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Behaviors Following Brain Injury
BIAMI Fall Conference 26 September 2013
Ray Kamoo, Ph.D., LP
Pinnacle Rehabilitation, Inc.
What We Will Cover Today TBI demographics Brain anatomy and physiology Intervention in the treatment of TBI Consequences of TBI Challenging behaviors Psychological impact Specialized treatment Discharge planning Implications with regards to future planning
Demographics CDC estimates 5.3 million Americans live with
disabilities resulting from TBI Each year 1.7 million people sustain a TBI Risk of TBI is highest among children 0 – 4 years of
age, older adolescents , and those older than 65 In 2000, cost > $60 billion Higher for males than females Although falls are leading cause of TBI, motor
vehicle-traffic injury is leading cause of TBI-related death
Survival rates have improved due to improved care
Causes of Injury The most common causes of TBI:
Falls (35%) Motor vehicle-traffic crashes (17%) Being struck by or against an object (16%) Assaults (10%)
Blasts are a leading cause of TBI for active duty military personnel in war zones
Two types of injury can occur
Open head injury
Closed head injury
Open head injury
Results from bullet wounds, etc. Largely focal damage Penetration of the skull Effects can be just as serious as in a
closed head injury
Closed head injury
Resulting from falls, motor vehicle crashes, etc.
Focal damage and diffuse damage to axons
Effects tend to be broad (diffuse) No penetration to the skull
Neuroanatomy
The Frontal Lobe The frontal lobe is the area of the brain responsible for our “executive skills” - higher cognitive functions.
These include:
• Problem solving • Spontaneity • Memory • Language • Motivation • Judgment • Impulse control • Social and sexual behavior.
Frontal Lobe
Observed Problems: Inability to plan a sequence of
complex events Loss of flexibility of thinking Mood changes Difficulty with problem solving
Prefrontal Cortex The prefrontal cortex is involved with intellect, complex learning, and personality.
Injuries to the frontal lobe can cause mental and personality changes.
Temporal Lobe The temporal lobe plays a role in emotions, and is also responsible for smelling, tasting, perception, memory, understanding music, aggressiveness, and sexual behavior.
The temporal lobe also contains the language area of the brain.
Temporal Lobe Observed Problems:
Difficulty in recognizing faces (prosopagnosia)
Difficulty with identification of and verbalization of objects
Increased aggressive behaviors
Parietal Lobe The parietal lobe plays a role in our sensations of touch, smell, and taste. It also processes sensory and spatial awareness, and is a key component in eye-hand co-ordination and arm movement.
The parietal lobe also contains a specialized area called Wernicke’s area that is responsible for matching written words with the sound of spoken speech.
Parietal Lobe Observed Problems:
Inability to attend to more than one object at a time
Inability to name an object (anomia) Inability to locate the words for writing
(agraphia) Problems with reading (alexia) and
math (dyscalculia)
Occipital Lobe
The occipital lobe is at the rear of the brain and controls vision and recognition.
Occipital Lobe Observed Problems:
Visual difficulties (visual field cuts) Difficulty in identifying colors
(color agnosia) Inability to recognize words (word
blindness) Problems with reading and writing
How do we Measure Severity? Duration of loss of consciousness Initial score on Glasgow Coma Scale (3
to 15) Length of post-traumatic amnesia Rancho Los Amigos Scale (1 to 10) Done in a hospital setting
Neuropsychological Tests Wechsler Adult Intelligence Scale-IV Wechsler Memory Scale-IV Minnesota Multiphasic Personality Inventory (MMPI-2RF) North American Adult Reading Test Symbol Digit Modalities Test Wisconsin Card Sorting Test Wide Range Achievement Test Category Fluency Trails A & B Symptom Checklist - 90
Common Neurobehavioral Deficits/Disorders
Post-concussion syndrome: Set of symptoms occurring in loose cluster following mild (sometimes moderate) TBI: Headache Dizziness Irritability Difficulty concentrating Impairment of memory Insomnia Reduced tolerance for stress, emotional excitement,
and alcohol
Frontal lobe syndromes
Common Neurobehavioral Deficits/Disorders (cont’d)
Frontal lobe syndromes Behavioral/Personality changes Cognitive (intellectual) deficits Mood disorders Sleep disorders Post traumatic epilepsy or seizures Chronic pain
Behavioral/Personality Changes Ö Exaggeration of premorbid negative personality
traits Ö Impulsivity Ö Aggression Ö Disinhibition Ö Poor judgment Ö Risk taking Ö Sexual disturbances
These behavioral issues can greatly affect the ability to resume community activities (work, school, independent living) and can interfere with relationships
Problems with �Behavioral Regulation
Patients may experience impaired initiation after TBI, having trouble getting started with things even if expressing an interest in engaging in activities.
Often misinterpreted as “laziness” or “noncompliance” by family members or caregivers, can be a significant source of stress.
However, initiation difficulties can occur as a result of damage to neural systems involved in activating motor sequences and are not a deficit of motivation.
Problems with �Behavioral Regulation (cont’d)
Inappropriate behaviors may occur, often due to disinhibition
Examples include: Asking casual acquaintances or strangers overly personal
questions (e.g., about finances or sexual issues) Disclosing overly personal information to others Engaging in inappropriate activities (e.g., childlike behaviors or
sexual behaviors)
Such problems are often very stressful for family members, friends, and caregivers
Anger and aggression People often report having a “shorter fuse” after TBI
Increased irritability noted for persons with all levels of injury severity
Violent behavior is rare, but can occur
More commonly, verbal and sometimes physical outbursts occur
Impaired Self-Awareness (ISA) Impaired Self-Awareness is different than denial
Denial: person is aware at some level that problem exists but uses defense mechanisms to deny the problem
ISA: person does not realize that a problem is present or is unaware of how problems might impact their ability to perform daily tasks.
As direct result of TBI, some individuals have difficulty seeing themselves and their abilities and behaviors accurately.
Problems with ISA are associated with: Poor treatment compliance Longer rehabilitation stays Increased caregiver distress Poorer vocational outcomes
Sexual Dysfunction Problems with sexual functioning and/or intimacy issues
are not uncommon among persons with TBI Although typically not addressed during medical
appointments, including a standard question or questions about sexual functioning may be important (especially if other factors such as prescription medications or depression may impact sexual functioning)
More common problems after TBI include: Diminished libido Decreased frequency of intercourse Difficulty achieving/maintaining erection or arousal Difficulty reaching orgasm
Sexual Dysfunction (cont’d) Much less commonly reported include:
Hyper-sexuality Problem sexual behaviors (e.g. exhibitionism,
public or frequent masturbation, promiscuity, sexual aggressiveness)
Sexual problems not limited to those with moderate/severe TBI, but may occur in those with mild TBI as well
Substance Use & Abuse Likelihood of confronting issues related to alcohol or other
substance use is high May be a pre-injury issue and often related to cause of injury Can also be a post-injury issue Alcohol and substance use/abuse associated with poorer outcomes Pre-injury abuse in patients with TBI is common Pre-injury history of alcohol abuse related to:
Higher mortality Greater frequency of mass lesions Poorer neuropsychological functioning acutely and at 1-year
follow-up Poorer global outcome
Substance Use & Abuse (cont’d)
If TBI occurred as result of alcohol intoxication, patient has a 4-fold increased risk of sustaining a second TBI
Substance use may have greater effect on cognition and judgment than may have been the case prior to injury
Highly problematic for patients with poor insight, reasoning, and judgment who become even more impaired while drinking or using illegal drugs
Mood Disorders Ö May not meet traditional “psychiatric” criteria Ö Patients will show features of several disorders; don’t
equate symptoms with diagnosis Ö Subtle symptoms of mania and depression
Ö Irritability Ö Uncooperativeness Ö Apathy Ö Poor progression or effort in rehabilitation
Depression Depression is the most common affective disturbance after
TBI and incidence rates far exceed those of community base rates
Depression also contributes to functional impairment and quality of life for those with TBI
Depression after TBI can exacerbate TBI-related cognitive impairments (e.g., attention, memory, etc.)
Diagnosis of depression post-TBI can be complicated as sequelae of TBI can lead to overdiagnosis or underdiagnosis
Changes in sleep, libido, fatigue, concentration, and memory may be direct result of injury and not a symptom of depression but overlap can lead to overdiagnosis
Poor self-awareness after TBI can lead to underreporting of symptoms contributing to underdiagnosis
Posttraumatic stress disorder (PTSD)
Diagnosis of PTSD in patients with TBI is controversial since concern over whether patients with no memory of circumstances around the traumatic event could develop features and meet criteria for PTSD (frequent re-experiencing of event unlikely to occur)
Evidence exists that PTSD can develop in a patient with TBI severe enough to result in period of amnesia surrounding the traumatic event
Generalized anxiety disorder is possibly the most common type of anxiety disorder diagnosed following TBI
PTSD (cont’d) Features of PTSD overlap with post-concussion syndrome:
Feeling of anxiety Disordered sleep Concentration difficulties Irritability/anger outbursts Trouble recalling important details of traumatic event Diminished interest or participation in significant activities Feelings of detachment from others
Specific features of PTSD for patients with TBI include: More common in patients who deny loss of consciousness Women are over-represented among those with TBI and PTSD
Patients with TBI are less likely to report re-experiencing phenomena
Suicide and TBI 17% of the individuals with TBI report suicidal thoughts,
plans and attempts in a five year post-injury period Majority of the individuals with suicidal thoughts/plans/
attempts are male, with ages 25-35 at the greatest risk. Males 65+ are the number two risk group Hopelessness is a key factor in suicidality Comorbidity with a psychiatric diagnosis or substance
abuse problem was a common factor Role of identity crisis and social disruption Risk increases in the first 15 year period post injury
A Model for Understanding Suicide Self worth vs. worthlessness Hopelessness/depression/despair Anger/Hostility Plan Method Access Previous history of suicidal thoughts and attempts Capacity to act on plan Social withdrawal In TBI cases, impulsivity is an important factor
Cognitive Deficits Generally, common nonspecific symptoms are
disturbances in arousal, attention, and concentration Depends on location and severity of injury
Poor planning Trouble shifting between tasks Memory impairments Trouble organizing thoughts Become easily confused Judgment is often affected
Communication Problems Word-finding difficulty Poor sentence formation Lengthy descriptions or explanations
Difficulty understanding multiple meanings in jokes, sarcasm, and figures of speech
Tangential or circumstantial speech Patients often unaware of their errors
Psychotherapy Needs to be implemented right after the injury Most likely will have a cognitive behavioral
approach Identify with the patient what the most pressing
issues are Build in realistic expectations Must be structured, supportive and problem
solving How will significant others play a role in the
patient’s rehabilitation
Psychotherapy (cont’d) Make patient aware of new limitations Help them to accept new limitations Debunk the myth that “recovery occurs within
one year” Address the Lourdes Phenomenon – May lead to
doctor hopping or program hunting Look at the role of medications in helping to
alleviate psychological pain
Brain Injury Rehabilitation Broadly encompasses re-entry into familial, social,
educational and working environments, as well as the reduction of dependence on assistive devices and services
Two essential processes or tracks Restoration of functions Learning how to do things differently when
functions cannot be restored to pre-morbid or pre-injury levels
Brain Injury Rehabilitation (cont’d)
Best treated early Neuropsychological testing to help determine areas
of deficit and degree of impairment Treatment plan to note practical and realistic goals
and objectives for the intervention Consistent degree of intervention
What Works? Gradual step-by-step therapy Eclectic treatment Prosthetic devices Academic remediation Functional skills training Individualized mnemonics Changing life-long habits Creating incentives and personal
relevance of treatment
What Works? (cont’d) Rehearsal training Group therapy Social skills integration training Nonverbal perception Concept communication Psychosocial memory skills
Mnemonics and Imagery Idea: Facilitate cuing and memory retrieval Training: Provide or develop memory cues Result: Unique mnemonics that solve a specific problem work best Applications: Work, ADLs, Academics, Training.
Working Memory Exercises Making change mentally Solving anagrams Estimating costs and benefits Playing logical memory rehearsal game Scenario generation game
Decision Making D o not procrastinate – Decide to begin E valuate your options – choose those that are WIN-WIN C reate new options when others won’t do I nvestigate existing policies – limit what you choose D iscuss the decision with others – listen to their advice E valuate your feelings – before acting think twice
Social Skills Training Idea: Practice appropriate social behavior Training: Voice inflections, facial expression, body
language, time management, social memory Result: Improved social acceptance Applications: Family, work, training.
What Does Not Work? Doing nothing Short-term treatment Most stimulation therapies Most insight oriented psychotherapies Forcing clients to do things your way Inappropriate residential placement
Apartment vs. home Semi-independent vs. fully staffed
Inappropriate treatment facility Individualized services (per treatment plan) Experience with TBI patients
Understanding Change Cognitive problems, behaviors, and personality traits
change over time Recovery evolves at a different pace for everybody;
many interacting factors affect this After returning to “daily life”:
Reduced cognitive efficiency Inconsistency of performance Difficulty dealing with novel or stressful situations
Measures of Efficacy or Success �(Yes, they are needed)
Functional Improvement – client defined Return to Home or placement in setting of choice Cost Benefit - insurance Return to Work Standardized testing, inventories and scales
Interval testing Goal attainment from treatment plan
Quality of Life RIC-FAS (Rehabilitation Institute of Chicago-Functional
Assessment Scale) – ordinal scale items used to measure various areas of functioning across many disciplines
Further Services/Treatment Neuropsychological and clinical testing Treatment plans (updates too) Behavioral monitoring
Behavior analysis Structured environment
Didactic services for family, friends, and significant others Support group Peer group
Vocational Sheltered workshop Job shadowing Volunteering Competitive employment
Communication – Making it Work
TBI Patient
Therapists
Nurse Case Manager
Other Professionals
Family
Goal – Integrated Patient
Pre-Morbid Functioning
Post-Injury Functioning
Patient
Thank You !!
