INTRODUCTION TO TRAUMATIC BRAIN INJURY (TBI) JULY, 2011 Cheryl L. Shigaki, Ph.D., ABPP & Thomas Martin, Psy.D., ABPP Psychologists in US Health Care Rehabilitation Psychology – focuses on adjustment to disability, maximizing function, full-participation in life activities. Health Psychology – focuses on the intersection between behavior and health. Neuropsychology – focuses on cognitive and behavioral sequelae from insults to the brain. Rusk Rehabilitation Center Columbia, Missouri 60 inpatient beds – serves post-acute: Brain injury Spinal Cord Injury Stroke Multi-trauma Debility TBI and Healthcare The public and many health care professionals have limited and/or inaccurate understanding of TBI. Overlap between TBI and psychiatric symptoms Benefit and challenges of screening to identify history of TBI? Benefit – Avoid misdiagnosis and promote care “Have you ever had a head injury?” not effective TBI in Rwanda People with new brain injuries Recognizing mild TBI Helping victims and families adjust to moderate-severe TBI People with previous TBI Understanding personality and behavior change Supporting chronic physical, cognitive and emotional effects TBI and Healthcare Typical rehabilitation approaches include: Restorative strategies: Direct intervention to improve the problem Compensatory strategies: Intervention focuses on adapting to the problem / working around it. Psychological intervention: Address emotional reaction to loss and/or trauma; support motivation for active recovery. Family caregiver support: Education about what to expect, how to manage problem behaviors and advocate for their loved one, and provide support for coping with stress and loss. The Brain and TBI The brain weighs about 1.4 kgs, with a consistency somewhere between butter and gelatin. TBI causes brain damage in a number of ways. Damage can be caused by both primary and secondary injuries. Overview of the Brain CEREBRAL HEMISPHERES Left hemisphere Right hemisphere FOUR LOBES OF THE BRAIN Frontal lobe Parietal lobe Temporal lobe Occipital lobe BRAIN CELLS (NEURONS) Lobes of the Brain Structure of a Neuron (brain cell) Axon Dendrite Axon terminal Soma Node Schwann cell Nucleus Myelin sheath CC-BY-SA-3.0; Released under the GNU Free Documentation License. The Corpus Callosum From Above Image from Gray’s Anatomy. In the public domain Good Neuroanatomy Website Florida Institute for Neurologic Rehabilitation http:// www. finr. Net Note: App for iPhone now available! Common Primary Injuries Skull fractures Contusions (bruising) Intracranial hemorrhage (hematomas) Diffuse axonal injury (DAI) Contusions Contusions are hemorrhagic lesions that typically form at the crests of gyri on the surface of the brain: contusions form at the site of cranial impact. Contrecoup contusions form opposite the cranial impact and are typically more severe. Coup Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. http://creativecommons.org/licenses/by/2.5/ The inside of the skull Is not smooth, it has sharp ridges Hematomas Classified by the location of bleeding; hematomas can damage the brain by exerting pressure on underlying brain structures Epidural Subdural Subarachnoid Hematomas Subdural within the layers of brain covering Due to vein bleeding which is slower than artery bleeding. May not be discovered until days or weeks after the accident Epidural Usually caused by tears in arteries, Results in quick blood build up between the dura mater and the skull. Hematomas Subdural hematoma as marked by the arrow with significant midline shift Epidural hematoma Signs and Symptoms of Hematoma Fluctuating levels of consciousness (or LOC) Irritability Seizures Pain/Numbness Headache Dizziness Hearing loss/ringing Disorientation/amnesia Weakness/lethargy Nausea/vomiting Loss of appetite Personality changes Difficulty speaking, slurred speech Difficulty walking Altered breathing Blurred vision/abnormal eye movement Diffuse Axonal Injury (DAI) Widespread neuronal axon damage is frequently associated with “stretching” of the brain (motor vehicle accidents). DAI is thought to contribute to LOC and prolonged coma. The problem associated with “shaken baby syndrome” Common Secondary Injuries Ischemia – lack of blood/oxygen in area leading to cell death Elevated intracranial pressure (swelling) & diminished blood flow Neurochemical events – blood is toxic to brain tissue Posttraumatic epilepsy Cerebral infection Elevated Intracranial Pressure (ICP) The cranium is inflexible, increased pressure compresses brain tissue. Edema Hematoma Sharp increases in intracranial pressure can contribute to cerebral ischemia and herniation. Management of intracranial pressure and maintaining cerebral blood flow are primary concerns. Edema (Swelling) Cerebral edema results from disruption of the blood-brain barrier and impairment of vasomotor autoregulation with concomitant dilation of cerebral blood vessels. Cerebral edema can lead to compression of the ventricular system, herniation, occlusion of intracranial vessels with secondary strokes, or increased intracranial pressure. Elevated Intracranial Pressure (ICP) Types of brain herniation: 1) Uncal 2) Central 3) Cingulate 4) Transcalvarial 5) Upward 6) Tonsillar TBI ASSESSMENT Terminology: “Cognitive” So far, we have been using the term “cognitive” to describe thinking styles in people with normal brain function Based on social & personal context and habits we learn Cognitive / Cognitive-Behavioral therapies are used to improve psychological wellbeing. Psychologists help patients explore and change thoughts and behaviors that are maladaptive Terminology: “Cognitive” Can also be used to describe thinking skills that are genetically/biologically driven and enhanced by opportunities for learning. Neuropsychological research has attempted to define distinct aspects of “cognition” such as auditory & visual memory, attention, problem-solving, speed, etc. Neuropsychological research also attempts to distinguish between normal and impaired cognition Clinical Neuropsychologists test brain function following brain injury or disease (using tasks and questions) and make recommendations for living with impairment. Assessment of Mild TBI Domestic violence Sports injuries Work-related injuries The effects of mild TBI can be cumulative “Have you ever had a head injury?” is not an effective way to evaluate. Assessment of Mild TBI Acute Concussion Evaluation (ACE) Heads Up: Brain Injury in Your Practice (CDC) http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html Interview and assessment of risk factors Symptom checklist Diagnostic codes (ICD) Sample follow-up plans/recommendations Versions for return to work, school & sports Assessment of Moderate-Severe TBI Three pathways to assess severity of acute TBI: Depth of coma Duration of coma The inability to continually register new experiences (Posttraumatic Amnesia or PTA) Glasgow Coma Scale (GCS) Glasgow Coma Scale (GCS) Mild Glasgow Coma Scale (GCS) score 13-15 Loss of consciousness (LOC) < 20 Minutes Posttraumatic amnesia (PTA) <24 hours Moderate Note: A GCS score can be broken down, GCS score 9 – 12 for example: GCS 12 = E4V3M5 LOC 20 - 36 hour PTA 1 - 7 days Forms and training scripts can be found at: Severe http://www.chems.alaska.gov/ems/docum GCS score 3-8 ents/GCS_Activity_2003.pdf LOC > 36 hours PTA > 7 days Rancho Los Amigos: Level of Cognitive Functioning Scale Helpful in assessing the patient in the first weeks or months following an injury. Does not require cooperation from the patient Rancho “levels” are based on observations of the patient’s response to external stimuli & provide a descriptive guideline of the various stages of brain injury. Forms and descriptions can be found at: http://tbims.org/combi/lcfs/ Galveston Orientation & Amnesia Test (GOAT) The GOAT can be used to track how much a person is recovering while in the hospital (no longer in a severe coma). Requires patient cooperation. Score is 100 MINUS error points. Score of 78 or more on three consecutive occasions/days indicates that patient is out of post-traumatic amnesia (PTA). Galveston Orientation & Amnesia Test (GOAT) What is your name? (2) When were you born? (4) Where do you live? (4) Where are you now? (5) City, (5) Hospital On what date were you admitted to this hospital? (5) How did you get here? (5) What is the first event you can remember after the injury? (5) Can you describe in detail the first event you recall after the injury? (5) Galveston Orientation & Amnesia Test (GOAT) Can you describe the last event you recall before the accident? (5) Can you describe in detail the first event you can recall before the injury? (5) What time is it now? (-1 for each 30 min incorrect, up to -5) What day of the week is it? (-1 for each day incorrect, -3) What day of the month is it? (-1 for each day incorrect, -5) What is the month? (-5 for each month incorrect, -15) What is the year? (-10 for each year incorrect, -30) Levin, H.S., O'Donnell, V.M., & Grossman, R.G. (1975). The Galveston orientation and amnesia test: A practical scale to assess cognition after head injury. Journal of Nervous and Mental Diseases, 167, 675-684. TBI OUTCOMES Consequences of TBI The brain controls every aspect of our being and a traumatic brain injury has the capability of impacting any aspect of a person’s physical, cognitive, or psychological functioning. In-depth evaluation of these skills is the domain of Neuropsychologists. Impact of Mild TBI Mild TBI is typically associated with modest and temporary changes in functioning, while severe TBI is associated with enduring changes and sometimes mortality. Reductions in attention and information processing speed and efficiency are the most frequent cognitive consequences following mild TBI. Physical Functioning: Mod-Severe TBI Arm/leg weakness & paralysis Compromised speech and swallowing ability Dizziness & dyscoordination Diminished sense of smell and taste Hearing (e.g., tinnitus) and visual disturbance (e.g., diplopia) Sleep disturbance and fatigue Chronic headaches and pain Sexual dysfunction Cognitive Impact: Mod–Severe TBI Although severe TBI can impact any aspect of cognition, the high incidence of orbitofrontal (front of the brain, around eye sockets) and anterior temporal lobe (tips of the temporal lobes) contusions often produces a constellation of symptoms that includes: Cognitive Impact: Mod–Severe TBI Slow speed of cognitive processing (functional) Slowed behavioral responding (functional) Attention deficits Impaired learning & memory (need more exposures) Behavioral symptoms: impulsivity Perseveration initiation deficits planning and organization Cognitive Impact: Mod-Severe TBI The Thinker – Musée Rodin, Paris TBI does not typically compromise intelligence in mild-moderate cases. Speed of Processing Speed of processing (reaction time) is very sensitive to any brain insult Following a brain injury, it often takes longer to take information in and react to events Reduced speed of processing can compromise other cognitive abilities Degree of impairment may render the patient dysfunctional in daily activities. Learning/Memory Memory problems are the most common cognitive complaint following a TBI Short term vs. long term memory Verbal memory vs. visual memory Explicit memory (e.g., experiences, facts, events) vs. implicit (e.g., skills, habits) memory Research suggests deficit is in learning Attention Attention is on a continuum and task specific: Simple Attention: Ability to register and attend to (e.g., focus on a noise) Focused Attention: Ability to focus on important information while ignoring irrelevant information Sustained Attention: Ability to focus for extended period Divided Attention: Shift attention between tasks (e.g., cook & talk on the phone) Executive Functions Executive Functions – Skills necessary for complex goal-directed behavior and adaptation to changes Planning and organization ability Problem-solving ability Ability to initiate and sustain action and anticipate consequences Ability to benefit from feedback and adjust behavior Personality Changes Impulsivity Grandiosity Apathy / lack of initiative Impaired ability to evaluate risk and need for safety measures (meta-awareness, metacognition) They don’t know what they don’t know Personality changes Impulsivity Grandiosity Apathy / lack of initiative Inability to be empathic / self-focused Impaired ability to evaluate risk; judge one’s physical, cognitive and emotional functioning Thinking about thinking - They don’t know what they don’t know Psychiatric/Behavioral Impact Altered mood, behavior, and personality are common following TBI; even mild TBI has been associated with significant affective disturbance. Reactive, “organic” or both? Psychiatric/Behavioral Impact Rates of psychiatric disorders following TBI: Major depression (44%) Substance abuse/dependence (22%) Post-traumatic stress disorder (14%) Panic disorder (9%) Generalized anxiety disorder (9%), Obsessive compulsive disorder (6%) Bipolar disorder (4%) Schizophrenia (0.7%) van Reekum et al., (2000) Psychiatric/Behavioral Impact Diminished tolerance for frustration Decreased social skills Adjustment disorders and emotional lability Aggressive behavior (verbal and physical), particularly when overwhelmed Increased rates of alcohol and substance abuse and risk of suicide Psychiatric/Behavioral Impact Symptom overlap between TBI and PTSD: Memory / attention Sensory changes (sensitivity) Depression/poor emotional control Headache, fatigue, other physical or sensory problems Co-occurrence can make diagnosis difficult TBI and Post-traumatic Stress Self-report study (N>3000) 4 Groups Multi-trauma, with no TBI Multi-trauma, with TBI (mild, mod, severe) Telephone survey, 12 months post-injury Asked about cognition and PTSD symptoms Zatzick, Rivara, Jurkovich et al. Arch Gen Psychiatry. 2010;61:1291-1300 TBI and Post-traumatic Stress More severe TBI was related to diminished signs and symptoms of PTSD Due to impaired consolidation of traumatic memories Those with facial injuries and spinal cord injuries (SCI) showed increased risk for PTSD symptoms At all levels of TBI, those with PTSD symptoms reported the greatest levels of impairment Cognition, activities physical health, and functioning in everyday TBI and Post-traumatic Stress In studies where cognition was tested Individuals exposed to combat, rape and childhood abuse have demonstrated difficulty with verbal learning.* Adults with chronic PTSD were found to have volume and activity differences in the brain (hippocampus)* *Bremner JD. The Relationship between cognitive and brain changes in Posttraumatic stress disorder. Ann NY Acad Sci 2006;1071: 80-86 . Working with individuals who have TBI and their families Outcomes Following TBI Severity of injury is the best predictor of outcome Age also noted to be a independent predictor Other factors that contribute to outcome include: prior history of TBI, history of substance abuse, PTSD, vocational history, and adequacy of social relationships Larger brain volume and higher educational level are known to exert a positive influence Genetic factors also play a role. General Cautions for Healthcare TBI can impact sensory functioning (e.g., diplopia and altered vision, ringing in ears, and decreased balance) TBI can contribute to the development of medical disorders such as sleep disturbance and substance abuse issues. Communication deficits can be a significant source of frustration and disability. General Cautions for Healthcare Many medical conditions can exacerbate TBI symptoms including sleep disorder, infection, and pain. Use of alcohol or other substances may have a worse effect or lead to worse consequences for individuals with TBI. Individuals with a history of TBI are at increased risk for future TBI. Cumulative effect of multiple concussions. Recommendations for Working with Individuals with TBI Allow adequate time to process information and respond Appreciate that the injured brain is easily overwhelmed by multiple stimuli (noise, lights, activity) Maintain a supportive setting that utilizes structure and avoids dramatic changes in routine Potential for behavioral problems increases when the individual is physically, cognitively or emotionally stressed (e.g., fatigue, pain) and with experience of expressive language dysfunction Recommendations for Working with Individuals with TBI Provide information in multiple modalities in a concrete and brief manner with limited distraction. Focus on one task at a time / limit multitasking. Memory for visual and verbal information may be individual strength. Diminished initiation can easily be mistaken for depression, apathy or resistance. Recommendations for Working with Individuals with TBI Receptive Language Deficits Speak slowly, using short phrases and sentences Use gestures with your speech; use visual cues Repeat your message in different ways Do not rush-allow time for response, alleviating pressure to speak and allowing time to process information Use an alternate communication system when appropriate (i.e., pictures) Include the individual in conversation, but don’t overload them with information General Recommendations For Expressive Language Deficits Ask one-part yes/no questions Acknowledge and discuss the frustration the person might be having when communication attempts are made Allow adequate time for the individual to speak Involve the individual in decision making whenever possible, practicing expressive reasoning and review of steps one might make to achieve a desired outcome Continue normal daily routines and encourage use of learned strategies (e.g., over-articulation and increased volume) Cheryl L. Shigaki, Ph.D., ABPP Associate Professor University of Missouri Department of Health Psychology Dc116.88 One Hospital Drive Columbia, MO 65212 USA shigakic@health.missouri.edu