Post-traumatic stress disorder (PTSD) is characterized by a specific clinical syndrome including re-experiencing symptoms, avoidance, and alterations in arousal, cognition, and mood, resulting from exposure to severe traumatic events. PTSD was first officially recognized in the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM III) in 1980,1 and since that time a great deal of knowledge has accumulated about the characteristics of post-traumatic symptomatology, the epidemiology of PTSD, and assessment and treatment of individuals suffering from this disorder. Traumatic events that can result in PTSD fall into a number of categories, including military combat, rape, physical assault, natural disaster, and witnessing violence.2 Since the beginning of the conflicts in Iraq and Afghanistan, it has become clear that PTSD has an important and complex relationship with traumatic brain injury (TBI). Both disorders are common in Iraq and Afghanistan veterans, and together they have been termed the “signature wounds” of these conflicts.3 TBI has emerged as a clear and important risk factor for the development of PTSD, although the reasons for this association are not fully understood.4,5 PTSD may also be an important mediator of the negative sequelae of TBI.4 At the same time, the substantial overlap in symptoms of PTSD and postconcussive symptoms may result in considerable diagnostic confusion.6 Finally, treatment of individuals with comorbid PTSD and TBI may present special challenges, and yet there is currently very little evidence base to guide pharmacologic and psychotherapeutic treatment in this population. In this chapter, we begin with a brief overview of the epidemiology of PTSD, followed by a longer discussion of the epidemiology of comorbid PTSD and TBI, with special attention to the role of TBI as a risk factor for PTSD. We then consider diagnostic issues surrounding PTSD and TBI, including the substantial overlap in symptoms of PTSD and postconcussive syndrome and the resulting difficulty in attributing symptoms to either PTSD or TBI. Next, we briefly review evidence-based treatments for PTSD, including psychopharmacology and psychotherapy. Finally, we discuss special considerations in treating individuals with comorbid PTSD and TBI, as well as offer some preliminary recommendations in treating these patients while highlighting the need for more treatment studies in this population.
