Emotional distress following a traumatic brain injury can be both real
and debilitating. Often times, severe emotional distress will mimic many
of the characteristics of organic brain dysfunction. It is the treatment
that differs in each case, however.
In the litigation setting, it is common for insurance companies, and their
lawyers, to contend that the dysfunction and deficits experienced by the
victim did not result from any trauma sustained, but rather from pre-existing
emotional difficulties. So standard is this defense that it is encountered
in virtually all cases of “mild” traumatic brain injury. Therefore,
for purposes of treatment, and in order to prevail over unmeritorious
defenses, it is important to understand the distinction between an organic
brain injury and a debilitating emotional injury.
(a) Post-Traumatic Stress Syndrome.
Perhaps the most common emotional injury following trauma is that of post-traumatic
stress disorder (PTSD). The most comprehensive definitions of PTSD can
be found in the Diagnostic and Statistical Manual – IV (DSM-IV).
Therein, PTSD is defined as follows:
“The essential feature of post-traumatic distress disorder is the development
of characteristic symptoms following exposure to an extreme traumatic
stressor involving direct personal experience of an event that involves
actual or threatened death or serious injury, or other threat to one´s
physical integrity; or witnessing an event that involves death, injury
or a threat to the physical integrity of another person; or learning about
unexpected or violent death, serious harm, or threat of death or injury
experienced by a family member or other close associate. The person´s
response to the event must involve intense fear, helplessness, or horror
(or in children, the response must involve disorganized or agitated behavior).
The characteristic symptoms resulting from the exposure to the extreme
trauma include persistent re-experiencing of the traumatic event, persistent
avoidance of stimuli associated with the trauma and numbing of general
responsiveness, and persistent symptoms of increased arousal. The full
symptom picture must be present for more than one month, and the disturbance
must cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.“
- Onset and duration of post-traumatic stress disorder have been classified
into three general areas:
- Acute – when the duration of symptoms is less than three months;
- Chronic – when the symptoms last three months or longer; and
- With Delayed Onset – where at least six months have past between
the traumatic event and the onset of symptoms.
The traumatic events found sufficient to give rise to PTSD are not insignificant.
These events include, but are not limited to, military combat, violent
personal assault (sexual assault, physical attack, robbery, mugging),
being kidnapped, being taken hostage, terrorist attack, torture, and severe
automobile accidents or other life threatening events.
Victims of PTSD often re-experience the traumatic event in various ways.
Many times, the victim has recurrent and intrusive recollections of the
event or recurrent distressing dreams during which the event is replayed.
In certain rare instances, victims actually experience dissociative states
that last from a few seconds to several hours, or even days, during which
components of the event are relived and the person behaves as though experiencing
the event at the moment.
Avoidance is common for victims with PTSD. Victims tend to avoid anything
associated with the trauma, making a conscious effort to avoid thinking
about, experiencing feelings related to, or even talking about the traumatic
event. Amnesia may even develop for some or all aspects of the trauma.
Victims of PTSD often times become “numb” experiencing “emotional
anesthesia” identified by decreased responsiveness to the external world.
Since the development of PTSD can be influenced by a victim´s previous
history, such as childhood upbringing, personality, pre-existing mental
problems, etc., it is common for insurance companies and their lawyers
to methodically search for pre-existing stressors, rather than the trauma
itself, which could give rise to the claim. However, the severity, duration,
and proximity of a victim´s exposure to the traumatic event tend
to be the most important factors affecting the likelihood of developing
this disorder. Accordingly, competent neuropsychologists must spend considerable
time analyzing all aspects of a victim´s experience before diagnosis.
Clearly, post traumatic stress disorder (PTSD) is an anxiety reaction to
a traumatic event. It has become known as the “signature injury”
of the Vietnam War. It continues to be an injury often sustained by our
soldiers in the Gulf and Iraqi conflicts. The existence of PTSD in individual
sustaining mild traumatic brain injury has been called into question.
Where an individual sustains a loss of consciousness or where the victim
has post traumatic amnesia for events occurring, or where the victim and
has antegrade or retrograde amnesia involving the events occurring, one
could question how anxiety could be experienced from the event itself.
In other words, there must be a memory of the traumatic event. It accordingly
follows that patients who cannot remember the trauma are less likely to
However, since many individual sustaining mild TBI do have some recall
of the traumatic event or of the circumstances surrounding the event,
PTSD and mild TBI due coexist. TBI patients who have intrusive memories
of the traumatic event, and who experienced fear and helplessness in avoidance
of the event, are likely to develop PTSD.
Diagnoses of both PTSD and TBI in patients may be extremely difficult to
make. Many of the symptoms overlap and are otherwise identical. Noise
sensitivity, insomnia, memory loss, quickness to fatigue, attention deficits,
disassociation, quickness to anger, dizziness, headaches, concentration
deficits, and depression are all earmarks of both PTSD and TBI.
In a vicious circle of compounding symptomology, PTSD has been found to
exacerbate the cognitive deficits experienced in mild TBI.
(b) Organic Brain Injury.
The Diagnostic and Statistical Manual – IV (DSM IV) describes underlying
organic injury as “dementia” due to head trauma. DSM IV defines
dementia due to head trauma as follows:
“Dementia Due to Head Trauma: The essential feature of Dementia Due to Head
Trauma is the presence of a dementia that is judged to be the direct pathopsysiological
consequence of head trauma. The degree and type of cognitive impairments
or behavioral disturbances depend upon the location and the extent of
the brain injury. Post-traumatic amnesia is frequently present, along
with persisting memory impairment. A variety of other behavioral symptoms
may be evident, with or without the presence of motor or sensory deficits.
These symptoms include aphasia, attentional problems, irritability, anxiety,
depression or affective lability, apathy, increased aggression, or other
changes in personality * * *.”
Likewise, The Diagnostic and Statistical Manual – IV (DSM IV) likewise
describes an organic injury as “Cognitive Disorder Not Otherwise
Specified” as follows:
“This category is for disorders that are characterized by cognitive dysfunction
presumed to be due to the direct physiological effects of a general medical
condition that do not meet criteria for any of the specified delirium´s,
dementias, or amnestic disorders listed in this section and that are not
better classified as Delirium Not Otherwise Specified, Dementia Not Otherwise
Specified, or Amnestic Disorder Not Otherwise Specified. For cognitive
dysfunction due to a specific or unknown substance, the specific Substance-Related
Disorder Not Otherwise Specified category should be used. ”
- Mild neurocognitive disorder: impairment in cognitive functioning as evidenced
by neuropsychological testing or quantified clinical assessment, accompanied
by objective evidence of a systemic general medical condition or central
nervous system dysfunction (citations omitted)
- Postconcussional disorder: following a head trauma, impairment in memory
or attention with associated symptoms (citations omitted).
In distinguishing PTSD from organic brain dysfunction, the neuropsychological
assessment becomes key. Through neuropsychological assessment cognitive
abilities are typically evaluated through a variety of testing. Since
the criteria for diagnosis of dementia requires impairment in “occupational”
or “social functioning”, and since there must be a “decline
from a previously higher level of functioning”, neuropsychological
assessment greatly aids in the diagnostic process.
Generally, the cause of PTSD is thought to be functional or psychologically
based. In contrast, the cause for organic brain injury involves an actual
change in the brain tissue itself.
Treatment modalities differ markedly between the two. PTSD is commonly
treated through psychotherapy or through the use of medications to control
anxiety and stress. Depending upon the pre-existing characteristics of
the individual, treatment for PTSD can be prolonged and the progression gradual.
In contrast, maximum recovery from organically based brain injury, at least
in terms of thinking skills, typically occurs soon after the event in
question, with gradual recovery continuing throughout the first year to
two years post-injury. Although technology changes with each day, treating
cognitive problems due to brain tissue changes with medications has not
proved highly fruitful thus far.
Perhaps the easiest manner of determining whether a particular victim is
suffering from PTSD – related symptoms only, versus organically
based brain impairments involves analyzing the overall pattern of neuropsychological
assessment results. For example, if the victim demonstrates problems with
motor or sensory abilities isolated on one side of the body (or other
abilities governed by one hemisphere of the brain), such injuries are
more likely to be the result of actual organic brain damage than due to
interference in efficiency of thinking due to PTSD or other emotional distress.
The problem is often times not nearly so clear. Making matters worse, a
victim may be experiencing both PTSD and organic brain injury. In these
cases, a synergistic result can occur heightening dysfunction both in
everyday life and on formal testing.
What must be recognized is that deficits can result from either organic
brain injury or post-traumatic stress syndrome. Neuropsychological assessment
can do much to identify the etiology of the deficits thereby allowing
prompt treatment to ensue.
It should also be recognized that many mild TBI patients experience emotional
distress, fatigue, depression and anxiety. After all, as the individual
sustaining the traumatic brain injury becomes a more self-aware of the
limitations imposed by the injury, why would the individual not become
depressed or experience emotional depress and anxiety? Fatigue in and
of itself can cause of emotional alterations. Add processing speed slowness
together with fatigue and a recipe for a emotional distress exists. Processing
speed difficulties required deliberate effort of the victim to accomplish
what was premorbidly accomplished automatically. The additional concentration
required to accomplish even the simplest of tasks overwhelms and compounds
to cause fatigue in the individual sustaining mild TBI. Irritability sets in.
It should also be recognized that the plethora of symptomology experienced
by individual´s sustaining mild TBI can likewise cause the onset
of depression and anxiety. Awareness of changes in cognitive efficiency
clearly result in anxiety to the patient. Depression in virtually all
minor TBI cases occurs within six months of the trauma, but may be delayed
as self recognition of the injury develops. Depression severity results
in a functional disability and can contribute to cognitive impairments.
The simple fact that one has sustained and organic brain injury does not
preclude the development of emotional disorders. It is not one or the
other. In virtually all cases, it is both. Unfortunately, a synergy of
response to the awareness of organic brain injury can heighten anxiety,
depression, a emotional distress and fatigue. Likewise, the symptoms of
depression, anxiety, and emotional distress can exacerbate the cognitive
deficits resulting from the organic brain injury. This circle of incapacitation
renders the victim helpless.
In the litigation arena, it is likewise often forgotten that we injure
the brains we already have. Any and all “personality flaws”
pre-existing the trauma will likely be amplified following the traumatic
brain injury. These “flaws” certainly will not improve with
the traumatic brain injury. It has unfortunately become the defense of
choice for the defense bar to argue that the cognitive deficits displayed
by the plaintiff resulted not from the trauma but from pre-existing emotional
disorders. It is therefore absolutely necessary that premorbid levels
of function be determined and verified with all corroboration possible.
If you or someone you know has been injured or suffered Traumatic Brain
Injury or TBI, you need the assistance of the Scarlett Law Group.
Call (415) 688-2176 today to speak with a California Personal Injury Attorney.