TBI `sequelae" require special care by behavioral health providers

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.”

Rebuilding the brain
How long rehabilitation should take for TBI is the subject of ongoing research. “We used to think that rehab should happen only in the first few months after the injury,” says Cornis-Pop. “But now we understand that rehabilitation can be successful at different times in the life of the individual.” The most intensive rehabilitation does have to take place at the beginning, so the person can relearn lost or damaged physical, emotional, and cognitive skills. Treatment should be tailored to the needs and skills of the person.

“We need to understand the changes in the brain,” says Cornis-Pop. “it’s not only that they make up what they lost, it’s a rebuilding of the brain,” she says. “I’m not saying we grow new brains, but research in the animal literature as well as in humans shows that with rehabilitation there is growth of neuroconnections.” On a long-term basis, this means that people continue to make gains. Rehabilitation doesn’t go on indefinitely, but when the patient backslides, there’s an opportunity to provide more help on certain skills or challenges.

Demographics of TBI
In the U.S., 1.7 million TBIs occur on average each year. This is a rate equal to 0.5 percent of the population, says Cornis-Pop.
In the total deployed population of about 2.4 million military, 10 to 20 percent have TBIs that are diagnosed in the field or immediately following an incident, says Cornis-Pop. She notes that not all incidents of TBI among veterans are related to combat – they have accidents and falls as well. It’s also important to note that the deployed population is mostly young males, who, relative to the general population, already have an elevated risk of TBI, a risk that increases further when their potential for motor vehicle accidents and other risk behaviors is taken into account. The highest risk for TBI occurs in children below the age of 4 and people over the age of 65 due to the occurrence of falls.

Cumulative injuries are also very common, especially in contact sports, says Rao. “There may be a blow to the head that someone isn’t even aware of,” she said. These “subconcussive” injuries can still add up to TBI, alone or in combination.

Any history of mental illness prior to a TBI is a risk factor for continuing symptoms, says Rao. Studies have shown there may be certain genes that are associated with risks for cognitive problems following a TBI. And, a lack of good psychosocial support is also associated with higher risk for post-TBI problems.  Finally, the degree of emotional and cognitive problems might also be related to the severity of the TBI, she says.

What non-VA providers should know
Non-VA providers should know that injuries that happen in combat are different from accidents, sports injuries, and falls. Even if they specialize in treating sports-related TBI, for example, they need to understand the military population to treat veterans, says Cornis-Pop. “This population is highly educated, with special training, and they have a close connection and support with one another.”

It’s also important to understand that even someone who has not had a TBI in combat has had an experience “that has changed their health, mental and physical,” she says. “They are trying to move from the combat environment into normal life.” Being in a combat situation is physically and psychologically demanding, she says. “There is terrible heat, nutrition is difficult, they are carrying 100 pounds of equipment – this cannot be compared to a sports injury.”

Alison Knopf is a freelance writer, based in New York.