Robert P. Granacher Jr, MD, MBA

Our returning military veterans remind us dramatically of the importance to consider traumatic brain injury (TBI) as a potential comorbid illness in cases of posttraumatic stress disorder (PTSD). The common causes of comorbid TBI and PTSD are assault and battery to the head, head trauma (personal or work-related injuries), civilian or military explosions, inflicted head trauma in children, motor vehicle accidents, and suicide attempts by jumping. Prevalence figures for comorbid TBI and PTSD historically have been lacking.

This article discusses the association between TBI and PTSD with a review of the possible mechanisms that link TBI and PTSD. Strategies for assessing and treating PTSD are also provided.

The American Neuropsychiatric Association Committee on Research recently published a critical review of the literature and noted that psychiatric disorders frequently complicate recovery and rehabilitation from TBI.

 This study reviewed the literature from 1978 to 2006 on psychosis, depression, PTSD, mania, and aggression following nonpenetrating TBI. Studies included in that report were reviewed using the American Academy of Neurology’s criteria for classification of articles on diagnostic methods (I is the highest classification; IV, the lowest). Of the 66 studies reviewed, none was found to be class I or II; the majority were class IV. There are significant gaps in the literature on post-TBI psychiatric conditions with respect to nosology, epidemiology, and risk factors. Larger multicenter prospective studies using standardized diagnostic instruments are needed to further clarify these topics.

 studied the rate at which PTSD symptoms developed without other psychiatric illness during the first 6 months after TBI in a group of 124 civilians. The cumulative incidence of meeting partial 

criteria for PTSD at 6 months was 11% and of meeting full criteria, 5.6%. Prevalence peaked at 1 month (10%). A large percentage of the participants (86%) had another psychiatric disorder; 29% had a history of PTSD.

A recent prevalence study from the CDC found that symptoms consistent with severe PTSD increased from 11% at 6 months to 16% at 12 months after the injury. The CDC concluded that regardless of severity, survivors with TBI are at risk for symptoms consistent with PTSD. Amnesia regarding the injury event did not protect against the development of these symptoms.

Clearly, it is difficult to accrue large cohorts of civilians with comorbid TBI and PTSD to study prevalence of the disorders. However, findings from a comprehensive study of a large military population with comorbid TBI and PTSD were reported by Hoge and colleagues.

 In the study, 4618 soldiers in 2 brigades of the US Army were offered an anonymous neuropsychiatric questionnaire: 2714 soldiers (59%) completed the questionnaire. Of the 2525 soldiers who met inclusion criteria for the study, 124 (4.9%) reported an injury with loss of consciousness that lasted between a few seconds to 3 minutes after injury; 260 (10.3%) reported an injury with altered mental status not involving loss of consciousness; 253 soldiers said they had been dazed, confused, or saw stars after an injury. Four additional soldiers reported loss of consciousness lasting longer than 30 minutes. PTSD was strongly associated with mild TBI. Overall, 43.9% of soldiers who reported loss of consciousness following an injury met the criteria for PTSD, compared with 27.3% of those reporting altered mental status.

After complex statistical analysis, only loss of consciousness and combat intensity remained significantly associated with PTSD compared with other physical injuries at multiple anatomical locations (odds ratio for loss of consciousness, 2.98). Overall, nearly 15% reported an injury during deployment that involved loss of consciousness or altered mental status. These findings were defined as mild TBI. The soldiers who had mild TBI were significantly more likely to report high combat exposure and blast mechanism of injury than were the 17% of soldiers who reported other injuries. Those with mild TBI reported significantly higher rates of physical and mental health problems than did soldiers with other injuries. Mild TBI was significantly associated with psychiatric symptoms, notably PTSD. This association remained significant after combat experiences had been controlled for.

 The data indicate that a history of mild TBI in the combat environment, particularly when associated with loss of consciousness, reflects exposure to an intense traumatic event that threatens loss of life and significantly increases the risk of PTSD.

The authors of that study concluded that the mechanisms between mild TBI and PTSD are complex.

 Studies have not confirmed any direct causative link between PTSD and injury to brain tissue from the concussion itself, although this is an important area of research. There is evidence that implicit processing of traumatic memories and fear conditioning, both mechanisms for the development of PTSD, occur even in persons with severe TBI who have amnesia about the traumatic event.

Biomechanics and pathophysiology of TBI as it relates to PTSD

At the time of impact, the kinetic energy of blunt force trauma, or blast-overpressure trauma, produces a mechanical loading. This loading is dynamic to the head. Brain deformation caused by tissue strain is the proximate cause of injury whether induced by massive inertia or by contact. The strain to tissue is a result of compression, tension, and shear. Characteristically, the brain withstands strain better if the tissue is deformed slowly rather than quickly. Therefore, the velocity of mechanical loading covaries positively with the level of tissue injury.

 The 4 pillars of cellular damage that cause injury are presented in 

. Cellular brain damage is a dynamic and evolving process that occurs over several hours and may go on for a few days.

 The 4 pillars of cellular damage cause enzyme modulation and gene modulation in brain tissue, which results in apoptosis (programmed cellular death), necrosis, or if gene modulation is sufficient, repair. Either apoptosis or necrosis leads to cellular death.

Many mechanisms are likely to underlie PTSD, but specific pathophysiology is not yet clear. Exposure to extreme stress activates the hypothalamic-pituitary-adrenal axis and increases autonomic reactivity, stress responses produce a reactive cell-mediated immune response, sleep physiology is disturbed, and perception of symptoms is psychologically altered.

Functional MRI studies have shown that trauma modulates the amygdala and medial prefrontal areas as a response to consciously attended fear.

outlines common neuro-psychiatric disorders seen following TBI. This author has delineated a medical model with evidence-based meth-odology for the assessment of TBI with comorbid medical, psychiatric, and neuropsychiatric conditions.

The history taken at the time of the psychiatric examination of a patient presenting to a psychiatrist with PTSD is the most telling. It is important to take not only a strong psychological history of traumatic events but also a careful history of physical injury that occurred at the time of the trauma that precipitated the PTSD.

For the child psychiatrist, a history of inflicted harm should arouse immediate suspicion of an underlying TBI. Clearly, a child injured in a motor vehicle accident or other accident by blunt force trauma should be historically evaluated to determine whether there was loss of consciousness or whether posttraumatic cognitive changes are present.

In adults, the most common scenarios for comorbid TBI and PTSD include assault and battery, blunt force trauma in motor vehicle or industrial accidents, suicide attempts associated with severe blunt force trauma (such as jumping from a building), and blunt force trauma or blast-overpressure trauma sustained from ordinance explosions during combat. In particular, psychiatrists should be suspicious when examining any returning combat veteran with PTSD symptoms that have resulted from an explosion (blast-overpressure trauma). Blast-overpressure brain injury is frequently underdiagnosed in soldiers returning from Iraq and Afghanistan who have sustained mild TBI or explosion-induced concussions. Among veterans who have been evaluated since April 2007, 15% have screened positive for mild TBI.

 Since the psychiatrist tends to see posttrauma victims well after the initial injury, it is important not to defer the diagnosis of comorbid PTSD and TBI to physicians who examined the victim at the time of injury. Often the physical trauma obviates the ability of physicians in the acute care setting to determine whether comorbid TBI and PTSD exist.

The assessment of potential TBI within the context of PTSD is no different from the assessment of potential TBI comorbid with any other medical or psychiatric condition. The procedures are fairly standard and comprehensive. The psychiatrist will have to determine whether he or she has the clinical experience and skills to perform the TBI assessment outlined in 

. If not, it may be wise to refer the patient to a colleague who practices neuropsychiatry or behavioral neurology. A comprehensive neuropsychiatric assessment is the most important single tool with which to determine whether a patient with PTSD has comorbid TBI.

 outlines the specific information that must be gathered to differentiate TBI from PTSD. If the neuropsychiatric history gathering is the most important variable in a quality TBI assessment, the second most important variable is a return to the scene of the accident. The psychiatrist should secure the original injury records-including the ambulance run sheet, police report, and emergency department records. These will help determine whether there was head trauma and its relationship to the onset of PTSD. For instance, if the emergency medical services (EMS) run sheet indicates a Glasgow Coma Scale below 15, the likelihood that the patient has sustained at least a mild TBI is increased. If the patient remained impaired based on the Glasgow Coma Scale (score below 15) after the emergency medical personnel released him to an emergency department, the likelihood of TBI is further increased, because it is obvious that the patient’s mental state did not improve during transit. Lastly, if the medical history from the emergency department and/or EMS observers and police indicates confusion, disorientation, inability to provide a history, or inability to be interviewed because of mental status changes, TBI is probable.

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.

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

• 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.

 Prognosis varies with the severity of TBI; PTSD with comorbid TBI significantly reduces the likelihood of full recovery.

 However, CBT has been shown to be effective in treating acute stress disorder and PTSD comorbid with mild TBI.


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				3. Greenspan AI, Stringer AY, Phillips VL, et al. Symptoms of post-traumatic stress: intrusion and avoidance 6 and 12 months after TBI. Brain Inj. 2006;20: 733-742.
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http://www.blastinjuryinstitute.org/ node/52

Articles

Our returning military veterans remind us dramatically of the importance to consider traumatic brain injury (TBI) as a potential comorbid illness in cases of posttraumatic stress disorder (PTSD). The common causes of comorbid TBI and PTSD are assault and battery to the head, head trauma (personal or work-related injuries), civilian or military explosions, inflicted head trauma in children, motor vehicle accidents, and suicide attempts by jumping. Prevalence figures for comorbid TBI and PTSD historically have been lacking

Traumatic Brain Injury and Posttraumatic Stress Disorder

Forensic psychiatry has increasingly become an acknowledged and respectedpsychiatric subspecialty. In recent decades, greater numbers of generalpsychiatrists have added the practice of forensic psychiatry to their clinicalpractice. More than 2,200 psychiatrists are members of the American Academyof Psychiatry and the Law, and at the present time, approximately 45 forensicfellowship programs offer specialized training in forensic psychiatry in the United States and Canada (Gold, 2004). Since fellowships in forensic psychiatry are new, and since the current number offellowships cannot produce all the psychiatrists needed for forensicexaminations, most psychiatrists add forensic psychiatry to an establishedpractice rather than completing a fellowship and practicing this subspecialtyon a full-time basis.

However, significant clinical and business distinctions exist between thepractice of clinical and forensic psychiatry that should be recognized whensetting up a forensic psychiatry practice. Unlike in a clinical context, adoctor-patient relationship is not established in the practice of forensicpsychiatry. In addition, a forensic psychiatrist is employed as an agent of alawyer, court or other entity requesting forensic services. Therefore, ratherthan producing a treatment examination, an expert examination or consultationservice is rendered, and a fee is generated for that service.

All new businesses should begin with a business plan. Most psychiatristslack skill in developing such plans. A written plan is not required, and manypsychiatrists may choose not to complete such a plan at all. However, abusiness plan can be an important tool in assisting forensic psychiatrists todevelop the methodology and metrics necessary to properly construct a business.This is particularly important for the solo practitioner, who may not have thebenefit of the checks and balances present in group practices. The developmentof a business plan requires a business model, even if that model is cognitiverather than written. The psychiatrist is advised touse an acceptable reference or professional advisors for developing a businessplan (Abrams and Kleiner, 2003).

 describes the four majorcomponents involved in planning any business, including a forensic psychiatrypractice. All businesses should begin with a 

, consisting of a few sentences that conciselydescribe the forensic psychiatrist's purpose. For instance, this might include:"The mission of the XYZ Forensic Psychiatry Practice is to provide state-of-the-artforensic psychiatric analysis of worker's compensation cases claimingpsychological harm." A well-articulated mission statement provides guidance toall individuals working within the practice.

 of a forensicpsychiatry practice is also described in a short sentence, if possible-or a fewsentences at most-to describe where the practice is headed, as guided by themission statement. In our current model, it might state, "The XYZ ForensicPsychiatry Practice will be recognized as this state's leading provider ofworker's compensation injury forensic psychiatric assessments."

 describe the ethicsand values of the practice (the business culture) that will be used by thepsychiatrist to guide the mission and vision of the forensic psychiatrypractice. Again, this should be a succinct statement, such as: "The XYZForensic Psychiatry Practice will at all times embody the core values ofhonesty and objectivity when providing forensic psychiatric examinations.Examinations will be completed with integrity, compassion and excellence."

The strategic portion of planning the forensic psychiatric practicedescribes the 

 for how the practice's mission and vision will be completed. Strategy is the 

Since most psychiatrists will add a forensic psychiatric practice to atreatment practice, they should analyze carefully how to balance the twoendeavors. It is critical to maintain dynamic stability in both practices asthey develop in a parallel fashion. Many well-honed clinical skills will applydirectly to the practice of forensic psychiatry. Nevertheless, certain businesstactics can enhance the incorporation of a forensic practice into a treatmentpractice.

.Forensic psychiatrists should maintain a customer orientation that may differfrom that of their clinical practice. In forensic psychiatric practice, one hasclients rather than patients; therefore, the complex interactions and communicationsnecessary in forensic psychiatry best lend themselves to having someoneavailable to answer calls and provide information to potential clients ratherthan using answering services or telephone voicemail systems. Loss of businessin a forensic psychiatric practice can be substantial as a result of usingvoicemail or other mechanical or electronic answering systems. The individualwho answers the phone for the forensic psychiatrist should be trained toprovide as much information as possible to the caller or prospective client.This enhancement of information transfer can be improved by the use of Websites for the benefit of the prospective client. In forensic psychiatricpractice, most juries are highly familiar with Web sites and will not find thisto be an unusual practice.

. Evidence-based medical models are becoming increasinglyutilized in the practice of psychiatry. Forensic psychiatrists should adhere to

 diagnostic categories and evidence-based medical models. Use of idiosyncratic diagnoses or failure to provide scientific evidence to support conclusions may render testimonyinadmissible under the legal criteria that govern the admissibility of expertevidence (

Daubert v Merrell Dow Pharmaceuticals, Inc.

,1993). In addition, mental evaluations should be standardized and based onacceptable mental measurements. While the face-to-face mental statusexamination is required within the psychiatric examination, triersof fact usually assume that a portion of certain types of forensic examinationswill be quantified. Therefore, the forensic psychiatrist should develop arelationship with a psychologist who can provide measurements of:

.The use of structural and functional brain imaging and appropriate laboratorytests should be included in the examination when appropriate. If thepsychiatrist does not perform neurological examinations when evaluating claimsof cognitive disorders or brain injury, this should be provided by otherpractitioners.

.A successful forensic psychiatry practice depends upon judicious use ofefficient and productive technology. Use of word processing technology,dictation services, templates and computer scheduling can increase efficiencyand reduce time demands. Conducting weekly staff meetings, wherein cases arediscussed and examination strategies completed before the examinee arrives, canenhance productivity further.

.The success or failure of a forensic psychiatry practice often revolves aroundfee issues. Financial arrangements between treatment and forensic psychiatrydiffer markedly. In forensic psychiatric practice, psychiatrists should haveclear, written contracts with their clients; this prevents professional orethical lapses. Obtaining a retainer fee prior to examination is advisable,ethical and customary in forensic psychiatry. Prepayment of the fee prior tothe examination ensures that no perception of contingency fee arrangementsexists, and it facilitates honesty and objectivity in the examination process.Acceptance by the client of the retainer fee seals the contractual arrangementand thus allows the psychiatrist unlimited objective latitude within the courseof the examination. This will become particularly important when thepsychiatrist's opinion is not helpful to the client or entity who retained the psychiatrist's services.

.Communication skills can make or break a developing forensic psychiatrypractice. Psychiatrists practicing in forensic arenas who cannot communicateeffectively by oral and written methods are at a distinct disadvantage.Regardless of one's academic credentials and clinical skills, an inability to communicateeffectively will reduce the likelihood of further forensic referrals. The roleof the forensic psychiatrist is to educate the trierof fact. Testimony is a method of teaching and providing information to thosewho must make decisions about the legal matters at hand. Forensic psychiatristsshould strive to teach clearly their opinions; plain language should be used atall times.

The quality of written reports is fundamental to a successful forensicpsychiatry practice. In many instances, the report may stand on its own meritsand a case may be settled without requiring the psychiatrist's oral testimony.Reports that are poorly written, digress, contain poor logic and do not answerspecifically the retaining party's questions will reduce the effectiveness andsuccess of the practice.

.Lastly, lack of clinical skills may severely limit practice opportunities for anovice forensic psychiatrist. The clinical practice of psychiatry on a dailybasis--while also practicing forensic psychiatry--has a twofold purpose: 1) Itmaintains the forensic psychiatrist's clinical skills at a high level andassists in the maintenance and development of current information in clinicalpsychiatry; and 2) Triers of fact are oftensuspicious of psychiatrists testifying as an expert if they do not activelytreat patients. In some jurisdictions, this can limit the type of referralspsychiatrists receive in a forensic practice, as they may require that at least50% of practice time be devoted to treatment and medical consultation beforethe psychiatrist can testify in a medical malpractice action or other types oflegal actions. The most effective forensic psychiatrists maintain psychiatricand medical skills at the highest level possible (Granacher,2004). 

 provides practiceguidelines that, if followed, should considerably enhance the ability of atreatment psychiatrist to establish and maintain a forensic psychiatricpractice.

The practice of forensic psychiatry is an intellectually challenging andextremely gratifying experience for most psychiatrists. Marketing andadvertising are not needed, as every report generated by the psychiatrist,every testimony provided by the psychiatrist and every interaction withprospective clients produces an effect that markets the psychiatrist's forensicskills in an ethical and professionally acceptable manner. The most criticalfactors for success in forensic arenas are the psychiatrist's clinical skillsand integrity.

 Abrams R, Kleiner E (2003), The Successful Business Plan: Secrets and Strategies, 4th ed. Palo Alto, Calif.: The Planning Shop.
 

 Gold LH (2004), Rediscovering forensic psychiatry.In: The American Psychiatric Publishing Textbook of Forensic Psychiatry, SimonRI, Gold LH, eds. Washington, D.C.: American Psychiatric Publishing, Inc.,pp3-36.
 

 Granacher RP (2004), Starting a forensic practice.In: The American Psychiatric Publishing Textbook of Forensic Psychiatry, SimonRI, Gold LH, eds. Washington, D.C.: American Psychiatric Publishing, Inc.,pp55-89.

Forensic psychiatry is increasingly emerging into treatment psychiatry as a respected subspecialty. However, there are important clinical and business distinctions between the practice of treatment psychiatry and the practice of forensic psychiatry. The essential components of setting up a forensic psychiatry practice are outlined.

Author | Robert P. Granacher Jr, MD, MBA

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