Review: Managing Posttraumatic Stress Disorder in Combat Veterans With Comorbid Traumatic Brain Injury

Bruce Capehart, Dale Bass
2013 FOCUS The Journal of Lifelong Learning in Psychiatry  
Military deployments to Afghanistan and Iraq have been associated with elevated prevalence of both posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) among combat veterans. The diagnosis and management of PTSD when a comorbid TBI may also exist presents a challenge to interdisciplinary care teams at Department of Veterans Affairs (VA) and civilian medical facilities, particularly when the patient reports a history of blast exposure. Treatment recommendations from VA and
more » ... ment of Defense's (DOD) recently updated VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress are considered from the perspective of simultaneously managing comorbid TBI. Abbreviations: CBT = cognitive-behavior psychotherapy, CPG = clinical practice guideline, CPT = cognitive processing therapy, DOD = Department of Defense, FDA = Food and Drug Administration, ICU = intensive care unit, IED = improvised explosive device, MACE = Military Acute Concussion Evaluation, MOS = military occupational specialty, MRI = magnetic resonance imaging, mTBI = mild TBI, OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom, PCL = PTSD Checklist, PE = prolonged exposure, PLMS = periodic limb movements of sleep, PTSD = posttraumatic stress disorder, RCT = randomized controlled trial, SNRI = serotonin-norepinephrine reuptake inhibitor, SSRI = serotonin-specific reuptake inhibitor, STAR*D = Sequenced Treatment Alternatives for Relief of Depression, T3 = tri-iodothyronine, TBI = traumatic brain injury, TCA = tricyclic antidepressant, VA = Department of Veterans Affairs, VBIED = vehicle-borne IED. As in prior military conflicts, improved combat medical care leads to an increased need for postwar rehabilitation of injuries. Among veterans of the present conflicts, the incidence of TBI is higher than it was in prior conflicts, perhaps because of blast injuries. The Department of Defense (DOD) and Department of Veterans Affairs (VA) mental health communities face a difficult clinical challenge in the diagnosis and management of psychiatric sequelae of war when the veteran was exposed to explosions: determining whether the presenting symptoms are best explained by PTSD or another psychiatric diagnosis, residual symptoms of mTBI, or both a psychiatric diagnosis and mTBI. This article addresses the diagnosis and treatment of PTSD among combat veterans with a particular focus on comorbid mTBI and the most recent version of the VA/DOD Clinical Practice Guideline for Management of Post-Traumatic Stress [5] . The military and VA healthcare systems are familiar with the high prevalence rate of PTSD among combat veterans. Among OIF/OEF veterans who sought treatment at a VA healthcare facility, the PTSD prevalence is 13 to 21 percent [6] [7] . The range of wartime traumatic events that can lead to PTSD must now include the dangers posed by exploding IEDs. To the practicing mental health clinician, it should be clear how an exploding IED could cause PTSD, but the patient's symptoms could also be caused by mTBI. Cognitive complaints can accompany the clinical presentation of PTSD, typically a subjective decline in short-term memory that can result from diminished concentration. However, if a comorbid TBI is present, memory could be affected directly. Two reports suggest blast-related TBI as a risk factor for memory impairments [8] [9] , although another study of combat veterans with blast-related mTBI found no memory changes compared with a control group [10]. However, mTBI from blunt trauma is not known to adversely affect memory, but moderate to severe TBI from blunt trauma can cause memory impairments [11] [12] . The possible presence of mTBI in the combat veteran causes additional diagnostic and management complications. TBI is associated with neuropsychiatric sequelae such as depression, mania, or psychosis [13] ; substance use disorders [14] ; and medical problems including sleep disorders [15] [16] , chronic pain [17] , and endocrine deficiencies [18] [19] . These associated neuropsychiatric conditions could occur as a direct result of the traumatic injury or present after the injury as an emotional reaction to the effect of TBI on daily life [20] . There may not be a clear underlying etiology for a mood or anxiety disorder occurring after TBI, and the informed clinician will employ the biopsychosocial formulation (or a similar multidimensional approach) to enhance the diagnosis and understanding of these symptoms [20] [21] . The psychiatric symptoms associated with TBI often respond to treatment based on the symptoms that correspond to the related Axis I condition [22] , although the presence of TBI may affect diagnostic considerations and treatment options. This review seeks to address four primary objectives related to managing comorbid PTSD and TBI: cognitive problems among combat veterans, blast as an injury source for TBI, diagnosis and management of PTSD in the setting of mTBI, and management of additional neuropsychiatric comorbidity in the combat veteran with PTSD and mTBI. These considerations will be placed in context with the 2010 update to the VA/DOD clinical practice guideline (CPG) for PTSD [5] . 2 METHODS We searched the MEDLINE database for published articles on psychiatric conditions associated with TBI and including blast trauma. The authors' clinical and laboratory experience supplemented these articles, particularly in the relationship of basic science studies of blast injury to clinical situations. RESULTS Cognitive Problems Among Combat Veterans Cognitive problems remain a major focus of attention for the treatment-seeking OIF/OEF veteran population diagnosed with PTSD, a relatively large group given the prevalence of PTSD noted previously. Cognitive problems can have many different etiologies, including psychiatric diagnoses (e.g., major depression, substance use disorders), medication effects (e.g., tricyclic medications prescribed for neuropathic pain), medical or neurologic disorders (e.g., sleep apnea), or TBI. Despite the possibility of a brain injury causing dysfunction among any of the major functions in the central nervous system, including cognition, no clear consensus exists in the medical literature regarding the underlying cause of cognitive complaints in the OIF/OEF veteran population with both PTSD and TBI. When faced with clinical symptoms but no clear etiology, clinicians should manage the patient's symptoms. This symptom-management approach is advocated by the VA/DOD CPG for concussion/mTBI [23] .
doi:10.1176/appi.focus.11.3.396 fatcat:mjrsdykm2vd4pdo7pddj7xq2ua