Whatever%20Happened%20to%20Me?%20A%20Neuropsychological%20Perspective%20of%20Traumatic%20Brain%20Injury

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Whatever Happened to Me?A Neuropsychological
Perspective of Traumatic Brain Injury

• Gabriel Salazar, M.A.
• Coastal Horizons Private Practice
• Antonio E. Puente, Ph.D.
• University of North Carolina Wilmington Private
  Practice
• Carolinas IARP
• Carolina Beach, NC
• April 23, 2010

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Overview

• HISTORY AND METHODOLOGY
• DEFINING NEUROPSYCHOLOGY
• DEFINING PERSONALITY
• DEFINING TRAUMATIC BRAIN INJURY
• NEUROPSYCHOLOGICAL RESIDUALS OF TBI
• The Interface Between Neuropsychology,
  Personality and Traumatic Brain Injury

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History

• SCIENCE
• Loeb
• 1903, University of Chicago
• Lashley
• 1929, Harvard University and Yerkes Laboratory
• Sperry
• 1981, California Institute of Technology
• Luria (Bechterew, 1900, St. Petersburg)
• 1980s, Moscow State University

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Methodology

• SCIENTIFIC
• THE IMPORTANCE AND OFTEN LACK OF DATA
• CLINICAL
• WHEN SCIENCE IS NOT AVAILABLE, CLINICAL EXPERTISE
  IS THE NEXT LEVEL OF INFORMATION
• ANECDOTAL
• SOMETIMES, ALL THAT YOU HAVE ARE INDIVIDUAL CASES
  TO GUIDE YOU

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Defining Neuropsychology

• PROFESSIONAL
• Neuropsychologist- Doctorate level (state
  license)
• Psychometrician- MA level (aspirational)
• SCIENTIFIC
• Interface between brain and behavior
• Focus on
• Behavior
• Cognition
• Emotion
• Personality

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Defining Personality

• CHARACTER TRAITS- WHO ARE YOU?
• PRESENT AND MEASURABLE BY LATE CHILDHOOD
• LIFELONG AND ENDURING QUALITIES
• OFTEN REVEALED BY REPEATED FEEDBACK FROM EXTERNAL
  SOURCES
• DIFFICULT TO CHANGE USING PSYCHOTHERAPEUTIC
  TECHNIQUES
• (Note DSM- Axis 1 vs. 2)

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Traumatic Brain Injury Statistics

• 56 billion a year spent on TBI
• 5 million Americans alive today have had a TBI
  resulting in a permanent need for help in
  performing daily activities.
• Survivors of TBI often left with significant
  cognitive, behavioral, and communicative
  disabilities
• Some patients develop long-term medical
  complications, such as epilepsy.
• Each year
• 1.4 million people experience a TBI
• 50,000 people die from head injury
• 1 million head-injured people are treated in
  hospital emergency rooms
• 230,000 people are hospitalized for TBI and
  survive

National Institute of Neurological Disorders and
Stroke, 2010
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Defining Traumatic Brain Injury

• ANYTHING THAT CHANGES THE STRUCTURE AND/OR
  FUNCTION OF THE BRAIN
• Closed Head Injury- the skull is intact and there
  is no penetration of the skull.  Direct or
  indirect force to the head can cause this type of
  injury.  This may be caused by rotational and/or
  deceleration in the case of both direct and
  indirect force. 
• Open Head Injury- penetration of the skull with
  direct injury to the head.

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Defining Traumatic Brain Injury

• Diffuse Axonal Injury- diffuse cellular injury to
  the brain from rapid rotational movement.  This
  is often seen in motor vehicle accidents or
  shaking injuries.  The axons are the projections
  of the brains nerve cells that attach to other
  nerve cells.  They are damaged or torn by the
  rapid deceleration.  The injury is from the
  shearing force disrupting the axons which
  compose the white matter of the brain.
• Contusion- a bruise to a part of the brain.  Like
  a bruise on the body, this is bleeding into the
  tissue. 

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Defining Traumatic Brain Injury

• Penetrating Trauma- any object that enters the
  brain.  Causes direct injury by impact and
  pushing skull fragments into the brain. 
• Secondary Injury
• Intracranial hemorrhage (bleeding inside the
  skull)
• Brain swelling
• Increased intracranial pressure (pressure inside
  the skull)
• Brain damage associated with lack of oxygen
• Infection inside the skull, common with
  penetrating trauma
• Chemical changes leading to cell death
• Increased fluid inside the skull (hydrocephalus)

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Defining Traumatic Brain Injury

• A TRADITIONAL PERSPECTIVE
• Caused by external stimulus
• Abrupt
• S shaped curve of recovery
• Possible that complete recovery is not
  attainable
• Hence, a residual change from premorbid level of
  function occurs resulting in a new person
• A NON-TRADITIONAL PERSPECTIVE
• Example, for Russians view brain injury from
• Socio-cultural context
• Recovery is a lifetime activity

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Describing the Physical Injury (Barth, 2009)
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(No Transcript)
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Causes of TBI
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Review of the Literature

• From 1900 to present
• BI and Neuropsychology
• 1974
• Steady increase over time starting the 1990s
• BI and Neuropsychology and Personality
• 84 citations
• Most emerging during the 1990s

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Methods of Diagnosing TBI

• Neurological examination
• Brain imaging with CAT scan, MRI, SPECT and/or
  PET
• Cognitive evaluation by a Neuropsychologist with
  formal neuropsychological testing.
• Evaluations by physical, occupational and speech
  therapists help clarify the specific deficits of
  an individual.

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Neuropsychological Assessment

• THREE LEVELS OF ASSESSMENTS
• NEUROSURGICAL
• NEUROLOGICAL
• NEUROPSYCHOLOGICAL
• DIFFERENCE BETWEEN PSYCHOLOGICAL AND
  NEUROPSYCHOLOGICAL ASSESSMENT
• TIME (much longer)
• FOCUS (on specific domains such as memory and
  their relationship to neurological status)

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Specifics of Assessment

• COMPONENTS
• Review of records
• Medical
• Educational, plus
• Interview (1-2 hours)
• Patient
• Collateral
• Tests (6-10 hours)
• Effort testing (Tomm)
• Domain testing (Category test)

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Specifics of Assessment

• Orientation
• Communication
• Fluency
• Motor
• Reasoning/Organization
• Memory
• Intellectual

• Academic
• Affective
• Personality
• Effort

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Specifics of Assessment

• STANDARD GOALS
• Cognitive focused
• Deficit based
• Highly technical
• Replicable
• Meant to be understood by PhDs
• General recommendations

• POSSIBLE ADDITIONAL
• Emotional
• Ecological
• Functional
• Educational
• Multidimensional
• Multidisciplinary
• Forensic sensitive

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Potential Symptoms of Neuropsychological
Residuals of TBI

• GREATER DISORGANIZATION REASONING ABILITIES
• IMPAIRMENT OF ATTENTION
• DIFFICULTIES WITH ENCODING OF INFORMATION
• LESS THAN OPTIMAL RECALL OF INFORMATION
• SLOWLED MENTAL PROCESSING
• LIMITED MENTAL STAMINA

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Psychological Symptoms

• REDUCED FRUSTRATION TO AMBIGUITY
• DECREASED TOLERANCE FOR STRESS
• APATHY/POOR MOTIVATION
• DEPRESSION
• ALCOHOL ABUE
• CHANGE IN SYSTEMS STABILITY
• FAMILY DYNAMICS
• VOCATIONAL PERFORMANCE
• SOCIETAL STATUS

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Interface Between Cognitive Emotional Variables

• SYNCHRONY OF SYMPTOMS
• COGNITIVE DYSFUNCTION AFFECTS EMOTIONAL PROBLEMS
• EMOTIONAL DYSFUNCTION AFFECTS COGNITIVE PROBLEMS
• ONE OF THESE VARIABLES CAN HAVE TEMPORARY EFFECT
  OF A LIMITED NATURE ON THE OTHER

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Recovery from TBI Individual Factors

• Mild trauma
• Negative MRI, CT, etc
• Glasgow Coma Scale (15?)
• Post-traumatic amnesia
• Age (very young and very old problematic)
• Co-morbid medical factors (e.g., diabetes, HBP)
• Co-morbid psych factors (e.g., pre-existing
  condition such as etoh abuse, depression)
• Limited cognitive and/or emotional reserve

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Recovery from TBI Contextual Factors

• MARITAL STATUS
• FAMILY SUPPORT
• INCOME LEVEL
• ECONOMIC RESOURCES (insurance, disability)
• SOCIAL ENGAGEMENT

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Recovery External Predictors

• NEUROCOGNITIVE TEST RESULTS
• IMPORTANCE OF SUBJECTIVE COMPLAINTS
• VALUE OF INFORMATION FROM SIGNIFICANT OTHERS

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Interventions

• PSYCHOLOGICAL
• COGNITIVE
• VOCATIONAL
• PHYSICAL
• MEDICAL
• PHYSICAL
• SYSTEMS

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How Long Should Therapy Continue?

• Insurance Based Response
• of sessions allocated
• Maximum medical improvement
• North American Perspective
• 6 to 12 months (until the insurance stops
  paying?)
• Russian Perspective
• Functionally defined (until you stop getting
  better)

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Residual Damage

• SIGNIFICANT OTHERS
• CHILDREN
• SYSTEMS
• SOCIETY

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Special Problems

• LIMITED INFORMATION FROM ACCIDENT REPORTS
• POOR EVALUATIONS THAT SKIRT COGNITIVE CONCERNS IN
  THE EMERGENCY ROOM
• FOCUS ON NEUROLOGICAL AND NEUROSURGICAL
  CONCERNS INITIALLY
• ENGAGEMENT OF COGNITIVE, EMOTIONAL AND SOCIAL
  ISSUES MUCH LATER IN THE RECOVERY CURVE

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Special Problems

• RESIDUALS OF A BLAST INJURIES AND HOW THEY ARE
  DIFFERENT THAN TYPICAL TBI THE PROBLEM WITH
  RETURNING VETS
• IS IT MENTAL OR IS IT PHYSICALWHEN DOES ONE
  BEGIN AND THE OTHER ONE STOP
• IMPACT ON VOCATIONAL OUTCOMES ARE PROBLEMATIC,
  ESPECIALLY WITH MILD TBI
• IMPORTANT TO UNDERSTAND THAT THE BRAIN EXISTS
  INSIDE A PERSON INSIDE A SYSTEM

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Special Problems

• CHRONIC TRAUMATIC ENCELAPOTHY
• Carolina Hurricanes
• Sports Concussions Blast Injuries
• The Case of Mike Borich
• From football to soccer to surfing
• The lack of interest and understanding
• The pressure to play and fight
• The hidden symptoms
• Initial
• cumulative

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What About Me?

• NOT A FUNCTIONAL LOSS
• NOT A BRAIN INJURY
• NOT AN AFFECTED FAMILY
• NOT A COMPENSABLE LOSS
• IT IS ABOUT ME
• I am a new person
• The system I am in has changed

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The Challenge of Forensic Concerns

• LITIGATION
• Civil
• Disability
• Work related
• Social Security
• QUANTIFYING DEFICITS STRENGTHS
• QUANTIFYING EFFORT
• QUANTIFYING LOSS

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What Happened to Me?

• IT IS ABOUT
• Rediscovery of self
• Rediscovery of the world I live in
• Discovery of how impairment can be an asset
• The concept of post-traumatic growth
• Can my brain impairment result in a better me?
• Can my brain impairment result in a better life?

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This is not what I planned for

• What am I to do