Traumatic Brain Injury and PTSD

It seems logical that many events that would lead to the potential for death or physical injury may also have high potential for traumatic brain injury (TBI). This is true for car accidents, combat exposure (e.g., bomb-blasts concussion), and even physical abuse. In my own clinical practice, I have worked with many victims of violent crime who suffered head injuries, some with TBI (e.g., from being hit with a pipe or baseball bat) and some with relatively mild difficulties (e.g., a mild concussion). However, the coexistence of PTSD and TBI is a controversial topic (Harvey, Kopelman, & Brewin, 2005) because oftentimes TBI patients have amnesia for a particular event, which would make the development of PTSD virtually impossible. How can someone reexperience something they don't remember, for example? Earlier research showed a concordance rate of 0 percent for TBI and PTSD (Warden et al., 1997). However, more recent research has shown rates of comorbid PTSD and TBI to be anywhere from 14 percent to 27 percent. They can coexist.

The TBI and PTSD picture is somewhat complicated. Traumatic brain injury patients, for example, may not experience the classic set of PTSD symptoms, and instead there may be differences in symptom experience and expression. An example of this is that intrusive memories may emerge much later in TBI patients than in non-TBI patients with PTSD. This is because posttraumatic amnesia fades with time, thus allowing for the emergence of intrusive memories at some point. Also, disruptions in cognitive processes may affect the form in which memories are recalled, as they may be more reconstructed and present within the context of common memory problems seen in TBI. That is, TBI patients often have memory deficits in general, and PTSD memories will not be exempt from these effects.

It is important to not confuse the clinical manifestations of neuropsychological deficits associated with PTSD in general with other mild signs of cognitive deficit secondary to TBI. These overlapping deficits include attention and concentration problems and speed of information processing. More severe TBI and its sequelae are probably less mistakable, such as severe memory deficits and major deficits in problem solving, executive functions, and speed of processing. This, of course, is a question of differential diagnosis, and the use of neuropsychological testing is highly recommended in such instances. Basso and Newman (2000) suggest operating from an initial stance that a client's initial presentation is the consequence of both PTSD and TBI and working to rule either out through thorough assessment and evaluation.

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