Although traumatic brain injury (TBI) and post traumatic stress disorder (PTSD) are two completely different diagnoses, they are often mentioned in the same breath by behavioral health professionals. That’s because the symptoms – or “sequelae” as the aftermath, when symptomatic, of TBI are referred to – are similar: sleeplessness, anxiety, depression, and problems with concentration and memory.
“We’re beginning to learn more and more about the connections between traumatic brain injury and potential sequelae, whether they be physical or psychological or both,” says Russell R. Lonser, M.D., senior investigator with the neurosurgical biology and therapeutics section in the division of intramural research at the National Institute of Neurological Disorders and Stroke.
Because of the heightened awareness of TBI due to the wars in Iraq and Afghanistan, scientists are learning more. Lonser pointed to improvements in imaging that could lead to more sensitive tests, one day making it possible to diagnose very mild TBI that may have gone undetected before. “Most physicians would define concussions as loss of consciousness,” he says. But TBI can occur without a person ever losing consciousness. Only if the TBI was very severe could an old injury be picked up by CT or MRI, the more routine scans, said Lonser, who is a neurosurgeon.
Management of TBI
If severe, TBI is managed by a neurologist, who should interact with a psychologist or psychiatrist, says Lonser. In the future, these interactions will be much more frequent, making for better patient care, he says. In this way TBI, which involves the brain both physiologically and psychologically, is a perfect example of the need for integrated care.
TBI is a clinical diagnosis, explains Vani Rao, M.D., associate professor and director of the brain injury program at Johns Hopkins. “The definition is a trauma to the head resulting in external or penetrating injury that disrupts the normal function of the brain.” After physical trauma to the head, there is inflammation that may need to be relieved. Depending on the severity of the brain injury, symptoms differ.
Soon after the injury, treatment is medical management and exactly what is done depends on the severity, says Rao. Neurosurgeons decide whether to treat bleeding in the brain medically or surgically; they need to prevent blood loss and may need to treat a clot in the brain, she says. “The most important thing is to prevent seizures, so at least for the first week they will be on seizure medication.”
Mild TBI – by definition 30 minutes or less of a loss of consciousness – accounts for 75 to 80 percent of head injuries. These usually resolve within a few days to a few months in terms of functioning, says Rao. But for 10 to 20 percent of people who suffer a mild TBI, sequelae continue.
Sequelae of TBI may present quickly. They are divided into somatic symptoms such as headaches, emotional symptoms such as anxiety and depression, neurological symptoms such as tinnitus, and cognitive symptoms such as memory loss, inattention, and concentration problems. Behavioral health providers, of course, primarily focus on the emotional and cognitive symptoms. For TBI, cognitive problems with memory, attention, and concentration can be chronic.
PTSD is an anxiety disorder, but people tend to confuse it with TBI because the symptoms are more or less the same, says Rao. “The depression, anxiety, and hyperarousal can be there for both,” she said.
Because most cognitive and emotional symptoms resolve on their own, they usually aren’t treated immediately, says Rao. “If they persist or worsen, then the patient would need a comprehensive evaluation to find out if something else is going on.”
TBI is divided into mild, moderate, and severe categories, depending on how long the person lost consciousness (although with mild TBI, the person might not have lost consciousness at all).
TBI in veterans
PTSD can be caused by a psychological trauma, not a TBI, and TBI can occur without any ensuing PTSD. In combat situations, however, when there is a blast, there are both physical and psychological traumas, making TBI and PTSD co-morbid clinical presentations.
But behavioral health providers shouldn’t have to focus on whether someone’s symptoms are caused by PTSD or TBI or both, experts say. “Although it is often difficult to attribute symptoms to a particular diagnosis – TBI, PTSD, or pain – treatment is not dependent on this,” says Micaela Cornis-Pop Ph.D., polytrauma/TBI coordinator with the U.S. Department of Veterans Affairs (VA) central office. “The mainstay of treatment for these veterans is symptom-specific intervention, such as managing headaches and improving sleep, and education.”
In combat, TBI and PTSD are more likely to go together, however. “There is a physical traumatic event which precipitates the TBI, but also a psychological event, where there is anxiety and terror, which happens quite frequently in a combat situation,” she says. It is estimated that in 70 percent of the cases of TBI in the VA, there is also PTSD, she says.
If you see a patient with symptoms resembling PTSD and TBI and you are trying to distinguish between them, the way this is done in the VA is through a clinical interview, says Cornis-Pop. Sometimes the brain injury is mild – the soldier might have been far away from the blast – but the psychological trauma still is there. It is essential to go into detail about the time of the injuries and whether the person has continuous memories of what happened during the incident, she says. “If they have continuous memories, there is a high probability that they do not have a TBI but do have PTSD.”