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

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


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


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


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


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.


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


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


Restoration example: AttentionSustained attentionSelective attentionAlternating attentionDivided attention


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


Improving Self-Awareness

Feedback ToolsMirrorsPhotosAudio tapesVideotapesWork samplesWriting samplesArts and crafts products


Improving Self-Awareness

Testing feedbackMedical RecordsSelf-Monitoring ExercisesGamesEducational MaterialsGroup TherapySupported FailureReal-Life ExperiencesDon’t say “I told you so”


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


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


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


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!


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)


Evaluation:Interview person with TBI and informantObservationsCheck for features of impulsive angerCheck risks, signs, motivation, awareness, things that help, trusted individuals


Episode LogDate and TimeWhat happened?CircumstancesWarning signsLevel of anger (1-10)Strategies usedOutcome


Middle StagesWork on awarenessStrengths and Problems listBuild trust and therapeutic allianceEmotional rehabilitation perspectiveAgreement for Time OutsIntroduce Cue CardOthers cue Time Outs


Typical Anger Cue Card Part 1

My Anger Risks: TiredNoise, activity, too many peopleFrustrated

My Anger Signs:Tight muscles, fists, jawViolent thoughtsLoud voiceFast breathing


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


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.


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)


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

Traumatic Brain Injury: Who Are You?

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