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Traumatic Brain Injury in Veterans. Robyn Mehlenbeck, PhD* Equal Justice Works Leadership Development Training October 23, 2014 Washington, DC. * George Mason University. WHAT IS TBI?. Traumatic Brain Injury:. Sudden physical damage and trauma to the brain

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traumatic brain injury in veterans

Traumatic Brain Injury in Veterans

Robyn Mehlenbeck, PhD*

Equal Justice Works Leadership Development Training

October 23, 2014

Washington, DC

* George Mason University

what is tbi
WHAT IS TBI?

Traumatic Brain Injury:

  • Sudden physical damage and trauma to the brain
    • Focal Lesion: foreign body enters brain, targets specific area
    • Mild Traumatic Brain Injury (mTBI): affects larger areas of the brain, white matter
      • White matter responsible for relaying electrical signals around brain
causes of tbi
Causes of TBI
  • Transportation accidents
    • Cars, motorcycles, bicycles, pedestrians (50%)
  • Falls
    • Majority of TBI in ages 75 and older from falls
  • Violence
    • Domestic violence, firearms assaults, child abuse (20%)
  • Sports injuries
    • Approximately 3%
  • Combat
    • Separate category, increasingly common in combat due to IED

(http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm)

combat related tbi
Combat-Related TBI
  • Especially common in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
    • 66% of service personnel in Iraq exposed to or injured by a blast injury
  • Frequently mTBI rather than focal lesion (80% mTBI)
  • Affects large sections of the brain
  • Effects not immediately noticeable
    • Concentration and cognitive decline over time
physical symptoms of tbi
Physical Symptoms of TBI
  • Unconsciousness (seconds or minutes)
  • Headache
  • Nausea and vomiting
  • Dizziness
  • Seizures
  • Weakness
  • Numbness in arms and legs
  • Dilated pupils
  • Metallic taste in mouth
  • Ringing in ears
  • Fatigue and lethargy
  • Change in sleep patterns
  • Difficulty with motor coordination
psych symptoms of tbi
Psych Symptoms of TBI
  • Slurred speech
  • Confusion
  • Agitation
  • Memory or concentration problems
  • Amnesia about events prior to injury
  • Behavioral changes
  • Mood changes
    • Depression
    • Anxiety
  • Difficulty with attention
  • Difficulty with complex thinking
neurology vs neuropsychology
Neurology vs Neuropsychology?
  • Neurology – MD
  • Specialty that assesses, diagnoses and treats problems with TBI, among other nervous system problems
  • Treats the physical symptoms and causes of TBI
  • Neuropsychology - PhD
    • Looking for behavioral manifestations of TBI
    • Assesses and treats the cognitive, behavioral and psychological effects of the TBI
types of tbi
Types of TBI
  • Two major types of traumatic brain injury
    • Penetrating brain injury
    • Closed head injury
penetrating tbi
Penetrating TBI
  • Types of penetrating TBI
    • Skull fracture  bone of skull cracks or breaks
    • Pieces of skull can press into brain tissue
    • Foreign object enters brain (e.g. bullet)
  • Damage occurs along path of injury (focal lesion)
  • Symptoms vary according to part of brain that is damaged
closed head tbi
Closed-head TBI
  • Results from blow to the head (e.g. car accident, football tackle, impact from IED blast)
  • Causes two type of brain injuries:
      • Primary
      • Secondary
primary closed head injuries
Primary Closed-head Injuries
  • Contusion
    • Bruising of brain tissue (swollen brain tissue and blood)
    • Can be in response to shaking of brain in skull (contrecoup)
  • Hematomas/blood clots
    • Occur between the skull and the brain or inside the brain itself
  • Diffuse axonal injury
    • Individual nerve cells damaged
    • Loss of connections between neurons
  • Laceration
    • Tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the brain
    • Force of the blow causes the brain to rotate across the hard ridges of the skull, causing the tears
secondary closed head injuries
Secondary Closed-head Injuries
  • Evolves over time (after trauma has occurred)
    • Brain swelling (edema)
    • Increased pressure inside of the skull (intracranial pressure)
    • Epilepsy
    • Intracranial infection
    • Fever
    • Anoxia: lack of oxygen supply to brain tissue
      • Without oxygen, brain cells die within minutes
    • Hematoma: heavy bleeding in or around brain
closed head injury illustration
Closed-head Injury Illustration

( http://health.allrefer.com/health/head-injury-prevention.html)

what does it mean to have a tbi
What does it mean to have a TBI?

Typical Impairments:

Communication

Thinking/Executive Functioning

Psychological

communication difficulties
Communication Difficulties
  • Difficulty picking up social cues
    • e.g. interrupting
  • Difficulty following conversations
  • Occasional difficulty modulating tone of voice
  • Difficulty processing subtleties/nuances in language
    • e.g. difference between tongue-in-cheek and seriousness
communication difficulties1
Communication Difficulties
  • More severe difficulties include:
    • Aphasia
      • difficulty understanding and producing spoken and written language
    • Word Recall
      • Trouble recalling words/speaking in complete sentences
    • Frequent pauses
    • Prosodic dysfunction
      • difficulties with inflection and intonation
cognitive difficulties
Cognitive Difficulties
  • Slower processing of information
  • Difficulty with short-term memory
  • Retrograde Amnesia (hippocampus/prefrontal cortex)
    • Loss of specific memories from pre-trauma (unconsolidated)
  • Anterograde Amnesia (hippocampus/prefrontal cortex)
    • Difficulty forming new memories after trauma
cognitive difficulties1
Cognitive Difficulties
  • Executive functioning difficulty (prefrontal cortex)
    • Poor planning, organizing skills
    • Setting goals
    • Completing tasks
    • Difficulty solving problems
    • Difficulty with abstract reasoning
    • Difficulty making judgments
  • Impulsivity (prefrontal cortex)
testing for effects of tbi
Testing for effects of TBI

Comprehensive Assessment with emphasis on Executive Functioning

  • Can be done by a neuropsychologist
  • Can be done by a psychologist with extensive experience in the types of tests needed to examine the deficits concerned about
testing for effects of tbi1
Testing for effects of TBI

Clinical Interview – looking for some identifying event/incident; any testing prior to the injury is a bonus

Cognitive Assessment – WAIS-V; Woodcock Johnson Cognitive/Achievement

Executive Functioning – Delis- Kaplan Executive Functioning System (D-KEFS)

Rey-Osterrieth Complex Figure Test/Beery VMI

Psychological – ADD scales, Mental Status Exam

Test of Memory Malingering (TOMM) – gives some validity to whether a client is intentionally exaggerating memory symptoms

rey osterrieth complex figure test
Rey-Osterrieth Complex Figure Test

- Add in figure; & scores on a sample w/deficits

treatment of tbi
Treatment of TBI
  • Treatment dependent on severity of TBI
    • Combination of medical management of symptoms & psychological intervention based on deficits
  • In mTBI Cognitive Behavioral Therapy most common treatment form for psychological effects
    • Structured work on goal setting/problem solving
    • Structured work on impact of thoughts on feelings and behaviors
  • Additional treatment:
    • Nutrition
    • Education
    • Counseling & family support
    • Medication for symptomatic relief