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Conceptual and Practical Overlap: Mild Traumatic Brain Injury, PTSD , and Pain. Rodney D. Vanderploeg , Ph.D., ABPP-CN James A. Haley Veterans Hospital, Tampa, FL Associate Professor of Psychology & Psychiatry, University of South Florida. Disclaimer.

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conceptual and practical overlap mild traumatic brain injury ptsd and pain

Conceptual and Practical Overlap: Mild Traumatic Brain Injury, PTSD, and Pain

Rodney D. Vanderploeg, Ph.D., ABPP-CN

James A. Haley Veterans Hospital, Tampa, FL

Associate Professor of Psychology & Psychiatry, University of South Florida

disclaimer
Disclaimer

The views expressed in this presentation are those of the author and do not reflect the official policy of the

Department of Veterans Affairs

hoge et al nejm jan 2008
Hoge et al. NEJM Jan. 2008
  • Survey data on 2714 OIF veterans

(59% survey completion rate)

  • 4.9% reported a mild TBI w/ LOC
  • 10.3% reported a mild TBI w/ AOC
  • 17.2% reported some other type of injury

15.2%

hoge nejm jan 2008 study cont
Hoge NEJM Jan. 2008 study (cont.)
  • mTBI was strongly associated with PTSD and with Depression, so . . .
  • Does mTBI cause PTSD & Depression or increase the risk of developing them?
hoge nejm jan 2008 study cont1
Hoge NEJM Jan. 2008 study (cont.)
  • Multiple physical, cognitive, and behavioral symptoms were compared across groups:
    • Various pains, dizziness/balance problems, shortness of breath, heart pounding, bowel problems, fatigue, sleep disturbance, ringing in the ears
    • Memory problems, concentration problems
    • Irritability
hoge nejm jan 2008 study results
Hoge NEJM Jan. 2008 study (results)
  • Returning soldiers who suffered a concussion have a higher number of somatic and postconcussive symptoms than soldiers with other injuries
  • However, after adjusting for demographic factors, and current PTSD and Depression, mild TBI was no longer associated with these symptoms, except for headache
slide8

% w % w

AOC LOC

n = 124 n = 260

(17.7% to 32.2%)

(5.9% to 8.3%)

slide9

+ PTSD

Re-experiencing

Arousal

Sensitive to noise

Concentration

Insomnia

Irritability

Avoidance

Social withdrawal

Memory gaps

Apathy

? Mild

TBI

Residual

Headaches Dizziness

Difficulty with decisions

Memory Problems Mental slowness

Concentration

Appetite changes

Fatigue

Sadness

+ Depression

slide11

Odds-Ratios for Presence of the

Postconcussion Symptom Complex (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

 15.7% increase

 12.5% increase

slide12

Odds-Ratios for Various Physical/NeurologicalPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

slide13

% w % w

AOC LOC

n = 124 n = 260

(17.7% to 32.2%)

(5.9% to 8.3%)

slide14

Mild TBI

Current Symptoms

PTSD

Possible Mediation Effects

PTSD

Hoge’s proposed mechanism

Current Symptoms

Mild TBI

Tested in the Vietnam Experience Data Set

mtbi and ptsd effects on pcs no mediation effect independent additive
mTBI and PTSD Effects on PCS:No Mediation Effect - Independent & Additive

mTBI Group

MVA Injury

27% PTSD Effect

15% mTBI Effect

what about non physical outcomes

What about non-physical outcomes?

Vietnam Experience Study Data

(continued)

slide18

Odds-Ratios for Various Cognitive/NeuropsychologicalPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

slide19

Odds-Ratios for Various Emotional/PsychologicalPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

slide20

Odds-Ratios for Various OtherNeurological Signs During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

slide21

This is fine for group data, but what about at the patient level?Can we tell what symptoms (or how much of a symptom) is due to what comorbid condition?

slide22

PTSD

Substance Use Disorder

Physical Injuries

Mild

TBI

Anxiety

Depression

Pain

slide23

Apples

Psychiatric Diagnosis(PTSD)

Pears

Remote

Historical Event

(mTBI)

Symptom (Pain)

Oranges

slide25

Palo Alto PNS Clinic – Mild TBI Group

Symptom % of Patients

Sleep Disturbances 84

Irritability 84

Attention/Concentration Problems 79

Memory Problems 76

Mood Swings 76

Anxiety 74

Headaches 71

Light/Noise Sensitivity 69

Depression 66

Visual Disturbances 66

Tinnitus 58

Excessive Fatigue 58

Balance Problems 42

Dizziness 40

Lew et al., 2007

early on while still at wramc mtbi symptom overlap
Early on while still at WRAMC:mTBI Symptom Overlap
  • Anxiety appears to be the significant contributor to other Symptoms
several months later mtbi symptom overlap
Several Months Later:mTBI Symptom Overlap
  • Initial Anxiety fades into a more chronic depression and sleep problem pattern

and

  • Sleep problems& Depression appear to become the significant contributors to other Symptoms
several months later mtbi symptom overlap1
Several Months Later:mTBI Symptom Overlap
  • When those with comorbid PTSD are removed from the sample:
  • Again initial Anxiety fades into a more chronic Depression

but

  • Headache pain in interaction with Sleep Problems become significant contributors to other symptoms following mTBI
mtbi symptom overlap changes over time
mTBI Symptom Overlap:Changes Over Time
  • Early:
    • Anxiety appears to be the significant contributor to other Symptoms
  • Several Months Later:
    • Depression & Sleep problems (in PTSD/mTBI)
    • Depression, Headaches & Sleep problems (in mTBI alone)

become the significant contributors to other Symptoms

  • Years Later:
    • Emotional Contributors fade, while chronic Sleep Problems& Irritability together become the significant contributors to other Symptoms
ft carson post deployment data n 907
Ft. Carson: Post-Deployment Data (n = 907)

Terrio et al., JHTR, 2009; 24, 14-23.

currently symptomatic onset of symptoms n 844
Currently Symptomatic: Onset of Symptoms (n = 844)

Terrio et al., JHTR, 2009; 24, 14-23.

Terrio et al., JHTR, 2009; 24, 14-23.

slide38

COGNITIVE ISSUES

IRRITABILITY / IMPULSIVITY

SELF-CARE ROUTINES*

SOMATIC COMPLAINTS

EDUCATION: Expectation of Recovery

TBI Step-Care Treatment Model†

BEHAVIORAL HEALTH ISSUES

†Begin each encounter at the bottom of the pyramid and progress upward

* Includes SLEEP HYGIENE, diet, exercise, and avoiding further TBI

Terrio 2009

va dod mild tbi clinical practice guidelines april 2009
VA/DoD Mild TBI Clinical Practice Guidelines(April 2009)

http://www.healthquality.va.gov/Rehabilitation_of_Concussion_mTBI.asp

research questions
Research Questions
  • Is Hoge correct? Is treating these conditions or the “P3+ Complex” (mTBI, PTSD, Pain, etc.) in specialty clinics a less than optimal approach?
  • Are we bringing excessive attention to and over-pathologizing expected post-deployment adjustment issues; thereby reinforcing them and making them worse or delaying recovery?
research questions1
Research Questions
  • Are patients more likely to seek help in one type of setting versus another?
    • Mental Health (general)
    • Mental Health (specific): PTSD
    • TBI/Polytrauma (physical/neurological problem; not mental health problem)
    • Primary Care Clinic (general)
    • Primary Care Clinic (OIF/OEF specific)
research questions2
Research Questions
  • Do patients’ assumptions or expectations regarding cause, treatment, and recovery differ across these different medical settings?
  • Is so, do these assumptions and expectations affect recovery trajectories?
possible research study
Possible Research Study
  • Identical teams, Identical programs
    • PTSD setting
    • TBI/Polytrauma setting (PNS)
    • Primary Care (OIF/OEF clinic) setting
  • Assess pre-treatment beliefs, assumptions, and expectations
  • See if recovery outcomes differ
    • Across settings
    • Based on patient beliefs, assumptions, and expectations