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

Department of Veterans Affairs 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

Mild Traumatic Brain Injury (mild TBI)

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% RAND telephone survey 19% with probable TBI

Hoge NEJM Jan. 2008 study (cont.) No Injury Other Injury mTBI w/ AOC w/ LOC PTSD 9.1% 16.2% 27.3% 43.9% Depression 3.3% 6.6% 8.4% 22.9% 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 (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) 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

% w % w AOC LOC n = 124 n = 260 (17.7% to 32.2%) (5.9% to 8.3%)

Difficulty with decisions Memory Problems Mental slowness + PTSD Re-experiencing Avoidance Social withdrawal Memory gaps Apathy Arousal Sensitive to noise Concentration Insomnia Irritability ? Mild TBI Residual Headaches Dizziness Difficulty with decisions Memory Problems Mental slowness Concentration Appetite changes Fatigue Sadness + Depression

Odds-Ratios for Presence of the Postconcussion Symptom Complex (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Diagnosis Normal Control (n = 3057) MVA Control (n = 521) Mild TBI (n = 254) DSM-IV Postconcussion Syndrome 1.0 (20.6%) 1.04 (0.82 - 1.31) (25.2%) 2.00 (1.49 - 2.69) (40.9%) ICD-10 (19.1%) 1.13 (0.90 - 1.44) (24.9%) 1.80 (1.33 - 2.43) (37.4%)  15.7% increase  12.5% increase

Odds-Ratios for Various Physical/Neurological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control (n = 3057) MVA Control (n = 521) Mild TBI (n = 254) Balance Problems or Dizziness 1.0 (3.4%) 1.58 (1.02 – 2.45) 2.43 (1.48 – 3.97) (5.8%) Sensitivity to Light 1.0 (3.6%) 1.14 (0.72 – 1.80) 1.92 (1.15 – 3.20) Headache Problems 1.0 (13.0%) 1.15 (0.89 – 1.50) 1.94 (1.42 – 2.68) (16.5%) Trouble Sleeping 1.0 (24.9%) 1.22 (1.01 – 1.51) 1.85 (1.39 – 2.45) Double Vision 1.0 (5.7%) 1.10 (0.75 – 1.61) 1.81 (1.17 – 2.79) Fatigue Easily 1.0 (20.9%) 1.00 (0.80 – 1.26) 1.42 (1.05 – 1.91)

% w % w AOC LOC n = 124 n = 260 (17.7% to 32.2%) (5.9% to 8.3%)

Tested in the Vietnam Experience Data Set Possible Mediation Effects PTSD Hoge’s proposed mechanism Current Symptoms Mild TBI Mild TBI Current Symptoms PTSD Tested in the Vietnam Experience Data Set

mTBI and PTSD Effects on PCS: No Mediation Effect - Independent & Additive mTBI Group MVA Injury 27% PTSD Effect 15% mTBI Effect

Does Having a mTBI Influence the Course of PTSD? Group PTSD w/in 1 yr of DC PTSD Past Year PTSD Past Month Percent Continue Uninjured Controls (n = 3218) 10.9% 4.6% 3.9% 35.3% Injured Controls (n = 548) 16.2% 6.2% 4.9% 30.3% Mild TBI (n = 278) 17.6% 10.1% 9.0% 51.0% 20.7%

What about non-physical outcomes? Vietnam Experience Study Data (continued)

Odds-Ratios for Various Cognitive/Neuropsychological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control (n = 3057) MVA Control (n = 521) Mild TBI (n = 254) Periods of Memory Loss or Confusion 1.0 (4.4%) 1.14 (0.76 – 1.72) 2.80 (1.83 – 4.28) Memory Problems 1.0 (13.7%) 1.13 (0.87 – 1.46) 1.75 (1.28 – 2.41) Concentration Problems 1.0 (13.4%) 1.40 (1.10 – 1.80) 1.28 (0.91 – 1.80)

Odds-Ratios for Various Emotional/Psychological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control (n = 3057) MVA Control (n = 521) Mild TBI (n = 254) Irritability or Short Temper 1.0 (26.5%) 1.10 (0.89 – 1.35) 1.36 (1.02 – 1.81) Aggressive and Angry Behavior 1.0 (10.2%) 1.34 (1.02 – 1.77) 1.32 (0.91 – 1.91) Sadness and Depression 1.0 (11.2%) 1.28 (0.97 – 1.69) 0.92 (0.62 – 1.37) Anxious 1.0 (13.8%) 1.29 (0.99 – 1.65) 1.10 (0.77 – 1.56)

Odds-Ratios for Various Other Neurological Signs During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Sign Normal Control (n = 3057) MVA Control (n = 521) Mild TBI (n = 254) Peripheral Visual Imperceptions 1.0 (5.1%) 1.00 (0.65 – 1.55) 1.98 (1.21 – 3.24) Impaired Tandem Gait 1.0 (1.3%) 1.15 (0.52 – 2.51) 2.93 (1.34 – 6.38) Impaired Sense of Smell 1.0 (3.1%) 1.05 (0.62 – 1.77) 1.52 (0.81 – 2.87)

This is fine for group data, but what about at the patient level 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?

Substance Use Disorder PTSD Physical Injuries Substance Use Disorder Mild TBI Anxiety Depression Pain

Psychiatric Diagnosis (PTSD) Apples Psychiatric Diagnosis (PTSD) Pears Remote Historical Event (mTBI) Symptom (Pain) Oranges

Patterns of Symptom Overlap in mTBI and PTSD: Implications for Assessment and Treatment

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 25

WRAMC NSI Data: mTBI (n = 115) Moderate to Very Severe Sx % with the symptom Sleep Headache Memory Irritab Concent Anx Fatig Vision Probl Hear Slow Think 71% 62% 59% 55% 50% 46% 45% 44% 41% Below are the Percent with Co-Symptom If Have Symptom Below Sleep = 82 100 82 87 83 92 91 90 80 86 Headache = 71 72 78 76 79 85 73 70 84 Memory = 71 77 88 Irritab = 68 71 75 Concent = 66 74 67 Anx = 58 65 64 68 63 Fatig = 53 57 61 58 Vision Prob = 52 53 56 60 62 Hear Prob = 51 55 50 Think Slow = 47 52 54

Early on while still at WRAMC: mTBI Symptom Overlap Anxiety appears to be the significant contributor to other Symptoms

Boston PNS NSI Data: mTBI (n = 200) Moderate to Very Severe Sx % with the symptom Sleep Irritab Anx Concent Memory Sad Headache Fatig Dizzy Balance 83% 81% 72% 66% 63% 60% 33% 31% Below are the Percent with Co-Symptom If Have Symptom Below Sleep = 165 100 86.1 87.6 87.5 84.7 91.6 90.4 89.9 92.4 93.4 Irritab = 165 91.9 91.0 88.9 95.4 88.0 94.1 90.9 88.5 Anx = 161 89.7 96.9 84.0 95.0 90.2 Concent = 144 79.4 81.4 86.8 87.0 76.0 89.1 87.9 Memory = 144 77.6 79.2 87.4 91.8 Sad = 131 75.8 78.9 76.4 72.0 85.7 81.8 78.7 Headache = 125 66.7 65.2 66.0 68.8 68.9 76.5 84.8 85.2 Fatig = 119 67.9 70.2 73.6 72.2 77.9 72.8 80.3 Dizzy = 66 36.4 37.9 40.3 42.4 41.2 44.8 47.1 73.8 Balance = 61 32.7 34.2 38.2 38.9 36.6 41.6 68.2

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

Below are the Percent with Co-Symptom Boston PNS NSI Data: (PTSD excluded) mTBI (n = 64) Moderate to Very Severe Sx % with the symptom Sleep Irritab Anx Concent Memory Sad Headache Fatig Dizzy Balance 74% 66% 59% 56% 44% 41% 38% 23% 20% Below are the Percent with Co-Symptom If Have Symptom Below Sleep = 165 100 83.3 84.2 78.9 75.0 92.9 96.2 87.5 80.0 92.3 Irritab = 165 74.5 89.5 72.2 69.2 73.3 61.5 Anx = 161 68.1 81.0 76.3 96.4 Concent = 144 63.8 71.4 80.6 82.1 66.7 76.9 Memory = 144 57.4 61.9 71.1 65.4 Sad = 131 55.3 60.5 55.6 50.0 Headache = 125 53.2 42.9 42.1 47.2 46.4 58.3 Fatig = 119 44.7 64.3 53.8 Dizzy = 66 25.5 26.2 28.9 26.3 33.3 35.7 38.5 41.7 Balance = 61 19.0 23.7 27.8 28.6 30.8 29.2 60.0

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

Vietnam Experience Study mTBI (n = 278) Moderate to Very Severe Sx % with the symptom Sleep Irritab Fatig Low back pain Memory Headache Concent Anx Sad Dizzy 45% 40% 39% 36% 29% 27% 23% 19% 17% 9% Below are the Percent with Co-Symptom If Have Symptom In this row  Sleep = 125 100 61.6 44.0 46.4 37.6 40.8 28.0 25.6 13.6 Fatig = 108 50.9 55.1 51.9 42.1 33.3 29.6 25.0 17.6 Irritab = 111 69.4 53.2 46.8 48.2 36.0 42.3 27.0 15.3 Low back pain = 100 55.0 51.5 55.4 42.0 34.7 31.7 22.8 21.8 16.8 Headache = 74 63.5 54.1 48.0 46.7 37.8 30.7 24.0 Dizzy = 26 65.4 73.1 60.0 69.2 38.5 26.9 Memory = 80 72.5 66.3 56.3 52.5 35.0 63.8 33.8 18.8 Concent = 65 78.5 72.3 49.2 35.4 32.3 15.4 Sad = 46 69.6 65.2 58.7 47.8 39.1 45.7 60.9 15.2 Anx = 53 66.0 57.7 60.4 43.4 52.8 34.0 18.9

Vietnam Experience Study PTSD (n = 249) Moderate to Very Severe Sx % with the symptom Sleep Irritab Low back pain Concent Fatig Headache Sad Memory Anx Dizzy 66% 64% 48% 45% 41% 39% 38% 37% 12% Below are the Percent with Co-Symptom If Have Symptom Below Sleep = 125 100 71.5 49.1 58.8 47.9 40.2 46.1 40.6 13.9 Irritab = 111 74.2 47.8 59.1 50.3 41.8 45.3 49.7 40.9 14.5 Fatig = 108 68.7 69.6 51.3 56.5 44.3 52.2 41.7 19.1 Low back pain = 100 68.1 63.9 48.7 49.6 42.9 40.3 44.5 39.5 15.1 Headache = 74 68.8 53.1 55.2 49.0 46.9 38.5 26.0 Dizzy = 26 76.7 60.0 66.7 73.3 83.3 63.3 53.3 Memory = 80 80.9 84.0 56.4 51.1 53.2 46.8 20.2 Concent = 65 87.4 84.7 52.3 58.6 47.7 55.0 68.5 45.9 18.0 Sad = 46 80.6 73.5 62.2 61.2 48.5 51.0 66.3 18.4 Anx = 53 73.6 71.4 51.6 56.0 60.4 41.1 48.4 17.6

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

Currently Symptomatic: Onset of Symptoms (n = 844) Terrio et al., JHTR, 2009; 24, 14-23. Terrio et al., JHTR, 2009; 24, 14-23.

EDUCATION: Expectation of Recovery BEHAVIORAL HEALTH ISSUES TBI Step-Care Treatment Model† EDUCATION: Expectation of Recovery BEHAVIORAL HEALTH ISSUES SOMATIC COMPLAINTS SELF-CARE ROUTINES* COGNITIVE ISSUES IRRITABILITY / IMPULSIVITY † 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) http://www.healthquality.va.gov/Rehabilitation_of_Concussion_mTBI.asp

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?

Hoge et al. Conclusions

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 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 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