Download Impact of Traumatic Brain Injury Among Recently Returned

Roles of Neuropsychology and
Psychology following
Positive TBI Clinical Reminders:
The Evaluation and Treatment Process
Rodney D. Vanderploeg, Ph.D.
Tampa VAMC
VA Psychology Leadership
Conference/APA
May 18, 2007
Objectives
 Provide
an overview of the TBI Clinical
Reminder screening process
 Describe a model follow-up evaluation and
treatment process
 Describe when and how neuropsychological
evaluations should be completed
 Describe other roles of psychology following
positive TBI Clinical Reminders
Although I love Harry Potter
There is No Magic!
And, things like this are Pseudo-Magic
“Automatic Clock Drawing Test”
Featured in the Journal of the
American Geriatrics
Society, NIH, and the American
Bar Association ElderLAW ENEWS. New!
5 minute evaluation
If you want to know if someone had
a Traumatic Brain Injury (TBI)
 ASK

THEM:
Did you experience a physical trauma or
injury that resulted in your being:
• Knocked out / Rendered unconscious,
• Dazed and confused for several
minutes, and/or
• With memory gaps for some or all of the
immediate period after the event
 If
the answer is “yes”, then they had a TBI
That is what the “TBI
Screening Reminder” Does
TBI Screening
Reminder
April 2007
So, what really are the issues?
1.
2.
3.
4.
5.
6.
7.
Who has ongoing symptoms and problems?
What are these symptoms and problems due to
(TBI, PTSD, Depression, Anxiety, Somatoform
Disorder, malingering, combinations of conditions)?
What is the appropriate treatment for any identified
problems/conditions?
Who is responsible for providing the assessment
and treatment?
Who is responsible for coordinating this process?
When should this be done locally, and when should
it be done by regional specialists?
What are the roles of psychology in points 3-6?
“TBI Screening Reminder” Functions
 Identify
possible OIF/OEF Participants
 Confirm deployment to OIF/OEF Theatres
of Deployment
 Screen for TBI if deployed in OIF/OEF
Theatres
 Identify those with an OIF/OEF-related
history of TBI
Criteria for Severity of TBI
Mild
Moderate
Severe
LOC < 30 min
with
normal CT &/or
MRI
LOC < 6
hours with
abnormal CT
&/or MRI
LOC > 6 hours
with
abnormal CT
&/or MRI
GCS 13-15
GCS 9-12
GCS < 9
PTA < 24hr
PTA < 7days
PTA > 7days
Don’t confuse combat-trauma psychological confusion
with post-TBI PTA (i.e., inability to lay down new
memories and therefore having post-TBI “memory gaps”)
Screening Questions:
4 Sections
 Section
1: Trauma Events
 Section 2: Immediate Disturbance of
Consciousness Symptoms after Events
 Section 3: New or Worsening Symptoms
after the event
 Section 4: Current Symptoms
Screen Interpretations
 A “no”
response to any of the sections
terminates screening and is a “negative
screen”
 A “yes”
response to ALL FOUR sections
is a “positive screen”
Section 1: Trauma Events
Section 2: Immediate Symptoms
Section 3: New/Worsening Symptoms
Section 4: Current Symptoms
Positive TBI Screen: Follow-up
 Positive
replies in all four sections
constitute a positive screen
 Positive screens automatically generate a
consult to a TBI specialist or clinic
 This specialist/clinic has 1 week to initiate
contact with patient for more detailed
follow-up evaluation
 Initial treatment trial is based on positive
problems on this follow-up evaluation
What to Know:
Relevant Background (1)
 Mild



TBI Symptoms
There is no symptom that is unique to or
diagnostic of mild TBI
Many postconcussion symptoms occur in
normal healthy individuals
All symptoms/problems overlap with one or
more other conditions (PTSD, Depression,
Anxiety, Chronic Pain, Somatoform Disorder,
chronic health conditions)
What to Know:
Relevant Background (2)
 In
prospective cases (non-clinical, nonlegal) virtually all symptoms of mild TBI
resolve within 1 - 3 months



Cognitive
Emotional
Physical
 Yet,
a subgroup (about 10-15%) continue
to experience a postconcussive syndrome

Psychological factors play a large role in
symptom presence in this subgroup
What to Know:
Relevant Background (3)
 In

this subgroup (of about 10-15%)
There is no relationship between symptom
complaints and objective findings on:
• Neuropsychological Testing
• Physical Examination
• Neurological Examination
 Again,
this is because psychological
factors play a large role in symptom
complaints
Predisposing Factors
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Causative Factors
Medical
Iatrogenesis
Personality
Traits
Medical
Conditions
SelfExpectation
Acute
Symptoms
mTBI
Coping
Abilities
Psychiatric
Conditions
Litigation
Iatrogenesis
Intelligence
Level
Demographic
Characteristics
Perpetuating and Mitigating Factors
Chronic
Symptoms
Intelligence
Level
Coping
Abilities
Social
Support
Predisposing Factors
Psychiatric
Conditions
Personality
Traits
Medical
Conditions
Causative Factors
Perpetuating and Mitigating Factors
Medical
Iatrogenesis
Psychiatric
Conditions
Litigation
Iatrogenesis
Medical
Conditions
SelfExpectation
Acute
Symptoms
Intelligence
Level
mTBI
Demographic
Characteristics
Coping
Abilities
Personality
Traits
Chronic
Symptoms
Intelligence
Level
Coping
Abilities
Psychological
Contributions
Social
Support
Issue One
1.
Who has ongoing symptoms and problems?
 Anyone who responds positively to all four
of the TBI Clinical Reminder sections
Section 1:Trauma Event(s)
Section 2:Immediate Disturbance of
Consciousness after Event(s)
Section 3:New or Worsening Symptoms after
the event(s)
Section 4:Current Symptoms
Issue Two: Symptom Etiologies
2. What are these symptoms and problems due to
(TBI, PTSD, Depression, Anxiety, Somatoform
Disorder, malingering, combinations of conditions)?

Initial post-TBI Clinical Reminder
Assessment (at Tampa and elsewhere)
Telephone Administration of:
 History Questions (e.g., confirmation of
exposure, details of TBI severity, history of
symptom course), Review of bodily systems
and associated complaints, etc.
 Neurobehavioral Symptom Inventory (22
items rating postconcussive symptoms)
 PTSD Checklist (PCL)
 Pain symptoms
Issue Two: Symptom Etiologies

Interpretation of Initial Assessment Findings




What are the most likely etiologies for the
symptoms?
What etiology(s) is/are primary?
(Does PTSD, chronic pain, sleep disturbance
likely explain the cognitive symptoms?)
Would successful treatment of the primary
etiology likely resolve most or all of the
symptoms?
Referring and Triaging:
Refer accordingly for further evaluation and/or
treatment
Issue Two: Symptom Etiologies

When to Refer
Refer if the evaluation/referral will:


Tell you something you don’t already know
Make a difference in the patient’s treatment or
management
Turning Down a Consult for
Neuropsychological Assessment


Referral received and chart reviewed. Veteran
currently has severe symptoms of PTSD and chronic
headaches. Given this, his cognitive complaints of
memory and concentration problems are expected. If
testing were performed in this situation, any cognitive
impairments would likely be attributed to the severity
and extent of the mental health problems. Testing
would not clarify diagnostic issues nor guide treatment - because mental health and pain management
treatment should to be the main focus at this time.
Once his mental health and pain symptoms are better
managed, and rated as no worse than mild to
moderate, if cognitive symptoms remain, a re-referral at
that time may be clinically useful.
Issue Two: Symptom Etiologies

Follow-up Additional Specialized
Assessments (and then treatment)






TBI: PNS or PSCT
(PM&R, (Neuro)Psychology, Speech,
Psychiatry)
PTSD: PTSD Program
Chronic Pain: Pain Program or PM&R
Somatoform Disorder(s): ?????
Depression, Anxiety, Stress: MHC
Seizures, Neurologic Conditions: Neurology
Issue Three:
Appropriate Treatment(s)
 Treat
the primary condition(s), the one(s)
that explains most or all of the symptoms
 Don’t invest time and effort in conditions
that account for only small amounts of
symptom variance
 Just because a condition was/is present
(e.g., history of mild TBI), doesn’t mean it
should be the focus of further assessment
or treatment if other conditions are primary
+ PTSD
Re-experiencing
Avoidance
Social withdrawal
Memory gaps
Apathy
? Mild
TBI
Residual
Difficulty with decisions
Mental slowness
Concentration
Headaches
Dizzy
Appetite changes
Fatigue
Sadness
+ Depression
Arousal
Sensitive to noise
Concentration
Insomnia
Irritability
Issue Four:
Who is Responsible?
 TBI
Clinical Reminder: Primary and
Specialty Clinics (including Urgent Care,
MHC, PTSD, Dental, etc.)
 Initial Follow-up Assessment:



Polytrauma Program staff
(Level II: PNS or Level III: PSCT),
SCI Program staff, or
Local Designated Specialist(s) - Physician
(e.g., Neurologist, PM&R physician)
Issue Four:
Who is Responsible? (cont.)
 Subsequent






Evaluations/Treatments:
TBI: PNS or PSCT
(PM&R, (Neuro)Psychology, Speech,
Psychiatry)
PTSD: PTSD Program
Chronic Pain: Pain Program or PM&R
Somatoform Disorder(s): ?????
Depression, Anxiety, Stress: MHC
Seizures, Neurologic Conditions: Neurology
Primary &
Specialty
Clinics
Polytrauma Program staff,
SCI Program staff, or
Designated Specialist(s)
Programs /
Clinics for
Identified
Conditions
Issue Five:
Coordination of Care Responsibilities
 If
a Level I, II, or III Polytrauma Program,
then the polytrauma team
 If not, the system is not clear who is
responsible for making sure evaluations are
completed, treatments are initiate, and
symptoms/problems are resolving
 But, if treatment is not successful within a
reasonable time (e.g., 90 days), patients
should to be referred to a PNS or PRC
Issue Six:
Local versus Regional Care
 If
the facility has a designated TBI
specialist who is assigned to respond to the
TBI Clinical Reminders, then initial
assessment and treatment should be local
 If not, assessment should be done by the
nearest PNS or PSCT staff
 If that assessment indicates that local
resources can provide the treatment, fine; if
not, and the problems are deemed to be
TBI-related, then the nearest PNS
Issue Seven: Role(s) of
Psychology / Neuropsychology
 Members
of the PNS or PSCT staff
 Assessment and treatment if indicated



Neuropsychological Evaluations (15% of cases)
Psychological Assessments (15-75+% of cases)
TBI Rehab Interventions
• Mild TBI Education & Support
• Compensatory Training / Cognitive Remediation


Stress Management, Education, Support
Specialty Treatment
• PTSD, Depression, Anxiety, Chronic Pain
Important Mild TBI
Facts
Causes of Persistent
Postconcussion Symptoms
“Expectation as Etiology”
and/or
“The Good Old Days”
 Symptom

Mis-Attribution
Willey Mittenberg, Ph.D.
 “Diagnostic

Threat”
Julie Suhr, Ph.D.
Expectation as Etiology
 Controls
asked to imagine symptoms of a
mild TBI “expected” symptom presence and
severity very similar to mild TBI patients’
actual symptoms
 Mild TBI patients “under-estimated” the
frequency and severity of pre-MTBI
symptoms and problems
 Athletes “expected” lower levels of postconcussion problems than non-athletes
 Athletes with a concussion “over-estimated”
pre-concussion levels of symptoms
Mild TBI “Diagnostic Threat”
 Non-clinical
evaluations of college
students with a remote history of mild TBI
(many months earlier)
 Neuropsychological Test Performance



If told they are participating in a study of the
effects of mild TBI, their performance is worse
than,
If told they are simply participating in a study
of cognitive functioning in college students
The “context” of the evaluation matters!
Mild TBI Treatment
 Change
expectation and attribution of
symptoms
 Provide education


Education regarding mild TBI
Education regarding symptoms and
their course
 Provide



Support/Treatment
Stress management
Psychological and cognitive coping
strategies and resources
Cognitive-Behavioral therapy
If There is Time
which there will not be
What to Expect:
Literature Review Findings
 Mild




TBI Findings
Neuropsychological Test Performance
Postconcussion Symptoms
Causes of Postconcussion Symptoms
Treatment of Mild TBI
Neuropsychological Test
Performance
Mild TBI: Neuropsychological
Meta-analytic Studies (1)
(Schretlen & Shapiro, 2003)
 A second
recent meta-analytic study found
that overall neuropsychological effect size
(d) for MTBI in prospective studies was
0.24
 Categorized into 4 time-since-injury
intervals the effect sizes were:
< 7 days 7-29 days
0.41
0.29
30-89 days
0.08
> 89 days
0.04
Mild TBI: Neuropsychological
Meta-analytic Studies (2)
(Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, in
press)
 A third
recent meta-analytic study found the
following, categorized into two time-sinceinjury intervals and three types of studies:
Time
Post-Inj.
Litigation
Based
Clinic
Based
Unselected
Samples
< 90 days
0.52
No studies
0.63
> 90 days
0.78
0.74
0.04
Vietnam Experience
Study (VES)
Neuropsychological and
Postconcussive Symptom
Findings
Subjects
 Vietnam
Experience Study Data/Center for
Disease Control Vietnam Experience Study
1988a, 1988b JAMA
 4,462 randomly selected male US Army vets
(community dwelling, not clinic-referred or selfreferred)
 Entered
military between 1/65 - 12/71
 Minimum of 4 months active duty
 Served only one tour of duty
Subjects cont’d

Racial makeup of the 4,462 participants:
 81.9%
Caucasian
 11.8% African-American
 4.5% Hispanic
 1.9% Other


Mean age = 38.36 years (SD = 2.53)
Mean level of education = 13.29 years (SD = 2.3)
 Mean IQ = 105 (SD = 20.32) (based on GTT)
Subjects cont’d
 Participants
underwent a 3 day evaluation
including:


extensive medical, psychological, and
neuropsychological examination
included were questions regarding MVA, head
injury, loss of consciousness, and subsequent
hospitalization
 Evaluations
took place approximately 16
years post-military discharge
Measures
 Diagnostic
Interview Schedule (DIS-III-A)
 Extensive
surveys of physical functioning
and symptoms
 Battery
of neuropsychological tests
Groups and Sample Sizes
Groups
Number
No MVA, No Head Injury 3057
MVA, No Head Injury
521
Head Injury with LOC
254
Neuropsychological Measures
 Multivariate
analysis of variance
(MANOVA) was conducted with 14
neuropsychological measures, which cover
the domains of:
» Complex Attention
» Non-Verbal Abilities
» Psychomotor Speed
(visuospatial)
» Verbal Memory
» Visual Memory
& Coordination
» Verbal Abilities
» Executive Abilities
Statistical Analyses:
Neuropsychological Measures
(Matching groups on premorbid IQ)
 MANOVA was
not significant
F(30,7620) = 1.28, p = 0.14,
eta squared = 0.005
 On
average, the MTBI group performed
0.03 of a standard deviation more poorly
than either control group
Current Cognitive Functioning:
Examples of the 14 Measures
Normal
Control
MVA
Control
Mild
TBI
(n = 3057)
(n = 521)
(n = 254)
Animal
Fluency
20.5
(5.1)
21.0
(5.4)
20.7
(5.3)
Rey-O
Copy
32.7
(3.4)
32.8
(3.0)
32.7
(3.0)
CVLT Sum of
Trials 1 to 5
46.0
(8.7)
45.9
(8.5)
46.3
(9.7)
Postconcussion
Symptoms
Postconcussion Symptoms
 Physical

Headache, dizziness, fatigue, noise/light
intolerance, insomnia
 Cognitive

Memory complaints, poor concentration
 Emotional

Depression, anxiety, irritability, mood lability
PCS Diagnostic Criteria
DSM-IV
Three or more of:
1. Fatigue
2. Disordered Sleep
3. Headache
4. Dizziness
5. Irritability
6. Anxiety, depression,
or affective lability
ICD-10
Three or more of:
1. Headache, dizziness,
malaise, fatigue, or noise
intolerance
2. Irritability, depression,
anxiety, or emotional lability
3. Subjective concentration,
memory, or intellectual
difficulties
4. Insomnia or affective lability
Odds-Ratios for Occurrence of the
Postconcussion Symptom Complex over Past Year
(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)
Diagnosis
Normal
Control
MVA
Control
Mild
TBI
DSM-IV
Postconcussion
Syndrome
1.0
(20.6%)
1.04 (0.82 - 1.31) 2.00 (1.49 - 2.69)
(25.2%)
(40.9%)
ICD-10
Postconcussion
Syndrome
1.0
(19.1%)
1.13 (0.90 - 1.44) 1.80 (1.33 - 2.43)
(24.9%)
(37.4%)
Odds-Ratios for Various Physical/Neurological
Postconcussion Symptoms During the Past Year
(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)
Symptom
Normal
Control
MVA
Control
Mild
TBI
Balance Problems
1.0 (3.4%)
1.58 (1.02 – 2.45) 2.43 (1.48 – 3.97)
Sensitivity to Light
1.0 (3.6%)
1.14 (0.72 – 1.80) 1.92 (1.15 – 3.20)
Headache Problems
1.0 (13.0%) 1.15 (0.89 – 1.50) 1.94 (1.42 – 2.68)
Trouble Sleeping
1.0 (24.9%) 1.22 (1.01 – 1.51) 1.85 (1.39 – 2.45)
Double Vision
1.0 (5.7%)
Fatigue Easily
1.0 (20.9%) 1.00 (0.80 – 1.26) 1.42 (1.05 – 1.91)
1.10 (0.75 – 1.61) 1.81 (1.17 – 2.79)
Odds-Ratios for Various
Cognitive/Neuropsychological
Postconcussion Symptoms During the Past Year
(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)
Symptom
Normal
Control
MVA
Control
Mild
TBI
Periods of Memory
Loss or Confusion
1.0 (4.4%)
1.14 (0.76 – 1.72) 2.80 (1.83 – 4.28)
Memory Problems
1.0 (13.7%)
1.13 (0.87 – 1.46) 1.75 (1.28 – 2.41)
Concentration
Problems
1.0 (13.4%)
1.40 (1.10 – 1.80) 1.28 (0.91 – 1.80)
Odds-Ratios for Various
Emotional/Psychological
Postconcussion Symptoms During the Past Year
(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)
Symptom
Normal
Control
MVA
Control
Mild
TBI
Irritability or Short
Temper
1.0 (26.5%)
1.10 (0.89 – 1.35)
1.36 (1.02 – 1.81)
Aggressive and
Angry Behavior
1.0 (10.2%)
1.34 (1.02 – 1.77)
1.32 (0.91 – 1.91)
Sadness and
Depression
1.0 (11.2%)
1.28 (0.97 – 1.69)
0.92 (0.62 – 1.37)
Anxious
1.0 (13.8%)
1.29 (0.99 – 1.65)
1.10 (0.77 – 1.56)
Causes of Persistent
Postconcussion Symptoms
“Expectation as Etiology”
and/or
“The Good Old Days”
 Symptom

Mis-Attribution
Willey Mittenberg, Ph.D.
 “Diagnostic

Threat”
Julie Suhr, Ph.D.
Expectation as Etiology
 Controls
asked to imagine symptoms of a
mild TBI “expect” symptom presence and
severity very similar to mild TBI patients’
actual symptoms
 Mild TBI patients “under-estimate” the
frequency and severity of pre-MTBI
symptoms and problems
 Athletes “expect” lower levels of postconcussion problems than non-athletes
 Athletes with a concussion “over-estimate”
pre-concussion levels of symptoms
Mild TBI “Diagnostic Threat”
 Non-clinical
evaluations of college
students with a remote history of mild TBI
(many months earlier)
 Neuropsychological Test Performance



If told they are participating in a study of the
effects of mild TBI, their performance is worse
than,
If told they are simply participating in a study
of cognitive functioning in college students
The “context” of the evaluation matters!
Other Factors Influencing the
Development and Persistence
of
Persistent Postconcussion
Symptoms
Predictors of Persistent PCS:
Vietnam Experience Study Data
 Examine
the influence of the following
predictors on the presence of a persistent
Postconcussion Symptom Complex
(PPCS) following mild head injury
 Predictors:




demographic variables
early life psychiatric difficulties
social support variables
loss of consciousness
Results

Overall model was significant


MTBI
R2 = 33.0
2 (26, N = 532) = 137.85, p < .001
Unique Variance per predictor





MTBI
demographic variables
early life psychiatric symptoms
(9.2%)
(6.3%)
• Internalizing (e.g., depression/anxiety) (4.9%)
• Externalizing (ASP, alcohol, drugs)

MTBI
social support
LOC / MVA
2-way Interactions
3-way Interactions
(0.9%)
(4.9%)
(1.4%)
(5.4%)
(0.1%)
Contribution of
Demographic Variables in MTBI
MTBI
Overall Demogr. Variance
9.2%
unique variance
Variable
Age at evaluation
Level of education
Race
Intelligence
MTBI
0.9%
0.2%
0.3%
3.3%
MTBI:
Intelligence by LOC (1.8%)
Frequency of PPCS by Level of Premorbid
Intelligence and LOC
Frequency of PPCSC
70
60
LOC
50
No LOC
40
30
20
10
GTT < 96
GTT 96 - 114
GTT > 114
MTBI:
Intelligence by Social Support (1.2%)
Frequency of PPCS by Level of Premorbid
Intelligence and Level of Social Support
Frequency of PPCSC
80
70
GTT < 96
60
GTT 96 - 114
GTT > 114
50
40
30
20
10
0
Poor Social Support
Average Social
Support
Good Social Support
MTBI:
Internalizing by Social Support (1.0%)
Frequency of PPCS by History of Premorbid
Internalizing problems and Level of Social Support
Frequency of PPCSC
80
70
60
50
Internalizing Problems
40
No Internalizing Problems
30
20
10
Poor Social Support
Average Social
Support
Good Social Support
PCS Conclusions
 LOC
is only a small factor in predicting the
presence of PPCS (1.4% unique
variance) in MHI
 Multiple factors and their interactions
accounted for approximately 33% of the
variance in PPCS status in the sample
with MHI
PCS Conclusions

Within a MTBI sample:
 Lower pre-injury intellectual ability,
 Less poor social support, and
 More early life emotional problems (e.g.,
depression, anxiety)
were associated with higher frequencies of
Persistent PCS
 Loss of consciousness (MTBI) interacts with
cognitive reserve in influencing the
development or persistence of PCS
Treatment of Mild TBI
Mild TBI Treatment
 Change
expectation and attribution of
symptoms
 Provide education


Education regarding mild TBI
Education regarding symptoms and
their course
 Provide



Support/Treatment
Stress management
Psychological and cognitive coping
strategies and resources
Cognitive-Behavioral therapy
References






Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg,
R. D. (2005). Factors moderating neuropsychological outcomes following
mild traumatic brain injury: A Meta-analysis. Journal of the International
Neuropsychological Society, 11, 215-227.
Belanger, H.G., & Vanderploeg, R.D. (2005). The Neuropsychological
Impact of Sports-Related Concussion: A Meta-Analysis. Journal of the
International Neuropsychological Society, 11, 345-357.
Luis, C. A., Vanderploeg, R. D., Curtiss, G. (2003). Predictors for a
postconcussion symptom complex in community dwelling male veterans.
Journal of the International Neuropsychology Society, 9, 1001-1015.
Miller, L.J. & Mittenberg, W. (1998). Brief cognitive behavioral interventions
in mild traumatic brain injury. Applied Neuropsychology, 5, 172-183.
Mittenberg, W., Tremont, G., Zeilinski, R., Fichera, S., & Rayls, K. (1996).
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