Neurobehavioral Based Problems in TBI: clinical, behavioral, and caregiver approaches to managing

same D. Bradley Burton, Ph.D.

Hannah Kersting, B.A., B.S.

The impact of brain injury can take three broad forms:

1. Neurocognitive

2. Neurobehavioral

3. Psychological

Reciprocal Model of Change and Recovery

Neurocognition

Neurobehavior Psychology

Functional Impact

Neurocognitive entails changes in cognitive and cognitive related

capacities,

e.g., learning, language, reasoning, organization and control functions.

Psychological is defined as the individual’s psychological/emotional

reaction to having sustained brain injury and all that implies.

Neurobehavioral involves changes in the individual’s capacity to accurately

perceive, monitor, plan, and control their internal and external behavior.

Primary ecological human strength

Adaptability

And that means behavioral variability

The primary Human motivating Trait:

“Seeking Control” thru our capacity for

adaptability

Neurobehavioral disorders

1. Hypoactivity/dysbulia vs Hyperactivity/lability

2. Anosognosia vs full insight

Dysbulia

Lability

Treatment Modalities

• Cognitive Behavioral: procedural memory / environmental engagement

• Pharmacological – mood / behavior stabilizer vs stimulant

• Natural recovery process

-2

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1

22.

2.16

2.3.

16

2.4.

16

2.5.

16

2.8.

16

2.9.

16

2.10

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2.11

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2.12

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2.15

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2.16

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2.17

.16

2.18

.16

2.19

.16

2.22

.16

2.23

.16

2.24

.16

2.25

.16

ST OT PT

Affective Instability Scale

l

Shunt Placement

-2

-1

0

1

22.

2.16

2.3.

16

2.4.

16

2.5.

16

2.8.

16

2.9.

16

2.10

.16

2.11

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2.12

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2.15

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2.16

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2.17

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2.18

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2.19

.16

2.22

.16

2.23

.16

2.24

.16

2.25

.16

2.26

.16

ST OT PT

Affective Instability Scale

Decreased Keppra

0

50

100

150

200

1/24/1

5-1/27

/15

2/4/15

-2/8/1

5

2/16/1

5-2/22

/15

3/9/15

-3/15

/15

4/1/20

15-4/

7/201

5

4/22/1

5-4/28

/15

5/27/1

5-6/2/

15

6/10/1

5-6/16

/15

6/24/1

5-6/30

/15

7/8/15

-7/14

/15

7/22/1

5-7/28

/15

8/5/15

-8/11

/15

8/19/1

5-8/25

/15

9/2/15

-9/8/1

5

9/16/1

5-9/22

/15

9/30/1

5-10/6

/15

10/14

/15-10

/20/15

10/28

/15-11

/3/15

11/11

/15-11

/17/15

11/25

/15-12

/1/15

12/11

/15-12

/15/15

12/23

/15-12

/29/15

1/6/16

-1/12

/16

1/20/1

6-1/26

/16

2/3/16

-2/9/1

6

2/17/1

6-2/23

/16

Verbal Outbursts Physical Outbursts Physcial Threats Verbal Threats cursing others Property Dest. Suicidal Verbal. Suicidal GestureSelf-abuse physical/sexual verbal/sexual attempt elopeactual elope test limits attempts to trip others attempts to get out of bed spitting steals food and drink releases seat belt beats on chair or wall resistive to care bite himself gets into staffs belongings attempts to go to courtyardinstances of orality goes into other pts rooms pressured talking restless behaviorreactive negative affect harms or destroys property perseverations

Behavior Tracking increased respiradol and prn ativan

increased ativan

Rehab participation

Greater sense of control

Neurobehavioral functional gain

Anosognosia

Full Insight

Not Psychological Denial

A special Case

• Anosognosia perceptual unawareness of neurocognitive deficit

• Alien limb syndrome • Anton’s syndrome • Denial of neurocognitive deficit “your all

crazy”. More likely with nondominant hemi process

Treatment Modalities

• Procedural memory – redundant re-conceptualization / cognitive rehearsal

• Daily orientation exercises • Environmental alteration – structured

daily activities / schedule • Insight oriented psychotherapy • Natural recovery process

OQ Tracking Data

65

45

7

11

13 1314

15

18 1819

20

1011

1213

1514

1314

16

1817

20 20

12

0

5

10

15

20

12/14

/2012

12/19

/2012

12/20

/2013

1/21/2

013

1/24/2

013

1/29/2

013

1/30/2

013

2/1/20

13

2/4/20

13

2/8/20

13

2/25/2

013

2/28/2

013

2/29/1

3

2/30/1

3

OQ W/O cues OQ W/ cues

Functional Convergence

OQ Tracking Data

10

21 1

0 0 0

4

8

6

1011

0

8 8

2

10

14

18

14

18

0

3

0 0

2

0

17

11

1615

0

17

12

14

16

2019

20

10

5

10

15

20

2/28/2

014

3/1/20

14

3/4/20

14

3/5/20

14

3/6/20

14

3/7/20

14

3/8/20

14

3/12/2

014

3/13/2

014

3/14/2

014

3/19/2

014

3/20/2

014

3/22/2

014

3/25/2

014

3/26/2

014

3/27/2

014

4/1/20

14

4/2/20

14

4/4/20

14

4/5/20

14

4/8/20

14

4/9/20

14

OQ W/O cues OQ W/ cues

The rubric of recovery

Insight

Compliance with treatment

Emotional/behavioral stability

Psychological adjustment

Recovery