Serving Men with Traumatic Brain Injuries

It is estimated that 1.7 million people suffer a traumatic brain injury (TBI) every year in the United States, and while most are treated and released, 52,000 die as a result (U.S. Department of Health and Human Services, Get the stats on traumatic brain injury in the United States. Retrieved from http://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf, 2010). Traumatic brain injury has a significant impact on children, and about 750 of 100,000 children experience a TBI every year (Anderson, Brown, Newitt, & Hoile, Neuropsychology, 25, 176–184, 2011). Although these numbers are concerning, improvements in technology as well as other advances are resulting in decreased mortality, albeit with increased morbidity, which means that neuropsychologists are likely to see more patients with TBI going forward. The Centers for Disease Control and Prevention (CDC, [Surveillance for Traumatic Brain Injury–Related Deaths — United States, 1997–2007]. MMWR 2011; 60, 1–32, 2011) noted that the decrease in TBI-related deaths could be due to the increased use of seat belts, child safety seats, and motorcycle helmets, as well as changes in driver’s licensing and education programs, and improved pre-hospital triage and hospital care. The prevalence, severity, and functional implications of TBIs vary depending upon factors such as the patient’s age, the type of TBI, the number of previous TBIs, the location of the injury, the duration of coma and Post Traumatic Amnesia (PTA), secondary injuries, the degree of mechanical trauma, environmental risk, ethnicity, and resiliency factors, as well as other considerations [Davis & D’Amato, Neuropsychology of Asians and Asian-Americans: Theory and practice. New York, NY: Springer, 2014; Lezak, Howieson, & Loring, Neuropsychological assessment (4th ed.). New York, NY: Oxford University Press, 2004]. The cognitive deficits that arise following a TBI can have a substantial impact on social, behavioral, and academic and/or vocational functioning, as well as the ability to independently perform activities of daily living. Furthermore, the cognitive and physical limitations associated with TBI may trigger or exacerbate stress within the family. In addition to these considerations, patient gender plays a significant role in the diagnosis and treatment of TBI. For example, males are nearly twice as likely as females to suffer a TBI (Bruns & Hauser, Epilepsia, 44(2), 2–10, 2003), which also places them at increased risk for subsequent TBIs. Men may also suffer greater deficits following a TBI [Schopp, Shigaki, Johnstone, & Kirkpatrick, Journal of Clinical Psychology in Medical Settings, 8(3), 181–188, 2001], although the research on outcomes related to sex are somewhat mixed (and are reviewed later in this chapter). Other concerns that should be considered when working with men and TBI are related to comorbid psychiatric conditions such as depression or Post-Traumatic Stress Disorder (PTSD) that can impact the sequelae of TBI. For example, Carlson et al. (The Journal of Head Trauma Rehabilitation, 26, 103–115, 2011) reviewed the literature regarding TBI and PTSD and noted that in three studies evaluating Iraq and Afghanistan war veterans, the frequency of probable PTSD/mild TBI ranged from 5 to 7 %, although among the war veterans with probable mild TBI the frequency of probable PTSD ranged from 33 to 39 %. These results suggest that the presence of mild TBI is a significant risk factor for comorbid PTSD. This can be troublesome for treatment planning given the overlap between some of the symptoms of PTSD and TBI. Similarly, Vasterling et al. (The British Journal of Psychiatry, 20, 186–192, 2012) evaluated 760 soldiers pre- and post-deployment and found that 17.6 % of the soldiers with TBI screened positive for PTSD and 31.3 % had positive depression screens. In summary, the understanding of sex differences in TBI should be an important consideration of neuropsychologists and other members of the treatment team. An understanding of sex differences can result in a more appropriate understanding of the mechanism of injury, and may affect the approach to neuropsychological assessment, as well as facilitate improved care for the patient and their family.