Applying a traumatic stress approach to understanding PCS following pediatric mild TBI

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children’s posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.     

Using Cognitive Processing Therapy–Cognitive in a Residential Treatment Setting With an OIF Veteran With PTSD and a History of Severe Traumatic Brain Injury: A Case Study

The co-occurrence of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) is common among military personnel returning from deployments in Iraq and Afghanistan. Despite the prevalence, scant evidence exists to inform clinicians as how to best treat these individuals, particularly for individuals with PTSD and a history of severe TBI. This case study presents the course of treatment in a VA residential PTSD/TBI program for an Operation Iraqi Freedom Veteran with PTSD, a history of severe TBI, and other psychiatric comorbidities. Cognitive Processing Therapy–Cognitive (CPT-C) was utilized as the primary PTSD treatment in conjunction with ancillary treatment. Data obtained during and following treatment suggest that CPT-C, without modifications to the protocol, offered within a residential treatment program may be an effective treatment for veterans with PTSD and a history of severe TBI.     

The syndrome of traumatic grief

Traumatic grief is a common and debilitating syndrome whose clinical presentation is well recognized but whose diagnostic criteria have only recently been delineated. Though it shares features with major depressive disorder, adjustment disorder, and posttraumatic stress disorder, none of these subsume the criteria set for traumatic grief, and the diagnostic overlap is limited in community samples. Furthermore, diagnosis of traumatic grief appears to have prognostic value for clinical course and treatment response among bereaved individuals. In the absence of empirically supported treatments of pathological grief, a new, manualized treatment for traumatic grief symptoms has been developed and is currently undergoing testing in a randomized controlled trial. The conceptual basis for Traumatic Grief Treatment (TGT) is presented, the structure of the treatment is outlined, and the primary clinical strategies employed are described.     

Latent classes of posttraumatic stress and growth

Background and Objectives: Potentially traumatic events may lead to different patterns of posttraumatic stress symptoms and posttraumatic growth. The objective of the present study was to identify subgroups with different patterns of posttraumatic reactions, and to determine whether these subgroups differed in terms of personal and social resources and indicators of adjustment. Design: This study used survey data collected 10 months after the 2011 Oslo bombing attack to investigate patterns of reactions among ministerial employees (N = 1970). Methods: We applied latent class analyses with covariates to extract subgroups of individuals. Results: Three classes of individual reactions were extracted, and these were similar among those who were and those who were not physically proximate to the bombing attack: “High stress/high growth” (27% and 11%, respectively), “Low stress/high growth” (74% and 42%, respectively), and “Low stress/low growth” (only among the not physically proximate: 47%). The classes differed in terms of gender, neuroticism, and social support as well as life satisfaction and daily functioning. Conclusions: Heterogeneous patterns of posttraumatic reactions were found. Physical proximity is not necessary to experience posttraumatic stress or growth after political violence. Among individuals with low stress, posttraumatic growth may not encompass higher life satisfaction or functioning.     

Cognitive Behavioral Treatment of PTSD with Comorbid Panic Attacks

Many individuals that experience traumatic events such as sexual and physical assault develop posttraumatic stress disorder (PTSD). More recently, research has indicated that a significant proportion of PTSD sufferers may also have comorbid panic attacks. Although there are several effective treatments that focus on alleviating PTSD symptoms, until now there were no treatments that focused on also treating comorbid panic attacks. Multiple channel exposure therapy (M-CET) is the first treatment developed to specifically treat comorbid PTSD and panic attacks. It is also unique in that it has been used to treat women who have multiple trauma histories as well as a wide range of different types of traumatic event exposure in a group format. This treatment is described in a session by session format and special considerations in implementing the treatment are discussed.     

Adaptive disclosure: an open trial of a novel exposure-based intervention for service members with combat-related psychological stress injuries

We evaluated the preliminary effectiveness of a novel intervention that was developed to address combat stress injuries in active-duty military personnel. Adaptive disclosure (AD) is relatively brief to accommodate the busy schedules of active-duty service members while training for future deployments. Further, AD takes into account unique aspects of the phenomenology of military service in war in order to address difficulties such as moral injury and traumatic loss that may not receive adequate and explicit attention by conventional treatments that primarily address fear-inducing life-threatening experiences and sequelae. In this program development and evaluation open trial, 44 marines received AD while in garrison. It was well tolerated and, despite the brief treatment duration, promoted significant reductions in PTSD, depression, negative posttraumatic appraisals, and was also associated with increases in posttraumatic growth.     

Examining the role of emotional avoidance in the relationship between posttraumatic stress disorder symptom severity and worry

A growing body of literature suggests that worry is a cognitive activity functioning to avoid unpleasant internal experiences such as negative thoughts, emotions, and somatic responses. Given the highly aversive internal events associated with posttraumatic stress disorder (PTSD), individuals experiencing PTSD symptoms following exposure to a traumatic event may be particularly motivated to engage in avoidant regulation strategies such as worry. Surprisingly, however, few studies to date have examined the relationship between PTSD and worry as well as potential factors that might explain this association. Therefore, the goal of this study was to examine the association between PTSD symptom severity and worry and the extent to which emotional avoidance explains this relationship. To this end, 207 college students with a history of traumatic exposure (meeting Criterion A for a PTSD diagnosis) completed a series of questionnaires assessing history of exposure to potentially traumatic events, PTSD symptom severity, emotional avoidance tendencies, and worry. Results demonstrated that PTSD symptom severity was positively associated with worry and emotional avoidance. Further, emotional avoidance was found to fully account for this relationship, providing support for the proposed emotionally avoidant function of worry. The implications of these findings for future research and the treatment of worry among individuals with a history of traumatic exposure are discussed.     

Mild Traumatic Brain Injury and Posttraumatic Stress Disorder in Returning Iraq and Afghanistan War Veterans: Implications for Assessment and Diagnosis

Mild traumatic brain injury (MTBI) and posttraumatic stress disorder (PTSD) are considered the “signature injuries” of combat soldiers returning from Iraq and Afghanistan. Both disorders can greatly affect the functioning of soldiers, yet the disorders often go undetected or are misdiagnosed by both military and civilian health care providers. This article provides information about MTBI and PTSD in returning combat soldiers along with implications for assessment and diagnosis.     

The effects of torture-related injuries on long-term psychological distress in a Punjabi Sikh sample

Torture survivors often report chronic debilitating physical and psychological distress. Prior research on the relationship between physical and psychological trauma suggests that the 2 are not independent. Injury sustained during torture may increase the likelihood of subsequent distress as either a moderator or mediator. For long-term psychopathology in a sample of Punjabi Sikh survivors of human rights violations (N = 116), chronic injuries mediated the path between torture and posttraumatic stress disorder, specifically the severity of numbing symptoms. Although injuries were associated with major depression, torture was not, and injuries did not moderate the relationship between major depression and torture. Chronic injuries may represent trauma severity or persistent traumatic cues. These findings emphasize connections between physical and psychological trauma and the importance of an interdisciplinary approach to torture treatment.     

Pharmacotherapy of posttraumatic cognitive impairments

Pharmacotherapy may contribute to the rehabilitation of persons with posttraumatic cognitive impairments. This article reviews first the neurobiological consequences of traumatic brain injury with a particular emphasis on acute and long-term posttraumatic neurochemical disturbances. Studies of pharmacotherapies for posttraumatic cognitive impairments are reviewed next, and are organized according to medication class and the neurotransmitter system they affect most. Based on the evidence provided by that review, augmentation of posttraumatic cerebral catecholaminergic and cholinergic function are suggested as potentially useful neurochemical targets for pharmacologic intervention in this population. More specifically, it is suggested that persons with posttraumatic impairments in arousal, speed of processing, and possibly attention may benefit most from treatment with an agent that augments cerebral catecholaminergic function, and that persons whose predominant posttraumatic impairment is in the domain of memory may benefit most from treatment with cholinesterase inhibitors. Practical considerations regarding the use of pharmacotherapies for posttraumatic cognitive impairments are offered, and the need for additional research in this area is highlighted.     

Commentary on “Trauma to the Psyche and Soma”

This case report addresses assessment and treatment considerations for a patient suffering from posttraumatic stress disorder (PTSD) in the context of mild traumatic brain injury and ongoing pain. Management of this case is based on the application of evidence-based therapy, and of cognitive behaviour therapy, for PTSD reduction. Assessment and treatment approaches recognize that delivery of treatment requires modification to allow exposure therapy for individuals who are partially amnesic of their traumatic experience. Further, administering exposure and cognitive therapy for patients with cognitive impairment requires specific means of treatment delivery to allow adequate compliance with therapy tasks. This case highlights that evidence-based approaches can be usefully applied to complex presentations but they may require modifications that recognize obstacles associated with comorbid conditions.     

Does Traumatic Brain Injury Attenuate the Exposure Therapy Process?

Research indicates that exposure therapy is efficacious for combat-related posttraumatic stress disorder (PTSD) comorbid with traumatic brain injury (TBI) as is shown by reduced PTSD treatment outcome scores. What is unknown, however, is whether the process of fear extinction is attenuated in veterans with TBI history. Increased PTSD symptomatology and possible cognitive deficits associated with TBI sequelae may indicate additional or longer exposure sessions to achieve habituation and extinction comparable to individuals without TBI history. As such, a more extensive course of treatment may be necessary to achieve comparable PTSD treatment outcome scores for individuals with TBI history. Using a sample of veterans with combat-related PTSD, some of whom were comorbid for TBI, this study compared process variables considered relevant to successful treatment outcome in exposure therapy. Individuals with and without TBI demonstrated similar rates of fear activation, length and number of exposure sessions, within-session habituation, between-session habituation, and extinction rate; results remained consistent when controlling for differential PTSD symptomatology. Furthermore, results indicated that self-perception of executive dysfunction did not impact the exposure process. Results suggest that individuals with PTSD and TBI history engage successfully and no differently in the exposure therapy process as compared to individuals with PTSD alone. Findings further support exposure therapy as a first-line treatment for combat-related PTSD regardless of TBI history.     

The Going Gets Tough,So Let's Go Shopping: On Materialism,Coping, and Consumer Behaviors Under Traumatic Stress

This study investigated the way in which exposure to traumatic stress, posttraumatic reactions, and materialistic values impact coping and maladaptive consumption behaviors in a real-life traumatic situation. One hundred thirty-nine Israelis were sampled from a town under constant rocket fire (a high-stress environment), and 187 comparison respondents were sampled from a low-stress location. Our data show a main effect for materialism for all of the distress and maladaptive consumer behaviors under study, as well as for most coping behaviors with the exception of interpersonal expressive coping. In the high-stress group, interpersonal expressive coping, reflecting an inclination to utilize social support, was highest among mildly materialistic individuals. Highly materialistic persons were, presumably, more oriented to objects than humans, rendering a more support-seeking way of coping less relevant for them. Highly materialistic participants in the high-stress group reported the highest levels of posttraumatic stress symptoms. The results of this study also suggest that the pleasures of shopping cannot attenuate posttraumatic distress and that maladaptive shopping behaviors increase with the level of traumatic exposure.     

Measures of prefrontal system dysfunction in posttraumatic stress disorder

Clinical observations have suggested that individuals who have suffered traumatic stressful events exhibit disruption in abilities mediated by frontal brain systems. Therefore, this study employed tasks sensitive to frontal lobe dysfunction, including delayed response (DR), delayed alternation (DA), object alternation (OA), delayed matching-to-sample (DMTS), and delayed nonmatching-to-sample (DNMTS), with participants having posttraumatic stress disorder (PTSD). Compared to controls, the PTSD participants were unimpaired on DA and DMTS, but they showed deficits on DR, OA, and DNMTS tasks. This pattern of results suggests disruption of functioning in selective prefrontal brain systems. Results are discussed in the context of the neuropsychological features of PTSD, as well as possible neuropathological and etiological underpinnings of this disorder.     

Self-Report Measures to Identify Post Traumatic Stress Disorder and/or Mild Traumatic Brain Injury and Associated Symptoms in Military Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)

Individuals serving in Iraq and Afghanistan sustain injuries associated with physical and psychological trauma. Among such injuries, mild traumatic brain injury (mTBI) and post traumatic stress disorder (PTSD) are common. Self-report measures are frequently used to identify mTBI and/or PTSD and symptoms associated with these conditions. In addition to providing information regarding mTBI and PTSD, the goal of this literature review was to identify and present information on the psychometric properties of measures used to obtain information regarding these common conditions among Veterans who have returned from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). A comprehensive review of studies in which self-report measures were used to evaluate mTBI, PTSD, and associated symptoms among OEF/OIF Veterans is presented. Findings suggest that additional work is needed to identify psychometrically sound and clinically useful self-report measures that assess mTBI and PTSD and associated symptoms among OEF/OIF Veterans.     

Complicating Factors Associated with Mild Traumatic Brain Injury: Impact on Pain and Posttraumatic Stress Disorder Treatment

The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.     

Severe traumatic brain injury: some effects on family caregivers

This study assesses the effects of severe traumatic brain injuries on family members and functioning-a topic of interest for those working with survivors and their families. This issue is receiving increased attention as recent findings suggest that family adjustment influences outcome for brain-injured persons. The Family Environment Scale and the Profile of Mood States were completed by 25 individuals who had a family member with a severe traumatic brain injury. These scales were also completed by a comparison group of 32 individuals who had no brain-injured family member. In terms of family functioning, the findings suggest that, when a family member suffers a severe traumatic brain injury, depression may be elevated, along with a decreased ability to express feelings, decreased time and energy for social and recreational activities, and increased control in comparison to families without a brain-injured member. While this might contribute to family isolation which could last for many years, the overall finding of the present study was that caregiver families were coping adequately.     

Trauma-Focused CBT in the Context of Parental Chronic Medical Conditions: A Case Report

Parental chronic medical conditions (CMCs) are relatively common and have been shown to impact children’s psychosocial functioning. Previous research suggests that, for some youth, parental CMCs may be conceptualized as a form of traumatic stress. Trauma-focused cognitive behavioral therapy (TF-CBT) is a multicomponent, evidence-based intervention that is designed to reduce symptoms of posttraumatic stress, depression, and anxiety, as well as behavioral problems, among children and adolescents. Despite its robust empirical support, however, no known studies have utilized this treatment approach to address the mental health needs of youth affected by parental CMCs. The purpose of this article is to describe the application of TF-CBT to treat an adolescent male whose mother was diagnosed with a CMC, which had resulted in continuous family stressors since his birth. Results suggest that TF-CBT offers a promising approach for treating symptoms of posttraumatic stress, anxiety, and depression among children of parents with CMCs, and clinical trials to investigate its effectiveness among this population may be warranted.     

Psychobiological Treatment Response to a Two-Week Posttraumatic Stress Disorder and Mild Traumatic Brain Injury Integrated Treatment Program: A Case Report

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) demonstrate high prevalence and comorbidity among post-9/11 veterans. Veterans with this comorbidity often present with multiple co-occurring healthcare needs and increased clinical complexity. The current case report describes the clinical presentation of a veteran with mild TBI and PTSD, both before, during, and after treatment within a multidisciplinary 2-week intensive outpatient program involving prolonged exposure, evidence-based PTSD treatment, and Cognitive Symptom Management and Rehabilitation Therapy, evidence-based treatment for postconcussive symptoms. Mr. A was a 25-year-old White, transgender male who presented with a complex mental health history. At intake, presenting complaints included anxiety, panic attacks, nightmares, and depression secondary to military sexual trauma, as well as reported cognitive difficulties secondary to a concussion. He met current criteria for PTSD as well as panic disorder with agoraphobia. Head injury history consisted of a motor vehicle collision with less than 30 seconds loss of consciousness, brief posttraumatic amnesia, and alterations of consciousness. Mr. A demonstrated habituation during individual exposure sessions as assessed via skin conductance during imaginal exposures and decreased subjective ratings during in vivo exposures, as well as a decrease in trauma-potentiated startle response to trauma cues. Posttreatment data indicates significant reduction in neurobehavioral, posttraumatic stress, and depression symptoms and significant improvement in subjective cognitive functioning. The current findings support the feasibility and efficacy of short-term integrated treatment for complex clinical presentations and the need for larger scale research investigating combined PTSD and TBI intervention.