Traumatic Brain Injury: Who Are You?
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Transcript of Traumatic Brain Injury: Who Are You?
Traumatic Brain Injury
Tedd Judd, PhDNeuropsychologist
Disability Awareness WeekCentral Washington
UniversityMay 22, 2007
Who are you?
OverviewCauses, prevention, medical evaluation and treatment of traumatic brain injury (TBI)Cognitive, emotional, and behavioral impactCognitive rehabilitation, emotional rehabilitation, medications, and educational accommodationsLiving with brain injury at the university and in the rest of the worldQuestions, discussion
Causes of Brain Disabilities
TraumaToxicityTumorsDegenerative disordersDevelopmental disordersDietary deficiencies
Vascular disordersAnoxiaEpilepsyHydrocephalusElectric shockInfectionsMetabolic disordersAutoimmune disorders
Causes of Brain DisabilitiesMost Likely to Affect University
Students
TraumaToxicityTumorsDegenerative disordersDevelopmental disorders
Learning DisabilitiesAttention Deficit DisorderAsperger’s Syndrome
Dietary deficienciesVascular disordersAnoxiaEpilepsyHydrocephalusElectric shockInfectionsMetabolic disordersAutoimmune disorders
Causes of TBI
motor vehicle accidents sports injuries
assaultsfallsblast concussion (59% of blast-
injured soldiers)shaken babies
Traumatic Brain Injury
Types of Traumatic Brain Injury
Open head (skull fracture, gunshot wounds, blunt instrument)
Risk of hemorrhage, seizure, infection, swelling
Closed head (most motor vehicle accidents, sports injuries)
Risk of hemorrhage, seizure, swelling, failure to detect
Traumatic Brain InjuryThere is often trauma to other parts of the body, as well Myth busting:
The head does not have to have contact with something for there to be a TBI (shaken baby, seat belts, air bags)There does not have to be a loss of consciousness for there to be a TBI (Phineas Gage, gunshot wound) There does not have to be a change on the CT or MRI for there to be a TBI
Traumatic Brain InjuryMechanisms of injury
Mechanical trauma—cell death, axonal shearingDiffuse Axonal Injury Hemorrhage (blood kills brain cells, blood is cut off from other areas, pressure effects)EdemaCascading chemical events—hope for interventionsAnoxiaHydrocephalus
Acute Medical evaluation:Glasgow Coma Scale
Best Eye Response. (4) No eye opening. Eye opening to pain. Eye opening to verbal command. Eyes open spontaneously
Best Verbal Response. (5) No verbal response Incomprehensible sounds. Inappropriate words. Confused Oriented
• Best Motor Response. (6) No motor response. Extension to pain. Flexion to pain. Withdrawal from pain. Localizing pain.
Obeys Commands.
TBI Levels of Severity
Severity loss of consciousness
posttraumatic amnesia
Mild 0-1 hour 0-1 day
Moderate 1 hour-1 day 1day-1 week
Severe >1 day >1 week
Traumatic Brain Injury
Acute Medical evaluation:CTPhysical and neurological examSerial assessment
Neurological Evaluation
Ancillary ExamsLaboratoryEEGEvoked potentialsLumbar punctureCT scanMRI scanFunctional imagingArteriography
Traumatic Brain InjuryTreatment:
Protect the airway & oxygenate Ventilate to normocapnia Correct hypovolaemia and hypotensionPrevent herniation Surgery for hemorrhage, edema, skull repairMedications for edema, infection, agitation, coagulants, anticonvulsives, etc. Rehabilitation
Traumatic Brain InjuryHigh Risk Populations
Violent, impulsive, young, male, substance abusersChildren ElderlySoldiersPedestriansCyclists
Traumatic Brain Injury
High Risk PopulationsWorkers in certain industries
LoggingMiningConstructionMilitaryTransportationSome agriculture
Traumatic Brain InjuryPrevention:
PeaceMeasures against interpersonal violence such as domestic violenceGun controlTraffic law and industrial safety law enforcementVehicle and road maintenanceSeat belts, air bagsHelmetsSport safetyFall prevention in children and elderly
Mild Traumatic Brain Injury
The focus of tremendous forensic and sports neuropsychology energyThe most common TBISeveral definitions but usually include:
Trauma to the headAlteration of consciousness<1 hour loss of consciousness <24 hours posttraumatic amnesia No focal deficits
Mild Traumatic Brain Injury
Many non-specific symptoms:HeadacheMemory lossAttention difficultyFatigueDepressionAnxietyDizzinessIrritabilityNauseaOversensitivity to noise, light, distractions
Mild Traumatic Brain InjuryHigh base rates for the non-specific symptomsHead injury vs brain injury
DizzinessHeadache
MTBI vs PTSDRule of thumb:
1/3 of people better within 1 week, 1/3 of people better within 3 months,1/3 of people still have problems at 1 year, “miserable minority”
Psychosocial Evaluation of TBI
Interview: “bracket” the loss of consciousness and posttraumatic amnesiaScreen for posttraumatic stress disorderCheck on attitudes, anger, guilt, lawsuits, disability claims, expectations, substance abuseThe course of recovery up to nowCompare pre-injury to now
Psychosocial Evaluation of TBI
Early evaluation (within a few months of injury)
Focus on priority problemsScreen and baseline testingSupport and educationProvide for follow-up
Neuropsychological Evaluation of TBI
Later evaluation (6 months or more after injury)
Focus on priority problemsComprehensive, problem-oriented testingAttention, memory, executive functions, effort, emotional adjustment, vocational or educational and social adjustment
Differential Diagnosis of Mild TBI
Rule outs:DepressionAnxietyPosttraumatic stress disorderSleep disturbanceChronic pain, especially headacheVestibular disturbance (dizziness)Symptom exaggeration for compensation or other gain
What is the impact of TBI?
Emotions and Personality in Traumatic Brain Injury
pre-injury personality
emotional
reactions
to injury
organic changes in emotions and behavior
Reactions to the experience of injury/illness:
GriefDenialDepressionAnxietyAngerPosttraumatic Stress DisorderPersonal Reformation
Reactions to illness/disability:
GriefDenialDepressionAnxiety
Perplexity Lezak, 1978
FrustrationAngerEmbarrassment
Organic Emotional Changes
Function Increased Decreased
Emotional Communication
Reflex crying, laughingAutomatic cursing
Monotone voiceMasked face
Emotional Reactivity
Labile emotionsImpulsive angerCatastrophic reactions
Indifference
Organic Emotional Changes
Organically induced major psychiatric disorders
DepressionManiaPsychosisObsessive-compulsive disorder
Temporal lobe epilepsy personality changes?
What are Executive Functions?
Choose a goalPlanExecute
Evaluate
What are Executive Dysfunctions?
Decreased self control
Euphoria
Mania
Despontaneity
Facetiousness
Disinhibition
Impulsiveness
Slowness of thinking
Poor judgment
Disorganized
Unreliable
Poor insight
Apathetic
Indifferent
Lack of ambition
Decreased initiative
What are Executive Dysfunctions?
ChildishSelf-centredUnempatheticConcreteLacking abstract attitudeUnable to shift attentionUnable to use feedbackUnable to maintain performance
Unable to self-monitor
Lack of self-reflectiveness
Unconcern
Outbursts of irritability
Perseverative
Impersistent
Assertive
Inflexible
What are Executive Dysfunctions?
Impaired sequencing
Grandiose
Confabulatory
Distractible
Unable to prioritize
Lacking drive
Restless
Shallow affect
Lethargic
Unrealistic
Socially inappropriate
Decreased self-concern
Withdrawn
Extroverted
Stimulus-bound
Executive Dysfunctions: Activation Changes
Function Increased DecreasedInitiation Impulsivene
ssDisinhibition
Apathy, no drive
Termination
Impersistence no follow-through
Perseveration stuck at one point
Conceptualization of Psychopathology
Executive Dysfunctions:
ConcretenessPoor Monitoring and JudgmentLack of Awareness of Problems (Anosognosia)Poor Planning and Organization Poor Communication Pragmatics
Executive Dysfunctions:
Neuroanatomical Syndromes:Dorsolateral—impaired planning, sequencing, complex attention
Medial dorsal—impaired initiation
Orbital (ventromedial)—disinhibited, don’t respond to feedback, “pseudopsychopathy”
Adaptive Aspects of Executive Functions
CompetenciesDrivingMoney managementPersonal decisions—life choices, medical consentWork
Dealing with emergenciesFamily and other social relationsImpulse control—addictions, spending, gambling, eating, sexual behavior, aggressionCriminal behavior
Alcohol and TBI
Alcohol use figures into many TBIs, especially motor vehicle accidents, falls, and assaults (roughly 1/3).
People with alcohol problems are more likely to get TBIs than people without.
TBI usually makes people more susceptible to the effects of alcohol.
Alcohol and TBI
Some people with TBI find they no longer like the effects of alcohol and avoid it.
Others become more susceptible to alcohol abuse.
Some medications for the effects of TBI cannot be taken with alcohol. Alcohol slows and limits recovery.
Cognitive Rehabilitation
Therapy programs which aid persons in the management of specific problems in perception, memory, attention, thinking and problem solving. Skills are practiced and strategies are taught to help improve function and/or compensate for remaining deficits.
Cognitive Rehabilitation
Interventions are based on an assessment and understanding of the person's brain-behavior deficits and are provided by qualified practitioners such as psychologists and neuropsychologists, speech/language pathologists, and occupational therapists. www.head-trauma-resource.com/glossary/c.htm
Cognitive Rehabilitation
Restoration: Repetitive exercises and activities designed to restore or improve damaged abilitiesCompensations: Tools and techniques adapted to and used by the individual to allow functioning in spite of disabilitiesAccommodations: Changes in the shared environment of the individual which allow functioning in spite of disabilities
Cognitive Rehabilitation
Restoration example: AttentionSustained attentionSelective attentionAlternating attentionDivided attention
Cognitive Rehabilitation
Compensation example: MemoryMemory Book – possible sections
Event calendarThings to Do listDaily scheduleDiary (memory log, feelings)Directory and family (name, address, phone numbers and relationship, photos)Medications (name, purpose, schedule, doctor)Transportation (directions, bus schedules, maps)FinancesShopping lists
Cognitive RehabilitationCompensation example: Memory
Electronic aidsCell phone LaptopPersonal Digital AssistantCalculatorKey alarmDigital recorderDigital cameraAlarmsTimerDictionary/thesaurusWatch with multiple alarms, countdown timer, hour chimes, database
Educational AccommodationsAllow a lighter course loadAllow tape recording of lectures. Provide a written outline of material covered. Use overhead and other visual media with oral instruction. Incorporate technology, e.g., computers, calculators, videos.
Educational AccommodationsAccept typed or word-processed assignments. Allow oral or audio taped assignments. Individualize assignments, e.g., length, number, due date, topic. Use peer tutoring. Teach specific study skills, e.g., organization, note taking.
Emotional Rehabilitation(Neuropsychotherapy and
beyond)
Neuropsychotherapy is the use of neuropsychological knowledge in the psychotherapy or counseling of people with brain disabilities and those close to them. It is specialized in technique and content to address the emotional and behavioral issues of brain disability.
Neuropsychotherapy
Executive Function Rehabilitation Schema
1. Compensate Externally (schedules, cues, reminders, written procedures, restrictions)
2. Build Awareness 3. Retrain Self-regulation (problem-solving
schemata, social skills, alarms, PDAs)4. Generalize Self-regulation train in other
settings (home, school, work, community)5. Fade External Compensations
The Content of Neuropsychotherapy
Emotional Rehabilitation
Accessible metaphorDemystify processReduce guilt and blameDefine rolesSkill-learning model
The Content of Neuropsychotherapy
Improving Self-Awareness
Feedback ToolsMirrorsPhotosAudio tapesVideotapesWork samplesWriting samplesArts and crafts products
The Content of Neuropsychotherapy
Improving Self-Awareness
Testing feedbackMedical RecordsSelf-Monitoring ExercisesGamesEducational MaterialsGroup TherapySupported FailureReal-Life ExperiencesDon’t say “I told you so”
The Content of Neuropsychotherapy
The New SelfNot necessarily better or worse, just differentDiscover who the new self isRethink abilitiesRethink goalsRethink relationships
The Techniques of Neuropsychotherapy
Cue Cards:
MY ANXIETY SIGNSTapping fingers, footFast breathing, heartSweatingTense musclesFussing and fidgeting
RELAXING BREAKAlone, quiet, darkClose eyesBreathe slowly, deeplyRelax musclesLet go of worried thoughtsPicture beach
The Techniques of Neuropsychotherapy
Cue Cards:
SIGNS OF DEPRESSION:1. Negative thoughts2. Crying3. Thoughts of drugs and suicide4. Things on TV that remind me of my life and children and pregnancy
WHEN I FEEL DEPRESSED OR WHEN FRED TELLS ME I NEED TO:
1. "I'm getting better. I can learn to control this myself!"
2. Distract myself:A. Watch Fred and the othersB. DrawC. WriteD. NintendoE. Clean
3. Ask Fred for help
The Techniques of Neuropsychotherapy
Cue Cards: ACTIVE LISTENINGQuiet, alone with other personNo TV, radio, musicNot doing anything elseFace other person, eye contactDon't interrupt or react (bite
tongue)Repeat other person's feelings
The Techniques of Neuropsychotherapy
Cue Cards: PUBLIC SPEAKINGUse written outlinePractice alone and with friendHave friend in audienceShort relaxation before going on"I can do it! I know my stuff. They are friendly and want
to hear me."Find friend in audienceSpeak to back of roomSlowly and clearlySmile!
The Techniques of Neuropsychotherapy
Cue Cards: TALKING TO A PHONE ANSWERING
MACHINEHello, this is Wanea White with a message
for Maria Sanchez. The head injury support group meeting will be on Friday, May 24th at 7 pm at the Mt. Zion Baptist Church. Call me if you have any questions at 639-4275. I hope to see you there.
Example:Impulsive Anger
Evaluation: Impulsive anger is:Develops after the injuryAnger episodes are:
SuddenOverreactiveUnplannedPurposelessEgo-dystonic (“that’s not me!”, embarrassing) Related to physiological stress (pain, fatigue, low blood sugar) (Miller, 1993; Silver & Yudofsky, 1994)
Example:Impulsive Anger
Evaluation:Interview person with TBI and informantObservationsCheck for features of impulsive angerCheck risks, signs, motivation, awareness, things that help, trusted individuals
Example:Impulsive Anger
Episode LogDate and TimeWhat happened?CircumstancesWarning signsLevel of anger (1-10)Strategies usedOutcome
Example:Impulsive Anger
Middle StagesWork on awarenessStrengths and Problems listBuild trust and therapeutic allianceEmotional rehabilitation perspectiveAgreement for Time OutsIntroduce Cue CardOthers cue Time Outs
Example:Impulsive Anger
Typical Anger Cue Card Part 1
My Anger Risks: TiredNoise, activity, too many peopleFrustrated
My Anger Signs:Tight muscles, fists, jawViolent thoughtsLoud voiceFast breathing
Example:Impulsive Anger
Typical Anger Cue Card Part 2
TIME OUT!Say: "I'm feeling angry, I need to take a time out"Go outside or bedroom.Walk or exercisePractice relaxing
Preparing To ReturnWhen I can smile I'm ready to go backWhat do I need to say:
Apologize?Set time to talk?Ask how they feel?Say what I want?
Check in
Example:Impulsive Anger
Cue Card for Telling Others About an Anger Problem
Because of my brain injury, I get angry more easily than I used to. Often I don't really mean to be angry. I'm learning to control it, so don't worry about it, and please don't take it too personally. If you see me get angry, just give me a chance to calm myself down, or let me walk away. Thanks.
Example:Impulsive Anger
Later StagesReduce cuing for Time OutsDo practice Time OutsThe person with the TBI participates in and then takes over Episode Log (becomes Feelings Journal)Introduce self-talk and self-calming without leaving for a time outGeneralize self-management to other settingsStress test the system (try coping in more difficult situations)
Example:Impulsive Anger
Feelings JournalDate and Time: What Happened? Anger Level (1-10): What did I do? What were my warning signs? What did I feel? Did I back off? What do I need to do now? What can I do better next time?
Medications and TBIPeople with TBI are often more sensitive to psychotropic medications than others, especially to the cognitive effects, for example, of benzodiazepines and phenothiazines (best avoided)For emotional and behavioral problems, try environmental and psychotherapeutic methods first, unless the problem predates the injury or is severe
Medications and TBI
Off-label uses:Stimulants are often useful for attention problemsModafinil (Provigil) is often used for fatigue (although a recent study suggests that caffeine is just as good)
Medications and TBIOff-label uses:
Acetylcholinesterase inhibitors (donepezil [Aricept], rivastigmine [Exelon], or galantamine [Razadyne]) are approved for Alzheimer’s disease but can be helpful for cognition in some individuals with TBI. Dopamine agonists such as amantadine can be useful for impaired initiation and other executive dysfunctions
Medications and TBI
Off-label uses:Options for managing impulsive anger:
Selective serotonin reuptake inhibitorsBeta blockersMood stabilizers (especially if there is epilepsy and they can do double duty)
Medications and TBI
Off-label uses:Options for managing sensory hypersensitivity (not well researched):
Atypical antipsychoticsLong-acting benzodiazepines (clonazepam)
Living with brain injury at the university and in the rest of the
world
A university is one of the hardest places to cope with a brain injury because of the demands of the institution.At the same time, because universities are supposed to be enlightened, it is or should be one of the most understanding and accommodating settings.
Living with brain injury at the university and in the rest of the
world
The “extra” curriculum for students with brain injuries at the university should include knowing their rights and how to stand up for them.The “extra” curriculum for temporarily able-brained students should include understanding, including, and accommodating those with disabilities.
Returning to University after a TBI
Take enough time to recover.Take a light course load, preferably electives.Get all the accommodations you think you might need. It’s easier to drop them than to add them.Budget lots of extra study time. Don’t let your schooling get in the way of your education.
Questions, discussion