Traumatic Brain Injury and Posttraumatic Stress Disorder

The neuropsychiatric history should focus on questions regarding alterations of attention, language, memory, constructional ability, executive function, affective and mood changes, thought processing, risk of injury to self or others, and inability to perform activities of daily living. The mental status examination should be focused on cognitive processing in addition to posttrauma psychological distress. The psychiatrist may defer the neurological examination to a neurologist, or if a quality neurological examination has been performed previously, it may be used in lieu of the psychiatrist performing a physical examination. However, the psychiatric portions of the examination should not be deferred.

With regard to structural imaging, the usual examination at the time of an acute head injury is CT of the head. For long-term outcome evaluation, however, CT is substantially inferior to MRI for detecting neurological tissue injury. The modern weightings on MRI sequences allow for the detection of traumatic signal changes (FLAIR), retained hemosiderin products (gradient echo), white matter tract injury (diffusion tensor), or loss of hippocampal volume (coronal T2). Consultation with a radiologist or a neuroradiologist will be required for most psychiatrists to analyze this information.

The standardized neurocognitive assessment is important because the commonly used mental status examination is incapable of detecting subtle neurocognitive changes. Moreover, frontal lobe disorders associated with executive dysfunction are difficult to detect on face-to-face mental examination. Apolipoprotein E examination may reveal an e4 allele. There is an association between the presence of 1 or 2 e4 alleles and a poorer prognosis for the patient with TBI. TBI has been convincingly implicated as a risk factor for Alzheimer disease in several epidemiological studies.⁸

Treatment and prognosis

Treating comorbid PTSD and TBI is a complex but rewarding process. It includes 3 major steps⁷:

• Pharmacological treatment aimed at improving cognitive symptoms.
• Pharmacological treatment aimed at suppressing PTSD symptoms.
• Psychotherapy directed at PTSD psychopathology.

Cognitive symptoms of PTSD are treated with either stimulants and/or cognitive enhancers of the acetylcholinesterase blockade type; psychiatric symptoms of PTSD are treated with SSRIs or dual-mechanism antidepressants. Psychotherapy directed at PTSD can include cognitive-behavioral therapy (CBT) or desensitization techniques.⁷ Prognosis varies with the severity of TBI; PTSD with comorbid TBI significantly reduces the likelihood of full recovery.⁷ However, CBT has been shown to be effective in treating acute stress disorder and PTSD comorbid with mild TBI.^11,12