Page 73 - Journal of Special Operations Medicine - Winter 2015

6. Restricted range of affect (e.g., unable to have lov- requiring further study. No specific definition of mild,
ing feelings) moderate, or severe TBI is included, although individu-
7. Sense of foreshortened future (e.g., does not ex- als who have suffered significant cognitive, memory,
pect to have a career, marriage, children, or a nor- and other higher cognitive deficits as a consequence of
mal life span) a brain injury would be diagnosed as dementia due to
E. Hyperarousal: Persistent symptoms of increasing TBI. Less severely impacted TBIs would be classified as
arousal (must not be present before the trauma; at cognitive disorders.
least two symptoms must be present)
1. Difficulty falling or staying asleep The definition of a TBI in the DSM-IV is not as up to
2. Irritability or outbursts of anger date as the current standards used by the World Health
3. Difficulty concentrating Organization or the diagnostic criteria of the National
4. Hypervigilance Academy of Neuropsychology. The DMS-V has been
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5. Exaggerated startle response updated and recognizes major to mild NCD due to TBI.
F. Duration: Duration of the disturbance (symptoms in TBIs can be subdivided into mild, moderate, or severe
B, C, and D) is more than 1 month. and are dependent on Glasgow Coma Scale ratings.
G. Functional significance: The disturbance causes clini- Mild TBI (mTBI) is the most prevalent type of injury
cally significant distress or impairment in social, oc- (approximately 80% of all head injuries/concussions are
cupational or interpersonal activities. in this category) and the most easily missed by physi-
H. The disturbance (i.e., the PTSD symptoms) are not cians and healthcare personnel. In combat medicine
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attributed to the effects of drugs (prescription or oth- and emergency department situations, the prevailing
erwise) or other medical conditions. opinion seems to be that if you are not bleeding (too
much) or in danger of dying (immediately) and they
These criteria cover a lot of ground and require that a can’t find anything obviously wrong with you, you get
clinical practitioner rule out other causes before providing shoved out the door or further down the hall. Besides,
a diagnosis of PTSD. Many of the symptoms of PTSD are your platoon, unit, squad, or best friend is heading out
shared with certain strokes, pituitary dysfunction, thy- on mission . . . and it’s only a headache (with nausea or
17
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roid deficiencies, 18–20 , and major depressive disorders. ringing in the ears or some other annoying symptoms);
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At the time of the DSM-IV, the psychiatric community others have had it worse, right? mTBIs are routinely
was split (and some schools continue to be split) as to uncovered well after the fact (weeks, months, or years)
whether PTSD is purely an emotional/memory construct and sufferers just find a way to cope—until they cannot.
(a means to repress an unpleasant memory), a structural Unfortunately, TBIs are cumulative: the more you get,
brain damage that produces the symptoms of PTSD, or the worse you can potentially become.
whether PTSD and TBI can occur simultaneously, 14,22 The
recent consensus decisions that PTSD and TBI can occur A diagnosis of mTBI can be made when there is an in-
simultaneously was just recognized by the American Psy- jury to the head as a result of blunt trauma, acceleration
chiatric Association in the DSM-V. Diagnosis is further or deceleration forces, or exposure to blast effects that
obscured by the fact that the symptoms are purely sub- result in one or more of the following conditions 10,23 :
jective: there are no objective measures or verifications
required for the diagnosis (e.g., no blood biomarkers or A. Any period of observed or self-reported:
easily obtained brain scans). Therefore, an individual 1. transient confusion, disorientation, or impaired
could merely state certain things and walk away with consciousness
a diagnosis of PTSD. It takes the careful analysis of a 2. dysfunction of memory immediately before or af-
complete medical and experiential history, diagnostic ter the time of injury
laboratory tests (to rule out other causes), and interviews 3. loss of consciousness (LOC) lasting less than 30
to reach the diagnosis of PTSD. A PTSD diagnosis (or minutes
any diagnosis) requires a deliberate and detailed review B. Observed signs of neurological or neuropsychologi-
to rule out what it is not, as much as what it is. Given cal dysfunction, such as:
the high rate of prescription medication used by active 1. becoming fatigued easily
duty personnel, PTSD symptoms might appear due to the 2. disordered sleep
medication, confounding attempts to diagnose properly. 3. headache
4. vertigo or dizziness
5. irritability or aggression on little or no provocation
Traumatic Brain Injury
6. anxiety, depression, or affective liability
The DSM-IV had a limited classification system for con- 7. changes in personality (e.g., social or sexual
cussion, including postconcussional disorder (or post- inappropriateness)
concussion syndrome [PCS]) in a section of diagnoses 8. apathy or lack of spontaneity

PTSD Versus TBI 61