References

1. Stahl SM, Mood Disorders, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 453–5102. Stahl SM, Antidepressants, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 511–6663. Stahl SM, Mood stabilizers, in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge University Press, New York, 2008, pp 667–7204. Stahl SM, Valproate, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 569–745. Stahl SM, Olanzapine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 497–5026. Stahl SM, Lamotrigine, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 259–667. Stahl SM, Zolpidem, in Stahl’s Essential Psychopharmacology The Prescriber’s Guide, 3rd edition, Cambridge University Press, New York, 2009, pp 595–8

Patient FileThe Case: Suck it up, soldier and quit whining

The Question: What is wrong with a soldier returning from his deployment in Afghanistan?

The Dilemma: Is it traumatic brain injury, PTSD or post-concussive syndrome, and how do you treat him?

Pretest Self Assessment Question(answer at the end of the case) Which symptom(s) below distinguish PTSD from persistent post concussive syndrome following a mild traumatic brain injury?

A. Problems with concentration/attention

B. Depression

C. Irritability/anger

D. Fatigue

E. Hyperarousal

F. Apathy

G. Emotional lability

H. None of the above

Patient Intake 27-year-old corporal

Returns from Afghanistan after a Humvee accident in which he suffered a head injury

Upon his return to the US one week later, experiences tremors and heart palpitations and feels that his surroundings are unreal

Psychiatric History Toward the end of his tour in Afghanistan, had a Humvee accident in which the vehicle flipped and he hit his head and lost consciousness momentarily

Afterwards he was “stunned”, upset but remembered the accident

He denies that it frightened him in any way

Upon return to the US he saw his primary care provider on the military base for his symptoms

Social and Personal History Has been in the army for 6 years

Married 4 years, 2 young children

One week ago finished his first 15-month deployment to Iraq

Has been exposed to combat

Smokes one to two packs of cigarettes per day

No drinking or alcohol in Iraq

Binge drinker on weekends at home in the US

Medical History None

BP normal

BMI normal

Normal blood tests

Family History Father: alcohol abuse

Treatment History Given a few zolpidem for sleep and a few lorazepam for anxiety by a medic in the field before departing Iraq

None since returning home last week

Attending Physician’s Mental Notes: Initial Psychiatric Evaluation Because of complaints of tremors and heart palpitations and a sense of unreality, the army primary care provider back on base in the US thinks this is mostly a normal stress reaction and a soldier decompressing from a combat experience

Suspects also that the soldier might also be having some panic attacks

Prescribes duloxetine and told the patient that his symptoms are probably to be expected given the circumstances of decompressing from a war zone and that he doubts whether any damage was done by the head injury

The patient is reassured that his symptoms are common in soldiers when they first come back from combat, and that he mostly just needs a few weeks of down time

Also told that if he “sucks it up” he will get over it but if he complains and whines to others in his unit, he could lose respect

Case Outcome: First Interim Followup, Week 1 Patient not improving

Now tells the army primary care provider something that he did not mention last week

The patient says he constantly hears a buzzing sound and has done so ever since the Humvee accident

“It is like a swarm of bees are buzzing right into my ear”

The patient also appears insensitive to external stimuli, doesn’t react to sounds or voices

He is also sweating constantly which he attributes to the fact that he feels extremely nauseated

Fearing a psychotic event, but not wanting to put that in the patient’s chart or to prescribe an antipsychotic, both of which could end the patient’s military career, the primary care provider prescribes a high dose of lorazepam 1 or 2 mg three or four times a day

The primary care provider tells the patient it is probably just a normal stress reaction that most soldiers get when they return home and that it will go away soon but if it gets worse, to go to the mental health clinic

Meanwhile, an appointment is made for one week back in primary care

The next day, however, the patient comes back exhibiting loss of balance, having to hold onto chairs while walking

Also exhibits odd rapid eye movements

Army primary care provider decides to admit the patient to the hospital on base for a medical evaluation

Also checks blood alcohol level (which was zero)

Primary care provider calls the patient’s wife and asks about the patient’s drinking but she says he is not drinking and is mostly just complaining about the buzzing in his ear and the increasing loss of balance, which got worse yesterday

Based on just what you have been told so far about this patient’s history and recurrent episodes of depression, do you think is going on with him?

– Acute stress disorder

– Post traumatic stress disorder

– Panic disorder

– Psychotic reaction

– Mild traumatic brain injury

– Persistent Post Concussive Syndrome

– Reaction and side effects from benzodiazepines

– Drug abuse

– Other

Case Outcome: First Interim Followup, Week 1, Continued Psychiatry was not consulted in the hospital so that the patient would not think he was crazy and to keep mental health notes out of his medical records

ENT(ear nose and throat specialist) was consulted who felt that there might have been some mild vestibular damage from the Humvee accident but that it would likely resolve

ENT also tells the primary care manager that vestibular dysfunction may cause anxiety and thinks maybe the patient is freaking out from his vestibular symptoms and is developing panic attacks

The patient is told that once his vestibular symptoms resolve, any mental health issues should also be resolved

Meanwhile the patient continued his duloxetine 60 mg/day and lowered his lorazepam to 0.5 mg as needed

Case Debrief Lots of information is missing here

Need more details of the patient’s symptoms following the head injury

Did he really lose consciousness or was he just dazed, confused or seeing stars (the latter appears more likely here since he remembered the accident)

Was he really not frightened by the Humvee accident?

Any delusions or hallucinations? (doubt that they are present)

Is his lack of reaction to external events accompanied by a subjective sense of numbing, detachment or absence of emotional responsiveness and if so– Does he seem to be in a daze?– Does he experience depersonalization or derealization?– Does he have any dissociative amnesia for events in Iraq?– Nightmares?– Flashbacks?

Is his problem with balance episodic, coming in attacks that might represent panic and is it accompanied by tremors and palpitations?

Are his balance symptoms entirely due to the high dose lorazepam or were these symptoms present previously and worsened by lorazepam?

Much more will be clear in a month, in which case persisting symptoms probably represent something more serious

Hopefully, all symptoms resolved and if so, it is likely this soldier was sent back for another combat tour in Iraq but further followup is not available

Two-Minute Tute: A brief lesson and psychopharmacology tutorial (tute) with relevant background material for this case – Differential Diagnosis of PTSD, acute stress and traumatic brain injury

Table 1: What is an Acute Stress Disorder and How Does It Differ from PTSD? Anxiety, dissociative symptoms within a month after exposure to an extreme traumatic stressor

Requires the same exposure to a traumatic event as required for the diagnosis of PTSD, namely:– The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others, and the person’s response was intense fear, helplessness or horror

Has dissociative symptoms of numbing, reduced awareness of surrounds, derealization, depersonalization or dissociative amnesia

Reexperiencing, avoidance and hyperarousal occurs and causes distress or impairment

Lasts 2 days and a maximum of 4 weeks

If it lasts longer, it is considered PTSD

How common is acute stress disorder in returning combat troops?

Is this a “normal” reaction to deployment in war?

PTSD does seem to occur in 10–20% of combat troops

Acute stress reactions that do not go on to become PTSD resolve within a month by definition

Table 2: What is TBI (Traumatic Brain Injury)? A physical or mechanical brain injury causing temporary or permanent impairment of brain function

Can be open (foreign object penetrating the brain) or closed (blunt force, acceleration/deceleration)

Mild TBI

Alteration in level of consciousness or loss of consciousness lasting up to 30 minutes

Normal CT and/or MRI scans

Glasgow Coma Scale score of 13–15

TBIs are the most frequent physical injury among personnel serving in the Iraq and Afghanistan wars, sometimes called the “signature wound” of these conflicts and are typically closed, resulting from explosion or blast injury

Table 3: Glasgow Coma Scale Table 4: Can TBI and PTSD Co-occur? Controversy over whether it is possible for both PTSD and TBI to result from the same trauma

Many soldiers would rather call their injury TBI than PTSD, one denoting heroic injury, and the other, weakness

The “signature wound” of the Iraq/Afghanistan conflict may be PTSD rather than TBI, or maybe both

How can you tell the difference between mild TBI and PTSD?

How can they co occur if TBI generally involves amnesia of the traumatic injury while PTSD presumably requires recollection of the traumatic event?

Large scale population studies suggest that TBI and PTSD can co-occur, with severe TBI actually protective against PTSD whereas mild TBI may increase risk for PTSD, perhaps because resulting cognitive deficits impair the ability to process emotional information related to the trauma

Table 5: What is PPCS (Persistent Post Concussive Syndrome? The majority of individuals who suffer a mild TBI (traumatic brain injury) experience acutely:– Disorientation– Confusion– Agitation

Many also experience– Fatigue– Headaches– Dizziness– Sleep disturbances– Seizures– Irritability/anger

Symptoms usually resolve over several days to weeks

A significant minority may experience persistent symptoms that comprise PPCS

All of the above symptoms plus additional cognitive impairments:– Memory– Attention– Concentration– Executive function– Plus additional emotional symptoms– Apathy– Emotional lability– Disinhibition

Figure 1: PPCS and PTSD: Symptom Overlap

Posttest Self Assessment Question: Answer Which symptom(s) below distinguish PTSD from persistent post concussive syndrome (PPCS) following a mild traumatic brain injury (TBI)?

A. Problems with concentration/attention

B. Depression

C. Irritability/anger

D. Fatigue

E. Hyperarousal

F. Apathy

G. Emotional lability

H. None of the above

Answer: H – none of the above, meaning that any of the symptoms listed can by common to both PTSD and PPCS. Distinguishing symptoms that occur in PTSD but not PPCS include nightmares, flashbacks and guilt. Distinguishing symptoms that occur in PPCS but not PTSD include headaches, sensitivity to light and sound, memory deficit, dizziness and disinhibition.