TBI, PTSD and Addiction
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Transcript TBI, PTSD and Addiction
Kristine Burkman, Ph.D.
Staff Psychologist
San Francisco VA Medical Center
ASAM Disclosure of
Relevant Financial Relationships
Content of Activity:
ASAM Medical –Scientific Conference 2013
Name
Kristine
Burkman, Ph.D.
Commercial
Interests
Relevant
Financial
Relationships:
What Was
Received
Relevant
Financial
Relationships:
For What Role
No Relevant
Financial
Relationships
with Any
Commercial
Interests
X
Definitions
Assessment
Prevalence
Overlapping Symptoms
Treatment Considerations
Suggested Strategies
a traumatically induced physiologic disruption of brain
function, as manifested by one of the following:
Loss of consciousness
Loss of memory for events immediately before or after the accident
Alteration of mental state at the time of the accident (e.g., feeling
dazed, disoriented, or confused)
Focal neurological deficit(s) that may or may not be transient
American Congress of Rehabilitation Medicine (ACRM)
KEEP IN MIND: TBI refers to original injury or etiology, there are
no symptoms for this diagnosis
Specifiers: Mild, Moderate, Severe
Refers to 24-48 hours following injury.
Severity of initial injury ≠ impairment in functioning
Prognosis often related to:
Length of loss of consciousness
Length of post traumatic amnesia
Eye opening
Spontaneous = 4
To speech = 3
To painful stimulation = 2
No response = 1
Verbal response
Oriented to person, place & date = 5
Converses but is disoriented = 4
Says inappropriate words = 3
Says incomprehensible sounds = 2
No response = 1
Motor response
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Follows commands = 6
Makes localizing movements to pain = 5
Makes withdrawal movements to pain = 4
Flexor (decorticate) posturing to pain = 3
Extensor (decerebrate) posturing to pain = 2
No response = 1
SCORING
Specifier is based on score
within 48 hrs of injury:
Severe = 1 - 8
Moderate = 9 - 12
Mild = 13 - 15
Not routinely assessed in combat situations
VA assesses via self-report months, even years after the
event
Screen (4 items, sensitive not specific)
Second level eval (22 items)
Often not documented
and military culture may
encourage minimization
91% of OEF/OIF casualties survive1
Compared to 84% of Vietnam, 80% WWII
Estimated 22% of returning servicemembers have
reported experiencing TBIs and concussions2
Of those injured, approximately 31% diagnosed w/ TBI3
77% of all head injuries are mild TBI4
1Holcomb
et al., 2006, 2Terrio et al., 2005,
3Hayward, 2008, 4Fischer, 2010
Persons w/ TBI more likely to have 2nd and 3rd TBI1
Repeat TBIs increase severity and chronicity of symptoms1
Twice as likely to screen positive for PTSD or
depression2
Increased risk for suicide3
1Center
for Disease Control (CDC); 2Maguen, Lau,
Madden & Seal, 2012; 3Brenner, Ignacio & Blow, 2011
Complicated literature
Bi-directional relationship between TBI and SUD
Pre-injury pattern of substance use predicts post-injury pattern
of use
Substance use impairs rehabilitation
and exacerbates symptoms
Increased risk of additional injury
Co-Occurring Disorders
SUD + Depression, 3-5 time more likely to relapse1
SUD + PTSD relapse more quickly 2,3
Co-occurring patterns of relapse 2, 4
Exposure to Trauma
Probability of relapse increases as the # of traumas types increase 5
1Curran
et al., 2000; 2Brown et al., 1996; 3Ouimette et al., 1997;
4Curran & Booth, 1999; 5Fraley et al., 1998
Feeling dizzy
Loss of balance
Poor coordination, clumsy
Headaches
Vision Problems
Sensitivity to Light
Nausea
Hearing difficulties
Sensitivity to noise
Numbness
Change in taste and/or smell
Loss/increase in appetite
Difficulty concentrating
Forgetfulness
Difficulty making decisions
Slowed thinking, disorganized
Fatigue, loss of energy
Feeling depressed or sad
Difficulty falling or staying asleep
Feeling anxious or tense
Irritability, easily annoyed
Poor frustration tolerance, easily
overwhelmed
Re-experiencing
Hyperarousal
Intrusive images, memories, thoughts
Nightmares
Flashbacks
Emotional distress at reminders
Physical reaction to reminders
Avoidant
Avoiding thinking/talking about trauma
Avoiding situations
Trouble remembering aspects of trauma
Loss of interest in activities used to enjoy
Feeling distant/ cut-off from others
Emotionally numb
Foreshortened sense of future
Insomnia
Irritability
Difficulty concentrating
Hypervigilence
Startle response
Common Challenges
Impulse Control
Frontal Lobe
Inhibited
Planning
Abstraction
Limbic System
Activated
Judgment
Emotion
Memory
Sleep problems
Dizziness
Headaches
Memory
problems
Light
sensitivity
Irritability
TBI
Depression
PTSD
Loss of interest
Feeling down,
hopeless
Emotional numbing
Avoidance
Nightmares
Hypervigilence
Maguen, Lau, Madden, Seal, 2012
Missed appointments
Avoidance, memory problems, difficulty w/ initiation, inability
to organize effectively, relapse
Difficulty tracking or recalling skills
Frustrated w/ pace, embarrassment in session
Crisis-prone
Relationships, work/school, legal, psychiatric crises
Distorted expectations and beliefs
Phase Based Model of Recovery
Stabilization
-Psychoeducation
-Coping skills
-Psychopharmacology
Establish “safety”
Improve self-regulation
Processing
-Construction of narrative
-Cognitive restructuring
-Exposure
Consolidation of memory
Habituation of fear response
Integration
-Interpersonal work
-Insight/existential
-Symptom maintenance
Reconnect with others/life
Meaning of experience
Titrate level of emotional content re: trauma material
Assess level impairment re: memory and emotion regulation to
inform when and how to approach trauma processing
Fear of symptoms exacerbation
Drop out rates
Insufficient training for protocol
among clinicians
“Fragile” patients
Chaotic/ high risk situations
KEEP IN MIND: Mild TBI should
resolve fully within 6 months, debate
over cause of ongoing symptoms
Integrated treatment of TBI, PTSD and
SUD is recommended!
Flexibility
Persistent outreach
Validate, reassure, challenge
Acknowledge problems as real to veteran
Education re: relapse, heterogeneity of injuries, expectation of
recovery from mTBI
Goal of recovery not adjustment to permanent disability
Multidisciplinary team
Harm reduction
MEMORY &
LEARNING
PROCESSING
SPEED
Write it down
Plan Ahead
Organize
Allow extra time
Visualize Info
Attach emotion
Repetition
Accuracy over
speed
Avoid
multitasking
Flexible
deadlines
FRONTAL LOBE
DAMAGE
Include support
members
Emotional
awareness &
management
Routine
Encourage
persistence
Keep it simple
Go slow
Write it down
Encourage veteran to
communicate back what
he/she understands
Repeat
Thank you for serving our Veterans!
Questions?
[email protected]