TBI & PTSD

Left untreated, both can lead to dire consequences:

IsolationTBI – being socially inappropriate, apathetic, labilePTSD – turn friends away, silence, “no one understands me”

UnemploymentTBI – loss of cognitive capacity to function at work, depressionPTSD – anger outbursts, lack of frustration tolerance, depression

DivorceTBI – role changes, husband/wife is more like a child/dependentPTSD – increased domestic violence

Death – through suicide, fighting, drug overdose

Involvement of Family and Friends

Family and friends are crucial to helping individuals with TBI and/or PTSD

They are likely to recognize signs and symptoms

Call support lines for help or encourage loved one to do so, because they may not have the cognitive capacity or motivation to do so themselves

Involvement of the Delivery System

VA SystemAn excellent organization for all veteransComprehensive evaluation and treatment of all issues, but now especially vigilant to addressing TBI and PTSD

Brain Injury AssociationProvides excellent resources to friends and families with TBIA great starting place to help understand what is happening and how to get the appropriate help

ResourcesBrain Injury Association

http://www.biausa.org/For Arizona: http://www.biaaz.org/bia/index.aspxBrain Injury Source – published quarterly by the Brain Injury Association

EMDR Institutehttp://www.emdr.com/

The International Society for Traumatic Stress Studies

http://www.istss.org/

Resources (cont.)National Institute of Mental Health

http://www.nimh.nih.gov/topics/ptsd.shtmlClinical trials on PTSD (i.e., searching for participants)PamphletsCurrent news regarding PTSD (e.g., risk factors, treatment, etc.)

Rehab Without Wallshttp://www.gentiva.com/index.asp

PTSD Support Serviceshttp://www.ptsdsupport.net/index.html

Resources (cont.)United States Department of Veterans Affairs

http://www.va.gov/National Center for Posttraumatic Stress Disorder

ReferencesAmerican Psychiatric Association. (1994). Diagnostic and statistical manual of

mental disorders (4th ed.). Washington, DC: Author.

Blake, D.D., Weathers, F.W., Nagy, L.M., Kaloupek, D., Klauminzer, G., Charney, D.S., Keane, T.M., & Buckley, T.C. (2000). Clinician-Administered PTSD Scale (CAPS) Instruction Manual. Boston, MA: National Center for PTSD.

Bolton, E.E., Lambert, J.F., Wolf, E.J., Raja, S., Varra, A.A., & Fisher, L.M. (2004). Evaluating a cognitive-behavioral group treatment program for veterans with posttraumatic stress disorder. Psychological Services 1(2), 140-146.

Davidson, G.C., & Neale, J.M. (1998). Abnormal Psychology (7th ed.). New York: John Wiley & Sons, Inc.

Giza, C.C., & Hovda, D.A. (2001). The neurometabolic cascade of concussion. Journal of Athletic Training, 36(3), 228-235.

Hoge, C.W., McGurk, D., Thomas, J.L., Cox, A.L., Engel, C.C., & Castro, C.A. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. The New England Journal of Medicine, 358(5), 453-463.

Hoge, C.W., Terhakopian, A., Castro, C.A., Messer, S.C., & Engel, C.C. (2007). Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. The American Journal of Psychiatry 164, 150–153.

ReferencesJorge, R.E., Robinson, R.G., Moser, D., Tateno, A., Crespo-Facorro, B., &

Arndt, S. (2004). Major depression following traumatic brain injury. Archives of General Psychiatry 61(1), 42-50.

Lubin, H., Loris, M., Burt, J., & Johnson, D.R. (1998). Efficacy of psychoeducational group therapy in reducing symptoms of posttraumatic stress disorder among multiply traumatized women. The American Journal of Psychiatry 155(9), 1172-1177.

Meythaler, J., & Novack, T. Posttraumatic seizures following head injury. The University of Alabama Traumatic Brain Injury Care System, Birmingham, AL. Retrieved November 9, 2008 from http://main.uab.edu/tbi/show.asp?durki=10213.

Mittenberg, W., Canyock, E.M., Condit, D., & Patton, C. (2001). Treatment of post-concussion syndrome following mild traumatic brain injury. Journal of Clinical and Experimental Neuropsychology, 23(6), 829-836.

Monson, C.M., Schnurr, P.P., Resick, P.A., Friedman, M.J., Young-Xu, Y., Stevens, S.P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898-907.

Perna, R.B., & Bordini, E.J. (2001). Cognitive impairments in TBI: Pharmacological treatment considerations. TBI Challeng 5(2), 1-8.

Resick, P.A., Monson, C.M., & Chard, K.M. (2007). Cognitive processing therapy: Veteran/military version. Washington, DC: Department of Veterans’ Affairs.

http://main.uab.edu/tbi/show.asp?durki=10213

ReferencesResick, P.A., Nishith, P., Weaver, T.L., Astin, M.C., & Feuer, C.A. (2002). A comparison of

cognitive processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867-879.

Schnurr, P.P., Friedman, M.J., Engel, C.C., Foa, E.B., Shea, M.T., Chow, B.K., Resick, P.A., Thurston, V., Orsillo, S.M., Haug, R., Turner, C., & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. The Journal of the American Medical Association 297(8), 820-830.

Svendsen, H.A., & Teasdale, T.W. (2006). The influence of neuropsychological rehabilitation on symptomatology and quality of life following a brain injury: A controlled long-term follow-up. Brain Injury, 20(12), 1295-1306.

Traumatic brain injury. (2006). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved November 6, 2008 from http://www.cdc.gov/ncipc/tbi/TBI.htm.

Schneiderman, A.I., Braver, E.R., & Kang, H.K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167(12), 1446-1452.

Van Etton, M.L., & Taylor, S. (1998). Comparative efficacy of treatments for post-traumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5(3), 1236-144.

Weathers, F.W., Litz, B.T., Herman, D.S., Huska, J.A., & Keane, T.M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Conference of the ISTSS, San Antonio, TX.

http://www.cdc.gov/ncipc/tbi/TBI.htm

Contact Information

Tracy L. Thomas, Ph.D.Clinical Neuropsychologist

Rehab Without [email protected]

(602) 943-1012(623) 512-8021

“Thank You!” to all the men and women who have and are currently serving our country.

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