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Relationship Between Posttraumatic Stress Disorder and Postconcussive Symptom Improvement After Completion of a Posttraumatic Stress Disorder/Traumatic Brain Injury Residential Treatment Program

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Abstract

Research has demonstrated that veterans with a history of traumatic brain injury (TBI) may experience persistent symptoms following injury. These symptoms are frequently maintained or exacerbated by psychiatric symptoms, including posttraumatic stress disorder (PTSD). Studies suggest that decreasing PTSD symptoms may also reduce postconcussive symptoms. This study examined whether (a) PTSD and postconcussive symptoms decreased over the course of residential PTSD/TBI treatment and (b) a reduction in PTSD symptoms was associated with a reduction in postconcussive symptoms. Twenty-eight veterans who met diagnostic criteria for PTSD and had a history of TBI were included in the study. Veterans received 8 weeks of treatment in a residential PTSD/TBI program and completed self-report measures of PTSD and postconcussive symptoms at pre- and posttreatment. Results indicated that PTSD and postconcussive symptoms significantly decreased over the course of treatment. Furthermore, the decreases in PTSD and postconcussive symptoms were significantly positively related. The reduction in PTSD symptoms is positively associated with a reduction in postconcussive symptoms following residential treatment in a PTSD/TBI program. These findings suggest that PTSD and postconcussive symptoms are interdependent and mutually influence one another.
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... Many of the types of events that can lead to PTSD, such as combat, motor vehicle accidents (MVAs), physical assaults, and intimate partner violence, also can cause TBI (Laker, 2011;Stein & McAllister, 2009). There is overlap between symptoms of TBI and PTSD (Walter, Kiefer, & Chard, 2012), as well as the behaviors and comorbidities associated with both disorders, such as lability, numbing, concentration problems, suicidality, sleep disturbance depression, and anxiety (Tanev, Pentel, Kredlow, & Charney, 2014). ...
... In general, there is limited research on what to do for those with PTSD and TBI. Two uncontrolled studies conducted in a Veterans Health Administration residential treatment program used CPT embedded within a larger comprehensive treatment program and found PTSD and depression improved over the course of treatment (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011;Walter et al., 2012). In addition, symptoms associated with TBI also improved along with the PTSD (Walter et al., 2012). ...
... Two uncontrolled studies conducted in a Veterans Health Administration residential treatment program used CPT embedded within a larger comprehensive treatment program and found PTSD and depression improved over the course of treatment (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011;Walter et al., 2012). In addition, symptoms associated with TBI also improved along with the PTSD (Walter et al., 2012). However, it is important to note that CPT was delivered within a program of comprehensive rehabilitation rather than as a stand-alone intervention. ...
Chapter
Prior chapters have reviewed the research evidence from both clinical trials and more applied research studies. These chapters have touched on issues around whether cognitive processing therapy (CPT) can work for clients with comorbidities and whether the comorbidities tend to improve along with the posttraumatic stress disorder (PTSD). Often there is a temptation to bring in elements from other therapies when faced with multiple comorbidities, but is that always the right choice? In this chapter, we discuss how to use CPT with clients with specific psychiatric (depression, substance use, panic disorder, personality disorders) and medical (TBI, chronic pain, sleep disorders) comorbidities. These particular comorbidities can be a challenge for clinicians to manage. We particularly focus on how to determine whether to use CPT or not with these comorbid presentations, when to adapt CPT to address these comorbidities, as well as ways to use CPT skills to address each of these conditions, along with the PTSD. In many cases, key research studies have been conducted that can help inform clinical decision-making regarding what to do and how to do it.
... Two studies examined the effectiveness of cognitive processing therapy among veterans with PTSD and comorbid TBI in a residential treatment setting. After 7 weeks of treatment, participants had pretreatment-to-posttreatment reductions in both PTSD scores (31,32) and postconcussive symptoms (32), and these reductions were positively correlated (32). However, the intervention included cognitive rehabilitation, which might have confounded the association between CBT and change in PTSD symptoms. ...
... Two studies examined the effectiveness of cognitive processing therapy among veterans with PTSD and comorbid TBI in a residential treatment setting. After 7 weeks of treatment, participants had pretreatment-to-posttreatment reductions in both PTSD scores (31,32) and postconcussive symptoms (32), and these reductions were positively correlated (32). However, the intervention included cognitive rehabilitation, which might have confounded the association between CBT and change in PTSD symptoms. ...
... Two studies examined the effectiveness of cognitive processing therapy among veterans with PTSD and comorbid TBI in a residential treatment setting. After 7 weeks of treatment, participants had pretreatment-to-posttreatment reductions in both PTSD scores (31,32) and postconcussive symptoms (32), and these reductions were positively correlated (32). However, the intervention included cognitive rehabilitation, which might have confounded the association between CBT and change in PTSD symptoms. ...
Article
Objective: Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. Methods: This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively). Results: Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD. Conclusions: These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.
... The sample included 28 veterans with an average age of 36 years and a history of TBI (n mTBI=24, n moderate TBI=4). The PCL -S was used pre-and post-treatment [29]. ...
... The Neurobehavioral Symptom Inventory (NSI) -a tool on neurobehavioral symptoms -was applied in the included studies at the following time points: pre-and post-intervention [29,31], and at baseline, after the program ended three months following the end of the intervention [38,39]. Other neurobehavioral tools employed were subscales from the Delis-Kaplan Executive Function System, such as the ones on inhibition/switching and the one on verbal fluency (D-KEFS letter and category fluency), which were employed in by Tanev et al. [42] immediately and at six months post-intervention, and by Crocker et al. immediately, and three-and six-months post-intervention completion [38]. ...
Article
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Patients with traumatic brain injury (TBI) of varying severities are experiencing adverse outcomes during and after rehabilitation. Besides depression and anxiety, post-traumatic stress disorder (PTSD) is highly encountered in civilian and military populations. As more prospective and retrospective studies - focused on evaluating new or old psychological therapies in inpatient, outpatient, or controlled environments, targeting patients with PTSD with or without a history of TBI - are carried out, researchers are employing various scales to measure PTSD as well as other psychiatric diagnoses or cognitive impairments that might appear following TBI. We aimed to explore the literature published between January 2010 and October 2021 by querying three databases. Our preliminary results showed that several scales - such as the Clinician-Administered PTSD Scale (CAPS), the Posttraumatic Stress Disorder Checklist Military Version (PCL-M) as well as Specific Version (PCL-S), and Civilian Version (PCL-C) - have been frequently used for PTSD diagnosis and symptom severity. However, heterogeneity in the scales used when assessing and evaluating additional psychiatric comorbidities and cognitive impairments are due to the study aim and therapeutic approaches. Therefore, conducting an intervention focusing on post-TBI PTSD patients requires increased attention to patients' medical history in capturing multiple cognitive impairments and affected neuropsychological processes when designing the study and including validated instruments for measuring primary and secondary neuropsychological outcomes.
... Deployment-related TBI (mild and moderate) has also been shown to increase severity of symptoms and worsen functional outcomes in veterans with PTSD (Vasterling et al., 2018). Outcomes related to PTSD and TBI are further complicated by a significant overlap and reciprocal influence of symptoms (Brenner et al., 2010;Walter et al., 2012). For example, individuals with both PTSD and TBI report more severe neurocognitive symptoms (Tanev et al., 2014). ...
... However, less work has focused on the role of deployment TBI in PTSD recovery and in the relationship between PTSD and functional outcomes. Notably, many studies examining post-9/11 deployment TBI include samples that report history of either exclusively mTBI (e.g., Brenner et al., 2010;Kennedy et al., 2010;Martindale et al., 2021) or primarily mTBI, with 86-90% of individuals with TBI history endorsing only mTBI (e.g., Martindale et al., 2018;Vasterling et al., 2018;Walter et al., 2012). Thus, it is important to examine factors associated with PTSD recovery in the context of deployment mTBI. ...
Article
Objective: Examine factors associated with recovery from posttraumatic stress disorder (PTSD) and evaluate the role of deployment mild traumatic brain injury (mTBI) in the relationship between PTSD recovery and functional outcomes. Method: Post 9/11 combat veterans with lifetime history of PTSD (N = 124, 84.7% male) completed the Mid-Atlantic MIRECC Assessment of Traumatic Brain Injury (MMA-TBI), Salisbury Blast Interview (SBI), Clinician Administered PTSD scale (CAPS-5), cognitive assessment battery, and measures of depression, PTSD symptoms, neurobehavioral symptoms, sleep quality, pain interference, and quality of life. Results: Analyses of variance (ANOVA) results revealed significant differences in most behavioral health outcomes based on PTSD recovery, with participants who have recovered from PTSD showing less severe neurobehavioral and depressive symptoms, better sleep quality, less functional pain interference, and higher quality of life. No differences were found in cognitive functioning between those who have recovered from PTSD and those who have not. History of deployment mTBI did not significantly moderate the relationship between PTSD recovery and most functional and cognitive outcomes with the exception of 2 measures of processing speed. Specifically, among participants with history of deployment mTBI, those who have recovered from PTSD displayed better cognitive functioning than those who have not. Additionally, participants who have not recovered from PTSD had higher levels of blast exposure during military service. Conclusions: PTSD recovery was associated with better psychological functioning and higher quality of life, but not with objective cognitive functioning. Deployment mTBI history moderated only the relationship between PTSD recovery status and tests of processing speed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... While symptoms of post-traumatic stress declined in the sample overall, those with mild TBI showed less improvement than those with more severe TBI. In the same care setting, individuals with TBI and PTSD showed reductions in PCS concurrent with reduced post-traumatic stress symptoms (24). The Home Base program in Boston, Massachusetts reports a comprehensive program with tracks for those with significant post-traumatic stress or a history of TBI (21). ...
Article
Full-text available
Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness. Methods: SMs ( n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge. Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 ( r = 0.59), followed by PHQ-8 ( r = 0.56), NSI ( r = 0.55), PCL-M ( r = 0.52), ESS ( r = 0.50), SWLS ( r = 0.49), and HIT-6 ( r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge. Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.
... Results indicated significant decreases on measures of depression and PTSD-however, there were no outcome measures for cognitive complaints. A follow-up study found that reduction in PTSD was related to reduction in PCS, reaffirming the interdependence of PTSD and PCS (Walter et al., 2012). Most recently, a randomized controlled trial compared SMART-CPT, an integration of CogSMART (Twamley et al., 2009) and CPT to standard CPT in 100 veterans with PTSD and mild-to-moderate TBI (Jak et al., 2019). ...
Article
Mild traumatic brain injury (mTBI) and posttraumatic stress disorder (PTSD) are pervasive consequences of the post-9/11 conflicts. Treatment of PTSD and mTBI has historically occurred separately and sequentially, which does not reflect the overlapping etiology of symptoms and may attenuate or delay recovery. This paper describes an integrated 2-week treatment program using prolonged exposure and cognitive symptom management and rehabilitation therapy to comprehensively treat PTSD and cognitive complaints attributed to mTBI, regardless of etiology. To minimize potential iatrogenic effects of treating presumed mTBI-related symptoms, a central focus of the program was to instill expectations of full recovery. Thirty patients with full or subclinical PTSD and self-reported TBI history completed the PTSD+TBI treatment program. Results indicated that self-reported PTSD, depression, and neurobehavioral symptoms significantly decreased following treatment, while satisfaction with participation in social roles increased. These preliminary effectiveness data indicate that PTSD complicated by mTBI history can be effectively treated within a 2-week intensive outpatient program.
... [13][14][15][16] Military-related TBI, PTSD, and depression may have additive roles in impacting cognition and daily functioning. 17 Previous research has shown that treatment of PTSD symptoms in service members and Veterans with comorbid mTBI leads to a reduction in post-concussive symptoms, 18 but it is unclear whether treating the cognitive sequelae can generalize to reduced PTSD symptoms. ...
Article
Difficulties in executive-control functions are common sequelae of both Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD). The goal of this study was to assess whether a cognitive rehabilitation training that was successfully applied in civilian and military TBI would be effective for military Veterans with comorbid PTSD and mild TBI (mTBI). In the prior study, Veterans with history of mild to severe TBI significantly improved after Goal-Oriented Attentional Self-Regulation (GOALS) training on measures of attention/executive function, functional task performance, and emotional regulation. The objective of this study was to assess effects of GOALS training in Veterans with comorbid PTSD and mTBI. Forty Veterans with current PTSD diagnosis and history of mTBI (6+ months post) were randomized to either five weeks of GOALS or Brain-Health Education (BHE) training matched in time and intensity. Evaluator-blinded assessments at baseline and post-training included neuropsychological and complex functional task performance, and self-report measures of emotional functioning/regulation. After GOALS, but not BHE training, participants significantly improved from baseline on primary outcome measures of: Overall Complex Attention/Executive Function neuropsychological performance composite [F = 12.35, p =.001; Cohen's d = .48], and Overall Mood Disturbance -POMS emotional regulation self-report [F=4.29, p=.05, Cohen's d = .41]. Additionally, GOALS, but not BHE participants indicated significant decrease in PTSD symptoms (PCL-M Total Score) [F=4.80, p=.05, Cohen's d =.60], and demonstrated improvement on complex functional task performance -GPS Learning and Memory [F=5.06, p=.05, Cohen's d =.56]. Training in attentional self-regulation applied to participant defined goals may improve cognitive functioning in Veterans with comorbid PTSD and mTBI. Improving cognitive control functioning may also improve functioning in other domains such as emotional regulation and functional performance, potentially making it particularly relevant for Veterans with history of mTBI and co-morbid psychiatric symptoms.
Article
Goal-Oriented Attentional Self-Regulation (GOALS) is a cognitive rehabilitation training program that combines mindfulness-based attention regulation with individualized goal management strategies to improve functioning in daily life after traumatic brain injury (TBI). While not a specific target of GOALS training, previous research has indicated improvements in emotional functioning following GOALS training, specifically symptoms related to depression and posttraumatic stress disorder (PTSD). The current study is based on the hypothesis that improvements in cognitive control processes related to executive functioning and attention after GOALS training generalize to improvements in emotional functioning, thereby resulting in reductions in emotional distress. The current study analyzed archival data from 33 Veteran participants with a confirmed diagnosis of PTSD and a history of mild TBI who received either GOALS training or a psychoeducational intervention matched for time, therapist attention, and participation format. Regression analysis was used to assess the strength of the relationship between improvements in Overall Attention/Executive Functioning and decreases in hyperarousal symptoms associated with PTSD. Results from the regression analysis revealed that improvements in Overall Attention/Executive Functioning after GOALS was significantly associated with reductions in hyperarousal symptoms associated with PTSD (R² = 0.26, F(1,15) = 5.01, β = −.51, p < .05). The current findings suggest that cognitive improvements after GOALS training may lead to changes in emotional functioning, resulting in decreased emotional distress. This is important, particularly in VA settings, because the results potentially highlight additional areas of research and focus on the treatment of comorbid mild TBI and PTSD among Veterans.
Chapter
Traumatic brain injury (TBI) affects military service members during times of both war and peace [1]. Between 2000 and 2018 Q1, 383,947 service members have sustained at least one TBI. Of these TBI, 82.3% were classified as mild, 9.7% as moderate, 1.1% as severe, 1.4% as penetrating, and 5.6% as not further classified [2]. While data on the exact number of troops deployed or number of individual deployments in support of Operations Iraqi Freedom (OIF), Enduring Freedom (OEF), New Dawn (OND), Inherent Resolve (OIR), and Freedom’s Sentinel (OFS) is unclear, there are 4,398,000 living veterans who have served since 2001 [3]. Compared to civilians, active duty service members and reservists are more likely to sustain a TBI [1]. Through June 2014, there were approximately 2.65 million deployments. Of that number, 1.2 million individuals were deployed more than once. These combat deployments increase the risk of TBI among service members [4].
Article
Posttraumatic stress disorder (PTSD) frequently co-occurs with traumatic brain injury (TBI). We conducted a systematic review to evaluate the appropriateness and effectiveness of treatments for PTSD in adult patients with a history of TBI. We searched for longitudinal studies aimed at treatments for PTSD patients who sustained a TBI, published in English between 1980 and February 2019. Twenty-three studies were found eligible, and 26 case studies were included for a separate overview. The quality of eligible studies was assessed using the Research Triangle Institute item bank. The majority of studies included types of cognitive-behavioral therapy (CBT) in male service members and veterans with a history of mild TBI in the United States. Studies using prolonged exposure (PE), cognitive-processing therapy (CPT) or other types of CBT, usually in combination with additional treatments, showed favorable outcomes. A smaller number of studies described complementary and novel therapies, which showed promising results. Overall, the quality of studies was considered low. We concluded that CBT seem appropriate for the patient population with history of TBI. The evidence is less strong for other therapies. We recommend controlled studies of PTSD treatments including more female patients and those with a history of moderate to severe TBIs in civilian and military populations.
Article
Objective: To examine the structure of persistent postconcussive symptoms in a sample of patients with mild traumatic brain injury. Design: Multivariate discriminant analysis in a series of 50 consecutive clinical referrals evaluated for postconcussive symptoms, neuropsychological functioning, and personality and emotional functioning at least 3 months after injury; follow-up information regarding level of disability was obtained for 37 patients at least 1 year after injury. Setting: Neuropsychology clinic affiliated with a comprehensive brain trauma rehabilitation center. Patients: 50 consecutively referred patients with a diagnosis of mild traumatic brain injury referred by physicians, rehabilitation nurses, or attorneys because of persistent deficits or subjective complaints consistent with a postconcussion syndrome. Main Outcome Measure: Postconcussive symptoms endorsed on the Post Mild Traumatic Brain Injury Symptom Checklist. Results: Four factors consisting of multiple symptoms were identified: cognitive factor, affective factor, somatic factor, and sensory factor. Using these four factors, K-means cluster analysis of subjects was applied to classify patients. Patient clusters consisted of those with minimal symptoms, those with primarily cognitive-affective symptoms, those with prominent somatic symptoms, and those with severe global symptoms (P = .000). Patient symptom clusters were largely unrelated to neurological or neuropsychological functioning. The presence of chronic disability and resumption of productive functioning differed significantly among groups (P = .003). Conclusions: Subjective complaints provide clinically meaningful information and are strongly related to the nature and extent of disability after mild traumatic brain injury. Characterization of a single postconcussive syndrome may be misleading, and it may be more meaningful to define a number of postconcussive syndromes with differing symptom profiles and recovery.
Article
Background: This study presents self-reported traumatic brain injury (TBI) prevalence rates for 2,337 active duty U.S. Army soldiers who underwent baseline testing as part of a larger study of military TBI. Methods: A computerized self-report questionnaire was administered to a convenience sample of 2,337 highly functioning active-duty soldiers at Fort Bragg, North Carolina, who underwent baseline testing during a 13-month period in 1999 and 2000 as part of a larger ongoing Institutional Review Board-approved study examining the consequences of brain injuries among paratroopers. Results: Approximately 23% of all of the soldiers surveyed reported sustaining a TBI after joining the Army. More than twice as many paratroopers reported sustaining TBI after joining the Army than did nonparatroopers (p < 0.001). Parachute-related TBI accounted for this difference. Nearly all of these injuries were mild. Less than 2% of paratroopers and no nonparatroopers reported loss of consciousness lasting more than 20 minutes. It was also shown that paratroopers with a history of TBI before joining the Army had a higher prevalence of TBI while serving in the Army (35%) than paratroopers without prior TBI (27.2%) (p = 0.002). Conclusion: This study demonstrates that parachuting appears to be a risk factor for mild TBI in the U.S. Army and that paratroopers with a history of TBI before joining the Army might be at somewhat increased risk of sustaining additional TBI while serving in the Army.