TBI, PTSD, and Addiction Treating Veterans with Complex Needs

1. Kristine Burkman, Ph.D. Staff Psychologist San Francisco VA Medical Center TBI, PTSD, and Addiction Treating Veterans with Complex Needs

2. ASAM Disclosure of Relevant Financial Relationships Content of Activity: ASAM Medical –Scientific Conference 2013

3. Presentation Outline • Definitions • Assessment • Prevalence • Overlapping Symptoms • Treatment Considerations • Suggested Strategies

4. Definitions

5. Traumatic Brain Injury (TBI) a traumatically induced physiologic disruption of brain function, as manifested by one of the following: • Loss of consciousness • Loss of memory for events immediately before or after the accident • Alteration of mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused) • Focal neurological deficit(s) that may or may not be transient American Congress of Rehabilitation Medicine (ACRM) KEEP IN MIND: TBI refers to original injury or etiology, there are no symptoms for this diagnosis

6. Traumatic Brain Injury (TBI) Specifiers: Mild, Moderate, Severe Refers to 24-48 hours following injury. Severity of initial injury ≠ impairment in functioning Prognosis often related to: • Length of loss of consciousness • Length of post traumatic amnesia

7. Assessment

8. TBI Assessment : Glasgow Coma Scale • Verbal response • Oriented to person, place & date = 5 • Converses but is disoriented = 4 • Says inappropriate words = 3 • Says incomprehensible sounds = 2 • No response = 1 SCORING Specifier is based on score within 48 hrs of injury: Severe = 1 - 8 Moderate = 9 - 12 Mild = 13 - 15 • Eye opening • Spontaneous = 4 • To speech = 3 • To painful stimulation = 2 • No response = 1 • Motor response • Follows commands = 6 • Makes localizing movements to pain = 5 • Makes withdrawal movements to pain = 4 • Flexor (decorticate) posturing to pain = 3 • Extensor (decerebrate) posturing to pain = 2 • No response = 1

9. TBI Assessment • Not routinely assessed in combat situations • VA assesses via self-report months, even years after the event • Screen (4 items, sensitive not specific) • Second level eval (22 items) • Often not documented and military culture may encourage minimization

10. Prevalence

11. Prevalence of TBI • 91% of OEF/OIF casualties survive1 • Compared to 84% of Vietnam, 80% WWII • Estimated 22% of returning servicemembers have reported experiencing TBIs and concussions2 • Of those injured, approximately 31% diagnosed w/ TBI3 • 77% of all head injuries are mild TBI4 1Holcomb et al., 2006, 2Terrio et al., 2005, 3Hayward, 2008, 4Fischer, 2010

12. Risks Associated with TBI • Persons w/ TBI more likely to have 2nd and 3rd TBI1 • Repeat TBIs increase severity and chronicity of symptoms1 • Twice as likely to screen positive for PTSD or depression2 • Increased risk for suicide3 1Center for Disease Control (CDC); 2Maguen, Lau, Madden & Seal, 2012; 3Brenner, Ignacio & Blow, 2011

13. TBI and Substance Abuse • Complicated literature • Bi-directional relationship between TBI and SUD • Pre-injury pattern of substance use predicts post-injury pattern of use • Substance use impairs rehabilitation and exacerbates symptoms • Increased risk of additional injury

14. Chronic Stress and Relapse • Co-Occurring Disorders • SUD + Depression, 3-5 time more likely to relapse1 • SUD + PTSD relapse more quickly 2,3 • Co-occurring patterns of relapse 2, 4 • Exposure to Trauma • Probability of relapse increases as the # of traumas types increase5 1Curran et al., 2000; 2Brown et al., 1996; 3Ouimette et al., 1997; 4Curran & Booth, 1999; 5Fraley et al., 1998

15. Overlapping Symptoms

16. Symptoms associated w/ TBI • Loss/increase in appetite • Difficulty concentrating • Forgetfulness • Difficulty making decisions • Slowed thinking, disorganized • Fatigue, loss of energy • Feeling depressed or sad • Difficulty falling or staying asleep • Feeling anxious or tense • Irritability, easily annoyed • Poor frustration tolerance, easily • overwhelmed • Feeling dizzy • Loss of balance • Poor coordination, clumsy • Headaches • Vision Problems • Sensitivity to Light • Nausea • Hearing difficulties • Sensitivity to noise • Numbness • Change in taste and/or smell

17. Symptoms of PTSD • Re-experiencing • Intrusive images, memories, thoughts • Nightmares • Flashbacks • Emotional distress at reminders • Physical reaction to reminders • Avoidant • Avoiding thinking/talking about trauma • Avoiding situations • Trouble remembering aspects of trauma • Loss of interest in activities used to enjoy • Feeling distant/ cut-off from others • Emotionally numb • Foreshortened sense of future • Hyperarousal • Insomnia • Irritability • Difficulty concentrating • Hypervigilence • Startle response

18. Common Challenges Frontal Lobe Inhibited Impulse Control Planning Abstraction Judgment Limbic System Activated Emotion Memory

19. Overlapping and Distinct Symptoms • Sleep problems • Dizziness • Headaches • Memory problems • Light sensitivity • Loss of interest • Feeling down, hopeless • Irritability • Emotional numbing • Avoidance • Nightmares • Hypervigilence Maguen, Lau, Madden, Seal, 2012

20. Treatment Considerations

21. Barriers to Engagement • Missed appointments • Avoidance, memory problems, difficulty w/ initiation, inability to organize effectively, relapse • Difficulty tracking or recalling skills • Frustrated w/ pace, embarrassment in session • Crisis-prone • Relationships, work/school, legal, psychiatric crises • Distorted expectations and beliefs

22. Trauma Treatment w/ TBI Phase Based Model of Recovery • Titrate level of emotional content re: trauma material • Assess level impairment re: memory and emotion regulation to inform when and how to approach trauma processing Stabilization Processing Integration • -Psychoeducation • Coping skills • Psychopharmacology -Construction of narrative -Cognitive restructuring -Exposure • Interpersonal work • Insight/existential • Symptom maintenance Establish “safety” Improve self-regulation Consolidation of memory Habituation of fear response Reconnect with others/life Meaning of experience

23. Concerns re: Trauma Processing • Fear of symptoms exacerbation • Drop out rates • Insufficient training for protocol among clinicians • “Fragile” patients • Chaotic/ high risk situations KEEP IN MIND: Mild TBI should resolve fully within 6 months, debate over cause of ongoing symptoms Integrated treatment of TBI, PTSD and SUD is recommended!

24. Suggested Strategies

25. Strategies: Therapeutic Stance • Flexibility • Persistent outreach • Validate, reassure, challenge • Acknowledge problems as real to veteran • Education re: relapse, heterogeneity of injuries, expectation of recovery from mTBI • Goal of recovery not adjustment to permanent disability • Multidisciplinary team • Harm reduction

26. Strategies: Problem Solving Memory & Learning Processing Speed Frontal Lobe Damage • Write it down • Organize • Visualize Info • Attach emotion • Repetition • Plan Ahead • Allow extra time • Accuracy over speed • Avoid multitasking • Flexible deadlines • Include support members • Emotional awareness & management • Routine • Encourage persistence

27. Strategies: Communication • Keep it simple • Go slow • Write it down • Encourage veteran to communicate back what he/she understands • Repeat

28. Thank you for serving our Veterans! Questions? Kristine.Burkman2@va.gov