Awareness and Outcome after TBI

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Awareness and Outcome after TBI

• Tina M. Trudel, PhD
• President/COO Lakeview Healthcare Systems
• of ME, NH, RI, VA WI
• Site Director, Defense Veterans Brain Injury
  Center at Lakeview Virginia NeuroCare
• Asst. Professor of Clinical Psychiatry
  Neurobehavioral Sciences,
• University of Virginia School of Medicine

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What is Awareness?

• Fredericks (1969) Etymology of the word
  consciousness cum (with) scire (to know)
• Objective state
• Subjective state
• Simons Case Example

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Dimension 1 - Knowledge

• Aware/has knowledge of specific deficit or
  disability
• Accurately describe post-injury changes
• Flashman McAllister, 2002

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Dimension 2 Emotional Response

• Emotional response manifested regarding
  difficulties or deficits.
• From complete apathy to bitter complaint from
  indifference to angry denial when confronted.
• Flashman McAllister, 2002

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Dimension 3 Generalizability

• Ability to comprehend the impact or consequence
  of deficit on daily life.
• Application and understanding of comparison to
  premorbid level in real life settings.
• Flashman McAllister, 2002

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Related Issue - Attribution

• Causal attribution of deficit or disability
  required with two elements
• First, the person acknowledges the deficit
• Second, the person attributes the deficit to the
  injury to a degree sufficient to have the trauma
  become part of their self-definition.
• Flashman McAllister, 2002

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Awareness Terms

• Agnosia impairment in recognition not based in
  sensory or motor impairment
• Anosognosia lack of knowledge about a deficit,
  loss of recognition L. hemiplegia example
• Denial of Illness implies psychological
  mechanism of blocking awareness
• Insight multidimensional mechanism that permits
  understanding of deficits
• Anosodiaphoria indifference, absence of concern
  regarding acknowledged deficit

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Awareness Outside of TBI

• Cognitive distortions psychologist job security
• The positive outlook illusion
• Well-being
• Positive effectivity
• Self-esteem
• Help direct person toward future goals or plans
• Positive self-deception
• Lack of concrete information
• Motivation to self-deceive is high
• Self serving biases
• Not a manifestation of a neurological phenomenon
  and mild in comparison i.e. contingency tests

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Awareness and Development

• Child-rearing approaches
• Educational practices
• Pubertal hormones
• Myelination of frontal system
• Maturation

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Awareness Problem Rates Post-TBI

• Up to 45
• Flashman McAllister, 2002
• 76 to 97 show some degree of impaired
  self-awareness
• Sherer, et al., 2003
• Overestimate of abilities global issue

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Measuring Awareness

• Inferred, not directly measured
• Comparison ratings - discrepancy
• Individual vs. family
• Individual vs. staff
• Individual vs. actual performance measures
• Self-questionnaires
• Structured interview

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Limits to Measuring Awareness

• Understanding questions
• Verbalizing responses
• Accuracy of relatives staff
• Accuracy of info regarding changes
• Scaling issues with discrepancy ratings

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Brain Regions in Awareness

• Most commonly injured areas in TBI
• Frontal system
• Parietal (non-dominant)
• More severe injury, higher rate (supported to
  some degree, although not robustly across studies)

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Neurobehavioral disorders, awareness and the
frontal lobes

• The brain is the organ of behavior.
• While most cortical structures have a role in
  contributing to purposeful behavior, damage to
  the frontal lobes can lead to particularly
  dramatic cognitive, emotional and behavioral
  changes and a lack of awareness of those changes.
• Stuss self awareness is highest cognitive
  function of frontal system

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The Story of Phineas Gage
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The Story of Phineas Gage(CONTINUED)

• The equilibrium of balance between his
  intellectual faculties and animal propensities
  seems to have been destroyed.
• He is fitful, irreverent, indulging at times in
  the grossest profanity
• Manifesting but little deference to his fellows
• Devising many plans of operation, which are no
  sooner arranged than they are abandoned ---Harlow
  1868

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Gage Web Pagewww.deakin.edu.au/hbs/GAGEPAGE/
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Plaque in Cavendish VT
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Frontal Lobes Anatomy

• Comprise 1/3 of the hemispheric surface.
• Most frequently damaged by trauma.

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Pre-frontal lobes Anatomy

• Major Lateral Divisions
• Motor Cortex Areas 4 6
• Pre Frontal
• Eye Movements Areas 8,9
• Motor Speech Area 44
• CognitionAreas 10,45-47,11

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The Prefrontal CortexEvolutionary
Considerations of Awareness

• 29 of total cortex in the adult human
• 17 of total cortex in the chimpanzee
• 7 of total cortex in the canine
• 3.5 of total cortex in the cat

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Overview of Prefrontal Lobe Function Executive
Cognition

• Executive function refers to the organizing
  principles necessary to navigate the fluctuating
  and ambiguous challenges confronted in autonomous
  social behavior (Duffy Campbell, 1994)
• Provides a compass for behavior
• Keeps us on task (e.g. a rudder )
• Makes us aware to interface with the environment
  successfully
• Metacognition and accurate feedback loops for
  self-appraisal

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Executive Functions

• Self Awareness most complex
• Planning, Prediction Judgment
• Initiation, Sequencing Organization
• Self monitoring Correction
• Emotional regulation
• Behavioral control
• Problem solving

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Frontal Lobe Injury Behavioral Challenges

• The Anatomy
• Lesions cause damage to the connections between
  the frontal cortex and the limbic (emotional) and
  reticular systems (activating).
• The Behavior
• Deficits in executive functions results in a
  break-down of regulated behavior leading to
  disinhibition, changes in affect and impaired
  awareness to self-regulate and monitor.

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Behavior Problems Following Frontal Lobe Injury
(continued)

• Cummings has identified three different syndromes
  that can arise from pre-frontal lobe damage
  depending on the site of injury.
• In reality, most patients display a mixture of
  syndromes.
• Awareness is often affected.

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Orbital Frontal Symptoms

• Disinhibition
• Inappropriate jocularity
• Emotional lability
• Poor judgement and insight
• Distractibility
• Self-centeredness
• Difficulty with perspectives
• Impaired awareness of disability

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Orbital Frontal Syndrome Barriers to
Treatment

• Often misdiagnosed as manic or antisocial
• Difficult to rehabilitate because of
• impaired awareness of disability
• diminished insight poor judgment
• poor attention
• emotional lability.

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Orbital Frontal Syndrome Barriers to
Treatment (Continued)

• They can end up arrested, assaulted and injured.
• Caregivers may find their efforts un-welcomed and
  can easily fall into a pattern of nagging,
  argument and power struggle (Trudel, 2004).

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Frontal ConvexitySymptoms

• Pseudo-depression
• Apathy/Indifference form of impaired awareness
• Perseveration
• Stimulus Bound
• Discrepant Behavior
• Poor Abstract Processes
• Stated another way
• Difficulty accomplishing anything because they
  are disorganized in thought and action

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Frontal Convexity Syndrome Barriers to
treatment

• Individuals are often misdiagnosed as depressed,
  passive-aggressive or avoidant
• Differs from depression in that there is a lack
  of the feelings of sadness or a state of misery.
• Mistakenly viewed as dishonest and lazy
  disinterest and apathy paramount
• Impaired awareness can be key element re
  emotional indifference

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Parietal LobeSymptoms

• Prosopagnosia (faces)
• Topographical agnosia
• Integrative deficits
• Anosagnosia

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Factors Impacting Awareness

• Psychological Factors-
• Denial of illness may be adaptive
• (Weinstein Kahn, 1955)
• Externalized coping style
• Breakdown of cognitive or sensory systems
• Integrated frontal system of self-awareness,
  self-reflectiveness and self-monitoring not
  functioning effectively
• May be able to analyze others behavior more
  accurately than own behavior
• May be more accurate for concrete (physical) than
  abstract (psychosocial) judgments Sawchyn et al.,
  2005

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Awareness and Outcome

• Increased awareness may be associated with
  depression - Deficit-focused personality style
• However, in some outcome studies, underestimators
  and accurate estimators both faired better than
  overestimators.
• Impaired awareness is associated with apathy ,
  poorer emotional adjustment, diminished
  motivation, lack of emotional distress, and lower
  generalizability of skills outside of the
  therapy/rehabilitation session
• Hoofien et al., 2004 Flashman McAllister 2002

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Awareness and Outcome

• Impaired awareness often persists over time
  past predicts future issues
• Awareness serves as a primary predictor of both
  independent living and behavioral status across
  numerous studies.
• Prigatano, 2005

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Awareness and Employment

• Discrepancy scores (awareness) were strongest
  predictor of vocational status, beyond that of
  all neuropsychological measures combined in a
  severe TBI long term sample (residential status
  as well)
• Trudel et al., 1998

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Awareness and Employment

• Impaired awareness - more predictive of gainful
  employment after injury than injury severity,
  injury chronicity, pre-employment status, prior
  use of alcohol and/or overall cognitive
  dysfunction.
• Prigatano, 2005

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Awareness Interventions

• Primary Areas of Intervention
• Psychological
• Cognitive/Neuropsychological
• Theoretical Orientation
• Address awareness as overarching deficit before
  change can occur
• Treat awareness deficits within broader,
  integrated program to improve functioning
• Address behavior change regardless of awareness
  insight is not necessary for change
• Manage environment - minimize awareness need

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Awareness Interventions

• Primary treatment components identified across
  research areas include
• Assessment
• Neuropsychological evaluation
• Development of therapeutic alliance
• Education of person with brain injury and their
  support system
• Intervene repeatedly and in small doses over time
  for best results

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Awareness Interventions Fleminger Ownsworth,
2006

• General neuropsychological rehabilitation
  programs and multidisciplinary programs such as
  Prigatano (AZ) Ben-Yishay (NY)
• NYU program model has awareness as core and has
  been well reviewed and analyzed in literature.
• Individual as well as small group intervention
• Some with low self-awareness do not respond
  favorably (emotional self-regulation)
• Includes therapeutic alliance, family work, peer
  feedback, in vivo experiences, education, role
  play, videotape feedback, milieu and individual
  therapy
• Difficult to determine effective ingredients in
  package

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Awareness Interventions Fleminger Ownsworth,
2006

• Psychotherapeutic Treatment
• Focus on exploring meaning of losses and
  impairments, accurately recognize new strengths
  and weaknesses and develop coping skills
• Not knowing about deficits
• Lack of access or ability to understand
• Neuropsychological difficulty gleaning
  implications
• Emotional pain and denial
• Group and individual therapy
• Performing activities, review of work and
  progress, continually monitor readiness.

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Awareness Interventions Fleminger Ownsworth,
2006

• Interventions Based on the Pyramid Model of
  Awareness (variety)
• Three levels of awareness interventions
• Intellectual basic brain/behavior knowledge
• Emergent problem recognition in vivo
• Anticipatory predict problem may occur
• Wide range of interventions including education,
  intensive feedback during sessions, videotape,
  strength weakness lists, planned failure
  experiences with supportive counseling,
  compensatory training, community training

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Awareness Interventions Fleminger Ownsworth,
2006

• Structured Experiences
• Focuses on task knowledge, self knowledge and
  beliefs (metacognition)
• And situational awareness during task
  performance (on-line awareness)
• Uses guided mastery experiences that allow for
  self-monitoring and self-evaluation
• Anticipatory training (examine obstacles and
  strategies) self-prediction training
  (difficulty, speed and accuracy) time
  monitoring self-checking self- evaluation
  self-questioning role reversal are all tools used

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Awareness Interventions Fleminger Ownsworth,
2006

• Direct Feedback
• Best for impaired awareness due to impairment of
  cognition as opposed to psychological denial
  (resistance and high emotional arousal to
  feedback) or neurological basis (passive response
  and indifference to feedback).
• Feedback can be via individual, small group,
  videotape or audiotape methods
• Subcomponent of other holistic approaches

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Awareness Interventions Fleminger Ownsworth,
2006

• Game formats
• Educational board games used as therapeutic tools
• Non-threatening and exploratory
• Knowledge may improve, but not necessarily
  increased accuracy of self-appraisal

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Awareness Interventions Fleminger Ownsworth,
2006

• Support Groups
• Psychoeducational programs in nature
• Benefit from peer feedback
• Opportunity to practice skills
• Included within comprehensive treatment packages

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Awareness Interventions Fleminger Ownsworth,
2006

• Behavioral Interventions
• Increase or decrease target behaviors and develop
  skills collaboratively with individual
• Self awareness may not be relevant or necessary
  for certain rehabilitation and functional gains
  to occur
• Behavioral/functional status may improve without
  gains in awareness
• Use learning principles and habit formation for
  compensatory techniques

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Awareness Interventions Fleminger Ownsworth,
2006

• Interventions for Children
• Low to high confrontation approaches (also a
  dynamic with adult interventions)
• Serious or excess confrontation may result in
  increased anger or denial
• Critical to consider developmental tasks, needs
  and identity formation challenges

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Critical Issues to Remember

• Impaired awareness often has some elements of
  both neurocognitive deficit and psychological
  denial
• Treatment must preserve self-esteem and minimize
  risk for depression and catastrophic responses
• Biopsychosocial models or well beyond that when
  we are addressing the very foundations of
  identity and self.

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Thank You -

• Tina M. Trudel, PhD
• Lakeview Healthcare Systems
• ttrudel_at_lakeview.ws
• 1-800-473-4221