Each year in the United States, almost 2 million people sustain a traumatic brain injury (TBI); it is actually more common than stroke and Alzheimer’s disease.[1] Awareness about TBI continues to rise, as noted by the regular and prominent media coverage of the “blast head injuries” to veterans who were in the Iraq and Afghanistan conflicts; student athletes who receive concussions; professional athletes with multiple concussions developing signs of dementia over their careers; the NFL’s rule-changes; and former Representative Gabby Giffords’ brain injury from a gunshot assault.
Traumatic brain injuries can be classified into mild, moderate and severe categories. The Glasgow Coma Scale (GCS), the most commonly used system for classifying TBI severity in an emergency care setting, grades a person’s level of consciousness and severity of coma on a scale of 3-15, based upon the injured person’s verbal, motor and eye-opening reactions to stimuli. Evaluators generally consider a TBI with a GCS of 13- 15 as mild; a 9-12 as moderate; and 8 or below as severe. [2] Grading scales also frequently assess severity of a TBI based upon the GCS after resuscitation, duration of post-traumatic amnesia, and loss of consciousness. By most grading systems, a “severe” TBI involves a period of post-traumatic amnesia and loss of consciousness following the injurious event.
While attention is often focused on physical and cognitive sequelae following a TBI, the occurrence of psychological disorders is significant, especially the occurrence of post-traumatic stress, post-traumatic depression, and post-traumatic anxiety.[3]
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), PTSD is the development of characteristic symptoms after experiencing an extreme traumatic event that threatens death or bodily harm. Those symptoms include re-experiencing the event over time (i.e., “intrusive memories,” or “flashbacks”), persistent avoidance of stimuli that remind individuals of the event, hyper-vigilance, difficulty controlling emotions, sleep disturbances, and social avoidance behaviors.
The disorder can be debilitating, wreaking havoc with work and social lives. However, many assume that post-traumatic stress disorder (PTSD) cannot develop after a “severe” TBI since it involves loss of consciousness and post-traumatic amnesia (“severe” TBI); and as a result, the nature of the injury prevents the survivor to encode the traumatic memory of the experience.[4] Despite the assumption that one who suffers a severe TBI cannot develop PTSD, many case studies have indeed described PTSD in such individuals.[5]
Study of PTSD After Traumatic Brain Injury
One such study was published in 2000 in the American Journal of Psychiatry and looked into the profile of PTSD after severe traumatic brain injury. The study assessed patients who suffered a severe TBI for PTSD, per the DSM-III-R criteria, six months post injury.[6] The study questioned 96 patients suffering a severe TBI utilizing the Post-traumatic Stress Disorder Interview (PTSD –I); a modified McGill Outcome Pain Questionnaire; the Bed Depression Inventory (BDI); the General Health Questionnaire (GHQ); the Community Integration Questionnaire (CIQ); the Satisfaction with Life Scale (SWL): and the Coping Style Questionnaire (CSQ).
The results included 27.1% of the patients meeting the criteria for PTSD, providing strong evidence challenging the claim that PTSD cannot occur after a severe TBI. While only 19.2% of the patients with PTSD reported intrusive memories of the trauma in the study, 96.2% of those patients reported emotional reactivity. The study concluded that PTSD can develop after severe TBI, despite the loss of consciousness and post-traumatic amnesia. And that the predominance of emotional reactivity and the relative absence of traumatic memories in patients with PTSD who suffered impaired consciousness during trauma suggest that traumatic experiences can be mediated PTSD at an implicit level. These findings indicate that assessments of and by therapeutic interventions after severe traumatic brain injury, to address the specific symptom profile of PTSD, if displaced by TBI patients.
Re-experiencing the trauma is a main feature of PTSD. One important issue when discussing whether TBI and PTSD can stem from the same event is the form that the re-experiencing takes on. For example, the criteria for “re-experiencing” the event can be met through exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event,[7] such as hearing cries of other people, feeling close to death, memories of being in an ambulance, waiting in the emergency room, or waking up in a hospital.
Implementation of PTSD Treatment to Traumatic Brain Injury Survivors
A more recent study in 2012 reaffirmed the relationship between PTSD and TBI following the completion of a PTSD/TBI residential treatment program.[8] The 2012 research team found that veterans with a history of TBI symptoms exacerbated by psychiatric symptoms, including PTSD, could have reducing post concussive symptoms with decreasing PTSD symptoms.
The 2012 study included 28 veterans who met the diagnostic criteria for PTSD and had a history of TBI. Each subject received 8 weeks of treatment in a residential PTSD/TBI program and completed self-report measures of PTSD and post-concussive symptoms at pre- and post-treatment. Results indicated that PTSD and post-concussive symptoms significantly decreased over the course of treatment. The decreases in PTSD and post concussive symptoms were significantly and positively related. The findings suggest that PTSD and TBI symptoms are interdependent and appear to mutually influence one another.
TBI is an injury that can impact a person’s daily activities, work and home life. And the impact can range from mild to severe. And, TBI can be accompanied by PTSD, post-traumatic depression and/or post-traumatic anxiety. Early evaluation and access to treatment with knowledgeable healthcare professionals are part of the solution, as is finding the right attorney with deep experience and commitment to top-tier advocacy for Traumatic Brain Injury survivors and their families. The attorneys at Adler ♦ Giersch ps are known as the firm of choice for those with TBI. We are available to answer your questions and explain the claim process to you, your patients, colleagues, family and friends. Simply give us a call. Consultations are without charge and complimentary.
[1]Jonathan Silver, M.D., “Traumatic Brain Injury: Why Psychiatrists Matter,” Psychiatry Online, December 7, 2012.
[2] Most traumatic brain injuries that occur are mild. And the mild-moderate-severe grading scale has been criticized as describing only the initial insult relative to the degree of neurological severity. The term “mild” usually does not relate to the degree of short or long term functional difficulties or disabilities.
[3] Most traumatic brain injuries that occur are mild. And the mild-moderate-severe grading scale has been criticized as describing only the initial insult relative to the degree of neurological severity. The term “mild” usually does not relate to the degree of short or long term functional difficulties or disabilities.
[4] Sbordone RJ, Liter JC: Mild traumatic brain injury does not produce post-traumatic stress disorder. Brain Inj 1995; 9:405–412
[5] Bryant RA: Posttraumatic stress disorder, flashbacks, and pseudomemories in closed head injury. J Trauma Stress 1996; 9:621–629; Bryant RA, Harvey AG: A comparison of traumatic memories and pseudomemories in posttraumatic stress disorder. Applied Cognitive Psychol 1998; 12:81–88
[6] Bryant, Richard A. PhD; Marosszeky, Jeno E. MB, BS; Crooks, Jenelle RN; Baguley, Ian J. MB, BS; Gurka, Joseph A. MB, BS, “Posttraumatic Stress Disorder After Severe Traumatic Brain Injury,” Am J Psychiatry 2000, 157:629-631.
[7] American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders IV. Washington D.C., 1994.
[8] Water, KH, “Relationship Between Posttraumatic Stress Disorder and Postconcussive Symptoms Improvement After Completion of a Posttraumatic Stress Disorder/Traumatic Brain Injury Residential Treatment Program,” Rehabilitation Psychol. 2012 Feb; 57 (1):13-7.
