Psychiatric issues in traumatic brain injury
-
Upload
wendy-renzulla-heitkamp -
Category
Health & Medicine
-
view
1.000 -
download
0
Transcript of Psychiatric issues in traumatic brain injury
![Page 1: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/1.jpg)
Psychiatric Issues in Traumatic Brain Injury
Establishing a Differential Diagnosis and Identifying Effective Treatment for Individuals
with TBI and Behavioral Health Problems
Rolf B. Gainer, PhD, Dip. ABDA
Neurologic Rehabilitation Institute, Brookhaven Hospital, Tulsa, OK (800) 927-3974 www.brookhavenhospital.com
![Page 2: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/2.jpg)
10/21/2004 Brookhaven Hospital 2
ObjectivesExplain the scope of problems experienced by traumatic brain injury (TBI) patients, including behavioral health issues Discuss effective strategies for diagnosing neurological impairment, psychiatric illness, and co-morbidityReview conditions created by TBI that can exacerbate underlying psychiatric conditions
![Page 3: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/3.jpg)
10/21/2004 Brookhaven Hospital 3
ObjectivesExamine clinical presentation of persons with a dual diagnosis, which includes TBIExamine treatment/rehabilitation implications for individuals with dual diagnosis
![Page 4: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/4.jpg)
10/21/2004 Brookhaven Hospital 4
Psychiatric Issues in Individuals with TBI
Behavioral components of TBI which resemble psychiatric illnessEffects of brain injury on individuals with pre-existing conditionsIssues of co-morbidityDiagnostic skills
![Page 5: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/5.jpg)
10/21/2004 Brookhaven Hospital 5
Facts About Brain InjuryEvery day nearly 6,000 Americans sustain a brain injury (www.biausa.org)400,000 individuals with moderate and severe brain injuries in the USA are hospitalized each year
![Page 6: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/6.jpg)
10/21/2004 Brookhaven Hospital 6
Causes of Brain InjuryMotor Vehicle Accidents 50%Falls 21%Assaults 12%Sports/Recreation 10%Other 7%
![Page 7: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/7.jpg)
10/21/2004 Brookhaven Hospital 7
Physical Effects of Brain Trauma in Closed Head Injuries
Direct ImpactCoup and Contra Coup InjuriesRotation and ShearingSwellingBleedingNeurochemical ChangesSecondary Effects
![Page 8: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/8.jpg)
10/21/2004 Brookhaven Hospital 8
TBI Severity Distribution InjuryMild 85%Moderate 10%Severe 5%Mortality Rate 11%
![Page 9: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/9.jpg)
10/21/2004 Brookhaven Hospital 9
Assumptions about TBIPhysiological impairmentDisruption of sensoriumDisinhibitionArousal and attention problemsUnstable mood statesProblems in learning and organization
![Page 10: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/10.jpg)
10/21/2004 Brookhaven Hospital 10
Behaviors in Early RecoveryDisorientationParanoid IdeationDepressionHypomaniaConfabulation
![Page 11: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/11.jpg)
10/21/2004 Brookhaven Hospital 11
Behaviors in Early Recovery RestlessnessAgitationCombativenessEmotional LabilityConfusionHallucinations
![Page 12: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/12.jpg)
10/21/2004 Brookhaven Hospital 12
In the early phase of TBI recovery, some behaviors can resemble a psychiatric illness.
![Page 13: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/13.jpg)
10/21/2004 Brookhaven Hospital 13
Biological Aspects of Injury Further Psychological Problems
Seizure disorder may include irritability and behavior dyscontrolCognitive problems, especially memory, affect, emotional responseDenial of deficits may affect capacity to receive helpPreviously effective medications may not work or may exacerbate injury-related problemsDepression may prevent participation
![Page 14: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/14.jpg)
10/21/2004 Brookhaven Hospital 14
The Basic Person Doesn’t ChangeThe injury alters specific aspects of the person’s psychological, cognitive and emotional functionSpecific personality traits or style remain
![Page 15: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/15.jpg)
10/21/2004 Brookhaven Hospital 15
TBI Affects All Aspects of LifePreviously competent individuals may show symptoms of psychiatric diseaseCoping skills are stressedBehavioral controls are lost
![Page 16: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/16.jpg)
10/21/2004 Brookhaven Hospital 16
TBI Affects All Aspects of LifeSocial skills and roles are affectedInsight into TBI-related changes may be limitedPreviously self-managed symptoms may become out of controlRelationships/support systems are stressed
![Page 17: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/17.jpg)
10/21/2004 Brookhaven Hospital 17
Positive Predictors of Recovery Outcome
Focal vs. Globalized injuryAggressive early intervention and trauma careWork history
![Page 18: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/18.jpg)
10/21/2004 Brookhaven Hospital 18
Positive Pre-Injury Predictors
Medical/behavioral complicationsPre-injury achievement levelLearning, school and work historyExtroverted personalityPositive social history
Level of severity, coma durationNatural recovery and return of functions
![Page 19: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/19.jpg)
10/21/2004 Brookhaven Hospital 19
Positive Pre-Injury Predictors
“Good character” and self controlStrong-willed, determined personality
Perseverance and motivationStrong social and family network and supportAbsence of pre-injury psychiatric symptomsAbsence of substance abuse
![Page 20: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/20.jpg)
10/21/2004 Brookhaven Hospital 20
Negative PredictorsPoor response to psychiatric medicationsPoor response to “talking” therapiesFailure in behavioral programs requiring memory and problem-solvingSocial network failure: divorce, separation
![Page 21: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/21.jpg)
10/21/2004 Brookhaven Hospital 21
Negative PredictorsFailure at workInvolvement in the criminal justice systemPersistence of chronic pain and headache symptomsLack of support system
![Page 22: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/22.jpg)
10/21/2004 Brookhaven Hospital 22
Lateralization Issues of Behavior Deficits
Left Hemisphere: depression, agitation, anxietyDiffuse: attention, concentration, arousal, response
Right Hemisphere: unable to respond, flat affect
![Page 23: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/23.jpg)
10/21/2004 Brookhaven Hospital 23
TBI and Psychiatric DiseaseTraumatic Brain Injury can mimic
psychiatric symptoms Examples: memory problems, behavioral
and emotional control problems, mood disorders
![Page 24: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/24.jpg)
10/21/2004 Brookhaven Hospital 24
Biological Brain Changes can Mimic Psychiatric Disease
Biological changes can exacerbate a pre-existing psychiatric diseaseExecutive Syndrome can resemble a thought disorderBehavioral features can resemble other conditions
![Page 25: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/25.jpg)
10/21/2004 Brookhaven Hospital 25
TBI and Psychiatric DiseaseTBI can mask psychiatric
symptomsExample: Frontal system
damage can produce expressive aposody/blunting, which may reduce the person’s ability to express sadness
![Page 26: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/26.jpg)
10/21/2004 Brookhaven Hospital 26
Risk Factors Associated with Psychiatric Diagnosis (Lishman, 1988)
Organic factors Psychosocial factors (socio-economics, pre-morbid personality)Past history of psychiatric illnessFamily history of psychiatric illnessMaleEmergence of problems one year post-injury
![Page 27: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/27.jpg)
10/21/2004 Brookhaven Hospital 27
Research HighlightsLocalization of injury (Fann, 1995)Noradrenergic and serotonergic projections are sites of contusion (Rosenthal, 1998)Individuals with depression and anxiety perceive themselves as more ill (Fann, 1995)
![Page 28: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/28.jpg)
10/21/2004 Brookhaven Hospital 28
Research HighlightsReaction to failure (Alexander, 1975, 1992)Right hemisphere damage (Silver, 1992)Pre-morbid factors and social adjustment (Robinson & Jorge, 1993)Biochemical response (Robinson & Jorge, 1993)
![Page 29: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/29.jpg)
10/21/2004 Brookhaven Hospital 29
Brain Injured Patients with Psychiatric Disorders (Van Reekum, 2003)
The level of severity of the person’s brain injury relates to the potential for the emergence of psychiatric disorders in the first 24 months post-injury
![Page 30: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/30.jpg)
10/21/2004 Brookhaven Hospital 30
Personality Disturbances After Brain Injury
Anxiety or “catastrophic reaction”Emotional lability/disinhibitionParanoia and psychomotor agitationDenialDepressionSocial withdrawalAmotivation/abulia
![Page 31: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/31.jpg)
10/21/2004 Brookhaven Hospital 31
Distinguishing Brain Injury from Psychiatric Problems
Physical injury to the brainCognitive and behavioral deficitsEmotional and personality changeAttention, concentration, arousal, filteringMemory problemsSeizure problemsSelf regulation
![Page 32: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/32.jpg)
10/21/2004 Brookhaven Hospital 32
Psychological Syndromes can Co-occur or Predate Injury
When did the symptoms emerge, before or after the TBI?What were persons like before injury?What were their coping styles?How have they adjusted to disability?What new symptoms/behaviors have developed?
![Page 33: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/33.jpg)
10/21/2004 Brookhaven Hospital 33
Problems in Diagnosing Psychiatric Illness in TBI
Timing between injury and emergence of symptomsIn mild cases lack of documentation of extent/severity of injuryPre-morbid personality traitsPre-injury issues
![Page 34: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/34.jpg)
10/21/2004 Brookhaven Hospital 34
Rate of Psychiatric Illness One Year Post Brain Injury
Past studies focused on individuals with TBI who were seen in psychiatric hospitals
21.7% of individuals with TBI had ICD-9 diagnosis vs 16.4% of general population (1998)
![Page 35: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/35.jpg)
10/21/2004 Brookhaven Hospital 35
Psychiatric Diagnosis Distribution Following TBI
Male - 21.6%Female – 11.3%Mild brain injury –17.2%Moderate and severe brain injury – 23.3%
![Page 36: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/36.jpg)
10/21/2004 Brookhaven Hospital 36
Psychiatric Diagnosis FeaturesRelationship of psychiatric diagnosis to:
Younger ageGlasgow outcome scale scoreHistory of pre-injury ETOH use/abuseHistory of psychiatric illnessLower Mini Mental State scoreFewer years of education (Deb, 1999)Not working before injury (Bowen, 1998)
![Page 37: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/37.jpg)
10/21/2004 Brookhaven Hospital 37
Psychiatric Issues in TBI CasesMale/female 70%/30% more likely to develop psychiatric symptomsElevated risk for bi-polar affective disorderSeizures noted in 50% of cases with mania (Shukla, 1987)Limbic system lesions in 75% of manic cases (Starkstein, 1987)Family history of mood disorders
![Page 38: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/38.jpg)
10/21/2004 Brookhaven Hospital 38
Diagnostic Issues in BI GroupDepressive episode 13.9% vs. 2.1%Panic Disorder 9.0% vs. 0.8%Generalized anxiety 2.5% vs. 3.1% Phobic disorder 0.8% vs. 1.1%Obsessive compulsive 1.6% vs. 1.2%Schizophrenia 0.8% vs. 0.4%ETOH dependence 4.9% vs. 4.7%
![Page 39: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/39.jpg)
10/21/2004 Brookhaven Hospital 39
Brain Injury and DepressionDepression following brain injury occurs at a rate of 44.3% vs. 5.9% in non-brain injured population
![Page 40: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/40.jpg)
10/21/2004 Brookhaven Hospital 40
Differential Diagnosis IssuesHow can the clinician determine the role of injury and pre/post injury psychiatric factors that contribute to behavioral dysfunction?
![Page 41: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/41.jpg)
10/21/2004 Brookhaven Hospital 41
Pre-existing Psychiatric Disorders Related to TBI
Dementia due to head injuryCognitive disorderBipolar disorder (manic or depressive typesMood disorders (depression, mania)Sleep disorderAnxiety disordersIntermittent explosive disorder
![Page 42: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/42.jpg)
10/21/2004 Brookhaven Hospital 42
Pre-existing Conditions can Affect Recovery from TBI
Limited coping skillsImpaired ability to manage symptomsCognitive problems limit capacity to manage disability and pre-existing conditionAdvent of new behaviorsPrior medications may increase cognitive problems
![Page 43: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/43.jpg)
10/21/2004 Brookhaven Hospital 43
Effect of TBI on Underlying Psychiatric Disease
Reduced capacity to self-manage symptomsDiminished impulse control leads to enhanced interpersonal problemsPsychological defenses and coping skills fail to functionDenial of deficits prevents person from responding to injury-related deficits
![Page 44: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/44.jpg)
10/21/2004 Brookhaven Hospital 44
Effect of TBI on Underlying Psychiatric Disease
Interpersonal relationships changeSocial role is alteredSeizures and dyscontrol event are misinterpretedEnhanced dependent needs affect psychological status
![Page 45: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/45.jpg)
10/21/2004 Brookhaven Hospital 45
Adjustment Difficulty due to Emotional & Behavioral Issues
Emotional changeImpaired perception of social interactionImpaired self controlIncrease dependencyBehavioral rigidity
![Page 46: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/46.jpg)
10/21/2004 Brookhaven Hospital 46
Most Frequent Problems Cited by Family Members
SlownessIrritabilityImpatienceDepressionMemory
![Page 47: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/47.jpg)
10/21/2004 Brookhaven Hospital 47
Co-Morbidity: PTSD & TBI (Arnon, 1998)
32% of motor vehicle accident victims meet diagnostic criteria for PTSD one year post-injuryThose with PTSD have higher rates of pre-morbid/co-morbid psychopathology (anxiety and affective disorders)Immediacy of PTSD symptoms is a better predictor of later PTSD than injury severity
![Page 48: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/48.jpg)
10/21/2004 Brookhaven Hospital 48
Role of Prior Learning or Attentional Problems in Occurrence of Psychiatric Diagnosis
Prior learning and attentionalproblems are enhanced Diminished filtering and stimuli selectionAltered coping skills produce dysfunctional responses
![Page 49: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/49.jpg)
10/21/2004 Brookhaven Hospital 49
Psychiatric Issue or Brain Injury?
Mania vs. Arousal problems AnxietyDenial ConfusionDepressionCognitive problemsPersonality changesIntellectual changesThought disorder vs. Thinking problem
![Page 50: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/50.jpg)
10/21/2004 Brookhaven Hospital 50
Psychiatric Features of TBI Mania - AgitationAnxiety - Catastrophic Reaction(Goldstein)Denial - Inability to accept deficitsConfusion - Disorientation and memory problemsDepression – Withdrawal, abulia
![Page 51: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/51.jpg)
10/21/2004 Brookhaven Hospital 51
Neurologic and Neuropsychiatric Features
Atypical seizure disordersIntermittent explosive disorder (Yudofsky)Neurologic rage or limbic-psychotic aggressive syndrome (Dorothy Lewis)
![Page 52: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/52.jpg)
10/21/2004 Brookhaven Hospital 52
Neurologic Rage IdentifiersSudden loss of behavioral control, “out of the blue”Inability to stop the behaviorSeizure-like quality, unawareness of the individual to the eventDeficient memory of the event (Dorothy Lewis)
![Page 53: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/53.jpg)
10/21/2004 Brookhaven Hospital 53
Factors Leading to Behavioral Problems in TBI
Primary and secondary aspects of the physical injuryDevelopment of emotional problemsDevelopment of cognitive problems
![Page 54: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/54.jpg)
10/21/2004 Brookhaven Hospital 54
Two Type of Behavioral Problems
Behavioral excess –too muchBehavioral deficit –too little
![Page 55: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/55.jpg)
10/21/2004 Brookhaven Hospital 55
Neurobehavioral IssuesHyper/hypo arousalLevel of response to external events/filteringStimulus control vs. stimulus boundDenialJudgmentImpulsivity vs. self-regulationIrritability and seizure-like events
![Page 56: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/56.jpg)
10/21/2004 Brookhaven Hospital 56
Neurobehavioral Features
Aggressivity and assaultivenessApathy, abulia, lack of motivationIrritability, impatience
Impulsivity (lack of self-regulation)Level of motor agitation/restlessness
![Page 57: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/57.jpg)
10/21/2004 Brookhaven Hospital 57
Interpersonal/Psycho-Social Factors of Behavioral Problems
Impaired self-perceptionEmotional changesEgocentric thinkingImpaired perception of social issuesIncreased dependencyBehavioral rigidity
![Page 58: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/58.jpg)
10/21/2004 Brookhaven Hospital 58
Interpersonal/Psycho-Social Factors of Behavioral Problems
IrritabilityAnger control problemsMood instabilityHypo/hyper sexualityDiminished drive/ motivationCognitive deficits
![Page 59: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/59.jpg)
10/21/2004 Brookhaven Hospital 59
Factors of Cognitive Problems in TBI
Level of arousalSensorium disruptionConcentration and focusFiltering, stimuli control
![Page 60: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/60.jpg)
10/21/2004 Brookhaven Hospital 60
Factors of Cognitive Problems
Problem-solving and decision-makingLanguage and communication
Orientation and confusionMemory, information retrieval
![Page 61: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/61.jpg)
10/21/2004 Brookhaven Hospital 61
Cognitive Problems Can Look Like Behavioral Problems
Attention and filtering problemsOver/under arousalConcentrationMemoryTask learningNovel learning (old to new)
![Page 62: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/62.jpg)
10/21/2004 Brookhaven Hospital 62
The first step in making a diagnosis is to think of it.
-- Thibault, 1992
![Page 63: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/63.jpg)
10/21/2004 Brookhaven Hospital 63
Evaluate and Separate Post-Injury from Pre-Injury Problems
![Page 64: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/64.jpg)
10/21/2004 Brookhaven Hospital 64
Diagnostic Approaches
Developmental and school historyNeurological evaluationNeuropsychological assessmentMedical file review
Interview with individualComprehensive medical and psychiatric history
![Page 65: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/65.jpg)
10/21/2004 Brookhaven Hospital 65
Pre-Morbid Issues Presence of known psychiatric conditionLevel of adjustment, degree of attainment (school, work, family)History of learning, behavior and conduct problemsHistory of substance problemsMedical historySchool and vocational history
![Page 66: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/66.jpg)
10/21/2004 Brookhaven Hospital 66
Post-Injury Effect on Coping Skills and Personality
Response to disabling condition(s)Cognitive deficitsNeurobehavioral deficitsExternal support systemMotivation/initiativeSubstance use/abuseEngagement in meaningful activities
![Page 67: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/67.jpg)
10/21/2004 Brookhaven Hospital 67
Persistent Problems of Recovery and Rehabilitation
Irritability ImpulsivityEgocentricityLabilityJudgment deficitsImpatienceTension/AnxietyDepression
![Page 68: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/68.jpg)
10/21/2004 Brookhaven Hospital 68
Implications for Rehabilitation:
Why Patients “Fail”
![Page 69: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/69.jpg)
10/21/2004 Brookhaven Hospital 69
Persistent Problems of Recovery and Rehabilitation
HypersexualityHyposexualityDependencySilliness/EuphoriaAggressivityApathyChildishnessDisinhibition
![Page 70: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/70.jpg)
10/21/2004 Brookhaven Hospital 70
Why Patients “Fail”
Strategy:Individual and Group Psychotherapy
Why?Can’t identify problems as shared by othersDifficulty maintaining behavioral alternatives
![Page 71: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/71.jpg)
10/21/2004 Brookhaven Hospital 71
Why Patients “Fail”Strategy:
Insight-Oriented Approaches
Why?Can’t identify problem with selfProblems with generalization
![Page 72: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/72.jpg)
10/21/2004 Brookhaven Hospital 72
Why Patients “Fail”Strategy:
Didactic Approaches
Why?Memory problems prevent use of previous learning
![Page 73: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/73.jpg)
10/21/2004 Brookhaven Hospital 73
Why Patients “Fail”Strategy:
Milieu Treatment
Why?Social deficits inhibit positive peer group membership
![Page 74: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/74.jpg)
10/21/2004 Brookhaven Hospital 74
Why Patients “Fail”Strategy:
Cognitive-Behavioral Therapy
Why?Memory problems and difficulty with generalizations
![Page 75: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/75.jpg)
10/21/2004 Brookhaven Hospital 75
Why Patients “Fail”Strategy:
Behavior Modification
Why?Problems with impulse controlMemory problems prevent reinforcement strategy from being effective
![Page 76: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/76.jpg)
10/21/2004 Brookhaven Hospital 76
Why Patients “Fail”Strategy:
Medication Management
Why?Some medications further cognitive problems or cause disinhibited behavior
![Page 77: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/77.jpg)
10/21/2004 Brookhaven Hospital 77
Why Patients “Fail”Strategy:
Addictive Treatment/Self-Help Groups
Why?Cognitive problems prevent identification with the speaker/group processIndividual cannot apply information to self
![Page 78: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/78.jpg)
10/21/2004 Brookhaven Hospital 78
Why Patients “Fail”Person cannot process “talking therapies”Limited insightNew behaviors (e.g. impulsivity) are related to the brain injuryIncreased dependenceUnable to relate to previously effective support groups (e.g. AA, NA)
![Page 79: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/79.jpg)
10/21/2004 Brookhaven Hospital 79
Support System Stresses Increase Psychological Issues
High incidence of divorce or loss of primary relationship (50% in first two years post-injury)Adult children return to aging parents for physical assistanceLoss of friends and workHigh potential for substance use/abuseLoss of social role with family, friends and communityCultural factors influence recovery
![Page 80: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/80.jpg)
10/21/2004 Brookhaven Hospital 80
Social Network Issues Complicate Rehabilitation
Social network failure seen 24-months post injury (Burke and Weslowski. 1989)Psychological effect of withdrawal or loss of supports
![Page 81: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/81.jpg)
10/21/2004 Brookhaven Hospital 81
Social Network Issues Complicate Rehabilitation
Changing social role post-injury affects self-image and self-worthIndividual response to loss of functions and social changesRecidivism and emergence of psychiatric symptoms commonly seen 12-24 months post-injury
![Page 82: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/82.jpg)
10/21/2004 Brookhaven Hospital 82
Increasing Success in Rehabilitation and
Treatment:
What Works!
![Page 83: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/83.jpg)
10/21/2004 Brookhaven Hospital 83
What Works?Early identification of problemsHighly structured, social learning environmentRepetitive “teaching” of behavioral alternativesExternal controls managed by staff, gradually transferred to the individualNeurological approach to medication managementIntegrated rehab program, including psychiatric and substance abuse treatment
![Page 84: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/84.jpg)
10/21/2004 Brookhaven Hospital 84
What Works?Emphasis on learning and relearning of social roleTeaching “scripts” for social interactionGuided/supported attendance at AA/NA/self-help groupsUse of “failures” within treatment to address denial and limited insight
![Page 85: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/85.jpg)
10/21/2004 Brookhaven Hospital 85
What Works?Focus on social role re-entry and response of family, friends, co-workers, peers, and others to the personStaff understanding of TBI-related behavioral, cognitive, emotional and psychological issuesUnderstanding of adjustment to disabilityTeaching individual about consequences of TBIPromoting return to work, avocational and recreational activities
![Page 86: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/86.jpg)
10/21/2004 Brookhaven Hospital 86
What Works?Consistent response from staff throughout the environment Use of behavioral analysis to understand brain/behavior issuesAvoidance of negative consequences for behavior problemsFocus on discharge engineering to assure that the individual moves to a supportive placement with the solid transfer of information and management techniques
![Page 87: Psychiatric issues in traumatic brain injury](https://reader031.fdocuments.us/reader031/viewer/2022030311/58f0114d1a28ab59778b4633/html5/thumbnails/87.jpg)
10/21/2004 Brookhaven Hospital 87
Neurological Rehabilitation Institute (NRI)
atBROOKHAVEN
Tulsa’s Specialty Hospital
800-927-3974www.brookhavenhospital.com