Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process Rodney D. Vanderploeg, Ph.D.

Tampa VAMC VA Psychology Leadership Conference/APA May 18, 2007

Objectives

 Provide an overview of the TBI Clinical Reminder screening process  Describe a model follow-up evaluation and treatment process  Describe when and how neuropsychological evaluations should be completed  Describe other roles of psychology following positive TBI Clinical Reminders

Although I love Harry Potter

There is No Magic!

And, things like this are Pseudo-Magic “Automatic Clock Drawing Test”

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

New!

5 minute evaluation

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

 ASK THEM:  Did you experience a physical trauma or injury that resulted in your being: • Knocked out / Rendered unconscious, • Dazed and confused for several minutes, and/or • With memory gaps for some or all of the immediate period after the event  If the answer is “yes”, then they had a TBI

That is what the “TBI Screening Reminder” Does

TBI Screening Reminder

April 2007

So, what really are the issues?

1.

Who has ongoing symptoms and problems?

2.

What are these symptoms and problems due to (TBI, PTSD, Depression, Anxiety, Somatoform Disorder, malingering, combinations of conditions)?

3.

4.

5.

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

Who is responsible for providing the assessment and treatment?

Who is responsible for coordinating this process?

6.

7.

When should this be done locally, and when should it be done by regional specialists?

What are the roles of psychology in points 3-6?

“TBI Screening Reminder” Functions

 Identify possible OIF/OEF Participants  Confirm deployment to OIF/OEF Theatres of Deployment  Screen for TBI if deployed in OIF/OEF Theatres  Identify those with an OIF/OEF-related history of TBI

Criteria for Severity of TBI

Mild Moderate

LOC < 30 min with normal CT &/or MRI LOC < 6 hours with abnormal CT &/or MRI GCS 13-15 GCS 9-12 PTA < 24hr PTA < 7days

Severe

LOC > 6 hours with abnormal CT &/or MRI GCS < 9 PTA > 7days Don’t confuse combat-trauma psychological confusion with post-TBI PTA (i.e., inability to lay down new memories and therefore having post TBI “memory gaps”)

Screening Questions: 4 Sections

 Section 1:

Trauma Events

 Section 2:

Immediate Disturbance of Consciousness

Symptoms after Events  Section 3:

New or Worsening

Symptoms after the event  Section 4:

Current

Symptoms

Screen Interpretations

 A “no” response to any of the sections terminates screening and is a “negative screen”  A “yes” response to ALL FOUR sections is a “positive screen”

Section 1:

Trauma Events

Section 2:

Immediate

Symptoms

Section 3:

New/Worsening

Symptoms

Section 4:

Current

Symptoms

Positive TBI Screen: Follow-up

 Positive replies in all four sections constitute a positive screen  Positive screens automatically generate a consult to a TBI specialist or clinic  This specialist/clinic has 1 week to initiate contact with patient for more detailed follow-up evaluation  Initial treatment trial is based on positive problems on this follow-up evaluation

What to Know: Relevant Background (1)

 Mild TBI Symptoms  There is

no symptom diagnostic

of mild TBI that is

unique

to or  Many postconcussion symptoms occur in normal healthy individuals  All symptoms/problems overlap with one or more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions)

What to Know: Relevant Background (2)

 In prospective cases (non-clinical, non legal) virtually all symptoms of mild TBI resolve within 1 - 3 months  Cognitive  Emotional  Physical  Yet, a subgroup (about 10-15%) continue to experience a postconcussive syndrome  Psychological factors play a large role in symptom presence in this subgroup

What to Know: Relevant Background (3)

 In this subgroup (of about 10-15%)  There is no relationship between symptom complaints and objective findings on: • • • Neuropsychological Testing Physical Examination Neurological Examination  Again, this is because

psychological factors

play a large role in symptom complaints

Predisposing Factors

Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Demographic Characteristics Coping Abilities

Causative Factors

Medical Iatrogenesis Litigation Iatrogenesis

Perpetuating and Mitigating Factors

Psychiatric Conditions Personality Traits Self Expectation mTBI Medical Conditions Acute Symptoms Intelligence Level Coping Abilities Social Support Chronic Symptoms

Predisposing Factors

Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Demographic Characteristics Coping Abilities

Causative Factors

Medical Iatrogenesis Litigation Iatrogenesis

Perpetuating and Mitigating Factors

Psychiatric Conditions Personality Traits Self Expectation Medical Conditions mTBI Acute Symptoms

Psychological Contributions

Intelligence Level Coping Abilities Social Support Chronic Symptoms

Issue One

1.

Who has ongoing symptoms and problems?

 Anyone who responds positively to all four of the TBI Clinical Reminder sections Section 1:Trauma

Event(s)

Section 2:

Immediate Disturbance of Consciousness

after Event(s) Section 3:

New or Worsening

the event(s) Symptoms after Section 4:

Current

Symptoms

Issue Two: Symptom Etiologies

2.

What are these symptoms and problems due to (TBI, PTSD, Depression, Anxiety, Somatoform Disorder, malingering, combinations of conditions)?

 Initial post-TBI Clinical Reminder Assessment (at Tampa and elsewhere)     Telephone Administration of: History Questions (e.g., confirmation of exposure, details of TBI severity, history of symptom course), Review of bodily systems and associated complaints, etc.

Neurobehavioral Symptom Inventory (22 items rating postconcussive symptoms) PTSD Checklist (PCL) Pain symptoms

Issue Two: Symptom Etiologies

 Interpretation of Initial Assessment Findings    What are the most likely etiologies for the symptoms?

What etiology(s) is/are primary?

(Does PTSD, chronic pain, sleep disturbance likely explain the cognitive symptoms?) Would successful treatment of the primary etiology likely resolve most or all of the symptoms?

 Referring and Triaging: Refer accordingly for further evaluation and/or treatment

Issue Two: Symptom Etiologies

 When to Refer

Refer if the evaluation/referral will:

 Tell you something you don’t already know  Make a difference in the patient’s treatment or management

Turning Down a Consult for Neuropsychological Assessment

 Referral received and chart reviewed. Veteran currently has severe symptoms of PTSD and chronic headaches. Given this, his cognitive complaints of memory and concentration problems are expected. If testing were performed in this situation, any cognitive impairments would likely be attributed to the severity and extent of the mental health problems. Testing would not clarify diagnostic issues nor guide treatment - because mental health and pain management treatment should to be the main focus at this time.  Once his mental health and pain symptoms are better managed, and rated as no worse than mild to moderate, if cognitive symptoms remain, a re-referral at that time may be clinically useful.

Issue Two: Symptom Etiologies

 Follow-up Additional Specialized Assessments (and then treatment)      

TBI:

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

PTSD:

PTSD Program

Chronic Pain:

Pain Program or PM&R

Somatoform Disorder(s):

?????

Depression, Anxiety, Stress:

MHC

Seizures, Neurologic Conditions:

Neurology

Issue Three: Appropriate Treatment(s)

 Treat the primary condition(s), the one(s) that explains most or all of the symptoms  Don’t invest time and effort in conditions that account for only small amounts of symptom variance  Just because a condition was/is present (e.g., history of mild TBI), doesn’t mean it should be the focus of further assessment or treatment if other conditions are primary

? Mild TBI Residual + PTSD

Re-experiencing Avoidance Social withdrawal Memory gaps Apathy Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness

+ Depression

Arousal Sensitive to noise Concentration Insomnia Irritability

Issue Four: Who is Responsible?

 TBI Clinical Reminder: Primary and Specialty Clinics (including Urgent Care, MHC, PTSD, Dental, etc.)  Initial Follow-up Assessment:    Polytrauma Program staff (Level II: PNS or Level III: PSCT), SCI Program staff, or Local Designated Specialist(s) - Physician (e.g., Neurologist, PM&R physician)

Issue Four: Who is Responsible?

(cont.)  Subsequent Evaluations/Treatments:      

TBI:

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

PTSD:

PTSD Program

Chronic Pain:

Pain Program or PM&R

Somatoform Disorder(s):

?????

Depression, Anxiety, Stress:

MHC

Seizures, Neurologic Conditions:

Neurology

Primary & Specialty Clinics

Polytrauma Program staff, SCI Program staff, or Designated Specialist(s)

Programs / Clinics for Identified Conditions

Issue Five: Coordination of Care Responsibilities

 If a Level I, II, or III Polytrauma Program, then the polytrauma team  If not, the system is not clear who is responsible for making sure evaluations are completed, treatments are initiate, and symptoms/problems are resolving  But, if treatment is not successful within a reasonable time (e.g., 90 days), patients should to be referred to a PNS or PRC

Issue Six: Local versus Regional Care

 If the facility has a designated TBI specialist who is assigned to respond to the TBI Clinical Reminders, then initial assessment and treatment should be local  If not, assessment should be done by the nearest PNS or PSCT staff  If that assessment indicates that local resources can provide the treatment, fine; if not, and the problems are deemed to be TBI-related, then the nearest PNS

Issue Seven: Role(s) of Psychology / Neuropsychology

 Members of the PNS or PSCT staff  Assessment and treatment if indicated  Neuropsychological Evaluations (15% of cases)  Psychological Assessments (15-75+% of cases)  TBI Rehab Interventions • Mild TBI Education & Support • Compensatory Training / Cognitive Remediation  Stress Management, Education, Support  Specialty Treatment • PTSD, Depression, Anxiety, Chronic Pain

Important Mild TBI Facts

Causes of Persistent Postconcussion Symptoms

“Expectation as Etiology” and/or “The Good Old Days”

 Symptom Mis-Attribution  Willey Mittenberg, Ph.D.

 “Diagnostic Threat”  Julie Suhr, Ph.D.

Expectation as Etiology

 Controls asked to imagine symptoms of a mild TBI “expected” symptom presence and severity very similar to mild TBI patients’ actual symptoms  Mild TBI patients “under-estimated” the frequency and severity of pre-MTBI symptoms and problems  Athletes “expected” lower levels of post concussion problems than non-athletes  Athletes with a concussion “over-estimated” pre-concussion levels of symptoms

Mild TBI “Diagnostic Threat”

 Non-clinical evaluations of college students with a remote history of mild TBI (many months earlier)  Neuropsychological Test Performance  If told they are participating in a study of the effects of mild TBI, their performance is worse than,   If told they are simply participating in a study of cognitive functioning in college students The “context” of the evaluation matters!

Mild TBI Treatment

 Change expectation and attribution of symptoms  Provide education   Education regarding mild TBI Education regarding symptoms and their course  Provide Support/Treatment    Stress management Psychological and cognitive coping strategies and resources Cognitive-Behavioral therapy

If There is Time

which there will not be

What to Expect: Literature Review Findings

 Mild TBI Findings  Neuropsychological Test Performance  Postconcussion Symptoms  Causes of Postconcussion Symptoms  Treatment of Mild TBI

Neuropsychological Test Performance

Mild TBI: Neuropsychological

Meta-analytic Studies (1)

(Schretlen & Shapiro, 2003)  A second recent meta-analytic study found that overall neuropsychological effect size (d) for MTBI in prospective studies was 0.24  Categorized into 4 time-since-injury intervals the effect sizes were:

< 7 days 7-29 days 0.41

0.29

30-89 days 0.08

> 89 days 0.04

Mild TBI: Neuropsychological

Meta-analytic Studies (2)

(Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, in press)  A third recent meta-analytic study found the following, categorized into two time-since injury intervals and three types of studies:

Time Post-Inj.

< 90 days > 90 days Litigation Based 0.52

0.78

Clinic Based No studies Unselected Samples 0.63

0.74

0.04

Vietnam Experience Study (VES)

Neuropsychological and Postconcussive Symptom Findings

Subjects

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

JAMA

 4,462 randomly selected male US Army vets (community dwelling, not clinic-referred or self referred)  Entered military between 1/65 - 12/71  Minimum of 4 months active duty  Served only one tour of duty

Subjects cont’d

 Racial makeup of the 4,462 participants:  81.9% Caucasian  11.8% African-American  4.5% Hispanic  1.9% Other  Mean age = 38.36 years (SD = 2.53)  Mean level of education = 13.29 years (SD = 2.3)  Mean IQ = 105 (SD = 20.32) (based on GTT)

Subjects cont’d

 Participants underwent a 3 day evaluation including:  extensive medical, psychological, and neuropsychological examination  included were questions regarding MVA, head injury, loss of consciousness, and subsequent hospitalization  Evaluations took place approximately 16 years post-military discharge

Measures

 Diagnostic Interview Schedule (DIS-III-A)  Extensive surveys of physical functioning and symptoms  Battery of neuropsychological tests

Groups and Sample Sizes

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

Neuropsychological Measures

 Multivariate analysis of variance (MANOVA) was conducted with 14 neuropsychological measures, which cover the domains of: » Complex Attention » Non-Verbal Abilities » » Psychomotor Speed & Coordination Verbal Abilities » » (visuospatial) Verbal Memory Visual Memory » Executive Abilities

Statistical Analyses: Neuropsychological Measures (Matching groups on premorbid IQ)

 MANOVA was not significant F(30,7620) = 1.28, p = 0.14, eta squared = 0.005

 On average, the MTBI group performed 0.03

of a standard deviation more poorly than either control group

Current Cognitive Functioning: Examples of the 14 Measures

Animal Fluency Rey-O Copy CVLT Sum of Trials 1 to 5 Normal Control (n = 3057) 20.5 (5.1) 32.7 (3.4) 46.0 (8.7) MVA Control (n = 521) 21.0 (5.4) 32.8 (3.0) 45.9 (8.5) Mild TBI (n = 254) 20.7 (5.3) 32.7 (3.0) 46.3 (9.7)

Postconcussion Symptoms

Postconcussion Symptoms

 Physical  Headache, dizziness, fatigue, noise/light intolerance, insomnia  Cognitive  Memory complaints, poor concentration  Emotional  Depression, anxiety, irritability, mood lability

PCS Diagnostic Criteria

DSM-IV ICD-10

Three or more of: 1. Fatigue 2. Disordered Sleep 3. Headache 4. Dizziness 5. Irritability 6. Anxiety, depression, or affective lability Three or more of: 1. Headache, dizziness, malaise, fatigue, or noise intolerance 2. Irritability, depression, anxiety, or emotional lability 3. Subjective concentration, memory, or intellectual difficulties 4. Insomnia or affective lability

Odds-Ratios for Occurrence of the Postconcussion Symptom Complex over Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Diagnosis DSM-IV Postconcussion Syndrome Normal Control 1.0 (20.6%) MVA Control Mild TBI 1.04 (0.82 - 1.31) (25.2%) 2.00 (1.49 - 2.69) (40.9%) ICD-10 Postconcussion Syndrome 1.0 (19.1%) 1.13 (0.90 - 1.44) (24.9%) 1.80 (1.33 - 2.43) (37.4%)

Odds-Ratios for Various Physical/Neurological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control MVA Control Mild TBI Balance Problems 1.0 (3.4%) 1.58 (1.02 – 2.45) 2.43 (1.48 – 3.97) Sensitivity to Light 1.0 (3.6%) 1.14 (0.72 – 1.80) 1.92 (1.15 – 3.20) Headache Problems 1.0 (13.0%) 1.15 (0.89 – 1.50) 1.94 (1.42 – 2.68) Trouble Sleeping Double Vision Fatigue Easily 1.0 (24.9%) 1.22 (1.01 – 1.51) 1.85 (1.39 – 2.45) 1.0 (5.7%) 1.10 (0.75 – 1.61) 1.81 (1.17 – 2.79) 1.0 (20.9%) 1.00 (0.80 – 1.26) 1.42 (1.05 – 1.91)

Odds-Ratios for Various Cognitive/Neuropsychological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control Periods of Memory Loss or Confusion 1.0 (4.4%) Memory Problems 1.0 (13.7%) MVA Control Mild TBI 1.14 (0.76 – 1.72) 2.80 (1.83 – 4.28) 1.13 (0.87 – 1.46) 1.75 (1.28 – 2.41) Concentration Problems 1.0 (13.4%) 1.40 (1.10 – 1.80) 1.28 (0.91 – 1.80)

Odds-Ratios for Various Emotional/Psychological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control Irritability or Short Temper 1.0 (26.5%) Aggressive and Angry Behavior Sadness and Depression Anxious 1.0 (10.2%) 1.0 (11.2%) 1.0 (13.8%) MVA Control 1.10 (0.89 – 1.35) 1.34 (1.02 – 1.77) 1.28 (0.97 – 1.69) 1.29 (0.99 – 1.65) Mild TBI 1.36 (1.02 – 1.81) 1.32 (0.91 – 1.91) 0.92 (0.62 – 1.37) 1.10 (0.77 – 1.56)

Causes of Persistent Postconcussion Symptoms

“Expectation as Etiology” and/or “The Good Old Days”

 Symptom Mis-Attribution  Willey Mittenberg, Ph.D.

 “Diagnostic Threat”  Julie Suhr, Ph.D.

Expectation as Etiology

 Controls asked to imagine symptoms of a mild TBI “expect” symptom presence and severity very similar to mild TBI patients’ actual symptoms  Mild TBI patients “under-estimate” the frequency and severity of pre-MTBI symptoms and problems  Athletes “expect” lower levels of post concussion problems than non-athletes  Athletes with a concussion “over-estimate” pre-concussion levels of symptoms

Mild TBI “Diagnostic Threat”

 Non-clinical evaluations of college students with a remote history of mild TBI (many months earlier)  Neuropsychological Test Performance  If told they are participating in a study of the effects of mild TBI, their performance is worse than,   If told they are simply participating in a study of cognitive functioning in college students The “context” of the evaluation matters!

Other Factors Influencing the Development and Persistence of Persistent Postconcussion Symptoms

Predictors of Persistent PCS: Vietnam Experience Study Data

 Examine the influence of the following predictors on the presence of a persistent Postconcussion Symptom Complex (PPCS) following mild head injury  Predictors:     demographic variables early life psychiatric difficulties social support variables loss of consciousness

Results

 Overall model was significant  MTBI

R 2 = 33.0

MTBI



2 (26, N = 532) = 137.85, p < .001

 Unique Variance per predictor  

demographic variables early life psychiatric symptoms

• •

Internalizing (e.g., depression/anxiety) Externalizing (ASP, alcohol, drugs)



social support

  

LOC / MVA 2-way Interactions 3-way Interactions

MTBI

(9.2%) (6.3%) (4.9%) (0.9%) (4.9%) (1.4%) (5.4%) (0.1%)

Contribution of Demographic Variables in MTBI

Overall Demogr. Variance

Variable

Age at evaluation Level of education Race Intelligence MTBI

9.2%

unique variance

MTBI 0.9% 0.2% 0.3% 3.3%

MTBI: Intelligence by LOC (1.8%)

Frequency of PPCS by Level of Premorbid Intelligence and LOC

40 30 20 10 70 60 50 LOC No LOC GTT < 96 GTT 96 - 114 GTT > 114

MTBI: Intelligence by Social Support (1.2%)

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

80 70 60 50 40 30 20 10 0 Poor Social Support GTT < 96 GTT 96 - 114 GTT > 114 Average Social Support Good Social Support

MTBI: Internalizing by Social Support (1.0%)

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

80 70 60 50 40 30 20 10 Poor Social Support Internalizing Problems No Internalizing Problems Average Social Support Good Social Support

PCS Conclusions

 LOC is only a small factor in predicting the presence of PPCS (1.4% unique variance) in MHI  Multiple factors and their interactions accounted for approximately 33% of the variance in PPCS status in the sample with MHI

PCS Conclusions

 Within a MTBI sample:  Lower pre-injury intellectual ability,  Less poor social support, and  More early life emotional problems (e.g., depression, anxiety) were associated with higher frequencies of Persistent PCS  Loss of consciousness (MTBI) interacts with cognitive reserve in influencing the development or persistence of PCS

Treatment of Mild TBI

Mild TBI Treatment

 Change expectation and attribution of symptoms  Provide education   Education regarding mild TBI Education regarding symptoms and their course  Provide Support/Treatment    Stress management Psychological and cognitive coping strategies and resources Cognitive-Behavioral therapy

References

      Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg, R. D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: A Meta-analysis. Journal of the International Neuropsychological Society, 11, 215-227. Belanger, H.G., & Vanderploeg, R.D. (2005). The Neuropsychological Impact of Sports-Related Concussion: A Meta-Analysis. Journal of the International Neuropsychological Society, 11, 345-357.

Luis, C. A., Vanderploeg, R. D., Curtiss, G. (2003). Predictors for a postconcussion symptom complex in community dwelling male veterans. Journal of the International Neuropsychology Society, 9, 1001-1015.

Miller, L.J. & Mittenberg, W. (1998). Brief cognitive behavioral interventions in mild traumatic brain injury. Applied Neuropsychology, 5, 172-183. Mittenberg, W., Tremont, G., Zeilinski, R., Fichera, S., & Rayls, K. (1996). Cognitive behavioral prevention of postconcussion syndrome. Archives of Clinical Neuropsychology, 11, 139-145.

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

References

      Schretlen, D. J., & Shapiro, A. M. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International Review of Psychiatry

,

15, 341-349.

Suhr, J.A. & Gunstad, J. (2005). Further exploration of the effect of “diagnosis threat” on cognitive performance in individuals with mild head injury. Journal of the International Neuropsychological Society, 11, 23-29.

Vanderploeg, R. D., Curtiss, G., & Belanger, H. G. (2005). Adverse long term neuropsychological outcomes following mild traumatic brain injury. Journal of the International Neuropsychological Society, 11, 228-236. Vanderploeg, R.D., Belanger, H.G., & Curtiss, G. (2006). Mild Traumatic Brain Injury: Medical and Neuropsychological Causality Modeling. (pp. 279-307). In Young, G., Kane, A. & Nicholson, K. (Eds.), Psychological Knowledge in Court: PTSD, Pain and TBI. New York: Springer-Verlag.

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

[1-31-04] Vanderploeg, R. D., Curtiss, G., Luis, C. A., & Salazar, A. M. (in press). Long-term morbidity and quality of life following mild head injury. Journal of Clinical and Experimental Neuropsychology.