Traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) have much in common. Both have symptoms that appear similar, and both are often considered untreatable. However, both conditions vary greatly, and treatments that go off course, do more harm than good.
TBIs can range from mild, as in the case of concussion, to severe, in the case of those who experience a coma after a head injury1. Regardless, medicine now recognizes that TBI can have persistent effects and that the damage from multiple concussions can accumulate2,3. Those with chronic TBI may experience a variety of symptoms: headache, balance problems, concentration problems, disrupted sleep, nightmares, anxiety, depression, irritability, relationship difficulties and increased substance abuse2-5.
Missing the connection
Often though, the connection is not made between the TBI and the symptoms. A common diagnostic error is to confuse the symptoms of TBI with the symptoms of PTSD. While this confusion can occur for any person from any walk of life, it is particularly prevalent for our military personnel and veterans. A recent study in Veterans Administration (VA) facilities revealed 73% of patients reporting TBI also had PTSD6 . Indeed, the VA experts acknowledge that they cannot distinguish chronic TBI from PTSD7. This is not surprising, since most often the diagnoses are made by symptom checklists. For example, several of the question items within the Clinician-Administered PTSD scale8 can also be symptoms of chronic TBI (poor concentration, memory difficulties, anhedonia, social isolation, sleep difficulties, and irritability).
Civilians experience the same bias. Civilian physicians tend to attribute emotional difficulties to psychiatric stressors and psychiatric diagnoses9. The car accident may have been emotionally traumatic, but the sudden change in memory function, concentration, sleep and organizational skills may reflect a frontal lobe brain injury, rather than PTSD.
Treating the wrong condition?
Unfortunately, many times the best treatment doctors can provide is based on an ill-informed guess. The symptoms could be the result of different conditions. It could be chronic TBI or PTSD or even a combination of both.
In fact, the treatments for PTSD may be harmful or, at best, not helpful in the case of TBI. The pharmacological treatments for PTSD include the serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, benzodiazepines, mood stabilizers and atypical antipsychotics5,10,11. While some evidence suggests antidepressants may be helpful for those with chronic TBI12, the prescribing of benzodiazepines to those with TBI can impede function or even be dangerous13-15. Curiously, having a diagnosis of TBI increases the likelihood a veteran will be prescribed a benzodiazepine or an antipsychotic. While 41% of Veterans with PTSD were prescribed benzodiazepines, those with both PTSD and TBI had a 67% chance of being prescribed a benzodiazepine. Similarly, antipsychotics are often prescribed for PTSD14,16-18; however, antipsychotics have been shown to impede recovery or be dangerous in clinical studies and animal models of TBI19,20. Antipsychotics were prescribed to 25% of veterans with PTSD, but 40% of those with both PTSD and TBI14.
Diagnosing TBI and PTSD
A recent pair of studies proved that brain scans could differentiate TBI from PTSD with some accuracy. In the September 2015 issue of Brain Imaging and Behavior, a paper on this question was published by a multicenter team of clinician-scientists (including myself)21. Our group examined the neuroimaging data of 196 military and veteran patients who had undergone SPECT (single-photon emission computed tomography) imaging. We found that TBI could be distinguished from PTSD using SPECT with 94% accuracy. This study was replicated by our group with a much larger sample of over 20,000 civilians and we found similar results22,23.
However, one barrier to changing the delivery of care is the perception among patients that PTSD treatments are not effective. In fact, only one-quarter to one-third of soldiers and veterans who screened positive for PTSD receive treatment24-26 . Guilt, shame, fears of medications, and lack of confidence in the therapies offered are among the reasons treatment is avoided by civilians and veterans alike24-27.
A second barrier to change is the persistent bias among physicians, particularly psychiatrists, against utilizing brain scans. Large clinical studies, such as the two described above21, 22 provide antidotes to this lingering and outdated perspective. Additionally, a third barrier to change is the default perception among physicians that there is not an effective treatment for TBI.
Seeing the light
Recent research and clinical work has begun to dismantle the third barrier. Four studies published in peer-reviewed journals in the last year show a new method using multi-Watt near-infrared light (NILT) to be effective in treating TBI5,28-30. Other new treatments for PTSD are emerging as well. For example, ketamine has proven to be a highly effective antidepressant recently31. Now, ketamine is gaining momentum as a treatment for PTSD, as well. Infrared light therapy may have benefit in PTSD and depression, as well. Our preliminary data on PTSD-related symptoms in our patients with TBI show a robust response5.
Behavioral healthcare providers, and those in the addiction treatment realm, must begin to look at TBI and PTSD differently. Indeed, even substance use disorder deserves a second look through the lens of chronic TBI or post-concussive syndrome. When we examine a patient with substance use disorder or a working diagnosis of PTSD, perhaps the first question we ask is “have you ever been hit in the head?”
Theodore A. Henderson, MD, PhD, from the Neuro-Laser Foundation, specializes in the diagnosis and treatment of complex adult, child and adolescent psychiatric cases. Board certified, Henderson earned his PhD in developmental neurobiology and has been widely published in journals of psychiatry, medicine, and nuclear medicine.