Dealing with TBI

An Overview of Behavioral Symptoms and Interventions

Facts About Mild Traumatic Brain Injury (MTBI)

• Approximately 80% of all brain injuries are mild

• Males outnumber females 2:1

• 5.3 million people are estimated to have ongoing problems related to MTBI

• Direct care costs are estimated at 5.3 billion annually, with indirect care estimated at 37.8 billion dollars annually

Diagnostic Criteria for MTBI

• Traumatically induced physiological disruption of the brain (an injury occurs)

• Any period of loss of consciousness not to exceed 30 minutes

• Loss of memory for events immediately before of after the accident

• Any alteration in mental state at the time of the accident

MTBI

• Focal neurological deficits that may or may not be transient

• Post-traumatic amnesia does not exceed 24 hours

• Glasgow Coma Scale of 13-15 after 30 minutes– Eyes open spontaneously– Oriented to place/time (Verbal output)– Obeys Commands (Motor output)

Assessment Questions

• Have you ever been told you have suffered a brain injury or concussion?

• Have you ever hit your head hard enough that you saw stars or had a headache that lasted the rest of the day?

• Have you ever been knocked unconscious? If so, for how long?

• Did you seek medical treatment?

Assessment Questions

• When you hit your head, did you feel nauseated or dizzy afterwards?

• Did you have any speech or coordination problems?

• Is there any part of the incident you cannot remember?

• Did you have any visual problems?

Assessment Questions

• Currently-– Do you have any memory problems?– Do you have problems keeping up with

conversations or what people are saying?– Do you have problems concentrating or staying

on task?– Are you sensitive to light? Does it cause you to

have headaches?– Do you have problems pulling up words (are

they on the tip of your tongue?)

Assessment Questions

• Are you more irritable than before the incident?• Do people often say you act before you think?• Do you have problems multi-tasking?• Are you having any current balance or

coordination issues?• Are you having any sensory problems (hearing,

smell, taste, etc.) ?• Are there any changes you have noticed since

the incident that I did not ask you about?

Frontal Lobe Injury

• Higher cognitive functioning or “executive functioning”

• Focusing attention• Generating and following through on decisions• Poor judgment• Self-awareness of deficits self-monitoring• Planning and carrying out activities (maintaining

a job, grocery shopping, completing household duties, repairs, etc.)

Frontal Lobe TBI

• Concrete thinking• Trouble staying on task• Possible disinhibition

and immaturity• Possible decreased

energy, motivation and spontaneity

• Possible speech and motor problems

Temporal Lobe TBI

• Storing NEW memories– Right: Visual memory– Left: Verbal memory

• Behavioral problems– Irritability– Aggression– Modulating behavior

• Word-finding and naming

Parietal Lobe TBI

• Processing sensory information– Right: Visual-spatial

information– Left: Comprehension of

spoken/written words• Get lost in familiar surroundings• Confused by multi-step

instructions

Occipital Lobe TBI

• Processing of visual information

• Visual deficits–Field cuts–Blindness–Inability to know

objects

Cerebellum TBI

• Coordination of movement

–Walking and control of upper extremities for day-to-day tasks

–Possible tremors associated with injury

Course of Recovery of MTBI

• In the majority of individuals symptoms of MTBI resolve in 6 months or less after injury

• In some cases, symptoms can persist longer (12 – 18 months) and even life-long

• The majority of people with moderate to severe TBI do not return to their full pre-injury status and will have ongoing cognitive and behavioral issues

Overview of Diffuse Symptoms of MTBI

• Cognitive– Memory, Attention, Processing Speed &

Intelligence

• Psychological– Depression, Anxiety, Irritability, and Sleep &

Personality change

• Physical– Light/sound sensitivity, dizziness & fatigue

Dealing with Impaired Attention/Concentration

• Work slowly• Break your work down

into small, manageable increments

• Double check your work• Prepare all materials for

tasks prior to starting• Take regular breaks to

minimize fatigue

Attention and Concentration Con’t.

• When reading and studying, read small passages, take a break, and then read them again

• Clear away any materials not needed for tasks/work

• Maintain a quiet environment with minimal distractions when focus is needed

Learning and Memory Difficulties

• Daily organizer/calendar to record appointments and important tasks

• Multiple modalities to learn new material– Read it aloud (hearing)– Picture it (visual)

• Set realistic goals– It will take longer to learn new things– Break material down into smaller

portions– Allow breaks between studying to allow

material to consolidate into memory– Be patient with yourself!

Dealing with Executive Control Dysfunction

• Work on one task at a time• Work slowly and carefully• Check your work for errors• Use a pocket organizer, smart phone

or palm pilot• Make a “to do” list and post it in a

designated place• Be willing to allow family

members/friends provide reminders without being upset

How to detect brain injury

• There are often no outward physical signs of Injury – Invisible Wounds

• We need to focus on observable behavioral Indicators of TBI

Dealing with TBI

• Signs to look for:– Distractibility– Difficulties focusing on what is

being said – Answering slowly or answering

questions that are not asked (poor comprehension issues or low comprehension)

– Long pauses in speech (word retrieval issues)

What to Look For

• Client’s with TBI are often very anxious, look for:– Restlessness– Face flushed– Sweatiness– Shakiness– Increased breathing rates

What to Look For cont.

• Talking very loud/yelling– Self-awareness and self-monitoring

• Staring– Inattentiveness

• Shakiness– Can be neurologically based

• Difficulty following orders– Delayed processing or comprehension

problems

What to Look For cont.

• Have significant short-term memory issues– They seem to understand instructions, then minutes

later cannot remember what you told them• May become agitated/irritable very quickly and appear

disinhibited due to frontal lobe injury• May have significant coordination issues and

involuntary movements that are neurologically based– Fail field test, NOT due to substance

use/intoxication• May have visual field cuts

What to Look For cont.

• Flat affect and seem apathetic• Poor initiation of conversations• Provide short & concrete answers to

complex questions

• Suspect’s body language and poor verbal output (yes/no responses) suggests disinterest in what you are saying (flat affect)– Remember this is neurologically based

Interventions

• Tell individual one thing at a time; no multistep directions

• Be willing to repeat instructions slowly and clearly– Memory, Processing speed, and

Comprehension• Keep questions as simple as possible• Make sure you have eye-contact with individual

– Attention

Interventions

•Have them reflect what you have told them

“Can you tell me what I ask you to do?”

•Loud speech does not always imply anger or opposition

More likely confused or anxious; Inability to self-monitor

Interventions cont.

• Individuals with TBI often get overwhelmed with environments that are over-stimulating (too much noise, lights, movement around them), so:

– When trying to talk to them or directing them, try to get them in quieter areas away from crowds, noise, lights, etc.

Interventions

Write down any follow-up andencourage them to put inPDAs

-Memory vs. non-compliance

For anxious or agitatedindividuals, encourage breathingand grounding skills

-Stress ball-Sensory loaded

modalities

Allow a time-out if necessary

Therapy Interventions- TBI

• Structure/routine– Pill reminder

• Marker board• Symptom journal

– Disorganization– Questions they want

answered• Take notes in session• Involve family

– Educational aspects– ADD-like aspects

• They often won’t admit deficits

TBI and PTSD: Overlapping and Differentiating symptoms

• TBI:– Concentration– Memory

• Commonly STM– Irritability– Fatigue

• Constant detours– Headaches

• Light sensitivity– Apathy

• Flat affect– Sexual inhibition or

impulsivity

• PTSD– Concentration– Memory

• Dissociative or amnestic– Irritability

• triggers– Headaches

• SNS arousal– Apathy

• Secondary depression – Sexual aggression,

heightened interest, or inhibition

TBI and PTSD: Overlapping and Differentiating Symptoms

TBI:• Sleep problems

– REM cycle disruption• Problems processing

– Slowed– Word retrieval– Problems shifting focus

• Emotional lability– Without external triggers– Overly emotional to small events

• Personality changes– Flat– Lack of initiation– Loss of self-awareness/self-

monitoring • Lack of spontaneity

PTSD:• Problems sleeping

– Nightmares– Hyperarousal– hypervigilance

• Problems processing – Scattered– Preoccupied

• Emotional Lability– Anxious, irritable, numbing, laughing

• Personality Changes– Self-esteem– Sense of damage

• Everything pre-planned• Severe numbing

REFRENCES

Brain Injury Association of Indiana

PO Box 24167

Indianapolis, Indiana 46224

P: (317) 356-7722 F: (317) 481-1825biausa.org/Indiana

Brain Injury Association of America Inc.

1608 Spring Hill Rd

Suite 110

Vienna, VA 22182

Biausa.org

Reference

Family Caregiver Alliance/National Center of Caregiving

180 Montgomery Street

Suite 1100

San Francisco, CA 94104

Caregiver.org

Defense and Veterans

Brain Injury Center

Dvbic.org