Sandeep Vaishnavi, MD, PhD

Everyone has experienced moments when one bad outcome convinces us we are doomed to a life of failure. These catastrophic thoughts are akin to making a proverbial mountain out of a mole hill. It is why after a breakup, we think no one will ever love us. It is that seizing fear when waiting on a doctor’s report. It is that gnawing feeling when someone vaguely texts “we need to talk.”

This exaggerated expectation that only the worst possible outcome will occur can exert a powerful and debilitating influence over our lives. Left unchecked, these catastrophic thoughts can set dangerous patterns that prohibit us from taking reasonable chances, following inspiration, or recognizing life’s silver linings.

As psychiatrists, we often encounter catastrophic thinking in our patients. We understand how difficult it can be to change these patterns, even with professional help. And while it is often easier to see this in others, the demands of our profession make us susceptible to falling into these very same traps. Tasked with supporting our patients’ well-being, psychiatrists—and physicians in general—feel enormous pressure to produce positive changes in their lives. When our patients suffer setbacks, it is hard to not take it personally. And it can cast a strong and deeply personal shadow of doubt on our abilities.

Then there are the traps of burnout that can lead to catastrophic thinking: regulatory hoops, the ever-increasing bureaucracy and paperwork, clinician shortages, training mandates, the threat of 

. Like a hamster on a treadmill, it is easy to feel that there is never enough time and no end in sight.

Getting out of a catastrophic funk requires following the same treatment and advice we might give our patients. This means asking for help when we need it—something many physicians find difficult to do. Our jobs require us to be stalwart and seemingly infallible, but without balance and mindfulness, we continue to walk a dangerous razor’s edge of catastrophic thinking.

Catastrophic thinking, also known as magnifying, is a kind of cognitive distortion—a thought pattern that is irrational or exaggerated. Psychologist Albert Ellis, PhD, first coined the phrase in 1957 as he was developing his rational-emotive behavior therapy, a precursor to modern-day 

. His ABC model involved an activating event, beliefs that were irrational, and the consequences of those beliefs. His theory was that our emotions and perceptions are not formed by an event—rather, how we think about the event directs how we feel.

Catastrophic thinking can be triggered by one’s perception of what is happening at present or what they anticipate will happen in the future. Situations that trigger magnifying usually fall into 3 categories: how we interpret vague or ambiguous information, how we cope with the loss of someone or something valuable, and fear—especially irrational fear.

Catastrophic thinking shares some similarities with 

. The difference is that anxiety may serve a purpose, such as justified fear, while catastrophizing involves irrational magnification. It is also linked to depression, where feelings of unhappiness and helplessness can trigger an avalanche of catastrophic thoughts. Catastrophizing is common among those who have experienced traumatic events, or anything that threatens their safety and security or shatters their sense of control. It is common among those suffering from 

 (PTSD), depression, and anxiety. Among combat military troops, those with high levels of catastrophic thinking were 29% more likely to develop PTSD. Additionally, those who experienced high levels of catastrophic thinking coupled with higher combat intensity were 274% more likely to develop PTSD.

Ironically, catastrophic thinking can serve as a dysfunctional coping mechanism. After all, if you are always expecting the worst, you will rarely be disappointed. But this comfort can come at a steep price—one that can increase debilitating feelings of anxiety, avoidance, and isolation.

Magnifying can also affect and intensify how we experience pain. This is especially true with those suffering from chronic 

. Pain catastrophizing can feed on the memory and 

 of past events, which can influence how patients perceive future pain. Additionally, it can cause patients to ruminate on it and ultimately feel helpless against the idea of it. Pain symptoms account for 80% of physician visits and $100 billion a year in health care expenditures and lost productivity.

 Because of this, it is essential for physicians to gauge patterns of catastrophic thinking in their patients—not just to recognize the exaggerations, but to notice symptoms of other potential problems. Patients suffering from painful medical disorders in particular report high levels of catastrophic thoughts, along with self-reported pain, disability, and fear-avoidance behaviors.

 In a worst-case situation, catastrophic pain is a risk factor for suicidal ideation in those suffering from chronic pain.

 is a leading cause of catastrophic thinking. Defined as emotional and physical exhaustion brought on by prolonged stress, burnout has been noted in 50% of physicians-in-training and practicing physicians.

 It is generally attributed to work environments rooted in excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, and a lack of input or control, leadership culture, or organizational support. Female and younger physicians are more likely to report higher rates of burnout.

 can reduce one’s sense of effectiveness and personal accomplishment, leaving a person feeling emotionally drained. At worst, depersonalization associated with burnout can lead some to regard patients as objects rather than human beings.

 Physical symptoms include fatigue, body aches, 

, gastrointestinal effects, increased susceptibility to common infections, and disrupted sleep patterns.

Physician burnout is a common problem that has far-reaching effects. For patients, it can result in lower-quality care, medical errors, longer recovery times, and lower patient satisfaction. Physicians are more likely to experience substance abuse problems, depressive and 

, and motor vehicle crashes. The health care industry suffers at large due to reduced physician productivity, turnover, and less access for patients. All of this has resulted in $4.6 billion a year in costs.

The pandemic has created its own unique breeding ground for burnout, with 53% of health care workers reporting high levels. Heading into its third year, the rebounding pandemic and its relentless pressure on the health care system creates an environment ripe for catastrophic thinking. Rather than succumb to its pitfalls, awareness is the first step in fortifying our mental defenses.

Psychiatrists are particularly susceptible to burnout, more so than surgeons and other physicians. In some ways, the stakes are higher, as our patients are more prone to violence and suicide. Because we use ourselves as tools to treat patients, we are vulnerable to a powerful range of emotions. These include feeling powerless against illness, fear of becoming ill, and the obsessive need to rescue patients.

Ellis did more than identify catastrophic thinking. He highlighted a way out of it by expanding the original ABC model to include ABCDE. The “D” refers to the disputation of beliefs, which calls for irrational thoughts to be converted into rational ones. And the “E” represents the effects these new and healthier thoughts might have on a person’s well-being. One of the best ways to counteract catastrophic thinking is by challenging it. Ellis’ method of decatastrophizing involves posing rational questions,

-What is the worst thing that can happen?

Sometimes, saying “stop” out loud can help disrupt the pattern of repetitive negative thoughts. In the heat of the moment, it can be difficult to recognize catastrophic thinking as it is happening. The help of a clinician can clearly define these patterns and use a cognitive-behavioral approach to decatastrophizing. In some situations, clinicians may prescribe antidepressants or other medications to address the root causes of catastrophic thinking.

Over time, this hard work of observing patterns and reframing our reaction pays off in the form of hard-earned 

. Resilience is measured by our ability to quickly recover from stress. It is a way of building mental fortitude despite—and because of—life’s hardships. Another benefit is that it can drown out catastrophic thoughts by interpreting failures as opportunities to learn and grow. Techniques to build resilience include taking on challenges where the risks are reasonable, discovering one’s personal meaning of life, and being surrounded by people who believe in you. Other methods to build resilience include:

TM is a meditation technique that involves silently repeated mantras to help reduce stress and promote a relaxed state of awareness. In one of the author’s studies, health care workers during the pandemic who practiced TM for 3 months showed significantly improved symptoms of emotional exhaustion, anxiety, and 

 over time when compared to a control group.

 In another pandemic study, emergency clinicians who practiced TM experienced significant reductions in burnout, along with fewer symptoms of depression, anxiety, stress, and sleep disturbances.

 This practice turns down the volume of mental chatter by engaging full attention on our daily and mundane tasks. By focusing on the here and now, mindfulness can help practitioners gain broader awareness of cognitive patterns and better control over irrational thoughts. One study found mindfulness was predictive of lower levels of disability, anxiety, 

, and catastrophizing in patients suffering from chronic back pain.

Through structured body postures, breathing exercises, and cognitive-behavioral processes, practitioners learn relaxation and stress-management techniques. Studies indicate that SKY offers a therapeutic option capable of reducing symptoms of depression and anxiety.

 Exercise, healthy eating, and getting enough sleep all help shore up our defenses against catastrophic thinking. Being kind and tending to one’s needs can have a calming effect on our tendency to dwell on the negative.

 Web- and phone-based apps provide quick, anonymous options to those hesitant about seeking mental health treatment. This technology helps users track moods, learn mindfulness techniques and exercises, and keep catastrophic moods in check. One study found that online tools helped reluctant health care workers reduce stress, burnout, depression, and suicidal ideation.

 Provides daily games tasked with increasing happiness, reducing stress, and overcoming negative thought patterns.

 Provides mindfulness and meditative tools designed to reduce stress and improve focus and sleep.

 Helps users track moods with guided journaling, coping techniques, check-ins, and positive affirmations.

They say physicians make the worst patients. Our need to display strength and dependability can prevent us from seeking help when we need it. As a result, many of us would prefer to cope alone rather than admit weakness and face the silent judgement of our peers. But this thinking runs counter to what motivated us to pursue a career in mental health in the first place. We often preach that our overall health is deeply grounded in mental health. Physicians can improve overall patient care by identifying situations that lead to catastrophizing and burnout and taking measures to correct it.

Catastrophizing can be catastrophic, but it can be managed by building resilience. As physicians, we need to apply this to ourselves just as we do our patients. As the saying goes, “Physician, heal thyself.” Never has this been more apt than in the current pandemic.

is a neuropsychiatrist, cognitive neuroscientist, adjunct associate in the department of medicine at Duke University,

1. Selva J. Albert Ellis’ ABC model in the cognitive behavioral therapy spotlight. Positive Psychology. December 13, 2021. Accessed February 2, 2022. 

https://positivepsychology.com/albert-ellis-abc-model-rebt-cbt/

2. Seligman MEP, Allen AR, Vie LL, et al. 

PTSD: catastrophizing in combat as risk and protection.

3. Lonczak HS. Catastrophizing and decatastrophizing: a PositivePsychology.com guide. Positive Psychology. December 7, 2021. Accessed February 2, 2022. 

https://positivepsychology.com/catastrophizing/

4. Quartana PJ, Campbell CM, Edwards RR. 

5. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Practical Pain Management. Accessed February 2, 2022. 

https://www.practicalpainmanagement.com/pain/other/co-morbidities/pain-catastrophizing-what-clinicians-need-know

Physician burnout: contributors, consequences and solutions.

Societal pandemic burnout: a COVID legacy.

Physician burnout: contributors, consequences and solutions

10. Joshi S, Vaishnavi S, Brucker A, et al. Targeting healthcare provider burnout during the COVID-19 pandemic. 2022 ATS (American Thoracic Society) International Conference, May 13-18, 2022.

11. Azizoddin DR, Kvaternik N, Beck M, et al. 

Heal the healers: a pilot study evaluating the feasibility, acceptability, and exploratory efficacy of a transcendental meditation intervention for emergency clinicians during the coronavirus disease 2019 pandemic.

12. Cassidy EL, Atherton RJ, Robertson N, et al. 

Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain. 

13. Hamilton-West K, Pellatt-Higgins T, Sharief F. 

Evaluation of a Sudarshan Kriya yoga (SKY) based breath intervention for patients with mild-to-moderate depression and anxiety disorders.

Web-based tools and mobile applications to mitigate burnout, depression, and suicidality among healthcare students and professionals: a systematic review.

Articles

Here’s how to help patients—and ourselves—recognize cognitive distortions.

Defusing Catastrophe

When the United States withdrew from Afghanistan earlier this year, clinicians noted a sharp increase in calls to veteran crisis center hotlines.

 One survey found that 90% of veterans with a history of mental illness were experiencing new or worsening symptoms since the country fell.

For veterans with posttraumatic stress disorder (PTSD), news about 

Afghanistan brought back powerful memories of traumas

 many of them were trying to forget. Nightmares invaded their sleep, intrusive thoughts distracted them from work and family, and flashbacks were so powerful there was no place to hide.

PTSD has a complicated history and neurobiology, and an array of potential comorbidities. In order to diagnose and treat it, clinicians should understand all these factors, and tailor their treatment plans accordingly.

The Prevalence of PTSD and Comorbid Disorders

Civil War General William Tecumseh Sherman put it bluntly when he said, “War is hell.” For veterans with PTSD, that hell can seem inescapable. Between the Iraq and Afghanistan wars, an estimated 500,000 US troops, about 20%, have been diagnosed with PTSD.

However, less than half of veterans in need of mental health services receive treatment. Of those who do get help, less than one-third receive evidence-based care.

 And of the 5 million service members being cared for by the US Department of Veterans Affairs (VA), only 8% have been diagnosed with PTSD. Left untreated, PTSD can lead to hospitalization, unemployment, and poverty.

There are myriad reasons for this lack of appropriate care. Veterans face unique barriers in getting treatment for 

. From the minute they enter the military, service members are trained to be tough. This, after all, is what gives them the mettle needed to survive. However, this attitude can also feed stigma, as any mental health condition might be considered a sign of weakness.

When the bullets stop flying and service members return home, the horrors they hoped to forget often follow. These unprocessed traumas bang on the door of their subconscious, demanding attention. However, talking about traumas can be an extremely uncomfortable experience, one that threatens to trigger retraumatization.

There are also societal barriers to access. Veterans who seek services from the VA must have received either an honorable or general discharge and, even then, there are usually long waits to receive services. Those living in rural areas are even less likely to get access.

Instead, many veterans turn to drugs and alcohol to dull the pain. In the 1980s, a study of Vietnam veterans with PTSD found that 74% had a comorbid substance use disorder (SUD).

 A more recent study found 76% met the criteria for both alcohol and SUDs.

Adding to the complexity, mood and anxiety 

 are high with PTSD and can complicate diagnosis and assessment. Veterans with PTSD are 3 to 5 times more likely to have major depressive disorder. Many also have anxiety disorders.

 wondering if they are irreparably broken. Between the wars in Afghanistan and Iraq, more than 30,000 veterans have died by suicide.

 It is a statistic that belies a troubling need for care.

PTSD has gone by many names over the years. During 

. During World War I, soldiers called it 

. After the Vietnam War, when almost 25% of soldiers required some kind of psychiatric care, it was known as 

The work of Charles Myers, MD, during World War I is widely credited with how PTSD is treated today. A medically trained psychologist, Myers was brought on by the British military to study and treat soldiers who were unable to function without any discernible cause.

At the time, many viewed shell shock as cowardice. Myers, on the other hand, argued that it was a psychiatric condition that caused affected soldiers to dissociate from a traumatic experience and repress its memory. The treatment, he concluded, involved connecting the traumatic memory back into one’s awareness through a series of psychotherapy sessions. These were ideally held within a military setting but away from gunfire.

 became an official diagnosis in the third edition of the DSM. Initially considered an anxiety disorder, PTSD is part of a separate group of trauma- and stressor-related disorders in DSM 5. DSM 5’s PTSD diagnosis also includes witnessing an event as a qualifying trauma.

PTSD is expressed by 4 main clusters of symptoms: reexperiencing the trauma in the form of intrusive memories, flashbacks, or nightmares; avoidance of anything that reminds an individual of the event; arousal and hyperreactivity, such as being easily startled or feeling tense; and effects on cognition and mood that include negative thoughts, feelings of guilt or blame, or a loss of interest. To receive a diagnosis of PTSD, these symptoms have to last more than a month and be functionally impairing.

Although anyone experiencing a trauma may have these reactions, symptoms usually fade over time and do not lead to PTSD. For others, however, the symptoms are severe, persist, and cause significant dysfunction.

The disorder can be diagnosed by using the Clinician-Administered PTSD Scale for DSM 5, a 30-item structured interview.

 It is considered the gold standard for measuring PTSD in clinical trials, but it is difficult to use in a clinic setting. The PTSD Checklist for DSM 5 is a 5- to 7-minute questionnaire that may be more practical to use in the clinic. It is regularly used to establish national PTSD outcome data.

Since the 9/11 terrorist attacks in 2001, 775,000 troops have 

 on a mission to retaliate and stabilize the region. More than 2400 died, about 20,000 were wounded, and countless others have been haunted by what they have seen and experienced.

When the Taliban regained control of Afghanistan in August, texts to the Veterans Crisis Line jumped 98% compared to a year prior. Chats and phone calls rose 40% and 7%, respectively.

 While this is troubling, the VA also noted it was an encouraging sign that more veterans were seeking help for their mental health issues. One survey revealed that one-third of veterans seeking counseling were doing so for the first time.

About 70% of veterans have struggled with mental health issues since serving in the Afghanistan war.

 Since August, 90% of Afghanistan service members have experienced new or worsening mental health issues. About 75% are experiencing new or worsening symptoms of depression, 58% have started or increased drug or alcohol use, and 64% have new or worsening thoughts of suicide.

 tend to experience more severe symptoms and lower remission rates compared to noncombat-related PTSD.

 Indeed, the kind of warfare experienced in Afghanistan is likely to put anyone on edge. This includes guerrilla attacks, roadside and suicide explosives, and a wary uncertainty about safe zones and battlegrounds. When an attack can come from anywhere at any time, the amygdala will be more active, and PTSD may be more likely.

Although improvements in body armor and combat medicine protect service members who would have died from their wounds in earlier wars, it leaves them with psychological scars as well as possible PTSD, brain injury, and a host of other lifelong debilities.

Troops today are serving at younger, more impressionable ages.

 In the Vietnam War, troops mostly served a single tour. Now, more than half return to action, with some serving more than 5 tours.

 Studies have shown that morale decreased and psychiatric problems as well as the use of psychotropic medication increased during the second or third deployment. Similarly, communication with family was difficult, and separation or divorce rates increased.

Younger age, female gender, minority background, as well as lower socioeconomic status, military rank, and education all indicate a higher risk of PTSD.

 In addition to trauma from battle, sexual trauma is common in the military, with about 1 in 3 women and 1 in 50 men reporting military sexual trauma (MST).

 With fewer women in the military, 1 in 3 veterans who report MST are men.

In addition to PTSD, many Afghanistan combat veterans also suffer from moral injuries, which occur when a trauma cuts so deep it violates an individual’s moral beliefs.

 Moral injury also describes an individual’s internal conflict over things they have done to others, actions they have failed to do, and events they have witnessed others doing or failing to do. Examples of moral injury include killing others (innocent or not), dismembering bodies, torturing others, or abandoning comrades during battle.

Moral injury is highly common among service members, with at least 1 symptom appearing in 90% of veterans and 80% of active duty military.

 It is a separate and distinct syndrome from PTSD that can co-occur and be influenced by the same event. Although it shares similar symptoms with PTSD, it would be a mistake to treat it the same. In fact, the existence of unresolved moral injury can hinder the treatment of PTSD, as well as 

Shame is the underlying theme of moral injury. It is shaped by the event that caused it, and it continues to develop for years after a service member has returned home.

 Disgust also plays a major role. Studies indicate that elevated levels of disgust, whether moral or bodily, can increase intrusive thoughts and tend to be higher in those with PTSD.

Moral injury also involves feelings of guilt, betrayal, loss of meaning and trust, difficulty forgiving, self-condemnation, and inner conflict over moral implications. Moral injury can shake a patient’s spirituality and call into question their relationship with a higher power.

 It is also correlated with social anxiety isolation, depression, and 

As the understanding of PTSD has advanced, it has become clear that it is a neurobiological disorder driven by environmental trauma. It is likely a product of both nature and nurture and may be caused by a combination of biological vulnerability and 

PTSD involves the amygdala, prefrontal cortex, and hippocampus. The amygdala regulates intense emotions, particularly fear. It governs fear conditioning and contributes to symptoms of altered arousal and reactivity. The prefrontal cortex regulates conditioned fear, normally turning down the alarm signal from the amygdala. PTSD can occur when decreased activity in the prefrontal cortex prevents it from appropriately regulating heightened activity in the amygdala.

The hippocampus can help buffer the effects of increased amygdala activity. There is evidence to suggest that the hippocampus tends to be smaller in those with PTSD, but it is not entirely clear whether that is the cause of PTSD or the result of it. Studies of identical twins have indicated that a smaller hippocampus at baseline may make people more vulnerable to developing PTSD.

Since the fall of Afghanistan, 31% of veterans have sought professional mental health services for the first time.

 It is a sign of hope that barriers to treatment are softening. 

, in particular, has become a useful way to reach patients who are either hesitant to engage in treatment or live in remote places.

A 2014 survey of 7600 veterans revealed that those who believed they needed treatment, kept a positive attitude, and had strong social networks were more likely to be successfully treated for PTSD.

 However, treating PTSD can be a challenge, and current treatment options are not always effective.

Close to 60% of those with PTSD do not achieve remission, and although treatment-resistant PTSD is hard to define, up to one-third of patients do not find relief with current therapies.

 Chronic PTSD can lead to decreased life satisfaction as well as increase suicide risk and depression rates.

Trauma-informed care seeks to tailor treatment around the unique vulnerabilities of each patient. The goal is to help a patient process their PTSD experiences without retraumatizing them in the process. To do this, clinicians need to fully understand every aspect of a patient’s traumatic event, including earlier ones. Additionally, they put a high emphasis on safety, encourage patients to rebuild control, and teach them to build upon their individual strengths.

Homeless veterans with PTSD, in particular, can benefit from trauma-informed care. While veterans comprise 7% of the total US population, they represent 12% of homeless adults.

Providing a trauma-informed approach necessitates adapting treatment to the needs of these patients. It helps earn their trust and protects them from retraumatization. PTSD is like a giant wound that many veterans will carry throughout their lives. Healing must start from the inside out. As clinicians, our job is to help them integrate the experience of trauma without being overwhelmed by it.

 used as first-line treatments of PTSD. With cognitive processing therapy, therapists teach patients coping skills and help them identify negative thoughts associated with a traumatic event and replace those thoughts with coping skills. With prolonged exposure (PE), patients revisit the trauma repeatedly in a safe, clinical setting to change how they react to the memories of the event. PE has an efficacy rate of about 60% of veterans with PTSD.

. In treating PTSD, the use of medications, specifically selective serotonin reuptake inhibitors (SSRIs), is to make therapy more effective by reducing the intensity of the overwhelming anxiety caused by PTSD. This anxiety can limit how effectively patients are able to discuss and process their trauma in therapy, which can hinder the healing process. SSRIs have a 60% rate of response in patients with PTSD, but only 20% to 30% achieve complete remission.

, such as ketamine and psilocybin mushrooms, is also currently being researched in their potential to treat PTSD, but these studies are still in the early stages of understanding how they might be useful.

Eye-movement desensitization reprocessing (EMDR).

 After ensuring a patient is prepared to process their trauma, this treatment works to replace negative images and beliefs with more positive ones. During treatment, a patient pays attention to a back-and-forth sound or movement while recalling a traumatic event. The sound or movement gives them a focus that allows them to explore and process their trauma.

 is showing potential as a possible future treatment. It works by delivering highly focused magnetic fields to modulate neural circuits in the brain. It is currently used for patients with treatment-resistant depression. Studies indicate TMS could be used to treat the poor extinction of traumatic memory by targeting the prefrontal cortex.

. Yoga and breathing-based meditation are thought to help calm the hyperactive sympathetic nervous system brought on by PTSD. In one study, veterans who practiced Sudarshan Kriya yoga showed reductions in PTSD scores, anxiety symptoms, and respiration rate.

 In another study, half of the group of veterans who practiced transcendental meditation for 3 months did not meet the criteria for PTSD at study completion, compared to a control group at 10%.

 has also been shown to indirectly reduce self-stigma felt by many veterans as well as other symptoms of PTSD.

. For veterans suffering from moral injury, programs such as 

 can help trauma survivors address a variety of spiritual concerns.

In these programs, which are administered by trained chaplains, veterans explore issues of forgiveness, their relationship with a higher power, and why that higher power allows evil to occur in the world.

 is still under investigation, it seems to have a positive effect on those with PTSD. One study found that cannabis lowered threat-related activity in the amygdala.

 A second study observed that cannabis seemed to diminish the intensity of memories associated with trauma.

 The use of cannabis to treat PTSD has not been approved by the US Food and Drug Administration and remains illegal in many states.

The US withdrawal from Afghanistan stirs memories of trauma among veterans.

PTSD’s Long Reach

Traumatic brain injury (TBI) is a public health epidemic. Approximately 2.8 million people sustain a TBI annually; of these, approximately 50,000 die, 282,000 are hospitalized, and 2.5 million are discharged from an emergency department.

 Mild TBI or concussion accounts for the majority of TBIs. Falls are the most common cause of TBI, followed by assault and motor vehicle accidents. According to recent statistics, during a 6-year period from 2007 to 2013, rates of TBI-related ER visits increased by 47%, but rates of hospitalization and death decreased by 2.5% and 5% respectively, underscoring the importance of managing TBI morbidity.

Psychiatric disturbances are the most common long-term sequelae of TBI. In a recent article on the epidemiology and natural history of psychiatric disorders after TBI, Ponsford and colleagues

 noted that compared with the general population, patients with TBI have increased incidence of depressive disorder, anxiety disorder, and PTSD; depressive disorders are likely to be chronic and persistent.

In this article, we define TBI psychiatric disturbances as the development of psychiatric symptoms (emotional, behavioral, or cognitive) after the occurrence of a single or multiple TBIs. It may not always be possible to establish a causative link between TBI and the onset of psychiatric problems. When not possible, TBI should be considered as a treatment-informing medical comorbidity rather than an etiological factor.

Appropriate management of psychiatric disturbances can result in better outcomes, improved quality of life, and decreased societal impact. Management of TBI psychiatric disturbances should always be multidisciplinary and include both pharmacological and non-pharmacological interventions. An extensive armamentarium of pharmacological options is available, and there have been a number of randomized controlled trials and meta-analyses (

 TBI-associated depression is characterized by prolonged, persistent sadness associated with other symptoms such as anhedonia, lack of motivation, decreased self-care, variable sleep and/or appetite pattern, feelings of hopelessness, and/or suicidal thoughts. These symptoms may last for a couple of weeks to months (major depressive episode) or persist in a milder form for two or more years (dysthymia).

SSRIs are often considered first-line agents because of their benign side effect profile. Sertraline, citalopram, and escitalopram are often favored because of their limited drug-drug interaction. Most clinical trials have focused on sertraline, but results have been inconsistent. In a trial comprising 15 patients with mild TBI 87% had a significant response and 67% achieved remission with sertraline.

 In a follow-up study of patients with TBI-associated depression no significant differences were seen between sertraline and placebo in depression severity, response, or remission rates.

 found no statistically significant difference between sertraline and placebo in a group of 52 patients with TBI-associated depression. However, the small sample size (N=11) and the high rate of discontinuations may have contributed to the lack of difference between the medication and placebo groups.

SNRIs have also been used with fair success and no significant adverse effects, but they have not been systematically studied. In a small study (N=10) the tricyclic antidepressant (TCA) desipramine was shown to reduce depressive symptoms.

 However, because of anticholin- ergic adverse effects and risk for seizures, TCAs are less favored. Nortriptyline is considered to be the least anticholinergic and antihistaminergic among the TCAs and has demonstrated efficacy in the treatment of depression following stroke.

 However, we are not aware of controlled trials of nortriptyline in the treatment of TBI depression.

Monoamine oxidase inhibitors (MAOIs) may also be considered in persons with recalcitrant depression. However, the need for dietary restriction can be challenging because adherence to a strict diet may be difficult for patients with TBI who have cognitive deficits.

 conducted a systematic review and meta-analysis to determine the effectiveness of pharmacotherapy for the treatment of TBI depression and found a large, favorable treatment effect (Hedges g = 1.169; 95% CI, 0.849-1.489; 

<.001) on pooled analysis of within-groups treatment effect. Even when the analysis focused on only placebo-controlled trials, treatment with antidepressants was associated with a statistically significant reduction in depressive symptoms.

Methylphenidate and other stimulants may be used to augment the effect of antidepressants, especially when there is evidence of fatigue, apathy, or executive function deficits. Lee and colleagues

 compared the efficacy of sertraline, methylphenidate, and placebo in a study of 30 patients with mild to moderate TBI. Both methylphenidate and sertraline significantly improved symptoms of depression, but only methylphenidate improved cognitive function. Patients treated with methylphenidate also had diminution in daytime sleepiness.

Electroconvulsive therapy (ECT) may be safe and effective in patients with TBI. Jorge and Arciniegas

 have suggested some common-sense approaches to using ECT in patients with TBI: use low energy levels to generate a seizure of about 20 seconds, use pulsatile currents, increase between-treatment time intervals to 2 to 5 days, and keep the number of treatments to a minimum. Non-dominant unilateral ECT has a decreased risk of cognitive adverse effects compared to bilateral ECT and may be preferable in TBI patients.

 In a review of 48 studies, Simpson and Tate

 concluded that the risk of suicide, suicide attempts, and suicidal ideation is increased in TBI survivors compared with the general population, even after adjusting for psychiatric comorbidities. Mackelprang and colleagues

 also noted that 25% of their sample of 560 patients with all severities of TBI reported suicidal ideation during the first year following a TBI, a number much higher than 3.7% reported for the general population.

As in other cases of suicidal ideation, the most important factor in the management of TBI-associated suicide is to maintain safety. Immediate hospitalization should be considered for patients with active suicidal thoughts with intent or plan to die. Management of suicidal thoughts associated with psychiatric disturbances after TBI should focus on the psychiatric disturbances themselves. Extra caution to maximize safety is needed not only in the inpatient setting but also in the outpatient setting, ensuring that the patient has consistent outpatient care and a strong supportive network.

 The incidence of bipolar spectrum disorders is low in the TBI population, with a range of 2% to 9% in the first year after injury.

 Findings indicate the estimated lifetime relative risk for bipolar and related disorders to be 1.1, similar to the lifetime risk of bipolar disorders in the general population.

TBI mania is characterized by changes in mood, sleep, and activation, which may manifest as irritability, euphoria, insomnia, agitation, aggression, impulsivity, or even violent behavior. There is scant literature on the pharmacological management of TBI mania.

Based on our clinical experience and case reports, we recommend use of quetiapine as a first-line and risperidone as a second-line agent for acute mania; we recommend valproate as first-line and carbamazepine as a second-line agent for maintenance. Although many psychopharmocologists might argue that lithium is the gold standard for the treatment of idiopathic bipolar disorder, we are concerned about the CNS and motor adverse effects in persons with TBI.

 A wide range of anxiety disorders may occur after TBI including generalized anxiety disorder, agoraphobia, social phobia, panic disorder, and obsessive-compulsive disorder. Results from a meta-analysis of the prevalence of generalized anxiety disorder and self-reported anxiety in adults with non-penetrating TBI showed that 11% had a diagnosis of GAD, and 37% reported clinically significant levels of anxiety.

Commonly used medications for treatment of anxiety include sertraline, escitalopram, citalopram, and venlafaxine at doses similar to the treatment of TBI-associated depression.

. In a study of 1084 patients with mild TBI, 13% of the patients had PTSD.

 Higher incidence has been seen in military studies. Carlson and colleagues

 found that 64% of 836 veterans from Iraq/Afghanistan had PTSD. A recent review confirmed that PTSD occurs after TBI, but is more common after mild TBI.

 Although rates of TBI vary in the civilian population, they are higher in the military population, and the risk increases with the severity of TBI. The researchers concluded that the risk of PTSD varies according to the context in which the TBI occurred, the psychological trauma experienced at the time of TBI, and pre-TBI history of trauma or PTSD.

Sertraline is the first-line option for treating comorbid PTSD and TBI. Citalopram is a second choice, but caution is recommended above 40 mg daily because of potential cardiac adverse effects. Second-line agents include fluoxetine and mirtazapine, although the latter may be associated with mild anticholinergic adverse effects. SNRI antidepressants can also be used safely. Tricyclic antidepressants are third-line options. Prazosin may be used as adjunctive treatment for persistent nightmares. However, there were no statistically significant differences in sleep quality between prazosin and placebo in a recent 10-week study.

Extreme caution should be used with benzodiazepines for treatment of anxiety disorders or PTSD. In general they should not prescribed for more than 2 weeks because longer use increases risk for dependence. TBI patients may have increased susceptibility to the adverse effects of benzodiazepines, including drowsiness, ataxia, slurred speech, memory impairment, psychomotor impairment, and possibly disinhibition. Moreover, benzodiazepines may aggravate the fear response in persons with PTSD.

. Psychotic symptoms are not uncommon after TBI. There are predominantly 2 types of TBI-related psychosis: delusional disorders and schizophrenia-like psychosis. As far as we know, there are no clinical medication trials on the management of TBI psychosis. Case reports suggest efficacy for second-generation antipsychotics.

 Based on our clinical experience, we recommend second-generation antipsychotics (risperidone, 0.25-4 mg; quetiapine, 25-200 mg; lurasidone, 20-80 mg) over first-generation antipsychotics because the latter may interfere with neural recovery in TBI. When there are concerns about the presence of seizures, anticonvulsants such as valproate or carbamazepine may be preferable.

. Apathy refers to a syndrome of disinterest, disengagement, inertia, lack of motivation, and absence of emotional responsivity. Although there are also emotional and cognitive aspects of apathy, we have chosen to include apathy under behavioral disturbance, as the disengagement and lack of involvement is most distressing for caregivers. Apathy can be a symptom of depression, which is the most common presentation, or occur as an isolated syndrome. As with most psychiatric disturbances in TBI, only reviews, anecdotal reports, and small case series are available to guide management. Most of the literature favors methylphenidate. Based on this and on our clinical experience, we recommend methylphenidate as a first-line agent.

. Sleep disturbances are common after TBI and can occur in isolation or as a symptom of a psychiatric disorder. Insomnia is the most common sleep disturbance, seen in about 50% of patients with TBI, although other disturbances such as hypersomnia, sleep apnea, and sleepwalking may also be present. Treatment of TBI sleep disturbance varies according to the type of sleep disorder and related comorbidities. Comprehensive medical evaluation including an overnight sleep study can help with the diagnosis of sleep disturbance. Maintenance of sleep hygiene is always first in the management of sleep disturbances. When sleep disturbance is comorbid with a psychiatric disorder, it is important to treat the underlying psychiatric disorder.

When insomnia occurs in isolation, consider use of a non-benzodiazepine hypnotic such as zolpidem for a short period. Other agents such as melatonin, amitriptyline, lorazepam, and zopiclone may also be considered. Benzodiazepines should be avoided secondary to risk for addiction, motor and cognitive adverse effects, and paradoxical rage outbursts. In patients with TBI who have excessive daytime sleepiness, sleep apnea should first be ruled out. Modafinil (100-400 mg) or armodafinil (150-300 mg) can be considered in patients with persistent and unexplainable daytime sleepiness.

. Other common behavior disturbances include impulsivity, aggression, and disinhibition. As with other psychiatric disturbances, management of post-TBI behavior problems should always be multifaceted. This includes a combination of environmental modification strategies, behavioral therapy, supportive therapy, family therapy, and pharmacotherapy. Medications should be based on presence of comorbid neuropsychiatric disturbances.

The constellation of cognitive impairments following TBI is variable and depends on the severity of the location of the injury on the brain. TBI can affect every cognitive domain, including attention, memory, visual-spatial processing, language, social cognition, and executive functioning.

The core intervention for cognitive impairments is cognitive rehabilitation, which includes use of remediation techniques and external strategies to help individuals compensate for the deficits. In addition to cognitive rehabilitation, there are some pharmacologic options for augmenting cognitive functioning. The three main classes of pharmacological agents utilized to treat the cognitive sequelae of TBI are psychostimulants, cholinergics, and NMDA receptor antagonists.

. Psychostimulant medications are commonly used to improve arousal/attention and related neurobehavioral symptoms after TBI. Methylphenidate is the first-line agent and most commonly used (5-40 mg/d). Methylphenidate may improve arousal, attention, and processing speed and general cognitive function in the subacute and chronic phase of injury. Lee and colleagues

 have also noted improvement in cognitive function and reduction in daytime sleepiness in addition to improvement in depression in persons with depression following TBI.

. Donepezil and rivastigmine have been studied for cholinergic augmentation following TBI. Donepezil is a centrally selective acetylcholinesterase inhibitor that has been may improve attention and memory during the subacute and chronic phase of injury and enhance sensory gating during the chronic TBI period. Rivastigmine, which inhibits both acetylcholinesterase and butyrylcholinesterase improved scores on the Hopkins Verbal Learning Test and the Cambridge Neuropsychological Test Automated Battery Rapid Visual Information Processing mean latency, but only in patients with severe memory impairment at baseline.

-methyl-D-aspartate (NMDA) receptor antagonists

Traumatic brain injury (TBI) is a public health epidemic. Psychiatric symptoms after TBI are not just common, but also troublesome.

Sandeep Vaishnavi, MD, PhD

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