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When humans are exposed to traumatic events that may or may not be sufficient enough to cause brain injury, many experience symptoms of post-traumatic anxiety and panic attacks. For example, motor vehicles accidents are a leading cause of post-traumatic stress disorder (PTSD) with a significant subgroup having persisting symptoms after a year (Mayou et al., 1997, 2002). They are also the leading cause of brain injury, particularly in younger adults (Langlois, 2003). Blast injury is another traumatic event that can cause brain injury from secondary or tertiary factors (see blast injury article) but can also cause one to be psychologically traumatized due to the threat to one’s life and/or physical integrity.
Too often, I encounter clinical situations where some health care providers have not specifically inquired into all posttraumatic stress disorder and panic attack symptoms in patients with a history of known or suspected mild traumatic brain injury (MTBI). On other occasions, some of the symptoms have been mentioned by the patient but the only diagnosis listed in the impression section is mild traumatic brain injury and “post concussion syndrome.” This is problematic since some of the signs and symptoms of PTSD in the Diagnostic and Statistical Manual of Mental Disorders-IV (APA, 1994) are identical to those of post-concussional disorder. Shared symptoms include irritability, sleep disturbance, and concentration problems. In addition, DSM-IV postconcussional disorder criteria include apathy and lack of spontaneity, which are very similar to the PTSD symptoms of restricted affect and diminished interest or participation in significant activities. Also, many patients with PTSD develop panic attacks. Dizziness is a symptom of panic attacks and is also a symptom of postconcussional disorder.
Whereas PTSD and panic attacks have enough research behind them to be considered legitimate diagnoses in DSM-IV, this is not the case for postconcussional disorder, which is listed in the section entitled “Criteria Sets and Axes Provided for Further Study.” According to the text, diagnoses are listed in that section because “…there was insufficient information to warrant inclusion of these proposals as official categories or axes in DSM-IV.” When considering this, clinicians need to be careful before telling patients that persisting symptoms after a known or suspected MTBI are caused by persisting effects of brain injury. In evaluating the possibility that other conditions may account for persisting symptoms, clinicians should routinely inquire about the presence of PTSD symptoms.
DSM-IV criteria for PTSD are as follows:
A. The person has been exposed to a traumatic event in which both of the following have been present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than 3 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With Delayed Onset: if onset of symptoms is at least 6 months after the stressor
Likewise, clinicians also should inquire about the presence of panic attacks symptoms.
DSM-IV criteria for panic attacks are as follows
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
1) palpitations, pounding heart, or accelerated heart rate
2) sweating
3) trembling or shaking
4) sensations of shortness of breath or smothering
5) feeling of choking
6) chest pain or discomfort
7) nausea or abdominal distress
8) feeling dizzy, unsteady, lightheaded, or faint
9) derealization (feelings of unreality) or depersonalization (being detached from oneself)
10) fear of losing control or going crazy
11) fear of dying
12) paresthesias (numbness or tingling sensations)
13) chills or hot flushes
When panic attacks recur and are followed by one month (or more) of one (or more) of the following, the person may be experiencing panic disorder: a) persistent concern about having additional panic attacks, b) worry about the implications of the panic attack or its consequences (e.g., losing control, having a heart attack, "going crazy"), and c) a significant change in behavior related to the attacks. To conclude someone is having panic attacks, one needs to rule out that the symptoms are not due to a general medical condition, the effects of a substance (e.g., drug abuse, medications), or another mental disorder.
Lastly, the clinical should also explore whether the patient is experiencing agoraphobia, which often co-occurs with panic disorder. In agoraphobia, there is anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd, or standing in a line; being on a bridge; and travelling in a bus, train, or automobile. The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion. Of course, the anxiety and phobic avoidance cannot be explained by another mental disorder to be diagnosed as agoraphobia.
If symptoms of PTSD, panic disorder, panic attacks, and/or agoraphobia are overlooked/ignored, an overemphasis can be placed on a brain injury diagnosis which may be inaccurate. When this happens, patients can continue to suffer with an anxiety-based condition (i.e., PTSD) that is generally responsive to treatment. In addition, patients may continue to incorrectly believe that symptoms of these anxiety-based disorders are actually brain injury symptoms. The symptoms will likely worsen over time because the anxiety condition remains untreated, whereas TBI symptoms should generally improve over time. This can lead to situations where clinicians misinterpret severe psychiatric symptoms as signs of “severe” brain injury when all objective evidence points to the brain injury as being mild. Of course, mild traumatic brain injury and anxiety-based conditions can co-occur but an early focus should be on identifying and treating anxiety based disorders (and depressive disorders) to improve outcome.
REFERENCES
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association.
Langlois, J.A. (2003). Traumatic Brain Injury-Related Hospital Discharges Results from a 14-State Surveillance System, 1997. Morbidity and Mortality Weekly Report. June 27, 2003, 52, No. SS-4, 1-20.
Mayou, R. A., et al. (1997). Long term outcome of motor vehicle accident injury. Psychosomatic Medicine, 59, 365–368.
Mayou, R.A., et al. (2002). Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study. Behaviour Research and Therapy, 40, 665–675
Dr. Carone Copyright © 2009, MTBIFacts.com.
New Advances allow detection of mental disorders which can arise from traumatic brain injury.
