Differentiating the long-term 

consequences of TBI and psychological 

trauma: 

When and why does it matter?

Jennifer J. Vasterling, Ph.D.

Mieke Verfaellie, Ph.D.

VA Boston Healthcare System

HSR & D Cyberseminar

May, 2014


Overview

 Epidemiology

 Clinical manifestations

 Mechanisms leading to comorbidity

 Clinical implications
Epidemiology 


OEF/OIF TBI, PTSD, 

Depression Prevalence

 RAND study (N = 1965)

 Overall If TBI: 

 TBI 20% -------

 

 PTSD 14% 34%

 Depression 14% 32%
Total (%) Women (%) Men (%) Odds Ratio

Etiology 

 Blast 82.7 60.9 83.9 

 Bullet 4.3 2.3 4.5 

 Fall 25.4 36.1 24.8 

 Vehicular Injury 27.3 30.6 27.1 

 Other blunt trauma 33.8 37.3 33.6 

Psychiatric diagnosis 

 PTSD 67.4 59.6 67.8 0.87 

 PTSD + Depression 28.9 37.8 28.4 1.66** 

N=12,605 Veterans with a dx of deployment-related TBI

Iverson et al. (2011; Women’s Health Issues) 
0%

10%

20%

30%

40%

50%

TBI +LOC TBI/LOC - Injury

Other No Injury

Hoge et al. (2008; N Eng J Med) 

PTSD 

N = 2525 Army infantry
TBI Severity and PTSD

Zatzick et al. (2010; Arch Gen Psychiatry) 

 N = 3047 civilians 

 Moderate and severe TBI decreased risk of PTSD, compared to other 

injury controls 

 

 

 

 PTSD assoc. with functional impairment, cognitive symptoms.

PTSD

TBI Severity
Clinical Manifestations 
TBI v. Postconcussive Symptoms

TBI = pathophysiological injury

PCS = expression of symptoms following mild TBI

---------------------------------------------------------------

Post-mTBI: Clinical presentation:

0-72 hrs Symptoms at worst

1-3 months Symptoms resolve

3 months Full recovery
Postconcussional Disorder (DSM-IV) 

 Objective neuropsychological deficits

 3 or more of the following symptoms:

fatigue, disordered sleep, headache,

vertigo, dizziness, irritability/aggression,

anxiety/depression/lability, personality 

change, apathy/lack of spontaneity

 Persists 3+ months

 Functional impairment
Mild Neurocognitive Disorder due to TBI 

(DSM-V) 

 Decline in cognitive performance

 Concern by individual/clinician

 Modest impairment in cognitive performance

 Deficits do not interfere with independence 

in everyday activities

 Evidence of TBI

 Presents immediately after TBI and persists 

past acute post-injury period
Postconcussion Symptoms 

• Symptoms (e.g., headache, concentration problems) 

are non-specific 

• Subjective complaints occur at relatively high levels in 

various non-TBI populations including healthy controls

• Symptoms overlap with PTSD
Overlapping Associated Symptoms

PTSD

Persistent PostConcussive 

Syndrome 

Re-experiencing

Shame

Guilt

Headache

Sensitivity to Light

Dizziness

++

Depression & Anxiety

Insomnia

Irritability/Anger

Poor Concentration

Fatigue

Hyperarousal

Avoidance

Memory deficits

Adapted from: Stein & McAllister (2009). Am J Psychiatry: 166, 768-776 
Postconcussion Symptoms 

• Symptoms (e.g., headache, concentration problems) 

are non-specific 

• Subjective complaints occur at relatively high levels in 

various non-TBI populations including healthy controls

• Symptoms overlap with PTSD

• While symptoms associated with acute effects of TBI, 

psychological factors play role in their maintenance
Scholten et al. (2012; Brain Injury) 
Spectrum of Psychological Trauma 

Reactions

Acute 

Stress 

Reactions

Acute 

Stress 

Disorder

Adjustment 

Disorder

PTSD Depression Other

Anxiety

Disorders

Stressor
DSM-V PTSD Criteria

A. death, serious injury, sexual violence

B. Intrusion symptoms

C. Avoidance

D. Negative alterations in cognition/mood

E. Alterations in arousal

F. > 1 month, clinical impact
Bonanno et al. (2012; Br J Psychiatry)
Mechanisms
TBI/PCS Stress/

PTSD

Combat 
Does TBI Increase Risk of PTSD?

 

 At 12 mos., mild TBI patients ~2x more likely to develop new:

 Adj OR CI

PTSD 1.92 1.08, 3.40

 Panic 2.10 1.03, 4.14

Social Phobia 2.07 1.03, 4.16

Agoraphobia 1.94 1.13, 3.39

 Functional impairment related to psychiatric status.

 Bryant et al. (2010; Am J Psych) 

 n = 1084 civilians with traumatic injuries
How does TBI 

increase risk of 

PTSD? 
Disease Burden

Bell et al., J Neurol, Neurosurg, Psychiatry, 2008

N= 366 acute mild TBI, civilian adults

2 group RCT (during 1st 3 months post- mild TBI): 

 - phone counseling (educ, reassurance, re-activation)

 - emergency care as usual

Intervention reduced:

 - symptoms (e.g., fatigue, sleep problems) and 

 - functional impairment (e.g., work, recreation, cognitive)
Neural Overlap

++

Dorsolateral Frontal 

Cortex

Orbital Frontal Cortex

Hippocampus
Neurocognitive Mechanisms

 Altered memory formation for the 

event and associated emotions, 

leading to poorly controlled recall 

of the event (i.e., re-experiencing 

symptoms)

 Changes in cognitive control may 

lead to emotional dysregulation. 
Does Emotional Distress 

Impede Recovery from TBI?

 Most evidence is from cross sectional work:

 When adjusted for PTSD symptoms, the relationship 

between TBI and most post-concussive symptoms 

disappears. (Hoge et al, N Eng J Med, 2008; Verfaellie et al., J Int Neuropsych 

Soc 2013; Belanger et al., J Int Neuropsych Soc, 2010) 

 Less longitudinal work, especially for mild TBI
Predictors of Postconcussional 

Symptoms (PCS) in Mild TBI

 Ponsford et al., Neuropsychology, 2012

 n = 123 mild TBI; n = 100 no-TBI trauma

Predictors PCS 1 week PCS 3 mo. 

 

 TBI + -- 

 PTA duration -- -- 

 1 wk cognitive performance -- -- 

 3 mo cognitive performance n/a -- 

 Pre-injury psych hx + + 

 1 week anxiety sx + + 

 3 month anxiety sx n/a + 

 3 month PTSD sx n/a + 
Iraq Baseline

assessment

Post-deployment

assessment

N = 760 Army Soldiers

(n = 68 TBI-D+; n= 692 no TBI-D)

Predictors of Cognitive Decline Over 

Deployment 

Vasterling et al. Br J Psychiatry, 2012

White Matter Changes in Relation to 

Deployment TBI

 Hayes et al. (under review)

n = 94 OEF/OIF veterans 

 (healthy control, blast control, TBI+/LOC-, TBI+/LOC+)

 TBI, but not PTSD, associated with white matter 

abnormalities

 TBI only associated with cognitive deficits via white 

matter abnormalities

 PTSD associated with cognitive deficits but not via 

white matter abnormalities
How does emotional 

distress impede 

recovery from TBI?
Resilience 

 Psychiatric status can affect resilience

Resilience - 

“adaptive coping, optimism 

and positive emotion, cognitive reappraisal, positive reframing and 

acceptance, social competence and 

support, purpose in life” (Iverson)
Somatic 

Pre-Occupation

Increased somatic pre-occupation 

(especially for anxiety disorders) 

Anxiety

Attention to 

somatic 

symptoms
Clinical Implications
When Does Etiology of Symptoms 

Matter?

 PTSD symptoms:

 - some symptoms are specific to PTSD

 (e.g., re-experiencing)

 - can be treated with evidence-based 

interventions (e.g., prolonged exposure, 

cognitive processing therapy)
When Does Etiology of Symptoms 

Matter?

 When there has been a TBI event, especially 

soon after the event

 Education around symptom course and 

recovery appears to be most effective 

intervention for mild TBI. 
When is Etiology of Symptoms Less 

Important?

 Treatment of cognitive deficits and non-specific 

symptoms via cognitive rehab and 

psychoeducation

 Examples: 

 CogSMART (Twamley et al., JRRD, 2014)

 Cognitive Strategy Training (Huckans et al., JRRD, 2010)
Summary

 PTSD occurs frequently in veterans with history of TBI

 Considerable symptom overlap between postconcussive symptoms and PTSD

 Bi-directional relationships are likely

 Determining the etiology of symptoms is helpful in some

circumstances but not others
QUESTIONS? 

Jennifer Vasterling: 

 jennifer.vasterling@va.gov

Mieke Verfaellie: 

 mieke.verfaellie@va.gov
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