Organic Brain Injury and/or Post Traumatic Stress Disorder
Emotional distress following a traumatic brain injury can be both real and debilitating. Often severe emotional distress will mimic many of the characteristics of organic brain dysfunction. However, the treatment differs in each case.
In litigation, it is common for insurance companies and their lawyers to contend that the dysfunction and deficits experienced by the victim did not result from the trauma, but from pre-existing emotional difficulties. This defense is standard in virtually all cases of mild traumatic brain injury. So, for purposes of treatment, and to prevail over unmeritorious defenses, it is important to understand the distinction between an organic brain injury and a debilitating emotional injury.
- (a) Post Traumatic Stress Syndrome. Perhaps the most common emotional injury following trauma is that of post traumatic stress disorder (PTSD). The most comprehensive definitions of PTSD can be found in the Diagnostic and Statistical Manual B IV (DSM IV).
"The essential feature of post traumatic distress disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate. The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re experiencing of the traumatic event, persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, and persistent symptoms of increased arousal. The full symptom picture must be present for more than one month, and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning."
Onset and duration of PTSD are classified into three general areas: (1) Acute when the duration of symptoms is less than three months; (2) Chronic when the symptoms last three months or longer; and (3) With Delayed Onset where at least six months have passed between the traumatic event and the onset of symptoms.
The traumatic events found sufficient to give rise to PTSD are not insignificant. These events include military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnaped, being taken hostage, terrorist attack, torture, and severe automobile accidents or other life threatening events.
Victims of PTSD often re-experience the traumatic event in various ways. The victim has recurrent and intrusive recollections of the event or recurrent distressing dreams during which the event is replayed. In certain rare instances, victims actually experience dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at the moment.
Avoidance is common for victims with PTSD. They tend to avoid anything associated with the trauma, making a conscious effort to avoid thinking about, experiencing feelings related to, or even talking about the traumatic event. Amnesia may even develop for some or all aspects of the trauma. Victims of PTSD often times become numb experiencing emotional anesthesia identified by decreased responsiveness to the external world.
Since the development of PTSD can be influenced by a victim's previous history, such as childhood upbringing, personality, pre existing mental problems, etc., insurance companies and their lawyers commonly methodically search for pre existing stressors, rather than the trauma itself, which could give rise to the claim. However, the severity, duration, and proximity of a victim's exposure to the traumatic event tend to be the most important factors affecting the likelihood of developing this disorder. Accordingly, competent neurophysiologists must spend considerable time analyzing all aspects of a victim's experience before diagnosis.
- (b) Organic Brain Injury. The Diagnostic and Statistical Manual B IV (DSM IV) describes underlying organic injury as dementia due to head trauma.
"Dementia Due to Head Trauma: The essential feature of Dementia Due to Head Trauma is the presence of a dementia that is judged to be the direct pathopsysiological consequence of head trauma. The degree and type of cognitive impairments or behavioral disturbances depend upon the location and the extent of the brain injury. Post traumatic amnesia is frequently present, along with persisting memory impairment. A variety of other behavioral symptoms may be evident, with or without the presence of motor or sensory deficits. These symptoms include aphasia, attentional problems, irritability, anxiety, depression or affective lability, apathy, increased aggression, or other changes in personality . . . ."
The neuropsychological assessment becomes key in distinguishing PTSD from organic brain dysfunction. Since the criteria for diagnosis of dementia requires impairment in occupational or social functioning, and since there must be a decline from a previously higher level of functioning, neuropsychological assessment greatly aids in the diagnostic process.
Generally, the cause of PTSD is thought to be functional or psychologically based. In contrast, the cause for organic brain injury involves an actual change in the brain tissue itself. Treatment modalities differ markedly between the two. PTSD is commonly treated through psychotherapy or through the use of medications to control anxiety and stress. Depending upon the preexisting characteristics of the individual, treatment for PTSD can be prolonged and the progression gradual.
In contrast, maximum recovery from organically based brain injury, at least in terms of thinking skills, typically occurs soon after the event in question, with gradual recovery continuing throughout the first year to two years post injury. Although technology changes with each day, treating cognitive problems due to brain tissue changes with medications has not proved highly fruitful thus far.
Perhaps the easiest way to determine whether a particular victim is suffering from PTSD B related symptoms only versus organically based brain impairments involves analyzing the overall pattern of neuropsychological assessment results. For example, if the victim demonstrates problems with motor or sensory abilities isolated on one side of the body or other abilities governed by one hemisphere of the brain, such injuries are more likely to be the result of actual organic brain damage than due to interference in efficiency of thinking due to PTSD or other emotional distress.
The problem is often not so clear. A victim may be experiencing both PTSD and organic brain injury. In these cases, a synergistic result can occur heightening dysfunction both in everyday life and on formal testing. Deficits can result from either organic brain injury or post traumatic stress syndrome. Neuropsychological assessment can do much to identify the etiology of the deficits thereby allowing prompt treatment to ensue.
Concussion in Sport
Concussion is defined as a traumatically induced alteration in mental status, not necessarily with loss of consciousness, and is a common form of sports related injury. Traumatic brain injury is common in contact sports, with an estimated 250,000 concussions and an average of eight deaths due to head injuries occurring every year in football alone. Twenty percent of football players suffer concussion during a single football season, and some more than once. Repeated concussions can lead to brain atrophy and cumulative neuropsychological deficits. Repeated concussions occurring within a short period can be fatal. Unfortunately, many physicians, coaches, athletes, and athletic trainers trivialize and dismiss the dangerous possibility of a traumatic brain injury and allow a hurt young person to continue to play. Repeated concussions can predispose the brain to vascular congestion from auto-regulatory dysfunction. The congestion leads to elevation of pressure and brain swelling.
Amnesia and confusion following an impact to the head are the hallmarks of concussion. Amnesia associated with concussion can be instantaneous, or delayed by several minutes. The delayed onset of amnesia or post concussion symptoms demonstrates a pathological process occurring gradually. This entire process is missed entirely if the athlete is returned to the event too early.
The Colorado Medical Society has established guidelines for the management of concussions in sports:
Grade No. 1: Confusion Without Amnesia, No Loss of Consciousness. Remove from contest. Examine immediately and every five minutes for the development of amnesia or post concussive symptoms at rest and with exertion. Permit to return to contest if amnesia does not appear and no symptoms appear for at least twenty minutes.
Grade No. 2: Confusion With Amnesia, No Loss of Consciousness. Remove from contest and disallow return. Examine frequently for signs of evolving intercranial pathology. Re examine the next day. Permit return to practice after one full week without symptoms.
Grade No. 3: Loss of Consciousness. Transport from field to nearest hospital by ambulance (with cervical spine immobilization if indicated). Perform thorough neurologic evaluation emergently. Admit to hospital if signs of pathology are detected. If findings are normal, instruct family for overnight observation. Permit return to practice only after two full weeks without symptoms.
Prolonged unconsciousness, persistent mental status alterations, worsening post concussion symptoms, or abnormalities on neurologic examination require urgent neurosurgical consultation or transfer to a trauma center
The primary concern is that those sustaining concussion during sports activity are immediately and promptly treated. The risk of second impact syndrome is significant and its consequences severe. In second impact syndrome the victim is thought to have sustained a second concussion while still symptomatic from an earlier concussion. The victim often suffers cerebral vascular congestion leading to malignant brain swelling and marked increase in intracranial pressure. Brain swelling is many times difficult, if not impossible, to control.
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