TBI increases odds for depression, behavior impulsivity, PTSD in this
A new study by a Rhode Island Hospital researcher has found that
traumatic brain injury (TBI) can significantly increase the odds of
having major depression, personality impulsivity and post-traumatic
stress disorder (PTSD) in patients with psychogenic nonepileptic
seizures (PNES). The paper, by W. Curt LaFrance Jr., MD, MPH, director
of neuropsychiatry and behavioral neurology, is published in the current
edition of the journal Epilepsia.
patients who sustain a TBI develop seizures,” LaFrance said. “Very
often, these seizures are believed to be epileptic in nature, and the
patient, therefore, is treated for epilepsy. Later the seizures are
found to be PNES. This study demonstrates the prevalence of co-morbid
mild TBI and PNES, which could suggest that some patients are being
inappropriately treated for epilepsy with antiepileptic drugs, while not
being treated for their actual illness: nonepileptic seizures.”
In this study, which compared patients with PNES and TBI to those
without TBI, LaFrance found that 45 percent of patients with PNES also
had TBI, and 73 percent of those TBIs were mild TBI. Patients who
suffered a TBI had more mood disorder diagnoses, were more likely to
receive disability, and had lower global functioning than PNES patients
who did not have a TBI. This study underscores the importance of
identifying and addressing the impact of TBI in patients with seizure
disorders to ensure appropriate and effective treatment.
Patients who have both PNES and TBI are not only more likely to develop
major depressive disorder, but also are more likely to have a history of
abuse. While these psychiatric disorders are common in patients with
PNES, they are exacerbated by the presence of TBI. Both groups of PNES
patients – with and without TBI – had similarly high rates of
unemployment, but twice as many patients with TBI received disability
payments. This may not only reflect a greater severity of symptoms, but
also may reflect the criteria for granting disability.
“Another significant finding from the study was that if a patient had
both PNES and TBI, the combination resulted in 2.75 odds increase of
having PTSD, and triple the odds increase of having a history of
trauma/abuse,” LaFrance said. “This finding illustrates the importance
of the ‘double hit’ of emotional and physical traumatic experiences that
may occur with abuse and/or a head injury commonly found in the PNES
population. This study shows that TBI and PNES are significantly
associated with a cluster of diagnoses including depression and PTSD,
personality, and/or trauma/abuse history, all of which could have an
impact on functioning.”
Mild TBI appears to be a significant risk factor in patients with PNES,
and is associated with increased psychiatric co-morbidity, symptom
severity, poor functioning and increased disability. Developing
appropriate protocols to more accurately diagnose these patients is the
first step to ensuring proper care is provided.
“This study underscores the necessity of assessing not only the
seizures, but also the somatic and psychiatric co-morbidities in
patients with seizures,” LaFrance emphasized.
Previous studies have assessed TBI as a risk factor for PNES, but did
not measure psychiatric and functioning outcome measures. More study is
needed to explore the development of new treatments as new
pharmacological and rehabilitative options become available.
The study was funded in part by a grant from the NINDS (5K23 NS45902)
awarded to principal investigator W. Curt LaFrance Jr., MD. LaFrance’s
principal affiliation is Rhode Island Hospital, a member hospital of the
Lifespan health system in Rhode Island. He also has an academic
appointment at The Warren Alpert Medical School of Brown University,
departments of neurology and psychiatry and a staff physician at the
Providence Veteran’s Administration Medical Center. Other researchers
involved in the study are Marie DeLuca of Brown University; Jason T.
Machan, PhD, Rhode Island Hospital; and Joseph L. Fava, PhD, The Miriam
Hospital, all of Providence, R.I.