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Title: Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process


1
Roles of Neuropsychology and Psychology following
Positive TBI Clinical RemindersThe Evaluation
and Treatment Process
  • Rodney D. Vanderploeg, Ph.D.
  • Tampa VAMC
  • VA Psychology Leadership Conference/APA
  • May 18, 2007

2
Objectives
  • Provide an overview of the TBI Clinical Reminder
    screening process
  • Describe a model follow-up evaluation and
    treatment process
  • Describe when and how neuropsychological
    evaluations should be completed
  • Describe other roles of psychology following
    positive TBI Clinical Reminders

3
Although I love Harry Potter
4
There is No Magic!
5
And, things like this are Pseudo-Magic
Automatic Clock Drawing Test
6
If you want to know if someone had a Traumatic
Brain Injury (TBI)
  • ASK THEM
  • Did you experience a physical trauma or injury
    that resulted in your being
  • Knocked out / Rendered unconscious,
  • Dazed and confused for several minutes, and/or
  • With memory gaps for some or all of the immediate
    period after the event
  • If the answer is yes, then they had a TBI

7
TBI Screening Reminder
That is what the TBI Screening Reminder Does
  • April 2007

8
So, what really are the issues?
  1. Who has ongoing symptoms and problems?
  2. What are these symptoms and problems due to (TBI,
    PTSD, Depression, Anxiety, Somatoform Disorder,
    malingering, combinations of conditions)?
  3. What is the appropriate treatment for any
    identified problems/conditions?
  4. Who is responsible for providing the assessment
    and treatment?
  5. Who is responsible for coordinating this process?
  6. When should this be done locally, and when should
    it be done by regional specialists?
  7. What are the roles of psychology in points 3-6?

9
TBI Screening Reminder Functions
  • Identify possible OIF/OEF Participants
  • Confirm deployment to OIF/OEF Theatres of
    Deployment
  • Screen for TBI if deployed in OIF/OEF Theatres
  • Identify those with an OIF/OEF-related history of
    TBI

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12
Criteria for Severity of TBI
Mild Moderate Severe
LOC lt 30 min with normal CT /or MRI LOC lt 6 hours with abnormal CT /or MRI LOC gt 6 hours with abnormal CT /or MRI
GCS 13-15 GCS 9-12 GCS lt 9
PTA lt 24hr PTA lt 7days PTA gt 7days
Dont confuse combat-trauma psychological
confusion with post-TBI PTA (i.e., inability to
lay down new memories and therefore having
post-TBI memory gaps)
13
Screening Questions4 Sections
  • Section 1 Trauma Events
  • Section 2 Immediate Disturbance of Consciousness
    Symptoms after Events
  • Section 3 New or Worsening Symptoms after the
    event
  • Section 4 Current Symptoms

14
Screen Interpretations
  • A no response to any of the sections terminates
    screening and is a negative screen
  • A yes response to ALL FOUR sections is a
    positive screen

15
Section 1 Trauma Events
16
Section 2 Immediate Symptoms
17
Section 3 New/Worsening Symptoms
18
Section 4 Current Symptoms
19
Positive TBI Screen Follow-up
  • Positive replies in all four sections constitute
    a positive screen
  • Positive screens automatically generate a consult
    to a TBI specialist or clinic
  • This specialist/clinic has 1 week to initiate
    contact with patient for more detailed follow-up
    evaluation
  • Initial treatment trial is based on positive
    problems on this follow-up evaluation

20
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21
What to Know Relevant Background (1)
  • Mild TBI Symptoms
  • There is no symptom that is unique to or
    diagnostic of mild TBI
  • Many postconcussion symptoms occur in normal
    healthy individuals
  • All symptoms/problems overlap with one or more
    other conditions (PTSD, Depression, Anxiety,
    Chronic Pain, Somatoform Disorder, chronic health
    conditions)

22
What to Know Relevant Background (2)
  • In prospective cases (non-clinical, non-legal)
    virtually all symptoms of mild TBI resolve within
    1 - 3 months
  • Cognitive
  • Emotional
  • Physical
  • Yet, a subgroup (about 10-15) continue to
    experience a postconcussive syndrome
  • Psychological factors play a large role in
    symptom presence in this subgroup

23
What to Know Relevant Background (3)
  • In this subgroup (of about 10-15)
  • There is no relationship between symptom
    complaints and objective findings on
  • Neuropsychological Testing
  • Physical Examination
  • Neurological Examination
  • Again, this is because psychological factors play
    a large role in symptom complaints

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25
Psychological Contributions
26
Issue One
  • Who has ongoing symptoms and problems?
  • Anyone who responds positively to all four of the
    TBI Clinical Reminder sections
  • Section 1 Trauma Event(s)
  • Section 2 Immediate Disturbance of Consciousness
    after Event(s)
  • Section 3 New or Worsening Symptoms after the
    event(s)
  • Section 4 Current Symptoms

27
Issue Two Symptom Etiologies
  • 2. What are these symptoms and problems due to
    (TBI, PTSD, Depression, Anxiety, Somatoform
    Disorder, malingering, combinations of
    conditions)?
  • Initial post-TBI Clinical Reminder Assessment (at
    Tampa and elsewhere)
  • Telephone Administration of
  • History Questions (e.g., confirmation of
    exposure, details of TBI severity, history of
    symptom course), Review of bodily systems and
    associated complaints, etc.
  • Neurobehavioral Symptom Inventory (22 items
    rating postconcussive symptoms)
  • PTSD Checklist (PCL)
  • Pain symptoms

28
Issue Two Symptom Etiologies
  • Interpretation of Initial Assessment Findings
  • What are the most likely etiologies for the
    symptoms?
  • What etiology(s) is/are primary?
  • (Does PTSD, chronic pain, sleep disturbance
    likely explain the cognitive symptoms?)
  • Would successful treatment of the primary
    etiology likely resolve most or all of the
    symptoms?
  • Referring and Triaging
  • Refer accordingly for further evaluation and/or
    treatment

29
Issue Two Symptom Etiologies
  • When to Refer
  • Refer if the evaluation/referral will
  • Tell you something you dont already know
  • Make a difference in the patients treatment or
    management

30
Turning Down a Consult for Neuropsychological
Assessment
  • Referral received and chart reviewed. Veteran
    currently has severe symptoms of PTSD and chronic
    headaches. Given this, his cognitive complaints
    of memory and concentration problems are
    expected. If testing were performed in this
    situation, any cognitive impairments would likely
    be attributed to the severity and extent of the
    mental health problems. Testing would not
    clarify diagnostic issues nor guide treatment --
    because mental health and pain management
    treatment should to be the main focus at this
    time.
  • Once his mental health and pain symptoms are
    better managed, and rated as no worse than mild
    to moderate, if cognitive symptoms remain, a
    re-referral at that time may be clinically useful.

31
Issue Two Symptom Etiologies
  • Follow-up Additional Specialized Assessments (and
    then treatment)
  • TBI PNS or PSCT
  • (PMR, (Neuro)Psychology, Speech, Psychiatry)
  • PTSD PTSD Program
  • Chronic Pain Pain Program or PMR
  • Somatoform Disorder(s) ?????
  • Depression, Anxiety, Stress MHC
  • Seizures, Neurologic Conditions Neurology

32
Issue Three Appropriate Treatment(s)
  • Treat the primary condition(s), the one(s) that
    explains most or all of the symptoms
  • Dont invest time and effort in conditions that
    account for only small amounts of symptom
    variance
  • Just because a condition was/is present (e.g.,
    history of mild TBI), doesnt mean it should be
    the focus of further assessment or treatment if
    other conditions are primary

33
PTSD Re-experiencing
Avoidance Social withdrawal Memory gaps Apathy
Arousal Sensitive to noise Concentration Insom
nia Irritability
? Mild TBI Residual
Difficulty with decisions Mental
slowness Concentration Headaches Dizzy Appetite
changes Fatigue Sadness
Depression
34
Issue Four Who is Responsible?
  • TBI Clinical Reminder Primary and Specialty
    Clinics (including Urgent Care, MHC, PTSD,
    Dental, etc.)
  • Initial Follow-up Assessment
  • Polytrauma Program staff
  • (Level II PNS or Level III PSCT),
  • SCI Program staff, or
  • Local Designated Specialist(s) - Physician
  • (e.g., Neurologist, PMR physician)

35
Issue Four Who is Responsible? (cont.)
  • Subsequent Evaluations/Treatments
  • TBI PNS or PSCT
  • (PMR, (Neuro)Psychology, Speech, Psychiatry)
  • PTSD PTSD Program
  • Chronic Pain Pain Program or PMR
  • Somatoform Disorder(s) ?????
  • Depression, Anxiety, Stress MHC
  • Seizures, Neurologic Conditions Neurology

36
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39
Issue Five Coordination of Care
Responsibilities
  • If a Level I, II, or III Polytrauma Program, then
    the polytrauma team
  • If not, the system is not clear who is
    responsible for making sure evaluations are
    completed, treatments are initiate, and
    symptoms/problems are resolving
  • But, if treatment is not successful within a
    reasonable time (e.g., 90 days), patients should
    to be referred to a PNS or PRC

40
Issue Six Local versus Regional Care
  • If the facility has a designated TBI specialist
    who is assigned to respond to the TBI Clinical
    Reminders, then initial assessment and treatment
    should be local
  • If not, assessment should be done by the nearest
    PNS or PSCT staff
  • If that assessment indicates that local resources
    can provide the treatment, fine if not, and the
    problems are deemed to be TBI-related, then the
    nearest PNS

41
Issue Seven Role(s) of Psychology /
Neuropsychology
  • Members of the PNS or PSCT staff
  • Assessment and treatment if indicated
  • Neuropsychological Evaluations (15 of cases)
  • Psychological Assessments (15-75 of cases)
  • TBI Rehab Interventions
  • Mild TBI Education Support
  • Compensatory Training / Cognitive Remediation
  • Stress Management, Education, Support
  • Specialty Treatment
  • PTSD, Depression, Anxiety, Chronic Pain

42
  • Important Mild TBI Facts

43
Causes of Persistent Postconcussion Symptoms
44
Expectation as Etiologyand/orThe Good Old
Days
  • Symptom Mis-Attribution
  • Willey Mittenberg, Ph.D.
  • Diagnostic Threat
  • Julie Suhr, Ph.D.

45
Expectation as Etiology
  • Controls asked to imagine symptoms of a mild TBI
    expected symptom presence and severity very
    similar to mild TBI patients actual symptoms
  • Mild TBI patients under-estimated the frequency
    and severity of pre-MTBI symptoms and problems
  • Athletes expected lower levels of
    post-concussion problems than non-athletes
  • Athletes with a concussion over-estimated
    pre-concussion levels of symptoms

46
Mild TBI Diagnostic Threat
  • Non-clinical evaluations of college students with
    a remote history of mild TBI (many months
    earlier)
  • Neuropsychological Test Performance
  • If told they are participating in a study of the
    effects of mild TBI, their performance is worse
    than,
  • If told they are simply participating in a study
    of cognitive functioning in college students
  • The context of the evaluation matters!

47
Mild TBI Treatment
  • Change expectation and attribution of symptoms
  • Provide education
  • Education regarding mild TBI
  • Education regarding symptoms and their course
  • Provide Support/Treatment
  • Stress management
  • Psychological and cognitive coping strategies and
    resources
  • Cognitive-Behavioral therapy

48
If There is Timewhich there will not be
49
What to ExpectLiterature Review Findings
  • Mild TBI Findings
  • Neuropsychological Test Performance
  • Postconcussion Symptoms
  • Causes of Postconcussion Symptoms
  • Treatment of Mild TBI

50
Neuropsychological Test Performance
51
Mild TBI Neuropsychological Meta-analytic
Studies (1)
  • (Schretlen Shapiro, 2003)
  • A second recent meta-analytic study found that
    overall neuropsychological effect size (d) for
    MTBI in prospective studies was 0.24
  • Categorized into 4 time-since-injury intervals
    the effect sizes were

lt 7 days 7-29 days 30-89 days gt 89 days
0.41 0.29 0.08 0.04

52
Mild TBI Neuropsychological Meta-analytic
Studies (2)
  • (Belanger, Curtiss, Demery, Lebowitz,
    Vanderploeg, in press)
  • A third recent meta-analytic study found the
    following, categorized into two time-since-injury
    intervals and three types of studies

Time Post-Inj. Litigation Based Clinic Based Unselected Samples
lt 90 days 0.52 No studies 0.63
gt 90 days 0.78 0.74 0.04

53
Vietnam Experience Study (VES)
Neuropsychological and Postconcussive Symptom
Findings
54
Subjects
  • Vietnam Experience Study Data/Center for Disease
    Control Vietnam Experience Study 1988a, 1988b
    JAMA
  • 4,462 randomly selected male US Army vets
  • (community dwelling, not clinic-referred or
    self-referred)
  • Entered military between 1/65 - 12/71
  • Minimum of 4 months active duty
  • Served only one tour of duty

55
Subjects contd
  • Racial makeup of the 4,462 participants
  • 81.9 Caucasian
  • 11.8 African-American
  • 4.5 Hispanic
  • 1.9 Other
  • Mean age 38.36 years (SD 2.53)
  • Mean level of education 13.29 years (SD 2.3)
  • Mean IQ 105 (SD 20.32) (based on GTT)

56
Subjects contd
  • Participants underwent a 3 day evaluation
    including
  • extensive medical, psychological, and
    neuropsychological examination
  • included were questions regarding MVA, head
    injury, loss of consciousness, and subsequent
    hospitalization
  • Evaluations took place approximately 16 years
    post-military discharge

57
Measures
  • Diagnostic Interview Schedule (DIS-III-A)
  • Extensive surveys of physical functioning and
    symptoms
  • Battery of neuropsychological tests

58
Groups and Sample Sizes
59
Neuropsychological Measures
  • Multivariate analysis of variance (MANOVA) was
    conducted with 14 neuropsychological measures,
    which cover the domains of
  • Complex Attention
  • Psychomotor Speed Coordination
  • Verbal Abilities
  • Executive Abilities
  • Non-Verbal Abilities
  • (visuospatial)
  • Verbal Memory
  • Visual Memory

60
Statistical AnalysesNeuropsychological
Measures(Matching groups on premorbid IQ)
  • MANOVA was not significant
  • F(30,7620) 1.28, p 0.14,
  • eta squared 0.005
  • On average, the MTBI group performed 0.03 of a
    standard deviation more poorly than either
    control group

61
Current Cognitive FunctioningExamples of the 14
Measures
62
Postconcussion Symptoms
63
Postconcussion Symptoms
  • Physical
  • Headache, dizziness, fatigue, noise/light
    intolerance, insomnia
  • Cognitive
  • Memory complaints, poor concentration
  • Emotional
  • Depression, anxiety, irritability, mood lability

64
PCS Diagnostic Criteria
  • ICD-10
  • Three or more of
  • Headache, dizziness, malaise, fatigue, or noise
    intolerance
  • Irritability, depression, anxiety, or emotional
    lability
  • Subjective concentration, memory, or
    intellectual difficulties
  • Insomnia or affective lability
  • DSM-IV
  • Three or more of
  • 1. Fatigue
  • 2. Disordered Sleep
  • 3. Headache
  • 4. Dizziness
  • 5. Irritability
  • 6. Anxiety, depression,
  • or affective lability

65
Odds-Ratios for Occurrence of the Postconcussion
Symptom Complex over Past Year (Controlling for
Demographics, Medical, Prior Psychiatric
Symptoms)
Diagnosis Normal Control MVA Control Mild TBI
DSM-IV Postconcussion Syndrome 1.0 (20.6) 1.04 (0.82 - 1.31) (25.2) 2.00 (1.49 - 2.69) (40.9)
ICD-10 Postconcussion Syndrome 1.0 (19.1) 1.13 (0.90 - 1.44) (24.9) 1.80 (1.33 - 2.43) (37.4)
66
Odds-Ratios for Various Physical/Neurological
Postconcussion Symptoms During the Past Year
(Controlling for Demographics, Medical, Prior
Psychiatric Symptoms)
Symptom Normal Control MVA Control Mild TBI
Balance Problems 1.0 (3.4) 1.58 (1.02 2.45) 2.43 (1.48 3.97)
Sensitivity to Light 1.0 (3.6) 1.14 (0.72 1.80) 1.92 (1.15 3.20)
Headache Problems 1.0 (13.0) 1.15 (0.89 1.50) 1.94 (1.42 2.68)
Trouble Sleeping 1.0 (24.9) 1.22 (1.01 1.51) 1.85 (1.39 2.45)
Double Vision 1.0 (5.7) 1.10 (0.75 1.61) 1.81 (1.17 2.79)
Fatigue Easily 1.0 (20.9) 1.00 (0.80 1.26) 1.42 (1.05 1.91)
67
Odds-Ratios for Various Cognitive/Neuropsychologic
alPostconcussion Symptoms During the Past
Year(Controlling for Demographics, Medical,
Prior Psychiatric Symptoms)
Symptom Normal Control MVA Control Mild TBI
Periods of Memory Loss or Confusion 1.0 (4.4) 1.14 (0.76 1.72) 2.80 (1.83 4.28)
Memory Problems 1.0 (13.7) 1.13 (0.87 1.46) 1.75 (1.28 2.41)
Concentration Problems 1.0 (13.4) 1.40 (1.10 1.80) 1.28 (0.91 1.80)
68
Odds-Ratios for Various Emotional/PsychologicalPo
stconcussion Symptoms During the Past
Year(Controlling for Demographics, Medical,
Prior Psychiatric Symptoms)
Symptom Normal Control MVA Control Mild TBI
Irritability or Short Temper 1.0 (26.5) 1.10 (0.89 1.35) 1.36 (1.02 1.81)
Aggressive and Angry Behavior 1.0 (10.2) 1.34 (1.02 1.77) 1.32 (0.91 1.91)
Sadness and Depression 1.0 (11.2) 1.28 (0.97 1.69) 0.92 (0.62 1.37)
Anxious 1.0 (13.8) 1.29 (0.99 1.65) 1.10 (0.77 1.56)
69
Causes of Persistent Postconcussion Symptoms
70
Expectation as Etiologyand/orThe Good Old
Days
  • Symptom Mis-Attribution
  • Willey Mittenberg, Ph.D.
  • Diagnostic Threat
  • Julie Suhr, Ph.D.

71
Expectation as Etiology
  • Controls asked to imagine symptoms of a mild TBI
    expect symptom presence and severity very
    similar to mild TBI patients actual symptoms
  • Mild TBI patients under-estimate the frequency
    and severity of pre-MTBI symptoms and problems
  • Athletes expect lower levels of post-concussion
    problems than non-athletes
  • Athletes with a concussion over-estimate
    pre-concussion levels of symptoms

72
Mild TBI Diagnostic Threat
  • Non-clinical evaluations of college students with
    a remote history of mild TBI (many months
    earlier)
  • Neuropsychological Test Performance
  • If told they are participating in a study of the
    effects of mild TBI, their performance is worse
    than,
  • If told they are simply participating in a study
    of cognitive functioning in college students
  • The context of the evaluation matters!

73
Other Factors Influencing the Development and
Persistence of Persistent Postconcussion Symptoms
74
Predictors of Persistent PCSVietnam Experience
Study Data
  • Examine the influence of the following predictors
    on the presence of a persistent Postconcussion
    Symptom Complex (PPCS) following mild head injury
  • Predictors
  • demographic variables
  • early life psychiatric difficulties
  • social support variables
  • loss of consciousness

75
Results
  • Overall model was significant MTBI
  • R2 33.0
  • MTBI ?2 (26, N 532) 137.85, p lt
    .001
  • Unique Variance per predictor MTBI
  • demographic variables (9.2)
  • early life psychiatric symptoms (6.3)
  • Internalizing (e.g., depression/anxiety) (4.9)
  • Externalizing (ASP, alcohol, drugs) (0.9)
  • social support (4.9)
  • LOC / MVA (1.4)
  • 2-way Interactions (5.4)
  • 3-way Interactions (0.1)

76
Contribution of Demographic Variables in MTBI
  • MTBI
  • Overall Demogr. Variance 9.2
  • unique variance
  • Variable MTBI
  • Age at evaluation 0.9
  • Level of education 0.2
  • Race 0.3
  • Intelligence 3.3

77
MTBIIntelligence by LOC (1.8)
78
MTBIIntelligence by Social Support (1.2)
79
MTBIInternalizing by Social Support (1.0)
80
PCS Conclusions
  • LOC is only a small factor in predicting the
    presence of PPCS (1.4 unique variance) in MHI
  • Multiple factors and their interactions accounted
    for approximately 33 of the variance in PPCS
    status in the sample with MHI

81
PCS Conclusions
  • Within a MTBI sample
  • Lower pre-injury intellectual ability,
  • Less poor social support, and
  • More early life emotional problems (e.g.,
    depression, anxiety)
  • were associated with higher frequencies of
    Persistent PCS
  • Loss of consciousness (MTBI) interacts with
    cognitive reserve in influencing the development
    or persistence of PCS

82
Treatment of Mild TBI
83
Mild TBI Treatment
  • Change expectation and attribution of symptoms
  • Provide education
  • Education regarding mild TBI
  • Education regarding symptoms and their course
  • Provide Support/Treatment
  • Stress management
  • Psychological and cognitive coping strategies and
    resources
  • Cognitive-Behavioral therapy

84
References
  • Belanger, H. G., Curtiss, G., Demery, J. A.,
    Lebowitz, B. K., Vanderploeg, R. D. (2005).
    Factors moderating neuropsychological outcomes
    following mild traumatic brain injury A
    Meta-analysis. Journal of the International
    Neuropsychological Society, 11, 215-227.
  • Belanger, H.G., Vanderploeg, R.D. (2005). The
    Neuropsychological Impact of Sports-Related
    Concussion A Meta-Analysis. Journal of the
    International Neuropsychological Society, 11,
    345-357.
  • Luis, C. A., Vanderploeg, R. D., Curtiss, G.
    (2003). Predictors for a postconcussion symptom
    complex in community dwelling male veterans.
    Journal of the International Neuropsychology
    Society, 9, 1001-1015.
  • Miller, L.J. Mittenberg, W. (1998). Brief
    cognitive behavioral interventions in mild
    traumatic brain injury. Applied Neuropsychology,
    5, 172-183.
  • Mittenberg, W., Tremont, G., Zeilinski, R.,
    Fichera, S., Rayls, K. (1996). Cognitive
    behavioral prevention of postconcussion syndrome.
    Archives of Clinical Neuropsychology, 11,
    139-145.
  • Mittenberg, W., Zielinski, R.E., Fichera, S.
    (1993). Recovery from mild head injury A
    treatment manual for patients. Psychotherapy in
    Private Practice, 12, 37-52.

85
References
  • Schretlen, D. J., Shapiro, A. M. (2003). A
    quantitative review of the effects of traumatic
    brain injury on cognitive functioning.
    International Review of Psychiatry, 15, 341-349.
  • Suhr, J.A. Gunstad, J. (2005). Further
    exploration of the effect of diagnosis threat
    on cognitive performance in individuals with mild
    head injury. Journal of the International
    Neuropsychological Society, 11, 23-29.
  • Vanderploeg, R. D., Curtiss, G., Belanger, H.
    G. (2005). Adverse long-term neuropsychological
    outcomes following mild traumatic brain injury.
    Journal of the International Neuropsychological
    Society, 11, 228-236.
  • Vanderploeg, R.D., Belanger, H.G., Curtiss, G.
    (2006). Mild Traumatic Brain Injury Medical and
    Neuropsychological Causality Modeling. (pp.
    279-307). In Young, G., Kane, A. Nicholson, K.
    (Eds.), Psychological Knowledge in Court PTSD,
    Pain and TBI. New York Springer-Verlag.
  • Vanderploeg, R.D. (2004). Veterans Health
    Initiative Traumatic Brain Injury. (Editor). VA
    Employee Education System. Web-based physician,
    psychologist, other health care professionals
    CME/CEU training program. http//www1.va.gov/vhi/
    docs/TBIfinal_www.pdf 1-31-04
  • Vanderploeg, R. D., Curtiss, G., Luis, C. A.,
    Salazar, A. M. (in press). Long-term morbidity
    and quality of life following mild head injury.
    Journal of Clinical and Experimental
    Neuropsychology.
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