Posttraumatic Stress Disorder Posttraumatic Stress Disorder and Traumatic Brain Injury: and Traumatic Brain Injury:

The Similarities and The Similarities and DifferencesDifferences

Brian A. Boatwright, Psy.D.Brian A. Boatwright, Psy.D.NeuropsychologistNeuropsychologist

Director of the Neurological Rehabilitation Director of the Neurological Rehabilitation Institute at Brookhaven HospitalInstitute at Brookhaven Hospital

ObjectivesObjectives

Compare PTSD and TBI noting the Compare PTSD and TBI noting the similarities and differencessimilarities and differencesReview basic neuroanatomy associated Review basic neuroanatomy associated with PTSD and TBIwith PTSD and TBILearn important interview questions and Learn important interview questions and considerations when working with considerations when working with TBI/PTSD populationTBI/PTSD populationDiscuss options for patients’ continuity of Discuss options for patients’ continuity of carecare

ObjectivesObjectives

Increase awareness of formal assessment Increase awareness of formal assessment

Clinical case examplesClinical case examples

The SimilaritiesThe Similarities

PTSD Cognitive PTSD Cognitive ComplaintsComplaints– AttentionAttention– Working memoryWorking memory– MemoryMemory– Slower mental Slower mental

processing speedprocessing speed

TBI Cognitive TBI Cognitive Complaints (Varies Complaints (Varies according to injury)according to injury)– AttentionAttention– Working memoryWorking memory– MemoryMemory– Slower mental Slower mental

processing speedprocessing speed

The SimilaritiesThe Similarities

PTSD PTSD Affective/PersonalityAffective/Personality– Traumatic eventTraumatic event– Sleep disturbanceSleep disturbance– HypervigilanceHypervigilance– Alteration in mood Alteration in mood

(irritability, affective (irritability, affective flattening, depressed flattening, depressed mood)mood)

– ParanoiaParanoia– AnxietyAnxiety– Substance AbuseSubstance Abuse

TBI Affective/PersonalityTBI Affective/Personality– Traumatic eventTraumatic event– Sleep disturbanceSleep disturbance– HypervigilanceHypervigilance– Alteration in mood Alteration in mood

(irritabilty, affective (irritabilty, affective flattening, depressed flattening, depressed mood)mood)

– ParanoiaParanoia– AnxietyAnxiety– Substance AbuseSubstance Abuse

Neuroanatomy ReviewNeuroanatomy Review

Neuropsychological DomainsNeuropsychological Domains

Acquired KnowledgeAcquired Knowledge

Attention & MemoryAttention & Memory

LanguageLanguage

Visual Spatial Visual Spatial

Motor & Sensory PerceptualMotor & Sensory Perceptual

Reasoning & Problem SolvingReasoning & Problem Solving

Executive FunctionsExecutive Functions– PlanningPlanning– Processing SpeedProcessing Speed– Cognitive FlexibilityCognitive Flexibility

PersonalityPersonality

Social CognitionSocial Cognition

Motivation / Response BiasMotivation / Response Bias

TBI and NeuropsychologyTBI and Neuropsychology

Performance IQ loss is generally greater Performance IQ loss is generally greater than Verbal IQ loss.than Verbal IQ loss.

Deficits may be seen in any number of Deficits may be seen in any number of domains, dependent on lesion location.domains, dependent on lesion location.

Memory is the most prominently effected Memory is the most prominently effected neuropsychological function but will also see neuropsychological function but will also see marked impairment in executive functioning.marked impairment in executive functioning.

Greatest improvement seen shortly post-Greatest improvement seen shortly post-injury but may be two years and beyond.injury but may be two years and beyond.

Basic Neuroanatomy and Basic Neuroanatomy and Functional LocalizationFunctional Localization

Frontal LobesFrontal Lobes– AttentionAttention– PlanningPlanning– SequencingSequencing– OrganizationOrganization– Mental FlexibilityMental Flexibility– Problem SolvingProblem Solving– Impulse ControlImpulse Control– Aspects of Memory (Executive Memory)Aspects of Memory (Executive Memory)

Temporal Lobes (Hippocampus, Temporal Lobes (Hippocampus, Amygdala, Basal Ganglia)Amygdala, Basal Ganglia)– Sound recognition and processingSound recognition and processing– Comprehension and production of speechComprehension and production of speech– Aspects of memoryAspects of memory

Parietal LobesParietal Lobes– Integration of sensory information from the Integration of sensory information from the

bodybody– Contains primary sensory cortexContains primary sensory cortex– ProprioceptionProprioception– Spatial FunctioningSpatial Functioning– VisuoconstructionVisuoconstruction– Aspects of memoryAspects of memory

Occipital LobeOccipital Lobe– Primary Visual CortexPrimary Visual Cortex

CerebellumCerebellum– BalanceBalance– MovementMovement– CoordinationCoordination– Some aspects of attention/executive Some aspects of attention/executive

functioning, frontal connectionsfunctioning, frontal connections

PTSD and CognitionPTSD and Cognition

Attention and Memory common complaintsAttention and Memory common complaintsSome confounding variables-Most research in Some confounding variables-Most research in PTSD involves veterans with comorbid PTSD involves veterans with comorbid psychiatric diagnosespsychiatric diagnosesAlcohol abuse-Right hemisphere more Alcohol abuse-Right hemisphere more vulnerable?vulnerable?Samuelson, et al. (2009) – lower scores on Samuelson, et al. (2009) – lower scores on working memory and verbal memory working memory and verbal memory (Contextually based)(Contextually based)

Samuelson, K.W., Metzler, T.J., Rothlind, J., Choucroun, G., Neylan, T.C., Lenoci, M., Henn-Haase, Samuelson, K.W., Metzler, T.J., Rothlind, J., Choucroun, G., Neylan, T.C., Lenoci, M., Henn-Haase, L., Weiner, M.W., & Marmar, C.R. (2006). Neuropsychological functioning in posttraumatic stress L., Weiner, M.W., & Marmar, C.R. (2006). Neuropsychological functioning in posttraumatic stress disorder and alcohol abuse. disorder and alcohol abuse. Neuropsychology, 20, Neuropsychology, 20, 716-726.716-726.

Studies show decreased hippocampal Studies show decreased hippocampal volume in those with chronic PTSDvolume in those with chronic PTSD

Verbal memory-increased intrusion errorsVerbal memory-increased intrusion errors

Mental flexibilityMental flexibility

Perseverative errorsPerseverative errors

Visuospatial deficits (Alcohol abuse-right Visuospatial deficits (Alcohol abuse-right hemisphere)hemisphere)

Chicken or the Egg???Chicken or the Egg???

Differences in cognitive functioning prior to Differences in cognitive functioning prior to traumatraumaLower cognitive capacity risk factor for Lower cognitive capacity risk factor for PTSD?PTSD?Premorbid dysexecutive functioningPremorbid dysexecutive functioningLess able to shift thoughtsLess able to shift thoughtsBecome stuck in behavior patternsBecome stuck in behavior patterns

Gilbertson, M.W., Gurvits, T.V., Lasko, N.B., Paulus, L.A., Williston, S.K., Pitman, R.K., & Orr, S.P. Gilbertson, M.W., Gurvits, T.V., Lasko, N.B., Paulus, L.A., Williston, S.K., Pitman, R.K., & Orr, S.P. (2006). Neurocognitive function in monozygotic twins discordant for combat exposure: (2006). Neurocognitive function in monozygotic twins discordant for combat exposure: Relationship to posttraumatic stress disorder. Relationship to posttraumatic stress disorder. Journal of Abnormal Psychology, 115, Journal of Abnormal Psychology, 115, 484-495.484-495.

Additional Neural ConsiderationsAdditional Neural Considerations

Studies using provocation techniques elicit Studies using provocation techniques elicit increased amygdala and lower frontal increased amygdala and lower frontal cortical activationcortical activation

Hypothesis-Verbal contextual abilities help Hypothesis-Verbal contextual abilities help one integrate the traumatic memory in one integrate the traumatic memory in one’s pastone’s past

Dorefl, D., Werner, A., Schaefer, M., & Karl, A. (2010). Pilot neuroimaging study in civilian trauma Dorefl, D., Werner, A., Schaefer, M., & Karl, A. (2010). Pilot neuroimaging study in civilian trauma survivors episodic recognition memory, hippocampal volume, and posttraumatic stress disorder survivors episodic recognition memory, hippocampal volume, and posttraumatic stress disorder symptom severity. symptom severity. Journal of Psychology, 218, Journal of Psychology, 218, 128-134.128-134.

The Clinical Interview-Areas of The Clinical Interview-Areas of FocusFocus

Background information (education, Background information (education, psychiatric, medical, family history, etc.)psychiatric, medical, family history, etc.)Inform patient that the interview will be Inform patient that the interview will be detailed and may be difficult at timesdetailed and may be difficult at timesObtain specific information about the eventObtain specific information about the eventWhen?When?Where? (Nearby, something you heard)Where? (Nearby, something you heard)What happened? (Blown off feet, ran over What happened? (Blown off feet, ran over IED, learned that peer was killed)IED, learned that peer was killed)

Be specific with timelineBe specific with timeline

Were you knocked out?Were you knocked out?

What’s the last thing you remember before What’s the last thing you remember before the accident?the accident?

What’s the first thing you remember once What’s the first thing you remember once you regained awareness of your you regained awareness of your surroundings?surroundings?

Ex Post FactoEx Post Facto

What problems have you had since the event?What problems have you had since the event?

MemoryMemory– What are you having trouble remembering? (Names, What are you having trouble remembering? (Names,

routes, written information, oral information, object routes, written information, oral information, object locations)locations)

– When does it happen?When does it happen?– How often do you forget this information?How often do you forget this information?– Is it more difficult at certain times? (When stressed, Is it more difficult at certain times? (When stressed,

just after panic attack, when around certain objects, just after panic attack, when around certain objects, places, etc.)places, etc.)

If you stop and think about it, does the If you stop and think about it, does the answer or information usually come to answer or information usually come to you?you?

Substance use?Substance use?

Complaints about attention/concentrationComplaints about attention/concentration– What situations are most problematic?What situations are most problematic?– Do you notice any specific topics that cause Do you notice any specific topics that cause

you difficulty focusing?you difficulty focusing?– Substance use?Substance use?

Other problems or concernsOther problems or concerns– Language changesLanguage changes– Personality changesPersonality changes– Relationships (Importance of collateral Relationships (Importance of collateral

informant)informant)

What do I do???!!!What do I do???!!!

If not clear PTSD only or suspect If not clear PTSD only or suspect combination of PTSD/TBI-Refer for combination of PTSD/TBI-Refer for neuropsychological evaluationneuropsychological evaluation

Look at timeline of TBI-Function at time of Look at timeline of TBI-Function at time of injury and post-injuryinjury and post-injury

Problems with return to work?Problems with return to work?

Complaints from coworkers/supervisors?Complaints from coworkers/supervisors?

Secondary GainsSecondary Gains

Neuropsychological EvaluationNeuropsychological Evaluation

Full review of records (MRI, CT, additional Full review of records (MRI, CT, additional documentation)documentation)

Neurobehavioral Status ExaminationNeurobehavioral Status Examination

Collateral InterviewCollateral Interview

Objective TestingObjective Testing

EffortEffort

Premorbid Estimate of AbilityPremorbid Estimate of Ability

Current Ability (IQ)Current Ability (IQ)

AcademicAcademic

Motor FunctioningMotor Functioning

MemoryMemory

Executive FunctioningExecutive Functioning

LanguageLanguage

Personality/PsychopathologyPersonality/Psychopathology

Outcome of EvaluationOutcome of Evaluation

Final report back to providerFinal report back to providerRefer for psychotherapy/counselingRefer for psychotherapy/counselingIf TBI, repeat neurocognitive evaluation If TBI, repeat neurocognitive evaluation Timeline of improvement of functioning Timeline of improvement of functioning post-TBIpost-TBIEarly treatment for PTSD (research shows Early treatment for PTSD (research shows hippocampal volume decrease in chronic hippocampal volume decrease in chronic patients)patients)Cognitive rehabilitationCognitive rehabilitation

Case ExampleCase Example

The patient is a 28-year-old, Caucasian, The patient is a 28-year-old, Caucasian, married, male who returned from married, male who returned from Afghanistan three months ago. He has two Afghanistan three months ago. He has two children who are ages 4 and 5. The patient children who are ages 4 and 5. The patient was referred to you by his primary care was referred to you by his primary care physician who suspects posttraumatic physician who suspects posttraumatic stress disorder and wants your stress disorder and wants your professional opinion. While in Afghanistan, professional opinion. While in Afghanistan, he was nearby a mortar explosion that he was nearby a mortar explosion that knocked him against a wall.knocked him against a wall.

““I am not like I was before going off to I am not like I was before going off to war.”war.”

““My family tells me that I’m difficult to be My family tells me that I’m difficult to be around.”around.”

““I am having trouble at work. I can’t do my I am having trouble at work. I can’t do my job like I used to.”job like I used to.”

““My friends don’t come around.”My friends don’t come around.”

““My friends, that are still coming around, My friends, that are still coming around, tell me I’m different.”tell me I’m different.”

““I can’t go places where there’s a bunch of I can’t go places where there’s a bunch of people.”people.”

““I’m having trouble driving.”I’m having trouble driving.”

““Reading is more difficult.”Reading is more difficult.”

““I just can’t watch t.v.”I just can’t watch t.v.”

The patient’s wife reports, “My husband The patient’s wife reports, “My husband stays away from the rest of the family. It’s stays away from the rest of the family. It’s like having a stranger in the house.”like having a stranger in the house.”

The patient’s wife reports, “He doesn’t The patient’s wife reports, “He doesn’t help with cooking and keeping up with help with cooking and keeping up with things around the house anymore.”things around the house anymore.”

The patient’s wife reports, “My husband The patient’s wife reports, “My husband forgot to pick up the kids from school.”forgot to pick up the kids from school.”

The patient’s wife reports, “His boss called The patient’s wife reports, “His boss called me and said he’s different at work.”me and said he’s different at work.”