Title: Whatever%20Happened%20to%20Me?%20A%20Neuropsychological%20Perspective%20of%20Traumatic%20Brain%20Injury
1Whatever 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
2Overview
- HISTORY AND METHODOLOGY
- DEFINING NEUROPSYCHOLOGY
- DEFINING PERSONALITY
- DEFINING TRAUMATIC BRAIN INJURY
- NEUROPSYCHOLOGICAL RESIDUALS OF TBI
- The Interface Between Neuropsychology,
Personality and Traumatic Brain Injury
3History
- 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
4Methodology
- 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
5Defining Neuropsychology
- PROFESSIONAL
- Neuropsychologist- Doctorate level (state
license) - Psychometrician- MA level (aspirational)
- SCIENTIFIC
- Interface between brain and behavior
- Focus on
- Behavior
- Cognition
- Emotion
- Personality
6Defining 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)
7Traumatic 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
8Defining 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.
9Defining 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.
10Defining 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)
11Defining 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
12Describing the Physical Injury (Barth, 2009)
13(No Transcript)
14Causes of TBI
15Review 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
16Methods 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.
17Neuropsychological 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)
18Specifics 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)
19Specifics of Assessment
- Orientation
- Communication
- Fluency
- Motor
- Reasoning/Organization
- Memory
- Intellectual
- Academic
- Affective
- Personality
- Effort
20Specifics 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
21Potential 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
22Psychological 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
23Interface 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
24Recovery 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
25Recovery from TBI Contextual Factors
- MARITAL STATUS
- FAMILY SUPPORT
- INCOME LEVEL
- ECONOMIC RESOURCES (insurance, disability)
- SOCIAL ENGAGEMENT
26Recovery External Predictors
- NEUROCOGNITIVE TEST RESULTS
- IMPORTANCE OF SUBJECTIVE COMPLAINTS
- VALUE OF INFORMATION FROM SIGNIFICANT OTHERS
27Interventions
- PSYCHOLOGICAL
- COGNITIVE
- VOCATIONAL
- PHYSICAL
- MEDICAL
- PHYSICAL
- SYSTEMS
-
28How 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)
29Residual Damage
- SIGNIFICANT OTHERS
- CHILDREN
- SYSTEMS
- SOCIETY
30Special 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
31Special 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 PHYSICALWHEN 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
32Special 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
33What 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
34The Challenge of Forensic Concerns
- LITIGATION
- Civil
- Disability
- Work related
- Social Security
- QUANTIFYING DEFICITS STRENGTHS
- QUANTIFYING EFFORT
- QUANTIFYING LOSS
35What 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?
36This is not what I planned for