TRAUMATIC BRAIN INJURY (TBI) OUTCOMES

JULY, 2013Cheryl L. Shigaki, Ph.D., ABPPCheryl L. Shigaki, Ph.D., ABPP& Thomas Martin, Psy.D., ABPP& Thomas Martin, Psy.D., ABPP

Psychologists who work with TBI patients and families

Rehabilitation Psychologists – focuses on adjustment to disability, maximizing function, full-participation in life activities.

Health Psychologists – focuses on the intersection of behavior and health.

Neuropsychologists – focuses on cognitive and behavioral sequelae from insults to the brain.

TBI and healthcare The public and many health care

professionals have limited and/or inaccurate understanding of TBI.

Overlap between TBI and psychiatric symptoms.

Benefit and challenges of screening to identify history of TBI? Benefit – Avoid misdiagnosis and

promote care “Have you ever had a head injury?” not

effective

TBI and healthcare Typical rehabilitation approaches

include: Restorative strategies: Direct intervention to

improve the physical problem Compensatory strategies: Intervention

focuses on adapting to the problem / working around it to improve function.

Psychological intervention: Address emotional reaction to loss and/or trauma; support motivation for active recovery.

Family caregiver support: Education about what to expect, how to manage problem behaviors and advocate for their loved one, and provide support for stress, coping and loss.

TBI in Rwanda People with new brain injuries

Recognizing mild TBI Helping victims and families adjust to

chronic TBI People with previous TBI (such

as occurring during acts of violence during genocide) Understanding & supporting chronic

cognitive, personality and behavior change

Objectives: To learn the ways that people are

affected by TBI: Cognition Psychological wellbeing Behavior / personality

To understand the difficulties that must be considered and addressed when treating individuals with TBI and their families.

As we proceed, please share your thoughts about cultural influences that would be important to consider in treating patients with TBI and their families.

TBI Outcomes

Consequences of TBI The brain controls every aspect of

our being and a traumatic brain injury has the capability of impacting any aspect of a person’s physical, cognitive, or psychological functioning.

In-depth evaluation of these skills is the domain of Neuropsychologists.

Outcomes following TBI Severity of injury is the best

predictor of outcome Age and genetic factors also play a

role Other factors: prior history of TBI,

history of substance abuse, PTSD, vocational history, and adequacy of social relationships

Larger brain volume and higher educational level are known to exert a positive influence

Causes of TBI Falls (especially older adults) Motor vehicle accidents Sports injuries Work-related injuries Domestic violence Child abuse

Shaken baby syndrome

Impact of mild TBI / concussion

Mild TBI is typically associated with modest and temporary changes in functioning, while severe TBI is associated with enduring changes and sometimes mortality. Most acute symptoms typically resolve

within a few days

Impact of mild TBI / concussionPhysical symptoms:

Dizziness/balance Fatigue Nausea Irritabile / restless Headache Lethargic /

disinterested Sleep problems

Cognitive symptoms:

Reduced attention Speed and

efficiency of information processing

Feeling “foggy” Feeling confused Repeats questions

Impact of mild TBI / concussion Public health issue: Potential for

more serious and chronic problems from REPEATED mild TBI. Cascade of cellular and vascular

changes increases vulnerability to irreparable damage

Impact of mild TBI / concussion Return to work/school or play:

Should be gradual shortened day fewer/less difficult responsibilities breaks

All symptoms should be resolvedhealth professional/parent monitors

REST! – limit physical & cognitive exertion Alcohol use may exacerbate symptoms

May take several weeks

Physical functioning: Moderate to severe TBI Arm/leg weakness & paralysis Compromised speech and swallowing

ability Dizziness & dyscoordination Diminished sense of smell and taste Hearing disturbance (e.g., tinnitus,

hypersensitivity) Visual disturbance (e.g., diplopia, light

sensitivity) Sleep disturbance and fatigue Chronic headaches and pain Sexual dysfunction

Cognitive impact: Moderate to severe TBI

Severe TBI can impact any aspect of cognition.

However, because of the high incidence of orbitofrontal (front of the brain, around eye sockets) and anterior temporal lobe (tips of the temporal lobes) contusions we frequently see a constellation of symptoms that includes:

Cognitive impact: Moderate to severe TBI

Slow speed of cognitive processing Slowed behavioral responding Attention deficits Impaired learning & memory

Need more exposures Behavioral symptoms:

impulsivity Perseveration initiation deficits planning and organization

Cognitive impact: Moderate to severe TBI

TBI does not typically compromise “intelligence” in mild-to-moderate cases.

The Thinker – Musée Rodin, Paris

Speed of processing Speed of processing (reaction time) is

very sensitive to any brain insult Following a brain injury, it often takes

longer to take information in and react to events

Reduced speed of processing can compromise other cognitive abilities

Degree of impairment may render the patient dysfunctional in daily activities.

Learning/Memory Memory problems are the most

common cognitive complaint following a TBI

Short term vs. long term memory Verbal memory vs. visual memory Explicit memory (e.g., experiences,

facts, events) vs. implicit (e.g., skills, habits) memory

Research suggests deficit is in learning

Attention Attention can be measured in different

ways: Simple Attention: Ability to orient to,

register, and attend to something (e.g., a sound)

Focused Attention: Ability to focus on important information while ignoring (suppressing) irrelevant information

Sustained Attention: Ability to focus for extended period (even if the task is boring)

Divided Attention: Shift attention between tasks (e.g., cook & watch small child)

Executive functions Executive Functions – Skills

necessary for complex, goal-directed behavior and adaptation to changes: Planning and organization ability Problem-solving ability Ability to initiate and sustain action and

anticipate consequences Ability to benefit from feedback and

adjust behavior

• Let’s take a moment to answer any questions.

• How do you think TBI affects psychosocial factors? (i.e. the person’s mood, behavior, personality, relationships, etc.?)

Discussion

Personality changes after TBI Impulsivity Grandiosity Apathy / lack of initiative Inability to be empathic / see things from

another perspective / tendency to be self-focused

Impaired ability to evaluate risk; judge one’s physical, cognitive and emotional functioning

Inability to appreciate cognitive impairments Thinking about thinking They don’t know what they don’t know

Psychiatric/behavioral impact of TBI

Altered mood, behavior, and personality are common following TBI; even mild TBI has been associated with significant affective disturbance.

Is the mood disturbance reactive, “organic” or both?

Psychiatric/behavioral impact of TBI

Rates of psychiatric disorders following TBI: Major depression (44%) Substance abuse/dependence (22%) Post-traumatic stress disorder (14%) Panic disorder (9%) Generalized anxiety disorder (9%), Obsessive compulsive disorder (6%) Bipolar disorder (4%) Schizophrenia (0.7%)van Reekum et al., (2000)

Psychiatric/behavioral impact of TBI Diminished tolerance for frustration Decreased social skills Adjustment disorders and emotional

lability Aggressive behavior (verbal and

physical), particularly when overwhelmed

Increased rates of alcohol and substance abuse and risk of suicide

TBI and post-traumatic stress Self-report study (N>3000)

4 Groups Multi-trauma, with no TBI Multi-trauma, with TBI (mild, mod, severe)

Telephone survey, 12 months post-injury Asked about cognition and PTSD

symptoms

Zatzick, Rivara, Jurkovich et al. Arch Gen Psychiatry. 2010;61:1291-1300

TBI and post-traumatic stress More severe TBI seems to result in fewer

signs and symptoms of PTSD Due to inability to consolidate traumatic

memories Those with facial injuries and spinal cord

injuries (SCI) are at increased risk for PTSD symptoms

At all levels of TBI, those with PTSD symptoms reported the greatest levels of impairment Cognition, physical health, and functioning in

everyday activities

PTSD and mild TBI (concussion) US soldiers from Afghanistan & Iraq

Combat-incurred mild TBI doubled risk for PTSD

PTSD was the factor most strongly associated with persistent concussive symptoms

US soldiers Iraq – who meets criteria for PTSD? 44% with loss of consciousness

(concussion) 16% with other injuries 9% with no injury

Mild TBIHeadacheSensitivity to light/soundMemory deficitDizziness

PTSDShameGuiltRe-experiencing symptoms

BothInsomniaFatigueIrritability/angerDepression/ anxietyTrouble concentratingHyper-arousalAvoidance

PTSD and mild TBI: Symptom overlap

Adapted from Stein & McAllister, Am J Psychiatry 2009; 166:768-776

PTSD and mild TBI Mild TBI typically resolves few

days/weeks 10-15% with mild TBI experience chronic

persistent symptoms 1 year or more This presentation and etiology are not

consistent with the literature on concussion In some cases, symptoms of mild TBI may

become chronic (unusual). Symptoms also may occur following other

types of emotional injury, or physical injury to areas other than the head.

TBI and Post-traumatic Stress

Hippocampus = sea horse

In studies where cognition was tested: Individuals exposed to combat,

rape and childhood abuse have shown difficulty with verbal learning.

Adults with chronic PTSD were found to have volume and activity differences in the brain (hippocampus) Small hippocampus may be a

predisposing factor for PTSDBremner 2006; Gilbertson et al., 2002

TBI and post-traumatic stress Many of the genetic, structural,

endocrine and neurochemical changes of TBI appear to have similar changes noted in the pathophysiology of PTSD

Some of these changes may enhance the biological risk of a patient with TBI developing PTSD symptoms or syndrome

TBI and post-traumatic stress

Functional symptoms (overlap) may improve substantially, if the psychological trauma is treated effectively.

We think the differences in physical health outcomes and symptoms may be mostly due to PTSD and/or depression.

Treating symptoms of PTSD is a priority

• Are there misconceptions about TBI that are commonly believed in Rwanda?

• What resources are available in Rwanda for individuals with TBI and their families?

Discussion

Working with patients & families

General cautions for healthcare

TBI can impact sensory functioning (e.g., diplopia and altered vision, ringing in ears, and decreased balance)

TBI can contribute to the development of medical disorders such as sleep disturbance and substance abuse issues.

Communication deficits can be a significant source of frustration and disability.

General cautions for healthcare Many medical conditions can exacerbate

TBI symptoms including sleep disorder, infection, and pain.

Use of alcohol or other substances may have a worse effect or lead to worse consequences for individuals with TBI.

Individuals with a history of TBI are at increased risk for future TBI. And, multiple concussions can have a cumulative effect.

Recommendations for working with individuals with TBI Allow adequate time to process

information and respond Appreciate that the injured brain is easily

overwhelmed by multiple stimuli (noise, lights, activity)

Recognize that potential for behavioral problems increases when the individual is physically, cognitively or emotionally stressed (e.g., fatigue, pain)

Maintain a supportive setting that utilizes structure and avoids dramatic changes in routine

Recommendations for working with individuals with TBI Memory for visual and verbal information may

be individual strength. Provide information in multiple modalities

Use concrete / literal language Avoid “figures of speech,” comments with “double

meaning” Avoid humor (sarcasm, irony, “deadpan”)

Diminished initiation can easily be mistaken for depression, apathy or resistance.

Focus on one task at a time / limit multitasking demands. Limit environmental distractions

Recommendations for working with individuals with TBI

For receptive Language Deficits Speak slowly, using short phrases and

sentences Use gestures with your speech; use visual cues Repeat your message in different ways Do not rush-allow time for response, alleviating

pressure to speak and allowing time to process information

Use an alternate communication system when appropriate (i.e., pictures)

Include the individual in conversation, but don’t overload them with information

Recommendations for working with individuals with TBI

For expressive Language Deficits Ask one-part yes/no questions Acknowledge and discuss the frustration the

person might be having when communication attempts are made

Allow adequate time for the individual to speak Involve the individual in decision making

whenever possible, practicing expressive reasoning and review of steps one might make to achieve a desired outcome

Continue normal daily routines and encourage use of learned strategies (e.g., over-articulation and increased volume)

Recommendations for working with individuals with TBI & PTSD/depression Cognitive-behavioral therapy (CBT) is the

treatment approach with the greatest research support Gains are generally maintained at 1+ year

follow up. Exposure is the most effective and fastest

acting technique (a component of CBT) Psychotropic medications are also a front-

line approach Other techniques include:

Stress/anxiety management Psycho-education Cognitive restructuring

Taylor, 2006

Some caveats…

Moderate-to-severe TBI

These individuals may not be motivated in psychotherapy, especially if they do not appreciate their impairments.

They may wish that things could be different, but have difficulty carrying out a treatment plan.

For many, environmental alterations established by caregivers may be the most effective approach to problem behavior.

Impact on familiesFamily and other caregivers Dealing with personality and

behavior change is frequently more stressful than dealing with physical disability or cognitive changes.

Caregiver stress and depression are common.

Family caregivers may be reluctant to focus on self-care.

Ambiguous loss: “No longer Gage”

• What questions do you have?

Discussion

Cheryl L. Shigaki, Ph.D., ABPP

Associate ProfessorUniversity of MissouriDepartment of Health PsychologyDc116.88One Hospital DriveColumbia, MO 65212 USAshigakic@health.missouri.edu http://cherylshigaki.wordpress.com/