![]() ![]() 24 PTSS severity is related to premorbid mental health symptoms, 13 emotional reactivity, and self-report of re-experiencing the trauma for individuals diagnosed with severe TBI and PTSD symptoms, 15, 25 and persons diagnosed with TBI and PTSD endorsed more symptoms related to intrusiveness, avoidance, and anxious arousal than veterans diagnosed only with TBI. Notably, TBI severity 14, 17, 23 does not prevent PTSS development, and veterans diagnosed with PTSD and a TBI endorsed more severe PTSD than individuals without a TBI. TBI symptoms and PTSS have been found to co-occur 19, 20 however, the cognitive and psychological sequelae of PTSS and TBI have been studied almost exclusively in mild TBI 21, 22 with limited research on PTSS in moderate and severe TBI samples. 13– 17 Layton and Wardi-Zonna 18 postulate the ability to recall and describe the event via accessing declarative memory is not necessary for development of PTSD symptoms rather, the event’s recording in non-declarative memory may increase PTSS and disruption in daily activities. 12 However, research supports lack of memory of a traumatic event does not prevent individuals from developing post-traumatic stress disorder (PTSD) in child, adolescent, or adult samples regardless of TBI status. 6, 8– 10 Historically, post-traumatic stress symptoms (PTSS) diagnostic criteria required memory of the trauma as well as intrusive, avoidant, cognitive, affective, and agitation symptoms, and it was initially hypothesized inability to remember a trauma is a protective factor limiting development of PTSS 11 given individuals with severe traumatic brain injuries (TBIs) are less likely to report PTSS. Most measures used to determine whether PTA symptoms have resolved include orientation questions and evaluating anterograde and retrograde amnesia severity, attention, executive functioning, and behavioral descriptors for agitation and confusion. ![]() 1– 5 Confusion (often resembling acute delirium), agitation (including but not limited to emotional lability, impulsivity, poor insight, and physical aggression), and compromised attention and executive functioning (i.e., planning, initiating and self-monitoring behaviors as well as decision-making processes) are included in more recent PTA conceptualizations. Post-traumatic amnesia (PTA), an indicator of brain injury severity, is defined as the interval before a person is able consolidate memories related to daily events and orientation and an inconsistent awareness of one’s environment before return of continuous memory. ![]() Traumatic brain injury, post-traumatic amnesia, post-traumatic stress symptoms, cognitive-behavioral therapy INTRODUCTION AND LITERATURE REVIEW Thus, these cases suggest amnestic individuals in the acute recovery stage after severe TBI benefit from CBT to replace maladaptive attributions minimizing PTA and PTSS (e.g., confusion, arousal, and agitation) and improving motivation, participation, and recovery. Notably, following a CBT intervention, agitation, confusion, and arousal were diminished despite having no recollection of the intervention. In this paper, two case studies present preliminary evidence for effective implicit learning following a CBT intervention for individuals in PTA after a severe TBI receiving care. However, cognitive-behavioral therapy (CBT), which uses explicit learning and memory strategies based on cognitive, trauma, and neuropsychology lowers agitation and confusion for amnestic individuals with PTSS. Historically, explicit learning and memory strategies were considered non-efficacious with amnestic individuals until PTA resolves therefore, rehabilitation therapies have utilized implicit learning in the initial phases of recovery. The acute phase of rehabilitation poses difficulties for amnestic individuals that may elicit classic PTA symptoms as well as premorbid PTSS, thereby activating maladaptive cognitions and an increase in agitation and arousal. Differentiation of symptoms associated with post-traumatic amnesia (PTA) versus post-traumatic stress symptoms (PTSS) following trauma presents many treatment challenges among veterans and active duty service members receiving rehabilitation after traumatic brain injury (TBI). ![]()
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