Transcript Psychiatric Rehabilitation Needs of Iraq and Afghanistan

TBI and PTSD among OEF/OIF
Veterans
and
UNC Cognitive Rehabilitation
Research
James Wolfe, M.S., NCC
Erin Clevenger, M.A.
Eric B. Elbogen, Ph.D.
UNC-Chapel Hill School of Medicine
Dept. of Psychiatry
Mental Health Needs of
Iraq and Afghanistan Veterans
• Over one million currently active military personnel
have served in Operation Enduring Freedom (OEF) or
Operation Iraqi Freedom (OIF)
• Estimates vary, but about 15-20% of troops returning
show some symptoms of posttraumatic stress
disorder (PTSD)
• 15%-20% of all returning veterans have experienced
some type of traumatic brain injury (TBI), often
associated with IEDs (improvised explosive devices)
• Some veterans have both TBI + PTSD
Mental Health Needs – Trend of
PTSD Diagnoses
Mental Health – Trend of TBI
Diagnoses
Mental Health Needs of
Iraq and Afghanistan Veterans
• Both TBI and PTSD can lead to a lifetime reduction in
social, cognitive, and vocational functioning
• The sooner the assessment of TBI and PTSD, the
sooner rehabilitation plans can be implemented,
which will dramatically improve effectiveness of
these efforts
• One report indicated that more North Carolinians
have served in Iraq and Afghanistan than any other
state; thus, we can anticipate a huge demand for
allied health services in the upcoming decade
What is TBI?
• Traumatic brain injury (TBI) occurs when a
sudden trauma causes damage to the brain
• TBI can result when the
head suddenly and
violently hits an object,
penetrating to the
brain, or simply causing
impact between the
skull and the brain
What is TBI?
• TBI can also result from a blast. Shockwaves from
explosions can damage the brain through the skull or can
cause small objects such as shrapnel to pierce the head
What is TBI?
• A person with a mild TBI (mTBI) may remain conscious or may
experience a loss of consciousness for a few seconds or
minutes
• Other symptoms of mild TBI:
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Headache
Confusion
Lightheadedness
Dizziness
Blurred vision/tired
eyes/sensitive to light
Ringing in ears
Trouble with memory/
concentration/attention
Fatigue/lethargy
Change in sleep pattern
Mood/behavioral changes
Bad taste in mouth
What is TBI?
• A person with a moderate
or severe TBI may show
symptoms of mTBI as well
as:
• Worsening/persistent
headache
• Nausea or vomiting
• Convulsions or seizures
• Inability to awaken from
sleep
• Dilation of one or both
pupils
• Slurred speech
• Weakness/numbness in the
extremities
• Loss of coordination
• Increased confusion,
restlessness, or agitation
What is TBI?
• Prognosis of a TBI depends upon the severity of the
injury, the location of the injury, and the age and
general health of the person. Problems with the
following are common:
• cognition (thinking, memory, and reasoning),
• sensory processing (sight, hearing, touch, taste, and
smell),
• communication (expression and understanding), and
• behavior or mental health (depression, anxiety,
personality changes, aggression, acting out, and social
inappropriateness).
What is PTSD?
• PTSD first presumes
that a person has
experienced a
traumatic event
involving actual or
threatened death or
injury to themselves or
others -- and where
they felt fear,
helplessness or horror.
• Diagnostic criteria: Three symptom clusters must persist for
more than a month after the traumatic event and cause
clinically significant distress or impairment.
What is PTSD?
Symptom clusters of PTSD:
• Intrusions - such as flashbacks or nightmares,
where the traumatic event is re-experienced
• Avoidance - when the person tries to reduce
exposure to people or things that might bring on
their intrusive symptoms
• Hyperarousal - meaning physiologic signs of
increased arousal, such as hypervigilance or
increased startle response
TBI/PTSD Overlap
TBI
Irritability
PTSD
Memory
Flashbacks
Decisionmaking
Avoidance
Learning new
things
Inhibition
Shame
Motor Skills
Emotional
regulation
Guilt
Anxiety
TBI/PTSD Overlap
% Having trouble making plans, decisions, learning new things
% Experiencing violence control issues
% of veterans
N= 568
How to Assess for TBI
TBI is the result of an external force that is indicated by new onset or
worsening of at least one of the following clinical signs, immediately
following the event:
• Any period of loss of or a decreased level of consciousness
• Any loss of memory for events immediately before or after the
injury (posttraumatic amnesia)
• Any alteration in mental state at the time of the injury (confusion,
disorientation, slowed thinking, etc.)
• Neurological deficits (weakness, loss of balance, change in vision,
praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may
not be transient
• Intracranial lesion
How to Assess for Impairments in
Functioning
Neuropsychological Assessment Tests:
• Attention – ability to focus and concentrate on verbal and visual
information for a short or long period of time at a given processing
speed
• Memory – ability to recognize and recall verbal and visual information
short-term and long-term
• Executive Functioning – ability to have higher order thinking and
problem solve; ability to think flexibly; ability to inhibit behaviors and
responses
Cognitive Task
• Please memorize the following words:
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Cup
Elbow
Sailboat
Broom
Pear
Building
Tornado
Pencil
Cognitive Task
PINK
GREEN
PINK
BLUE
GREEN
BLUE
PINK
BLUE
PINK
GREEN
PINK
BLUE
PINK
GREEN
GREEN
BLUE
PINK
BLUE
GREEN
BLUE
GREEN
Cognitive Task
BLUE
PINK
GREEN
PINK
BLUE
GREEN
BLUE
PINK
GREEN
PINK
BLUE
GREEN
BLUE
PINK
BLUE
PINK
GREEN
PINK
BLUE
GREEN
PINK
Attention vs. Executive Functioning
• The first color-word task involves straight attentional
abilities and taps into processing speed
• The second task is harder because it involves the
ability to inhibit the overlearned response to read
the word
• This exercise measures executive functioning because it involves
higher order ability to keep a rule in mind, to inhibit initial
responses, and to instead execute the new rule
Cognitive Task
• Remember the list of words you were asked to
memorize?
• Please write down as many of the words from
the previous list as you can.
Cognitive Task
• Now, we’re going to list words, some were on the original list
and others weren’t. Which ones were on the list?
Cap?
Umbrella?
Sailboat?
Broom?
Apple?
Elbow?
Hat?
Building?
Zebra?
Pencil?
Free Recall vs. Recognition
• The first task is much harder because it involves
retrieval of encoded information without cues (free
recall)
• The second task is easier because it assists retrieval
of encoded information with cues (recognition)
• Many people with TBI do poorly on the first and not
the second, which signals that the information was
encoded but that there is a problem retrieving the
information
Neurocognitive Effects of
TBI and PTSD
• Literature agrees that attentional impairments are
associated with PTSD
• With respect to TBI, depends on type of injury (focal
or diffuse)
• Attention is generally affected with reduced working memory
and slower processing speed
• Memory retrieval often affected, but recognition remains intact
• Executive dysfunction, typically disinhibition, is related to TBI
Rehabilitation of
Trauma-Related Disability
• Cognitive Remediation
• Help improve attention, memory, or problem solving
• For veterans who’ve experienced a TBI, research shows
most improvement in cognitive functioning comes in the
first 18 months
• Speech Therapy
• Retrain injured veteran if needed
• Basic communication skills may also need to be addressed
Rehabilitation of
Trauma-Related Disability
• Vocational Rehabilitation
• Match job with cognitive strengths or weaknesses
• Provide employment support on an ongoing basis if
necessary
• Occupational Therapy
• Modify living or work environment to compensate for
deficits (e.g., cues)
• Help structure veteran’s time and schedule to achieve
realistic life goals
PTSD Treatment
• Posttraumatic stress disorder is usually treated
with a combination of medications and
counseling
• The medications are designed to reduce anxiety
and to help patients overcome depression
• Common types of counseling for veterans with
PTSD include cognitive-behavior therapy,
exposure therapy, group therapy, and family
therapy.
PTSD Treatment
• Stress management techniques and meditation
can help people with anxiety disorders calm
themselves and may enhance the effects of
therapy
• There is preliminary evidence that aerobic
exercise may have a calming effect
• Since caffeine, certain illicit drugs, and even
some over-the-counter cold medications can
aggravate the symptoms of anxiety disorders,
they should be avoided
Summary
• Thousands of Iraq and Afghanistan veterans are returning to North
Carolina and have suffered a trauma resulting in social, cognitive, or
vocational deficits
• The most prevalent issues are traumatic brain injury (TBI) and
posttraumatic stress disorder (PTSD), which can lead to a lifetime
reduction in basic functioning
• Comprehensive assessment of TBI and PTSD give information about
the accuracy of the diagnosis and about which types of
rehabilitation strategies will be effective
• To address these trauma-related disabilities, allied health
professionals will be critical in developing rehabilitation plans to
help veterans reintegrate and readjust to civilian life
UNC Study
Brain Functioning and Cognitive
Rehabilitation In Veterans
• Aimed at improving brain function of veterans with TBI and
PTSD
• Involves participation for six months
• Use an iPod Touch to practice techniques for improving
memory and planning skills
• Data collection at the beginning and end of study including
interview, testing of memory and attention, EEG, and MRI
• Three in-home support sessions involving a family member
or friend
• Veteran will be paid $500, participating family member or
friend will be paid $200, and veteran will keep iPod
UNC Study
Eligibility requirements to participate:
• Served in a branch of the military since Oct. 2011
• Has had a head injury that meets diagnostic
criteria for TBI (had the head injury while in the
military)
• Has military-related PTSD
• Can have an MRI and EEG
Recruitment Area (within 125 miles of Chapel Hill)
UNC Study
• If you know of a veteran who might be
interested in participating in the study, please
have them call for more information:
Dr. Eric Elbogen
UNC Forensic Psychiatry
919-972-7459