Post-traumatic stress disorder and traumatic brain injury

Improving Outcomes for Work-Related Concussions: A Mental Health Screening and Brief Therapy Model

OBJECTIVE

This study assessed the efficacy of a neurocognitive screening evaluation and brief therapy model to improve RTW outcomes for workers who experienced mild head injuries.

METHODS

Patients referred were evaluated using a neurocognitive and psychological screening battery. Work-focused cognitive behavioral therapy was provided when appropriate, addressing the role of negative emotional adjustment and functional sleep disturbance in prolonging recovery.

RESULTS

Average time to RTW was 7 weeks post-evaluation, despite workers being off an average of 10 months between injury and referral dates. Overall, 99% were released to full-duty work without restrictions or accommodations.

CONCLUSIONS

This study demonstrates the favorable outcomes achieved via a structured, clinically driven program for workers who experience head-involved injuries, validating previous research on the importance of recognizing the role of psychological factors in prolonging concussion recovery.

Traumatic brain injury and forensic evaluations: Three case studies of U.S. asylum-seekers

Traumatic brain injuries are common among refugees and asylum-seekers and can result from a range of etiologies, including intimate partner violence, gang violence, war-related trauma, and torture. Regardless of the cause, these injuries often result in a host of neuropsychiatric and other symptoms that may complicate individuals' subsequent health outcomes. For asylum-seekers, documenting prior head trauma is essential to the legal process, since traumatic brain injuries and their subsequent effects on memory and cognition may affect the ability to provide thorough testimony. Using three case vignettes, we explore how to approach the forensic evaluation of asylum-seekers with a history of traumatic brain injury, illustrating the range of etiologies and sequelae of traumatic brain injury in this complex population.

Social Emotional Learning Program Boosts Early Social and Behavioral Skills in Low-Income Urban Children

Social emotional learning (SEL) programs are increasingly being implemented in elementary schools to facilitate development of social competencies, decision-making skills, empathy, and emotion regulation and, in effect, prevent poor outcomes such as school failure, conduct problems, and eventual substance abuse. SEL programs are designed to foster these abilities in children with a wide range of behavioral, social, and learning needs in the classroom, including children who are economically disadvantaged. In a previous study of kindergartners residing in a high-poverty community (N = 327 at baseline), we observed significant behavioral improvements in children receiving an SEL program-The PATHS® curriculum (PATHS)-relative to an active control condition within one school year. The present investigation sought to determine whether these improvements were sustained over the course of two school years with intervention and an additional year when intervention was no longer provided. Further, using multilevel models, we examined whether baseline measures of neurocognition and stress physiology-known to be adversely impacted by poverty-moderated heterogeneous outcomes. Finally, a preliminary linear regression analysis explored whether neurocognition and physiological stress reactivity (heart rate variability, HRV) predict change in outcomes postintervention. Results confirmed that students who received PATHS sustained significant behavioral improvements over time. These effects occurred for the full sample, irrespective of putative baseline moderators, suggesting that children in high-risk environments may benefit from SEL interventions irrespective of baseline cognitive functioning as a function of overall substantial need. Of interest is that our exploratory analysis of change from waves three to four after the intervention concluded brought to light possible moderation by baseline physiology. Should subsequent studies confirm this finding, one plausible explanation may be that, when an intervention providing protective effects is withdrawn, children with higher HRV may not be able to regulate physiological stress responses to environmental challenges, leading to an uptick in maladaptive behaviors. In reverse, children with lower HRV-generally associated with poorer emotion regulation-may incur relatively greater gains in behavioral improvement due to lesser sensitivity to the environment, enabling them to continue to accrue benefits. Results are discussed in the context of possible pathways that may be relevant to understanding the special needs of children reared in very low-income, high-stress neighborhoods.

Laurent-Arriot K, Tsirka SE, Bergold PJ. Increased Behavioral Deficits and Inflammation in a Mouse Model of Co-Morbid Traumatic Brain Injury and Post-Traumatic Stress Disorder

Comorbid post-traumatic stress disorder with traumatic brain injury (TBI) produce more severe affective and cognitive deficits than PTSD or TBI alone. Both PTSD and TBI produce long-lasting neuroinflammation, which may be a key underlying mechanism of the deficits observed in co-morbid TBI/PTSD. We developed a model of co-morbid TBI/PTSD by combining the closed head (CHI) model of TBI with the chronic variable stress (CVS) model of PTSD and examined multiple behavioral and neuroinflammatory outcomes. Male C57/Bl6 mice received sham treatment, CHI, CVS, CHI then CVS (CHI → CVS) or CVS then CHI (CVS → CHI). The CVS → CHI group had deficits in Barnes maze or active place avoidance not seen in the other groups. The CVS → CHI, CVS and CHI → CVS groups displayed increased basal anxiety level, based on performance on elevated plus maze. The CVS → CHI had impaired performance on Barnes Maze, and Active Place Avoidance. These performance deficits were strongly correlated with increased hippocampal Iba-1 level an indication of activated MP/MG. These data suggest that greater cognitive deficits in the CVS → CHI group were due to increased inflammation. The increased deficits and neuroinflammation in the CVS → CHI group suggest that the order by which a subject experiences TBI and PTSD is a major determinant of the outcome of brain injury in co-morbid TBI/PTSD.

Post-traumatic stress disorder and self-reported outcomes after traumatic brain injury in victims of assault

Introduction

Assault is the third most common cause of traumatic brain injury (TBI), after falls and road traffic collisions. TBI can lead to multiple long-term physical, cognitive and emotional sequelae, including post-traumatic stress disorder (PTSD). Intentional violence may further compound the psychological trauma of the event, in a way that conventional outcome measures, like the Glasgow Outcome Scale (GOS), fail to capture. This study aims to examine the influence of assault on self-reported outcomes, including quality of life and symptoms of PTSD.

Methods

Questionnaire were completed by 256 patients attending a TBI clinic, including Quality of Life after Brain Injury (QOLIBRI) and PTSD checklist (PCL-C). Medical records provided demographics, clinical data and aetiology of injury. Subjective outcomes were compared between assault and other causes.

Results

Of 202 patients analysed, 21% sustained TBI from assault. There was no difference in severity of injuries between assault and non-assault groups. No relationship was found between self-reported outcomes and TBI severity or GOS. The assault group scored worse in all self-reported questionnaires, with statistically significant differences for measures of PTSD and post-concussion symptoms. However, using threshold scores, the prevalence of PTSD in assaulted patients was not higher than non-assault. After adjusting for age, ethnicity and the presence of extra-cranial trauma, assault did not have a significant effect on questionnaire scores. Exploratory analysis showed that assault and road traffic accidents were associated with significantly worse outcomes compared to falls.

Conclusion

Quality of life is significantly related to functional and psychological outcomes after TBI. Assaulted patients suffer from worse self-reported outcomes than other patients, but these differences were insignificant when adjusted for demographic factors. Intentionality behind the traumatic event is likely more important than cause alone. Differences in quality of life and other self-reported outcomes are not reflected by the Glasgow Outcome Scale. This information is useful in arranging earlier and targeted review and support.

Circulating insulin-like growth factor I modulates mood and is a biomarker of vulnerability to stress: from mouse to man

Individual susceptibility to anxiety disorders after maladaptive responses to stress is not well understood. We now report that while exploring stress responses in mice after traumatic brain injury (TBI), a condition associated to stress susceptibility, we observed that the anxiogenic effects of either TBI or exposure to life-threatening experiences (predator) were blocked when both stressors were combined. Because TBI increases the entrance into the brain of serum insulin-like growth factor I (IGF-I), a known modulator of anxiety with a wide range of concentrations in the human population, we then determined whether circulating IGF-I is related to anxiety measures. In mice, anxiety-like responses to predator were inversely related to circulating IGF-I levels. Other indicators of mood regulation such as sensitivity to dexamethasone suppression and expression levels of blood and brain FK506 binding protein 5 (FKBP5), a co-chaperone of the glucocorticoid receptor that regulates its activity, were also associated to circulating IGF-I. Indeed, brain FKBP5 expression in mice was stimulated by IGF-I. In addition, we observed in a large human cohort (n = 2686) a significant relationship between plasma IGF-I and exposure to recent stressful life events, while FKBP5 expression in blood cells was significantly associated to plasma IGF-I levels. Collectively, these data indicate that circulating IGF-I appears to be involved in mood homeostasis across different species. Furthermore, the data in mice allow us to indicate that IGF-I may be acting at least in part by modulating FKBP5 expression.

Novel therapies for combating chronic neuropathological sequelae of TBI

Traumatic brain injury (TBI) is a risk factor for development of chronic neurodegenerative disorders later in life. This review summarizes the current knowledge and concepts regarding the connection between long-term consequences of TBI and aging-associated neurodegenerative disorders including Alzheimer's disease (AD), chronic traumatic encephalopathy (CTE), and Parkinsonism, with implications for novel therapy targets. Several aggregation-prone proteins such as the amyloid-beta (Aβ) peptides, tau proteins, and α-synuclein protein are involved in secondary pathogenic cascades initiated by a TBI and are also major building blocks of the hallmark pathological lesions in chronic human neurodegenerative diseases with dementia. Impaired metabolism and degradation pathways of aggregation-prone proteins are discussed as potentially critical links between the long-term aftermath of TBI and chronic neurodegeneration. Utility and limitations of previous and current preclinical TBI models designed to study the link between TBI and chronic neurodegeneration, and promising intervention pharmacotherapies and non-pharmacologic strategies to break this link, are also summarized. Complexity of long-term neuropathological consequences of TBI is discussed, with a goal of guiding future preclinical studies and accelerating implementation of promising therapeutics into clinical trials. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".

Anxiety and Posttraumatic Stress Disorder Among Medicare Beneficiaries After Traumatic Brain Injury

OBJECTIVE

To estimate rates of anxiety and posttraumatic stress disorder (PTSD) diagnoses after traumatic brain injury (TBI) among Medicare beneficiaries, quantify the increase in rates relative to the pre-TBI period, and identify risk factors for diagnosis of anxiety and PTSD.

PARTICIPANTS

A total of 96 881 Medicare beneficiaries hospitalized with TBI between June 1, 2006 and May 31, 2010.

DESIGN

Retrospective cohort study.

MEASURES

Diagnosis of anxiety (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 300.0x) and/or PTSD (ICD-9-CM code 309.81).

RESULTS

After TBI, 16 519 (17%) beneficiaries were diagnosed with anxiety and 269 (0.3%) were diagnosed with PTSD. Rates of anxiety and PTSD diagnoses were highest in the first 5 months post-TBI and decreased over time. Pre-TBI diagnosis of anxiety disorder was significantly associated with post-TBI anxiety (risk ratio, 3.55; 95% confidence interval, 3.42-3.68) and pre-TBI diagnosis of PTSD was significantly associated with post-TBI PTSD (risk ratio 70.09; 95% confidence interval 56.29-111.12).

CONCLUSION

This study highlights the increased risk of anxiety and PTSD after TBI. Routine screening for anxiety and PTSD, especially during the first 5 months after TBI, may help clinicians identify these important and treatable conditions, especially among patients with a history of psychiatric illness.

High-Fidelity Measures of Whole-Brain Functional Connectivity and White Matter Integrity Mediate Relationships between Traumatic Brain Injury and Post-Traumatic Stress Disorder Symptoms

Traumatic brain injury (TBI) disrupts brain communication and increases risk for post-traumatic stress disorder (PTSD). However, mechanisms by which TBI-related disruption of brain communication confers PTSD risk have not been successfully elucidated in humans. This may be in part because functional MRI (fMRI), the most common technique for measuring functional brain communication, is unreliable for characterizing individual patients. However, this unreliability can be overcome with sufficient within-individual data. Here, we examined whether relationships could be observed among TBI, structural and functional brain connectivity, and PTSD severity by collecting ∼3.5 hours of resting-state fMRI and diffusion tensor imaging (DTI) data in each of 26 United States military veterans. We observed that a TBI history was associated with decreased whole-brain resting-state functional connectivity (RSFC), while the number of lifetime TBIs was associated with reduced whole-brain fractional anisotropy (FA). Both RSFC and FA explained independent variance in PTSD severity, with RSFC mediating the TBI-PTSD relationship. Finally, we showed that large amounts of per-individual data produced highly reliable RSFC measures, and that relationships among TBI, RSFC/FA, and PTSD could not be observed with typical data quantities. These results demonstrate links among TBI, brain connectivity, and PTSD severity, and illustrate the need for precise characterization of individual patients using high-data fMRI scanning.