Psychiatric Issues In Traumatic Brain Injury - Nbia.ca
Psychiatric Issues inTraumatic Brain InjuryEstablishing a Differential Diagnosis andIdentifying Effective Treatment for Individualswith TBI and Behavioral Health ProblemsRolf B. Gainer, PhD, Dip. ABDANeurologic Rehabilitation Institute, Brookhaven Hospital, Tulsa, OK(800) 927-3974 www.brookhavenhospital.com
Objectives Explainthe scope of problemsexperienced by traumatic brain injury(TBI) patients, including behavioralhealth issues Discuss effective strategies fordiagnosing neurological impairment,psychiatric illness, and co-morbidity Review conditions created by TBI thatcan exacerbate underlying psychiatricconditions10/21/2004Brookhaven Hospital2
Objectives Examineclinical presentation ofpersons with a dual diagnosis, whichincludes TBI Examine treatment/rehabilitationimplications for individuals with dualdiagnosis10/21/2004Brookhaven Hospital3
Psychiatric Issues inIndividuals with TBI Behavioralcomponents of TBI whichresemble psychiatric illness Effects of brain injury on individuals withpre-existing conditions Issues of co-morbidity Diagnostic skills10/21/2004Brookhaven Hospital4
Facts About Brain Injury Everyday nearly 6,000 Americans sustaina brain injury (www.biausa.org) 400,000 individuals with moderate andsevere brain injuries in the USA arehospitalized each year10/21/2004Brookhaven Hospital5
Causes of Brain Injury MotorVehicle Accidents 50% Falls21% Assaults12% Sports/Recreation10% Other7%10/21/2004Brookhaven Hospital6
Physical Effects of BrainTrauma in Closed Head Injuries DirectImpact Coup and Contra Coup Injuries Rotation and Shearing Swelling Bleeding Neurochemical Changes Secondary Effects10/21/2004Brookhaven Hospital7
TBI Severity Distribution Injury Mild Moderate Severe Mortality10/21/2004Rate85%10%5%11%Brookhaven Hospital8
Assumptions about TBI Physiologicalimpairment Disruption of sensorium Disinhibition Arousal and attention problems Unstable mood states Problems in learning and organization10/21/2004Brookhaven Hospital9
Behaviors in Early Recovery Disorientation ParanoidIdeation Depression Hypomania Confabulation10/21/2004Brookhaven Hospital10
Behaviors in Early Recovery Restlessness Agitation Combativeness EmotionalLability Confusion Hallucinations10/21/2004Brookhaven Hospital11
In the early phase ofTBI recovery, somebehaviors canresemble a psychiatricillness.10/21/2004Brookhaven Hospital12
Biological Aspects of InjuryFurther Psychological Problems Seizuredisorder may include irritability andbehavior dyscontrol Cognitive problems, especially memory,affect, emotional response Denial of deficits may affect capacity toreceive help Previously effective medications may notwork or may exacerbate injury-relatedproblems Depression may prevent participation10/21/2004Brookhaven Hospital13
The Basic Person Doesn’t Change Theinjury alters specific aspects of theperson’s psychological, cognitive andemotional function Specific personality traits or styleremain10/21/2004Brookhaven Hospital14
TBI Affects All Aspects of Life Previouslycompetent individuals mayshow symptoms of psychiatric disease Coping skills are stressed Behavioral controls are lost10/21/2004Brookhaven Hospital15
TBI Affects All Aspects of Life Socialskills and rolesare affected Insight into TBI-relatedchanges may be limited Previously self-managedsymptoms may becomeout of control Relationships/supportsystems are stressed10/21/2004Brookhaven Hospital16
Positive Predictors ofRecovery Outcome Focalvs. Globalized injury Aggressive early intervention andtrauma care Work history10/21/2004Brookhaven Hospital17
Positive Pre-Injury Predictors Levelof severity, coma duration Natural recovery and return of functions Medical/behavioralcomplications Pre-injury achievement level Learning, school and workhistory Extroverted personality Positive social history10/21/2004Brookhaven Hospital18
Positive Pre-Injury Predictors Perseveranceand motivation Strong social and familynetwork and support Absence of pre-injurypsychiatric symptoms Absence of substance abuse “Goodcharacter” and self control Strong-willed, determined personality10/21/2004Brookhaven Hospital19
Negative Predictors Poorresponse to psychiatric medications Poor response to “talking” therapies Failure in behavioral programs requiringmemory and problem-solving Social network failure: divorce, separation10/21/2004Brookhaven Hospital20
Negative Predictors Failureat work Involvement in thecriminal justicesystem Persistence ofchronic pain andheadache symptoms Lack of supportsystem10/21/2004Brookhaven Hospital21
Lateralization Issues ofBehavior Deficits RightHemisphere: unable to respond,flat affect Left Hemisphere:depression,agitation, anxiety Diffuse: attention,concentration,arousal, response10/21/2004Brookhaven Hospital22
TBI and Psychiatric DiseaseTraumatic Brain Injury can mimicpsychiatric symptomsExamples: memory problems, behavioraland emotional control problems, mooddisorders10/21/2004Brookhaven Hospital23
Biological Brain Changes canMimic Psychiatric Disease Biologicalchanges canexacerbate a preexisting psychiatricdisease Executive Syndromecan resemble a thoughtdisorder Behavioral features canresemble otherconditions10/21/2004Brookhaven Hospital24
TBI and Psychiatric DiseaseTBI can mask psychiatricsymptomsExample: Frontal systemdamage can produceexpressiveaposody/blunting,which may reduce theperson’s ability toexpress sadness10/21/2004Brookhaven Hospital25
Risk Factors Associated withPsychiatric Diagnosis (Lishman, 1988) Organicfactors Psychosocial factors (socio-economics,pre-morbid personality) Past history of psychiatric illness Family history of psychiatric illness Male Emergence of problems one year postinjury10/21/2004Brookhaven Hospital26
Research HighlightsLocalization of injury (Fann, 1995) Noradrenergic and serotonergic projectionsare sites of contusion (Rosenthal, 1998) Individuals withdepression andanxiety perceivethemselves asmore ill (Fann,1995) 10/21/2004Brookhaven Hospital27
Research Highlights Reactionto failure (Alexander, 1975,1992) Right hemisphere damage (Silver,1992) Pre-morbid factors and socialadjustment (Robinson & Jorge, 1993) Biochemical response (Robinson &Jorge, 1993)10/21/2004Brookhaven Hospital28
Brain Injured Patients withPsychiatric Disorders (Van Reekum, 2003)The level of severity ofthe person’s braininjury relates to thepotential for theemergence ofpsychiatric disordersin the first 24 monthspost-injury10/21/2004Brookhaven Hospital29
Personality DisturbancesAfter Brain InjuryAnxiety or “catastrophicreaction” Emotional lability/disinhibition Paranoia and psychomotoragitation Denial Depression Social withdrawal Amotivation/abulia 10/21/2004Brookhaven Hospital30
Distinguishing Brain Injuryfrom Psychiatric Problems Physicalinjury to the brain Cognitive and behavioral deficits Emotional and personality change Attention, concentration,arousal, filtering Memory problems Seizure problems Self regulation10/21/2004Brookhaven Hospital31
Psychological Syndromes canCo-occur or Predate Injury Whendid 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 havedeveloped?10/21/2004Brookhaven Hospital32
Problems in DiagnosingPsychiatric Illness in TBI Timingbetween injury and emergenceof symptoms In mild cases lackof documentationof extent/severityof injury Pre-morbidpersonality traits Pre-injury issues10/21/2004Brookhaven Hospital33
Rate of Psychiatric IllnessOne Year Post Brain Injury 21.7%of individuals with TBI had ICD9 diagnosis vs 16.4% of generalpopulation (1998) Paststudiesfocused onindividuals withTBI who wereseen in psychiatrichospitals10/21/2004Brookhaven Hospital34
Psychiatric DiagnosisDistribution Following TBI Male- 21.6% Female – 11.3% Mild brain injury –17.2% Moderate andsevere brain injury– 23.3%10/21/2004Brookhaven Hospital35
Psychiatric DiagnosisFeaturesRelationship 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)10/21/2004Brookhaven Hospital36
Psychiatric Issues in TBI Cases Male/female70%/30% more likely todevelop psychiatric symptoms Elevated risk for bi-polar affectivedisorder Seizures noted in 50% of cases withmania (Shukla, 1987) Limbic system lesions in 75% of maniccases (Starkstein, 1987) Family history of mood disorders10/21/2004Brookhaven Hospital37
Diagnostic Issues in BI Group Depressiveepisode13.9% vs. 2.1% Panic Disorder9.0% vs. 0.8% Generalized anxiety2.5% vs. 3.1% Phobic disorder0.8% vs. 1.1% Obsessive compulsive 1.6% vs. 1.2% Schizophrenia0.8% vs. 0.4% ETOH dependence4.9% vs. 4.7%10/21/2004Brookhaven Hospital38
Brain Injury and DepressionDepressionfollowing braininjury occurs at arate of 44.3% vs.5.9% in non-braininjured population10/21/2004Brookhaven Hospital39
Differential Diagnosis IssuesHow can the clinician determine the roleof injury and pre/post injury psychiatricfactors that contribute to behavioraldysfunction?10/21/2004Brookhaven Hospital40
Pre-existing PsychiatricDisorders Related to TBIDementia due to head injury Cognitive disorder Bipolar disorder (manic ordepressive types Mood disorders (depression,mania) Sleep disorder Anxiety disorders Intermittent explosive disorder 10/21/2004Brookhaven Hospital41
Pre-existing Conditions canAffect Recovery from TBILimited coping skills Impaired ability to managesymptoms Cognitive problems limitcapacity to manage disabilityand pre-existing condition Advent of new behaviors Prior medications mayincrease cognitive problems 10/21/2004Brookhaven Hospital42
Effect of TBI on UnderlyingPsychiatric Disease Reducedcapacity to self-managesymptoms Diminished impulse control leads toenhanced interpersonal problems Psychological defenses and copingskills fail to function Denial of deficits prevents person fromresponding to injury-related deficits10/21/2004Brookhaven Hospital43
Effect of TBI on UnderlyingPsychiatric Disease Interpersonalrelationships change Social role is altered Seizures anddyscontrol event aremisinterpreted Enhanced dependentneeds affectpsychological status10/21/2004Brookhaven Hospital44
Adjustment Difficulty due toEmotional & Behavioral Issues Emotionalchange Impaired perceptionof social interaction Impaired self control Increasedependency Behavioral rigidity10/21/2004Brookhaven Hospital45
Most Frequent Problems Citedby Family Members Slowness Irritability Impatience Depression Memory10/21/2004Brookhaven Hospital46
Co-Morbidity: PTSD & TBI(Arnon, 1998) 32%of motor vehicle accident victimsmeet diagnostic criteria for PTSD oneyear post-injury Those with PTSD have higher rates ofpre-morbid/co-morbid psychopathology(anxiety and affective disorders) Immediacy of PTSD symptoms is abetter predictor of later PTSD thaninjury severity10/21/2004Brookhaven Hospital47
Role of Prior Learning orAttentional Problems inOccurrence of PsychiatricDiagnosisPrior learning and attentionalproblems are enhanced Diminished filtering andstimuli selection Altered coping skills producedysfunctional responses 10/21/2004Brookhaven Hospital48
Psychiatric Issue orBrain Injury?Mania vs. Arousal problems Anxiety Denial Confusion Depression Cognitive problems Personality changes Intellectual changes Thought disorder vs. Thinking problem 10/21/2004Brookhaven Hospital49
Psychiatric Features of TBI Mania- Agitation Anxiety - Catastrophic Reaction(Goldstein) Denial - Inability to accept deficits Confusion - Disorientation and memoryproblems Depression – Withdrawal, abulia10/21/2004Brookhaven Hospital50
Neurologic andNeuropsychiatric Features Atypicalseizuredisorders Intermittent explosivedisorder (Yudofsky) Neurologic rage orlimbic-psychoticaggressive syndrome(Dorothy Lewis)10/21/2004Brookhaven Hospital51
Neurologic Rage Identifiers Suddenloss of behavioral control,“out of the blue” Inability to stop the behavior Seizure-like quality, unawareness of theindividual to the event Deficient memory of the event (DorothyLewis)10/21/2004Brookhaven Hospital52
Factors Leading toBehavioral Problems in TBI Primaryandsecondary aspectsof the physical injury Development ofemotional problems Development ofcognitive problems10/21/2004Brookhaven Hospital53
Two Type ofBehavioral Problems Behavioralexcess –too much Behavioral deficit –too little10/21/2004Brookhaven Hospital54
Neurobehavioral Issues Hyper/hypoarousal Level of response to externalevents/filtering Stimulus control vs. stimulus bound Denial Judgment Impulsivity vs. self-regulation Irritability and seizure-like events10/21/2004Brookhaven Hospital55
Neurobehavioral Features Impulsivity(lack of self-regulation) Level of motor agitation/restlessness Aggressivity andassaultiveness Apathy, abulia,lack of motivation Irritability,impatience10/21/2004Brookhaven Hospital56
Interpersonal/Psycho-SocialFactors of Behavioral Problems Impairedself-perception Emotional changes Egocentric thinking Impaired perception ofsocial issues Increased dependency Behavioral rigidity10/21/2004Brookhaven Hospital57
Interpersonal/Psycho-SocialFactors of Behavioral Problems Irritability Angercontrolproblems Mood instability Hypo/hyper sexuality Diminished drive/motivation Cognitive deficits10/21/2004Brookhaven Hospital58
Factors ofCognitive Problems in TBI Levelof arousal Sensorium disruption Concentration andfocus Filtering, stimulicontrol10/21/2004Brookhaven Hospital59
Factors of Cognitive Problems Orientationand confusion Memory, information retrieval Problem-solvinganddecision-making Language andcommunication10/21/2004Brookhaven Hospital60
Cognitive Problems Can LookLike Behavioral Problems Attentionand filtering problems Over/under arousal Concentration Memory Task learning Novel learning (old to new)10/21/2004Brookhaven Hospital61
The first step in making adiagnosis is to think of it.-- Thibault, 199210/21/2004Brookhaven Hospital62
Evaluate and SeparatePost-Injury from Pre-InjuryProblems10/21/2004Brookhaven Hospital63
Diagnostic Approaches Interviewwithindividual Comprehensivemedical andpsychiatric history Developmental and school history Neurological evaluation Neuropsychological assessment Medical file review10/21/2004Brookhaven Hospital64
Pre-Morbid IssuesPresence of known psychiatriccondition Level of adjustment, degree ofattainment (school, work,family) History of learning, behaviorand conduct problems History of substance problems Medical history School and vocational history 10/21/2004Brookhaven Hospital65
Post-Injury Effect on CopingSkills and Personality Responseto disabling condition(s) Cognitive deficits Neurobehavioral deficits External support system Motivation/initiative Substance use/abuse Engagement in meaningfulactivities10/21/2004Brookhaven Hospital66
Persistent Problems ofRecovery and Rehabilitation Irritability Impulsivity Egocentricity Lability Judgmentdeficits Impatience Tension/Anxiety Depression10/21/2004Brookhaven Hospital67
Implications forRehabilitation:Why Patients “Fail”10/21/2004Brookhaven Hospital68
Persistent Problems ofRecovery and Rehabilitation Hypersexuality Hyposexuality Dependency Silliness/Euphoria Aggressivity Apathy Childishness Disinhibition10/21/2004Brookhaven Hospital69
Why Patients “Fail”Strategy: Individual and Group PsychotherapyWhy? Can’t identify problems as shared byothers Difficulty maintaining behavioralalternatives10/21/2004Brookhaven Hospital70
Why Patients “Fail”Strategy: Insight-Oriented ApproachesWhy? Can’t identify problem with self Problems with generalization10/21/2004Brookhaven Hospital71
Why Patients “Fail”Strategy: Didactic ApproachesWhy? Memory problems prevent use ofprevious learning10/21/2004Brookhaven Hospital72
Why Patients “Fail”Strategy: Milieu TreatmentWhy? Social deficits inhibit positive peer groupmembership10/21/2004Brookhaven Hospital73
Why Patients “Fail”Strategy: Cognitive-Behavioral TherapyWhy? Memory problems and difficulty withgeneralizations10/21/2004Brookhaven Hospital74
Why Patients “Fail”Strategy: Behavior ModificationWhy? Problems with impulse control Memory problems preventreinforcement strategy from beingeffective10/21/2004Brookhaven Hospital75
Why Patients “Fail”Strategy: Medication ManagementWhy? Some medications further cognitiveproblems or cause disinhibited behavior10/21/2004Brookhaven Hospital76
Why Patients “Fail”Strategy: Addictive Treatment/Self-Help GroupsWhy? Cognitive problems preventidentification with the speaker/groupprocess Individual cannot apply information toself10/21/2004Brookhaven Hospital77
Why Patients “Fail” Personcannot process “talkingtherapies” Limited insight New behaviors (e.g. impulsivity) arerelated to the brain injury Increased dependence Unable to relate to previously effectivesupport groups (e.g. AA, NA)10/21/2004Brookhaven Hospital78
Support System StressesIncrease Psychological Issues Highincidence of divorce or loss of primaryrelationship (50% in first two years postinjury) Adult children return to aging parents forphysical assistance Loss of friends and work High potential for substance use/abuse Loss of social role with family, friends andcommunity Cultural factors influence recovery10/21/2004Brookhaven Hospital79
Social Network IssuesComplicate Rehabilitation Socialnetwork failureseen 24-months postinjury (Burke andWeslowski. 1989) Psychological effect ofwithdrawal or loss ofsupports10/21/2004Brookhaven Hospital80
Social Network IssuesComplicate Rehabilitation Changingsocial role post-injury affectsself-image and self-worth Individual response to loss of functionsand social changes Recidivism and emergence ofpsychiatric symptoms commonly seen12-24 months post-injury10/21/2004Brookhaven Hospital81
Increasing Success inRehabilitation andTreatment:What Works!10/21/2004Brookhaven Hospital82
What Works?Early identification of problems Highly structured, social learning environment Repetitive “teaching” of behavioralalternatives External controls managed by staff, graduallytransferred to the individual Neurological approach to medicationmanagement Integrated rehab program, includingpsychiatric and substance abuse treatment 10/21/2004Brookhaven Hospital83
What Works? Emphasison learning and relearning ofsocial role Teaching “scripts” for social interaction Guided/supported attendance atAA/NA/self-help groups Use of “failures” within treatment toaddress denial and limited insight10/21/2004Brookhaven Hospital84
What Works?Focus on social role re-entry and response offamily, friends, co-workers, peers, and othersto the person Staff understanding of TBI-related behavioral,cognitive, emotional and psychological issues Understanding of adjustment to disability Teaching individual about consequences ofTBI Promoting return to work, avocational andrecreational activities 10/21/2004Brookhaven Hospital85
What Works?Consistent response from staff throughout theenvironment Use of behavioral analysis to understandbrain/behavior issues Avoidance of negative consequences forbehavior problems Focus on discharge engineering to assurethat the individual moves to a supportiveplacement with the solid transfer ofinformation and management techniques 10/21/2004Brookhaven Hospital86
Neurological RehabilitationInstitute (NRI)atBROOKHAVENTulsa’s Specialty 1/2004Brookhaven Hospital87
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)
Brain injury can be called by different names, like concussion, shaken baby syndrome, and head injury. The brain can be hurt in many different ways; injuries to the brain are typically classified as non-traumatic or traumatic. Non-Traumatic injuries occur as a result of something internal to the brain like stroke, lack of oxygen, infection .
Traumatic Brain Injury A traumatic brain injury (TBI) is caused by a bump, blow, jolt or penetration to the head disrupting the normal function of the brain.1 When one or more of the following clinical signs is observed, it constitutes an alteration in brain function: a) any period of loss of, or decreased, consciousness; b) any loss of
The Tennessee Traumatic Brain Injury registry began collecting brain . Table 1 includes the ICD-10-CM diagnosis codes used for traumatic brain injury surveillance. If one or more of these diagnoses codes appears in a patient's record, the patient must be reported to the TBI registry.
Acquired Brain Injury (ABI). Trauma, stroke, aneurysm, loss of oxygen to the brain (caused by heart attack, near drowning, suffocation, etc.), infectious disease and toxic exposure are some of the causes of ABI. Traumatic Brain Injury A Traumatic Brain Injury (TBI) is a form of acquired brain injury that results
Traumatic Brain Injury Recovery Guide - 2 - The diagnosis of a Traumatic Brain Injury (TBI) can be overwhelming for family members and caregivers. This guide will help you understand a TBI diagnosis and learn about ways you can help. We follow the Ranchos Los Amigos Scale of Cognitive Functioning. This scale was created to track the recovery .
Traumatic Brain Injury Initiatives. Home and Community-Based Services . NEW YORK STATE DEPARTMENT OF HEALTH . Medicaid Waiver for Individuals with . Traumatic Brain Injury. PROGRAM MANUAL (June 2006) June 2006 1. June 2006 2 TABLE OF CONTENTS Page No. . The cost of the Service Plan is above the level necessary to meet the federally
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Literary Studies. London: Longman, 1993. INTRODUCTION While most of you have already had experience of essay writing, it is important to realise that essay writing at University level may be different from the practices you have so far encountered. The aim of this tutorial is to discuss what is required of an English Literature essay at University level, including: 1. information on the .
