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Diagnostic Relationship Between PTSD and TBI
Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) have recently been viewed as comorbidities, diseases that are simultaneously present in a patient. While brain injury has been a suspected cause of certain pathologies since before recorded history, it was not until the invention of imaging techniques like CT and MRI that new diagnoses and treatment for brain injury could be created. Only from the 1970's was TBI recognized as a public health problem, and from the 1990's standardized guides for protocols and treatments created. A Medical Surveillance Monthly Report in 2015 found that increased reported cases of PTSD and TBI were mainly due to improved ascertainment. The report also concluded that the risk associated with active war service had actually decreased from 2003 to 2014. The report predicts continued higher incidence rates of PTSD and TBI diagnoses if funding for ascertainment programs continues.

A debate still goes on today about the clinical definition of TBI, developed by the Department of Defense and Department of Veteran Affairs (VA) and consequently the diagnosis of TBI, PTSD, or PTSD and TBI. PTSD diagnostic symptoms have been established in the DSM-5 whereas TBI diagnoses are not standardized. TBI is currently diagnosed by a combination of the Glasgow Coma Scale (GCS), duration of loss of consciousness, duration of post-traumatic amnesia, and clinician interview. A 2014 literature review established that there is no current test that can establish or refute a diagnosis of TBI. This is due to the fact that PTSD and TBI have huge overlap between their symptoms and share neuroimaging characteristics. The researchers also found that the impact on cognitive functioning of patients with co-morbid PTSD and TBI is unclear. This is supported by another study conducted with Iraq and Afghanistan veterans which found a strong correlation between self-reported injury markers and neurological symptoms and clinically diagnosed TBI. The study concluded that physical complaints were more consistent with TBI diagnosis than cognitive symptoms. This makes sense given emotional changes in a patient are often attributed to psychiatric issues as opposed to frontal lobe brain injury. This can cause serious issues as certain therapies like pharmacological treatments for PTSD may be dangerous to those with TBI.

A literature review in 2016 provided recommended exam protocols for evaluation and treatment of patients with co-morbid PTSD and TBI. The review found that a neurological exam, head imaging, psychological testing, and lab evaluation were all crucial for proper diagnosis. The study also acknowledged the importance of personalized treatment plans given the varied nature of TBI.

Multiple studies have found, however, that current tests for diagnoses and treatment plans must be more cautiously considered. A study on returning veterans from Iraq and Afghanistan found that failure on a well-validated PTSD test (the Word Memory Test, WMT) was associated with poorer performance on almost all other cognitive tests; however, there was no significant difference between the scores of individuals with PTSD and individuals without. The authors noted that the results did not imply there were no cognitive deficits associated with PTSD but that validity of current diagnostic tests are to be questioned. Another study in 2018 found that co-morbidity complicates diagnoses of both PTSD and TBI, the potential causes for pathophysiological changes, and likewise treatment tools. This is due to both changes in various neurological systems (cognitive, arousal, etc.) as well as the relative compensations of those systems in response. Evidence has suggested that these compensations can fluctuate and evolve over time, implying the same intervention may not be effective in all cases. In addition, a study of the underlying neural differences among a mild-traumatic brain injury (mTBI) group, a mTBI and PTSD group, and a control group found that those with mTBI had hypoactivation of certain brain regions whereas those with mTBI and PTSD had hyperconnectivity of regions of the brain associated with complex cognitive activity. The researchers believed this hyperconnectivity is due to compensation.

Disruptions in sleep is a main symptom of both PTSD and TBI and corrections in sleeping habits and schedules is a recommended form of treatment. However, a study found that it is particularly complex to study because sleep both affects psychological, cognitive, and physical functioning but is also affected by various psychological and physical conditions. Another study showed that among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, there was an increase in the rate of veterans with co-morbid TBI and PTSD with clinically significant insomnia symptoms over a period of time even though the overall rate lowered rate lowered. The researchers found, however, that other factors including unemployment and being unenrolled from school were associated with trouble sleeping. Thus, other confounding factors outside the pathologies of TBI and PTSD must be considered.

New ideas for diagnosing and distinguishing TBI and PTSD have begun to emerge. Researchers found that artificial neural networks can be utilized as a new diagnostic tool for PTSD and TBI. A study used a neural network to create an algorithm to perform pattern analysis matching (PAM) to distinguish those with PTSD, TBI, and other diseases. They found the algorithm was able to make diagnoses with 90% accuracy.