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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 33-39

Post-traumatic stress disorder: Relationship to traumatic brain injury and approach to forensic psychiatry evaluation


1 Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
2 Faculty of Forensic Medicine; Guangdong Province Translational Forensic Medicine Engineering Technology Research Center; Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China

Date of Web Publication28-Mar-2019

Correspondence Address:
Dr. Hu Zhao
Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou 510080, Guangdong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_46_18

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  Abstract 


Posttraumatic stress disorder (PTSD) has an important and complex relationship with traumatic brain injury (TBI). The prevalence of comorbid PTSD and TBI is increasing in both military and civilian populations. Moreover, TBI has emerged as an important risk factor for the development and manifestation of PTSD. Meanwhile, PTSD is also a significant mediator of the negative sequelae of TBI. PTSD and TBI, especially mild TBI (mTBI), have overlapping neural substrates and neuroanatomical functional features. Given that comorbid PTSD and TBI remain a challenge for forensic psychiatry evaluation, we review the relationship between the two disorders and discuss special considerations during evaluation of the condition.

Keywords: Forensic psychiatry evaluation, neural mechanism, posttraumatic stress disorder, traumatic brain injury


How to cite this article:
Chen YF, Zhao H. Post-traumatic stress disorder: Relationship to traumatic brain injury and approach to forensic psychiatry evaluation. J Forensic Sci Med 2019;5:33-9

How to cite this URL:
Chen YF, Zhao H. Post-traumatic stress disorder: Relationship to traumatic brain injury and approach to forensic psychiatry evaluation. J Forensic Sci Med [serial online] 2019 [cited 2019 Jun 16];5:33-9. Available from: http://www.jfsmonline.com/text.asp?2019/5/1/33/255130




  Introduction Top


Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) are both common conditions that affect individuals who have experienced mental or physical injuries.[1] There has been significant controversy surrounding the complex relationship between these two disorders for decades.[2],[3] Indeed, TBI has emerged as an important risk factor for the development of PTSD, while PTSD may also be a significant mediator of the negative sequelae of TBI.[2],[4] In addition, individuals with PTSD or TBI, especially combat veterans, have a high rate of criminal violence, substance abuse, and suicidal behavior, which can create difficulties in forensic psychiatry evaluation.[5],[6]

In this review, we begin with a brief description and definition of PTSD and TBI, followed by an analysis of the epidemiology of the two disorders. Next, we briefly review the complex and controversial relationship between TBI and PTSD based on characteristics of the overlapping neural substrates and neuroanatomical functional features, paying particular attention to the role of TBI as a risk factor for PTSD. Finally, we discuss special considerations in evaluating individuals with comorbid PTSD and TBI in forensic psychiatry contexts.


  Description and Definitions of Posttraumatic Stress Disorder and Traumatic Brain Injury Top


According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PTSD is defined as an anxiety disorder that requires a history of exposure to a traumatic event with symptoms from each of the following four symptom clusters: (1) exposure to or witnessing of an event that is threatening to one's well-being; (2) symptoms of re-experiencing, such as intrusive memories, nightmares, a sense of reliving the trauma, or psychological and physiological distress when reminded of the trauma; (3) avoidance of thoughts, feelings, or reminders of the trauma, and inability to recall parts of the trauma, withdrawal, and emotional numbing; and (4) arousal, manifesting as sleep disturbance, irritability, difficulty concentrating, hypervigilance, or heightened startle response.

Traumatic events that can result in PTSD fall into several categories, including military combat, rape, physical assault, natural disaster, and witnessing violence.[7] Since the beginning of the conflicts in Iraq and Afghanistan, it has become clear that PTSD has an important and complex relationship with TBI. Both disorders are common in Iraq and Afghanistan veterans,[8],[9] whereas among civilian populations, the comorbidity is most common as a result of motor vehicle accidents.[10]

The most common form of TBI is mild TBI or concussion, and it has multiple definitions derived from various sources. In particular, mild TBI is considered a “silent epidemic” because many of the acute and enduring alterations in cognitive, motor, and somatosensory functions may not be readily apparent to external observers. The Glasgow Coma Scale (GCS) score, which measures the level of consciousness, has been the primary clinical tool for assessing initial brain injury severity in mild (GCS 13–15), moderate (GCS 9–12), or severe (GCS <8) cases.[11] Concussion is a frequent occurrence in contact sports, and there is increasing evidence that athletes may sustain multiple concussions throughout their career.[12],[13],[14] Another significant population is soldiers suffering from blast-related injuries, with one in six Iraq veterans meeting the criteria for concussion.[15] Two primary complications of concussion are postconcussion syndrome and second impact syndrome.

Neurobehavioral symptoms are commonly reported in TBI. However, the symptoms vary in type and duration and may manifest as somatic or neuropsychiatric symptoms.[16] Neuropsychiatric sequelae after TBI comprise cognitive deficits and behavioral disorders and are identified in almost all TBI patients for up to 3 months, with a small percentage exhibiting persistent symptoms for months or years.[17]

The sequelae of TBI and psychological trauma exposure may be difficult to distinguish, especially at lower levels of TBI severity.[18] In addition to confusing diagnostic decisions, their shared attributes and associated features can potentially complicate forensic evaluation of each disorder. For example, TBI sequelae and PTSD may each be associated with an elevated risk of substance abuse and suicidal behavior, as well as with symptoms of irritability, anxiety, depression, cognitive impairment, and sleep disturbance.[19]


  Does Traumatic Brain Injury Protect Against Posttraumatic Stress Disorder? Top


Prior to the Iraq and Afghanistan conflicts, comorbid PTSD and TBI received relatively little attention and was considered to be a rare phenomenon. In particular, it was argued that impairment or loss of consciousness, which occurs with severe TBI, may prevent PTSD by interfering with the encoding of trauma-related memories.[20],[21] Indeed, some researchers have argued that limited awareness at the time of trauma makes it less likely that traumatic memories can be encoded and that, as a result, these memories remain unavailable for the mediation of re-experiencing symptoms.[22] It was also suggested that amnesia regarding the traumatic event minimizes the possibility that any cognitive representations of the trauma will be established.[23] Other researches indicate that PTSD is in fact rare among road-accident survivors with TBI.[24] An additional study involving 188 road-accident victims who sustained loss of consciousness reports that none exhibited symptoms of PTSD compared with road-accident survivors without TBI.[20]

However, as summarized by Jones et al.,[25] there are several mitigating factors that allow PTSD to develop in the context of amnesia for the event. These are as follows: (1) affective responses and sensory-perceptual experiences associated with the trauma may be encoded at an implicit (i.e., unconscious) level that influences subsequent physiological, behavioral, and emotional responses; (2) amnesia may only be partial, with some aspects of the trauma preserved in conscious memory; (3) reconstruction of memory from secondary sources such as family, friends, or other observers may influence the development of PTSD symptoms; and (4) the circumstances of the trauma and peritraumatic events are psychologically traumatic in and of themselves and therefore may lead to PTSD.

Moreover, a computed tomography (CT) study of brain lesions in veterans of the Vietnam War found that damage to either the amygdala or ventromedial prefrontal cortex protects against PTSD.[26] However, while this result does suggest that damage to one of the two specific regions of the brain, which are critically involved in the pathogenesis of PTSD, can reduce the occurrence of PTSD, it fails to explain the complex relationship between TBI and PTSD.


  Can Traumatic Brain Injury and Posttraumatic Stress Disorder Coexist? Top


Early epidemiological studies of veterans of the Iraq and Afghanistan conflicts observed high rates of comorbid PTSD and TBI and reported that TBI is in fact an important risk factor for PTSD. Moreover, research of Iraq veterans reported that 4.9% reported an injury with loss of consciousness, and an additional 10.3% reported an injury with altered mental status but without loss of consciousness. The study found a strong association between TBI and PTSD: of those who reported loss of consciousness, 43.9% developed PTSD, and of those who reported altered mental status, 27.3% developed PTSD. In contrast, among those with an injury without loss of consciousness or altered mental status, the rate of PTSD was 16.2%, and in those without an injury, it was 9.1%.[4] Another study of Iraq and Afghanistan veterans reported that 11% screened positive for PTSD and 12% reported a history consistent with mild TBI.[2] Moreover, mild TBI was associated with a 2.37-fold increase in the prevalence of PTSD. Furthermore, among veterans with mild TBI, 34% also met criteria for PTSD. An investigation of veterans performed by the RAND Corporation found that 19.5% of returned service members had sustained a probable TBI, and of these, about 34% were affected by probable PTSD.[27]

These studies generally indicate that both PTSD and acute stress disorder can coexist with TBI, even following a single incident in which the patient lost consciousness. PTSD has been documented in cases of moderate and severe TBI. However, several studies have suggested that PTSD is more likely to occur in the context of mild TBI (mTBI) rather than severe TBI, which is of particular relevance to veterans.[28] Consistent with this, a longitudinal study of patients with mTBI documented an inverse relationship between the severity of re-experiencing symptoms at 3-month follow-up and the duration of posttraumatic amnesia. The results suggest that the strength with which trauma memories are encoded may in part determine whether PTSD develops, with clearer memories of the trauma associated with a greater likelihood of developing PTSD.[29]

In general, PTSD and TBI can coexist, and PTSD is more likely to develop in association with mTBI. Evidence also suggests that PTSD may be inversely related to TBI severity and potentially to the strength with which trauma memories are consolidated.


  Does Traumatic Brain Injury Act as an Additional Risk of Posttraumatic Stress Disorder Development? Top


Physical injury of any type, even if not involving the brain, is a risk factor for PTSD. However, TBI may confer additional risk of adverse mental health outcomes, including PTSD, following psychological trauma exposure. In Operation Enduring Freedom/Operation Iraqi Freedom veterans, PTSD is more prevalent among those who report mTBI compared with both veterans who suffered no injury and those who suffered injuries not involving the head. Moreover, the Vietnam Experience Study, which enrolled Vietnam-era veterans, reported that the presence of mTBI increased the risk of current PTSD experienced at an average of 16 years after military discharge.[30]


  Neural Substrates Underlying Traumatic Brain Injury and Posttraumatic Stress Disorder Top


Mild neuropsychological impairment, such as dysfunction of attention, learning and memory, and executive functioning, can often characterize both PTSD and TBI. While there is significant overlap in these neuropsychological domains, their manifestations are potentially different in each disorder. A meta-analytic research has indicated that most measurable neuropsychological deficits associated with mTBI resolve within a few weeks of the injury, returning to baseline within 1–3 months.[31] In contrast, PTSD symptoms and neuropsychological deficits associated with PTSD more often persist years after psychological trauma exposure.[32]

The potentially transient nature of cognitive sequelae in most mTBI cases and the neuropsychological consequences of mTBI might be relevant to PTSD for several reasons. First, heterogeneity in injury attributes across cases classified as mTBI partly reflected variability in recovery from mTBI.[33] Furthermore, individual differences, such as premorbid psychological factors and subsequent life stressors, might be more important in predicting recovery.[34] Moreover, genetic vulnerability is also being explored as a potential determinant of outcomes.[35] At least 17 genes have been reported to be associated with PTSD. These genes are also reported to be critical in modulating neurotransmitters and neuromodulators.[36],[37],[38],[39],[40],[41],[42],[43],[44],[45] It has been argued that there is a particularly increased risk of PTSD and depression with postconcussive symptoms following war-zone mTBI.[46] However, a study of Vietnam-era veterans reported that mTBI and PTSD contributed independently to variance in residual somatic, cognitive, and emotional complaints experienced years after injury/psychological trauma exposure, suggesting that the effects of mTBI and PTSD on postconcussive symptoms may be additive.[47]

Second, neuropsychological deficits associated with mTBI always occur during the period relevant to the formation of trauma memories. Short-term consolidation allows for the formation of memory traces within 24 h, and this period is critical to the consolidation and integration of the trauma memory.[48] TBI-related deficits are most likely to surface shortly after the event. Similarly, emotional responses to psychological aspects of the event during or shortly after exposure have been found to be one of the strongest predictors of subsequent PTSD and emotional symptoms.[47],[49],[50],[51] It is noteworthy that, even in the absence of demonstrable cognitive deficits, mTBI may be associated with an increased risk of developing anxiety and depression symptoms more generally, especially in the context of multiple concussions.[52],[53],[54],[55] These deficits are thought to reflect reduced information-processing capacity, either in terms of speed of processing or the amount of information that can be handled simultaneously, and may affect the course of PTSD.[30]


  Overlapping Neuroanatomical Functional Features Underlying Posttraumatic Stress Disorder and Traumatic Brain Injury Top


Neural circuitry models and neuroimaging data suggest several key frontal and limbic structures, including the prefrontal cortex, the amygdala, and the hippocampus, as critical for PTSD development.[56],[57],[58],[59],[60] These results suggest that the amygdala response underlies a heightened responsivity to potential threat, whereas both the hippocampus and medial prefrontal cortex are thought to be critical for appropriate contextual tagging of fear responses. Our team found that right-handed patients with PTSD are more vulnerable to left than right hippocampal damage.[61]

Enduring pathophysiological effects are evident in mTBI.[62] This damage is often not visible with conventional CT and magnetic resonance imaging. However, it can be seen with diffusion tensor imaging, which measures the functional integrity of white matter, as well as in postmortem brain studies. The primary pathology associated with mTBI is traumatic axonal injury, caused by shearing and tensile forces that result from sudden deceleration and rotation of the head.[63] Shearing effects may lead to the tearing and disconnection of axons and primarily affect deep frontal white-matter and subcortical structures, with white-matter projections to the frontal cortex.[64] Shearing may also disrupt small veins, resulting in microhemorrhagic lesions in the frontal and temporal regions.[65] The hippocampus is especially vulnerable to axonal damage and may be affected indirectly by the damaging effects of trauma-induced release of excitatory neurotransmitters.[66]

The c-Jun N-terminal kinases (JNKs) are a subfamily of mitogen-activated protein kinases that play important roles in the central nervous system, in both physiological and pathological conditions.[67] JNK activation has been observed in both neurons and axons in experimental models of TBI, as well as in humans.[68] The disruption of axonal transport appeared to be mediated by the neuron-specific JNK3 isoform, which may explain the observed protective effect of genetic deletion of the JNK3 isoform after axotomy of dopaminergic neurons.[69],[70]


  Dual Challenges: Posttraumatic Stress Disorder and Traumatic Brain Injury in Forensic Psychiatry Evaluation Top


Posttraumatic stress disorder, traumatic brain injury, and aggression

A crucial question in forensic psychiatry evaluation is whether PTSD and/or TBI is associated with a neuropsychiatric profile that diminishes culpability, either by interfering with the ability to appreciate the wrongfulness of one's actions or by reducing the ability to conform to one's behavior to the requirements of the law. The Aspen Neurobehavioral Conference Consensus Statement[71] notes that all human behaviors are variably governed by the interaction of numerous factors, including genes, early life experience, acquired brain damage, learned behavioral patterns, and situational contingencies. PTSD and TBI appear to cause neurobiological dysfunction that impairs an individual's capacity to inhibit violent behavior. Nonetheless, it is crucial to appreciate that illness is not destiny, and that many preinjury and postinjury psychosocial factors are at play in any individual who exhibits violent behavior toward others.

Organic aggressive syndrome is characterized by aggression that is reactive (provoked by seemingly trivial stimuli), nonreflective (unplanned), nonpurposeful (serves no clear aim or objective), explosive (occurs suddenly and without any apparent buildup), periodic (prolonged periods of relative calm punctuated by aggressive outbursts), and ego-dystonic (the individual feels bad about the behavior).[72] This type of posttraumatic aggression is relatively uncommon and is generally observed among individuals who are severely neurologically compromised. In such instances, causative relationships between injury and behavior are relatively straightforward. Impulsive violence, wherein unplanned aggressive behavior is directed at a specific person in response to a perceived threat, is far more common among neurobehaviorally impaired patients with PTSD and TBI survivors. It is particularly observed among those with generalized impairments of impulse control (i.e., disinhibited behavior) and those with comorbid severe cognitive impairments, depression, mania, anxiety, or psychosis.

However, aggression of any kind may also arise in the absence of such neuropsychiatric conditions. Indeed, it may be a function of problems that bear no direct relation to a neuropsychiatric injury per se, including states of intoxication, premorbid personality traits and disorders (especially antisocial, borderline, and narcissistic), or as a premeditated, purposeful, instrumental violent act. Attribution of aggressive behavior to PTSD or TBI (i.e., impaired impulse control resulting from neuropsychiatric illness) rather than to purposeful, instrumental violence must be undertaken with caution and only after careful consideration of all circumstances surrounding such acts. This includes (but is not limited to) specific details of the neuropsychiatric condition, psychosocial factors in existence before and after the event, the context in which the particular violent act occurred, potential precipitants, and possible objectives.


  Posttraumatic Stress Disorder, Traumatic Brain Injury, and Criminal Responsibility Top


Another crucial question in forensic psychiatry evaluation is how traumatic exposure may lead to impaired emotionality and cognition that may offer a basis for legal defenses. The defense of insanity, impaired legal capacity, and sentence mitigation have always been a controversial issue.[73],[74] In general, both PTSD- and TBI-induced concussion syndrome and brain contusion syndrome are not psychiatric disorders. It is cautioned that assessment cannot be based solely on self-reported traumatic exposure, a lesson learned by forensic evaluators of veterans from earlier eras.[75],[76] Bryant and Harvey found that the qualitative features of trauma memories that had been continuously recalled were largely indistinguishable from those of inaccurate “memories” that were reconstructed following severe TBI. This finding highlights that it is difficult to determine the historical accuracy of a memory on the basis of the respondent's subjective experience.[6] These various findings converge on the conclusion that reported memories of events that occurred during periods of impaired consciousness need to be interpreted as reflections of a narrative truth rather than historical truth.[3],[77]


  Posttraumatic Stress Disorder, Traumatic Brain Injury, and Compensation Medicine Top


Within judicial practice, cases of mental disability caused by traumatic events or brain injury are increasing. The susceptibility to and chronic course of PTSD are often controversial issues in court. It can be questioned why only a few people develop PTSD despite similar or identical stressful environments. Moreover, most patients with PTSD can recover from stressful conditions after treatment. Why are some patients unable to recover, with their condition evolving into chronic illness and mental disability? When PTSD patients have comorbid TBI, does TBI increase or decrease the susceptibility to and chronicity of PTSD? The possibility of malingering is another consideration in PTSD and TBI litigation. Because judicial identification of mental injury still relies on traditional mental examination, neuroimaging, and psychological testing, it is necessary to establish more objective identification techniques in the future.


  Conclusion Top


Comorbid PTSD and TBI is a common and challenging forensic and clinical situation that requires attention to develop better strategies for assessment and treatment. Accumulating evidence has supported TBI as an important risk factor for PTSD. However, the causal relationship between TBI and PTSD remains unclear, although neurological factors may be involved. Furthermore, significant overlap in the symptoms of PTSD and TBI leads to difficulties in differential diagnosis. Multiple studies have shown that PTSD is associated with postconcussive symptoms, creating debate over whether these symptoms are related to neurological injury, psychological stress, or both. The evaluation of comorbid PTSD and TBI in forensic psychiatry may be complicated by several considerations. For instance, diagnosis might be interfered with by these overlapping symptoms, as well as the cognitive and other sequelae of TBI. Therefore, further studies are needed to clarify these issues.

Acknowledgment

We thank Rhianna Goozee, PhD, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

Financial support and sponsorship

This work was supported by the National Key Technology R&D Program of China (2012BAK16B03), Science and Technology Projects of Guangdong Province, China (2013B022000054).

Conflicts of interest

There are no conflicts of interest.



 
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Abstract
Introduction
Description and ...
Does Traumatic B...
Can Traumatic Br...
Does Traumatic B...
Neural Substrate...
Overlapping Neur...
Dual Challenges:...
Posttraumatic St...
Posttraumatic St...
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