Guest Perspective: Understanding and Treating Traumatic Brain Injury
Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
By Alison Cernich, PhD, ABPP-Cn
Guest Columnist
A U.S. Veteran, I’ll call him Steve, walked into my office following his third and final military deployment. He was referred to me for an evaluation of a potential traumatic brain injury (TBI). As a member of an artillery unit, traveling across Iraq in convoys, Steve, who is a composite, not an actual person, witnessed many deaths and injuries; he felt lucky to have returned safely home without significant limitations, other than post-traumatic stress disorder (PTSD).
Like many other conscientious veterans, Steve didn’t see the need to be chatting with me or why I was evaluating him for TBI. Yes, he noted, there was the time he lost consciousness for about 10 minutes after hitting his head in the armored tank. And the time his unit drove over an improvised explosive device. After the explosion, all he remembered was waking up at base and asking his buddies what happened. Dizzy afterwards? Yes, both times. Nausea? Just the second time. Headache, yes and still…..
Hmm. There was more. As the interview continued, Steve mentioned continued headaches, occasional problems with balance and memory, specifically when paying attention in the classes he was taking to complete his degree. He was having trouble focusing on his studies and was less organized than when he started his military career.
Steve is all too typical—in both his symptoms and the potential for long-term, severe complications without treatment. TBI remains a challenge to accept, understand and treat. It is a challenge not only for injured veterans and their families, but also for providers and clinicians because it is difficult to distinguish the symptoms of TBI from other conditions.
What is traumatic brain injury?
According to the Defense and Veterans Brain Injury Center, a total of 339,462 service members have been diagnosed with TBI since 2000.
The U.S. Department of Veteran Affairs Clinical Practice Guideline defines TBI as a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event:
- Any period of loss of or decreased level of consciousness (LOC)
- Any loss of memory for events immediately before or after the injury (post-traumatic amnesia [PTA])
- Any alteration in mental state at the time of injury (confusion, disorientation, slowed thinking, etc.). Also called alteration of consciousness, or AOC.
- Neurological deficits (weakness, loss of balance, change in vision, etc.) that may or may not be transient
- Intracranial lesion
Two major points to understand about these injuries is that there has to be an event that causes a TBI, and not everyone who experiences a blow to the head will have a TBI. The severity of a TBI is categorized based on the length of LOC, AOC, or PTA. Generally, TBI is classified as either mild, moderate, or severe; mild injuries often are called concussions.
Most importantly for the clinician, the severity of the injury should not be confused with the outcome following the injury. A person with a mild brain injury may recover quickly or may take months before symptoms resolve. Our ability to predict these outcomes as researchers is improving. Poor outcomes are associated with pre-existing psychiatric conditions, older age, experience of previous TBI, and other factors, but this is not yet an exact, predictive model.
Co-occurrence of TBI with mental health diagnoses
PTSD and TBI have a relatively high rate of co-occurrence among Veterans and active Service members, with some studies showing an estimated overlap of about 30%. Those with TBI are more likely to be diagnosed with PTSD, other anxiety disorders, and adjustment disorders than those without a TBI diagnosis. In addition, other psychiatric diagnoses, such as depression, are common in people with TBI, though it’s unclear how prevalent these disorders are among Service members and Veterans. However, previous research has shown that male Service members are more likely to have a co-occurring diagnosis of PTSD, and female Service members are more likely to have a co-occurring diagnosis of depression.
The co-occurrence of these conditions also affects the number of symptoms. For example, people diagnosed with TBI and PTSD reported more symptoms than those with either condition alone. Moreover, they experience these symptoms as more severe, especially related to headaches, balance, and cognition.
How to manage and treat TBI
Where does the clinician start? A careful history is my best practice to determine if an event occurred where the individual was at risk for TBI (explosion, motor vehicle accident, fall, sports injury, etc.). I also aim to identify what symptoms developed at the time of the injury, following the injury, and continue still. While the Service member may have experienced an injury, it is important to understand that the symptoms may have resolved. The clinician may not need to provide specific treatment.
However, if the person still experiences symptoms, such as headache, problems with balance, or cognition, then more evaluation and referral is needed to enhance his or her overall functioning. When prescribing pharmacologic treatment, clinicians should consider TBI in their decision making, as certain medications are not indicated for people with TBI and could make certain symptoms, especially cognitive ones, worse.
Distinguishing between some co-occurring conditions and TBI can be tricky. There are overlapping symptoms of PTSD and TBI, most notably potential irritability, anxiety, depression, and cognitive difficulty. Similarities between TBI and depression can include fatigue, cognitive challenges, and low motivation for completing tasks. The clinician should work through a time course, clarify symptoms during that course, and distinguish symptoms and causes.
Treatment of TBI is symptomatic, especially for persistent symptoms of mild TBI. Mental health providers, in consultation with primary care physicians, as well as specialists in neurology, neuropsychology, physical and occupational therapy, or speech pathology, can determine the best course of care. When symptoms are treated, Service members can experience improvement and may be more responsive to treatments for other mental health conditions. There are no current guidelines on how best to treat mental health conditions that co-occur with TBI, and the clinical consensus is to offer evidence-based practices that have demonstrated efficacy in cases of PTSD and depression.
While Service members, such as Steve, can be skeptical of mental health treatment and TBI diagnosis, clinicians can help them navigate and provide accurate assessments. They also can offer symptomatic treatment and ultimately gain a better understanding of the potential effects of these hidden injuries. Our goal is to promote recovery and enable optimal functioning.
***
Alison Cernich, PhD, ABPP-Cn, is a neuropsychologist and director of the National Center for Medical Rehabilitation Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Maryland. She previously served as deputy director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in the Department of Defense and as deputy director for VA-DoD Mental Health Integration in Mental Health Services in the Department of Veterans Affairs. She received her doctoral degree in clinical psychology from Fairleigh Dickinson University in Teaneck, New Jersey.
Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
By Alison Cernich, PhD, ABPP-Cn
Guest Columnist
A U.S. Veteran, I’ll call him Steve, walked into my office following his third and final military deployment. He was referred to me for an evaluation of a potential traumatic brain injury (TBI). As a member of an artillery unit, traveling across Iraq in convoys, Steve, who is a composite, not an actual person, witnessed many deaths and injuries; he felt lucky to have returned safely home without significant limitations, other than post-traumatic stress disorder (PTSD).
Like many other conscientious veterans, Steve didn’t see the need to be chatting with me or why I was evaluating him for TBI. Yes, he noted, there was the time he lost consciousness for about 10 minutes after hitting his head in the armored tank. And the time his unit drove over an improvised explosive device. After the explosion, all he remembered was waking up at base and asking his buddies what happened. Dizzy afterwards? Yes, both times. Nausea? Just the second time. Headache, yes and still…..
Hmm. There was more. As the interview continued, Steve mentioned continued headaches, occasional problems with balance and memory, specifically when paying attention in the classes he was taking to complete his degree. He was having trouble focusing on his studies and was less organized than when he started his military career.
Steve is all too typical—in both his symptoms and the potential for long-term, severe complications without treatment. TBI remains a challenge to accept, understand and treat. It is a challenge not only for injured veterans and their families, but also for providers and clinicians because it is difficult to distinguish the symptoms of TBI from other conditions.
What is traumatic brain injury?
According to the Defense and Veterans Brain Injury Center, a total of 339,462 service members have been diagnosed with TBI since 2000.
The U.S. Department of Veteran Affairs Clinical Practice Guideline defines TBI as a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs immediately following the event:
- Any period of loss of or decreased level of consciousness (LOC)
- Any loss of memory for events immediately before or after the injury (post-traumatic amnesia [PTA])
- Any alteration in mental state at the time of injury (confusion, disorientation, slowed thinking, etc.). Also called alteration of consciousness, or AOC.
- Neurological deficits (weakness, loss of balance, change in vision, etc.) that may or may not be transient
- Intracranial lesion
Two major points to understand about these injuries is that there has to be an event that causes a TBI, and not everyone who experiences a blow to the head will have a TBI. The severity of a TBI is categorized based on the length of LOC, AOC, or PTA. Generally, TBI is classified as either mild, moderate, or severe; mild injuries often are called concussions.
Most importantly for the clinician, the severity of the injury should not be confused with the outcome following the injury. A person with a mild brain injury may recover quickly or may take months before symptoms resolve. Our ability to predict these outcomes as researchers is improving. Poor outcomes are associated with pre-existing psychiatric conditions, older age, experience of previous TBI, and other factors, but this is not yet an exact, predictive model.
Co-occurrence of TBI with mental health diagnoses
PTSD and TBI have a relatively high rate of co-occurrence among Veterans and active Service members, with some studies showing an estimated overlap of about 30%. Those with TBI are more likely to be diagnosed with PTSD, other anxiety disorders, and adjustment disorders than those without a TBI diagnosis. In addition, other psychiatric diagnoses, such as depression, are common in people with TBI, though it’s unclear how prevalent these disorders are among Service members and Veterans. However, previous research has shown that male Service members are more likely to have a co-occurring diagnosis of PTSD, and female Service members are more likely to have a co-occurring diagnosis of depression.
The co-occurrence of these conditions also affects the number of symptoms. For example, people diagnosed with TBI and PTSD reported more symptoms than those with either condition alone. Moreover, they experience these symptoms as more severe, especially related to headaches, balance, and cognition.
How to manage and treat TBI
Where does the clinician start? A careful history is my best practice to determine if an event occurred where the individual was at risk for TBI (explosion, motor vehicle accident, fall, sports injury, etc.). I also aim to identify what symptoms developed at the time of the injury, following the injury, and continue still. While the Service member may have experienced an injury, it is important to understand that the symptoms may have resolved. The clinician may not need to provide specific treatment.
However, if the person still experiences symptoms, such as headache, problems with balance, or cognition, then more evaluation and referral is needed to enhance his or her overall functioning. When prescribing pharmacologic treatment, clinicians should consider TBI in their decision making, as certain medications are not indicated for people with TBI and could make certain symptoms, especially cognitive ones, worse.
Distinguishing between some co-occurring conditions and TBI can be tricky. There are overlapping symptoms of PTSD and TBI, most notably potential irritability, anxiety, depression, and cognitive difficulty. Similarities between TBI and depression can include fatigue, cognitive challenges, and low motivation for completing tasks. The clinician should work through a time course, clarify symptoms during that course, and distinguish symptoms and causes.
Treatment of TBI is symptomatic, especially for persistent symptoms of mild TBI. Mental health providers, in consultation with primary care physicians, as well as specialists in neurology, neuropsychology, physical and occupational therapy, or speech pathology, can determine the best course of care. When symptoms are treated, Service members can experience improvement and may be more responsive to treatments for other mental health conditions. There are no current guidelines on how best to treat mental health conditions that co-occur with TBI, and the clinical consensus is to offer evidence-based practices that have demonstrated efficacy in cases of PTSD and depression.
While Service members, such as Steve, can be skeptical of mental health treatment and TBI diagnosis, clinicians can help them navigate and provide accurate assessments. They also can offer symptomatic treatment and ultimately gain a better understanding of the potential effects of these hidden injuries. Our goal is to promote recovery and enable optimal functioning.
***
Alison Cernich, PhD, ABPP-Cn, is a neuropsychologist and director of the National Center for Medical Rehabilitation Research at the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda, Maryland. She previously served as deputy director of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury in the Department of Defense and as deputy director for VA-DoD Mental Health Integration in Mental Health Services in the Department of Veterans Affairs. She received her doctoral degree in clinical psychology from Fairleigh Dickinson University in Teaneck, New Jersey.