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Psychiatric issues in traumatic brain injury

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Psychiatric issues in traumatic brain injury

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Psychiatric issues in traumatic brain injury

  1. 1. Psychiatric Issues in Traumatic Brain Injury Establishing a Differential Diagnosis and Identifying Effective Treatment for Individuals with TBI and Behavioral Health Problems Rolf B. Gainer, PhD, Dip. ABDA Neurologic Rehabilitation Institute, Brookhaven Hospital, Tulsa, OK (800) 927-3974 www.brookhavenhospital.com
  2. 2. 10/21/2004 Brookhaven Hospital 2 Objectives Explain the scope of problems experienced by traumatic brain injury (TBI) patients, including behavioral health issues Discuss effective strategies for diagnosing neurological impairment, psychiatric illness, and co-morbidity Review conditions created by TBI that can exacerbate underlying psychiatric conditions
  3. 3. 10/21/2004 Brookhaven Hospital 3 Objectives Examine clinical presentation of persons with a dual diagnosis, which includes TBI Examine treatment/rehabilitation implications for individuals with dual diagnosis
  4. 4. 10/21/2004 Brookhaven Hospital 4 Psychiatric Issues in Individuals with TBI Behavioral components of TBI which resemble psychiatric illness Effects of brain injury on individuals with pre-existing conditions Issues of co-morbidity Diagnostic skills
  5. 5. 10/21/2004 Brookhaven Hospital 5 Facts About Brain Injury Every day nearly 6,000 Americans sustain a brain injury (www.biausa.org) 400,000 individuals with moderate and severe brain injuries in the USA are hospitalized each year
  6. 6. 10/21/2004 Brookhaven Hospital 6 Causes of Brain Injury Motor Vehicle Accidents 50% Falls 21% Assaults 12% Sports/Recreation 10% Other 7%
  7. 7. 10/21/2004 Brookhaven Hospital 7 Physical Effects of Brain Trauma in Closed Head Injuries Direct Impact Coup and Contra Coup Injuries Rotation and Shearing Swelling Bleeding Neurochemical Changes Secondary Effects
  8. 8. 10/21/2004 Brookhaven Hospital 8 TBI Severity Distribution Injury Mild 85% Moderate 10% Severe 5% Mortality Rate 11%
  9. 9. 10/21/2004 Brookhaven Hospital 9 Assumptions about TBI Physiological impairment Disruption of sensorium Disinhibition Arousal and attention problems Unstable mood states Problems in learning and organization
  10. 10. 10/21/2004 Brookhaven Hospital 10 Behaviors in Early Recovery Disorientation Paranoid Ideation Depression Hypomania Confabulation
  11. 11. 10/21/2004 Brookhaven Hospital 11 Behaviors in Early Recovery Restlessness Agitation Combativeness Emotional Lability Confusion Hallucinations
  12. 12. 10/21/2004 Brookhaven Hospital 12 In the early phase of TBI recovery, some behaviors can resemble a psychiatric illness.
  13. 13. 10/21/2004 Brookhaven Hospital 13 Biological Aspects of Injury Further Psychological Problems Seizure disorder may include irritability and behavior dyscontrol Cognitive problems, especially memory, affect, emotional response Denial of deficits may affect capacity to receive help Previously effective medications may not work or may exacerbate injury-related problems Depression may prevent participation
  14. 14. 10/21/2004 Brookhaven Hospital 14 The Basic Person Doesn’t Change The injury alters specific aspects of the person’s psychological, cognitive and emotional function Specific personality traits or style remain
  15. 15. 10/21/2004 Brookhaven Hospital 15 TBI Affects All Aspects of Life Previously competent individuals may show symptoms of psychiatric disease Coping skills are stressed Behavioral controls are lost
  16. 16. 10/21/2004 Brookhaven Hospital 16 TBI Affects All Aspects of Life Social skills and roles are affected Insight into TBI-related changes may be limited Previously self-managed symptoms may become out of control Relationships/support systems are stressed
  17. 17. 10/21/2004 Brookhaven Hospital 17 Positive Predictors of Recovery Outcome Focal vs. Globalized injury Aggressive early intervention and trauma care Work history
  18. 18. 10/21/2004 Brookhaven Hospital 18 Positive Pre-Injury Predictors Medical/behavioral complications Pre-injury achievement level Learning, school and work history Extroverted personality Positive social history Level of severity, coma duration Natural recovery and return of functions
  19. 19. 10/21/2004 Brookhaven Hospital 19 Positive Pre-Injury Predictors “Good character” and self control Strong-willed, determined personality Perseverance and motivation Strong social and family network and support Absence of pre-injury psychiatric symptoms Absence of substance abuse
  20. 20. 10/21/2004 Brookhaven Hospital 20 Negative Predictors Poor response to psychiatric medications Poor response to “talking” therapies Failure in behavioral programs requiring memory and problem-solving Social network failure: divorce, separation
  21. 21. 10/21/2004 Brookhaven Hospital 21 Negative Predictors Failure at work Involvement in the criminal justice system Persistence of chronic pain and headache symptoms Lack of support system
  22. 22. 10/21/2004 Brookhaven Hospital 22 Lateralization Issues of Behavior Deficits Left Hemisphere: depression, agitation, anxiety Diffuse: attention, concentration, arousal, response Right Hemisphere: unable to respond, flat affect
  23. 23. 10/21/2004 Brookhaven Hospital 23 TBI and Psychiatric Disease Traumatic Brain Injury can mimic psychiatric symptoms Examples: memory problems, behavioral and emotional control problems, mood disorders
  24. 24. 10/21/2004 Brookhaven Hospital 24 Biological Brain Changes can Mimic Psychiatric Disease Biological changes can exacerbate a pre- existing psychiatric disease Executive Syndrome can resemble a thought disorder Behavioral features can resemble other conditions
  25. 25. 10/21/2004 Brookhaven Hospital 25 TBI and Psychiatric Disease TBI can mask psychiatric symptoms Example: Frontal system damage can produce expressive aposody/blunting, which may reduce the person’s ability to express sadness
  26. 26. 10/21/2004 Brookhaven Hospital 26 Risk Factors Associated with Psychiatric Diagnosis (Lishman, 1988) Organic factors Psychosocial factors (socio-economics, pre-morbid personality) Past history of psychiatric illness Family history of psychiatric illness Male Emergence of problems one year post- injury
  27. 27. 10/21/2004 Brookhaven Hospital 27 Research Highlights Localization of injury (Fann, 1995) Noradrenergic and serotonergic projections are sites of contusion (Rosenthal, 1998) Individuals with depression and anxiety perceive themselves as more ill (Fann, 1995)
  28. 28. 10/21/2004 Brookhaven Hospital 28 Research Highlights Reaction to failure (Alexander, 1975, 1992) Right hemisphere damage (Silver, 1992) Pre-morbid factors and social adjustment (Robinson & Jorge, 1993) Biochemical response (Robinson & Jorge, 1993)
  29. 29. 10/21/2004 Brookhaven Hospital 29 Brain Injured Patients with Psychiatric Disorders (Van Reekum, 2003) The level of severity of the person’s brain injury relates to the potential for the emergence of psychiatric disorders in the first 24 months post-injury
  30. 30. 10/21/2004 Brookhaven Hospital 30 Personality Disturbances After Brain Injury Anxiety or “catastrophic reaction” Emotional lability/disinhibition Paranoia and psychomotor agitation Denial Depression Social withdrawal Amotivation/abulia
  31. 31. 10/21/2004 Brookhaven Hospital 31 Distinguishing Brain Injury from Psychiatric Problems Physical injury to the brain Cognitive and behavioral deficits Emotional and personality change Attention, concentration, arousal, filtering Memory problems Seizure problems Self regulation
  32. 32. 10/21/2004 Brookhaven Hospital 32 Psychological Syndromes can Co-occur or Predate Injury When did the symptoms emerge, before or after the TBI? What were persons like before injury? What were their coping styles? How have they adjusted to disability? What new symptoms/behaviors have developed?
  33. 33. 10/21/2004 Brookhaven Hospital 33 Problems in Diagnosing Psychiatric Illness in TBI Timing between injury and emergence of symptoms In mild cases lack of documentation of extent/severity of injury Pre-morbid personality traits Pre-injury issues
  34. 34. 10/21/2004 Brookhaven Hospital 34 Rate of Psychiatric Illness One Year Post Brain Injury Past studies focused on individuals with TBI who were seen in psychiatric hospitals 21.7% of individuals with TBI had ICD- 9 diagnosis vs 16.4% of general population (1998)
  35. 35. 10/21/2004 Brookhaven Hospital 35 Psychiatric Diagnosis Distribution Following TBI Male - 21.6% Female – 11.3% Mild brain injury – 17.2% Moderate and severe brain injury – 23.3%
  36. 36. 10/21/2004 Brookhaven Hospital 36 Psychiatric Diagnosis Features Relationship of psychiatric diagnosis to: Younger age Glasgow outcome scale score History of pre-injury ETOH use/abuse History of psychiatric illness Lower Mini Mental State score Fewer years of education (Deb, 1999) Not working before injury (Bowen, 1998)
  37. 37. 10/21/2004 Brookhaven Hospital 37 Psychiatric Issues in TBI Cases Male/female 70%/30% more likely to develop psychiatric symptoms Elevated risk for bi-polar affective disorder Seizures noted in 50% of cases with mania (Shukla, 1987) Limbic system lesions in 75% of manic cases (Starkstein, 1987) Family history of mood disorders
  38. 38. 10/21/2004 Brookhaven Hospital 38 Diagnostic Issues in BI Group Depressive episode 13.9% vs. 2.1% Panic Disorder 9.0% vs. 0.8% Generalized anxiety 2.5% vs. 3.1% Phobic disorder 0.8% vs. 1.1% Obsessive compulsive 1.6% vs. 1.2% Schizophrenia 0.8% vs. 0.4% ETOH dependence 4.9% vs. 4.7%
  39. 39. 10/21/2004 Brookhaven Hospital 39 Brain Injury and Depression Depression following brain injury occurs at a rate of 44.3% vs. 5.9% in non-brain injured population
  40. 40. 10/21/2004 Brookhaven Hospital 40 Differential Diagnosis Issues How can the clinician determine the role of injury and pre/post injury psychiatric factors that contribute to behavioral dysfunction?
  41. 41. 10/21/2004 Brookhaven Hospital 41 Pre-existing Psychiatric Disorders Related to TBI Dementia due to head injury Cognitive disorder Bipolar disorder (manic or depressive types Mood disorders (depression, mania) Sleep disorder Anxiety disorders Intermittent explosive disorder
  42. 42. 10/21/2004 Brookhaven Hospital 42 Pre-existing Conditions can Affect Recovery from TBI Limited coping skills Impaired ability to manage symptoms Cognitive problems limit capacity to manage disability and pre-existing condition Advent of new behaviors Prior medications may increase cognitive problems
  43. 43. 10/21/2004 Brookhaven Hospital 43 Effect of TBI on Underlying Psychiatric Disease Reduced capacity to self-manage symptoms Diminished impulse control leads to enhanced interpersonal problems Psychological defenses and coping skills fail to function Denial of deficits prevents person from responding to injury-related deficits
  44. 44. 10/21/2004 Brookhaven Hospital 44 Effect of TBI on Underlying Psychiatric Disease Interpersonal relationships change Social role is altered Seizures and dyscontrol event are misinterpreted Enhanced dependent needs affect psychological status
  45. 45. 10/21/2004 Brookhaven Hospital 45 Adjustment Difficulty due to Emotional & Behavioral Issues Emotional change Impaired perception of social interaction Impaired self control Increase dependency Behavioral rigidity
  46. 46. 10/21/2004 Brookhaven Hospital 46 Most Frequent Problems Cited by Family Members Slowness Irritability Impatience Depression Memory
  47. 47. 10/21/2004 Brookhaven Hospital 47 Co-Morbidity: PTSD & TBI (Arnon, 1998) 32% of motor vehicle accident victims meet diagnostic criteria for PTSD one year post-injury Those with PTSD have higher rates of pre-morbid/co-morbid psychopathology (anxiety and affective disorders) Immediacy of PTSD symptoms is a better predictor of later PTSD than injury severity
  48. 48. 10/21/2004 Brookhaven Hospital 48 Role of Prior Learning or Attentional Problems in Occurrence of Psychiatric Diagnosis Prior learning and attentional problems are enhanced Diminished filtering and stimuli selection Altered coping skills produce dysfunctional responses
  49. 49. 10/21/2004 Brookhaven Hospital 49 Psychiatric Issue or Brain Injury? Mania vs. Arousal problems Anxiety Denial Confusion Depression Cognitive problems Personality changes Intellectual changes Thought disorder vs. Thinking problem
  50. 50. 10/21/2004 Brookhaven Hospital 50 Psychiatric Features of TBI Mania - Agitation Anxiety - Catastrophic Reaction (Goldstein) Denial - Inability to accept deficits Confusion - Disorientation and memory problems Depression – Withdrawal, abulia
  51. 51. 10/21/2004 Brookhaven Hospital 51 Neurologic and Neuropsychiatric Features Atypical seizure disorders Intermittent explosive disorder (Yudofsky) Neurologic rage or limbic-psychotic aggressive syndrome (Dorothy Lewis)
  52. 52. 10/21/2004 Brookhaven Hospital 52 Neurologic Rage Identifiers Sudden loss of behavioral control, “out of the blue” Inability to stop the behavior Seizure-like quality, unawareness of the individual to the event Deficient memory of the event (Dorothy Lewis)
  53. 53. 10/21/2004 Brookhaven Hospital 53 Factors Leading to Behavioral Problems in TBI Primary and secondary aspects of the physical injury Development of emotional problems Development of cognitive problems
  54. 54. 10/21/2004 Brookhaven Hospital 54 Two Type of Behavioral Problems Behavioral excess – too much Behavioral deficit – too little
  55. 55. 10/21/2004 Brookhaven Hospital 55 Neurobehavioral Issues Hyper/hypo arousal Level of response to external events/filtering Stimulus control vs. stimulus bound Denial Judgment Impulsivity vs. self-regulation Irritability and seizure-like events
  56. 56. 10/21/2004 Brookhaven Hospital 56 Neurobehavioral Features Aggressivity and assaultiveness Apathy, abulia, lack of motivation Irritability, impatience Impulsivity (lack of self-regulation) Level of motor agitation/restlessness
  57. 57. 10/21/2004 Brookhaven Hospital 57 Interpersonal/Psycho-Social Factors of Behavioral Problems Impaired self-perception Emotional changes Egocentric thinking Impaired perception of social issues Increased dependency Behavioral rigidity
  58. 58. 10/21/2004 Brookhaven Hospital 58 Interpersonal/Psycho-Social Factors of Behavioral Problems Irritability Anger control problems Mood instability Hypo/hyper sexuality Diminished drive/ motivation Cognitive deficits
  59. 59. 10/21/2004 Brookhaven Hospital 59 Factors of Cognitive Problems in TBI Level of arousal Sensorium disruption Concentration and focus Filtering, stimuli control
  60. 60. 10/21/2004 Brookhaven Hospital 60 Factors of Cognitive Problems Problem-solving and decision-making Language and communication Orientation and confusion Memory, information retrieval
  61. 61. 10/21/2004 Brookhaven Hospital 61 Cognitive Problems Can Look Like Behavioral Problems Attention and filtering problems Over/under arousal Concentration Memory Task learning Novel learning (old to new)
  62. 62. 10/21/2004 Brookhaven Hospital 62 The first step in making a diagnosis is to think of it. -- Thibault, 1992
  63. 63. 10/21/2004 Brookhaven Hospital 63 Evaluate and Separate Post-Injury from Pre-Injury Problems
  64. 64. 10/21/2004 Brookhaven Hospital 64 Diagnostic Approaches Developmental and school history Neurological evaluation Neuropsychological assessment Medical file review Interview with individual Comprehensive medical and psychiatric history
  65. 65. 10/21/2004 Brookhaven Hospital 65 Pre-Morbid Issues Presence of known psychiatric condition Level of adjustment, degree of attainment (school, work, family) History of learning, behavior and conduct problems History of substance problems Medical history School and vocational history
  66. 66. 10/21/2004 Brookhaven Hospital 66 Post-Injury Effect on Coping Skills and Personality Response to disabling condition(s) Cognitive deficits Neurobehavioral deficits External support system Motivation/initiative Substance use/abuse Engagement in meaningful activities
  67. 67. 10/21/2004 Brookhaven Hospital 67 Persistent Problems of Recovery and Rehabilitation Irritability Impulsivity Egocentricity Lability Judgment deficits Impatience Tension/Anxiety Depression
  68. 68. 10/21/2004 Brookhaven Hospital 68 Implications for Rehabilitation: Why Patients “Fail”
  69. 69. 10/21/2004 Brookhaven Hospital 69 Persistent Problems of Recovery and Rehabilitation Hypersexuality Hyposexuality Dependency Silliness/Euphoria Aggressivity Apathy Childishness Disinhibition
  70. 70. 10/21/2004 Brookhaven Hospital 70 Why Patients “Fail” Strategy: Individual and Group Psychotherapy Why? Can’t identify problems as shared by others Difficulty maintaining behavioral alternatives
  71. 71. 10/21/2004 Brookhaven Hospital 71 Why Patients “Fail” Strategy: Insight-Oriented Approaches Why? Can’t identify problem with self Problems with generalization
  72. 72. 10/21/2004 Brookhaven Hospital 72 Why Patients “Fail” Strategy: Didactic Approaches Why? Memory problems prevent use of previous learning
  73. 73. 10/21/2004 Brookhaven Hospital 73 Why Patients “Fail” Strategy: Milieu Treatment Why? Social deficits inhibit positive peer group membership
  74. 74. 10/21/2004 Brookhaven Hospital 74 Why Patients “Fail” Strategy: Cognitive-Behavioral Therapy Why? Memory problems and difficulty with generalizations
  75. 75. 10/21/2004 Brookhaven Hospital 75 Why Patients “Fail” Strategy: Behavior Modification Why? Problems with impulse control Memory problems prevent reinforcement strategy from being effective
  76. 76. 10/21/2004 Brookhaven Hospital 76 Why Patients “Fail” Strategy: Medication Management Why? Some medications further cognitive problems or cause disinhibited behavior
  77. 77. 10/21/2004 Brookhaven Hospital 77 Why Patients “Fail” Strategy: Addictive Treatment/Self-Help Groups Why? Cognitive problems prevent identification with the speaker/group process Individual cannot apply information to self
  78. 78. 10/21/2004 Brookhaven Hospital 78 Why Patients “Fail” Person cannot process “talking therapies” Limited insight New behaviors (e.g. impulsivity) are related to the brain injury Increased dependence Unable to relate to previously effective support groups (e.g. AA, NA)
  79. 79. 10/21/2004 Brookhaven Hospital 79 Support System Stresses Increase Psychological Issues High incidence of divorce or loss of primary relationship (50% in first two years post- injury) Adult children return to aging parents for physical assistance Loss of friends and work High potential for substance use/abuse Loss of social role with family, friends and community Cultural factors influence recovery
  80. 80. 10/21/2004 Brookhaven Hospital 80 Social Network Issues Complicate Rehabilitation Social network failure seen 24-months post injury (Burke and Weslowski. 1989) Psychological effect of withdrawal or loss of supports
  81. 81. 10/21/2004 Brookhaven Hospital 81 Social Network Issues Complicate Rehabilitation Changing social role post-injury affects self-image and self-worth Individual response to loss of functions and social changes Recidivism and emergence of psychiatric symptoms commonly seen 12-24 months post-injury
  82. 82. 10/21/2004 Brookhaven Hospital 82 Increasing Success in Rehabilitation and Treatment: What Works!
  83. 83. 10/21/2004 Brookhaven Hospital 83 What Works? Early identification of problems Highly structured, social learning environment Repetitive “teaching” of behavioral alternatives External controls managed by staff, gradually transferred to the individual Neurological approach to medication management Integrated rehab program, including psychiatric and substance abuse treatment
  84. 84. 10/21/2004 Brookhaven Hospital 84 What Works? Emphasis on learning and relearning of social role Teaching “scripts” for social interaction Guided/supported attendance at AA/NA/self-help groups Use of “failures” within treatment to address denial and limited insight
  85. 85. 10/21/2004 Brookhaven Hospital 85 What Works? Focus on social role re-entry and response of family, friends, co-workers, peers, and others to the person Staff understanding of TBI-related behavioral, cognitive, emotional and psychological issues Understanding of adjustment to disability Teaching individual about consequences of TBI Promoting return to work, avocational and recreational activities
  86. 86. 10/21/2004 Brookhaven Hospital 86 What Works? Consistent response from staff throughout the environment Use of behavioral analysis to understand brain/behavior issues Avoidance of negative consequences for behavior problems Focus on discharge engineering to assure that the individual moves to a supportive placement with the solid transfer of information and management techniques
  87. 87. 10/21/2004 Brookhaven Hospital 87 Neurological Rehabilitation Institute (NRI) at BROOKHAVEN Tulsa’s Specialty Hospital 800-927-3974 www.brookhavenhospital.com

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