1. 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

2. 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

3. Mild Traumatic Brain Injury (mild TBI)

4. 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

5. 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?

6. 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

7. 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

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

9. 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

11. 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 ( )
(25.2%)
2.00 ( )
(40.9%)
ICD-10
(19.1%)
1.13 ( )
(24.9%)
1.80 ( )
(37.4%)
 15.7% increase
 12.5% increase

12. 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)

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

14. 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

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

16. 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%

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

18. 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)

19. 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)

20. 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)

21. 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?

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

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

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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. Ft. Carson: Post-Deployment Data (n = 907)
Terrio et al., JHTR, 2009; 24,

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

38. 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

39. VA/DoD Mild TBI Clinical Practice Guidelines (April 2009)

40. 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?

41. Hoge et al. Conclusions

42. 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)

43. 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?

44. 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