Traumatic Brain Injury
in Veterans
Robyn Mehlenbeck, PhD*
Equal Justice Works Leadership Development Training
October 23, 2014
Washington, DC
* George Mason University
WHAT IS TBI?
Traumatic Brain Injury:
• Sudden physical damage and trauma to the
brain
• Focal Lesion: foreign body enters brain, targets
specific area
• Mild Traumatic Brain Injury (mTBI): affects
larger areas of the brain, white matter
• White matter responsible for relaying electrical
signals around brain
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Causes of TBI
• Transportation accidents
• Cars, motorcycles, bicycles, pedestrians (50%)
• Falls
• Majority of TBI in ages 75 and older from falls
• Violence
• Domestic violence, firearms assaults, child abuse (20%)
• Sports injuries
• Approximately 3%
• Combat
• Separate category, increasingly common in combat due to IED
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(http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm)
Combat-Related TBI
• Especially common in Operation Iraqi Freedom
(OIF) and Operation Enduring Freedom (OEF)
• 66% of service personnel in Iraq exposed to or injured
by a blast injury
• Frequently mTBI rather than focal lesion (80%
mTBI)
• Affects large sections of the brain
• Effects not immediately noticeable
• Concentration and cognitive decline over time
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Physical Symptoms of TBI
• Unconsciousness
(seconds or
minutes)
• Headache
• Nausea and
vomiting
• Dizziness
• Seizures
• Weakness
• Numbness in arms
and legs
• Dilated pupils
• Metallic taste in mouth
• Ringing in ears
• Fatigue and lethargy
• Change in sleep
patterns
• Difficulty with motor
coordination
Psych Symptoms of TBI
• Slurred speech
• Confusion
• Agitation
• Memory or
concentration
problems
• Amnesia about
events prior to injury
• Behavioral changes
• Mood changes
• Depression
• Anxiety
• Difficulty with
attention
• Difficulty with
complex thinking
Neurology vs
Neuropsychology?
• Neurology – MD
• Specialty that
assesses, diagnoses
and treats problems
with TBI, among other
nervous system
problems
• Treats the physical
symptoms and
causes of TBI
• Neuropsychology - PhD
• Looking for behavioral
manifestations of TBI
• Assesses and treats
the cognitive,
behavioral and
psychological effects
of the TBI
Types of TBI
• Two major types of traumatic brain injury
• Penetrating brain injury
• Closed head injury
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Penetrating TBI
• Types of penetrating TBI
• Skull fracture  bone of skull cracks or breaks
• Pieces of skull can press into brain tissue
• Foreign object enters brain (e.g. bullet)
• Damage occurs along path of injury (focal
lesion)
• Symptoms vary according to part of brain that
is damaged
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Closed-head TBI
• Results from blow to the head (e.g. car accident,
football tackle, impact from IED blast)
• Causes two type of brain injuries:
1. Primary
2. Secondary
Primary Closed-head Injuries
• Contusion
• Bruising of brain tissue (swollen brain tissue and blood)
• Can be in response to shaking of brain in skull (contrecoup)
• Hematomas/blood clots
• Occur between the skull and the brain or inside the brain itself
• Diffuse axonal injury
• Individual nerve cells damaged
• Loss of connections between neurons
• Laceration
• Tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of
the brain
• Force of the blow causes the brain to rotate across the hard ridges of the skull,
causing the tears
Secondary Closed-head Injuries
• Evolves over time (after trauma has occurred)
• Brain swelling (edema)
• Increased pressure inside of the skull (intracranial
pressure)
• Epilepsy
• Intracranial infection
• Fever
• Anoxia: lack of oxygen supply to brain tissue
• Without oxygen, brain cells die within minutes
• Hematoma: heavy bleeding in or around brain
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Closed-head Injury Illustration
( http://health.allrefer.com/health/head-injury-prevention.html)
What does it mean to have a TBI?
Typical Impairments:
Communication
Thinking/Executive Functioning
Psychological
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Communication Difficulties
• Difficulty picking up social cues
• e.g. interrupting
• Difficulty following conversations
• Occasional difficulty modulating tone of
voice
• Difficulty processing subtleties/nuances in
language
• e.g. difference between tongue-in-cheek and seriousness
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Communication Difficulties
• More severe difficulties include:
• Aphasia
• difficulty understanding and producing spoken and written
language
• Word Recall
• Trouble recalling words/speaking in complete sentences
• Frequent pauses
• Prosodic dysfunction
• difficulties with inflection and intonation
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Cognitive Difficulties
• Slower processing of information
• Difficulty with short-term memory
• Retrograde Amnesia (hippocampus/prefrontal cortex)
• Loss of specific memories from pre-trauma (unconsolidated)
• Anterograde Amnesia (hippocampus/prefrontal
cortex)
• Difficulty forming new memories after trauma
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Cognitive Difficulties
• Executive functioning difficulty (prefrontal cortex)
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Poor planning, organizing skills
Setting goals
Completing tasks
Difficulty solving problems
Difficulty with abstract reasoning
Difficulty making judgments
• Impulsivity (prefrontal cortex)
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Testing for effects of TBI
Comprehensive Assessment with emphasis on
Executive Functioning
- Can be done by a neuropsychologist
- Can be done by a psychologist with extensive
experience in the types of tests needed to
examine the deficits concerned about
Testing for effects of TBI
Clinical Interview – looking for some identifying
event/incident; any testing prior to the injury is a bonus
Cognitive Assessment – WAIS-V; Woodcock Johnson
Cognitive/Achievement
Executive Functioning
– Delis- Kaplan Executive Functioning
System (D-KEFS)
Rey-Osterrieth Complex Figure Test/Beery VMI
Psychological – ADD scales, Mental Status Exam
Test of Memory Malingering (TOMM)
– gives some
validity to whether a client is intentionally exaggerating memory
symptoms
Rey-Osterrieth Complex Figure Test
- Add in figure; & scores on a sample w/deficits
Treatment of TBI
• Treatment dependent on severity of TBI
• Combination of medical management of symptoms &
psychological intervention based on deficits
• In mTBI Cognitive Behavioral Therapy most common
treatment form for psychological effects
• Structured work on goal setting/problem solving
• Structured work on impact of thoughts on feelings and
behaviors
• Additional treatment:
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Nutrition
Education
Counseling & family support
Medication for symptomatic relief
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