Title: Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process
1Roles 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
2Objectives
- 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
3Although I love Harry Potter
4There is No Magic!
5And, things like this are Pseudo-Magic
Automatic Clock Drawing Test
6If 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
7TBI Screening Reminder
That is what the TBI Screening Reminder Does
8So, what really are the issues?
- Who has ongoing symptoms and problems?
- What are these symptoms and problems due to (TBI,
PTSD, Depression, Anxiety, Somatoform Disorder,
malingering, combinations of conditions)? - What is the appropriate treatment for any
identified problems/conditions? - Who is responsible for providing the assessment
and treatment? - Who is responsible for coordinating this process?
- When should this be done locally, and when should
it be done by regional specialists? - What are the roles of psychology in points 3-6?
9TBI 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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12Criteria 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)
13Screening 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
14Screen 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
15Section 1 Trauma Events
16Section 2 Immediate Symptoms
17Section 3 New/Worsening Symptoms
18Section 4 Current Symptoms
19Positive 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
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21What 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)
22What 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
23What 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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25Psychological Contributions
26Issue 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
27Issue 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
28Issue 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
29Issue 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
30Turning 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.
31Issue 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
32Issue 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
34Issue 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)
35Issue 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
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39Issue 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
40Issue 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
41Issue 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 43Causes of Persistent Postconcussion Symptoms
44Expectation as Etiologyand/orThe Good Old
Days
- Symptom Mis-Attribution
- Willey Mittenberg, Ph.D.
- Diagnostic Threat
- Julie Suhr, Ph.D.
45Expectation 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
46Mild 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!
47Mild 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
48If There is Timewhich there will not be
49What to ExpectLiterature Review Findings
- Mild TBI Findings
- Neuropsychological Test Performance
- Postconcussion Symptoms
- Causes of Postconcussion Symptoms
- Treatment of Mild TBI
50Neuropsychological Test Performance
51Mild 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
52Mild 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
53Vietnam Experience Study (VES)
Neuropsychological and Postconcussive Symptom
Findings
54Subjects
- 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
55Subjects 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)
56Subjects 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
57Measures
- Diagnostic Interview Schedule (DIS-III-A)
- Extensive surveys of physical functioning and
symptoms - Battery of neuropsychological tests
58Groups and Sample Sizes
59Neuropsychological 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
60Statistical 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
61Current Cognitive FunctioningExamples of the 14
Measures
62Postconcussion Symptoms
63Postconcussion Symptoms
- Physical
- Headache, dizziness, fatigue, noise/light
intolerance, insomnia - Cognitive
- Memory complaints, poor concentration
- Emotional
- Depression, anxiety, irritability, mood lability
64PCS 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
65Odds-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)
66Odds-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)
67Odds-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)
68Odds-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)
69Causes of Persistent Postconcussion Symptoms
70Expectation as Etiologyand/orThe Good Old
Days
- Symptom Mis-Attribution
- Willey Mittenberg, Ph.D.
- Diagnostic Threat
- Julie Suhr, Ph.D.
71Expectation 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
72Mild 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!
73Other Factors Influencing the Development and
Persistence of Persistent Postconcussion Symptoms
74Predictors 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
75Results
- 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)
76Contribution 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
-
77MTBIIntelligence by LOC (1.8)
78MTBIIntelligence by Social Support (1.2)
79MTBIInternalizing by Social Support (1.0)
80PCS 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
81PCS 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
82Treatment of Mild TBI
83Mild 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
84References
- 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.
85References
- 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.