Traumatic Brain Injury (TBI) Outcomes July, 2013

1. Traumatic Brain Injury (TBI) OutcomesJuly, 2013 Cheryl L. Shigaki, Ph.D., ABPP Cheryl L. Shigaki, Ph.D., ABPP & Thomas Martin, Psy.D., ABPP & Thomas Martin, Psy.D., ABPP

2. 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.

3. 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

4. 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.

5. 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

6. 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.

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

8. 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.

9. 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

10. Causes of TBI • Falls (especially older adults) • Motor vehicle accidents • Sports injuries • Work-related injuries • Domestic violence • Child abuse • Shaken baby syndrome

11. 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

12. Impact of mild TBI / concussion Physical 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

13. 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

14. 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 resolved • health professional/parent monitors • REST! – limit physical & cognitive exertion • Alcohol use may exacerbate symptoms • May take several weeks

15. 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

16. 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:

17. 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

18. Cognitive impact: Moderate to severe TBI • TBI does not typically compromise “intelligence” in mild-to-moderate cases. The Thinker – Musée Rodin, Paris

19. 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.

20. 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

21. 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)

22. 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

23. Discussion 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.?)

24. 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

25. 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?

26. 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)

27. 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

28. 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

29. 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

30. 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

31. PTSD and mild TBI: Symptom overlap Both Insomnia Fatigue Irritability/anger Depression/ anxiety Trouble concentrating Hyper-arousal Avoidance Mild TBI Headache Sensitivity to light/sound Memory deficit Dizziness PTSD Shame Guilt Re-experiencing symptoms Adapted from Stein & McAllister, Am J Psychiatry 2009; 166:768-776

32. 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.

33. 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 PTSD Bremner 2006; Gilbertson et al., 2002

34. 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

35. 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 dueto PTSD and/or depression. Treating symptoms of PTSD is a priority

36. Discussion Are there misconceptions about TBI that are commonly believed in Rwanda? What resources are available in Rwanda for individuals with TBI and their families?

37. Working with patients & families

38. 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.

39. 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.

40. 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

41. 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

42. 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

43. 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)

44. 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

45. 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.

46. Impact on families • Family 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”

47. Discussion What questions do you have?

48. Cheryl L. Shigaki, Ph.D., ABPP Associate Professor University of Missouri Department of Health Psychology Dc116.88 One Hospital Drive Columbia, MO 65212 USA shigakic@health.missouri.edu http://cherylshigaki.wordpress.com/