Whatever Happened to Me?

A Neuropsychological Perspective of Traumatic Brain Injury Gabriel Salazar, M.A.

Coastal Horizons &Private Practice & Antonio E. Puente, Ph.D.

University of North Carolina Wilmington & Private Practice Carolinas IARP Carolina Beach, NC April 23, 2010

Overview

• • • • • • HISTORY AND METHODOLOGY DEFINING NEUROPSYCHOLOGY DEFINING PERSONALITY DEFINING TRAUMATIC BRAIN INJURY NEUROPSYCHOLOGICAL RESIDUALS OF TBI

The Interface Between Neuropsychology, Personality and Traumatic Brain Injury

History

• SCIENCE – Loeb • 1903, University of Chicago – Lashley • 1929, Harvard University and Yerkes Laboratory – Sperry • 1981, California Institute of Technology – Luria (Bechterew, 1900, St. Petersburg) • 1980s, Moscow State University

Methodology

• • • SCIENTIFIC – THE IMPORTANCE AND OFTEN LACK OF DATA CLINICAL – WHEN SCIENCE IS NOT AVAILABLE, CLINICAL EXPERTISE IS THE NEXT LEVEL OF INFORMATION ANECDOTAL – SOMETIMES, ALL THAT YOU HAVE ARE INDIVIDUAL CASES TO GUIDE YOU

Defining Neuropsychology

• • PROFESSIONAL – Neuropsychologist- Doctorate level (state license) – Psychometrician- MA level (aspirational) SCIENTIFIC – Interface between brain and behavior – Focus on; • Behavior • Cognition • • Emotion Personality

Defining Personality

• • • • • CHARACTER TRAITS- WHO ARE YOU?

PRESENT AND MEASURABLE BY LATE CHILDHOOD LIFELONG AND ENDURING QUALITIES OFTEN REVEALED BY REPEATED FEEDBACK FROM EXTERNAL SOURCES DIFFICULT TO CHANGE USING PSYCHOTHERAPEUTIC TECHNIQUES (Note: DSM- Axis 1 vs. 2)

Traumatic Brain Injury Statistics

• • • • • • • • • $56 billion a year spent on TBI 5 million Americans alive today have had a TBI resulting in a permanent need for help in performing daily activities. Survivors of TBI often left with significant cognitive, behavioral, and communicative disabilities Some patients develop long-term medical complications, such as epilepsy. Each year: 1.4 million people experience a TBI 50,000 people die from head injury 1 million head-injured people are treated in hospital emergency rooms 230,000 people are hospitalized for TBI and survive National Institute of Neurological Disorders and Stroke, 2010

Defining Traumatic Brain Injury

• • • ANYTHING THAT CHANGES THE STRUCTURE AND/OR FUNCTION OF THE BRAIN Closed Head Injury- the skull is intact and there is no penetration of the skull. Direct or indirect force to the head can cause this type of injury. This may be caused by rotational and/or deceleration in the case of both direct and indirect force.

Open Head Injury- penetration of the skull with direct injury to the head.

Defining Traumatic Brain Injury

• Diffuse Axonal Injury- diffuse cellular injury to the brain from rapid rotational movement. This is often seen in motor vehicle accidents or shaking injuries. The axons are the projections of the brains nerve cells that attach to other nerve cells. They are damaged or torn by the rapid deceleration. The injury is from the shearing force disrupting the axons which compose the white matter of the brain.

• Contusion- a bruise to a part of the brain. Like a bruise on the body, this is bleeding into the tissue.

Defining Traumatic Brain Injury

• Penetrating Trauma- any object that enters the brain. Causes direct injury by impact and pushing skull fragments into the brain.

• Secondary Injury: – Intracranial hemorrhage (bleeding inside the skull) – – Brain swelling Increased intracranial pressure (pressure inside the skull) – – Brain damage associated with lack of oxygen Infection inside the skull, common with penetrating trauma – Chemical changes leading to cell death – Increased fluid inside the skull (hydrocephalus)

Defining Traumatic Brain Injury

• • A TRADITIONAL PERSPECTIVE – – Caused by external stimulus Abrupt – – S shaped curve of recovery Possible that “complete” recovery is not attainable – Hence, a residual change from premorbid level of function occurs resulting in a “new” person A NON-TRADITIONAL PERSPECTIVE – Example, for Russians view brain injury from; • • Socio-cultural context Recovery is a lifetime activity

Describing the Physical Injury

(Barth, 2009)

Causes of TBI

Review of the Literature

• • • From 1900 to present BI and Neuropsychology – 1974 – Steady increase over time starting the 1990s BI and Neuropsychology and Personality – 84 citations – Most emerging during the 1990s

Methods of Diagnosing TBI

• • • • Neurological examination Brain imaging with CAT scan, MRI, SPECT and/or PET Cognitive evaluation by a Neuropsychologist with formal neuropsychological testing. Evaluations by physical, occupational and speech therapists help clarify the specific deficits of an individual.

Neuropsychological Assessment

• • THREE LEVELS OF ASSESSMENTS – NEUROSURGICAL – NEUROLOGICAL – NEUROPSYCHOLOGICAL DIFFERENCE BETWEEN PSYCHOLOGICAL AND NEUROPSYCHOLOGICAL ASSESSMENT – TIME (much longer) – FOCUS (on specific domains such as memory and their relationship to neurological status)

Specifics of Assessment

• COMPONENTS – Review of records • Medical • Educational, plus – Interview (1-2 hours) • Patient • Collateral – Tests (6-10 hours) • Effort testing (Tomm) • Domain testing (Category test)

Specifics of Assessment

• Orientation • Communication • Fluency • Motor • Reasoning/Organization • Memory • Intellectual • • • • Academic Affective Personality Effort

Specifics of Assessment

• STANDARD GOALS – – Cognitive focused Deficit based – Highly technical – Replicable – Meant to be understood by PhDs – General recommendations • POSSIBLE ADDITIONAL – – Emotional Ecological – Functional – “Educational” – Multidimensional – Multidisciplinary – Forensic sensitive

Potential Symptoms of Neuropsychological Residuals of TBI

• • • • • • GREATER DISORGANIZATION & REASONING ABILITIES IMPAIRMENT OF ATTENTION DIFFICULTIES WITH ENCODING OF INFORMATION LESS THAN OPTIMAL RECALL OF INFORMATION SLOWLED MENTAL PROCESSING LIMITED MENTAL STAMINA

“Psychological” Symptoms

• • • • • • REDUCED FRUSTRATION TO AMBIGUITY DECREASED TOLERANCE FOR STRESS APATHY/POOR MOTIVATION DEPRESSION ALCOHOL ABUE CHANGE IN SYSTEMS STABILITY; – FAMILY DYNAMICS – VOCATIONAL PERFORMANCE – SOCIETAL STATUS

Interface Between Cognitive & Emotional Variables

• • • • SYNCHRONY OF SYMPTOMS COGNITIVE DYSFUNCTION AFFECTS EMOTIONAL PROBLEMS EMOTIONAL DYSFUNCTION AFFECTS COGNITIVE PROBLEMS ONE OF THESE VARIABLES CAN HAVE TEMPORARY EFFECT OF A LIMITED NATURE ON THE OTHER

Recovery from TBI: Individual Factors

– Mild trauma – Negative MRI, CT, etc – Glasgow Coma Scale (15?) – Post-traumatic amnesia – Age (very young and very old problematic) – Co-morbid medical factors (e.g., diabetes, HBP) – Co-morbid psych factors (e.g., pre-existing condition such as etoh abuse, depression) – Limited cognitive and/or emotional reserve

Recovery from TBI: Contextual Factors

• • • • • MARITAL STATUS FAMILY SUPPORT INCOME LEVEL ECONOMIC RESOURCES (insurance, disability) SOCIAL ENGAGEMENT

Recovery: External Predictors

• • • NEUROCOGNITIVE TEST RESULTS IMPORTANCE OF SUBJECTIVE COMPLAINTS VALUE OF INFORMATION FROM SIGNIFICANT OTHERS

Interventions

• • • • • • • PSYCHOLOGICAL COGNITIVE VOCATIONAL PHYSICAL MEDICAL PHYSICAL SYSTEMS

How Long Should Therapy Continue?

• • • Insurance Based Response – # of sessions allocated – Maximum medical improvement North American Perspective – 6 to 12 months (until the insurance stops paying?) Russian Perspective – Functionally defined (until you stop getting better)

Residual Damage

• • • • SIGNIFICANT OTHERS CHILDREN SYSTEMS SOCIETY

Special Problems

• • • • LIMITED INFORMATION FROM ACCIDENT REPORTS POOR EVALUATIONS THAT SKIRT COGNITIVE CONCERNS IN THE EMERGENCY ROOM FOCUS ON “NEUROLOGICAL” AND “NEUROSURGICAL” CONCERNS INITIALLY ENGAGEMENT OF COGNITIVE, EMOTIONAL AND SOCIAL ISSUES MUCH LATER IN THE RECOVERY CURVE

Special Problems

– RESIDUALS OF A BLAST INJURIES AND HOW THEY ARE DIFFERENT THAN “TYPICAL” TBI; THE PROBLEM WITH RETURNING VETS – IS IT “MENTAL” OR IS IT “PHYSICAL”…WHEN DOES ONE BEGIN AND THE OTHER ONE STOP – IMPACT ON VOCATIONAL OUTCOMES ARE PROBLEMATIC, ESPECIALLY WITH MILD TBI – IMPORTANT TO UNDERSTAND THAT THE BRAIN EXISTS INSIDE A PERSON INSIDE A SYSTEM

Special Problems

• CHRONIC TRAUMATIC ENCELAPOTHY – Carolina Hurricanes – Sports Concussions & Blast Injuries • The Case of Mike Borich • • From football to soccer to surfing The lack of interest and understanding • The pressure to play and fight • The hidden symptoms – Initial – cumulative

What About Me?

• • • • • NOT A FUNCTIONAL LOSS NOT A BRAIN INJURY NOT AN AFFECTED FAMILY NOT A COMPENSABLE LOSS IT IS ABOUT ME… – I am a new person – The system I am in has changed

The Challenge of Forensic Concerns

• • • • LITIGATION – Civil – Disability • Work related • Social Security QUANTIFYING DEFICITS & STRENGTHS QUANTIFYING EFFORT QUANTIFYING LOSS

What Happened to Me?

• IT IS ABOUT: – Rediscovery of self – Rediscovery of the world I live in – Discovery of how impairment can be an asset • The concept of post-traumatic growth • Can my brain impairment result in a better me?

• Can my brain impairment result in a better life?

“This is not what I planned for…

What am I to do…”