Traumatic Brain Injury: Who Are You?
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  • PTSD controversy, personal reformation idea
  • From Lloyd Cripe
  • Lawyer with mirror. Right hemisphere tbi teen who wanted to be a singer.
  • Prigatano with MRIs on the wall.
  • Limited literacy use of cue cards.

Traumatic Brain Injury: Who Are You? Traumatic Brain Injury: Who Are You? Presentation Transcript

  • Traumatic Brain Injury Tedd Judd, PhD Neuropsychologist Disability Awareness Week Central Washington University May 22, 2007
  • Who are you?
  • Overview
    • Causes, prevention, medical evaluation and treatment of traumatic brain injury (TBI)
    • Cognitive, emotional, and behavioral impact
    • Cognitive rehabilitation, emotional rehabilitation, medications, and educational accommodations
    • Living with brain injury at the university and in the rest of the world
    • Questions, discussion
  • Causes of Brain Disabilities
    • Trauma
    • Toxicity
    • Tumors
    • Degenerative disorders
    • Developmental disorders
    • Dietary deficiencies
    • Vascular disorders
    • Anoxia
    • Epilepsy
    • Hydrocephalus
    • Electric shock
    • Infections
    • Metabolic disorders
    • Autoimmune disorders
  • Causes of Brain Disabilities Most Likely to Affect University Students
    • Trauma
    • Toxicity
    • Tumors
    • Degenerative disorders
    • Developmental disorders
      • Learning Disabilities
      • Attention Deficit Disorder
      • Asperger’s Syndrome
    • Dietary deficiencies
    • Vascular disorders
    • Anoxia
    • Epilepsy
    • Hydrocephalus
    • Electric shock
    • Infections
    • Metabolic disorders
    • Autoimmune disorders
  • Causes of TBI
    • motor vehicle accidents
    • sports injuries
    • assaults
    • falls
    • blast concussion (59% of blast-
    • injured soldiers)
    • shaken babies
  • Traumatic Brain Injury
  • 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 Injury
    • There 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 Injury
    • Mechanisms of injury
    • Mechanical trauma—cell death, axonal shearing
    • Diffuse Axonal Injury
    • Hemorrhage (blood kills brain cells, blood is cut off from other areas, pressure effects)
    • Edema
    • Cascading chemical events— hope for interventions
    • Anoxia
    • Hydrocephalus
  •  
  • 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 >1 week >1 day Severe 1day-1 week 1 hour-1 day Moderate 0-1 day 0-1 hour Mild posttraumatic amnesia loss of consciousness Severity
  • Traumatic Brain Injury
    • Acute Medical evaluation:
      • CT
      • Physical and neurological exam
      • Serial assessment
  • Neurological Evaluation
    • Ancillary Exams
      • Laboratory
      • EEG
      • Evoked potentials
      • Lumbar puncture
      • CT scan
      • MRI scan
      • Functional imaging
      • Arteriography
  • Traumatic Brain Injury
    • Treatment:
      • Protect the airway & oxygenate
      • Ventilate to normocapnia
      • Correct hypovolaemia and hypotension
      • Prevent herniation
      • Surgery for hemorrhage, edema, skull repair
      • Medications for edema, infection, agitation, coagulants, anticonvulsives, etc.
      • Rehabilitation
  • Traumatic Brain Injury
    • High Risk Populations
      • Violent, impulsive, young, male, substance abusers
      • Children
      • Elderly
      • Soldiers
      • Pedestrians
      • Cyclists
  • Traumatic Brain Injury
    • High Risk Populations
      • Workers in certain industries
        • Logging
        • Mining
        • Construction
        • Military
        • Transportation
        • Some agriculture
  • Traumatic Brain Injury
    • Prevention:
      • Peace
      • Measures against interpersonal violence such as domestic violence
      • Gun control
      • Traffic law and industrial safety law enforcement
      • Vehicle and road maintenance
      • Seat belts, air bags
      • Helmets
      • Sport safety
      • Fall prevention in children and elderly
  • Mild Traumatic Brain Injury
    • The focus of tremendous forensic and sports neuropsychology energy
    • The most common TBI
    • Several definitions but usually include:
      • Trauma to the head
      • Alteration of consciousness
      • <1 hour loss of consciousness
      • <24 hours posttraumatic amnesia
      • No focal deficits
  • Mild Traumatic Brain Injury
    • Many non-specific symptoms:
      • Headache
      • Memory loss
      • Attention difficulty
      • Fatigue
      • Depression
      • Anxiety
      • Dizziness
      • Irritability
      • Nausea
      • Oversensitivity to noise, light, distractions
  • Mild Traumatic Brain Injury
    • High base rates for the non-specific symptoms
    • Head injury vs brain injury
      • Dizziness
      • Headache
    • MTBI vs PTSD
    • Rule 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 amnesia
      • Screen for posttraumatic stress disorder
      • Check on attitudes, anger, guilt, lawsuits, disability claims, expectations, substance abuse
      • The course of recovery up to now
      • Compare pre-injury to now
  • Psychosocial Evaluation of TBI
    • Early evaluation (within a few months of injury)
      • Focus on priority problems
      • Screen and baseline testing
      • Support and education
      • Provide for follow-up
  • Neuropsychological Evaluation of TBI
    • Later evaluation (6 months or more after injury)
      • Focus on priority problems
      • Comprehensive, problem-oriented testing
      • Attention, memory, executive functions, effort, emotional adjustment, vocational or educational and social adjustment
  • Differential Diagnosis of Mild TBI
    • Rule outs:
    • Depression
    • Anxiety
    • Posttraumatic stress disorder
    • Sleep disturbance
    • Chronic pain, especially headache
    • Vestibular 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:
    • Grief
    • Denial
    • Depression
    • Anxiety
    • Anger
    • Posttraumatic Stress Disorder
    • Personal Reformation
  • Reactions to illness/disability:
    • Grief
    • Denial
    • Depression
    • Anxiety
    • Perplexity Lezak, 1978
    • Frustration
    • Anger
    • Embarrassment
  • Organic Emotional Changes Indifference Labile emotions Impulsive anger Catastrophic reactions Emotional Reactivity Monotone voice Masked face Reflex crying, laughing Automatic cursing Emotional Communication Decreased Increased Function
  • Organic Emotional Changes
    • Organically induced major psychiatric disorders
      • Depression
      • Mania
      • Psychosis
      • Obsessive-compulsive disorder
    • Temporal lobe epilepsy personality changes?
  • What are Executive Functions?
    • Choose a goal
    • Plan
    • Execute
    • 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
  • What are Executive Dysfunctions?
    • Childish
    • Self-centred
    • Unempathetic
    • Concrete
    • Lacking abstract attitude
    • Unable to shift attention
    • Unable to use feedback
    • Unable to maintain performance
    • Unable to self-monitor
    • Lack of self-reflectiveness
    • Unconcern
    • Outbursts of irritability
    • Perseverative
    • Impersistent
    • Assertive
    • Inflexible
  • What are Executive Dysfunctions?
    • 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 Perseveration stuck at one point Impersistence no follow-through Termination Apathy, no drive Impulsiveness Disinhibition Initiation Decreased Increased Function
  • Conceptualization of Psychopathology Executive Dysfunctions:
    • Concreteness
    • Poor Monitoring and Judgment
    • Lack 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
    • Competencies
      • Driving
      • Money management
      • Personal decisions—life choices, medical consent
      • Work
    • Dealing with emergencies
    • Family and other social relations
    • Impulse control—addictions, spending, gambling, eating, sexual behavior, aggression
    • Criminal 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.
  • Cognitive Rehabilitation
    • 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
  • Cognitive Rehabilitation
    • Restoration : Repetitive exercises and activities designed to restore or improve damaged abilities
    • Compensations : Tools and techniques adapted to and used by the individual to allow functioning in spite of disabilities
    • Accommodations : Changes in the shared environment of the individual which allow functioning in spite of disabilities
  • Cognitive Rehabilitation
    • Restoration example: Attention
      • Sustained attention
      • Selective attention
      • Alternating attention
      • Divided attention
  • Cognitive Rehabilitation
    • Compensation example: Memory
    • Memory Book – possible sections
      • Event calendar
      • Things to Do list
      • Daily schedule
      • Diary (memory log, feelings)
      • Directory and family (name, address, phone numbers and relationship, photos)
      • Medications (name, purpose, schedule, doctor)
      • Transportation (directions, bus schedules, maps)
      • Finances
      • Shopping lists
  • Cognitive Rehabilitation
    • Compensation example: Memory
    • Electronic aids
    • Cell phone
    • Laptop
    • Personal Digital Assistant
    • Calculator
    • Key alarm
    • Digital recorder
    • Digital camera
    • Alarms
    • Timer
    • Dictionary/thesaurus
    • Watch with multiple alarms, countdown timer, hour chimes, database
  • Educational Accommodations
    • Allow a lighter course load
    • Allow 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 Accommodations
    • Accept 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
    • Compensate Externally (schedules, cues, reminders, written procedures, restrictions)
    • Build Awareness
    • Retrain Self-regulation (problem-solving schemata, social skills, alarms, PDAs)
    • Generalize Self-regulation train in other settings (home, school, work, community)
    • Fade External Compensations
  • The Content of Neuropsychotherapy Emotional Rehabilitation
    • Accessible metaphor
    • Demystify process
    • Reduce guilt and blame
    • Define roles
    • Skill-learning model
  • The Content of Neuropsychotherapy Improving Self-Awareness
    • Feedback Tools
    • Mirrors
    • Photos
    • Audio tapes
    • Videotapes
    • Work samples
    • Writing samples
    • Arts and crafts products
  • The Content of Neuropsychotherapy Improving Self-Awareness
    • Testing feedback
    • Medical Records
    • Self-Monitoring Exercises
    • Games
    • Educational Materials
    • Group Therapy
    • Supported Failure
    • Real-Life Experiences
    • Don’t say “I told you so”
  • The Content of Neuropsychotherapy The New Self
    • Not necessarily better or worse, just different
    • Discover who the new self is
    • Rethink abilities
    • Rethink goals
    • Rethink relationships
  • The Techniques of Neuropsychotherapy Cue Cards:
    • MY ANXIETY SIGNS
    • Tapping fingers, foot
    • Fast breathing, heart
    • Sweating
    • Tense muscles
    • Fussing and fidgeting
    • RELAXING BREAK
    • Alone, quiet, dark
    • Close eyes
    • Breathe slowly, deeply
    • Relax muscles
    • Let go of worried thoughts
    • Picture beach
  • The Techniques of Neuropsychotherapy Cue Cards:
    • SIGNS OF DEPRESSION:
    • 1. Negative thoughts
    • 2. Crying
    • 3. Thoughts of drugs and suicide
    • 4. 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. &quot;I'm getting better. I can learn to control this myself!&quot;
    • 2. Distract myself:
    • A. Watch Fred and the others
    • B. Draw
    • C. Write
    • D. Nintendo
    • E. Clean
    • 3. Ask Fred for help
  • The Techniques of Neuropsychotherapy Cue Cards:
    • ACTIVE LISTENING
    • Quiet, alone with other person
    • No TV, radio, music
    • Not doing anything else
    • Face other person, eye contact
    • Don't interrupt or react (bite tongue)
    • Repeat other person's feelings
  • The Techniques of Neuropsychotherapy Cue Cards:
    • PUBLIC SPEAKING
    • Use written outline
    • Practice alone and with friend
    • Have friend in audience
    • Short relaxation before going on
    • &quot;I can do it! I know my stuff. They are friendly and want to hear me.&quot;
    • Find friend in audience
    • Speak to back of room
    • Slowly and clearly
    • Smile!
  • The Techniques of Neuropsychotherapy Cue Cards:
    • TALKING TO A PHONE ANSWERING MACHINE
    • Hello, 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 injury
    • Anger episodes are:
      • Sudden
      • Overreactive
      • Unplanned
      • Purposeless
      • Ego-dystonic (“that’s not me!”, embarrassing)
      • Related to physiological stress (pain, fatigue, low blood sugar) (Miller, 1993; Silver & Yudofsky, 1994)
  • Example: Impulsive Anger
    • Evaluation:
    • Interview person with TBI and informant
    • Observations
    • Check for features of impulsive anger
    • Check risks, signs, motivation, awareness, things that help, trusted individuals
  • Example: Impulsive Anger
    • Episode Log
    • Date and Time
    • What happened?
    • Circumstances
    • Warning signs
    • Level of anger (1-10)
    • Strategies used
    • Outcome
  • Example: Impulsive Anger
    • Middle Stages
    • Work on awareness
    • Strengths and Problems list
    • Build trust and therapeutic alliance
    • Emotional rehabilitation perspective
    • Agreement for Time Outs
    • Introduce Cue Card
    • Others cue Time Outs
  • Example: Impulsive Anger Typical Anger Cue Card Part 1
    • My Anger Risks:
    • Tired
    • Noise, activity, too many people
    • Frustrated
    • My Anger Signs:
    • Tight muscles, fists, jaw
    • Violent thoughts
    • Loud voice
    • Fast breathing
  • Example: Impulsive Anger Typical Anger Cue Card Part 2
    • TIME OUT!
    • Say: &quot;I'm feeling angry, I need to take a time out&quot;
    • Go outside or bedroom.
    • Walk or exercise
    • Practice relaxing
    • Preparing To Return
    • When I can smile I'm ready to go back
    • What do I need to say:
      • Apologize?
      • Set time to talk?
      • Ask how they feel?
      • Say what I want?
    • Check in
  • Example: Impulsive Anger
    • 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.
  • Example: Impulsive Anger
    • Later Stages
    • Reduce cuing for Time Outs
    • Do practice Time Outs
    • The 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 out
    • Generalize self-management to other settings
    • Stress test the system (try coping in more difficult situations)
  • Example: Impulsive Anger
    • Feelings Journal
    • Date 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 TBI
    • People 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 problems
    • Modafinil (Provigil) is often used for fatigue (although a recent study suggests that caffeine is just as good)
  • Medications and TBI
    • Off-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 inhibitors
      • Beta blockers
      • Mood 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 antipsychotics
      • Long-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