Download - Traumatic Brain Injury in Veterans
Traumatic Brain Injury in Veterans
Robyn Mehlenbeck, PhD*Equal Justice Works Leadership Development
TrainingOctober 23, 2014Washington, DC
* George Mason University
WHAT IS TBI?
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• Sudden physical damage and trauma to the brain
• Focal Lesion: foreign body enters brain, targets specific area
• Mild Traumatic Brain Injury (mTBI): affects larger areas of the brain, white matter
• White matter responsible for relaying electrical signals around brain
Traumatic Brain Injury:
Causes of TBI
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• Transportation accidents• Cars, motorcycles, bicycles, pedestrians (50%)
• Falls• Majority of TBI in ages 75 and older from falls
• Violence• Domestic violence, firearms assaults, child abuse (20%)
• Sports injuries• Approximately 3%
• Combat• Separate category, increasingly common in combat due to IED
(http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm)
Combat-Related TBI
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• Especially common in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
• 66% of service personnel in Iraq exposed to or injured by a blast injury
• Frequently mTBI rather than focal lesion (80% mTBI)
• Affects large sections of the brain
• Effects not immediately noticeable
• Concentration and cognitive decline over time
Physical Symptoms of TBI
• Unconsciousness (seconds or minutes)
• Headache• Nausea and
vomiting• Dizziness• Seizures• Weakness
• Numbness in arms and legs
• Dilated pupils• Metallic taste in mouth• Ringing in ears• Fatigue and lethargy• Change in sleep
patterns• Difficulty with motor
coordination
Psych Symptoms of TBI
• Slurred speech• Confusion• Agitation• Memory or
concentration problems
• Amnesia about events prior to injury
• Behavioral changes• Mood changes
• Depression• Anxiety
• Difficulty with attention
• Difficulty with complex thinking
Neurology vs Neuropsychology?
• Neurology – MD
• Specialty that assesses, diagnoses and treats problems with TBI, among other nervous system problems
• Treats the physical symptoms and causes of TBI
• Neuropsychology - PhD
• Looking for behavioral manifestations of TBI
• Assesses and treats the cognitive, behavioral and psychological effects of the TBI
Types of TBI
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• Two major types of traumatic brain injury
• Penetrating brain injury
• Closed head injury
Penetrating TBI
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• Types of penetrating TBI
• Skull fracture bone of skull cracks or breaks
• Pieces of skull can press into brain tissue
• Foreign object enters brain (e.g. bullet)
• Damage occurs along path of injury (focal lesion)
• Symptoms vary according to part of brain that is damaged
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Closed-head TBI
• Results from blow to the head (e.g. car accident, football tackle, impact from IED blast)
• Causes two type of brain injuries:
1. Primary
2. Secondary
Primary Closed-head Injuries
• Contusion• Bruising of brain tissue (swollen brain tissue and blood)
• Can be in response to shaking of brain in skull (contrecoup)
• Hematomas/blood clots• Occur between the skull and the brain or inside the brain itself
• Diffuse axonal injury• Individual nerve cells damaged
• Loss of connections between neurons
• Laceration• Tearing of the frontal (front) and temporal (on the side) lobes or blood vessels of the
brain
• Force of the blow causes the brain to rotate across the hard ridges of the skull, causing the tears
Secondary Closed-head Injuries
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• Evolves over time (after trauma has occurred)• Brain swelling (edema)• Increased pressure inside of the skull (intracranial
pressure)• Epilepsy• Intracranial infection• Fever• Anoxia: lack of oxygen supply to brain tissue
• Without oxygen, brain cells die within minutes
• Hematoma: heavy bleeding in or around brain
Closed-head Injury Illustration
( http://health.allrefer.com/health/head-injury-prevention.html)
What does it mean to have a TBI?
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Typical Impairments:
Communication
Thinking/Executive Functioning
Psychological
Communication Difficulties
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• Difficulty picking up social cues • e.g. interrupting
• Difficulty following conversations
• Occasional difficulty modulating tone of voice
• Difficulty processing subtleties/nuances in language • e.g. difference between tongue-in-cheek and seriousness
Communication Difficulties
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• More severe difficulties include:• Aphasia
• difficulty understanding and producing spoken and written language
• Word Recall • Trouble recalling words/speaking in complete sentences
• Frequent pauses• Prosodic dysfunction
• difficulties with inflection and intonation
Cognitive Difficulties
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• Slower processing of information
• Difficulty with short-term memory
• Retrograde Amnesia (hippocampus/prefrontal cortex)• Loss of specific memories from pre-trauma (unconsolidated)
• Anterograde Amnesia (hippocampus/prefrontal cortex)• Difficulty forming new memories after trauma
Cognitive Difficulties
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• Executive functioning difficulty (prefrontal cortex)
• Poor planning, organizing skills• Setting goals• Completing tasks• Difficulty solving problems• Difficulty with abstract reasoning• Difficulty making judgments
• Impulsivity (prefrontal cortex)
Testing for effects of TBI
Comprehensive Assessment with emphasis on Executive Functioning
- Can be done by a neuropsychologist- Can be done by a psychologist with extensive
experience in the types of tests needed to examine the deficits concerned about
Testing for effects of TBI
Clinical Interview – looking for some identifying event/incident; any testing prior to the injury is a bonus
Cognitive Assessment – WAIS-V; Woodcock Johnson Cognitive/Achievement
Executive Functioning – Delis- Kaplan Executive Functioning System (D-KEFS)Rey-Osterrieth Complex Figure Test/Beery VMI
Psychological – ADD scales, Mental Status Exam
Test of Memory Malingering (TOMM) – gives some validity to whether a client is intentionally exaggerating memory symptoms
Rey-Osterrieth Complex Figure Test
- Add in figure; & scores on a sample w/deficits
Treatment of TBI
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• Treatment dependent on severity of TBI• Combination of medical management of symptoms &
psychological intervention based on deficits
• In mTBI Cognitive Behavioral Therapy most common treatment form for psychological effects• Structured work on goal setting/problem solving• Structured work on impact of thoughts on feelings and
behaviors
• Additional treatment: • Nutrition• Education• Counseling & family support• Medication for symptomatic relief