Transcript Combat Stress vs. TBI

Dealing with TBI
An Overview of Behavioral
Symptoms and Interventions
Facts About Mild Traumatic Brain
Injury (MTBI)
• Approximately 80% of all
brain injuries are mild
• Males outnumber females
2:1
• 5.3 million people are
estimated to have
ongoing problems related
to MTBI
• Direct care costs are
estimated at 5.3 billion
annually, with indirect
care estimated at 37.8
billion dollars annually
Diagnostic Criteria for MTBI
• Traumatically induced physiological
disruption of the brain (an injury occurs)
• Any period of loss of consciousness not to
exceed 30 minutes
• Loss of memory for events immediately
before of after the accident
• Any alteration in mental state at the time of
the accident
MTBI
• Focal neurological deficits that may or may
not be transient
• Post-traumatic amnesia does not exceed
24 hours
• Glasgow Coma Scale of 13-15 after 30
minutes
– Eyes open spontaneously
– Oriented to place/time (Verbal output)
– Obeys Commands (Motor output)
Assessment Questions
• Have you ever been told you have
suffered a brain injury or concussion?
• Have you ever hit your head hard enough
that you saw stars or had a headache that
lasted the rest of the day?
• Have you ever been knocked
unconscious? If so, for how long?
• Did you seek medical treatment?
Assessment Questions
• When you hit your head, did you feel
nauseated or dizzy afterwards?
• Did you have any speech or coordination
problems?
• Is there any part of the incident you cannot
remember?
• Did you have any visual problems?
Assessment Questions
• Currently– Do you have any memory problems?
– Do you have problems keeping up with
conversations or what people are saying?
– Do you have problems concentrating or
staying on task?
– Are you sensitive to light? Does it cause you
to have headaches?
– Do you have problems pulling up words (are
they on the tip of your tongue?)
Assessment Questions
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Are you more irritable than before the incident?
Do people often say you act before you think?
Do you have problems multi-tasking?
Are you having any current balance or
coordination issues?
• Are you having any sensory problems (hearing,
smell, taste, etc.) ?
• Are there any changes you have noticed since
the incident that I did not ask you about?
Frontal Lobe Injury
• Higher cognitive functioning or “executive
functioning”
• Focusing attention
• Generating and following through on decisions
• Poor judgment
• Self-awareness of deficits self-monitoring
• Planning and carrying out activities (maintaining
a job, grocery shopping, completing household
duties, repairs, etc.)
Frontal Lobe TBI
• Concrete thinking
• Trouble staying on task
• Possible disinhibition
and immaturity
• Possible decreased
energy, motivation and
spontaneity
• Possible speech and
motor problems
Temporal Lobe TBI
• Storing NEW memories
– Right: Visual memory
– Left: Verbal memory
• Behavioral problems
– Irritability
– Aggression
– Modulating behavior
• Word-finding and naming
Parietal Lobe TBI
• Processing sensory information
– Right: Visual-spatial
information
– Left: Comprehension of
spoken/written words
• Get lost in familiar surroundings
• Confused by multi-step
instructions
Occipital Lobe TBI
• Processing of visual
information
• Visual deficits
–Field cuts
–Blindness
–Inability to know
objects
Cerebellum TBI
• Coordination of movement
–Walking and control of upper
extremities for day-to-day tasks
–Possible tremors associated
with injury
Course of Recovery of MTBI
• In the majority of individuals symptoms of
MTBI resolve in 6 months or less after
injury
• In some cases, symptoms can persist
longer (12 – 18 months) and even life-long
• The majority of people with moderate to
severe TBI do not return to their full preinjury status and will have ongoing
cognitive and behavioral issues
Overview of Diffuse Symptoms
of MTBI
• Cognitive
– Memory, Attention, Processing Speed &
Intelligence
• Psychological
– Depression, Anxiety, Irritability, and Sleep &
Personality change
• Physical
– Light/sound sensitivity, dizziness & fatigue
Dealing with Impaired
Attention/Concentration
• Work slowly
• Break your work down
into small, manageable
increments
• Double check your work
• Prepare all materials for
tasks prior to starting
• Take regular breaks to
minimize fatigue
Attention and Concentration Con’t.
• When reading and studying, read small
passages, take a break, and then read
them again
• Clear away any materials not needed for
tasks/work
• Maintain a quiet environment with minimal
distractions when focus is needed
Learning and Memory Difficulties
• Daily organizer/calendar to record
appointments and important tasks
• Multiple modalities to learn new material
– Read it aloud (hearing)
– Picture it (visual)
• Set realistic goals
– It will take longer to learn new things
– Break material down into smaller
portions
– Allow breaks between studying to allow
material to consolidate into memory
– Be patient with yourself!
Dealing with Executive Control
Dysfunction
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Work on one task at a time
Work slowly and carefully
Check your work for errors
Use a pocket organizer, smart phone
or palm pilot
• Make a “to do” list and post it in a
designated place
• Be willing to allow family
members/friends provide reminders
without being upset
How to detect brain injury
• There are often no outward physical signs
of Injury – Invisible Wounds
• We need to focus on observable
behavioral Indicators of TBI
Dealing with TBI
• Signs to look for:
– Distractibility
– Difficulties focusing on what is
being said
– Answering slowly or answering
questions that are not asked (poor
comprehension issues or low
comprehension)
– Long pauses in speech (word
retrieval issues)
What to Look For
• Client’s with TBI are often very
anxious, look for:
– Restlessness
– Face flushed
– Sweatiness
– Shakiness
– Increased breathing rates
What to Look For cont.
• Talking very loud/yelling
– Self-awareness and self-monitoring
• Staring
– Inattentiveness
• Shakiness
– Can be neurologically based
• Difficulty following orders
– Delayed processing or comprehension
problems
What to Look For cont.
• Have significant short-term memory issues
– They seem to understand instructions, then minutes
later cannot remember what you told them
• May become agitated/irritable very quickly and appear
disinhibited due to frontal lobe injury
• May have significant coordination issues and
involuntary movements that are neurologically based
– Fail field test, NOT due to substance
use/intoxication
• May have visual field cuts
What to Look For cont.
• Flat affect and seem apathetic
• Poor initiation of conversations
• Provide short & concrete answers to
complex questions
• Suspect’s body language and poor
verbal output (yes/no responses)
suggests disinterest in what you are
saying (flat affect)
– Remember this is neurologically based
Interventions
• Tell individual one thing at a time; no multistep
directions
• Be willing to repeat instructions slowly and
clearly
– Memory, Processing speed, and
Comprehension
• Keep questions as simple as possible
• Make sure you have eye-contact with individual
– Attention
Interventions
•Have them reflect what
you have told them
“Can you tell me what I
ask you to do?”
•Loud speech does not
always imply anger or
opposition
More likely confused or
anxious; Inability to selfmonitor
Interventions cont.
• Individuals with TBI often get overwhelmed with
environments that are over-stimulating (too much noise,
lights, movement around them), so:
– When trying to talk to them or directing them,
try to get them in quieter areas away from
crowds, noise, lights, etc.
Interventions
Write down any follow-up and
encourage them to put in
PDAs
-Memory vs. non-compliance
For anxious or agitated
individuals, encourage breathing
and grounding skills
-Stress ball
-Sensory loaded modalities
Allow a time-out if necessary
Therapy Interventions- TBI
• Structure/routine
– Pill reminder
• Marker board
• Symptom journal
– Disorganization
– Questions they want
answered
• Take notes in session
• Involve family
– Educational aspects
– ADD-like aspects
• They often won’t admit deficits
TBI and PTSD: Overlapping and
Differentiating symptoms
• TBI:
– Concentration
– Memory
• Commonly STM
– Irritability
– Fatigue
• Constant detours
– Headaches
• Light sensitivity
– Apathy
• Flat affect
– Sexual inhibition or
impulsivity
• PTSD
– Concentration
– Memory
• Dissociative or amnestic
– Irritability
• triggers
– Headaches
• SNS arousal
– Apathy
• Secondary depression
– Sexual aggression,
heightened interest, or
inhibition
TBI and PTSD: Overlapping and
Differentiating Symptoms
TBI:
• Sleep problems
PTSD:
• Problems sleeping
– REM cycle disruption
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Problems processing
– Slowed
– Word retrieval
– Problems shifting focus
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Emotional lability
– Without external triggers
– Overly emotional to small events
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Personality changes
– Flat
– Lack of initiation
– Loss of self-awareness/selfmonitoring
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– Nightmares
– Hyperarousal
– hypervigilance
Lack of spontaneity
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Problems processing
– Scattered
– Preoccupied
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Emotional Lability
– Anxious, irritable, numbing, laughing
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Personality Changes
– Self-esteem
– Sense of damage
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Everything pre-planned
Severe numbing
REFRENCES
Brain Injury Association of Indiana
PO Box 24167
Indianapolis, Indiana 46224
P: (317) 356-7722 F: (317) 481-1825
biausa.org/Indiana
Brain Injury Association of America Inc.
1608 Spring Hill Rd
Suite 110
Vienna, VA 22182
Biausa.org
Reference
Family Caregiver Alliance/National Center of Caregiving
180 Montgomery Street
Suite 1100
San Francisco, CA 94104
Caregiver.org
Defense and Veterans
Brain Injury Center
Dvbic.org