Traumatic brain injury

1. BY- DR. ARMAAN SINGHBY- DR. ARMAAN SINGH

3. 
 Causes, prevention, medical evaluation and
treatment of traumatic brain injury (TBI)
 Cognitive, emotional, and behavioral impact
 Cognitive rehabilitation, emotional
rehabilitation, medications, and educational
accommodations
 Living with brain injury at the university and in
the rest of the world
 Questions, discussion
Overview

4. 
Causes of Brain Disabilities
 Trauma
 Toxicity
 Tumors
 Degenerative disorders
 Developmental
disorders
 Dietary deficiencies
 Vascular disorders
 Anoxia
 Epilepsy
 Hydrocephalus
 Electric shock
 Infections
 Metabolic disorders
 Autoimmune disorders

5. 
Causes of Brain Disabilities
Most Likely to Affect University Students
 Trauma
 Toxicity
 Tumors
 Degenerative disorders
 Developmental
disorders
 Learning Disabilities
 Attention Deficit
Disorder
 Asperger’s Syndrome
 Dietary deficiencies
 Vascular disorders
 Anoxia
 Epilepsy
 Hydrocephalus
 Electric shock
 Infections
 Metabolic disorders
 Autoimmune disorders

6.  motor vehicle accidents
 sports injuries
 assaults
 falls
 blast concussion (59% of blast-
injured soldiers)
 shaken babies
Causes of TBI

7. 
Traumatic Brain Injury

8. 
 Open head (skull fracture, gunshot
wounds, blunt instrument)
 Risk of hemorrhage, seizure, infection,
swelling
 Closed head (most motor vehicle
accidents, sports injuries)
 Risk of hemorrhage, seizure, swelling,
failure to detect
Types of Traumatic Brain Injury

9. 
 There is often trauma to other parts of the body, as
well
 Myth busting:
 The head does not have to have contact with
something for there to be a TBI (shaken baby, seat
belts, air bags)
 There does not have to be a loss of consciousness for
there to be a TBI (Phineas Gage, gunshot wound)
 There does not have to be a change on the CT or MRI
for there to be a TBI
Traumatic Brain Injury

10. 
Mechanisms of injury
 Mechanical trauma—cell death, axonal
shearing
 Diffuse Axonal Injury
 Hemorrhage (blood kills brain cells, blood is
cut off from other areas, pressure effects)
 Edema
 Cascading chemical events—hope for
interventions
 Anoxia
 Hydrocephalus
Traumatic Brain Injury

11. 

12. 
 Glasgow Coma Scale
 Best Eye Response. (4)
 No eye opening.
 Eye opening to pain.
 Eye opening to verbal command.
 Eyes open spontaneously
 Best Verbal Response. (5)
 No verbal response
 Incomprehensible sounds.
 Inappropriate words.
 Confused
 Oriented
• Best Motor Response. (6)
 No motor response.
 Extension to pain.
 Flexion to pain.
 Withdrawal from pain.
 Localizing pain.
 Obeys Commands.
Acute Medical evaluation:

13. 
Severity loss of
consciousness
posttraumatic
amnesia
Mild 0-1 hour 0-1 day
Moderate 1 hour-1 day 1day-1 week
Severe >1 day >1 week
TBI Levels of Severity

14.  Acute Medical evaluation:
 CT
 Physical and neurological exam
 Serial assessment
Traumatic Brain Injury

15. 
 Ancillary Exams
 Laboratory
 EEG
 Evoked potentials
 Lumbar puncture
 CT scan
 MRI scan
 Functional imaging
 Arteriography
Neurological Evaluation

16.  Treatment:
 Protect the airway & oxygenate
 Ventilate to normocapnia
 Correct hypovolaemia and hypotension
 Prevent herniation
 Surgery for hemorrhage, edema, skull repair
 Medications for edema, infection, agitation,
coagulants, anticonvulsives, etc.
 Rehabilitation
Traumatic Brain Injury

17. 
 High Risk Populations
 Violent, impulsive, young, male,
substance abusers
 Children
 Elderly
 Soldiers
 Pedestrians
 Cyclists
Traumatic Brain Injury

18.  High Risk Populations
 Workers in certain industries
 Logging
 Mining
 Construction
 Military
 Transportation
 Some agriculture
Traumatic Brain Injury

19. 
 Prevention:
 Peace
 Measures against interpersonal violence such as
domestic violence
 Gun control
 Traffic law and industrial safety law enforcement
 Vehicle and road maintenance
 Seat belts, air bags
 Helmets
 Sport safety
 Fall prevention in children and elderly
Traumatic Brain Injury

20. 
 The focus of tremendous forensic and sports
neuropsychology energy
 The most common TBI
 Several definitions but usually include:
 Trauma to the head
 Alteration of consciousness
 <1 hour loss of consciousness
 <24 hours posttraumatic amnesia
 No focal deficits
Mild Traumatic Brain Injury

21. 
 Many non-specific symptoms:
 Headache
 Memory loss
 Attention difficulty
 Fatigue
 Depression
 Anxiety
 Dizziness
 Irritability
 Nausea
 Oversensitivity to noise, light, distractions
Mild Traumatic Brain Injury

22. 
 High base rates for the non-specific symptoms
 Head injury vs brain injury
 Dizziness
 Headache
 MTBI vs PTSD
 Rule of thumb:
 1/3 of people better within 1 week,
 1/3 of people better within 3 months,
 1/3 of people still have problems at 1 year, “miserable
minority”
Mild Traumatic Brain Injury

23. 
 Interview:
 “bracket” the loss of consciousness and posttraumatic
amnesia
 Screen for posttraumatic stress disorder
 Check on attitudes, anger, guilt, lawsuits, disability
claims, expectations, substance abuse
 The course of recovery up to now
 Compare pre-injury to now
Psychosocial Evaluation of TBI

24. 
 Early evaluation (within a few months of injury)
 Focus on priority problems
 Screen and baseline testing
 Support and education
 Provide for follow-up
Psychosocial Evaluation of
TBI

25.  Later evaluation (6 months or more after injury)
 Focus on priority problems
 Comprehensive, problem-oriented testing
 Attention, memory, executive functions, effort,
emotional adjustment, vocational or educational and
social adjustment
Neuropsychological Evaluation of
TBI

26. 
Rule outs:
 Depression
 Anxiety
 Posttraumatic stress disorder
 Sleep disturbance
 Chronic pain, especially headache
 Vestibular disturbance (dizziness)
 Symptom exaggeration for compensation or other
gain
Differential Diagnosis of
Mild TBI

27. 
What is the impact of
TBI?

28. 
Emotions and Personality in
Traumatic Brain Injury
pre-injury
personality
emotional
reactions
to injury
organic
changes in
emotions
and
behavior

29.  Grief
 Denial
 Depression
 Anxiety
 Anger
 Posttraumatic Stress Disorder
 Personal Reformation
Reactions to the experience of
injury/illness:

30. 
Reactions to illness/disability:
 Grief
 Denial
 Depression
 Anxiety
 PerplexityLezak, 1978
 Frustration
 Anger
 Embarrassment

31. Organic Emotional Changes
Function Increased Decreased
Emotional
Communication
Reflex crying,
laughing
Automatic
cursing
Monotone
voice
Masked face
Emotional
Reactivity
Labile emotions
Impulsive anger
Catastrophic
reactions
Indifference

32.  Organically induced major psychiatric disorders
 Depression
 Mania
 Psychosis
 Obsessive-compulsive disorder
 Temporal lobe epilepsy personality changes?
Organic Emotional Changes

33. 
 Choose a goal
 Plan
 Execute
 Evaluate
What are Executive
Functions?

34. 
What are Executive Dysfunctions?
 Decreased self control
 Euphoria
 Mania
 Despontaneity
 Facetiousness
 Disinhibition
 Impulsiveness
 Slowness of thinking
 Poor judgment
 Disorganized
 Unreliable
 Poor insight
 Apathetic
 Indifferent
 Lack of ambition
 Decreased initiative

35. 
What are Executive
Dysfunctions?
 Childish
 Self-centred
 Unempathetic
 Concrete
 Lacking abstract attitude
 Unable to shift attention
 Unable to use feedback
 Unable to maintain
performance
 Unable to self-monitor
 Lack of self-
reflectiveness
 Unconcern
 Outbursts of irritability
 Perseverative
 Impersistent
 Assertive
 Inflexible

36. 
What are Executive
Dysfunctions?
 Impaired sequencing
 Grandiose
 Confabulatory
 Distractible
 Unable to prioritize
 Lacking drive
 Restless
 Shallow affect
 Lethargic
 Unrealistic
 Socially inappropriate
 Decreased self-concern
 Withdrawn
 Extroverted
 Stimulus-bound

37. Executive Dysfunctions:
Activation Changes
Function Increased Decreased
Initiation Impulsiveness
Disinhibition
Apathy, no
drive
Termination Impersistence
no follow-
through
Perseveration
stuck at one
point

38. 
 Concreteness
 Poor Monitoring and Judgment
 Lack of Awareness of Problems
(Anosognosia)
 Poor Planning and Organization
 Poor Communication Pragmatics
Conceptualization of Psychopathology
Executive Dysfunctions:

39. Neuroanatomical Syndromes:
 Dorsolateral—impaired planning,
sequencing, complex attention
 Medial dorsal—impaired initiation
 Orbital (ventromedial)—
disinhibited, don’t respond to
feedback, “pseudopsychopathy”
Executive Dysfunctions:

41.  Competencies
 Driving
 Money management
 Personal decisions—life choices, medical consent
 Work
 Dealing with emergencies
 Family and other social relations
 Impulse control—addictions, spending,
gambling, eating, sexual behavior, aggression
 Criminal behavior
Adaptive Aspects of
Executive Functions

42. 
 Alcohol use figures into many TBIs, especially motor
vehicle accidents, falls, and assaults (roughly 1/3).
 People with alcohol problems are more likely to get
TBIs than people without.
 TBI usually makes people more susceptible to the
effects of alcohol.
Alcohol and TBI

43.  Some people with TBI find they no longer like the
effects of alcohol and avoid it.
 Others become more susceptible to alcohol abuse.
 Some medications for the effects of TBI cannot be
taken with alcohol.
 Alcohol slows and limits recovery.
Alcohol and TBI

44. 
 Therapy programs which aid persons in the
management of specific problems in perception,
memory, attention, thinking and problem solving.
 Skills are practiced and strategies are taught to help
improve function and/or compensate for remaining
deficits.
Cognitive Rehabilitation

45. 
 Interventions are based on an assessment and
understanding of the person's brain-behavior deficits
and are provided by qualified practitioners such as
psychologists and neuropsychologists,
speech/language pathologists, and occupational
therapists.
www.head-trauma-resource.com/glossary/c.htm
Cognitive Rehabilitation

46. 
 Restoration: Repetitive exercises and activities
designed to restore or improve damaged abilities
 Compensations: Tools and techniques adapted to and
used by the individual to allow functioning in spite of
disabilities
 Accommodations: Changes in the shared
environment of the individual which allow
functioning in spite of disabilities
Cognitive Rehabilitation

47.  Restoration example: Attention
 Sustained attention
 Selective attention
 Alternating attention
 Divided attention
Cognitive Rehabilitation

48. 
 Compensation example: Memory
 Memory Book – possible sections
 Event calendar
 Things to Do list
 Daily schedule
 Diary (memory log, feelings)
 Directory and family (name, address, phone
numbers and relationship, photos)
 Medications (name, purpose, schedule, doctor)
 Transportation (directions, bus schedules, maps)
 Finances
 Shopping lists
Cognitive Rehabilitation

49. 
• Compensation example: Memory
Electronic aids
• Cell phone
• Laptop
• Personal Digital Assistant
• Calculator
• Key alarm
• Digital recorder
• Digital camera
• Alarms
• Timer
• Dictionary/thesaurus
• Watch with multiple alarms, countdown timer, hour
chimes, database
Cognitive Rehabilitation

50. 
 Allow a lighter course load
 Allow tape recording of lectures.
 Provide a written outline of
material covered.
 Use overhead and other visual
media with oral instruction.
 Incorporate technology, e.g.,
computers, calculators, videos.
Educational Accommodations

51. 
 Accept typed or word-processed
assignments.
 Allow oral or audio taped
assignments.
 Individualize assignments, e.g.,
length, number, due date, topic.
 Use peer tutoring.
 Teach specific study skills, e.g.,
organization, note taking.
Educational Accommodations

52.  Neuropsychotherapy is the use of neuropsychological
knowledge in the psychotherapy or counseling of people
with brain disabilities and those close to them. It is
specialized in technique and content to address the
emotional and behavioral issues of brain disability.
Emotional Rehabilitation
(Neuropsychotherapy and beyond)

53. 
Executive Function Rehabilitation Schema
1. Compensate Externally (schedules, cues,
reminders, written procedures, restrictions)
2. Build Awareness
3. Retrain Self-regulation (problem-solving
schemata, social skills, alarms, PDAs)
4. Generalize Self-regulation train in other
settings (home, school, work, community)
5. Fade External Compensations
Neuropsychotherapy

54. 
 Accessible metaphor
 Demystify process
 Reduce guilt and blame
 Define roles
 Skill-learning model
The Content of Neuropsychotherapy
Emotional
Rehabilitation

55. 
Feedback Tools
 Mirrors
 Photos
 Audio tapes
 Videotapes
 Work samples
 Writing samples
 Arts and crafts products
The Content of Neuropsychotherap
Improving Self-
Awareness

56. 
• Testing feedback
• Medical Records
• Self-Monitoring Exercises
• Games
• Educational Materials
• Group Therapy
• Supported Failure
• Real-Life Experiences
• Don’t say “I told you so”
The Content of
Neuropsychotherap
Improving Se
Awareness

57.  Not necessarily better or worse, just
different
 Discover who the new self is
 Rethink abilities
 Rethink goals
 Rethink relationships
The Content of Neuropsychotherapy
The New Self

58. 
The Techniques of Neuropsychotherapy
Cue Cards:
MY ANXIETY SIGNS
 Tapping fingers, foot
 Fast breathing, heart
 Sweating
 Tense muscles
 Fussing and fidgeting
RELAXING BREAK
 Alone, quiet, dark
 Close eyes
 Breathe slowly, deeply
 Relax muscles
 Let go of worried
thoughts
 Picture beach

59. 
The Techniques of Neuropsychotherapy
Cue Cards:
SIGNS OF DEPRESSION:
 1. Negative thoughts
 2. Crying
 3. Thoughts of drugs
and suicide
 4. Things on TV that
remind me of my life
and children and
pregnancy
WHEN I FEEL DEPRESSED OR
WHEN FRED TELLS ME I
NEED TO:
1. "I'm getting better. I can learn to
control this myself!"
2. Distract myself:
A. Watch Fred and the others
B. Draw
C. Write
D. Nintendo
E. Clean
3. Ask Fred for help

60. ACTIVE LISTENING
Quiet, alone with other person
No TV, radio, music
Not doing anything else
Face other person, eye contact
Don't interrupt or react (bite
tongue)
Repeat other person's feelings
The Techniques of Neuropsychotherapy
Cue Cards:

61. 
PUBLIC SPEAKING
Use written outline
Practice alone and with friend
Have friend in audience
Short relaxation before going on
"I can do it! I know my stuff. They are friendly and want to
hear me."
Find friend in audience
Speak to back of room
Slowly and clearly
Smile!
The Techniques of Neuropsychotherapy
Cue Cards:

62. 
TALKING TO A PHONE ANSWERING
MACHINE
Hello, this is Wanea White with a message for
Maria Sanchez. The head injury support group
meeting will be on Friday, May 24th at 7 pm at
the Mt. Zion Baptist Church. Call me if you
have any questions at 639-4275. I hope to see
you there.
The Techniques of Neuropsychotherapy
Cue Cards:

63. 
Evaluation: Impulsive anger is:
 Develops after the injury
 Anger episodes are:
 Sudden
 Overreactive
 Unplanned
 Purposeless
 Ego-dystonic (“that’s not me!”, embarrassing)
 Related to physiological stress (pain, fatigue, low
blood sugar) (Miller, 1993; Silver & Yudofsky, 1994)
Example:
Impulsive Anger

64. Evaluation:
 Interview person with TBI and informant
 Observations
 Check for features of impulsive anger
 Check risks, signs, motivation, awareness, things that
help, trusted individuals
Example:
Impulsive Anger

65. Episode Log
 Date and Time
 What happened?
 Circumstances
 Warning signs
 Level of anger (1-10)
 Strategies used
 Outcome
Example:
Impulsive Anger

66. Middle Stages
 Work on awareness
 Strengths and Problems list
 Build trust and therapeutic alliance
 Emotional rehabilitation perspective
 Agreement for Time Outs
 Introduce Cue Card
 Others cue Time Outs
Example:
Impulsive Anger

67. 
Example:Impulsive Anger
Typical Anger Cue Card
Part 1
My Anger
Risks:
 Tired
 Noise, activity,
too many
people
 Frustrated
My Anger Signs:
 Tight muscles,
fists, jaw
 Violent thoughts
 Loud voice
 Fast breathing

68. 
Example:Impulsive Anger
Typical Anger Cue Card
Part 2
TIME OUT!
 Say: "I'm feeling angry, I
need to take a time out"
 Go outside or bedroom.
 Walk or exercise
 Practice relaxing
Preparing To Return
 When I can smile I'm
ready to go back
 What do I need to say:
 Apologize?
 Set time to talk?
 Ask how they feel?
 Say what I want?
 Check in

69. Cue Card for Telling Others About an Anger
Problem
Because of my brain injury, I get angry more easily
than I used to. Often I don't really mean to be
angry. I'm learning to control it, so don't worry
about it, and please don't take it too personally. If
you see me get angry, just give me a chance to calm
myself down, or let me walk away. Thanks.
Example:
Impulsive Anger

70. Later Stages
 Reduce cuing for Time Outs
 Do practice Time Outs
 The person with the TBI participates in and
then takes over Episode Log (becomes
Feelings Journal)
 Introduce self-talk and self-calming without
leaving for a time out
 Generalize self-management to other settings
 Stress test the system (try coping in more
difficult situations)
Example:
Impulsive Anger

71. Feelings Journal
 Date and Time:
 What Happened?
 Anger Level (1-10):
 What did I do?
 What were my warning signs?
 What did I feel?
 Did I back off?
 What do I need to do now?
 What can I do better next time?
Example:
Impulsive Anger

72. 
 People with TBI are often more sensitive to
psychotropic medications than others, especially to
the cognitive effects, for example, of benzodiazepines
and phenothiazines (best avoided)
 For emotional and behavioral problems, try
environmental and psychotherapeutic methods first,
unless the problem predates the injury or is severe
Medications and TBI

73. 
Off-label uses:
 Stimulants are often useful for attention problems
 Modafinil (Provigil) is often used for fatigue
(although a recent study suggests that caffeine is just
as good)
Medications and TBI

74. 
Off-label uses:
 Acetylcholinesterase inhibitors (donepezil [Aricept],
rivastigmine [Exelon], or galantamine [Razadyne])
are approved for Alzheimer’s disease but can be
helpful for cognition in some individuals with TBI.
 Dopamine agonists such as amantadine can be useful
for impaired initiation and other executive
dysfunctions
Medications and TBI

75. 
Off-label uses:
 Options for managing impulsive anger:
 Selective serotonin reuptake inhibitors
 Beta blockers
 Mood stabilizers (especially if there is epilepsy and
they can do double duty)
Medications and TBI

76. 
Off-label uses:
 Options for managing sensory hypersensitivity (not
well researched):
 Atypical antipsychotics
 Long-acting benzodiazepines (clonazepam)
Medications and TBI

77. 
 A university is one of the hardest places to cope with a
brain injury because of the demands of the institution.
 At the same time, because universities are supposed to
be enlightened, it is or should be one of the most
understanding and accommodating settings.
Living with brain injury at the
university and in the rest of the
world

78. 
 The “extra” curriculum for students with brain
injuries at the university should include knowing their
rights and how to stand up for them.
 The “extra” curriculum for temporarily able-brained
students should include understanding, including,
and accommodating those with disabilities.
Living with brain injury at the
university and in the rest of the
world

79.  Take enough time to recover.
 Take a light course load, preferably electives.
 Get all the accommodations you think you
might need. It’s easier to drop them than to
add them.
 Budget lots of extra study time.
 Don’t let your schooling get in the way of your
education.
Returning to University
after a TBI