TBI and PTSD among OEF/OIF Veterans and UNC Cognitive Rehabilitation Research

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TBI and PTSD among OEF/OIF VeteransandUNC
Cognitive Rehabilitation Research

• James Wolfe, M.S., NCC
• Erin Clevenger, M.A.
• Eric B. Elbogen, Ph.D.
• UNC-Chapel Hill School of Medicine
• Dept. of Psychiatry

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Mental Health Needs of Iraq and Afghanistan
Veterans

• Over one million currently active military
  personnel have served in Operation Enduring
  Freedom (OEF) or Operation Iraqi Freedom (OIF)
• Estimates vary, but about 15-20 of troops
  returning show some symptoms of posttraumatic
  stress disorder (PTSD)
• 15-20 of all returning veterans have
  experienced some type of traumatic brain injury
  (TBI), often associated with IEDs (improvised
  explosive devices)
• Some veterans have both TBI PTSD

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Mental Health Needs Trend of PTSD Diagnoses
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Mental Health Trend of TBI Diagnoses
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Mental Health Needs of Iraq and Afghanistan
Veterans

• Both TBI and PTSD can lead to a lifetime
  reduction in social, cognitive, and vocational
  functioning
• The sooner the assessment of TBI and PTSD, the
  sooner rehabilitation plans can be implemented,
  which will dramatically improve effectiveness of
  these efforts
• One report indicated that more North Carolinians
  have served in Iraq and Afghanistan than any
  other state thus, we can anticipate a huge
  demand for allied health services in the upcoming
  decade

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What is TBI?

• Traumatic brain injury (TBI) occurs when a sudden
  trauma causes damage to the brain

TBI can result when the head suddenly and violently hits an object, penetrating to the brain, or simply causing impact between the skull and the brain
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What is TBI?

• TBI can also result from a blast. Shockwaves from
  explosions can damage the brain through the skull
  or can cause small objects such as shrapnel to
  pierce the head 

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What is TBI?

• A person with a mild TBI (mTBI) may remain
  conscious or may experience a loss of
  consciousness for a few seconds or minutes
• Other symptoms of mild TBI

Headache Confusion Lightheadedness Dizziness Blurred vision/tired eyes/sensitive to light Ringing in ears Trouble with memory/ concentration/attention Fatigue/lethargy Change in sleep pattern Mood/behavioral changes Bad taste in mouth
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What is TBI?

• A person with a moderate or severe TBI may show
  symptoms of mTBI as well as
• Worsening/persistent headache
• Nausea or vomiting
• Convulsions or seizures
• Inability to awaken from sleep
• Dilation of one or both pupils
• Slurred speech
• Weakness/numbness in the extremities
• Loss of coordination
• Increased confusion, restlessness, or agitation

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What is TBI?

• Prognosis of a TBI depends upon the severity of
  the injury, the location of the injury, and the
  age and general health of the person. Problems
  with the following are common
• cognition (thinking, memory, and reasoning),
• sensory processing (sight, hearing, touch, taste,
  and smell),
• communication (expression and understanding), and
  
• behavior or mental health (depression, anxiety,
  personality changes, aggression, acting out, and
  social inappropriateness).

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What is PTSD?

• PTSD first presumes that a person has experienced
  a traumatic event involving actual or threatened
  death or injury to themselves or others -- and
  where they felt fear, helplessness or horror.

• Diagnostic criteria Three symptom clusters must
  persist for more than a month after the traumatic
  event and cause clinically significant distress
  or impairment.

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What is PTSD?

• Symptom clusters of PTSD
• Intrusions - such as flashbacks or nightmares,
  where the traumatic event is re-experienced
• Avoidance - when the person tries to reduce
  exposure to people or things that might bring on
  their intrusive symptoms
• Hyperarousal - meaning physiologic signs of
  increased arousal, such as hypervigilance or
  increased startle response

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TBI/PTSD Overlap
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TBI/PTSD Overlap
Having trouble making plans, decisions,
learning new things
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How to Assess for TBI

• TBI is the result of an external force that is
  indicated by new onset or worsening of at least
  one of the following clinical signs, immediately
  following the event
• Any period of loss of or a decreased level of
  consciousness
• Any loss of memory for events immediately before
  or after the injury (posttraumatic amnesia)
• Any alteration in mental state at the time of the
  injury (confusion, disorientation, slowed
  thinking, etc.)
• Neurological deficits (weakness, loss of balance,
  change in vision, praxis, paresis/plegia, sensory
  loss, aphasia, etc.) that may or may not be
  transient
• Intracranial lesion

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How to Assess for Impairments in Functioning

• Neuropsychological Assessment Tests
• Attention ability to focus and concentrate on
  verbal and visual information for a short or long
  period of time at a given processing speed
• Memory ability to recognize and recall verbal
  and visual information short-term and long-term
• Executive Functioning ability to have higher
  order thinking and problem solve ability to
  think flexibly ability to inhibit behaviors and
  responses

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Cognitive Task

• Please memorize the following words
• Cup
• Elbow
• Sailboat
• Broom
• Pear
• Building
• Tornado
• Pencil

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Cognitive Task

• PINK BLUE GREEN
• GREEN PINK BLUE
• PINK GREEN PINK
• BLUE PINK BLUE
• GREEN BLUE GREEN
• BLUE PINK BLUE
• PINK GREEN GREEN

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Cognitive Task

• BLUE PINK BLUE
• PINK GREEN PINK
• GREEN PINK GREEN
• PINK BLUE PINK
• BLUE GREEN BLUE
• GREEN BLUE GREEN
• BLUE PINK PINK

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Attention vs. Executive Functioning

• The first color-word task involves straight
  attentional abilities and taps into processing
  speed
• The second task is harder because it involves the
  ability to inhibit the overlearned response to
  read the word
• This exercise measures executive functioning
  because it involves higher order ability to keep
  a rule in mind, to inhibit initial responses, and
  to instead execute the new rule

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Cognitive Task

• Remember the list of words you were asked to
  memorize?
• Please write down as many of the words from the
  previous list as you can.

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Cognitive Task

• Now, were going to list words, some were on the
  original list and others werent. Which ones
  were on the list?
• Cap? Elbow?
• Umbrella? Hat?
• Sailboat? Building?
• Broom? Zebra?
• Apple? Pencil?

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Free Recall vs. Recognition

• The first task is much harder because it involves
  retrieval of encoded information without cues
  (free recall)
• The second task is easier because it assists
  retrieval of encoded information with cues
  (recognition)
• Many people with TBI do poorly on the first and
  not the second, which signals that the
  information was encoded but that there is a
  problem retrieving the information

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Neurocognitive Effects of TBI and PTSD

• Literature agrees that attentional impairments
  are associated with PTSD
• With respect to TBI, depends on type of injury
  (focal or diffuse)
• Attention is generally affected with reduced
  working memory and slower processing speed
• Memory retrieval often affected, but recognition
  remains intact
• Executive dysfunction, typically disinhibition,
  is related to TBI

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Rehabilitation of Trauma-Related Disability

• Cognitive Remediation
• Help improve attention, memory, or problem
  solving
• For veterans whove experienced a TBI, research
  shows most improvement in cognitive functioning
  comes in the first 18 months
• Speech Therapy
• Retrain injured veteran if needed
• Basic communication skills may also need to be
  addressed

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Rehabilitation of Trauma-Related Disability

• Vocational Rehabilitation
• Match job with cognitive strengths or weaknesses
• Provide employment support on an ongoing basis if
  necessary
• Occupational Therapy
• Modify living or work environment to compensate
  for deficits (e.g., cues)
• Help structure veterans time and schedule to
  achieve realistic life goals

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PTSD Treatment

• Posttraumatic stress disorder is usually treated
  with a combination of medications and counseling
• The medications are designed to reduce anxiety
  and to help patients overcome depression
• Common types of counseling for veterans with PTSD
  include cognitive-behavior therapy, exposure
  therapy, group therapy, and family therapy.

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PTSD Treatment

• Stress management techniques and meditation can
  help people with anxiety disorders calm
  themselves and may enhance the effects of therapy
• There is preliminary evidence that aerobic
  exercise may have a calming effect
• Since caffeine, certain illicit drugs, and even
  some over-the-counter cold medications can
  aggravate the symptoms of anxiety disorders, they
  should be avoided

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Summary

• Thousands of Iraq and Afghanistan veterans are
  returning to North Carolina and have suffered a
  trauma resulting in social, cognitive, or
  vocational deficits
• The most prevalent issues are traumatic brain
  injury (TBI) and posttraumatic stress disorder
  (PTSD), which can lead to a lifetime reduction in
  basic functioning
• Comprehensive assessment of TBI and PTSD give
  information about the accuracy of the diagnosis
  and about which types of rehabilitation
  strategies will be effective
• To address these trauma-related disabilities,
  allied health professionals will be critical in
  developing rehabilitation plans to help veterans
  reintegrate and readjust to civilian life

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UNC StudyBrain Functioning and Cognitive
Rehabilitation In Veterans

• Aimed at improving brain function of veterans
  with TBI and PTSD
• Involves participation for six months
• Use an iPod Touch to practice techniques for
  improving memory and planning skills
• Data collection at the beginning and end of study
  including interview, testing of memory and
  attention, EEG, and MRI
• Three in-home support sessions involving a family
  member or friend
• Veteran will be paid 500, participating family
  member or friend will be paid 200, and veteran
  will keep iPod

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UNC Study

• Eligibility requirements to participate
• Served in a branch of the military since Oct.
  2011
• Has had a head injury that meets diagnostic
  criteria for TBI (had the head injury while in
  the military)
• Has military-related PTSD
• Can have an MRI and EEG

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Recruitment Area (within 125 miles of Chapel Hill)
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UNC Study

• If you know of a veteran who might be interested
  in participating in the study, please have them
  call for more information
• Dr. Eric Elbogen
• UNC Forensic Psychiatry
• 919-972-7459