Can someone have post traumatic stress disorder and mild traumatic brain injury at the same time from the same event?  Some experts say no while others say yes.

Approximately 7.7 million Americans suffer from PTSD, according to recent population-based survey research. The most common causes of PTSD in the civilian sector are motor vehicle crashes and assaults (including domestic violence and rape), with women approximately
twice as likely as men to suffer from PTSD.

Surveys of military personnel returning from deployments to Iraq and Afghanistan find prevalence rates of PTSD ranging from 8% to 16%; it is likely that these rates are underestimates, given the many barriers to reporting mental health problems in the military . Approximately 15% of
these veterans seeking care at Veterans Administration hospitals in the United States have been given a diagnosis of PTSD.

One train of thought says that in order to have post traumatic stress disorder you must remember the traumatic event.  Indeed it is the very memory of the event that causes the post traumatic stress.  Yet others opine that mild traumatic brain injury must involve some loss of consciousness and therefore memory of the event is missing.  Hence you can not have mild traumatic brain injury and post traumatic stress disorder.  However the fact of realizing what happened when revived leaves the post traumatic stress question wide open for discussion.

An estimated 1.5 million brain injuries occur every year in the United States, and over 5 million Americans (2% of the population) live with disabilities resulting from TBI. In the civilian sector, the leading causes of TBI are falls, motor vehicle crashes, struck-by-or-against events, and assaults . Interestingly, motor vehicle crashes and assaults are also two of the most common causes of PTSD in the U.S. civilian population, highlighting the overlap in exposures to TBI- and PTSD-causative events.

In the U.S. military, TBI is the most common type of physical injury sustained by combatants in Afghanistan and Iraq, and explosion or blast injury is the most common cause. In a 2006 survey of more than 2,500 recently returned army infantry soldiers, 5% reported injuries with loss of consciousness during a yearlong deployment to Iraq, and 10% reported injuries with altered mental status. A recent RAND report suggested even higher rates of probable TBI in a 2007 telephone survey of almost 2,000 previously deployed service personnel. A similarly high rate (23%) of clinician-confirmed TBI history in a U.S. Army brigade combat team with at least one deployment corroborates these findings.

 It is important clinically to recognize that both disorders are associated with higher rates of other psychological health problems, including depression, substance abuse, and suicidal behavior in both civilian and military populations . Furthermore, the presence of these comorbid conditions may have an impact on conventional treatments, lending additional impetus to the need to understand these interactions more completely.

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 Depression in traumatic brain injury cases is a classic symptom. Traumatic brain injury is associated with an increase in the relative risk of developing a variety of psychiatric
disorders, particularly depression and cognitive impairment.

This relationship is best understood in the context of both the neuropathophysiology and the typical profile of regional brain injury associated with biomechanical trauma. The disturbance of brain function from MTBI is related more to dysfunction of brain metabolism rather than to structural injury or damage. The current understanding of the underlying pathology of MTBI involves a paradigm shift away from a focus on anatomic damage to an emphasis on neuronal dysfunction involving a complex cascade of ionic, metabolic and physiologic events. Clinical signs and symptoms of MTBI such as poor memory, speed of processing, fatigue, and dizziness result from this underlying neurometabolic cascade.

The relationship is further understood as the psychosocial sequelae that often follow the injury and their attendant effects on social, vocational, and family functioning. Thus, in many ways TBI
is a prototypical neuropsychiatric disorder.

There remains much that is incompletely understood about neuropsychiatric and functional outcome after TBI. Individuals may have disparate long-term outcomes after seemingly similar injuries. Probable contributors to this variance include preinjury host factors, injury-specific
biomechanics, and genetic factors.  Further investigation of these matters is needed to improve our ability to understand, identify, and more effectively treat those individuals at risk for poor outcomes following mild TBI.

Currently, a multidimensional approach is critical to the assessment and treatment of the neuropsychiatric sequelae of mild TBI. The most important initial step is accurate diagnosis, which can be challenging in cases of mild TBI. A combination of psychotherapeutic and
pharmacologic interventions can alleviate many symptoms, and improved quality of life for persons with TBI and their families can be achieved.

Psychiatrists, armed with a neuropsychiatric approach to mild TBI, are critical members of the health care team attending to persons with mild TBI and have an important role in the
management of this significant public health problem.

I typically involve a psychiatrist in the treatment team, along with a neurologist, neuropsychologist, neuroradiologist, and others in my cases.

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 Guidelines to Buying the Right Car Insurance in Nevada

               I frequently counsel people about what the appropriate car insurance coverage is after a car accident. Far too many times coverage is inadequate when an accident happens. Since it is the coverage that is in effect on the date of the accident that applies, I counsel clients about coverage after it is too late.

               I always go over what changes should be made for the future but, as I say, this does not apply to the accident before the changes. This article is written to provide guidance when considering what insurance coverage to buy now – before an accident.

               We must first draw a distinction between those from whom you may receive advice: the insurance agent, the insurance adjuster, and the lawyer. The attorney will have the best perspective.

Insurance Agent

               An insurance agent sells you your “insurance policy.” She represents the insurance company and herself. The incentive for the agent is to sell you insurance and make money doing it. She must adhere to guidelines set by the insurance company regarding malpractice. They are typically the least informed about legal repercussion concerning coverage.

Insurance Adjuster

               The insurance adjuster represents the insurance company. Plain and simple: not you. The adjuster evaluates and investigates claims. Their incentive is to keep claim payments low. Indeed they may get bonuses based on how low they keep payment of claims. They too must adhere to guidelines set by the insurance company which should be governed by law. They frequently receive legal opinions regarding how they handle claims. They have a working knowledge of legal issues.

Attorney

               The attorney represents the client’s interest. The attorney you retain to assist you with your claim has a legal fiduciary duty to represent your best interests. He will evaluate, investigate, and advise you about your claim and potential lawsuit. He should be well versed in insurance law and coverage issues. He is also guided by a canon of ethics. 

               The point in distinguishing the agent, adjuster, and attorney is to illustrate that the individual who sells you an insurance policy, the agent, is not most informed about coverage issues. The agent does not deal with claims to collect benefits after an accident. The adjuster does that. But the adjuster represents the insurance company – not you! Therefore you need to know what coverage to purchase and not blindly rely on what the agent or adjuster tells you. The attorney is best trained in this area.

               The following explanation is broken down as follows:

I.               Bodily Injury

a.    Liability insurance protects the other driver

b.    Insurance that protects you:

                                                                                 i.     Medical Payment (Med Pay)

                                                                              ii.     Uninsured/Underinsured Motorist (UM/UIM)

II.            Property damage and other expenses

a.    Property damage

b.    Collision

c.    Rental

I.               Bodily Injury

a.    Liability Insurance protects the other driver

Nevada law requires each driver have a minimum of $15,000 per person and $30,000 per accident “liability coverage.” This means all, non-fault, injured people in an accident can collect a total of $30,000 where no one person collects more than $15,000. Liability coverage costs the most – it has the highest premium – and for good reason: the insurance company charges the most for what you are required by law to purchase. Insurance companies charge less for coverage you are not required to purchase. If they charged more for coverage you are not required to purchase more insureds would opt out of purchasing additional coverage. If the insurance company sells less, they lower their profit.

It is very important to understand that liability coverage protects other, non-fault drivers. In other words, if you cause an accident, the other driver collects from your liability coverage. The more coverage you have, and you can typically buy up to $100,000, the more that is available to the other driver. You never collect from your liability coverage. We will examine the advantages to carrying more liability coverage when we discuss uninsured/underinsured (UM/UIM) coverage below.

Nevada law also requires that you carry property damage. This coverage applies to the car and other property damage to the other vehicle. Your property damage is not paid for under this portion of your policy.

b.    Insurance that Protects You

                                                                                 i.     Medical Payment (Med Pay)

Agents may advise their clients to forego getting optional Med Pay coverage especially if they have health insurance. This is bad advice. While coverage may apply through your health insurance to pay for your medical bills, those companies more times than not require reimbursement from any money received for the accident from the other driver’s insurance company. This is called subrogation.

Conversely, Med Pay does not require reimbursement. Therefore, the insured receives full Med Pay from their insurance policy benefits and recovers from the other driver’s insurance (assuming the other driver has liability coverage).

Finally, Med Pay is a relatively inexpensive premium and form of health insurance and, for the benefits availed, outweighs the increase in premium. Med Pay benefits offered to an insured vary but can range from $1,000 to $100,000.

                                                                     ii.     Uninsured/Underinsured Motorist Coverage (UM/UIM)

In the event a driver is driving unlawfully, with no insurance, or carries minimal and inadequate coverage, you can recover from the UM/UIM portion of your policy.

This is very important coverage to have and is frequently over looked and not purchased. Here is why that is a very dangerous choice.

Suppose, for example, that a mother and her two children are coming home after grocery shopping and are stopped at a red light at a busy intersection. Suddenly there is collision in front of them resulting in one care flipping and crushing the front hood of the car that mom and the two kids are in. One of the children’s feet is crushed and the mother receives glass in her fact resulting in blindness.

Now suppose there is $100,000/$300,000 liability coverage on mom’s car and 0 UM/UIM coverage, and 0 Med Pay. The other driver carries the state law minimum liability coverage of $15,000 per person and $30,000 per accident.

This results in distributing $30,000 to all injured people (save the at-fault driver). Assuming no one else is hurt, that means mom and child collect $15,000 from the other driver’s liability policy; this is obviously inadequate compensation for the injuries. Had mom also purchased UM/UIM she would have availed herself and her child that extra coverage – up to $100,000. The same is true for Med Pay; that money would have gone to pay medical bills.

It is important to realize that going after the at-fault driver personally (that is, after collecting from his insurance) will typically result in bankruptcy protection and most attorneys will not pursue that course of action.

Protecting yourself with adequate coverage is very important. Planning insurance coverage is prudent because we cannot plan accidents. UM/UIM benefits typically range from $15,000 to $100,000 per person and $30,000 to $300,000 per accident.

As pointed out earlier, there are advantages to having more liability coverage; one of them is to avail higher UM/UIM coverage. Nevada allows insurance companies to limit the amount of insurance that protects you in an accident – UM/UIM – to the amount of coverage you purchase that protects other drivers – liability. You can only have as much UM/UIM as you have liability coverage. In other words, you cannot have $15,000 liability and $100,000 UIM; although, since UM/UIM is much cheaper and protects you, that would be desirable. You can, however, have $100,000 liability and $15,000 UM/UIM; this results in higher premiums for liability coverage and decreased protection.

You want to be sure to carry as much UM/UIM coverage as liability coverage. That is all you can have; it’s cheaper and it protects you. This is why you should consider higher liability coverage; to be allowed to buy more UM/UIM.

II.            Property Damage and Other Expenses

a.   Property Damage

Property damage is included with liability coverage. In other words, when you purchase mandatory liability coverage, property damage is included. For example, “15/30/10 is injury coverage of $15,000 per person, $30,000 per accident, and $10,000 property damage. This coverage, like liability, protects the other person’s car when you are at fault.

It is important to distinguish property damage from personal injury coverage. Very often people will consider themselves “fully covered.” What they are saying is that their car is fully covered; meanwhile their bodies and injuries are not.

b.    Collision

This coverage you can opt to buy. The cost depends on the deductible you choose, the value of the car you are insuring and your driving records, among other things. This coverage protects your car regardless of fault.

c.    Rental

The other at-fault driver’s insurance company is responsible for your rental costs where no dispute exists and the losses are reasonable. This may take a while to determine, in terms of days or weeks, pending the insurance company’s investigation.

If you opt to buy rental coverage, you can have a car immediately and let your insurance company worry about collecting from the at-fault driver’s insurance company.

Conclusion

     Since we do not plan for accidents, the only thing we can do to avoid tragedy as much as possible is to plan our insurance coverage. Nevada embodies an insurance system that entitles you to purchase different coverage.

       If you would like further explanation of the types of coverage you ought to have to protect you and your family, or if you are currently in a dispute with an insurance company regarding coverage, you can contact me, Tim Titolo at tim@titololawoffice.com or 702.869.5100.

       My web site is http://www.titololawoffice.com. I also publish several blogs. The Brain and Spine Injury Law Blog, Truck Accident Blog, Las Vegas Injury Attorney Blog, and Tim Titolo. You can visit any of these sites and get a good idea of the type of cases I handle regularly. You can also get to know me by seeing and hearing me. 

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The Brain Injury Association of America published its position paper on the definition of traumatic brain injury entitled Conceptualizing Brain Injury as a Chronic Disease.  The organization tasked with providing legislation and lobbying for victims of traumatic brain injury, published its paper in 2009.

The gist of the paper is that traumatic brain injury is not an event but a process. 

• MORTALITY - The paper states that individuals with a TBI were twice as likely to die as a similar non-brain injured cohort and had a life expectancy reduction of seven years.
• ETIOLOGY - There is an indirect effect on other organs from traumatic brain injury.
• MORBIDITY - Individuals with a TBI are 1.5-17 times (depending on the severity of the TBI) more likely than the general population to develop seizures.  Chances of getting epilepsy after traumatic brain injury increase and account for 5% of all epilepsy in the general population.
• INCONTINENCE
• PSYCHIATRIC DISEASE
• SEXUAL DYSFUNCTION
• MUSCULOSKELETAL DYSFUNCTION
   

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 Traumatic Brain Injury has significant and distinct psychiatric effects.  The following is a brief discussion of what those effects can be:

• Loss of consciousness - Can be either brief or protracted. On recovery of consciousness, patients develop confusion, agitation, disorientation and delirium.

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 Center for Disease Control Reports Increase in Traumatic Brain Injury Related to Youth Sports

The number of youth sports related traumatic brain injury has increased 60% in young athletes.  The report by the Centers for Disease Control attributes the increase, in part, to greater public awareness.

Traumatic brain injuries (TBIs) from participation in sports and recreation activities have received increased public awareness, with many states and the federal government considering or implementing laws directing the response to suspected brain injury.

Fellow Brain Injury Blogger, Michael Kaplen, reports on traumatic brain injury issues in athletes regularly.

Bicycling, football, and playground activities account for greatest increase

Emergency department visits for sports– and recreation–related traumatic brain injuries, including concussions, among children and adolescents increased by 60 percent during the last decade, according to a report by the Centers for Disease Control and Prevention. CDC experts believe much of the increase occurred because more adults realized the youngsters needed to be seen by health care providers.

Traumatic brain injuries, or TBIs, rose from 153,375 in 2001 to 248,418 in 2009, said the analysis in CDC′s Morbidity and Mortality Weekly Report. Bicycling, football, playground activities, basketball, and soccer were the primary sports involved, the study said.

If you have a child playing sports in school, check to see if the coach has basic understanding of Traumatic Brain Injury Protocol.  Knowing when not to put your child back into play may be the difference between recovery and injury.

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