BOSTON – For clinicians evaluating returning soldiers for posttraumatic stress disorder and traumatic brain injury, one of the greatest obstacles may be the soldiers’ inability to admit they may have a problem, said a specialist at a conference on the complexities and challenges of PTSD and TBI.
The DSM-IV diagnostic criteria for PTSD include experiencing or witnessing an event involving actual or threatened death or serious injury, and a response involving "intense fear, helplessness, or horror," noted Dr. Lisa Brenner, associate professor of psychiatry, neurology, and physical medicine and rehabilitation at the University of Colorado, Aurora.
"When I have a 25- or 26-year-old soldier or a veteran in my office, and I say, ‘Were you afraid?’ What do you think they say to me? ‘No. I wasn’t afraid. I am trained to not be afraid.’ How do you engage in a conversation about whether or not this event really did have the impact on them that we think it did, in language that makes sense to our returning soldiers?" she asked.
Combat-associated trauma differs significantly from trauma experienced by, say, an auto-accident victim, Dr. Brenner added. PTSD in military service members develops following long-term exposure to multiple traumatic events, possibly during multiple deployments.
In addition, at least two of the key symptom clusters of PTSD – numbness/detachment from others and hyperarousal – may be protective or even lifesaving on the battlefield, but don’t work well when soldiers return home, she noted. Soldiers may need help finding alternative ways of coping in their off-duty lives, without losing the advantage that the aforementioned coping mechanisms could give them should they return to the front lines.
Equally challenging for the clinician is differentiating symptoms of mild TBI from those of PTSD, especially when they co-occur, Dr. Brenner said.
Screening for PTSD and TBI
Screening instruments can help to identify those who need further assessment for PTSD, but screening alone is not sufficient for a diagnosis, Dr. Brenner cautioned.
In the military, service members are commonly screened with the PTSD checklist, a 17-item self-report measure of the 17 DSM-IV–designated symptoms of PTSD. The checklist appears to be a clinically useful screening instrument, but a critical review published in 2010 showed that it performs differently across civilian, military, and other specific populations. The authors concluded that it should be used with a second-tier diagnostic test such as a standardized interview (Clin. Psychol. Rev. 2010;30:976-87).
Traumatic brain injury (TBI) involves an alteration in consciousness, ranging from brief changes (mild TBI) to an extended period of unconsciousness or amnesia (severe TBI).
"Most of the people in Iraq and Afghanistan who sustain TBIs sustain mild brain injuries, and we expect recovery," Dr. Brenner said.
Nearly everyone who sustains a mild TBI or concussion reports immediate postinjury symptoms that may include headache, poor concentration, memory loss, irritability, fatigue, depression, anxiety, dizziness, or light and sound sensitivity. These symptoms are not specific, however, and should not be the basis for a diagnosis of TBI.
Returning service members are screened with a questionnaire that asks whether they had an injury event and, if so, whether they lost consciousness, felt dazed or confused, didn’t recall experiencing the event, or had a diagnosed concussion or head injury. They are also asked about acute and persistent problems with memory, balance, ringing in the ears, photosensitivity, headache, and sleep problems.
"I think this is a perfectly good screen; we just need to be really, really clear about what we’re screening for. We’re not screening for a history of TBI; we’re screening for a history of TBI with persistent symptoms," Dr. Brenner said.
TBI screening of soldiers returning from Iraq and Afghanistan has been routine since 2007 in the Veterans Affairs health system and since 2008 in the Department of Defense medical system. As a result, many veterans deployed earlier may have had TBIs that went undetected. In addition, returning soldiers, anxious to get home, may falsely report having no exposure, in the fear that a positive response would further delay their return, Dr. Brenner said.
Co-Occurring PTSD and TBI
PTSD and mild TBI can co-occur and have many overlapping symptoms, including problems with sleep, memory, cognition, and mood. The gold standard for diagnosing the conditions is a validated, structured clinical interview such as the Clinician-Administered PTSD Scale (CAPS) or the Ohio State University Traumatic Brain Injury Identification Method.
Dr. Brenner and her colleagues found in a recent study that "in soldiers with histories of physical injury, mild TBI and PTSD were independently associated with postconcussive symptom reporting. Those with both conditions were at greater risk for postconcussive symptoms than those with either PTSD, mild TBI, or neither" (J. Head Trauma Rehabil. 2010;25:307-12).