Kristine Burkman, Ph.D.
Staff Psychologist
San Francisco VA Medical Center
ASAM Disclosure of
Relevant Financial Relationships
Content of Activity:
ASAM Medical –Scientific Conference 2013
Name
Kristine
Burkman, Ph.D.
Commercial
Interests
Relevant
Financial
Relationships:
What Was
Received
Relevant
Financial
Relationships:
For What Role
No Relevant
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Relationships
with Any
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X
 Definitions
 Assessment
 Prevalence
 Overlapping Symptoms
 Treatment Considerations
 Suggested Strategies
a traumatically induced physiologic disruption of brain
function, as manifested by one of the following:
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Loss of consciousness
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Loss of memory for events immediately before or after the accident
Alteration of mental state at the time of the accident (e.g., feeling
dazed, disoriented, or confused)
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Focal neurological deficit(s) that may or may not be transient
American Congress of Rehabilitation Medicine (ACRM)
KEEP IN MIND: TBI refers to original injury or etiology, there are
no symptoms for this diagnosis
Specifiers: Mild, Moderate, Severe
Refers to 24-48 hours following injury.
Severity of initial injury ≠ impairment in functioning
Prognosis often related to:
 Length of loss of consciousness
 Length of post traumatic amnesia
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Eye opening
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Spontaneous = 4
To speech = 3
To painful stimulation = 2
No response = 1
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Verbal response
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Oriented to person, place & date = 5
Converses but is disoriented = 4
Says inappropriate words = 3
Says incomprehensible sounds = 2
No response = 1
Motor response
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Follows commands = 6
Makes localizing movements to pain = 5
Makes withdrawal movements to pain = 4
Flexor (decorticate) posturing to pain = 3
Extensor (decerebrate) posturing to pain = 2
No response = 1
SCORING
Specifier is based on score
within 48 hrs of injury:
Severe = 1 - 8
Moderate = 9 - 12
Mild = 13 - 15
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Not routinely assessed in combat situations
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VA assesses via self-report months, even years after the
event
 Screen (4 items, sensitive not specific)
 Second level eval (22 items)
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Often not documented
and military culture may
encourage minimization
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91% of OEF/OIF casualties survive1
 Compared to 84% of Vietnam, 80% WWII
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Estimated 22% of returning servicemembers have
reported experiencing TBIs and concussions2
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Of those injured, approximately 31% diagnosed w/ TBI3
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77% of all head injuries are mild TBI4
1Holcomb
et al., 2006, 2Terrio et al., 2005,
3Hayward, 2008, 4Fischer, 2010
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Persons w/ TBI more likely to have 2nd and 3rd TBI1
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Repeat TBIs increase severity and chronicity of symptoms1
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Twice as likely to screen positive for PTSD or
depression2
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Increased risk for suicide3
1Center
for Disease Control (CDC); 2Maguen, Lau,
Madden & Seal, 2012; 3Brenner, Ignacio & Blow, 2011
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Complicated literature
 Bi-directional relationship between TBI and SUD
 Pre-injury pattern of substance use predicts post-injury pattern
of use
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Substance use impairs rehabilitation
and exacerbates symptoms
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Increased risk of additional injury
Co-Occurring Disorders
 SUD + Depression, 3-5 time more likely to relapse1
 SUD + PTSD relapse more quickly 2,3
 Co-occurring patterns of relapse 2, 4
Exposure to Trauma
 Probability of relapse increases as the # of traumas types increase 5
1Curran
et al., 2000; 2Brown et al., 1996; 3Ouimette et al., 1997;
4Curran & Booth, 1999; 5Fraley et al., 1998
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Feeling dizzy
Loss of balance
Poor coordination, clumsy
Headaches
Vision Problems
Sensitivity to Light
Nausea
Hearing difficulties
Sensitivity to noise
Numbness
Change in taste and/or smell
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Loss/increase in appetite
Difficulty concentrating
Forgetfulness
Difficulty making decisions
Slowed thinking, disorganized
Fatigue, loss of energy
Feeling depressed or sad
Difficulty falling or staying asleep
Feeling anxious or tense
Irritability, easily annoyed
Poor frustration tolerance, easily
overwhelmed
Re-experiencing
Hyperarousal
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Intrusive images, memories, thoughts
Nightmares
Flashbacks
Emotional distress at reminders
Physical reaction to reminders
Avoidant
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Avoiding thinking/talking about trauma
Avoiding situations
Trouble remembering aspects of trauma
Loss of interest in activities used to enjoy
Feeling distant/ cut-off from others
Emotionally numb
Foreshortened sense of future
Insomnia
Irritability
Difficulty concentrating
Hypervigilence
Startle response
Common Challenges
Impulse Control
Frontal Lobe
Inhibited
Planning
Abstraction
Limbic System
Activated
Judgment
Emotion
Memory
 Sleep problems
 Dizziness
 Headaches
 Memory
problems
 Light
sensitivity
 Irritability
TBI
Depression
PTSD
 Loss of interest
 Feeling down,
hopeless
 Emotional numbing
 Avoidance
 Nightmares
 Hypervigilence
Maguen, Lau, Madden, Seal, 2012
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Missed appointments
 Avoidance, memory problems, difficulty w/ initiation, inability
to organize effectively, relapse
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Difficulty tracking or recalling skills
 Frustrated w/ pace, embarrassment in session
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Crisis-prone
 Relationships, work/school, legal, psychiatric crises
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Distorted expectations and beliefs
Phase Based Model of Recovery
Stabilization
-Psychoeducation
-Coping skills
-Psychopharmacology
Establish “safety”
Improve self-regulation
Processing
-Construction of narrative
-Cognitive restructuring
-Exposure
Consolidation of memory
Habituation of fear response
Integration
-Interpersonal work
-Insight/existential
-Symptom maintenance
Reconnect with others/life
Meaning of experience
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Titrate level of emotional content re: trauma material
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Assess level impairment re: memory and emotion regulation to
inform when and how to approach trauma processing
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Fear of symptoms exacerbation
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Drop out rates
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Insufficient training for protocol
among clinicians
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“Fragile” patients
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Chaotic/ high risk situations
KEEP IN MIND: Mild TBI should
resolve fully within 6 months, debate
over cause of ongoing symptoms
Integrated treatment of TBI, PTSD and
SUD is recommended!
 Flexibility
 Persistent outreach
 Validate, reassure, challenge
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Acknowledge problems as real to veteran
Education re: relapse, heterogeneity of injuries, expectation of
recovery from mTBI
Goal of recovery not adjustment to permanent disability
 Multidisciplinary team
 Harm reduction
MEMORY &
LEARNING
PROCESSING
SPEED
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Write it down
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Plan Ahead
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Organize
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Allow extra time
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Visualize Info
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Attach emotion
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Repetition
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Accuracy over
speed
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Avoid
multitasking
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Flexible
deadlines
FRONTAL LOBE
DAMAGE
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Include support
members
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Emotional
awareness &
management
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Routine
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Encourage
persistence
 Keep it simple
 Go slow
 Write it down
 Encourage veteran to
communicate back what
he/she understands
 Repeat
Thank you for serving our Veterans!
Questions?
Kristine.Burkman2@va.gov