Q. Four years ago, I was the victim of a push-in robbery. I am female, was 44 at the time of the attack, weigh 117 lbs and my assailant was male, 25 and around 180 lbs. During the course of which, I was struck twice in the left temple by my assailant's fist. I saw lights during both blows.

I have noted personality/behavioral changes, as have those around me. I have had one diagnosis (Neuropsych) of PTSD (posttraumatic stress disorder) and mild TBI (traumatic brain injury). I am now seeing another neurologist who seems bent on only a PTSD/anxiety diagnosis who tells me that a fist to the head doesn't necessarily lead to a TBI. It doesn't make sense to me. Is he correct in this statement?

A. I can sense the frustration in your question, but I would never second guess a clinician who has actually examined you, regarding your diagnosis.

What I can tell you is this:

1. Traumatic Brain Injury (TBI) exists on a continuum of severity, ranging from mild to severe; and that even the milder type of TBI can lead to significant anxiety, depression, irritability, mental fatigability, and memory dysfunction, three months after the injury (cognitive problems involving calculation, memory, and so on, are more common with severe TBI, usually involving a loss of consciousness. For a review, see Rapoport et al, Neuropsychiatry Neuropsychol Behav Neurol 2002 Jun;15(2):123-32).
2. Minor brain injury--also called postconcussion syndrome--can follow a blow to the head that does not lead to actual loss of consciousness. Post concussion syndrome may include both cognitive and emotional problems, such as depression, anxiety, or irritability.
3. There is a good deal of overlap between minor brain injury (postconcussion syndrome) and posttraumatic stress disorder (PTSD), and the same patient may, indeed, have both conditions. Usually, however, postconcussion symptoms diminish over about 3 months, whereas PTSD symptoms (e.g., flashbacks, nightmares) may not diminish until 6 months or more after the trauma.

Since you are apparently experiencing problems four years after the event, PTSD may be more likely as an explanation of your symptoms--but since you don't describe those in detail, it's hard for me to say.

Rather than focusing on what's the right diagnosis, I would encourage you to develop a list of target symptoms you would like help with, and to consult with the appropriate professional. For example, if you are primarily experiencing trouble with calculation, short-term memory, planning complex tasks, and abstract thinking, seeking treatment in a Neuro-rehabilitation program may make sense.

If you are primarily experiencing anxiety, depression, intrusive thoughts, nightmares, flashbacks of the robbery, emotional numbing, or other psychological symptoms, it may be most helpful for you to consult a mental health professional with special expertise in trauma.

If it turns out you do have PTSD, there are several psychotherpeutic and medication treatments that may be very helpful. You may also benefit from integrated treatment in a center specializing in neuropsychiatric problems. I hope this is a start toward recovering.

October 2003

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