Psychosocial Factors in Mild
Traumatic Brain Injury (MTBI)
Bradley J. Hufford, Ph.D., HSPP
Clinical Neuropsychologist
Reha...
Mild Traumatic Brain Injury:
Injury Description and Mechanisms
Traumatic Brain Injury (TBI)
 1.5 million TBIs annually, 90% survive
 5.3 million persons in US living with TBI
 500,00...
Mild TBI
 80% of all TBIs are “mild”
 Mayo Classification System for TBI Severity
 “Mild (Probable) TBI”
 One or more ...
 “Symptomatic (Possible) TBI”
 One or more in the absence of Mod-
Severe or Mild (Probable) criteria:
 Blurred vision
...
MTBI-Pathophysiology
 Diffuse Axonal Injury (Ylvisaker & Feeney, 1998)
Diffuse Axonal Disruption
 Most MTBI have no neuroimaging abnormalities
 Concussive injuries thought to be more metaboli...
Mild TBI Incurred in Military
Situations (Combat)
OEF/OIF
 Nearly 1.6 million
deployed through 7/07
 Mortality rate for
injuries (Jackson et al., 2008)
 WWII = 30%
 Vie...
OEF/OIF TBI
 Military TBI > Civilian, even in peacetime
 Military females = civilian males
 TBI = “signature wound” of ...
Blast Injury
As of 8/07, ~ 1,599 Coalition fatalities were due to IEDs
Blast Injury
 “Any injury secondary
to explosive
munitions” (Gaylord, et
al., 2008)
 43-50% of all injuries
in modern wa...
Blast Causes
 Improvised Explosive
Device (IED)
 Rocket Propelled
Grenade (RPG)
 Explosively-Formed
Projectiles (EFP)
...
Types of Blast-Related Injuries
 Primary
 Secondary*
 Tertiary*
 Quaternary
Primary Blast Injury
 Injury due solely to blast wave
 Explosion => rapid expansion of gas => shock
wave
 Shock wave tr...
Secondary Blast Injury
 Blast puts objects into motion that collide with
individual
 Projectile injuries; often penetrat...
Tertiary Blast Injury
 The individual is
propelled by the
force of the blast
 Effects due to wind
from blast
 Can colli...
Quaternary Blast Injury
 Injuries that occur from aftereffects of a blast
 Burns
 Chemical, toxic dust inhalation
 Poi...
Blast Injury--Pathophysiology
 Transfer of kinetic energy from blast wave to
brain, causing DAI, esp. with primary blast
...
Mild Traumatic Brain Injury:
Effects
Post-Concussion Disorder (PCD)
 DSM-IV (provisional): “Acquired impairment
in cognitive functioning, accompanied by
speci...
Post-Concussion Syndrome (PCS)
 ICD-10 criteria: Head trauma with LOC
that precedes symptom onset by < 4 weeks
 >3 sx: s...
Post-Concussion Syndrome
 38% of pts with MTBI
met ICD-10 criteria
for PCS 6 weeks post
injury (Mittenberg & Strauman,
20...
Good News for Most…
 Outcomes are generally positive
 International Coma Data Bank: 83% of
persons with PTA< 2 weeks had...
…but Not All
 Ponsford et al. (2000)
 84 adults with MTBI
 Pts had significantly greater PCS
complaints than controls 1...
Persistent PCS (PPCS)
 “Miserable Minority”
 Prevalence estimates vary:
 < 5% by 6-12 months (Iverson, 2005)
 7-15% ha...
Physiogenesis vs. Psychogenesis
“Mind Over Matter”
by
Bora Turkoglu
What’s Causing PCS/PPCS? (Ruff, 2005)
 Brain injury as the basis of persistent
cognitive and emotional symptoms
 More co...
The argument of whether “brain injury”
versus “psychological factors” cause PCS is
nothing new
Patient suffering from “she...
Shell Shock (Jones et al., 2007)
 Early in WWI, attributed to cerebral trauma
 50-60% of SS pts claim concussion
 Sx we...
Post-Traumatic Stress Disorder (PTSD)
 DSM-IV
 Anxiety disorder
 Person exposed to event that involved
actual/threatene...
PTSD Symptom Triad
1) Re-experiencing
 Dreams, flashbacks, intrusive recollections
2) Avoidance and numbing of general
re...
MTBI and PTSD Symptom Overlap
 Physiologic hyperactivity
 Memory problems
 Fatigue
 Increased sensitivity to noise/lig...
MTBI and PTSD (Civilian)
 Prevalence varies considerably
 13 – 84% of MTBI met criteria for
PTSD
 PTSD sx different for...
MTBI and PTSD (Military)
Surveyed 2525 soldiers 3-4 months after
return home from Iraq
 4.9% reported injuries with LOC
...
 Compared to soldiers with “other” injuries, those with
LOC or altered mental status:
 Had significantly greater combat ...
Neuropathological Factors in PCS
 “There is little doubt that abnormal
neurophysiology is predominant cause of
symptoms s...
Rat Studies (Cernak et al., 2000, 2001)
 Endocrine, plasma magnesium, blood oxidant
changes
 Both whole-body and local (...
Hoge et al., 2008
 No direct link between PTSD and injury to brain
(yet)
 Biological processes likely underlie onset of
...
Psychological Factors in PCS
Psychological Factors Suspected Because:
1) PCS symptoms: Non-specific and
subjective
 Brain injury not necessary for sym...
1) Specificity of PCS Symptoms
 Iverson & McCracken (1997)
 81% of chronic pain pts reported >3 PCS sx
 39% could have ...
2) The Effect of Additional Stressors
 Millis and Putnam (1996)
 Having additional injuries (orthopedic, soft
tissue inj...
Strongest predictor for PPCS is
litigation/compensation (Carroll et al., 2004)
Social Factors
 Having a relative with TBI
changes everyone in family
 Role loss, caregiving
expectations, financial
and...
When a Parent
Has a TBI
 Often has lowered self-control
 Responds to parenting situations with
bullying, threatening, ot...
3) Premorbid Psychological Factors
 Fenton et al. (1993): 45 MTBI pts vs. controls
 TBI group had significantly more adv...
Premorbid Psychological Factors
 Lack of a documented psychiatric history
does not eliminate the possibility of a
premorb...
4) Psychological Maintenance (Mittenberg & Colleagues)
MTBI
Selective
Attention to
Internal States
Attribute
Sx to brain
d...
Spiral of Deterioration
Pre-injury Personality
Injury
Transient or
Permanent Cognitive
Impairments
Awareness of Impairment...
Case Example 1 (Civilian)
 Age = 47, Education = 12
 Restrained driver in a head-on collision 6
months previously
 No L...
Case 1: Cognitive and Pain Complaints
 Poor memory, word-finding, and
organization ability.
 Pt unsure if worsening over...
Case 1: Emotional Complaints
 Poor sleep maintenance, tearfulness
 Pt reports “reliving accident,” seeing a mental
“docu...
Case 1: Emotional Complaints
 No history of inpatient psychiatric
treatment.
 Received psychotherapy after accident to
h...
Case 1: Neuropsychological Test Results
Mildly Imp.
Moderate Imp
Severely Imp
Average
IQ Verbal
Memory
Visual
Memory
Attn....
 Personality testing: Moderate concern over
health and somatic functioning
 Conclusions:
 No sign of TBI
 Results more...
Case Example 2 —Military
 Age = 31; Education =15 years
 No significant medical history
 Seen 21 months after exposure ...
Case 2: Cognitive and Pain Complaints
 Poor concentration, inability to multi-task,
forgetful, slow processing speed
 Co...
Case 2: Emotional Complaints
 Rates sadness as a 5/10 (10 = worst).
 Poor sleep initiation and maintenance
 Denied cryi...
Case 2: Neuropsychological Test Results
Mildly Imp.
Moderate Imp
Severely Imp
Average
IQ Verbal
Memory
Visual
Memory
Attn....
Case 2: Neuropsychological Test Results
 Good effort
 Significantly impaired olfaction, right-sided
touch, auditory, mot...
Organic vs. Psychological Revisited
 Hardly a simple distinction
 In any case, either/both could be present at
different...
The Effect of Aging
Frank Buckles, age 108, last known living US WWI Veteran
Later Effects of MTBI
 Most persons recover well and quickly
 Moderate/severe TBI have more
persistent effects
 Need mo...
MTBI Sustained Later in Life
 Elderly have worse outcomes after severe TBI
 After MTBI, outcomes may not differ
 Older ...
Brain Reserve Capacity
 Biological, genetic, or behavioral factors
that can increase brain’s ability to recover
from an i...
Behavioral BRC (Valenzuela and Sachdev, 2006)
 Meta-analysis of 22 studies
 Education reduced risk of dementia 47%
 Hig...
PTSD and Aging
 Older veterans
 May show more somatic sx than
psychiatric
 More likely to attribute sx to aging
 Frequ...
Treatment
Sir John Pringle, (April 10, 1707- January 18, 1782)
Considered the "father of military medicine"
First and Foremost…
 Need standardized definitions, improved and
standardized diagnostic criteria
 Improved screening an...
Education for PCS Patients
 Normalize, but don’t minimize, symptoms
 Assure pts that symptoms common after
MTBI, and gen...
Education for Patients
 Gave pts a 10-page manual, one hour
discussion session (Mittenberg, 1996)
 What happens to brain...
 Clients using the manual showed:
 Significantly shorter symptom duration
 60% fewer symptoms at 6 months
 Fewer sympt...
Education for Practitioners (Fann et al., 2002)
 Educate medical practitioners, pts, families about
increased risk for TB...
Cognitive Behavioral Treatments for PPCS
 12 week CBT program
 How to gradually resume activities to minimize
PCS-prolon...
Medications
 Symptom relief
 Antidepressants
 Anxiety and
depression
 Avoid cognitively
sedating agents
 Pain, sleep,...
Supports
 Rehabilitation therapies
 Strategies and
compensations for
attention, memory,
and organizational
problems
 Ps...
Role of Neuropsychology in Acute and Post-Acute Rehabilitation of ...
Role of Neuropsychology in Acute and Post-Acute Rehabilitation of ...
Role of Neuropsychology in Acute and Post-Acute Rehabilitation of ...
Role of Neuropsychology in Acute and Post-Acute Rehabilitation of ...
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  • This picture was taken when he was 106. He also served in WWII and was a POW. When asked about his secret for long life, he said, “When you start to die, don’t.”
  • Role of Neuropsychology in Acute and Post-Acute Rehabilitation of ...

    1. 1. Psychosocial Factors in Mild Traumatic Brain Injury (MTBI) Bradley J. Hufford, Ph.D., HSPP Clinical Neuropsychologist Rehabilitation Hospital of Indiana
    2. 2. Mild Traumatic Brain Injury: Injury Description and Mechanisms
    3. 3. Traumatic Brain Injury (TBI)  1.5 million TBIs annually, 90% survive  5.3 million persons in US living with TBI  500,000 individuals require hospitalization due to TBI annually  Third most common cause of death in US  Accounts for more than 30% of all injury- related deaths in the United States.  TBI-associated costs estimated at $48.3 billion
    4. 4. Mild TBI  80% of all TBIs are “mild”  Mayo Classification System for TBI Severity  “Mild (Probable) TBI”  One or more of the following: • Loss of consciousness < 30 minutes • Post-Traumatic Amnesia < 24 hours • Depressed, basilar, or linear skull fracture • No neuroimaging abnormalities
    5. 5.  “Symptomatic (Possible) TBI”  One or more in the absence of Mod- Severe or Mild (Probable) criteria:  Blurred vision  Confusion  Dazed  Dizziness  Focal neurologic symptoms  Headache  Nausea
    6. 6. MTBI-Pathophysiology  Diffuse Axonal Injury (Ylvisaker & Feeney, 1998)
    7. 7. Diffuse Axonal Disruption  Most MTBI have no neuroimaging abnormalities  Concussive injuries thought to be more metabolic in nature (Collins, Stump, & Lovell, 2004)  Injured cells exposed to dramatic changes in intracellular/ extracellular environments  Energy demand and supply mismatched  Cells become vulnerable to even minor changes in blood flow, pressure, etc.  This state lasts > 2 weeks in animal models, perhaps longer in humans  Problems worst in first 72 hours, rapid improvement over first week
    8. 8. Mild TBI Incurred in Military Situations (Combat)
    9. 9. OEF/OIF  Nearly 1.6 million deployed through 7/07  Mortality rate for injuries (Jackson et al., 2008)  WWII = 30%  Vietnam = 24%  OEF/OIF = 10%  Improvements due to improved battlefield medicine and armor/protective devices Interceptor Body Armor Vest
    10. 10. OEF/OIF TBI  Military TBI > Civilian, even in peacetime  Military females = civilian males  TBI = “signature wound” of OEF/OIF  Incidence of TBI among wounded ~ 22% (Martin et al., 2008)  May be as high as 50% (Jackson, et al., 2008)  (Vietnam = 14-18% of casualties had TBI)  Blast injuries most common cause
    11. 11. Blast Injury As of 8/07, ~ 1,599 Coalition fatalities were due to IEDs
    12. 12. Blast Injury  “Any injury secondary to explosive munitions” (Gaylord, et al., 2008)  43-50% of all injuries in modern warfare  ~ 60% of blast injuries result in TBI  WRAMC  62% of pts had TBI  92% due to blast
    13. 13. Blast Causes  Improvised Explosive Device (IED)  Rocket Propelled Grenade (RPG)  Explosively-Formed Projectiles (EFP)  Mortar rounds  Grenades  Vehicle –Born Improvised Explosive Device (VBIED)
    14. 14. Types of Blast-Related Injuries  Primary  Secondary*  Tertiary*  Quaternary
    15. 15. Primary Blast Injury  Injury due solely to blast wave  Explosion => rapid expansion of gas => shock wave  Shock wave travels supersonic speeds of 3,000- 8,000 meters/second  Can be reflected off of solid surfaces  Those close enough to blast generally die instantly  Often results in polytrauma  Medical personnel may be overwhelmed with multiple injuries, may miss MTBI
    16. 16. Secondary Blast Injury  Blast puts objects into motion that collide with individual  Projectile injuries; often penetrating injuries  Most common injuries to those who survive
    17. 17. Tertiary Blast Injury  The individual is propelled by the force of the blast  Effects due to wind from blast  Can collide with object, walls, ground  Abrasive, contusive, blunt trauma injuries
    18. 18. Quaternary Blast Injury  Injuries that occur from aftereffects of a blast  Burns  Chemical, toxic dust inhalation  Poisoning  Radiation exposure  Crush injuries due to building collapse  Of servicemen who sustained both burn and blast injuries, 1/3 had PTSD, 1/3 had MTBI, 1/5 had both (Gaylord et al., 2008)
    19. 19. Blast Injury--Pathophysiology  Transfer of kinetic energy from blast wave to brain, causing DAI, esp. with primary blast  Direct and indirect  Unclear if blast injury is the same as MTBI from other causes  Lack of good, systematic protocols  Animal studies do not use standardized protocols  “There is no evidence that LOC from a blast is clinically different from similar LOC from another mechanism” (Hoge et al., 2008)
    20. 20. Mild Traumatic Brain Injury: Effects
    21. 21. Post-Concussion Disorder (PCD)  DSM-IV (provisional): “Acquired impairment in cognitive functioning, accompanied by specific neurobehavioral symptoms, that occurs as a consequence of a CHI of sufficient severity…”  > 3 of the following persist for > 3 months:  Fatigability; sleep disruption; headache; vertigo/ dizziness; irritability/aggression; anxiety/ affective lability; apathy/lack of spontaneity; personality change (e.g., social/sexual inappropriateness).
    22. 22. Post-Concussion Syndrome (PCS)  ICD-10 criteria: Head trauma with LOC that precedes symptom onset by < 4 weeks  >3 sx: somatic, emotional, subjective cognitive deficits (with no neuropsych. evidence of marked impairment), insomnia, reduced alcohol tolerance  Preoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role
    23. 23. Post-Concussion Syndrome  38% of pts with MTBI met ICD-10 criteria for PCS 6 weeks post injury (Mittenberg & Strauman, 2000)  PCS occurs in 38-80% of MTBI (Hall et al., 2005)
    24. 24. Good News for Most…  Outcomes are generally positive  International Coma Data Bank: 83% of persons with PTA< 2 weeks had good outcome  Cognitive deficits resolve in 1-3 months  Other PCS symptoms commonly resolve within 12 months at the latest  True for 85-95% of veterans with MTBI  Majority of people recover from PCS in 3-6 months (Hall et al., 2005)
    25. 25. …but Not All  Ponsford et al. (2000)  84 adults with MTBI  Pts had significantly greater PCS complaints than controls 1 week post  By 3 months, most symptoms had resolved  Subset of 24% of participants complained of marked symptoms  Significant psychopathology  Little evidence of cognitive impairment  No difference in injury severity
    26. 26. Persistent PCS (PPCS)  “Miserable Minority”  Prevalence estimates vary:  < 5% by 6-12 months (Iverson, 2005)  7-15% have any symptoms one year postinjury (Hall et al., 2005)  10-20% of MTBI pts who have persistent symptoms at 6-12 months and beyond (Millis and Putnam, 1996)  Incidence of PPCS: ~ 27/100,000  Equal to annual incidence of Parkinson’s Disease, Multiple Sclerosis, Guillain-Barre, motor neuron disease, myasthenia gravis combined (Satz, et al., 1999)
    27. 27. Physiogenesis vs. Psychogenesis “Mind Over Matter” by Bora Turkoglu
    28. 28. What’s Causing PCS/PPCS? (Ruff, 2005)  Brain injury as the basis of persistent cognitive and emotional symptoms  More consistent with DSM-IV view — Versus—  Psychopathology is primary cause for persistent symptoms  More consonant with ICD-10 definition
    29. 29. The argument of whether “brain injury” versus “psychological factors” cause PCS is nothing new Patient suffering from “shell shock” during WWI
    30. 30. Shell Shock (Jones et al., 2007)  Early in WWI, attributed to cerebral trauma  50-60% of SS pts claim concussion  Sx were non-specific, occurred in absence of obvious lesions  Some thought must be psychological  Argument about brain injury vs. neuroses  Huge expense (military pensions)  Difficulty persists to this day
    31. 31. Post-Traumatic Stress Disorder (PTSD)  DSM-IV  Anxiety disorder  Person exposed to event that involved actual/threatened death, serious injury to self or others  Person’s response involved intense fear, helplessness, or horror
    32. 32. PTSD Symptom Triad 1) Re-experiencing  Dreams, flashbacks, intrusive recollections 2) Avoidance and numbing of general responsiveness  Avoid thoughts, feelings, events associated with event; detachment; inability to recall part of trauma; sense of foreshortened future 3) Increased arousal  Insomnia, irritability, hypervigilance, easily startled  Duration over one month
    33. 33. MTBI and PTSD Symptom Overlap  Physiologic hyperactivity  Memory problems  Fatigue  Increased sensitivity to noise/light  Decreased concentration
    34. 34. MTBI and PTSD (Civilian)  Prevalence varies considerably  13 – 84% of MTBI met criteria for PTSD  PTSD sx different for MTBI than non-BI  Dreams, nightmares, hyperarousal more common than intrusive thoughts  MTBI protects against intrusive sx, because pt cannot remember event
    35. 35. MTBI and PTSD (Military) Surveyed 2525 soldiers 3-4 months after return home from Iraq  4.9% reported injuries with LOC  43.9% met criteria for PTSD  10.3% reported altered mental status  27.3 % met criteria for PTSD  17.2% reported other injuries  16.2% met criteria for PTSD Hoge et al., 2008
    36. 36.  Compared to soldiers with “other” injuries, those with LOC or altered mental status:  Had significantly greater combat exposure  More likely to have had blast injury  More likely to report poor general health, more missed work, higher number medical visits.  Physical health problems largely mediated by PTSD or depression.  Controlling for PTSD eliminated associations with PCS
    37. 37. Neuropathological Factors in PCS  “There is little doubt that abnormal neurophysiology is predominant cause of symptoms shortly after injury” (Iverson, 2005)  qEEG changes in combat veterans with history of blast concussion (Trudeau et al., 1998)  All veterans had chronic PTSD  Substance abuse, prior TBI, ADHD did not affect findings
    38. 38. Rat Studies (Cernak et al., 2000, 2001)  Endocrine, plasma magnesium, blood oxidant changes  Both whole-body and local (chest) blast exposure resulted in structural/chemical change in hippocampus, causing cognitive deficits  Direct and indirect Ratatouille, © 2007 Disney/Pixar
    39. 39. Hoge et al., 2008  No direct link between PTSD and injury to brain (yet)  Biological processes likely underlie onset of PTSD and physical sx related to depression and PTSD  Biological processes associated with exposure to extreme stress  Activation of the hypothalamic-pituitary- adrenal axis  Frontal, temporal, subcortical regions usually implicated in TBI thought to underlie PTSD sx
    40. 40. Psychological Factors in PCS
    41. 41. Psychological Factors Suspected Because: 1) PCS symptoms: Non-specific and subjective  Brain injury not necessary for symptoms to exist 2) Increased stressors associated with increased sx 3) Premorbid psychological factors  Certain persons may be more vulnerable to developing PCS 4) Psychological maintenance of symptoms  Neuropathology may begin the process, but emotional factors maintain PCS
    42. 42. 1) Specificity of PCS Symptoms  Iverson & McCracken (1997)  81% of chronic pain pts reported >3 PCS sx  39% could have been diagnosed with PCS  PCS symptoms also common in healthy persons, psychiatric outpatients (Fox et al., 1995), minor medical outpatients, and whiplash pts  Non-TBI groups endorse more PCS symptoms with increased life stressors (Mateer et al., 2005)  23% more forensic cases are symptomatic than are TBI patients not seeking compensation (Mittenberg and Strauman, 2000)
    43. 43. 2) The Effect of Additional Stressors  Millis and Putnam (1996)  Having additional injuries (orthopedic, soft tissue injuries) in same accident is related to psychosocial difficulties  Only 18% of persons who sustained MTBI and orthopedic injuries and/or soft tissue injuries returned to work at one month  88% of “pure” MTBI returned to work
    44. 44. Strongest predictor for PPCS is litigation/compensation (Carroll et al., 2004)
    45. 45. Social Factors  Having a relative with TBI changes everyone in family  Role loss, caregiving expectations, financial and other pressures  Can lead to increased depression, anxiety, frustration, stress for family members  Family stress influences pt behavior  Pt’s psychiatric distress determined by number of critical comments from family
    46. 46. When a Parent Has a TBI  Often has lowered self-control  Responds to parenting situations with bullying, threatening, other forms of maltreatment  Very common for children to have increased emotional, relationship, acting out, disobedience, temper outbursts, avoidance of injured parent  Fortunately, skill training can help
    47. 47. 3) Premorbid Psychological Factors  Fenton et al. (1993): 45 MTBI pts vs. controls  TBI group had significantly more adverse life events in past year than controls  At 6 weeks, symptomatic pts had 4 times the chronic social difficulties than asymptomatic  At 6 months, pts with persistent symptoms had twice as many chronic social difficulties  Psychological problems cannot be automatically attributed to TBI
    48. 48. Premorbid Psychological Factors  Lack of a documented psychiatric history does not eliminate the possibility of a premorbid emotional problem  Less than 40% of persons who have a lifetime psychiatric disorder receive any formal treatment (Millis and Putnam, 1996)
    49. 49. 4) Psychological Maintenance (Mittenberg & Colleagues) MTBI Selective Attention to Internal States Attribute Sx to brain damage Symptoms Anxiety ANS Arousal
    50. 50. Spiral of Deterioration Pre-injury Personality Injury Transient or Permanent Cognitive Impairments Awareness of Impairments (and Functional Limitations) Catastrophic Reaction Co-Morbities Emerge: Depression PTSD Anxiety Interpersonal and Social Withdrawal Modified from Trexler & Fordyce, 2000
    51. 51. Case Example 1 (Civilian)  Age = 47, Education = 12  Restrained driver in a head-on collision 6 months previously  No LOC, anterograde/ retrograde amnesia  Felt “fuzzy” few minutes  EEG, head CT normal  Left hand, ribs broken; skin burns  Legal action being pursued
    52. 52. Case 1: Cognitive and Pain Complaints  Poor memory, word-finding, and organization ability.  Pt unsure if worsening over time  Continuing pain in broken hand  Constant headaches starting 2-3 weeks before assessment.  Present upon awakening, worsened by stress
    53. 53. Case 1: Emotional Complaints  Poor sleep maintenance, tearfulness  Pt reports “reliving accident,” seeing a mental “documentary over and over” of the accident  Discouraged over how his recent cognitive difficulties interfere with his efficiency at “following through on business ideas”  Girlfriend feels he is more demanding and moody, she has threatened to end relationship
    54. 54. Case 1: Emotional Complaints  No history of inpatient psychiatric treatment.  Received psychotherapy after accident to help with intrusive thoughts.  Had history of “heavy drinking;” treatment at Alcoholics Anonymous. No alcohol whatsoever in the past 12-14 years
    55. 55. Case 1: Neuropsychological Test Results Mildly Imp. Moderate Imp Severely Imp Average IQ Verbal Memory Visual Memory Attn. EF Visual Spatial
    56. 56.  Personality testing: Moderate concern over health and somatic functioning  Conclusions:  No sign of TBI  Results more consistent with anxiety d/o, likely PTSD
    57. 57. Case Example 2 —Military  Age = 31; Education =15 years  No significant medical history  Seen 21 months after exposure to mortar fire  LOC = few seconds  Confused for “a couple of minutes”  Unsure about the duration of any retrograde or anterograde amnesia  Brain MRI was essentially unremarkable
    58. 58. Case 2: Cognitive and Pain Complaints  Poor concentration, inability to multi-task, forgetful, slow processing speed  Constant, mild tinnitus  Frequent headaches that vary in terms of onset and severity.  Intermittent blurriness of his vision  Unsure if smell/taste has changed  Wife notes he is less interested in foods
    59. 59. Case 2: Emotional Complaints  Rates sadness as a 5/10 (10 = worst).  Poor sleep initiation and maintenance  Denied crying, but "I feel like it on the inside."  Irritability and frustration: 6-7/10.  Intermittent worthlessness, lowered energy, and hopelessness.  Nightmares at least once nightly  Multiple flashbacks per day.  "I feel insecure...I make sure to check the kids when they are asleep, I check twice to see if the doors are locked, and I jam the door closed."
    60. 60. Case 2: Neuropsychological Test Results Mildly Imp. Moderate Imp Severely Imp Average IQ Verbal Memory Visual Memory Attn. EF Visual Spatial
    61. 61. Case 2: Neuropsychological Test Results  Good effort  Significantly impaired olfaction, right-sided touch, auditory, motor problems  Significant anxious and depressive sx  Results consistent with both MTBI and PTSD
    62. 62. Organic vs. Psychological Revisited  Hardly a simple distinction  In any case, either/both could be present at different points in healing  MTBI & emotional distress each complicate healing from and coping with the other  Likely there are overlapping brain areas involved  Treatment needs to take both into account  Outcomes similar between PCD and PCS (McCauley et al., 2005)
    63. 63. The Effect of Aging Frank Buckles, age 108, last known living US WWI Veteran
    64. 64. Later Effects of MTBI  Most persons recover well and quickly  Moderate/severe TBI have more persistent effects  Need more research--studies vary in terms of quality—many not carefully controlled  Multiple concussions in athletes often associated with higher rate of memory and cognitive problems over time (Guskiewicz et al., 2005; Moser et al., 2005)  Link b/t MTBI and Alzheimer’s not consistently demonstrated
    65. 65. MTBI Sustained Later in Life  Elderly have worse outcomes after severe TBI  After MTBI, outcomes may not differ  Older MTBI had better GOS scores than younger at 1 month (Rapoport et al., 2001)  Older MTBI not different from younger cognitively at 2 weeks (Stapert et al., 2006)  Functional outcome after 6 months good to excellent for old and young (Mosenthal et al., 2004)  Having multiple injuries +TBI more detrimental to older patients
    66. 66. Brain Reserve Capacity  Biological, genetic, or behavioral factors that can increase brain’s ability to recover from an injury and/or resistance to the effects of aging/cognitive decline.  Neuronal redundancy  Efficiency of cognitive functions and cognitive decline due to age highly heritable
    67. 67. Behavioral BRC (Valenzuela and Sachdev, 2006)  Meta-analysis of 22 studies  Education reduced risk of dementia 47%  High occupational status reduced risk 44%  Managerial status may be important  High premorbid IQ reduced risk ~ 42%  Mentally stimulating leisure lessened risk 50%  Overall high brain reserve decreased risk 46%  Findings persist after controlling for other predictors of dementia (e.g., age, health, CVD)
    68. 68. PTSD and Aging  Older veterans  May show more somatic sx than psychiatric  More likely to attribute sx to aging  Frequently misdiagnosed  Sx often occur after trauma, decline, then resurge in later life  Combat-related PTSD sx can occur 50 years later (triggered by other losses?)  May have less social support, worse health
    69. 69. Treatment Sir John Pringle, (April 10, 1707- January 18, 1782) Considered the "father of military medicine"
    70. 70. First and Foremost…  Need standardized definitions, improved and standardized diagnostic criteria  Improved screening and more timely identification of MTBI  Military has made advances in this area  Thorough medical eval  Neuropsychological eval  Thorough history
    71. 71. Education for PCS Patients  Normalize, but don’t minimize, symptoms  Assure pts that symptoms common after MTBI, and generally get better  Not that symptoms are “nothing.”  In meantime, help pts regulate their lifestyle and environment to avoid problems and to recognize and reduce stress
    72. 72. Education for Patients  Gave pts a 10-page manual, one hour discussion session (Mittenberg, 1996)  What happens to brain in MTBI  Typical symptoms, time to resolution  Effects of fatigue  Techniques to reduce symptoms during recovery period  Relaxation  Cognitive restructuring  Thought-stopping techniques
    73. 73.  Clients using the manual showed:  Significantly shorter symptom duration  60% fewer symptoms at 6 months  Fewer symptomatic days  Lower average symptom severity levels  Levels of headache, fatigue, memory/ attention problems, anxiety, depression, dizziness decreased by up to 50% compared to controls
    74. 74. Education for Practitioners (Fann et al., 2002)  Educate medical practitioners, pts, families about increased risk for TBI in psych populations  Discuss ways to decrease behaviors that can put one at risk for TBI, preventative measures  Recognize complex interplay of factors initiating/maintaining PCS  Cannot automatically assume psychiatric deficits are/are not secondary to MTBI
    75. 75. Cognitive Behavioral Treatments for PPCS  12 week CBT program  How to gradually resume activities to minimize PCS-prolonging stress, maximizing reinforcement of positive behaviors  Adequate rest  Cognitive restructuring: replace negative beliefs re: symptoms with accurate ones  Taught to recognize selective attention tendencies, misattribution, etc.  Recognize early signs of stress response (body, thought cues, etc.)  Relaxation to control initial response to stress
    76. 76. Medications  Symptom relief  Antidepressants  Anxiety and depression  Avoid cognitively sedating agents  Pain, sleep, headache  Medications to enhance attention  Ritalin, amantadine
    77. 77. Supports  Rehabilitation therapies  Strategies and compensations for attention, memory, and organizational problems  Psychiatric/ psychotherapy support  No age limit  Family education and support  Parenting training  Thankfulness

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