Transcript Presentation 3 - Equal Justice Works
Traumatic Brain Injury in Veterans
Robyn Mehlenbeck, PhD* Equal Justice Works Leadership Development Training October 23, 2014 Washington, DC * George Mason University
WHAT IS TBI?
Traumatic Brain Injury:
• 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 2
Causes of TBI
• • • •
•
•
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 4 (http://www.ninds.nih.gov/disorders/tbi/detail_tbi.htm)
Combat-Related TBI
• 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 5
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 • Neuropsychology - PhD • Specialty that assesses, diagnoses and treats problems with TBI, among other nervous system problems • Treats the physical symptoms and causes of TBI • • Looking for behavioral manifestations of TBI Assesses and treats the cognitive, behavioral and psychological effects of the TBI
Types of TBI
• Two major types of traumatic brain injury
• Penetrating brain injury • Closed head injury 9
Penetrating TBI
• 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 10
11
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
• • • • • • • •
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 14
Closed-head Injury Illustration
( http://health.allrefer.com/health/head-injury-prevention.html
)
What does it mean to have a TBI?
Typical Impairments:
Communication Thinking/Executive Functioning Psychological 16
Communication Difficulties
• •
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 17
Communication Difficulties
• • • • •
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 18
Cognitive Difficulties
•
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 19
Cognitive Difficulties
• • • • • • •
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) 20
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
– Cognitive/Achievement WAIS-V; Woodcock Johnson
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
• 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 24