Each year in the U.S., there are as many as 2.9 million emergency department visits, hospitalizations, and deaths from traumatic brain injuries (TBIs). Most of these are mild TBIs, which we know as concussions. Some people with concussions also will develop post-traumatic stress disorder (PTSD) as a result of the experience.
PTSD is caused by a reaction of the sympathetic nervous system, which directs the body’s rapid involuntary response to dangerous or stressful situations. The reaction causes a flashflood of hormones, which boosts the body’s alertness and heart rate, sending extra blood to the muscles. An estimated 7 to 8 percent of Americans will experience PTSD at some point in their lives. For military service members and veterans, the incidence of PTSD is even higher.
Since 2001, more than 262,000 military members and veterans have experienced concussions. But according to a report by the RAND Corporation, 57% of those in military service who have experienced a concussion without a loss of consciousness were never evaluated by a physician for a brain injury afterward.
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The Concussion-PTSD Link
“Anybody who receives a concussion from an accident can also experience PTSD afterward —whether it was a fall, a car crash, or a bomb blast,” says Michael “Micky” Collins, PhD, an internationally renowned expert in concussion and the director of the UPMC Sports Medicine Concussion Program. “Because many symptoms of PTSD overlap the symptoms of concussion, such as headache, fatigue, dizziness, and anxiety, it can be difficult to determine if the patient has a concussion, PTSD, or both. So, it is critically important for someone who has experienced a traumatic injury to get a comprehensive evaluation by a medical provider trained in diagnostic measures for both concussion and PTSD.”
An evaluation by a professional with concussion management and treatment experience can help sort out a complex clinical profile. “It’s easy to miss the vestibular symptoms when combined with PTSD symptoms because it’s a complicated diagnosis,” says Dr. Collins. He has seen patients who have suffered mild concussions go undiagnosed for months or even years because their symptoms were attributed to PTSD and not to a concussion or the possibility of both concussion and PTSD.
That can be a real problem because the treatment for a person with vestibular symptoms of concussion alone is very different from the treatment for a person who has a vestibular symptoms and PTSD. And when symptoms of either condition go undiagnosed, the person can develop sleep issues, depression, and even suicidal thoughts.
For example, depressed mood and increased anxiety associated with PTSD may contribute to ongoing cognitive problems, which could also be attributed to concussion. Likewise, physical symptoms of concussion, such as headaches or imbalance, may reduce the tolerance a patient has for the potentially emotionally demanding psychotherapeutic exercises needed for PTSD.
Separating the Symptoms
The vestibular system is responsible for providing sensory information between the inner ear and the brain related to motion, head position, and spatial orientation; it also is involved with motor functions that control balance, stabilize the head and body during movement, and maintain posture.
“When a patient has vestibular symptoms of a concussion, they report dizziness, fogginess, balance issues, and environmental sensitivity,” says Dr. Collins, “When you add in the PTSD, they may report that they avoid going to loud, bright, busy places. In addition to complicating the diagnosis, overlapping symptoms of PTSD and concussion may lead to a more complex course of treatment.”
Management and Treatment
Both PTSD and concussion should be actively managed, and the treatment approach should take into consideration the interplay of both concussion and PTSD symptoms, while recognizing that the two distinct diagnoses have different clinical characteristics and treatment pathways. The concussion often is treated first with vestibular rehabilitation therapy, an exercise-based approach to improving balance and movement.
PTSD is usually treated with exposure therapy to retrain the body’s systems by building up a tolerance to the stimuli that cause the reaction. “With PTSD, we push our patients out of their comfort zone,” says Dr. Collins. “We tell them don’t avoid loud places, don’t turn off the lights; we want you to watch TV, use the phone, be around people. That’s why it’s important to separate the vestibular symptoms from the PTSD symptoms so we can create the right treatment course. We can achieve good outcomes through a dual approach to the dual diagnosis.”
The UPMC Sports Medicine Concussion Program offers a comprehensive approach to concussion—and we don’t just follow the best practice protocols for diagnosis, management, and rehabilitation: We create them. Visit our website to learn more or call us at 412-432-3681 for an appointment.
Dr. Micky Collins, Rand Corp., Dept of Veterans Affairs
About Sports Medicine
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