Humanistic and Biological Interface in
Brain Injury Rehabilitation
Anjum Bashir
Leyla Ziyal
Tim Warren
www.partnershipsinc...
The enigma of Brain Injury
• Brain Injury: a complex
condition
• Not an illness
• Disease model not suitable
• Pathology o...
What is the Pathology?
• Pituitary Tumour excised
• Tuberculous Abcess in temporal
region treated
• Epilepsy and fronto te...
What is the Pathology?
• Complex and varied
• Regional injury rather than focal
• Events before and after:
• Brain oscilla...
Biological Dilemma
• Take example of an essential
cognitive function:
Memory
• Memory systems in brain
• Regional distribu...
Brain Regions
• Hippocampus is the key area
• Involved in declarative, anterograde
or new knowledge or information
• Right...
Non medial Temporal region
• Same Right (non verbal) and
left (verbal) specialisation
• Retrograde or past memories
Other regions
• Ventromedial frontal lobe:
• Emotion/feelings and Memory
• Prospective memory;
remembering to do things in...
Brain Regions
Basal Ganglia
• Procedural memory (riding a
bike, swimming, habits, seeking
automatic support and
encouragem...
Dilemma of Pathology?
• Biological Explanations
incomplete or vague
• Scientific advancement
imprecise
• Some key laborato...
Patients our best Guides
• TO THOSE WHO CANNOT ACCEPT MY CHANGE
•
People change over time and most change is by choice.
Th...
Listening to relatives
• He is not the person I knew
• She is self centred
• He is unpredictable
• She cannot decide what ...
What ICD says?
• Organic Personality
Disorder
• A category for all
disorders
Discovering the person?
Behind the organic fog
• A lost person
• New fantasies
• New realities
• A new personality
• Can s...
Biological Promise
• Is it limited?
• Goal: recreate availability to self
discovery
• Treat as whole:
Illness vulnerabilit...
No head injury is too serious to
despair of, nor too trivial to ignore“
In order to be walked on, you have
to be lying dow...
Thank you for Listening
Now our next
speaker
Leyla Ziyal
BIOLOGICAL AND
HUMANISTIC INTERFACE
IN BRAIN INJURY
REHABILITATION
LEYLÂ ZIYAL M Phil AFBPsS C Psychol
Chartered Consultan...
A. INTRODUCTION
Aim
Share our practice at Elm Park BIS – Clinical
Neuropsychology Perspective
This paper: Practice overvie...
A.1 Setting the scene
Male patients
Severe acquired brain injury
Present with complex challenging behaviours
Our shared go...
A.2 Setting the scene
Multidisciplinary work
Discharge objectives
Home-based reintegration within the
community
Community ...
1 HOW WE DO THE THINGS WE DO
Accessing the person behind the
injury
‘’the human being is first and last…a
subject, not an ...
1 HOW WE DO WHAT WE DO
Neuropsychological
Assessment
Cognitive Retraining
(CRt)
Self repair (SR)
Attention
Memory
Informat...
1 HOW WE WHAT WE DO
1.1 neuropsychological assessment helps us to:
Generate a functional map of
the brain
Contribute to th...
1 HOW WE DO WHAT WE DO
1.1 Neuropsychological assessment
a continuous process
repeat neuropsychological assessments
rehabi...
1 HOW WE DO WHAT WE DO
Cognitive Retraining
Memory
Attention
Information processing
Executive function
Self Repair Therapi...
1 HOW WE DO WHAT WE DO
1.2 cognitive retraining and self repair
Intervention format:
Groups - Metacognition
Develops self-...
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
Key concepts
The way we think determines the way we behav...
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
Mobilisation of the Core-belief – Life rule system
Belief...
2 WHY WE DO WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
Mobilisation of the Core-belief – Life rule system
SCH...
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
What happens when our protective behaviours break down
SH...
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
ABI: What happens when
protective behaviours break down?
...
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
Reconstituting personal meaning an identity
Develop self-...
BIOLOGICAL AND
HUMANISTIC INTERFACE
IN BRAIN INJURY
REHABILITATION
part 2
LEYLÂ ZIYAL M Phil AFBPsS C Psychol
Chartered Co...
3 ILLUSTRATIVE CASE STUDY
History
Late 40s sustained severe head injury in age
16. Depressed right frontal skull fracture....
3 ILLUSTRATIVE CASE STUDY
Admission
Early 2008 on section 37 but this was allowed to lapse:
currently informal
Behaviour
D...
3 ILLUSTRATIVE CASE STUDY
Referral to Clinical Neuropsychology and goals
February 2009
Reduce inappropriate sexual behavio...
3 ILLUSTRATIVE CASE STUDY
Clinical Neuropsychological assessment
CHART 1: COMPARISON OF COGNITIVE AND EXECUTIVE FUNCTIONS
...
3 ILLUSTRATIVE CASE STUDY
Formulation
RTA –
FRONTAL LOBE INJURY
AVALANCHE
OF SEXUAL IMPULSES
IMPAIRED
IMPULSE CONTROL RESP...
3 ILLUSTRATIVE CASE STUDY
Therapeutic strategy and criteria of success
Therapeutic strategy
Corrective therapy of SOT indi...
3 ILLUSTRATIVE CASE STUDY
Individual CBT
Figure 1: Possible thought sequence triggered by an activating event
ACTIVATING E...
3 ILLUSTRATIVE CASE STUDY
Individual CBT: outcomes
CHART 01 'A': INAPPROPROPRIATE SEXUAL BEHAVIOURS JAN - JUN 2009
therapy...
3 ILLUSTRATIVE CASE STUDY
Individual CBT: outcomes
Figure 2: touching hand cognitive sequence
ACTIVATING EVENTS:
1. ASKED ...
3 ILLUSTRATIVE CASE STUDY
Individual CBT: outcomes
0
1
2
3
4
5
6
7
8
9
JULY AUG SEPT OCT NOV DEC JAN FEB
CHART 02: ‘A’ INA...
4 THE NEXT STEP IN THE
DEVELOPMENT OF OUR PRACTICE
Develop our work in awareness training
Improve change-readiness through...
CASE STUDY OF PATIENT SK
By Tim Warren Assistant Psychologist
31st
March 2010
Summary
• Background of SK
• History of SK
• Injury Details
• Post Injury
• Admission to Elm Park
• Treatment plan
• Group...
Patient Details:
• SK
• Gender: Male
• Age: 57 years old
• Profession: Milkman
• Marital Status: Divorced
• Children: 2 Da...
SK Childhood
• All normal Milestones Reached
• Normal early childhood
• Normal primary school education
• Mother died duri...
Injury Details
• Injury sustained on 09.06.2008 from a
fall down the stairs of his flat
• GCS = 3
• CT scan showed the fol...
Post injury
Behaviours:
• Sexual disinhibition
• Physical aggression toward objects
• Verbal aggression towards others
• P...
Admission To Elm Park
• Admitted on 11/8/08
• Baseline of Behaviours
• Assessment of function
• Identify strengths and wea...
Treatment Plan
Behaviours:
• Sexual comments – TOOTS and feedback
• Verbal Aggression – TOOTS and feedback
• Self Harm – O...
Treatment plan (psychology)
Cognitive:
• Neuropsychological assessment
• WAIS III
• WMS III
• WTAR
• DKEFS
• 1:1 therapy f...
Cognitive assessment (WAIS III):
0
20
40
60
80
100
120
SCORE 95 91 100 86 107 86 88
CENTILE 37 27 50 18 68 18 21
FSIQ VIQ ...
Cognitive function:
Summary:
• SK is at the AVERAGE range of cognitive
function
• His non-verbal abilities are significant...
Memory assessment (WMS III)
0
10
20
30
40
50
60
70
80
90
100
Score 65 67 100 75 62 63 69 85
Percentile 1 1 50 5 1 1 2 16
A...
Memory function:
Summary:
• Impairment in memory in both visual
and verbal modalities
• Impaired immediate and delayed rec...
Executive Function (DKEFS)
Tests used: Trail Making, Verbal Fluency, Design
Fluency, Sorting Test (Free and recognition).
...
Executive function continued:
Summary:
• On the baseline conditions SK’s
performance ranged between the 62nd
to 38th
perce...
Psychological Interventions:
• Assessment showed no evidence of
diffuse cognitive impairment
• Main areas of impairment ar...
SK Attention
• Targeting:
1. Sustained
2. Selective
3. Alternating
4. Divided
• Exercises Auditory and Visual
• Accuracy R...
SK Attention:
Mean accuracy score across all attention exercises
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
1 2 3 4 5
Exercise number...
SK Memory:
• Develop insight through practice
• Understanding
• Internal strategies
• External strategies
• Ecological exe...
SK Memory:
Memory Percent Accuracy
69.6
82.5
60 65 70 75 80 85
NO STRATEGY
STRATEGY
SK Life Narrative
• Means of linking self pre-injury to now
• Looking at attributes of person
• Linking attributes to beha...
SK life narrative Example 1:
• Identified self as Introverted, Flexible,
Belief focused and creative
• Didn’t organise or ...
SK Life narrative Example 1:
• Behaviour Experiment
• What I feel when I have nothing
planned: Bored
Lonely
• What I feel ...
SK Life Narrative Example 2:
• Looking at core beliefs
• Early childhood
• Significant life event
• Leading to behaviour
•...
Core Belief
Must be clean and presentable:
Mother / acceptance
Good behaviour
Life events:
Bullied at high school
Mothers ...
Core belief continued:
Maladaptive core belief: Need to be rebellious
Behaviour: Unkempt
Protective behaviours
Wrong crows...
Intervention
• Change maladaptive core belief
Behaviour experiments
cumulative insight
cost benefit analysis
Therapeutic t...
Discharge Planning:
• Identification of needs:
– Structured day
– Continuation of Alcohol therapy
– Need for check ups
– C...
Closing remarks
• Holistic approach
• Knowing patient
• Structure therapy
• Application to everyday
• Successful discharge
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PiC Conference Presentations

  1. 1. Humanistic and Biological Interface in Brain Injury Rehabilitation Anjum Bashir Leyla Ziyal Tim Warren www.partnershipsincare.co.uk
  2. 2. The enigma of Brain Injury • Brain Injury: a complex condition • Not an illness • Disease model not suitable • Pathology obscure • Psychopathology multifactorial
  3. 3. What is the Pathology? • Pituitary Tumour excised • Tuberculous Abcess in temporal region treated • Epilepsy and fronto temporal scarring • RTA and subdural haematoma in frontal region • Heroin overdose and found unconscious anoxia of brain • Diabetic and found unconscious possibly low blood sugar • Cerebral atrophy with large ventricles • And so on
  4. 4. What is the Pathology? • Complex and varied • Regional injury rather than focal • Events before and after: • Brain oscillates 3000 times before coming to rest when in an accident with a car at 60mph • Loss of oxygenation or over • Biochemical imbalance
  5. 5. Biological Dilemma • Take example of an essential cognitive function: Memory • Memory systems in brain • Regional distribution
  6. 6. Brain Regions • Hippocampus is the key area • Involved in declarative, anterograde or new knowledge or information • Right Hippocampal complex (non verbal) • Specialize in faces, geographical routes, melodies, spatial information • Left Hippocampal complex • Verbal language
  7. 7. Non medial Temporal region • Same Right (non verbal) and left (verbal) specialisation • Retrograde or past memories
  8. 8. Other regions • Ventromedial frontal lobe: • Emotion/feelings and Memory • Prospective memory; remembering to do things in future • Dorsolateral frontal lobe: • How many times and how along ago an event has occurred
  9. 9. Brain Regions Basal Ganglia • Procedural memory (riding a bike, swimming, habits, seeking automatic support and encouragement Thalamus • Acquisation of factual information and main transmitter or memory related information
  10. 10. Dilemma of Pathology? • Biological Explanations incomplete or vague • Scientific advancement imprecise • Some key laboratory tests only for research
  11. 11. Patients our best Guides • TO THOSE WHO CANNOT ACCEPT MY CHANGE • People change over time and most change is by choice. The person I am is not the person I was. Not over time, but in an instant, it all changed. I am different. It wasn't my choice, it wasn't my fault, but you treat me like it was. The person I was died and I went to my own funeral. I am different. You didn't like the person you saw in front of you. The person in the mirror wasn't me and I didn't like her either. But, I looked beyond the mirror and slowly became the person I am. If you hang on to the past, you die a little each day; once was enough for me. I am different, but not by choice, so don't reprimand me for being me. I am different. If you can't accept that, you can't accept me and I can't accept that. • Sandee Rager
  12. 12. Listening to relatives • He is not the person I knew • She is self centred • He is unpredictable • She cannot decide what to do • Oh those mood swings • Memory is so poor • Gets angry and can be so unkind
  13. 13. What ICD says? • Organic Personality Disorder • A category for all disorders
  14. 14. Discovering the person? Behind the organic fog • A lost person • New fantasies • New realities • A new personality • Can s/he rediscover themselves
  15. 15. Biological Promise • Is it limited? • Goal: recreate availability to self discovery • Treat as whole: Illness vulnerability increased Mental dis- ease a challenge Brain Dysfunction a challenge
  16. 16. No head injury is too serious to despair of, nor too trivial to ignore“ In order to be walked on, you have to be lying down." No way! Be stubborn! The greatest indicator of success in TBI recovery is said by some professionals to be how stubborn you can be: Persist! Brian Weir,TBI survivor
  17. 17. Thank you for Listening Now our next speaker Leyla Ziyal
  18. 18. BIOLOGICAL AND HUMANISTIC INTERFACE IN BRAIN INJURY REHABILITATION LEYLÂ ZIYAL M Phil AFBPsS C Psychol Chartered Consultant Clinical Neuropsychologist 31 03 2010
  19. 19. A. INTRODUCTION Aim Share our practice at Elm Park BIS – Clinical Neuropsychology Perspective This paper: Practice overview 1. How we do what we do 2. Why we do what we do – rationale 3. Illustrative case study 4. Next step in practice development Next paper A further illustrative case study
  20. 20. A.1 Setting the scene Male patients Severe acquired brain injury Present with complex challenging behaviours Our shared goal: Mobilise the potential of our patients to attain the maximum level of independence and quality of life that is possible for them to achieve
  21. 21. A.2 Setting the scene Multidisciplinary work Discharge objectives Home-based reintegration within the community Community Assisted Living Facilities, Through to probably long-term step down Facilities in residential contexts
  22. 22. 1 HOW WE DO THE THINGS WE DO Accessing the person behind the injury ‘’the human being is first and last…a subject, not an object” Sacks, O. (1984) A leg to stand on Duckworth, London
  23. 23. 1 HOW WE DO WHAT WE DO Neuropsychological Assessment Cognitive Retraining (CRt) Self repair (SR) Attention Memory Information Processing Executive Function Life narrative (LNar) Emotion Management (EMg) Awareness Training (Aw) Systemic/corrective Interventions Behaviour Modification (BM) as a means to relationship maintenance and enhancement
  24. 24. 1 HOW WE WHAT WE DO 1.1 neuropsychological assessment helps us to: Generate a functional map of the brain Contribute to the multi- disciplinary enterprise of setting first stage discharge planning goals Develop a needs-analysis that prioritises needs in terms of these discharge goals Formulate a rehabilitation strategy in light of these goals within the compass of the patient’s current level of mastery Pitch the level of intervention to the patient’s current level of capability and receptivity Open a window of understanding into what and how the patient is construing his situation and what/how he is feeling
  25. 25. 1 HOW WE DO WHAT WE DO 1.1 Neuropsychological assessment a continuous process repeat neuropsychological assessments rehabilitation performance records behaviour records
  26. 26. 1 HOW WE DO WHAT WE DO Cognitive Retraining Memory Attention Information processing Executive function Self Repair Therapies LNar EMg Aw Corr T Behaviour Modification as appropriate and only as means of replacing disruptive or undesirable behaviours with new more adaptive responses, and of selectively reinforcing desired behaviours whilst discouraging maladaptive ones. 1.2 cognitive retraining and self repair [and behaviour modification]
  27. 27. 1 HOW WE DO WHAT WE DO 1.2 cognitive retraining and self repair Intervention format: Groups - Metacognition Develops self-concept and self-efficacy in a supportive and safe milieu that promotes sense of self discovery and control Enables Self evaluation through other observation and self-prediction Facilitates multi-sourced Constructive feedback Offers 0pportunity to further understand the nature of injury and its effects in the roles that the patient had adopted until now and may be likely to adopt from now onwards Inter-session and modular Cross fertilisation Individual – one to one Reinforces group work Addresses special needs: anxiety/depression, OCD, SOT Trouble shoots Builds therapeutic alliance and facilitates engagement Affords the opportunity to develop special relationship
  28. 28. 2 WHY WE WHAT WE DO: RATIONALE Cognitive Behaviour Therapy (CBT) Key concepts The way we think determines the way we behave. Identity is a unifying construct The approach must be capable of encompassing the cognitive, emotional and psycho-social domains of functioning Task is to help our patients to reconnect with their pre-injury identity in their journey of readjustment to the post ABI order through developing a sense of self efficacy and locus of and through locating the locus of control within themselves Key method Mobilisation of the Core-belief – Life rule system
  29. 29. 2 WHY WE WHAT WE DO: RATIONALE Cognitive Behaviour Therapy (CBT) Mobilisation of the Core-belief – Life rule system Belief system about me about others about the word Rule system conditional beliefs: ‘if – then’ statements Life rules: Injunctions Protective behaviours Enforce the rule Keep the core belief below the level of awareness Maintains emotional balance
  30. 30. 2 WHY WE DO WHAT WE DO: RATIONALE Cognitive Behaviour Therapy (CBT) Mobilisation of the Core-belief – Life rule system SCHEMA RULE RULE RULE PROTECTIVE BEHAVIOURS PROTECTIVE BEHAVIOURS PROTECTIVE BEHAVIOURS DISTORTED AUTOMATIC THOUGHTS NEGATIVE EMOTION
  31. 31. 2 WHY WE WHAT WE DO: RATIONALE Cognitive Behaviour Therapy (CBT) What happens when our protective behaviours break down SHATTERED LIFE RULES ACTIVATED CORE BELIEFS NEGATIVE EMOTION LOSS OF IDENTITY INERT PROTECTIVE BEHAVIOURS
  32. 32. 2 WHY WE WHAT WE DO: RATIONALE Cognitive Behaviour Therapy (CBT) ABI: What happens when protective behaviours break down? loss of self self-knowledge self by comparison self in the eyes of the world impaired sense of identity impaired sense of continuity ‘me before/me after’ grief
  33. 33. 2 WHY WE WHAT WE DO: RATIONALE Cognitive Behaviour Therapy (CBT) Reconstituting personal meaning an identity Develop self-efficacy; self control Access and repair self-identity Re-align the belief-rule system to post-injury reality Re-align the belief-rule system to pre-injury reality Promote acceptance, adjustment and reconstitution of personal meaning and identity
  34. 34. BIOLOGICAL AND HUMANISTIC INTERFACE IN BRAIN INJURY REHABILITATION part 2 LEYLÂ ZIYAL M Phil AFBPsS C Psychol Chartered Consultant Clinical Neuropsychologist 31 03 2010
  35. 35. 3 ILLUSTRATIVE CASE STUDY History Late 40s sustained severe head injury in age 16. Depressed right frontal skull fracture. unconscious for 6 weeks with slow recovery Diagnosis Organic personality disorder (F07.0) Frontal Lobe Syndrome (secondary to acquired brain injury) Forensic history Sexual offending history of dating back to age 21. Onset soon after head injury listed as a schedule 1 Offender
  36. 36. 3 ILLUSTRATIVE CASE STUDY Admission Early 2008 on section 37 but this was allowed to lapse: currently informal Behaviour Displays of inappropriate sexual behaviours, making inappropriate sexual comments, touching females and wearing sexually revealing garments. Intervention Intermittent forensic counselling aimed at inculcating in him the idea that he was a criminal and that any further offending would put him behind bars. This led to no significant reduction in his displays of unacceptable sexual behaviours
  37. 37. 3 ILLUSTRATIVE CASE STUDY Referral to Clinical Neuropsychology and goals February 2009 Reduce inappropriate sexual behaviours totally Consolidate the gains he makes during his stay at the Unit Facilitate his integration within a setting commensurate with his progress and with his cognitive potential as part of discharge planning Methodology Conduct neuropsychological assessment Develop formulation Determine therapeutic strategy and criteria of success Determine method of evaluation
  38. 38. 3 ILLUSTRATIVE CASE STUDY Clinical Neuropsychological assessment CHART 1: COMPARISON OF COGNITIVE AND EXECUTIVE FUNCTIONS 0 20 40 60 80 100 ABSTRACT IN HIBITION IN HISW ITCH ALTERN A TE CATEGORYSW ITCH FSIQ VIQ PIQ VCI PO I W M I PSI percentilescores EXECUTIVE COGNITIVE
  39. 39. 3 ILLUSTRATIVE CASE STUDY Formulation RTA – FRONTAL LOBE INJURY AVALANCHE OF SEXUAL IMPULSES IMPAIRED IMPULSE CONTROL RESPONSE INHIBITION RULE ATTAINMENT
  40. 40. 3 ILLUSTRATIVE CASE STUDY Therapeutic strategy and criteria of success Therapeutic strategy Corrective therapy of SOT individual format - CBT CRt in information processing and Executive functions in group format SR therapies in group format Criteria of success Zero display of sexual behaviours – behaviour charts Development of insight – therapeutic assignments in SOT and SR Increased competence in CRt – performance evaluation
  41. 41. 3 ILLUSTRATIVE CASE STUDY Individual CBT Figure 1: Possible thought sequence triggered by an activating event ACTIVATING EVENT PROTECTIVE BEHAVIOURS RULES THIS IS DIFFERENT IF NOT NOW WHEN I AM DEPRIVED INAPPROPRIATE BEHAVIOURS
  42. 42. 3 ILLUSTRATIVE CASE STUDY Individual CBT: outcomes CHART 01 'A': INAPPROPROPRIATE SEXUAL BEHAVIOURS JAN - JUN 2009 therapy begins end February 2009 0 1 2 3 4 SEXUALLY SUGGESTIVE COMMENTS TOUCHBOTTOM TOUCHHAIR NIPPLETALK WEARING REVEAGARMENTS TOUCHHAND JAN FEB MAR APR JUNE
  43. 43. 3 ILLUSTRATIVE CASE STUDY Individual CBT: outcomes Figure 2: touching hand cognitive sequence ACTIVATING EVENTS: 1. ASKED TO HELP WITH DINING ROOM 2. HANDED WIPING CLOTH AUTOMATIC THOUGHTS I AM IMPORTANT THEY NEED ME SHE CAN TRUST ME TO DO IT SHE THINKS WELL OF ME I AM GRATEFUL I FEEL WARM TOWARDS HER I WANT TO SHOW MY APPRECIATION I WANT TO HOLD HER HAND RULES/CONSEQUENCES UNAWARE BEHAVIOUR HOLDS HER HAND TOO LONG
  44. 44. 3 ILLUSTRATIVE CASE STUDY Individual CBT: outcomes 0 1 2 3 4 5 6 7 8 9 JULY AUG SEPT OCT NOV DEC JAN FEB CHART 02: ‘A’ INAPPROPRIATE SEXUAL BEHAVIOURS JULY 2009 - FEBRUARY 2010 Standing too close to female staff/attempting to touch Brushing past / touching female staff Looking for long periods at female staff Complimenting female staff Sexual comments/inappropriate comments Drawing sexually explicit pictures & showing it to staff Sleep walking in the Nude/Boxers
  45. 45. 4 THE NEXT STEP IN THE DEVELOPMENT OF OUR PRACTICE Develop our work in awareness training Improve change-readiness through the incorporation of Prochaska, Norcross & DeClemente’s 05-stage change theory Improve engagement levels through incorporation of motivational interviewing
  46. 46. CASE STUDY OF PATIENT SK By Tim Warren Assistant Psychologist 31st March 2010
  47. 47. Summary • Background of SK • History of SK • Injury Details • Post Injury • Admission to Elm Park • Treatment plan • Groups and therapy • Planning for Discharge • Questions
  48. 48. Patient Details: • SK • Gender: Male • Age: 57 years old • Profession: Milkman • Marital Status: Divorced • Children: 2 Daughters • Lives alone in a first floor flat • History of alcoholism
  49. 49. SK Childhood • All normal Milestones Reached • Normal early childhood • Normal primary school education • Mother died during high school • Was bullied at high school • Reported to have fallen in with the wrong crowd • No qualifications gained from high- school
  50. 50. Injury Details • Injury sustained on 09.06.2008 from a fall down the stairs of his flat • GCS = 3 • CT scan showed the following: • Sub gleal haematoma in left occipital lobe • Contusions to right inferior frontal and temporal lobes • Contusions to left temporal lobes • Evidence of traumatic subarachnoid blood in right hemisphere • No mid-line shift or fracture to skull • Minimal cerebral swelling • CT repeated several days later with no change.
  51. 51. Post injury Behaviours: • Sexual disinhibition • Physical aggression toward objects • Verbal aggression towards others • Prone to self harm • Suicidal ideation Cognitive: • Dis-orientated to time and place • Confabulation and memory deficits • Lack of insight and awareness • Depression and anxiety
  52. 52. Admission To Elm Park • Admitted on 11/8/08 • Baseline of Behaviours • Assessment of function • Identify strengths and weaknesses • Target areas of treatment • Streamline into appropriate group for cognitive re-training • Identify goals and care pathway • Goal setting and planning MDT & SK
  53. 53. Treatment Plan Behaviours: • Sexual comments – TOOTS and feedback • Verbal Aggression – TOOTS and feedback • Self Harm – One to One therapy • Aggression against objects – Verbal de- escalation with feedback • Positive Reinforcement of appropriate behaviours
  54. 54. Treatment plan (psychology) Cognitive: • Neuropsychological assessment • WAIS III • WMS III • WTAR • DKEFS • 1:1 therapy for anxiety and depression • Therapy for alcoholism • Cognitive re-training in groups • Unit sessions • Community access programme
  55. 55. Cognitive assessment (WAIS III): 0 20 40 60 80 100 120 SCORE 95 91 100 86 107 86 88 CENTILE 37 27 50 18 68 18 21 FSIQ VIQ PIQ VCI POI WMI PSI
  56. 56. Cognitive function: Summary: • SK is at the AVERAGE range of cognitive function • His non-verbal abilities are significantly superior to his verbal abilities • Significant impairment in working memory • His non-verbal abilities are significantly higher than WTAR predicted scores
  57. 57. Memory assessment (WMS III) 0 10 20 30 40 50 60 70 80 90 100 Score 65 67 100 75 62 63 69 85 Percentile 1 1 50 5 1 1 2 16 AI AD ARD VI VD IM GM WM
  58. 58. Memory function: Summary: • Impairment in memory in both visual and verbal modalities • Impaired immediate and delayed recall of information • Impaired working memory confirmed • Average level of recognition memory • Results suggest a retrieval deficit within memory function
  59. 59. Executive Function (DKEFS) Tests used: Trail Making, Verbal Fluency, Design Fluency, Sorting Test (Free and recognition). 0 5 10 15 20 25 Score 6 3 7 5 8 Percentile 9 1 16 5 25 TM VF DF Sf Sr
  60. 60. Executive function continued: Summary: • On the baseline conditions SK’s performance ranged between the 62nd to 38th percentile • On the conditions designed to tap into executive function he ranged between the 16th and 1st percentile • His performance was consistent with that of dysexecutive syndrome • More pronounced in left frontal lobe abilities
  61. 61. Psychological Interventions: • Assessment showed no evidence of diffuse cognitive impairment • Main areas of impairment are within the domains of Memory and executive function • Put into Attention, Memory and Life Narrative groups • 1:1 sessions for anxiety and memory strategies
  62. 62. SK Attention • Targeting: 1. Sustained 2. Selective 3. Alternating 4. Divided • Exercises Auditory and Visual • Accuracy Rating • Self Rating
  63. 63. SK Attention: Mean accuracy score across all attention exercises 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 1 2 3 4 5 Exercise number score Self mean Obj mean
  64. 64. SK Memory: • Develop insight through practice • Understanding • Internal strategies • External strategies • Ecological exercises • 1:1 sessions feedback
  65. 65. SK Memory: Memory Percent Accuracy 69.6 82.5 60 65 70 75 80 85 NO STRATEGY STRATEGY
  66. 66. SK Life Narrative • Means of linking self pre-injury to now • Looking at attributes of person • Linking attributes to behaviour • Significant life events • Developing insight into self
  67. 67. SK life narrative Example 1: • Identified self as Introverted, Flexible, Belief focused and creative • Didn’t organise or structure self • Spare time Depression Drinking • Lead to significant sad events
  68. 68. SK Life narrative Example 1: • Behaviour Experiment • What I feel when I have nothing planned: Bored Lonely • What I feel when I have things structured and Planned: Active Engaged Happier
  69. 69. SK Life Narrative Example 2: • Looking at core beliefs • Early childhood • Significant life event • Leading to behaviour • Altered core belief
  70. 70. Core Belief Must be clean and presentable: Mother / acceptance Good behaviour Life events: Bullied at high school Mothers death Maladaptive core belief: Not accepted if clean and presentable Acceptance if rebellious & unstructured “Wrong crowd”
  71. 71. Core belief continued: Maladaptive core belief: Need to be rebellious Behaviour: Unkempt Protective behaviours Wrong crows Drinking Consequences: Loss of job Loss of family Challenging behaviour Injury
  72. 72. Intervention • Change maladaptive core belief Behaviour experiments cumulative insight cost benefit analysis Therapeutic trust • Alteration of core belief
  73. 73. Discharge Planning: • Identification of needs: – Structured day – Continuation of Alcohol therapy – Need for check ups – Care package • Graded Discharge – Day visits home – Over night stays – Discharge • Successful Discharge
  74. 74. Closing remarks • Holistic approach • Knowing patient • Structure therapy • Application to everyday • Successful discharge
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