The Role of Premorbid Factors and Awareness in Patients With Neurobehavioural Problems' - PowerPoint PPT Presentation


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The Role of Premorbid Factors and Awareness in Patients With Neurobehavioural Problems'


it's not only the kind of injury that matters its the kind of head' Symonds 1937 ... Avoids a grief response to loss. 14. Intention and Awareness Ouellete & Wood 1998 ... – PowerPoint PPT presentation

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Title: The Role of Premorbid Factors and Awareness in Patients With Neurobehavioural Problems'

The Role of Premorbid Factors and Awareness in
Patients With Neurobehavioural Problems.
  • …its not only the kind of injury that matters
    its the kind of head Symonds 1937
  • Shona McIntosh consultant clinical psychologist/
    senior clinical tutor.

  • Why dont interventions work?
  • Ethics…
  • The difficult to work with/help patient.
  • Case example.
  • Awareness, anosognosia, denial, intention
  • What might affect oral care for people with ABI
    and neurobehavioural problems?

Ethical issues in changing behaviours…
  • What is challenging behaviour, who decides and

Plato 427BC 347BC there is a single general
pure idea of goodness that all good things
Aristotle 384BC 322BC there is no completely
universal idea of The good
Similarities differences with learning
disability population.
  • Complex presentation may include physical,
    cognitive, emotional and psychosocial
  • ABI presentation may vary over time depending on
    stage of recovery.
  • Often global cognitive impairments but may be
    lesion specific impairments too.
  • Developmental issues in both.
  • Premorbid factors influence behaviour and
    interact with cognitive abilities.

The Difficult to Help Patient 1
  • ABI affecting cognitive functions memory,
    executive functioning and metacognitions.
  • Behaviour control poor.
  • Understanding short/long term consequences poor.
  • Loss of empathy.
  • Impaired ability for new learning.
  • Procedural learning only.
  • Few interests or rewards applicable.

  • Premorbid and/or habitual behaviours repeated,
    rewarding behaviours.
  • Use of drugs/alcohol
  • Culture or experience of violence.
  • Forensic history.
  • Psychosocial difficulties contributing to low
    self esteem.
  • Poor socio-economic background.
  • Psychiatric history / previous head injury.
  • Poor self care.

What do we mean by awareness?
  • Complex different levels, uses feedback,
    neurological and psychogenic components.

Anosognosia unawareness or imperception of
Anosodiaphora indifference, lack of concern.
Motivated or defensive denial, lack of insight.
Current model of Insight/Awareness in Clinical
Psychiatry (Markova 2003)
Neurological Model of Disorders of Self Awareness
  • Frontal impaired self awareness as a social
    being, inappropriate, cannot anticipate.
  • Occipital No awareness of cortical blindness.
  • Temporal No awareness of memory impairment.
    Visual auditory problems are distorted. Problems
    explained on the basis of external causes, may
    lead to paranoid thinking.

Neurological Model of Disorders of Self Awareness
  • Anton Roderscheidt (Right parietal damage)
  • Parietal No awareness of impaired sensorimotor
    function hemiplegia, hemi-inattention, reduced
    balance, reduced capacity to navigate freely and
    safely in space.

Self Awareness Theory Carver Sheier 1981
(image from Aronson et al 1999)
Biopsychosocial model of factors relevant to
awareness (Clare in press 2003)
Denial implies awareness and understanding of
  • Good rehabilitation prospects
    Realistic self appraisal confronts impairments.
  • Poor rehabilitation prospects
    Protective mechanism maintaining hope, self
    constructs and self esteem. Avoids a grief
    response to loss.

Intention and Awareness Ouellete Wood 1998
  • Behaviour is guided by intentions.
  • Past behaviour (and a persons beliefs and
    attitudes) contribute to intentions.
  • Intentions require understanding of consequences
    of an act.
  • Understanding of consequences awareness.
  • intentions reflect attitudes towards the
    behaviour defined as the favourability of the
    consequences of an act and the importance of
    these effects….
  • Intentions need to be more powerful than existing
    well practised behaviours.
  • Azjen (1987) Theory of planned behaviour.
    Intentions reflect attitude toward the
    behaviour, subjective experiences (whats usual
    for a person) and perceived behavioural control

  • Anosognosia is organic but psychological coping
    mechanisms may also present, e.g. denial.
  • Feedback is essential for awareness.
  • Acquired brain injury can damage many areas and
    mechanisms required for awareness.
  • Without awareness there will be no understanding
    of needs to change intentions and behaviours.

You can take a horse to water….
  • The importance of intention….

Factors which influence oral health for people
with mental health problems/learning disabilities
  • Type severity and stage of mental illness.
  • Mood, motivation and self esteem.
  • Perception of oral health problems.
  • Habits, lifestyle and ability to sustain
    self-care and dental attendance.
  • Attitudes to oral care.
  • Griffiths,Jones et al 2000 Oral Health for People
    with Mental Health Problems Guidelines and
    Recommendations. Report of the BSDH working group.

Factors which influence oral care for people with
acquired brain injury and neurobehavioural
  • Nature, severity and subsequent cognitive,
    physical and neurobehavioural impairments.
  • Premorbid and current perception of oral health
  • Mood, executive functioning and stage of
    adjustment to impairments.
  • Premorbid and current habits, lifestyle, ability
    and intention to sustain self-care and dental
  • Oral side effects of medication on physical and
    cognitive functions.
  • Premorbid and current attitudes to oral care.

Possible CPD or professional training
requirements for working with people with ABI and
neurobehavioural problems.
  • Pharmacological risks and complexity of drug
    interactions of drugs used.
  • An understanding of cognitive and communication
    impairments including anosognosia.
  • Behavioural management techniques.
  • Understanding the roles of the multidisciplinary

How not to get bitten…
  • Ask the right questions
  • Work with person before appointment
  • double appointment
  • risk assessment
  • get info cognitive, language, physical abilities
    (comprehension,memory, bite reflex, self control,
  • Keep it short and simple.
  • Check drug side effects

Managing disinhibited or challenging behaviour.
  • Give information before, during, after. To
    patient, to carer/relative.
  • Allow time warn patient of intervention, leave
    alone and go back if necessary.
  • Desensitise bite response.