Evaluation of an Immunomodulatory Probiotic Intervention for Veterans with Co-occurring Mild Traumatic Brain Injury and Posttraumatic Stress Disorder: A Pilot Study

Background: US military Veterans returned from Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) with symptoms associated with mild traumatic brain injury [mTBI; i.e., persistent post-concussive (PPC) symptoms] and posttraumatic stress disorder (PTSD). Interventions aimed at addressing symptoms associated with both physical and psychological stressors (e.g., PPC and PTSD symptoms) are needed. This study was conducted to assess the feasibility, acceptability, and safety of a probiotic intervention, as well as to begin the process of evaluating potential biological outcomes

Chronic Traumatic Encephalopathy and Suicide: A Systematic Review

Traumatic brain injury (TBI) is a global health concern, and the recent literature reports that a single mild TBI can result in chronic traumatic encephalopathy (CTE). It has been suggested that CTE may lead to death by suicide, raising important prevention, treatment, and policy implications. Thus, we conducted a systematic review of the medical literature to answer the key question: What is the existing evidence in support of a relationship between CTE and suicide? Systematic searches of CTE and suicide yielded 85 unique abstracts. Seven articles were identified for full text review. Only two case series met inclusion criteria and included autopsies from 17 unique cases, 5 of whom died by suicide. Neither studies used blinding, control cases, or systematic data collection regarding TBI exposure and/or medical/neuropsychiatric history. The identified CTE literature revealed divergent opinions regarding neuropathological elements of CTE and heterogeneity regarding clinical manifestations. Overall quality of evidence regarding a relationship between CTE and suicide was rated as very low using Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) criteria. Further studies of higher quality and methodological rigor are needed to determine the existence and nature of any relationship between CTE and suicide

Mild Traumatic Brain Injury Update: Forensic Neuropsychiatric Implications

Traumatic brain injury (TBI) involves a wide range of potential neuropsychiatric outcomes, from death or profound impairment to full and fast recovery. This circumstance has contributed to an atmosphere with considerable potential for both clinical confusion and unjustified medicolegal outcomes. Given that mild (m)TBI accounts for most (ϳ80%) TBI events and is generally associated with an excellent prognosis, the risk for erroneous clinical formulations and unmerited legal outcomes seems particularly high in cases involving mTBI. In this article, we summarize the recent results published by the International Collaboration on Mild Traumatic Brain Injury Prognosis (ICMTBIP) and the new approach of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, to TBI, and we explore the clinical and medicolegal implications. Symptoms that emerge after mTBI remain nonspecific, and potential etiologies are diverse. Clinicians and medicolegal experts should be familiar with the natural history of mTBI, able to recognize atypical outcomes, and willing to search for alternative explanations when confronted with persistent or severe impairment

A Forensic Neuropsychiatric Approach to Traumatic Brain Injury, Aggression, and Suicide A N A L Y S I S A N D C O M M E N T A R Y

Aggression is a common neuropsychiatric sequela of traumatic brain injury (TBI), one which interferes with rehabilitation efforts, disrupts social support networks, and compromises optimal recovery. Aggressive behavior raises critical safety concerns, potentially placing patients and care providers in harm's way. Such aggression may be directed outwardly, manifesting as assaultive behavior, or directed inwardly, resulting in suicidal behavior. Given the frequency of TBI and posttraumatic aggression and the potential medicolegal questions surrounding the purported causal relationships between the two, forensic psychiatrists need to understand and recognize posttraumatic aggression. They also must be able to offer cogent formulations about the relative contributions of neurotrauma versus other relevant neuropsychiatric factors versus combinations of both to any specific act of violence. This article reviews the relationships between TBI and aggression and discusses neurobiological and cognitive factors that influence the occurrence and presentation of posttraumatic aggression. Thereafter, a heuristic is offered that may assist forensic psychiatrists attempting to characterize the relationships between TBI and externally or internally directed violent acts. J Am Acad Psychiatry Law 41:274 -86, 2013 Traumatic brain injury (TBI) is a common problem in the United States. TBIs are sustained by approximately 1.5 million civilians each year, 1,2 124,000 of whom are expected to experience long-term disability. 3 Current estimates suggest that 1.1 percent of the U.S. civilian population is living with long-term disability from TBI. 4 TBI is also common in soldiers returning from the wars in Iraq and Afghanistan, with an estimated 15 to 20 percent of nearly 2 million deployed U.S. troops having experienced a possible mild TBI. 12 It includes externally directed acts (e.g., verbal outbursts, physical violence toward objects, and physical violence toward persons) as well as self-directed violence (e.g., nonsuicidal self-directed violence, suicide attempts, and suicide). Aggression interferes with rehabilitation efforts, disrupts social support networks, and compromises optimal recovery. Caregivers and families have described posttraumatic behavior, including aggres

Diffusion tensor imaging in mild traumatic brain injury litigation

A growing body of literature addresses the application of diffusion tensor imaging (DTI) to traumatic brain injury (TBI). Most TBIs are of mild severity, and their diagnosis and prognosis are often challenging. These challenges may be exacerbated in medicolegal contexts, where plaintiffs seek to present objective evidence that supports a clinical diagnosis of mild (m)TBI. Because DTI permits quantification of white matter integrity and because TBI frequently involves white matter injury, DTI represents a conceptually appealing method of demonstrating white matter pathology attributable to mTBI. However, alterations in white matter integrity are not specific to TBI, and their presence does not necessarily confirm a diagnosis of mTBI. Guided by rules of evidence shaped by Daubert v. Merrell Dow Pharmaceuticals, Inc., we reviewed and analyzed the literature describing DTI findings in mTBI and related neuropsychiatric disorders. Based on this review, we suggest that expert testimony regarding DTI findings will seldom be appropriate in legal proceedings focused on mTBI