Page 75 - Journal of Special Operations Medicine - Winter 2015

“The essential feature of post traumatic stress disorder of a TBI. Depending on how the physician interprets
(PTSD) is the development of characteristic symptoms the symptoms, memories, and findings of a patient, the
following exposure to one or more traumatic events.” memory of the trauma may be interpreted as intrusive.
4
The requirement for a traumatic event for PTSD is im- The remainder of the criteria required for a diagnosis of
portant, but vague. “Traumatic event” is a ubiquitous PTSD are listed in the PTSD section of this article.
definition for a broad set of conditions. A wide variety
of traumatic events can cause stress and produce PTSD Finally, duration and functional significance are direct
symptoms: car accidents, exposure to combat, seeing overlaps between PTSD and TBI. It takes an involved
someone hurt, even being confronted with a phobia- and observant physician to discern the subtle differences
linked situation can be called a traumatic event and im- between PTSD and TBI. It also requires that the phy-
plicated as a cause of PTSD. Therefore, when applying sician be aware of her/his bias with regard to making
the term traumatic event to PTSD, having a bomb ex- diagnoses and to learn to ask the patient a simple ques-
plode nearby, being hit in the head with debris or getting tion: have you ever experienced one or more injuries
T-boned at an intersection can count toward PTSD. to your head or injuries to yourself that altered your
perception?
Unfortunately, all the conditions just described can also
result in a brain injury. Bomb blasts (with no direct head Currently, an ongoing debate within the psychiatric
injury), direct head hits, or getting thrown around a car community rests on the assumption that PTSD and TBI
(acceleration-deceleration injuries) produce concussive are two distinct conditions. The problem comes in sepa-
damage to the brain. Differentiating between PTSD and rating the physical damage portion from the behavioral
TBI is very difficult initially. Figure 3 compares PTSD to (emotional, cognitive process) damage. Case reports
TBI, side by side, and where they overlap. suggest that the links between physical damage and
PTSD are close, but decades of training and historic re-
Figure 3 Diagnostic overlap of symptoms and criteria porting instill in doctors the idea that PTSD occurs often
between PTSD and TBI/PCS. without a link to brain injury. It is time to reassess the
link between PTSD and TBI.

Summary of Diagnostic Overlap
Any concussive event, even if small and repetitive, such
as distant exposure to explosives, repetitive large-cal-
iber fire, improvised explosive devise, sports trauma
that results in violent collisions, or falling down, may
result in TBI. Evidence is now accumulating that re-
petitive head trauma, whether it is classified as a con-
cussive event or not, can result in TBI. LOC or being
stunned or dazed is not required. Even where stress-
ful events have occurred and are used to construct a
diagnosis of PTSD, the possibility of TBI cannot be
ignored and an appropriate diagnosis neglected. Gen-
eral memory problems, headaches, sleeplessness, light
sensitivity, and balance issues are byproducts of TBI,
not PTSD. Head injuries can develop into hormonal
disorders, 17,29–32 which can overlap with some PTSD
symptoms, but can lead to changes in blood pressure
regulation, disturbed sleep cycle, weight gain, and
fight-or-flight responses (panic attack). Then again,
DX, diagnosis; QOL, quality of life; PCS, postconcussion syndrome; the use of certain psychoactive compounds can induce
PTSD, posttraumatic stress disorder; TBI, traumatic brain injury. similar symptoms and physiological changes that are
identical to TBI and PTSD symptoms.
Traumatic events overlap, as indicated by DSM-IV cri-
teria (section A), but the next set of criteria for PTSD Unless diagnosed properly, psychoactive medications
(DSM-IV, B section) requires that the event be recalled for depression, anxiety, sleep, pain, and panic attacks
intrusively. With TBI, memory loss is common. Disori- can worsen these symptoms by further destabilizing the
entation or scattered recollection of the event can oc- neuronal networks that regulate hormonal balance. Fur-
cur with TBI, but intrusive thoughts are not a hallmark thermore, many psychoactive medications can lead to

PTSD Versus TBI 63