TBI & PTSD’s Impact On Returning Veterans Tracy L. Thomas, Ph.D. Clinical Neuropsychologist November 10, 2008
Objectives Identifying Signs and Symptoms of TBI and PTSD Course of Treatment Success in Treatment Long-Term Effects of TBI and PTSD Involvement of Family and Friends Involvement in the Delivery Systems Questions and Answers
Identifying Signs and Symptoms of TBI Giza, CC and Hovda, DA (2001). The Neurometabolic Cascade of Concussion. Journal of Athletic Training, 36(3); 228-235.
Identifying Signs and Symptoms of TBI Physical Symptoms Headaches (may get worse over time) Weakness Numbness Decreased coordination Vomiting Lethargy Slurred speech Seizures/Convulsions Sleep pattern changes Loss of balance Blurred vision/visual disturbance Loss of sense of smell/taste Tinnitus (ringing in the ears) Sensitivity to noise or light
Identifying Signs and Symptoms of TBI (cont.) Cognitive/Emotional Symptoms Confusion Restlessness/Agitation Personality changes Attention/Concentration difficulties Word finding difficulties Memory difficulties Decreased ability to plan/organize Hard time making decisions Slow to respond or understand (processing speed) Reduced/Heightened libido Reduced motivation/initiation Depression Irritability Anxiety/hypervigilance/exaggerated startle
Identifying Signs and Symptoms of TBI (cont.) Assessment Neuropsychological Assessment Screening measures COGNISTAT Takes 10-20 minutes to administer RBANS Takes 15-30 minutes to administer Full batteries Fixed Can take up to 8-10 hours to administer Flexible Can take 2-10 hours to administer Neuroimaging Computed Tomography (CT) Scans Magnetic Resonance Imaging (MRI) Scans Positron Emission Tomography (PET) Scans Neurological Exam
Identifying Signs and Symptoms of PTSD Symptoms: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DMS-IV) criteria: A. Exposure to a traumatic event in which both were present: 1. Experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others 2. Response involved intense fear, helplessness, or horror B. Reexperiencing 1. Intrusive memories, including images, thoughts, or perceptions 2. Nightmares 3. Flashbacks 4. Intense psychological distress upon exposure to internal /external trauma cues 5. Physiological reactivity upon exposure to internal/external trauma cues
Identifying Signs and Symptoms of PTSD (cont.) Symptoms: C. Avoidance/Numbing 1. Avoid thoughts, feelings, or conversations about trauma 2. Avoid activities, places, or people associated with trauma 3. Unable to recall important aspects of the trauma 4. Diminished interest/participation in significant activities 5. Feel detached/estranged from others 6. Restricted range of affect 7. Sense of foreshortened future D. Arousal 1. Sleep difficulties 2. Irritability/Anger outbursts 3. Concentration difficulties 4. Hypervigilance 5. Startle response E. Duration of symptoms last for more than one month F. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
Identifying Signs and Symptoms of PTSD (cont.) Assessment: Clinician Administered PTSD Scale (CAPS-IV) 30-item structured interview that corresponds to the DSM-IV criteria for PTSD Can be used to assess Current or Lifetime diagnosis of PTSD Takes 45-60 minutes to administer Posttraumatic Stress Disorder Checklist (PCL) 17-item self-report scale based on DSM-IV criteria Takes 5-7 minutes to administer 3 versions available Military Civilian “Specific Stressful Event”
PTSD Prevalence in Veterans 16.6% of soldiers from 4 Army combat infantry brigades surveyed 1 year after returning from deployment were diagnosed with PTSD (Hoge, et al., 2007) PTSD prevalence increases with the presence of TBI (Hoge, et al., 2007 & Schneiderman, et al., 2008) Injured active duty OIF personnel = 32% Uninjured active duty OIF personnel = 14%
Treatment for TBI Education Cognitive Remediation Social Skills Training Relaxation Group Therapy Family Therapy Medication
Treatment for TBI Education Providing education can lead to relief, as it validates the client’s experience and helps them realize that they are not “crazy.” Knowledge is Power – by recognizing your limitations you can learn to compensate for them or work around them Example 1: By knowing that your memory is poor, you may learn to write down important information so it is not forgotten Example 2: Establish external organization. If you keep forgetting keys, wallet, etc. when leaving the house, put a stand by the front door where you put them immediately upon entering the home.
Treatment for TBI Cognitive Remediation The goals of cognitive remediation are to bolster specific cognitive capacities that are weak and also to teach compensatory strategies to work around limitations Typically use a gradual increase in complexity, based upon the clients performance. Once they establish consistency at 80% or above, increase the complexity of the task. Areas of focus: Attention/Concentration Language Visuospatial skills Memory Organization/Planning
Treatment for TBI Social Skills Training TBI can affect the natural “feedback loop” that allows us to assess and modify our social interactions with others. When this is “broken” people may talk too much (i.e., fail to take turns in conversation), impulsively state what’s on their mind even if it is not appropriate, or fail to recognize social cues (e.g., not recognizing that someone may be in a hurry when they are looking at their watch).
Treatment for TBI Relaxation Biofeedback – this training allows clients to reestablish control over their arousal levels, as lowered frustration tolerance is often seen with TBI. Group Therapy At Rehab Without Walls we offer several groups. Coping group – allows individuals an opportunity to share with and learn from others who have also suffered a brain insult. Stress Management Group – where clients learn about the physiological aspect of stress and practice relaxation techniques together. Memory Group – a didactic group that provides education regarding the cognitive, behavioral, and emotional sequelae of TBI. T’ai Chi Group – helps clients develop a nice balance between healing the mind and the body.
Treatment for TBI Group Therapy (cont.) VA – offers a “Brain Booster” group, which provides veterans with education regarding the effects of TBI and homework assignments geared towards improving areas of cognitive limitation. Benefits of group therapy: Accountability – feeling peer pressure to follow through with homework assignments Support – often times individuals with TBI feel that they are alone, that no one understands what they are going through, until they meet others with similar issues
Treatment for TBI Family Therapy Family/friends are also affected by TBI “Changes” are often noted in personality and behavior, which can confuse family/friends. Client is not “lazy” or “acting out” Education provides family/friends with relief and gives a sense of hope Knowledge also makes them better supporters of the injured person Important to help children understand changes seen in their parent as well
Treatment for TBI Medication Psychostimulants For attention deficits and initiation difficulties Increases frontal lobe activity, which is an important area for attention processing (Perna & Bordini, 2001) Antidepressants Depression following TBI is common and can hinder recovery (Jorge et al., 2004) Typically first choice is from the SSRI group Anticonvulsants Approximately 5-10% of TBI clients will develop new-onset seizures (Meythaler & Novack) Typically given as a prophylactic to help prevent seizures after an injury The risk of seizures increases with severity of injury The risk is greatest the first two years and then gradually declines thereafter
Treatment for PTSD Cognitive Therapy Exposure Therapy EMDR Relaxation Group Therapy Family Therapy Medication
Treatment for PTSD Cognitive Processing Therapy (CPT; Resick et al., 2007) A manualized, 12-session, specific form of CBT for PTSD Provides both cognitive and exposure therapy elements Focuses on a range of emotions, such as anxiety, shame, sadness, anger, etc. CPT has produced statistically significant improvements compared with Prolonged Exposure (PE) therapy in trauma-related guilt (Resick, et al., 2002) CPT was found effective in treating military-related PTSD as well (Monson et al., 2006)
Treatment for PTSD CPT (cont.): Session 1: Introduction and Education Psychoeducation – PTSD symptoms are explained Homework – Write an “Impact Statement” (the meaning of the traumatic event and beliefs as to why it happened) Session 2: The Meaning of the Event Read “Impact Statement” – geared towards identifying problematic beliefs and cognitions (“stuck points”) Education – to identify the connection between events, thoughts, and feelings Homework – Practice identifying connection between events, thoughts, and feelings
Treatment for PTSD CPT (cont.): Session 3: Identification of Thoughts and Feelings Review self-monitoring homework Homework – Write a detailed account of the most traumatic event and read it every day before Session 4 Session 4: Remembering the Traumatic Event Recall and better contextualize traumatic events and to experience the natural emotions that they may have suppressed following these events Homework – Rewrite the trauma account with more details and emotions and document current thoughts and beliefs as they write the account. Read daily before Session 5
Treatment for PTSD CPT (cont.): Session 5: Second Trauma Account Read second account Cognitive challenging using a Socratic style of questioning Teach clients to ask questions regarding their assumptions and self-statements in order to begin challenging them Session 6-7: Challenging Questions & Patterns of Problematic Thinking Education regarding using worksheets in day-to-day lives to challenge and modify maladaptive thoughts and beliefs related to traumatic experience
Treatment for PTSD CPT (cont.): Session 8-12: Overgeneralized beliefs in five areas (i.e., safety, trust, power/control, esteem, & intimacy) are challenged as they relate to self and others
Treatment for PTSD Exposure Therapy (EP): A client is asked to vividly recount a traumatic event repeatedly until the client’s emotional response decreases and to gradually confront safe but fear-evoking trauma reminders. If multiple traumas exist, focus upon the most distressing memory. Successfully processing the worst trauma usually generalizes to other memories.
Treatment for PTSD Exposure Therapy (EP): Compared to Present Centered Therapy (PCT; focusing on today’s issues as manifested by having PTSD), EP was superior: (Schnurr, et al., 2007)
Treatment for PTSD Eye Movement Desensitization and Reprocessing (EMDR): Developed by Francine Shapiro, Ph.D. It is an Information Processing Therapy “When a traumatic or very negative event occurs, information processing may be incomplete, perhaps because strong negative feelings or dissociation interfere with information processing. This prevents the forging of connections with more adaptive information that is held in other memory networks. “ (Shapiro)
Treatment for PTSD Eye Movement Desensitization and Reprocessing (EMDR): It uses an 8 phase approach Phase 1: Client History & Treatment Planning Identify possible targets for EMDR processing 3-pronged: Recent distressing events Related historical incidents Development of skills/behaviors needed by client in future situations
Treatment for PTSD Eye Movement Desensitization and Reprocessing (EMDR, cont.): Phase 2: Client Preparation Teach self-soothing techniques (i.e., establish a “safe place” the client can return to during times of emotional distress) Client identifies type of bilateral attention process preferred to use (visual, auditory, or tactile) Client’s fears and concerns are addressed Phase 3: Assessment Identify target incident State what picture represents the worst part of the experience Rate negative and positive cognitions Describe related body feelings
Treatment for PTSD Eye Movement Desensitization and Reprocessing (EMDR, cont.): Phase 4: Desensitization Client focuses on bilateral stimulation while holding target event in mind Lasts 30 seconds to several minutes depending upon client’s response Clear the mind and allow whatever comes into awareness Repeat the procedure Phase 5: Installation of Positive Cognition Determine validity of positive cognition Conduct bilateral attention until it is experienced as being totally valid
Treatment for PTSD Eye Movement Desensitization and Reprocessing (EMDR, cont.): Phase 6: Body Scan Clients close their eyes and scan their body for tension or negative sensations Bilateral stimulation is conducted until negative sensations subside or a positive feeling is experienced Phase 7: Closure Education is provided regarding experiences the client may have after the session, such as having new insights, vivid dreams, intrusive thoughts, etc. Client is to record and report these experiences during the next session
Treatment for PTSD Eye Movement Desensitization and Reprocessing (EMDR, cont.): Phase 8: Reevaluation Review the week, discussing any new sensations Review the client’s log Assess the previous session’s target in order to determine whether further desensitization work is needed
Treatment for PTSD Relaxation Therapy: Progressive Muscle Relaxation Squeezing and releasing different muscle groups Diaphragmatic Breathing Breathing into the belly rather than into the chest Meditation Aromatherapy Massage
Treatment for PTSD Group Therapy: These groups provide mutual support from others who have experienced similar traumas and encourage the patient to begin confronting their traumas (Davidson & Neale, 1998). Family Therapy: There are no research studies on the effectiveness of marital/family therapy for the treatment of PTSD. However, because of trauma's unique effects on interpersonal relatedness, clinical wisdom indicates that spouses and families be included in treatment of those with PTSD. Of note, marriage counseling is typically contraindicated in cases of domestic violence, until the batterer has been successfully (individually) rehabilitated.
Treatment for PTSD Medication: SSRIs – research shows that these medications tend to decrease anxiety, depression, and panic. They may also reduce aggression, impulsivity, and suicidal thoughts. Types of SSRIs: citalopram (Celexa) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) Take 6-8 weeks to work Many do not get relief from the first prescription and will need to try another medication A relapse is less likely to occur if prescribed for at least one year
Treatment for PTSD Medication: Atypical antipsychotics Types of antipsychotics: risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) Most useful for those with agitation, dissociation, hypervigilance, paranoia, or brief psychotic reactions Mood stabilizers Types of mood stabilizers: lamotrigine (Lamictal) tiagabine (Gabitril) divalproex sodium (Depakote)
Treatment Success for TBI A review of studies conducted in several countries, over 20 years, found early intervention involving education, reassurance, and reattribution of symptoms to benign causes to be effective (Mittenberg et al., 2001) Long-term benefits have been found for symptomatology and quality of life after undergoing neuropsychological rehabilitation after a brain injury (Svendsen & Teasdale, 2006).
Treatment Success for PTSD A meta-analysis on 61 treatment outcome trials for PTSD (Van Etton & Taylor, 1998) revealed: Psychological therapies had a lower drop-out rates than pharmacotherapies Psychological therapies were more effective in symptom reduction than pharmacotherapies Both therapies were more effective than controls Of drug therapies, SSRIs and carbamazepine had the greatest effect sizes Of psychological therapies, behavior and EMDR were most effective SSRIs were more effective than any other therapy in treating depression
Long-Term Effects of TBI & PTSD Left untreated, both can lead to dire consequences: Isolation TBI – being socially inappropriate, apathetic, labile PTSD – turn friends away, silence, “no one understands me” Unemployment TBI – loss of cognitive capacity to function at work, depression PTSD – anger outbursts, lack of frustration tolerance, depression Divorce TBI – role changes, husband/wife is more like a child/dependent PTSD – increased domestic violence Death – through suicide, fighting, drug overdose
Involvement of Family and Friends Family and friends are crucial to helping individuals with TBI and/or PTSD They are likely to recognize signs and symptoms Call support lines for help or encourage loved one to do so, because they may not have the cognitive capacity or motivation to do so themselves
Involvement of the Delivery System VA System An excellent organization for all veterans Comprehensive evaluation and treatment of all issues, but now especially vigilant to addressing TBI and PTSD Brain Injury Association Provides excellent resources to friends and families with TBI A great starting place to help understand what is happening and how to get the appropriate help
Resources Brain Injury Association http://www.biausa.org/ For Arizona: http://www.biaaz.org/bia/index.aspx Brain Injury Source – published quarterly by the Brain Injury Association EMDR Institute http://www.emdr.com/ The International Society for Traumatic Stress Studies http://www.istss.org/
Resources (cont.) National Institute of Mental Health http://www.nimh.nih.gov/topics/ptsd.shtml Clinical trials on PTSD (i.e., searching for participants) Pamphlets Current news regarding PTSD (e.g., risk factors, treatment, etc.) Rehab Without Walls http://www.gentiva.com/index.asp PTSD Support Services http://www.ptsdsupport.net/index.html
Resources (cont.) United States Department of Veterans Affairs http://www.va.gov/ National Center for Posttraumatic Stress Disorder
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References Jorge, R.E., Robinson, R.G., Moser, D., Tateno, A., Crespo-Facorro, B., & Arndt, S. (2004). Major depression following traumatic brain injury. Archives of General Psychiatry 61(1), 42-50. Lubin, H., Loris, M., Burt, J., & Johnson, D.R. (1998). Efficacy of psychoeducational group therapy in reducing symptoms of posttraumatic stress disorder among multiply traumatized women. The American Journal of Psychiatry 155(9), 1172-1177. Meythaler, J., & Novack, T. Posttraumatic seizures following head injury. The University of Alabama Traumatic Brain Injury Care System, Birmingham, AL. Retrieved November 9, 2008 from http://main.uab.edu/tbi/show.asp?durki=10213. Mittenberg, W., Canyock, E.M., Condit, D., & Patton, C. (2001). Treatment of post-concussion syndrome following mild traumatic brain injury. Journal of Clinical and Experimental Neuropsychology, 23(6), 829-836. Monson, C.M., Schnurr, P.P., Resick, P.A., Friedman, M.J., Young-Xu, Y., Stevens, S.P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898-907. Perna, R.B., & Bordini, E.J. (2001). Cognitive impairments in TBI: Pharmacological treatment considerations. TBI Challeng 5(2), 1-8. Resick, P.A., Monson, C.M., & Chard, K.M. (2007). Cognitive processing therapy: Veteran/military version. Washington, DC: Department of Veterans’ Affairs.
References Resick, P.A., Nishith, P., Weaver, T.L., Astin, M.C., & Feuer, C.A. (2002). A comparison of cognitive processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867-879. Schnurr, P.P., Friedman, M.J., Engel, C.C., Foa, E.B., Shea, M.T., Chow, B.K., Resick, P.A., Thurston, V., Orsillo, S.M., Haug, R., Turner, C., & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. The Journal of the American Medical Association 297(8), 820-830. Svendsen, H.A., & Teasdale, T.W. (2006). The influence of neuropsychological rehabilitation on symptomatology and quality of life following a brain injury: A controlled long-term follow-up. Brain Injury, 20(12), 1295-1306. Traumatic brain injury. (2006). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Retrieved November 6, 2008 from http://www.cdc.gov/ncipc/tbi/TBI.htm. Schneiderman, A.I., Braver, E.R., & Kang, H.K. (2008). Understanding sequelae of injury mechanisms and mild traumatic brain injury incurred during the conflicts in Iraq and Afghanistan: Persistent postconcussive symptoms and posttraumatic stress disorder. American Journal of Epidemiology, 167(12), 1446-1452. Van Etton, M.L., & Taylor, S. (1998). Comparative efficacy of treatments for post-traumatic stress disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5(3), 1236-144. Weathers, F.W., Litz, B.T., Herman, D.S., Huska, J.A., & Keane, T.M. (1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Conference of the ISTSS, San Antonio, TX.
Contact Information Tracy L. Thomas, Ph.D. Clinical Neuropsychologist Rehab Without Walls email@example.com (602) 943-1012 (623) 512-8021
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