Vasterling, Bryant, and Keane tackle the complex and dynamic interplay between post-traumatic stress disorder (PTSD) and mild Traumatic Brain Injury (mTBI)/concussion. The editors address issues related to the potentially complicating neural and psychosocial mechanisms of each injury and those factors which interfere with recovery. The assessment and treatment of individuals with both diagnoses are reviewed in depth. To address these subjects, the editors assembled an impressive array of contributors and created a comprehensive volume geared toward practitioners assessing and treating these patients.
While, today, an overarching societal focus of co-morbid PTSD and concussion/mTBI is due to the war and concerns for service member health, the volume does not provide an over-focus on the military. Military topics are provided coverage; however, co-morbid PTSD and TBI also occur in civilian cases, such as in motor vehicle accidents and assaults. This volume provides information on these topics as well and integrates the research findings from all populations making it applicable for providers serving a wide variety of individuals.
Although the title indicates that PTSD and mTBI will be the key topics, the book does an excellent job of addressing additional areas of concern, to include other co-morbid conditions and variables which need to be integrated into any case formulation. Outcome research is reviewed with reference to premorbid issues such as intellectual functioning and personality characteristics, as well as post-injury anxiety, depression and somatic concerns, expectations, misattribution of symptoms, and issues related to secondary gain. Significant coverage is provided on co-occurring pain, typically headaches, and the relationship between pain, PTSD, and mTBI. Substance use disorders, a significant complicating factor in the effective assessment and treatment of any disorder, are summarized in the context of emotional trauma and brain injury. The interconnectedness among pain, PTSD, concussion/mTBI and substance use can be inordinately complex, but this volume provides a clear foundation in which to address the constellation of these dynamic symptom presentations.
While neuroimaging research in these areas can be controversial, the volume reviews how brain imaging has been used to examine mTBI and PTSD, factors that appear to correlate with imaging findings, and potential avenues for further examination with various types of imaging. In addition, the interplay between the neurocognitive effects of both brain injury and PTSD are examined in the context of how cognitive factors influence symptom expression, recovery, and treatment interventions. Of particular value are the discussions pertaining to the effective treatment of pain, detection of reduced effort in both PTSD and mTBI assessments, and the efficacy of early education and intervention for concussion/mTBI. The dilemmas associated with assessing and treating multiple conditions which share similar symptom presentations are explored throughout the work.
Overall, this is an outstanding volume, the content of which is essential for any provider to understand when addressing either of these conditions alone or in combination. Only two areas remain comparatively murky. First, although the authors address the lack of professional consensus regarding the definition of mTBI, they use the term mTBI to the exclusion of the term concussion, noting early in the volume that concussion is a less serious injury than mTBI. This term is used regardless of the studies cited and the fact that many professionals conceptualize these injuries as concussion. This inconsistent application of terminology (throughout the medical field) may have the unintended clinical consequence of setting up poor expectations of recovery. For example, military members are provided their diagnoses in the field in the terms of Grade I, II, or III concussion per the American Academy of Neurology (AAN) guidelines (Quality Standards Subcommittee of the AAN, 1997). In addition, assessment, treatment, and return to duty determinations in the combat zone are based on concussive diagnoses (Department of Defense, 2010). Yet, once service members have returned home, the injury is now couched as an mTBI. In my experience as a military neuropsychologist, it has not been unusual to hear a service member comment that he/she was diagnosed with a concussion in theater but now is worse, since the diagnosis was changed to mTBI. On the other hand, there may be a good argument that using the term mTBI as opposed to concussion may assist in getting the message across that these injuries should not be taken lightly and may mitigate the tendency of athletes and service members in particular to minimize symptoms. Which view is correct needs to be determined and explicated. The work does not address this problem of terminology and simply opts to use the term mTBI exclusively, a nosological proclamation that is premature, and potentially confusing to the reader and consequently to the patients they treat.
From this reviewer's military neuropsychological perspective, it was also disappointing that the book did not allocate more space to blast concussive injury. Although the book integrates findings from Operation Iraqi Freedom, Operation Enduring Freedom, and other limited blast research throughout the chapters and spends time in discussing military policies and prevalence, there is no chapter dedicated to what is currently known about blasts, blast concussions, and combat stress. Given the large numbers of service members who have experienced blast injury, a growing literature on blast concussions, and concerns that blast represents a distinct form of injury, the inclusion of a chapter specifically devoted to this issue would be high priority in future editions.
In sum, this book is a major contribution to the field, pulling together disparate resources and presenting them in a manner that is immediately usable by a wide range of practitioners. It will certainly help neuropsychologists navigate these difficult symptom presentations as they conduct assessments of these individuals. The volume is geared to provide valuable information to providers throughout the entire spectrum of care, from acute management and early intervention, to informed assessment practices, and finally to longer term empirically validated treatments. This volume may easily be considered one of the key resources on PTSD and mTBI/concussion at this time.
The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Navy, United States Marine Corps, Department of Defense, or the United States Government.