PiC Conference Presentations

Humanistic and Biological Interface in Brain Injury Rehabilitation

Anjum BashirLeyla Ziyal

Tim Warren www.partnershipsincare.co.uk

The enigma of Brain InjuryThe enigma of Brain Injury

• Brain Injury: a complex condition

• Not an illness

• Disease model not suitable

• Pathology obscure

• Psychopathology multifactorial

What is the Pathology?What is the Pathology?

• Pituitary Tumour excised• Tuberculous Abcess in temporal

region treated• Epilepsy and fronto temporal

scarring• RTA and subdural haematoma in

frontal region• Heroin overdose and found

unconscious anoxia of brain• Diabetic and found unconscious

possibly low blood sugar• Cerebral atrophy with large

ventricles• And so on

What is the Pathology?What is the Pathology?

• Complex and varied• Regional injury rather than focal• Events before and after:• Brain oscillates 3000 times before

coming to rest when in an accident with a car at 60mph

• Loss of oxygenation or over • Biochemical imbalance

Biological Dilemma Biological Dilemma

• Take example of an essential cognitive function:

Memory • Memory systems in brain• Regional distribution

Brain RegionsBrain Regions

• Hippocampus is the key area• Involved in declarative, anterograde

or new knowledge or information• Right Hippocampal complex (non

verbal)• Specialize in faces, geographical

routes, melodies, spatial information

• Left Hippocampal complex• Verbal language

Non medial Temporal regionNon medial Temporal region

• Same Right (non verbal) and left (verbal) specialisation

• Retrograde or past memories

Other regionsOther regions

• Ventromedial frontal lobe:• Emotion/feelings and Memory• Prospective memory;

remembering to do things in future

• Dorsolateral frontal lobe:• How many times and how

along ago an event has occurred

Brain RegionsBrain Regions

Basal Ganglia• Procedural memory (riding a

bike, swimming, habits, seeking automatic support and encouragement

Thalamus• Acquisation of factual information

and main transmitter or memory related information

Dilemma of Pathology?Dilemma of Pathology?

• Biological Explanations incomplete or vague

• Scientific advancement imprecise

• Some key laboratory tests only for research

Patients our best GuidesPatients our best Guides• TO THOSE WHO CANNOT ACCEPT MY CHANGE•

People change over time and most change is by choice.The person I am is not the person I was.Not over time, but in an instant, it all changed.I am different.It wasn't my choice, it wasn't my fault, but you treat me like it was.The person I was died and I went to my own funeral. I am different.You didn't like the person you saw in front of you.The person in the mirror wasn't me and I didn't like her either.But, I looked beyond the mirror and slowly became the person I am.If you hang on to the past, you die a little each day;once was enough for me.I am different, but not by choice, so don't reprimand me for being me.I am different.If you can't accept that, you can't accept me and I can't accept that.

• Sandee Rager

Listening to relativesListening to relatives

• He is not the person I knew• She is self centred• He is unpredictable• She cannot decide what to do• Oh those mood swings• Memory is so poor• Gets angry and can be so unkind

What ICD says?What ICD says?

• Organic Personality Disorder

• A category for all disorders

Discovering the person?Discovering the person?

Behind the organic fog

• A lost person• New fantasies• New realities• A new personality• Can s/he rediscover themselves

Biological PromiseBiological Promise

• Is it limited?• Goal: recreate availability to self

discovery

• Treat as whole:

Illness vulnerability increased

Mental dis- ease a challenge

Brain Dysfunction a challenge

No head injury is too serious to despair of, nor too trivial to ignore“

In order to be walked on, you have to be lying down."

No way! Be stubborn! The greatest indicator of success in TBI recovery is said by some professionals to be how stubborn you can be:

Persist! Brian Weir,TBI survivor

Thank you for ListeningThank you for Listening

Now our next speaker

Leyla Ziyal

BIOLOGICAL AND HUMANISTIC INTERFACE

IN BRAIN INJURY REHABILITATION

LEYLÂ ZIYAL M Phil AFBPsS C PsycholChartered Consultant Clinical Neuropsychologist

31 03 2010

A. INTRODUCTIONA. INTRODUCTION

Aim Share our practice at Elm Park BIS – Clinical

Neuropsychology Perspective

This paper: Practice overview1. How we do what we do

2. Why we do what we do – rationale

3. Illustrative case study

4. Next step in practice development

Next paperA further illustrative case study

A.1 Setting the sceneA.1 Setting the scene

Male patients

Severe acquired brain injury

Present with complex challenging

behaviours

Our shared goal:

Mobilise the potential of our patients to attain the maximum level of independence and quality of life that is possible for them to

achieve

A.2 Setting the sceneA.2 Setting the scene

Multidisciplinary work

Discharge objectives

Home-based reintegration within the community

Community Assisted Living Facilities,

Through to probably long-term step down

Facilities in residential contexts

1 HOW WE DO THE THINGS WE DO 1 HOW WE DO THE THINGS WE DO

Accessing the person behind the injury

‘’the human being is first and last…a subject, not an object”

Sacks, O. (1984) A leg to stand on Duckworth, London

1 HOW WE DO WHAT WE DO1 HOW WE DO WHAT WE DO

Neuropsychological Assessment

Cognitive Retraining (CRt)

Self repair (SR)

Attention

Memory

Information Processing

Executive Function

Life narrative (LNar)

Emotion Management (EMg)

Awareness Training (Aw)

Systemic/corrective Interventions

Behaviour Modification (BM)

as a means to relationship maintenance and

enhancement

1 HOW WE WHAT WE DO1.1 neuropsychological assessment helps us to:1 HOW WE WHAT WE DO1.1 neuropsychological assessment helps us to:

Generate a functional map of the

brain

Contribute to the multi-

disciplinary enterprise of setting

first stage discharge planning

goals

Develop a needs-analysis that

prioritises needs in terms of

these discharge goals

Formulate a rehabilitation

strategy in light of these goals

within the compass of the

patient’s current level of mastery

Pitch the level of

intervention to the

patient’s current level

of capability and

receptivity

Open a window of

understanding into

what and how the

patient is construing

his situation and

what/how he is feeling

1 HOW WE DO WHAT WE DO1 HOW WE DO WHAT WE DO

1.1 Neuropsychological assessment

a continuous process

repeat neuropsychological assessmentsrehabilitation performance recordsbehaviour records

1 HOW WE DO WHAT WE DO1 HOW WE DO WHAT WE DO

Cognitive RetrainingMemoryAttentionInformation processingExecutive function

Self Repair TherapiesLNarEMgAwCorr T

Behaviour Modificationas appropriate and only as means of replacing disruptive or undesirable behaviours with new more adaptive responses, and of selectively reinforcing desired behaviours whilst discouraging maladaptive ones.

1.2 cognitive retraining and self repair[and behaviour modification]

1 HOW WE DO WHAT WE DO1.2 cognitive retraining and self repair

Intervention format:

1 HOW WE DO WHAT WE DO1.2 cognitive retraining and self repair

Intervention format:

Groups - MetacognitionDevelops self-concept and self-efficacy in a supportive and safe milieu that promotes sense of self discovery and control

Enables Self evaluation through other observation and self-prediction

Facilitates multi-sourced Constructive feedback

Offers 0pportunity to further understand the nature of injury and its effects in the roles that the patient had adopted until now and may be likely to adopt from now onwards

Inter-session and modular Cross fertilisation

Individual – one to oneReinforces group work

Addresses special needs: anxiety/depression, OCD, SOT

Trouble shoots

Builds therapeutic alliance and facilitates engagement

Affords the opportunity to develop special relationship

2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT) 2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)Key concepts

The way we think determines the way we behave.

Identity is a unifying construct

The approach must be capable of encompassing the cognitive, emotional and psycho-social domains of functioning

Task is to help our patients to reconnect with their pre-injury identity in their journey of readjustment to the post ABI order through developing a sense of self efficacy and locus of and through locating the locus of control within themselves

Key methodMobilisation of the Core-belief – Life rule system

2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)Mobilisation of the Core-belief – Life rule system

Belief system

about me

about others

about the word

Rule system

conditional beliefs: ‘if – then’ statements

Life rules: Injunctions

Protective behaviours

Enforce the rule

Keep the core belief below the level of awareness

Maintains emotional balance

2 WHY WE DO WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)2 WHY WE DO WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)Mobilisation of the Core-belief – Life rule system

SCHEMA

RULE

RULE

RULEPROTECTIVE BEHAVIOURS

PROTECTIVE BEHAVIOURS

PROTECTIVE BEHAVIOURS

DISTORTED AUTOMATIC THOUGHTS NEGATIVE EMOTION

2 WHY WE WHAT WE DO: RATIONALECognitive Behaviour Therapy (CBT)

What happens when our protective behaviours break down

2 WHY WE WHAT WE DO: RATIONALECognitive Behaviour Therapy (CBT)

What happens when our protective behaviours break down

SHATTERED LIFE RULES

ACTIVATEDCORE BELIEFS

NEGATIVE EMOTION LOSS

OF IDENTITY

INERT PROTECTIVE BEHAVIOURS

2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)ABI: What happens when

protective behaviours break down?

loss of self self-knowledgeself by comparison self in the eyes of the world

impaired sense of identity

impaired sense of continuity ‘me before/me after’

grief

2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)2 WHY WE WHAT WE DO: RATIONALE

Cognitive Behaviour Therapy (CBT)

Reconstituting personal meaning an identity

Develop self-efficacy; self control

Access and repair self-identity

Re-align the belief-rule system to post-injury reality

Re-align the belief-rule system to pre-injury reality

Promote acceptance, adjustment and reconstitution of personal meaning and identity

BIOLOGICAL AND HUMANISTIC INTERFACE

IN BRAIN INJURY REHABILITATION

part 2

LEYLÂ ZIYAL M Phil AFBPsS C PsycholChartered Consultant Clinical Neuropsychologist

31 03 2010

3 ILLUSTRATIVE CASE STUDY3 ILLUSTRATIVE CASE STUDY

HistoryLate 40s sustained severe head injury in age 16. Depressed right frontal skull fracture. unconscious for 6 weeks with slow recovery

DiagnosisOrganic personality disorder (F07.0)Frontal Lobe Syndrome (secondary to acquired brain injury)

Forensic historySexual offending history of dating back to age 21. Onset soon after head injury listed as a schedule 1 Offender

3 ILLUSTRATIVE CASE STUDY3 ILLUSTRATIVE CASE STUDY

AdmissionEarly 2008 on section 37 but this was allowed to lapse: currently informal

BehaviourDisplays of inappropriate sexual behaviours, making inappropriate sexual comments, touching females and wearing sexually revealing garments.

Intervention Intermittent forensic counselling aimed at inculcating in him the idea that he was a criminal and that any further offending would put him behind bars. This led to no significant reduction in his displays of unacceptable sexual behaviours

3 ILLUSTRATIVE CASE STUDYReferral to Clinical Neuropsychology and goals

3 ILLUSTRATIVE CASE STUDYReferral to Clinical Neuropsychology and goals

February 2009 Reduce inappropriate sexual behaviours totally

Consolidate the gains he makes during his stay

at the Unit

Facilitate his integration within a setting commensurate

with his progress and with his cognitive potential as

part of discharge planning

MethodologyConduct neuropsychological assessment

Develop formulation

Determine therapeutic strategy and criteria of success

Determine method of evaluation

3 ILLUSTRATIVE CASE STUDY3 ILLUSTRATIVE CASE STUDY

Clinical Neuropsychological assessment

CHART 1: COMPARISON OF COGNITIVE AND EXECUTIVE FUNCTIONS

0

20

40

60

80

100

perc

enti

le s

core

s

EXECUTI VE

COGNI TI VE

3 ILLUSTRATIVE CASE STUDYFormulation

3 ILLUSTRATIVE CASE STUDYFormulation

RTA – FRONTAL LOBE INJURY

AVALANCHE OF SEXUAL IMPULSES

IMPAIRED IMPULSE CONTROL RESPONSE INHIBITION RULE ATTAINMENT

3 ILLUSTRATIVE CASE STUDYTherapeutic strategy and criteria of success

3 ILLUSTRATIVE CASE STUDYTherapeutic strategy and criteria of success

Therapeutic strategyCorrective therapy of SOT individual format - CBT

CRt in information processing and Executive functions in group format

SR therapies in group format

Criteria of successZero display of sexual behaviours – behaviour charts

Development of insight – therapeutic assignments in SOT and SR

Increased competence in CRt – performance evaluation

3 ILLUSTRATIVE CASE STUDYIndividual CBT

3 ILLUSTRATIVE CASE STUDYIndividual CBT

Figure 1: Possible thought sequence triggered by an activating event

ACTIVATING EVENT

PROTECTIVE BEHAVIOURS

RULES

THIS IS DIFFERENT

IF NOT NOW WHENI AM DEPRIVED

INAPPROPRIATE BEHAVIOURS

3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes

3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes

CHART 01 'A': I NAPPROPROPRI ATE SEXUAL BEHAVI OURS J AN - J UN 2009

therapy begins end February 2009

0

1

2

3

4

SE

XU

ALL

Y

SU

GG

ES

TIV

E

CO

MM

EN

TS

TO

UC

H B

OT

TO

M

TO

UC

H H

AIR

NIP

PLE

TA

LK

WE

AR

ING

RE

VE

AG

AR

ME

NT

S

TO

UC

HH

AN

D

JAN

FEB

MAR

APR

JUNE

3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes

3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes

Figure 2: touching hand cognitive sequence

ACTIVATING EVENTS:1. ASKED TO HELP WITH

DINING ROOM 2. HANDED WIPING CLOTH

AUTOMATIC THOUGHTSI AM IMPORTANTTHEY NEED ME

SHE CAN TRUST ME TO DO ITSHE THINKS WELL OF ME

I AM GRATEFULI FEEL WARM TOWARDS HER

I WANT TO SHOW MY APPRECIATIONI WANT TO HOLD HER HAND

RULES/CONSEQUENCESUNAWARE

BEHAVIOURHOLDS HER HAND TOO LONG

3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes

3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes

0

1

2

3

4

5

6

7

8

9

JULY AUG SEPT OCT NOV DEC JAN FEB

CHART 02: ‘A’ INAPPROPRIATE SEXUAL BEHAVIOURS

JULY 2009 - FEBRUARY 2010

Standing too close to female

staff/attempting to touch

Brushing past / touching female

staff

Looking for long periods at female

staff

Complimenting female staff

Sexual comments/inappropriate

comments

Drawing sexually explicit pictures &

showing it to staff

Sleep walking in the Nude/Boxers

4 THE NEXT STEP IN THE DEVELOPMENT OF OUR PRACTICE4 THE NEXT STEP IN THE DEVELOPMENT OF OUR PRACTICE

Develop our work in awareness training

Improve change-readiness through the incorporation of Prochaska, Norcross & DeClemente’s 05-stage change theory

Improve engagement levels through incorporation of motivational interviewing

CASE STUDY OF PATIENT SK

By Tim Warren Assistant Psychologist

31st March 2010

SummarySummary

• Background of SK• History of SK• Injury Details• Post Injury• Admission to Elm Park• Treatment plan• Groups and therapy• Planning for Discharge• Questions

Patient Details:Patient Details:• SK• Gender: Male• Age: 57 years old• Profession: Milkman• Marital Status: Divorced• Children: 2 Daughters• Lives alone in a first floor flat• History of alcoholism

SK ChildhoodSK Childhood

• All normal Milestones Reached• Normal early childhood• Normal primary school education• Mother died during high school• Was bullied at high school• Reported to have fallen in with the

wrong crowd • No qualifications gained from high-

school

Injury DetailsInjury Details• Injury sustained on 09.06.2008 from a

fall down the stairs of his flat• GCS = 3• CT scan showed the following:

• Sub gleal haematoma in left occipital lobe• Contusions to right inferior frontal and temporal

lobes• Contusions to left temporal lobes• Evidence of traumatic subarachnoid blood in right

hemisphere• No mid-line shift or fracture to skull• Minimal cerebral swelling

• CT repeated several days later with no change.

Post injuryPost injuryBehaviours:• Sexual disinhibition• Physical aggression toward objects• Verbal aggression towards others• Prone to self harm • Suicidal ideationCognitive:• Dis-orientated to time and place• Confabulation and memory deficits• Lack of insight and awareness• Depression and anxiety

Admission To Elm ParkAdmission To Elm Park

• Admitted on 11/8/08• Baseline of Behaviours• Assessment of function

• Identify strengths and weaknesses

• Target areas of treatment

• Streamline into appropriate group for cognitive re-training

• Identify goals and care pathway

• Goal setting and planning MDT & SK

Treatment PlanTreatment PlanBehaviours:• Sexual comments – TOOTS and feedback

• Verbal Aggression – TOOTS and feedback

• Self Harm – One to One therapy

• Aggression against objects – Verbal de-escalation with feedback

• Positive Reinforcement of appropriate behaviours

Treatment plan (psychology)Treatment plan (psychology)Cognitive:

• Neuropsychological assessment• WAIS III

• WMS III

• WTAR

• DKEFS

• 1:1 therapy for anxiety and depression• Therapy for alcoholism• Cognitive re-training in groups• Unit sessions• Community access programme

Cognitive assessment (WAIS III):Cognitive assessment (WAIS III):

0

20

40

60

80

100

120

SCORE 95 91 100 86 107 86 88

CENTILE 37 27 50 18 68 18 21

FSIQ VIQ PIQ VCI POI WMI PSI

Cognitive function:Cognitive function:Summary:• SK is at the AVERAGE range of cognitive

function• His non-verbal abilities are significantly

superior to his verbal abilities• Significant impairment in working memory• His non-verbal abilities are significantly

higher than WTAR predicted scores

Memory assessment (WMS III)Memory assessment (WMS III)

0

10

20

30

40

50

60

70

80

90

100

Score 65 67 100 75 62 63 69 85

Percentile 1 1 50 5 1 1 2 16

AI AD ARD VI VD IM GM WM

Memory function:Memory function:

Summary:• Impairment in memory in both visual

and verbal modalities• Impaired immediate and delayed recall

of information• Impaired working memory confirmed• Average level of recognition memory• Results suggest a retrieval deficit

within memory function

Executive Function (DKEFS)Executive Function (DKEFS)Tests used: Trail Making, Verbal Fluency, Design

Fluency, Sorting Test (Free and recognition).

0

5

10

15

20

25

Score 6 3 7 5 8

Percentile 9 1 16 5 25

TM VF DF Sf Sr

Executive function continued:Executive function continued:

Summary:• On the baseline conditions SK’s

performance ranged between the 62nd to 38th percentile

• On the conditions designed to tap into executive function he ranged between the 16th and 1st percentile

• His performance was consistent with that of dysexecutive syndrome

• More pronounced in left frontal lobe abilities

Psychological Interventions:Psychological Interventions:

• Assessment showed no evidence of diffuse cognitive impairment

• Main areas of impairment are within the domains of Memory and executive function

• Put into Attention, Memory and Life Narrative groups

• 1:1 sessions for anxiety and memory strategies

SK Attention SK Attention

• Targeting: 1. Sustained

2. Selective

3. Alternating

4. Divided

• Exercises Auditory and Visual

• Accuracy Rating

• Self Rating

SK Attention:SK Attention:

Mean accuracy score across all attention exercises

4.2

4.3

4.4

4.5

4.6

4.7

4.8

4.9

1 2 3 4 5

Exercise number

scor

e Self mean

Obj mean

SK Memory:SK Memory:

• Develop insight through practice

• Understanding

• Internal strategies

• External strategies

• Ecological exercises

• 1:1 sessions feedback

SK Memory:SK Memory:Memory Percent Accuracy

69.6

82.5

60 65 70 75 80 85

NO STRATEGY

STRATEGY

SK Life NarrativeSK Life Narrative

• Means of linking self pre-injury to now

• Looking at attributes of person

• Linking attributes to behaviour

• Significant life events

• Developing insight into self

SK life narrative Example 1:SK life narrative Example 1:

• Identified self as Introverted, Flexible,

Belief focused and creative

• Didn’t organise or structure self

• Spare time Depression

Drinking

• Lead to significant sad events

SK Life narrative Example 1:SK Life narrative Example 1:

• Behaviour Experiment• What I feel when I have nothing

planned: Bored

Lonely• What I feel when I have things

structured and Planned:

Active

Engaged

Happier

SK Life Narrative Example 2:SK Life Narrative Example 2:

• Looking at core beliefs

• Early childhood

• Significant life event

• Leading to behaviour

• Altered core belief

Core BeliefCore Belief

Must be clean and presentable:

Mother / acceptance

Good behaviour

Life events:

Bullied at high school

Mothers death

Maladaptive core belief:

Not accepted if clean and presentable

Acceptance if rebellious & unstructured

“Wrong crowd”

Core belief continued:Core belief continued:

Maladaptive core belief: Need to be rebellious

Behaviour: Unkempt

Protective behaviours

Wrong crows

Drinking

Consequences: Loss of job

Loss of family

Challenging behaviour

Injury

InterventionIntervention• Change maladaptive core belief

Behaviour experiments

cumulative insight

cost benefit analysis

Therapeutic trust

• Alteration of core belief

Discharge Planning:Discharge Planning:• Identification of needs:

– Structured day

– Continuation of Alcohol therapy

– Need for check ups

– Care package

• Graded Discharge – Day visits home

– Over night stays

– Discharge

• Successful Discharge

Closing remarksClosing remarks

• Holistic approach

• Knowing patient

• Structure therapy

• Application to everyday

• Successful discharge