PTSD versus TBI Diagnostic Difficulties

Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD):

Different, Yet Commonly Confused Disorders
It is important that providers are mindful of the fact that very different mental illnesses can present similar features in a clinical setting. According to Theodore A. Henderson’s article, “TBI and PTSD Appear Similar but Treatments Must Differ,” confusion between traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) is particularly common among providers treating military personnel and veterans. This is exacerbated by the fact that the Clinician-Administered PTSD Scale contains many symptoms which exhibit features of PTSD, making diagnosis for providers which rely upon such instruments very challenging. An estimated 73% of veterans with TBI also have PTSD. Yet even civilians may receive inappropriate diagnoses, as the anxiety and trauma reported after a car accident may be diagnosed as PTSD even though it is actually caused by a TBI.
There are significant risks in confused diagnosis for both disorders. It is not simply that correct diagnosis can delay treatment. In fact, the classes of drugs used for PTSD such as serotonin reuptake inhibitors and benzodiazepines may be inappropriate for TBI, particularly benzodiazepines which may exacerbate the TBI patient’s symptoms. There are indications that brain scans may be useful in differentiating the two disorders, but psychiatrists are often resistant to using them. Treatment for both disorders are becoming further refined, including the use of infrared light for TBI and new drugs for PTSD. But this makes correct diagnosis all the more critical, and providers must be aware of new and more sophisticated diagnostic techniques to ensure patients get appropriate care.
The types of sophisticated insight about TBI are clear in Alison Knopf’s article, “TBI ‘Sequelae’ Require Special Care by Behavioral Health Providers.” Knopf’s article likewise stresses the physicality inherent to a diagnosis of TBI, which is caused by an “external or penetrating injury that disrupts the normal function of the brain” (Knopf 42). The article acknowledges that TBI and PTSD can occur at the same time but while PTSD is an anxiety disorder which can be triggered by a psychological incident without any physical cause, a TBI can be caused by a purely physical incident such as a concussion without PTSD. The problem is that the symptoms can be so similar, including headaches, anxiety, memory loss, and concentration issues, a clinician may struggle if the triggering event is not immediately obvious. For veterans who have been exposed to multiple physical and emotional traumas in wartime, the challenges of differentiation become even more acute.
Knopf suggests that one of the most useful screening devices to distinguish the two disorders is that of analyzing loss of memory or the patient’s experience of memory. With TBI, the most frequent symptom is memory loss, due to changes in brain structure. “It is essential to go into detail about the time of the injuries and whether the person has continuous memories of what happened during the incident” (Knopf 45). Continuous memories are more likely to be associated with PTSD. In fact, one of the possible signs of patients with PTSD is difficulty in forgetting rather than remembering the traumatic incident, and experiencing the incident through flashbacks and dreams. TBI patients are more apt to have missing segments of memory when the injury occurred.
Read in conjunction, the articles highlight the challenges of differentiating the two diagnoses, particularly for providers who do not know the patient before the incident particularly well, as is often the case when veterans are treated. For individuals who have experienced a severe physical trauma, the triggering of a TBI may be more obvious. But even so, some patients may be experiencing PTSD as a result of lingering fear rather than an actual physical complaint. The fact that the disorder can occur in conjunction but are distinct makes separating symptoms difficult for even trained and aware clinicians. The need to avoid treatments which may be inappropriate for one patient type versus another is highlighted in the Henderson article in particular. Although the two disorders can be treated concurrently, certain drug classes should be avoided for patients with TBI, as they may merely exacerbate patient symptoms.
The articles also suggest the need to make full use of all diagnostic tools for patients that may be experiencing either disorder or both. Brain scans are not always used if a diagnosis is made quickly, but given the fact that TBIs exhibit notable physical markers on the brain, ruling out or conclusively determining that one is present can be a useful guide for clinicians. Patients, given the symptoms of both disorders, are also not always reliable for giving a full account of their symptoms, so objective classification is a useful tool. This suggests the need for diagnostic protocols to be reviewed, to ensure that scans are more often used as standard operating procedures and are, of course, covered by insurance.
The Knopf article provides a more hopeful portrait of clinicians’ ability to use discretion in distinguishing the two disorders, including how memories present themselves to the patient. Given the frequently blurred lines in diagnostic screening tools as outlined in Henderson, the Henderson article suggests the need for further research and refining of screening instruments, to more quickly and accurately diagnose PTSD or TBI, versus the Clinician-Administered PTSD Scale which can often create more confusion than lessen it. Still, although more work clearly needs to be done in this area in terms of offering specific treatment for patients, both articles highlight an important problem about what can seem like mysterious illnesses. Particularly when patients are unlikely to be able to fully analyze their symptoms themselves, due to trauma or physical damage, clinicians must step in and act as patient advocates, beginning with a correct diagnosis.



Works Cited
Henderson, Theodore A. “TBI and PTSD Appear Similar but Treatments Must Differ.”
Addiction Professional, 15.1 (2017), 32-37.
Knopf, Alison. “TBI ‘Sequelae’ Require Special Care by Behavioral Health Providers.”
Behavioral Healthcare, 32.4 (2012), 42