Roles of Neuropsychology and Roles of Neuropsychology and Psychology following Psychology following

Positive TBI Clinical Reminders:Positive TBI Clinical Reminders:The Evaluation and Treatment ProcessThe Evaluation and Treatment Process

Rodney D. Vanderploeg, Ph.D.Rodney D. Vanderploeg, Ph.D.Tampa VAMCTampa VAMC

VA Psychology Leadership VA Psychology Leadership Conference/APA Conference/APA

May 18, 2007May 18, 2007

ObjectivesObjectives

Provide an overview of the TBI Clinical Provide an overview of the TBI Clinical Reminder screening process Reminder screening process

Describe a model follow-up evaluation and Describe a model follow-up evaluation and treatment process treatment process

Describe when and how neuropsychological Describe when and how neuropsychological evaluations should be completed evaluations should be completed

Describe other roles of psychology following Describe other roles of psychology following positive TBI Clinical Reminderspositive TBI Clinical Reminders

Although I love Harry PotterAlthough I love Harry Potter

There is No Magic!There is No Magic!

And, things like this are Pseudo-MagicAnd, things like this are Pseudo-Magic

Featured in the Journal of the American Geriatrics Society,  NIH, and the American Bar Association ElderLAW E-NEWS.   New!New!

5 minute evaluation

““Automatic Clock Drawing Test”Automatic Clock Drawing Test”

If you want to know if someone had If you want to know if someone had a Traumatic Brain Injury (TBI)a Traumatic Brain Injury (TBI)

ASK THEM:ASK THEM: Did you experience a physical trauma or Did you experience a physical trauma or

injury that resulted in your being:injury that resulted in your being:• Knocked out / Rendered unconscious,Knocked out / Rendered unconscious,

• Dazed and confused for several Dazed and confused for several minutes, and/or minutes, and/or

• With With memory gapsmemory gaps for some or all of the for some or all of the immediate period after the eventimmediate period after the event

If the answer is “yes”, then they had a TBIIf the answer is “yes”, then they had a TBI

TBI Screening TBI Screening ReminderReminder

April 2007April 2007

That is what the “TBI That is what the “TBI Screening Reminder” DoesScreening Reminder” Does

So, what really are the issues?So, what really are the issues?

1.1. Who has ongoing symptoms and problems?Who has ongoing symptoms and problems?2.2. What are these symptoms and problems due to What are these symptoms and problems due to

(TBI, PTSD, Depression, Anxiety, Somatoform (TBI, PTSD, Depression, Anxiety, Somatoform Disorder, malingering, combinations of conditions)?Disorder, malingering, combinations of conditions)?

3.3. What is the appropriate treatment for any identified What is the appropriate treatment for any identified problems/conditions?problems/conditions?

4.4. Who is responsible for providing the assessment Who is responsible for providing the assessment and treatment?and treatment?

5.5. Who is responsible for coordinating this process?Who is responsible for coordinating this process?6.6. When should this be done locally, and when should When should this be done locally, and when should

it be done by regional specialists?it be done by regional specialists?7.7. What are the roles of psychology in points 3-6?What are the roles of psychology in points 3-6?

““TBI Screening Reminder” FunctionsTBI Screening Reminder” Functions

Identify possible OIF/OEF ParticipantsIdentify possible OIF/OEF Participants Confirm deployment to OIF/OEF Theatres Confirm deployment to OIF/OEF Theatres

of Deploymentof Deployment Screen for TBI if deployed in OIF/OEF Screen for TBI if deployed in OIF/OEF

TheatresTheatres Identify those with an OIF/OEF-related Identify those with an OIF/OEF-related

historyhistory of TBI of TBI

Criteria for Severity of TBICriteria for Severity of TBIMild Mild ModerateModerate SevereSevere

LOC LOC << 30 min 30 min with with normal CT &/or normal CT &/or MRIMRI

LOC LOC << 6 6 hours withhours withabnormal CT abnormal CT &/or MRI&/or MRI

LOC > 6 hours LOC > 6 hours withwithabnormal CT abnormal CT &/or MRI&/or MRI

GCS 13-15GCS 13-15 GCS 9-12GCS 9-12 GCS < 9GCS < 9

PTA PTA << 24hr 24hr PTA PTA << 7days 7days PTA > 7daysPTA > 7days

Don’t confuse combat-trauma psychological confusion Don’t confuse combat-trauma psychological confusion with post-TBI PTA (i.e., inability to lay down new with post-TBI PTA (i.e., inability to lay down new memories and therefore having post-TBI “memory gaps”)memories and therefore having post-TBI “memory gaps”)

Screening Questions:Screening Questions:4 Sections4 Sections

Section 1: Section 1: Trauma EventsTrauma Events Section 2: Section 2: ImmediateImmediate Disturbance of Disturbance of

ConsciousnessConsciousness Symptoms after Events Symptoms after Events Section 3: Section 3: New or WorseningNew or Worsening Symptoms Symptoms

after the eventafter the event Section 4: Section 4: CurrentCurrent Symptoms Symptoms

Screen InterpretationsScreen Interpretations

A “no” response to any of the sections A “no” response to any of the sections terminates screening and is a “negative terminates screening and is a “negative screen”screen”

A “yes” response to ALL FOUR sections A “yes” response to ALL FOUR sections is a “positive screen”is a “positive screen”

Section 1: Section 1: Trauma EventsTrauma Events

Section 2: Section 2: ImmediateImmediate Symptoms Symptoms

Section 3: Section 3: New/Worsening New/Worsening SymptomsSymptoms

Section 4: Section 4: Current Current SymptomsSymptoms

Positive TBI Screen: Follow-upPositive TBI Screen: Follow-up

Positive replies in all four sections Positive replies in all four sections constitute a positive screenconstitute a positive screen

Positive screens automatically generate a Positive screens automatically generate a consult to a TBI specialist or clinicconsult to a TBI specialist or clinic

This specialist/clinic has 1 week to initiate This specialist/clinic has 1 week to initiate contact with patient for more detailed contact with patient for more detailed follow-up evaluationfollow-up evaluation

Initial treatment trial is based on positive Initial treatment trial is based on positive problems on this follow-up evaluationproblems on this follow-up evaluation

What to Know: What to Know: Relevant Background (1)Relevant Background (1)

Mild TBI SymptomsMild TBI Symptoms There is There is no symptomno symptom that is that is uniqueunique to or to or

diagnosticdiagnostic of mild TBI of mild TBI Many postconcussion symptoms occur in Many postconcussion symptoms occur in

normal healthy individualsnormal healthy individuals All symptoms/problems overlap with one or All symptoms/problems overlap with one or

more other conditions (PTSD, Depression, more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions)chronic health conditions)

What to Know: What to Know: Relevant Background (2)Relevant Background (2)

In prospective cases (non-clinical, non-In prospective cases (non-clinical, non-legal) virtually all symptoms of mild TBI legal) virtually all symptoms of mild TBI resolve within 1 - 3 monthsresolve within 1 - 3 months CognitiveCognitive EmotionalEmotional PhysicalPhysical

Yet, a subgroup (about 10-15%) continue Yet, a subgroup (about 10-15%) continue to experience a postconcussive syndrome to experience a postconcussive syndrome Psychological factors play a large role in Psychological factors play a large role in

symptom presence in this subgroupsymptom presence in this subgroup

What to Know: What to Know: Relevant Background (3)Relevant Background (3)

In this subgroup (of about 10-15%)In this subgroup (of about 10-15%) There is no relationship between symptom There is no relationship between symptom

complaints and objective findings on:complaints and objective findings on:• Neuropsychological TestingNeuropsychological Testing

• Physical ExaminationPhysical Examination

• Neurological ExaminationNeurological Examination

Again, this is because Again, this is because psychological psychological factorsfactors play a large role in symptom play a large role in symptom complaintscomplaints

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-Expectation

mTBImTBI

Psychiatric Conditions

Personality Traits

Medical Conditions

Intelligence Level

Demographic Characteristics

Medical Iatrogenesis

Litigation Iatrogenesis

Acute Symptoms

Chronic Symptoms

Psychiatric Conditions

Personality Traits

Medical Conditions

Intelligence Level

Coping Abilities

Social Support

Coping Abilities

Predisposing Factors Causative Factors Perpetuating and Mitigating Factors

Self-Expectation

mTBImTBI

Psychiatric Conditions

Personality Traits

Medical Conditions

Intelligence Level

Demographic Characteristics

Medical Iatrogenesis

Litigation Iatrogenesis

Acute Symptoms

Chronic Symptoms

Psychiatric Conditions

Personality Traits

Medical Conditions

Intelligence Level

Coping Abilities

Social Support

Coping Abilities

Psychological Psychological ContributionsContributions

Issue OneIssue One

1.1. Who has ongoing symptoms and problems?Who has ongoing symptoms and problems? Anyone who responds positively to all four Anyone who responds positively to all four

of the TBI Clinical Reminder sectionsof the TBI Clinical Reminder sectionsSection 1:Section 1:Trauma Trauma Event(s)Event(s)Section 2:Section 2: ImmediateImmediate Disturbance of Disturbance of

ConsciousnessConsciousness after Event(s) after Event(s)Section 3:Section 3:New or WorseningNew or Worsening Symptoms after Symptoms after

the event(s)the event(s)Section 4:Section 4:CurrentCurrent Symptoms Symptoms

Issue Two: Symptom EtiologiesIssue Two: Symptom Etiologies

2.2. What are these symptoms and problems due to What are these symptoms and problems due to (TBI, PTSD, Depression, Anxiety, Somatoform (TBI, PTSD, Depression, Anxiety, Somatoform Disorder, malingering, combinations of conditions)?Disorder, malingering, combinations of conditions)? Initial post-TBI Clinical Reminder Initial post-TBI Clinical Reminder

AssessmentAssessment (at Tampa and elsewhere) (at Tampa and elsewhere)Telephone Administration ofTelephone Administration of: : History Questions (e.g., confirmation of History Questions (e.g., confirmation of

exposure, details of TBI severity, history of exposure, details of TBI severity, history of symptom course), Review of bodily systems symptom course), Review of bodily systems and associated complaints, etc.and associated complaints, etc.

Neurobehavioral Symptom InventoryNeurobehavioral Symptom Inventory (22 (22 items rating postconcussive symptoms)items rating postconcussive symptoms)

PTSD ChecklistPTSD Checklist (PCL) (PCL) Pain symptomsPain symptoms

Issue Two: Symptom EtiologiesIssue Two: Symptom Etiologies Interpretation of Initial Assessment FindingsInterpretation of Initial Assessment Findings

What are the most likely etiologies for the What are the most likely etiologies for the symptoms?symptoms?

What etiology(s) is/are primary?What etiology(s) is/are primary?(Does PTSD, chronic pain, sleep disturbance (Does PTSD, chronic pain, sleep disturbance likely explain the cognitive symptoms?)likely explain the cognitive symptoms?)

Would successful treatment of the primary Would successful treatment of the primary etiology likely resolve most or all of the etiology likely resolve most or all of the symptoms?symptoms?

Referring and TriagingReferring and Triaging: : Refer accordingly for further evaluation and/or Refer accordingly for further evaluation and/or

treatmenttreatment

Issue Two: Symptom EtiologiesIssue Two: Symptom Etiologies When to Refer When to Refer

Refer if the evaluation/referral willRefer if the evaluation/referral will::

Tell you something you don’t already knowTell you something you don’t already know

Make a difference in the patient’s treatment or Make a difference in the patient’s treatment or managementmanagement

Turning Down a Consult for Turning Down a Consult for Neuropsychological AssessmentNeuropsychological Assessment

Referral received and chart reviewed. Veteran Referral received and chart reviewed. Veteran currently has currently has severe symptoms of PTSDsevere symptoms of PTSD and and chronic chronic headachesheadaches. Given this, his cognitive complaints of . Given this, his cognitive complaints of memory and concentration problems are expected. If memory and concentration problems are expected. If testing were performed in this situation, any cognitive testing were performed in this situation, any cognitive impairments would likely be attributed to the severity impairments would likely be attributed to the severity and extent of the mental health problems. Testing and extent of the mental health problems. Testing would not clarify diagnostic issues nor guide treatment would not clarify diagnostic issues nor guide treatment -- because mental health and pain management -- because mental health and pain management treatment should to be the main focus at this time. treatment should to be the main focus at this time.

Once his mental health and pain symptoms are better Once his mental health and pain symptoms are better managed, and rated as no worse than mild to managed, and rated as no worse than mild to moderate, if cognitive symptoms remain, a re-referral at moderate, if cognitive symptoms remain, a re-referral at that time may be clinically useful.that time may be clinically useful.

Issue Two: Symptom EtiologiesIssue Two: Symptom Etiologies Follow-up Additional Specialized Follow-up Additional Specialized

Assessments (and then treatment)Assessments (and then treatment)

TBI:TBI: PNS or PSCT PNS or PSCT (PM&R, (Neuro)Psychology, Speech, (PM&R, (Neuro)Psychology, Speech, Psychiatry)Psychiatry)

PTSD:PTSD: PTSD Program PTSD Program Chronic Pain:Chronic Pain: Pain Program or PM&R Pain Program or PM&R Somatoform Disorder(s):Somatoform Disorder(s): ????? ????? Depression, Anxiety, Stress:Depression, Anxiety, Stress: MHC MHC Seizures, Neurologic Conditions:Seizures, Neurologic Conditions: Neurology Neurology

Issue Three: Issue Three: Appropriate Treatment(s)Appropriate Treatment(s)

Treat the primary condition(s), the one(s) Treat the primary condition(s), the one(s) that explains most or all of the symptomsthat explains most or all of the symptoms

Don’t invest time and effort in conditions Don’t invest time and effort in conditions that account for only small amounts of that account for only small amounts of symptom variancesymptom variance

Just because a condition was/is present Just because a condition was/is present (e.g., history of mild TBI), doesn’t mean it (e.g., history of mild TBI), doesn’t mean it should be the focus of further assessment should be the focus of further assessment or treatment if other conditions are primaryor treatment if other conditions are primary

+ PTSD + PTSD Re-experiencingRe-experiencing

AvoidanceAvoidance Social withdrawal Social withdrawal

Memory gapsMemory gapsApathyApathy

? Mild? Mild TBITBIResidualResidual

Difficulty with decisionsDifficulty with decisionsMental slownessMental slowness

ConcentrationConcentrationHeadachesHeadaches

DizzyDizzyAppetite changesAppetite changes

FatigueFatigueSadnessSadness

ArousalArousal

Sensitive to noiseSensitive to noise ConcentrationConcentration

InsomniaInsomniaIrritabilityIrritability

+ Depression+ Depression

Issue Four: Issue Four: Who is Responsible?Who is Responsible?

TBI Clinical Reminder:TBI Clinical Reminder: Primary and Primary and Specialty Clinics (including Urgent Care, Specialty Clinics (including Urgent Care, MHC, PTSD, Dental, etc.)MHC, PTSD, Dental, etc.)

Initial Follow-up Assessment:Initial Follow-up Assessment: Polytrauma Program staff Polytrauma Program staff

(Level II: PNS or Level III: PSCT),(Level II: PNS or Level III: PSCT), SCI Program staff, orSCI Program staff, or Local Designated Specialist(s) - Local Designated Specialist(s) - PhysicianPhysician

(e.g., Neurologist, PM&R physician)(e.g., Neurologist, PM&R physician)

Issue Four: Issue Four: Who is Responsible? Who is Responsible? (cont.)(cont.)

Subsequent Evaluations/Treatments:Subsequent Evaluations/Treatments:

TBI:TBI: PNS or PSCT PNS or PSCT (PM&R, (Neuro)Psychology, Speech, (PM&R, (Neuro)Psychology, Speech, Psychiatry)Psychiatry)

PTSD:PTSD: PTSD Program PTSD Program Chronic Pain:Chronic Pain: Pain Program or PM&R Pain Program or PM&R Somatoform Disorder(s):Somatoform Disorder(s): ????? ????? Depression, Anxiety, Stress:Depression, Anxiety, Stress: MHC MHC Seizures, Neurologic Conditions:Seizures, Neurologic Conditions: Neurology Neurology

Primary & Primary & Specialty Specialty ClinicsClinics

Polytrauma Program staff, Polytrauma Program staff, SCI Program staff, or SCI Program staff, or

Designated Specialist(s)Designated Specialist(s)

Programs / Programs / Clinics for Clinics for Identified Identified

ConditionsConditions

Issue Five: Issue Five: Coordination of Care ResponsibilitiesCoordination of Care Responsibilities If a Level I, II, or III Polytrauma Program, If a Level I, II, or III Polytrauma Program,

then the polytrauma teamthen the polytrauma team If not,If not, the system is the system is not clearnot clear who is who is

responsible for making sure evaluations are responsible for making sure evaluations are completed, treatments are initiate, and completed, treatments are initiate, and symptoms/problems are resolvingsymptoms/problems are resolving

But,But, if treatment is if treatment is not successfulnot successful within a within a reasonable time (e.g., 90 days), patients reasonable time (e.g., 90 days), patients should to be referred to a PNS or PRCshould to be referred to a PNS or PRC

Issue Six: Issue Six: Local versus Regional CareLocal versus Regional Care

If the facility has a If the facility has a designated TBI designated TBI specialistspecialist who is assigned to respond to the who is assigned to respond to the TBI Clinical Reminders, then initial TBI Clinical Reminders, then initial assessment and treatment should be assessment and treatment should be locallocal

If not,If not, assessment should be done by the assessment should be done by the nearest nearest PNS or PSCTPNS or PSCT staff staff

If that assessment indicates that local If that assessment indicates that local resources can provide the treatment, resources can provide the treatment, finefine; ; if if not,not, and the problems are deemed to be and the problems are deemed to be TBI-related, then the nearest TBI-related, then the nearest PNSPNS

Issue Seven: Role(s) of Issue Seven: Role(s) of Psychology / NeuropsychologyPsychology / Neuropsychology

Members of the PNS or PSCT staffMembers of the PNS or PSCT staff Assessment and treatment if indicated Assessment and treatment if indicated

Neuropsychological Evaluations (15% of cases)Neuropsychological Evaluations (15% of cases) Psychological Assessments (15-75+% of cases)Psychological Assessments (15-75+% of cases) TBI Rehab InterventionsTBI Rehab Interventions

• Mild TBI Education & SupportMild TBI Education & Support• Compensatory Training / Cognitive RemediationCompensatory Training / Cognitive Remediation

Stress Management, Education, SupportStress Management, Education, Support Specialty TreatmentSpecialty Treatment

• PTSD, Depression, Anxiety, Chronic PainPTSD, Depression, Anxiety, Chronic Pain

Important Mild TBI Important Mild TBI FactsFacts

Causes of Persistent Causes of Persistent Postconcussion SymptomsPostconcussion Symptoms

““Expectation as Etiology”Expectation as Etiology”and/orand/or

“The Good Old Days”“The Good Old Days” Symptom Mis-AttributionSymptom Mis-Attribution

Willey Mittenberg, Ph.D.Willey Mittenberg, Ph.D.

““Diagnostic Threat”Diagnostic Threat”

Julie Suhr, Ph.D.Julie Suhr, Ph.D.

Expectation as EtiologyExpectation as Etiology Controls asked to imagine symptoms of a Controls asked to imagine symptoms of a

mild TBI “expected” symptom presence and mild TBI “expected” symptom presence and severity very similar to mild TBI patients’ severity very similar to mild TBI patients’ actual symptomsactual symptoms

Mild TBI patients “under-estimated” the Mild TBI patients “under-estimated” the frequency and severity of pre-MTBI frequency and severity of pre-MTBI symptoms and problemssymptoms and problems

Athletes “expected” lower levels of post-Athletes “expected” lower levels of post-concussion problems than non-athletesconcussion problems than non-athletes

Athletes with a concussion “over-Athletes with a concussion “over-estimated” pre-concussion levels of estimated” pre-concussion levels of symptomssymptoms

Mild TBI “Diagnostic Threat”Mild TBI “Diagnostic Threat” Non-clinical evaluations of college Non-clinical evaluations of college

students with a remote history of mild TBI students with a remote history of mild TBI (many months earlier)(many months earlier)

Neuropsychological Test PerformanceNeuropsychological Test Performance If told they are participating in If told they are participating in a study of the a study of the

effects of mild TBIeffects of mild TBI, their performance is , their performance is worseworse than,than,

If told they are simply participating in a study If told they are simply participating in a study of cognitive functioning in college studentsof cognitive functioning in college students

The “context” of the evaluation matters!The “context” of the evaluation matters!

Mild TBI TreatmentMild TBI Treatment Change expectation and attribution of Change expectation and attribution of

symptomssymptoms Provide educationProvide education

Education regarding mild TBIEducation regarding mild TBI Education regarding symptoms and Education regarding symptoms and

their coursetheir course Provide Support/TreatmentProvide Support/Treatment

Stress managementStress management Psychological and cognitive coping Psychological and cognitive coping

strategies and resourcesstrategies and resources Cognitive-Behavioral therapyCognitive-Behavioral therapy

If There is TimeIf There is Timewhich there will not bewhich there will not be

What to Expect:What to Expect:Literature Review FindingsLiterature Review Findings

Mild TBI FindingsMild TBI Findings Neuropsychological Test PerformanceNeuropsychological Test Performance Postconcussion SymptomsPostconcussion Symptoms Causes of Postconcussion SymptomsCauses of Postconcussion Symptoms Treatment of Mild TBITreatment of Mild TBI

Neuropsychological Test Neuropsychological Test PerformancePerformance

Mild TBI: Neuropsychological Mild TBI: Neuropsychological Meta-analytic Studies (1)Meta-analytic Studies (1)

(Schretlen & Shapiro, 2003)(Schretlen & Shapiro, 2003)

A second recent meta-analytic study found A second recent meta-analytic study found that that overall neuropsychologicaloverall neuropsychological effect size effect size (d) for MTBI in prospective studies was (d) for MTBI in prospective studies was 0.24 0.24

Categorized into 4 time-since-injury intervals Categorized into 4 time-since-injury intervals the effect sizes were: the effect sizes were:

< 7 days< 7 days 7-29 days7-29 days 30-89 days30-89 days > 89 days> 89 days

0.410.41 0.290.29 0.080.08 0.040.04

(Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, in (Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, in press)press)

A third recent meta-analytic study found the A third recent meta-analytic study found the following, categorized into two time-since-following, categorized into two time-since-injury intervals and three types of studies: injury intervals and three types of studies:

Time Time Post-Inj.Post-Inj.

Litigation Litigation BasedBased

ClinicClinic

BasedBased

UnselectedUnselected

SamplesSamples

< 90 days< 90 days 0.520.52 No studiesNo studies 0.630.63

>> 90 days 90 days 0.780.78 0.740.74 0.040.04

Mild TBI: Neuropsychological Mild TBI: Neuropsychological Meta-analytic Studies (2)Meta-analytic Studies (2)

Vietnam Experience Vietnam Experience Study (VES)Study (VES)

Neuropsychological and Neuropsychological and Postconcussive Symptom Postconcussive Symptom

FindingsFindings

SubjectsSubjects

Vietnam Experience Study Data/Center for Vietnam Experience Study Data/Center for Disease Control Vietnam Experience Study Disease Control Vietnam Experience Study 1988a, 1988b 1988a, 1988b JAMAJAMA

4,462 randomly selected 4,462 randomly selected malemale US Army vets US Army vets

(community dwelling, not clinic-referred or self-(community dwelling, not clinic-referred or self-referred)referred)

Entered military between 1/65 - 12/71Entered military between 1/65 - 12/71 Minimum of 4 months active dutyMinimum of 4 months active duty Served only one tour of dutyServed only one tour of duty

Subjects cont’dSubjects cont’d

Racial makeup of the 4,462 participants:Racial makeup of the 4,462 participants: 81.9% Caucasian81.9% Caucasian 11.8% African-American11.8% African-American 4.5% Hispanic4.5% Hispanic 1.9% Other1.9% Other

Mean age = 38.36 years (SD = 2.53)Mean age = 38.36 years (SD = 2.53) Mean level of education = 13.29 years (SD = 2.3)Mean level of education = 13.29 years (SD = 2.3) Mean IQ = 105 (SD = 20.32) (based on GTT)Mean IQ = 105 (SD = 20.32) (based on GTT)

Subjects cont’dSubjects cont’d

Participants underwent a 3 day evaluation Participants underwent a 3 day evaluation including:including: extensive medical, psychological, and extensive medical, psychological, and

neuropsychological examinationneuropsychological examination included were questions regarding MVA, head included were questions regarding MVA, head

injury, loss of consciousness, and subsequent injury, loss of consciousness, and subsequent hospitalization hospitalization

Evaluations took place approximately 16 Evaluations took place approximately 16 years post-military dischargeyears post-military discharge

MeasuresMeasures

Diagnostic Interview Schedule (DIS-III-A)Diagnostic Interview Schedule (DIS-III-A)

Extensive surveys of physical functioning Extensive surveys of physical functioning and symptomsand symptoms

Battery of neuropsychological testsBattery of neuropsychological tests

Groups and Sample SizesGroups and Sample Sizes

Groups Number No MVA, No Head Injury 3057 MVA, No Head Injury 521 Head Injury with LOC 254

Neuropsychological MeasuresNeuropsychological Measures

Multivariate analysis of variance (MANOVA) Multivariate analysis of variance (MANOVA) was conducted with 14 neuropsychological was conducted with 14 neuropsychological measures, which cover the domains of:measures, which cover the domains of:

» Complex AttentionComplex Attention» Psychomotor Speed Psychomotor Speed

& Coordination& Coordination» Verbal AbilitiesVerbal Abilities» Executive AbilitiesExecutive Abilities

» Non-Verbal AbilitiesNon-Verbal Abilities

(visuospatial)(visuospatial)» Verbal MemoryVerbal Memory» Visual MemoryVisual Memory

Statistical Analyses:Statistical Analyses:Neuropsychological MeasuresNeuropsychological Measures

(Matching groups on premorbid IQ)(Matching groups on premorbid IQ)

MANOVA was not significant MANOVA was not significant

FF(30,7620) = 1.28, (30,7620) = 1.28, pp = 0.14, = 0.14,

eta squared = 0.005eta squared = 0.005

On average, the MTBI group performed On average, the MTBI group performed 0.030.03 of a standard deviation more poorly of a standard deviation more poorly than either control groupthan either control group

Current Cognitive Functioning:Current Cognitive Functioning:Examples of the 14 MeasuresExamples of the 14 Measures

Normal Control (n = 3057)

MVA Control (n = 521)

Mild TBI

(n = 254) Animal Fluency

20.5 (5.1)

21.0 (5.4)

20.7 (5.3)

Rey-O Copy

32.7 (3.4)

32.8 (3.0)

32.7 (3.0)

CVLT Sum of Trials 1 to 5

46.0 (8.7)

45.9 (8.5)

46.3 (9.7)

Postconcussion Postconcussion SymptomsSymptoms

Postconcussion SymptomsPostconcussion Symptoms

PhysicalPhysical Headache, dizziness, fatigue, noise/light Headache, dizziness, fatigue, noise/light

intolerance, insomnia intolerance, insomnia CognitiveCognitive

Memory complaints, poor concentrationMemory complaints, poor concentration EmotionalEmotional

Depression, anxiety, irritability, mood lability Depression, anxiety, irritability, mood lability

PCS Diagnostic CriteriaPCS Diagnostic Criteria

DSM-IVDSM-IVThree or more of:Three or more of:1. Fatigue1. Fatigue2. Disordered Sleep2. Disordered Sleep3. Headache3. Headache4. Dizziness4. Dizziness5. Irritability5. Irritability6. Anxiety, depression, 6. Anxiety, depression, or affective labilityor affective lability

ICD-10 ICD-10

Three or more of:Three or more of:

1.1. Headache, dizziness, Headache, dizziness, malaise, fatigue, or noise malaise, fatigue, or noise intoleranceintolerance

2.2. Irritability, depression, Irritability, depression, anxiety, or emotional labilityanxiety, or emotional lability

3.3. Subjective concentration, Subjective concentration, memory, or intellectual memory, or intellectual difficultiesdifficulties

4.4. Insomnia or affective labilityInsomnia or affective lability

DiagnosisDiagnosis

Normal Normal ControlControl

MVAMVA

ControlControl

MildMild

TBITBI

DSM-IVDSM-IV

PostconcussionPostconcussion

SyndromeSyndrome

1.0 1.0

(20.6%)(20.6%)

1.04 (0.82 - 1.31) 1.04 (0.82 - 1.31)

(25.2%)(25.2%)

2.00 (1.49 - 2.69) 2.00 (1.49 - 2.69)

(40.9%)(40.9%)

ICD-10ICD-10

PostconcussionPostconcussion

SyndromeSyndrome

1.0 1.0

(19.1%)(19.1%)

1.13 (0.90 - 1.44) 1.13 (0.90 - 1.44)

(24.9%)(24.9%)

1.80 (1.33 - 2.43) 1.80 (1.33 - 2.43)

(37.4%)(37.4%)

Odds-Ratios for Occurrence of the Odds-Ratios for Occurrence of the Postconcussion Symptom Complex over Past Postconcussion Symptom Complex over Past

YearYear(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

SymptomSymptom

Normal Normal ControlControl

MVAMVA

ControlControl

MildMild

TBITBI

Balance ProblemsBalance Problems 1.0 (3.4%)1.0 (3.4%) 1.58 (1.02 – 2.45)1.58 (1.02 – 2.45) 2.43 (1.48 – 3.97)2.43 (1.48 – 3.97)

Sensitivity to LightSensitivity to Light 1.0 (3.6%)1.0 (3.6%) 1.14 (0.72 – 1.80)1.14 (0.72 – 1.80) 1.92 (1.15 – 3.20)1.92 (1.15 – 3.20)

Headache ProblemsHeadache Problems 1.0 (13.0%)1.0 (13.0%) 1.15 (0.89 – 1.50)1.15 (0.89 – 1.50) 1.94 (1.42 – 2.68)1.94 (1.42 – 2.68)

Trouble SleepingTrouble Sleeping 1.0 (24.9%)1.0 (24.9%) 1.22 (1.01 – 1.51)1.22 (1.01 – 1.51) 1.85 (1.39 – 2.45)1.85 (1.39 – 2.45)

Double VisionDouble Vision 1.0 (5.7%)1.0 (5.7%) 1.10 (0.75 – 1.61)1.10 (0.75 – 1.61) 1.81 (1.17 – 2.79)1.81 (1.17 – 2.79)

Fatigue EasilyFatigue Easily 1.0 (20.9%)1.0 (20.9%) 1.00 (0.80 – 1.26)1.00 (0.80 – 1.26) 1.42 (1.05 – 1.91)1.42 (1.05 – 1.91)

Odds-Ratios for Various Odds-Ratios for Various Physical/NeurologicalPhysical/Neurological Postconcussion Symptoms During the Past YearPostconcussion Symptoms During the Past Year

(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

SymptomSymptom

Normal Normal ControlControl

MVAMVA

ControlControl

MildMild

TBITBI

Periods of Memory Periods of Memory Loss or ConfusionLoss or Confusion

1.0 (4.4%)1.0 (4.4%) 1.14 (0.76 – 1.72)1.14 (0.76 – 1.72) 2.80 (1.83 – 4.28)2.80 (1.83 – 4.28)

Memory ProblemsMemory Problems 1.0 (13.7%)1.0 (13.7%) 1.13 (0.87 – 1.46)1.13 (0.87 – 1.46) 1.75 (1.28 – 2.41)1.75 (1.28 – 2.41)

Concentration Concentration ProblemsProblems

1.0 (13.4%)1.0 (13.4%) 1.40 (1.10 – 1.80)1.40 (1.10 – 1.80) 1.28 (0.91 – 1.80)1.28 (0.91 – 1.80)

Odds-Ratios for Various Odds-Ratios for Various Cognitive/NeuropsychologicalCognitive/Neuropsychological

Postconcussion Symptoms During the Past YearPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

SymptomSymptom

Normal Normal ControlControl

MVAMVA

ControlControl

MildMild

TBITBI

Irritability or Short Irritability or Short TemperTemper

1.0 (26.5%)1.0 (26.5%) 1.10 (0.89 – 1.35)1.10 (0.89 – 1.35) 1.36 (1.02 – 1.81)1.36 (1.02 – 1.81)

Aggressive and Aggressive and Angry BehaviorAngry Behavior

1.0 (10.2%)1.0 (10.2%) 1.34 (1.02 – 1.77)1.34 (1.02 – 1.77) 1.32 (0.91 – 1.91)1.32 (0.91 – 1.91)

Sadness and Sadness and DepressionDepression

1.0 (11.2%)1.0 (11.2%) 1.28 (0.97 – 1.69)1.28 (0.97 – 1.69) 0.92 (0.62 – 1.37)0.92 (0.62 – 1.37)

AnxiousAnxious 1.0 (13.8%)1.0 (13.8%) 1.29 (0.99 – 1.65)1.29 (0.99 – 1.65) 1.10 (0.77 – 1.56)1.10 (0.77 – 1.56)

Odds-Ratios for Various Odds-Ratios for Various Emotional/PsychologicalEmotional/Psychological

Postconcussion Symptoms During the Past YearPostconcussion Symptoms During the Past Year(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)

Causes of Persistent Causes of Persistent Postconcussion SymptomsPostconcussion Symptoms

““Expectation as Etiology”Expectation as Etiology”and/orand/or

“The Good Old Days”“The Good Old Days” Symptom Mis-AttributionSymptom Mis-Attribution

Willey Mittenberg, Ph.D.Willey Mittenberg, Ph.D.

““Diagnostic Threat”Diagnostic Threat”

Julie Suhr, Ph.D.Julie Suhr, Ph.D.

Expectation as EtiologyExpectation as Etiology Controls asked to imagine symptoms of a Controls asked to imagine symptoms of a

mild TBI “expect” symptom presence and mild TBI “expect” symptom presence and severity very similar to mild TBI patients’ severity very similar to mild TBI patients’ actual symptomsactual symptoms

Mild TBI patients “under-estimate” the Mild TBI patients “under-estimate” the frequency and severity of pre-MTBI frequency and severity of pre-MTBI symptoms and problemssymptoms and problems

Athletes “expect” lower levels of post-Athletes “expect” lower levels of post-concussion problems than non-athletesconcussion problems than non-athletes

Athletes with a concussion “over-estimate” Athletes with a concussion “over-estimate” pre-concussion levels of symptomspre-concussion levels of symptoms

Mild TBI “Diagnostic Threat”Mild TBI “Diagnostic Threat” Non-clinical evaluations of college Non-clinical evaluations of college

students with a remote history of mild TBI students with a remote history of mild TBI (many months earlier)(many months earlier)

Neuropsychological Test PerformanceNeuropsychological Test Performance If told they are participating in If told they are participating in a study of the a study of the

effects of mild TBIeffects of mild TBI, their performance is , their performance is worseworse than,than,

If told they are simply participating in a study If told they are simply participating in a study of cognitive functioning in college studentsof cognitive functioning in college students

The “context” of the evaluation matters!The “context” of the evaluation matters!

Other Factors Influencing the Other Factors Influencing the Development and Persistence Development and Persistence

of of Persistent Postconcussion Persistent Postconcussion

SymptomsSymptoms

Predictors of Persistent PCS:Predictors of Persistent PCS:Vietnam Experience Study DataVietnam Experience Study Data

Examine the influence of the following Examine the influence of the following predictors on the presence of a persistent predictors on the presence of a persistent Postconcussion Symptom Complex Postconcussion Symptom Complex (PPCS) following mild head injury(PPCS) following mild head injury

Predictors:Predictors: demographic variables demographic variables early life psychiatric difficultiesearly life psychiatric difficulties social support variablessocial support variables loss of consciousnessloss of consciousness

ResultsResults Overall model was significantOverall model was significant MTBIMTBI

RR22 = 33.0 = 33.0 MTBI MTBI 2 (26, 2 (26, NN = 532) = 137.85, = 532) = 137.85, pp < .001 < .001

Unique Variance per predictorUnique Variance per predictor MTBIMTBI demographic variablesdemographic variables (9.2%)(9.2%) early life psychiatric symptomsearly life psychiatric symptoms (6.3%)(6.3%)

• Internalizing (e.g., depression/anxiety)Internalizing (e.g., depression/anxiety) (4.9%)(4.9%)• Externalizing (ASP, alcohol, drugs)Externalizing (ASP, alcohol, drugs) (0.9%)(0.9%)

social supportsocial support (4.9%)(4.9%) LOC / MVALOC / MVA (1.4%)(1.4%) 2-way Interactions2-way Interactions (5.4%)(5.4%) 3-way Interactions3-way Interactions (0.1%)(0.1%)

Contribution of Contribution of Demographic Variables in MTBIDemographic Variables in MTBI MTBIMTBI

Overall Demogr. VarianceOverall Demogr. Variance 9.2% 9.2%

unique varianceunique variance VariableVariable MTBIMTBI

Age at evaluationAge at evaluation 0.9%0.9%

Level of education Level of education 0.2%0.2%

Race Race 0.3%0.3%

IntelligenceIntelligence 3.3%3.3%

MTBI:MTBI:Intelligence by LOC (1.8%)Intelligence by LOC (1.8%)

Frequency of PPCS by Level of Premorbid Intelligence and LOC

10

20

30

40

50

60

70

GTT < 96 GTT 96 - 114 GTT > 114

Freq

uenc

y of

PP

CS

C

LOC

No LOC

MTBI:MTBI:Intelligence by Social Support (1.2%)Intelligence by Social Support (1.2%)

Frequency of PPCS by Level of Premorbid Intelligence and Level of Social Support

0

10

20

30

40

50

60

70

80

Poor Social Support Average SocialSupport

Good Social Support

Freq

uenc

y of

PP

CS

C

GTT < 96

GTT 96 - 114

GTT > 114

MTBI:MTBI:Internalizing by Social Support (1.0%)Internalizing by Social Support (1.0%)

Frequency of PPCS by History of Premorbid Internalizing problems and Level of Social Support

10

20

30

40

50

60

70

80

Poor Social Support Average SocialSupport

Good Social Support

Freq

uenc

y of

PP

CS

C

Internalizing Problems

No Internalizing Problems

PCS ConclusionsPCS Conclusions

LOC is only a small factor in predicting LOC is only a small factor in predicting the presence of PPCS (1.4% unique the presence of PPCS (1.4% unique variance) in MHIvariance) in MHI

Multiple factors and their interactions Multiple factors and their interactions accounted for approximately 33% of the accounted for approximately 33% of the variance in PPCS status in the sample variance in PPCS status in the sample with MHIwith MHI

PCS ConclusionsPCS Conclusions

Within a MTBI sample: Within a MTBI sample: Lower pre-injury intellectual ability,Lower pre-injury intellectual ability, Less poor social support, andLess poor social support, and More early life emotional problems (e.g., More early life emotional problems (e.g.,

depression, anxiety)depression, anxiety)

were associated with higher frequencies of were associated with higher frequencies of Persistent PCSPersistent PCS

Loss of consciousness (MTBI) interacts with Loss of consciousness (MTBI) interacts with cognitive reserve in influencing the cognitive reserve in influencing the development or persistence of PCSdevelopment or persistence of PCS

Treatment of Mild TBITreatment of Mild TBI

Mild TBI TreatmentMild TBI Treatment Change expectation and attribution of Change expectation and attribution of

symptomssymptoms Provide educationProvide education

Education regarding mild TBIEducation regarding mild TBI Education regarding symptoms and Education regarding symptoms and

their coursetheir course Provide Support/TreatmentProvide Support/Treatment

Stress managementStress management Psychological and cognitive coping Psychological and cognitive coping

strategies and resourcesstrategies and resources Cognitive-Behavioral therapyCognitive-Behavioral therapy

ReferencesReferences Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg, Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg,

R. D. (2005). Factors moderating neuropsychological outcomes following R. D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: A Meta-analysis. mild traumatic brain injury: A Meta-analysis. Journal of the International Journal of the International Neuropsychological SocietyNeuropsychological Society, , 1111, 215-227. , 215-227.

Belanger, H.G., & Vanderploeg, R.D. (2005). The Neuropsychological Belanger, H.G., & Vanderploeg, R.D. (2005). The Neuropsychological Impact of Sports-Related Concussion: A Meta-Analysis. Impact of Sports-Related Concussion: A Meta-Analysis. Journal of the Journal of the International Neuropsychological SocietyInternational Neuropsychological Society, , 1111, 345-357., 345-357.

Luis, C. A., Vanderploeg, R. D., Curtiss, G. (2003). Predictors for a Luis, C. A., Vanderploeg, R. D., Curtiss, G. (2003). Predictors for a postconcussion symptom complex in community dwelling male veterans. postconcussion symptom complex in community dwelling male veterans. Journal of the International Neuropsychology SocietyJournal of the International Neuropsychology Society, , 99, 1001-1015., 1001-1015.

Miller, L.J. & Mittenberg, W. (1998). Brief cognitive behavioral interventions Miller, L.J. & Mittenberg, W. (1998). Brief cognitive behavioral interventions in mild traumatic brain injury. in mild traumatic brain injury. Applied NeuropsychologyApplied Neuropsychology, , 55, 172-183. , 172-183.

Mittenberg, W., Tremont, G., Zeilinski, R., Fichera, S., & Rayls, K. (1996). Mittenberg, W., Tremont, G., Zeilinski, R., Fichera, S., & Rayls, K. (1996). Cognitive behavioral prevention of postconcussion syndrome. Cognitive behavioral prevention of postconcussion syndrome. Archives of Archives of Clinical Neuropsychology, 11, Clinical Neuropsychology, 11, 139-145.139-145.

Mittenberg, W., Zielinski, R.E., & Fichera, S. (1993). Recovery from mild Mittenberg, W., Zielinski, R.E., & Fichera, S. (1993). Recovery from mild head injury: A treatment manual for patients. head injury: A treatment manual for patients. Psychotherapy in Private Psychotherapy in Private Practice, 12, Practice, 12, 37-52.37-52.

ReferencesReferences Schretlen, D. J., & Shapiro, A. M. (2003). A quantitative review of the effects Schretlen, D. J., & Shapiro, A. M. (2003). A quantitative review of the effects

of traumatic brain injury on cognitive functioning. of traumatic brain injury on cognitive functioning. International Review of International Review of PsychiatryPsychiatry, , 1515, 341-349., 341-349.

Suhr, J.A. & Gunstad, J. (2005). Further exploration of the effect of Suhr, J.A. & Gunstad, J. (2005). Further exploration of the effect of “diagnosis threat” on cognitive performance in individuals with mild head “diagnosis threat” on cognitive performance in individuals with mild head injury. injury. Journal of the International Neuropsychological SocietyJournal of the International Neuropsychological Society, , 1111, 23-29., 23-29.

Vanderploeg, R. D., Curtiss, G., & Belanger, H. G. (2005). Adverse long-Vanderploeg, R. D., Curtiss, G., & Belanger, H. G. (2005). Adverse long-term neuropsychological outcomes following mild traumatic brain injury. term neuropsychological outcomes following mild traumatic brain injury. Journal of the International Neuropsychological SocietyJournal of the International Neuropsychological Society, , 1111, 228-236. , 228-236.

Vanderploeg, R.D., Belanger, H.G., & Curtiss, G. (2006). Mild Traumatic Vanderploeg, R.D., Belanger, H.G., & Curtiss, G. (2006). Mild Traumatic Brain Injury: Medical and Neuropsychological Causality Modeling. (pp. Brain Injury: Medical and Neuropsychological Causality Modeling. (pp. 279-307). In Young, G., Kane, A. & Nicholson, K. (Eds.), 279-307). In Young, G., Kane, A. & Nicholson, K. (Eds.), Psychological Psychological Knowledge in Court: PTSD, Pain and TBIKnowledge in Court: PTSD, Pain and TBI. New York: Springer-Verlag.. New York: Springer-Verlag.

Vanderploeg, R.D. (2004). Veterans Health Initiative: Traumatic Brain Injury. Vanderploeg, R.D. (2004). Veterans Health Initiative: Traumatic Brain Injury. (Editor). VA Employee Education System. Web-based physician, (Editor). VA Employee Education System. Web-based physician, psychologist, & other health care professionals CME/CEU training program. psychologist, & other health care professionals CME/CEU training program. http://www1.va.gov/vhi/docs/TBIfinal_www.pdfhttp://www1.va.gov/vhi/docs/TBIfinal_www.pdf [1-31-04] [1-31-04]

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