Comorbidity

Psychiatric Comorbidity

People with traumatic brain injuries don’t just have physical comorbidities. They also have Psychiatric Comorbidities. Psychiatric comorbidities are conditions that can happen after the physical injury has occurred and may even be improving. One of the most common problems occurring after a traumatic injury is post-traumatic stress disorder or PTSD.

PTSD is a psychiatric condition where a person experiences emotional symptoms that remind the individual of the trauma they went through. The more serious the injury, the more likely the chances of developing PTSD, although some people seem more resistant to PTSD than others. The common causes of PTSD include sexual assault, witnessing a tragedy, warfare or suffering a serious injury, particularly a traumatic brain disorder.  Anything that threatens death can cause PTSD. Women are more likely to develop PTSD because they are more likely to experience high impact events. Children less than ten years of age seem to be less likely to develop PTSD following a trauma when compared to adults.  War vets who have traumatic brain injury are at one of the greatest risks for PTSD.  

Some researchers believe that certain people are susceptible to PTSD because of genetics.  Genetic factors alone increase the chances of getting PTSD by 30%.  In one study, twins were followed in combat. The study found that identical twins had a higher risk of getting PTSD in the same way when compared to non-identical twins. Researchers found that people who had a gene called RGS2 and who were exposed to trauma had an increased risk of developing PTSD. Other researchers have found even newer genes that are related to getting PTSD. People who have PTSD often suffer from substance abuse, in part, because they are self-medicating their disease.  The substance can be alcohol, benzodiazepines, or illicit drugs. Often, these conditions need to be treated first or possibly along with PTSD. To have PTSD, you need to have exposure to a traumatic event accompanied by the persistent re-experiencing of the event. Flashbacks are possible as are recurring distressing dreams. Additionally, one may experience persistent avoidance and emotional numbing, persistent symptoms of increased arousal that are new since the trauma, significant life impairment and a duration of symptoms greater than a month.   

Depression is another comorbidity to traumatic brain trauma.  Depression is a psychiatric disorder that has a lot of brain chemistry associated with it.  It appears to be related to low levels of brain serotonin or possibly norepinephrine.  Even though it is a chemical disease, there is great deal of evidence that traumatic incidents, especially if the traumatic incidents cause traumatic brain injury, predispose a person to becoming depressed. In addition, people with traumatic brain injury have had interpersonal and social losses since becoming injured and this will add to the chances of becoming depressed. Substance abuse such as alcohol abuse, abuse of opiates, abuse of benzodiazepines or abuse of illicit drugs is common in depression. Like PTSD, these are individuals who are self-medicating their emotional pain and suffering. Anxiety disorders are common after a person has suffered a traumatic brain injury.  These people have chemical changes in their brain that trigger anxiety.  They feel fearful all the time, during certain situations or at certain times of the day.  The anxiety can be quite disabling, even worse than the disability associated with the traumatic brain injury.

PTSD as Comorbidity of Brain Injury

Post-traumatic stress disorder or PTSD is a common comorbidity of brain trauma. PTSD involves experiencing anxiety, sleep disturbance, nightmares, repetitive reliving of the traumatic event, flashbacks, numbing and dissociation from the event.

Even though many people have amnesia from having a sudden blow to the head, the brain can remember what happened to the individual and they can have post- traumatic stress symptoms even without a conscious memory of the event. Amnesia of the event may protect the victim from some aspects of PTSD; however, if the victim sustained loss of another person or people because of the trauma, there may be some PTSD symptoms.  Since PTSD symptoms and traumatic brain injury symptoms are similar, it may be difficult to tease out which symptoms are from a traumatic brain injury and which are from PTSD.

Symptoms of a traumatic brain injury include the following:
  • Dizziness
  • Headache
  • Fatigue
  • Difficulty sleeping
  • Bothered by noise and light
  • Visual issues
  • Memory difficulties
  • Poor judgment
  • Focus problems
  • Trouble speaking thoughts
  • Feeling slowed down
  • Depression
  • Anxiety
  • Personality changes
  • Anger
Just because a person has these symptoms does not mean the PTSD or TBI is getting worse.  It is part of the healing process and may even mean that one is improving.  There are similar symptoms when it comes to traumatic brain injury and PTSD.  It can be hard to know which symptoms are which.  In some ways it is important to know which is which because some medications used in PTSD shouldn’t be used if the problem is related to TBI.  Talk to your trauma doctor or a good psychiatrist to help sort out the symptoms and prescribe proper medications.

Regardless of the mildness or severity of the injury, the effects relating to TBI or PTSD can be serious and life threatening.  Diagnosing PTSD related to TBI can be extremely difficult because in both cases, there may not be any physical signs of injury.  The details of the accident can be hazy because of loss of memory of the event.  The event that caused the TBI may be confusing because of a variety of situations, such as a combat situation. It takes a skilled clinician to decide which symptoms are related to which situation.

Some people recover from their TBI but do not recover from their PTSD.  Lingering memories and thoughts can incapacitate the patient because they might not have let go of the emotional trauma of the event.  This takes skilled psychotherapy and sometimes medications to help the person process the trauma they experienced.

Fatigue is an issue with both TBI and PTSD.  As the individual returns to his or her regular schedule, it is common to have fatigue with basic activities. Headaches may impact daily activities.  Thoughts may be intrusive and it may feel as though the event is happening all over again.  Nightmares may interfere with sleep. A good psychotherapist can help the patient overcome these difficulties and learn how to be a healthy survivor of traumatic incidences.

Anxiety

Anxiety as a Comorbidity of brain injury research has shown that more than 60% of people with brain damage had a psychiatric problem up to 5.5 years after the injury. Many people had new episodes of anxiety and depression that were not present before the injury. For this reason, a victim of traumatic brain injury should be screened for psychiatric illnesses several times after the injury so they can by helped as soon as possible.

Having a brain injury can change the way people express or feel emotions. A person with a TBI can have several kinds of emotional issues. Some have “rolling emotions” or up and downs that last a short period of time and go away.  They can have a mood or anxiety that lasts just a few minutes and then the person gets over the feeling only to have another feeling take over. Anxiety and other mental illness symptoms are often the result of damage to the aspect of the brain that controls emotions.  There is no specific event that triggers an emotional response. Families can feel confused by these emotional changes, especially without understanding the reason behind the emotion.

Anxiety is a feeling of nervousness or fear that is out of proportion to the situation.  A brain-injured individual can feel anxious without knowing why they feel that way.  It may be because they made mistakes or failed at tasks.  They might feel like they are being criticized at every turn. Situations are more difficult to cope with after a brain injury leading to states of anxiety. Other situations that can cause anxiety or even panic attacks include feeling rushed or being in crowds. Panic attacks are sudden attacks of serious anxiety that make one feel dizziness, dissociation, chest pain and shortness of breath. There are medications that control panic attacks, in particular Paxil, a SSRI antidepressant.

Anxiety in traumatic brain injury can cause the individual to replay the incident that caused the trauma.  It can show up in difficulty sleeping, flashbacks, generalized anxiety or situations that remind the individual of the trauma.  These types of anxiety respond to Paxil, as well as to the SSRIs like Prozac, Celexa, Lexapro and Effexor. While these treat depression, they also treat the anxiety that goes along with it. Anxiety is also treated with benzodiazepines such as Ativan, Klonopin, and Xanax.  As benzodiazepines, they act directly on the part of the brain associated with anxiety. The major side effects are sedation and potentially addiction.  

What causes anxiety after suffering from a traumatic brain injury? Some of it is difficulty concentrating and reasoning. This makes the TBI victim have difficulty solving problems. This makes the person feel inept and they will experience anxiety when their cognition is put to the test or when they have to perform in front of others.  Anxiety comes also from fear that the situation causing the trauma could happen again. The driver who sustained a traumatic brain injury during an accident might be afraid to drive again or will experience anxiety just being in a moving car.

Depression

Depression as a Comorbidity of brain trauma is a feeling of loss, sadness, hopelessness and despair that comes on over time and doesn’t seem to get better.  It is so overwhelming that it interferes with daily life.  If it lasts longer than two weeks it is called major depression. It is important to seek medical attention for major depression. Major depression symptoms include: sadness, hopelessness, changes in sleep or appetite, feelings of worthlessness, loss of interest in usual activities, fatigue, loss of energy, problems concentrating, withdrawing from others, feeling restless or thoughts of death or suicide.

While its normal to feel losses when one has had a TBI, if these feelings last longer than expected, it is called depression.  Depression is common after a TBI.  In fact, about half of all people with a TBI suffer from depression in the first year after their injury. About two-thirds of people with a TBI develop symptoms within 7 years of their injury.  For normal people, the rate of depression is one in ten persons a year. More than half of the people with depression following a TBI also suffer from anxiety.

What are the causes of depression following a TBI? Part of it can be due to physical changes in the brain because of the injury.  Neurotransmitters can be in different concentrations, resulting in depression. There can be changes in emotions following an injury that leads to disability, and changes in one’s role in a family and in society. It may be due to factors unrelated to the trauma and more related to genetics, personal and family relationships that were there before the trauma. If one develops depression after TBI, seeking medical attention as soon as possible is a good idea.  Seek the advice of a professional who understands the ins and outs of this disorder after suffering a traumatic brain injury.   

Depression is an illness not unlike diabetes or high blood pressure that cannot be wished away. Depression may require a multifactorial approach to manage.  If there are thoughts of suicide, immediate medical attention is necessary.  Try a crisis hotline or make use of an emergency room. Depression following TBI is best treated with a combination of medications and psychotherapy. Medications are designed to alter the combinations of neurotransmitters in the brain. They are not addictive and can be used for long periods of time. Antidepressants work well on all features of depression as well as anxiety symptoms.  

There are several classes of antidepressants. The most commonly used antidepressants are called selective serotonin reuptake inhibitors or SSRIs. They include Prozac, Celexa, Zoloft and Paxil.  They have the fewest side effects of any antidepressants, except for sexual side effects.  There are also serotonin norepinephrine reuptake inhibitors or SNRIs.  These have fewer sexual side effects and might be helpful in patients who have traumatic brain injuries.  Tricyclic antidepressants should be avoided in TBI patients.  The same is true for MAOI inhibitors.  They have side effects that can be bad for people who have had traumatic brain injuries. When starting antidepressant medication, expect it to take up to 4 weeks from the outset in order to feel better.  If one type of antidepressant does not seem to work, there are plenty of others that can be attempted in order to help the patient improve.  Psychotherapy and counseling can help depression.  The patient can have cognitive behavioral therapy which helps reframe what is going on in the patient’s mind.  Behavioral activation therapy helps the patient enjoy activities again, which in turn improves overall behavior.

Other

People with Traumatic Brain Injury often have Comorbidities which can be more serious than the traumatic brain injury itself.  Comorbidity is defined as another injury or condition that occurs at the same time as the brain injury.  During an evaluation of an injured patient, the doctor looks at a patient’s airway, bleeding areas, circulation and trauma to the chest, abdomen, neck, back and extremities.  Sometimes the comorbidities can be so severe that the traumatic brain injury is considered relatively minor when compared to the other injuries. A common comorbidity in traumatic brain injuries is cervical, thoracic or lumbar spinal injuries.  These can be fractures, fracture-dislocations or spinal cord injuries.  In such cases, the spinal injury takes precedence over the brain injury, especially if the traumatic brain injury isn’t involving active bleeding such as is seen in subdural or epidural hematomas.  The spine is immobilized and possibly surgery is done to correct the fracture dislocation or to remove bone fragments from the spinal canal.

Another common comorbidity is chest trauma. This can include lung contusions that interfere with breathing and rib fractures which can make it difficult to expand the chest.  If the patient is having difficulties with breathing, treating the traumatic brain injury first will only serve to kill the patient because they cannot breathe properly.

Abdominal injuries are also common comorbidities.  When people fall from a great height or are in an automobile accident, the abdomen is relatively exposed and prone to injury.  For example, if a person struck the steering wheel with their abdomen, they can rupture their bowel, mesentery,  spleen or liver, causing excessive bleeding and the need for urgent surgery. These abdominal injuries must be cared for before anything can be done with the traumatic brain injury.

Extremity fractures can happen in any kind of a traumatic injury and is one of the only injuries that carry a lesser priority over traumatic brain injuries.  Extremity injuries, particularly of the upper extremity, are simply wrapped for protection and dealt with later. Sometimes, lower extremity fractures cut off the circulation to the lower limb.  Additional, there can be open fractures that require orthopedic attention to restore the integrity of the bones and tissues so that the limb does not suffer tissue damage or infection.

It is up to the treating team of emergency room doctors and specialists to prioritize the multiple injuries and take care of them in order of priority.  Sometimes the traumatic brain injury is considered top priority but in patients with multiple injuries the traumatic brain injury will be treated at a later time.

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