It came to my attention last week that while I was blogging a series about Post Traumatic Stress Disorder during the month of February, there was something similar going on.  Dan Ball of Channel 3 News in Las Vegas (KSNV) was running a series on Post Traumatic Stress Disorder for soldiers returning from war.

You can see part 2 of his series on the Channel 3 website.  

The series concluded with a discussion of a Las Vegas District Court Judge's son, a career veteran, taking his own life due to the stress of the war and post trauma.  It is sad but worth taking the time to view since it demonstrates just how real this problem is.

There are several disorders associated with Traumatic Brain Injury (TBI). In representingpeople with Traumatic Brain Injury, I find some or more of the Disorders contribute to difficulty handling a case. For Instance, when communication is affected, it can make gathering specific facts hard. I occasionally see facts patterns change over time; like when a client begins to confabulate (to give fictitious accounts of past events, believing they are true, in order to cover a gap in the memory caused by a medical condition such as dementia or Post-Concussion Syndrome.) Or, when memory is impaired, there may be concerns about a client getting to work, doctor appointments, or other tasks.

Another difficulty is separating out symptoms of disorders from a person’s pre-existing propensity and personality. People or entities interested in someone NOT having a Neuropsychiatric Disorder, (ie. An insurance company, defense lawyer, defendant) will usually point to a person’s pre-existing personality as a basis to argue that any claimed Neuropsychiatric Disorders are not related to Traumatic Brain Injury.

Here is a list of potential Neuropsychiatric Disorders that can result after a Traumatic Brain Injury.

·        Delirium and Post-Traumatic Confusion

·        Mood Disorders

·        Psychotic Disorders

·        Post-Traumatic Stress Disorder

·        Personality Change

·        Aggressive Disorders

·        Mild Brain Injury

·        Post Traumatic Epilepsy

Delirium and Post-Traumatic Confusion

Delirium is a state somewhere between Coma and normal consciousness. It is an abnormal state of consciousness and is characterized by inattentiveness, language and thought abnormality, motor and affective changes, and sleep cycle disturbance.

Mood Disorders

Neuropsychiatric illness is prevalent in Traumatic Brain Injury.  TBI has been dubbed the “signature wound” in much of the literature describing blast injury to soldiers in operation Iraqi Freedom and Operation Enduring Freedom in the last decade.

Psychotic Disorders

               A predisposition to psychotic illness following brain injury in childhood has been documented. There is also substantial evidence of elevated psychosis incidence among those exposed to Traumatic Brain Injury.

Post-Traumatic Stress Disorder

               Traumatic Events often precipitate acute anxiety and stress reactions. Focus on Post-Traumatic Stress Disorder has received significant attention as military personnel return from overseas deployment.

Personality Change

               Most often disputed as pre-existing, Personality Change is shown to be related to Traumatic Brain Injury. Studies of patients with TBI find that the most significant problems at 1, 5, and 15 years post-injury are personality changes.

Aggressive Disorders

               Frequently mischaracterized are the symptoms of aggression in TBI cases. But aggression has long been linked to Traumatic Brain Injury. Irritability and aggressiveness are significant disabilities for people with TBI as well as a source of stress for those around them.

Mild Brain Injury

               There are three generally accepted definitions of Mild Traumatic Brain Injury. One is from the Centers of Disease Control, another from the World Health Organization and another from the American Congress of Rehabilitative Medicine. There is overlap in these definitions. A main point is that Mild Traumatic Brain Injury can be diagnosed without a loss of consciousness. An altered state of consciousness is sufficient.

Post Traumatic Epilepsy

               Trauma is one of the most identifiable causes for the development of Epilepsy. It occurs in roughly 20% of the cases of symptomatic Epilepsy.

Concluding Thoughts

               Since these potential Disorders create a subterfuge to effective communication, representing people with Traumatic Brain Injury presents a unique set of challenges. Patience and perseverance are necessary. It is fair to suggest that most lawyers do not have specific training in Traumatic Brain Injury cases. Similarly, most physicians are not properly trained to diagnose or detect symptoms or Disorders as being caused by Traumatic Brain Injury.

               If you or someone you know has suffered Traumatic Brain Injury as a result of an accident, fall, car crash, truck collision or other event caused by another, research the attorney’s in your State and be sure to understand what they practice. For instance, 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.

This is the final post in my series on Post Traumatic Stress Disorder.  Last week we looked at Treatment for Post-Traumatic Stress Disorder.  Today we will look at how the disorder and litigation relate.

In law, trauma which produces post-traumatic stress disorder is referred to as a tort. For many years only physical injury related to a trauma could form the basis of a lawsuit since it was observable and quantifiable. As the behavioral sciences gained ground, the concept of “traumatic neurosis” emerged and by the 1940s, testimony relevant to this psychiatric syndrome was accepted in many courts. By 1980, post-traumatic stress disorder found its way in the Diagnostic and Statistical Manual – the DSM – and the condition became a source of monetary damages to one so inflicted.

 The legal cause of action for emotional distress and psychiatric disorder including post-traumatic stress is readily accepted by courts for the person involved in the physical trauma. However the only time one not involved in the physical trauma can recover for emotional distress or post-traumatic stress disorder is if they were within the “zone of danger.” Please refer to my previous post.

 The Zone of Danger Rule - The Zone of Danger Rule, applied in almost every jurisdiction, allows a plaintiff to recover for emotional distress caused by a defendant’s negligent conduct if the plaintiff was in a location where the defendant’s conduct could have caused physical harm to the plaintiff.

 The theory supporting this doctrine is that the likely truth of a claim of emotional distress is increased if the person making the claim came close to suffering physical harm from the conduct that caused the person’s emotional distress.

 Predisposition to PTSD is frequently contested. Whether a person’s personality type gave way to PTSD where others with other personality types would have avoided the disorder is bandied about in trials. The question of predisposition has puzzled doctors over the years. Not all soldiers in the same battle, passengers in the same automobile accident, or workers exposed to the same industrial calamity develop PTSD. A dispute often arises in my practice over how a driver or passenger in the same car crash could develop PTSD while the other does not. Why certain individuals are vulnerable to PTSD must have something to do with heredity (genetics), environmental factors (family upbringing) together with the nature and impact of the trauma.

 Since my legal practice is significantly defined by the many traumatic brain injury cases I handle and have handled over many years, I come in contact with the PTSD diagnosis quite frequently. It is my experience that the condition is typically disputed and attempts are made to relate any psychiatric injury claims to predisposing factors.

 Today we are continuing our discussion of post-traumatic stress disorder by identifying treatments options.

Post-traumatic stress disorder consists of a spectrum of pathologic symptoms and behaviors involving the environment, the brain, and psychosocial influences. The environment is both cause and effect as the trauma from the environment initiates the disorder and leaves its imprint as an aftermath. The brain interacts with the trauma to produce symptoms of intense fear, dissociative flashback episodes, and physiological reactivity upon exposure to cues that resemble the traumatic event. Because of the constellation of symptoms typical of PTSD, the conceptualization of symptoms and pathologic behaviors related to the environment, the brain and psychosocial factors allows the clinician to select biologic, cognitive-behavior, psychosocial and environmental modalities to formulate a comprehensive treatment plan. (C.B. Scrignar)

The Mayo Clinic describes treatments.

Medications
Several types of medications can help symptoms of post-traumatic stress disorder improve.

•  Antipsychotics. In some cases, you may be prescribed a short course of antipsychotics to relieve severe anxiety and related problems, such as difficulty sleeping or emotional outbursts.
• Antidepressants. These medications can help symptoms of both depression and anxiety. They can also help improve sleep problems and improve your concentration. The selective serotonin reuptake inhibitor (SSRI) medications sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved for the treatment of PTSD.
• Anti-anxiety medications. These drugs also can improve feelings of anxiety and stress.
• Prazosin. If your symptoms include insomnia or recurrent nightmares, a drug called prazosin (Minipress) may help. Prazosin, which has been used for years in the treatment of hypertension, also blocks the brain's response to an adrenaline-like brain chemical called norepinephrine. Although this drug is not specifically approved for the treatment of PTSD, prazosin may reduce or suppress nightmares in many people with PTSD.

Psychotherapy
Several types of therapy may be used to treat both children and adults with post-traumatic stress disorder. You may try more than one, or combine types, before finding the right fit for you. You may also try individual therapy, group therapy or both. Group therapy can offer a way to connect to others going through similar experiences.

Some types of therapy used in PTSD treatment include:

• Cognitive therapy. This type of talk therapy helps you recognize the ways of thinking (cognitive patterns) that are keeping you stuck — for example, negative or inaccurate ways of perceiving normal situations.

In PTSD treatment, cognitive therapy often is used along with a behavioral therapy called exposure therapy.

• Exposure therapy. This behavioral therapy technique helps you safely face the very thing that you find frightening, so that you can learn to cope with it effectively. A new approach to exposure therapy uses "virtual reality" programs that allow you to re-enter the setting in which you experienced trauma — for example, a "Virtual Iraq" program.
• Eye movement desensitization and reprocessing (EMDR). This type of therapy combines exposure therapy with a series of guided eye movements that help you process traumatic memories.

All these approaches can help you gain control of lasting fear after a traumatic event. The type of therapy that may be best depends on a number of factors that a PTSD sufferer and a health care professional can discuss.

As identified above, Medications and psychotherapy also can help you with other problems related to traumatic experience, such as depression, anxiety. Many PTSD sufferers engage in “self-medication” with alcohol or substance abuse. Therapy and treatment can help curb the burden of PTSD.

Next week we will look at special issues germane to litigation and post-traumatic stress disorder.

 II.               What are the Types of Trauma that Causes of Post-Traumatic Stress Disorder?

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

According to http://www.medicinenet.com/posttraumatic_stress_disorder  

 Virtually any trauma, defined as an event that is life-threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear, may cause PTSD. Such events often include either experiencing or witnessing a severe accident or physical injury, receiving a life-threatening medical diagnosis, being the victim of kidnapping or torture, exposure to war combat or to a natural disaster, exposure to other disaster (for example, plane crash) or terrorist attack, being the victim of rape, mugging, robbery, or assault, enduring physical, sexual, emotional, or other forms of abuse, as well as involvement in civil conflict. Although the diagnosis of PTSD currently requires that the sufferer has a history of experiencing a traumatic event as defined here, people may develop PTSD in reaction to events that may not qualify as traumatic but can be devastating life events like divorce or unemployment.

It is an interesting observation that the traditional “Trauma Principle” discussed in my last post has been broadened to include trauma where the “zone of danger” is no longer requisite. In my experiences, I am most exposed, as a consumer rights attorney, to those individuals who suffer traumatic events that injure either themselves or someone with them. The following is a summary of such common events and others that can cause PTSD.

•       Vehicular Trauma

There is no denying that a vehicle weighing several thousand pounds can cause injury, trauma and even death. That is typical in cases of car “accidents.” But consider for a moment, big rig trucks carrying heavy loads of cargo or hazardous materials. Think of train wrecks and airplane crashes. As I state on my website, before there were trains, planes and automobiles, we simply did not travel or crash in the manner we see quite frequently today.

•       Industrial Trauma

Industrial settings – factories, oil refineries, construction sites, and other blue collar work places – have a high potential for accidents. Work related trauma could well be any trauma that is sustained while at work or on the job. Sometimes trauma can be very job specific like falling off scaffolding. Other times it could be like any other; a truck crash while hauling dirt. The point is trauma related to the job can result in PTSD.

•       Criminal Assaults

Statistics of criminal assault are staggering. When a person is attacked, beaten or hit, a trauma occurs. In cases of of negligent security, one can see how criminals and trespassers could gain access to apartments, hotels and other public sites and commit crimes that include injury to the victim.

•       Sexual Assaults

Sexual assault is defined as any sort of sexual activity between two or more people in which one of the people is involved against his or her will.

The sexual activity involved in an assault can include many different experiences. Women can be the victims of unwanted touching, grabbing, oral sex, anal sex, sexual penetration with an object, and/or sexual intercourse.

•       Child Sex Abuse
•       Terrorism

Veterans, like other people, respond to traumatic events in a number of ways. They may feel concern, anger, fear, and helplessness. These are all normal responses to an abnormal event. Research shows, though, that people who have been through traumas in the past may be even more likely than others to be affected by new events such as terror attacks and war.

•       Torture
•       The Holocaust
•       War Trauma

Now that the war in Iraq is over, the return of military personnel will reveal the residual injury of war, PTSD. The signature injury has already been well recognized by the military and government. Getting care will be the next challenge.

Experts think PTSD occurs:

§ In about 11-20% of Veterans of the Iraq and Afghanistan wars (Operations Iraqi and Enduring Freedom), or in 11-20 Veterans out of 100.

§ In as many as 10% of Gulf War (Desert Storm) Veterans, or in 10 Veterans out of 100.

§ In about 30% of Vietnam Veterans, or about 30 out of 100 Vietnam Veterans.

•       Natural or Man-Made Disasters

Every year, millions of people are affected by both human-caused and natural disasters. Disasters may be explosions, earthquakes, floods, hurricanes, tornados, or fires. In a disaster, you face the danger of death or physical injury. You may also lose your home, possessions, and community. Such stressors place you at risk for emotional and physical health problems.

Trauma producing post-traumatic stress disorder – PTSD – comes in many shapes and sizes and not in a one size fits all. As an attorney whose practice is defined by the significant cases of traumatic brain injury handled over the years, I am often disappointed at how difficult it is to convince insurance companies, defense lawyers and defense experts of the relation of trauma to a diagnosis of post-traumatic stress disorder – PTSD.

Next week we will continue our discussion of post-traumatic stress disorder. We will look at the treatments used to manage it and will look at the nuances PTSD brings to litigation.

In late July, the National Football League introduced a new poster to be hung in league locker rooms, warning players of possible long-term effects of concussions.  Public awareness of the pathological consequences of traumatic brain injury has been elevated not only by the recognition of the potential clinical significance of repetitive head injuries in such high-contact sports as American football and boxing, but also by the prevalence of vehicular crashes and efforts to improve passenger safety features, and by modern warfare, especially blast injuries.

The article, by Dekosky et al., N Engl J Med 2010; 363:1293-1296, Sept. 30, 2010, goes on to contrast immediate consequences of traumatic brain injury and how long they last with delayed consequences of traumatic brain injury.

Many complications of traumatic brain injury are evident immediately or soon after injury....Seemingly mild closed-head injuries (i.e., those without skull fracture) may lead to diverse and sometimes disabling symptoms, such as chronic headaches, dizziness and vertigo, difficulty concentrating, word-finding problems, depression, irritability, and impulsiveness. The duration of such symptoms varies but can be months. Post-traumatic stress disorder frequently accompanies traumatic brain injury, though the relationship is poorly understood.

However, "Causal relationships between traumatic brain injury and delayed sequelae have been less studied because of the variable latency period before overt neurologic dysfunction."  However that does not mean relationships do not exist.  We know of certain repetitive mild brain injury (boxers); pugilistic parkinsonism.

 "Neurocognitive effects of repetitive mild head injury were initially recognized in boxers, with a syndrome that was distinct from the clinical and pathological sequelae of single-incident severe traumatic brain injury." Now other contact sports and blast injuries are also known to impact the brain.  In severe cases, as soon as two hours after the injury, scientists have discovered a protein, also seen in Alzheimer's patients, that causes cellular degeneration in the brain.  However in "mild brain injuries" the protein plaque is not evident. 

Further studies will help us understand why.  Currently precursers of the protein are seen in "mild brain injury" studies.  And, repetitive injury is replete with evidence of pugilistic parkinsonism

With the War in Iraq technically over, many veterans are returning home. 

The American Academy of Neurology reports Soldiers With Brain Injuries are at Higher Risk Of Epilepsy Years after Returning Home. 

The new research is published in the July 20, 2010, print issue of Neurology®, the medical journal of the American Academy of Neurology, entitled correlates of posttraumatic epilepsy 35 years following combat brain injury (cme). - Raymont, V., Salazar, A.M., Lipsky, R., Goldman, D., Tasick, G., Grafman, J.. Pages: 224-229.

This is certainly consistent with what I have posted about previously including previous studies and articles.  We have known for years that traumatic brain injury increases the chance of developing epilepsy.

Epilepsy is a general term for conditions with recurring seizures. There are many kinds of seizures, but all involve abnormal electrical activity in the brain that causes an involuntary change in body movement or function, sensation, awareness, or behavior.  Epilepsy can be caused by many different conditions that affect a person’s brain. Examples of these conditions include stroke, head trauma, complications during childbirth, infections (such as meningitis, encephalitis, cysticercosis, or brain abscess), and certain genetic disorders. Often, no definite cause can be found.

Epilepsy affects an estimated 2.5 million people in the United States and each year accounts for $15.5 billion in direct costs (medical) and indirect costs (lost or reduced earnings and productivity). More than one-third of people with epilepsy continue to have seizures despite treatment.

Each year, about 200,000 new cases of epilepsy are diagnosed in the United States. Children younger than age 2 years and adults older than age 65 are most likely to be affected. In addition, people of low socioeconomic status, those who live in urban areas, and members of some minority populations are at increased risk for epilepsy.
 

Nearly 300,000 troops have served, three, four or more tours of duty in Afghanistan or Iraq.  The signs, symptoms and consequences of multiple blast injuries to the brain and PTSD show up when soldiers come home and too often are misunderstood and neglected.

With two long wars — Afghanistan is in its ninth year and Iraq just entered its eighth — the U.S. military finds itself straining to maintain a steady flow of troops. More than 2 million men and women have been deployed to serve in both conflicts, and more than 40 percent of them have served at least two tours, according to military records.

Nearly 300,000 troops have served three, four or more times. And, records show, more than half of those currently at war are at least on their second tour. (The vast majority of deployments last more than six months.)

For these men and women, life becomes a revolving door of war, home, then back to combat — sometimes within months — as they face the same dangers, the same stresses and the same agonizing separation from family. Some soldiers are gone so often, they're more comfortable being away.

The article looks deeper into the issues surrounding these military men and women.

An IED is a device fabricated or placed in an improvised manner, incorporating lethal, noxious, pyrotechnic, or incendiary materials designed to destroy, incapacitate, harass, or distract. It may incorporate military parts, but is normally constructed from nonmilitary components.

What the movie does not provide is the reality these repeated trauma have on soldiers. 

To study such biomechanics and injury, the North American Brain Injury Society (NABIS) formed one of the first committees.   Blast Injury and TBI by Ronald C. Savage, EdD Executive Vice President, NABIS, states:

During the Vietnam War and the Persian Gulf War, 76 percent of American troops survived combat wounds. But in this century, the U.S. military's surgical teams "have saved the lives of an unprecedented 90 percent of the soldiers wounded in battle…" (New England Journal of Medicine, December, 2006). Furthermore, Walter Reed Army Medical Center reported that nearly 30% of all patients with combat-related injuries seen at Walter Reed from 2003 to 2005 sustained a TBI and that blast injuries are a significant cause of TBIs In addition, they reported that TBI is often associated with severe multiple trauma, post traumatic stress disorder (PTSD) or undiagnosed concussions. Thus, screening soldiers who are at risk for a TBI is important in order to ensure that TBIs are identified and appropriately treated.

Diagnosis can be difficult even when TBI is apparent or the patient is able to describe a concussive head injury to their doctors. The more common mild brain injury often has more than mild consequences and can cause depression, reduced cognitive functioning, nausea,
sleep disturbance, erratic behavior, and mood swings. These impairments are exacerbated by misdiagnosis, lack of treatment and the public’s misperceptions about brain injury and mental illness. For veterans with brain injuries, the lack of physical signs and the diffuse nature of symptoms may be met with skepticism, considered to be psychological, or worse, malingering.

As professionals in the field know, the “walking wounded” do not disappear. And many more will be seen and heard in this decade. Thanks to improvements in protective gear and swift medical treatment, more of America's wounded are surviving - and returning home with serious, permanent injuries. How will these veterans fare in the routines of daily life? Will they be able to maintain employment? How will their injuries impact their families, friends, co-workers, and communities?

The North American Brain Injury Society has begun to address these important issues. We recently published a special edition of Brain Injury Professional that focused solely on blast injury and TBI. NABIS would like to extend our sincere appreciation and thanks to Representative Bill Pascrell, co-chair of the Congressional Brain Injury Task Force, who wrote a thoughtful introduction, and also to Dr. Tina Trudel who served as Guest Editor.

In addition, the Planning Committee of our 2007 conference has organized a number of sessions devoted to the topic of blast injury. NABIS will continue to explore additional ways that we can create positive change in this area and we look forward to sharing those ideas with our membership in the future. 
 

Susan Lance, a speech pathologist specializing in •developmental problems •strokes
•brain injuries and •other neurological disorders, states, 

The study, from Yale University, evaluated whether posttraumatic stress disorder (PTSD) mediated the relationship between mild traumatic brain injury (MTBI) and general health ratings, psychosocial functioning, and perceived barriers to receiving mental healthcare 2 years following return from deployment in veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF).

"Compared with respondents who screened negative for MTBI, respondents who screened positive for MTBI were younger, more likely to have PTSD, more likely to report fair/poor overall health and unmet medical and psychological needs, and scored higher on measures of psychosocial difficulties and perceived barriers to mental healthcare. Injuries involving loss of consciousness were associated with greater work-related difficulties and unmet psychological needs. PTSD mediated the relationship between MTBI and all of these outcomes." 

The researchers concluded: "These results underscore the importance of assessing PTSD in OEF/OIF veterans who screen positive for MTBI."

For additional information, contact R.H. Pietrzak, Yale University, School Medical, National Center PTSD, VA Connecticut Healthcare Systems, 950 Campbell Avenue 151E, West Haven, CT 06516, USA.
 

Military personnel evacuated out of Iraq and Afghanistan because of back pain are unlikely to return to the line of duty regardless of the treatment they receive, according to research led by a Johns Hopkins pain management specialist.

In a study published in the  Archives of Internal Medicine, researchers found that just 13 percent of service members who left their units with back pain as their primary diagnosis eventually returned to duty in the field. Women, officers, those deployed in Afghanistan and those with previous back pain had better outcomes, but only marginally. Aside from combat injuries sustained during battle, the return-to-duty rate for spinal pain and other musculoskeletal disorders is lower than for any other disease or non-combat injury category except for psychiatric illness, the researchers said.
 

Read more here.

The good news is nearly three-quarters of the 200 military men and women interviewed by the American Psychiatric Association (APA) said that it was very or somewhat easy for them to seek out mental health care. But 60% still feared that doing so could have negative consequences on their career. More than half reported they believe others would think less of them if they sought out counseling, and most surveyed said they have rarely or never spoken even to family and friends about mental health issues. These numbers show "there's still a long way to go towards reducing the stigma surrounding care," says APA board member Dr. Mary Helen Davis.

Click here to read the whole article.