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Psychiatric Problems Following TBI Jesse R. Fann, MD, MPH Departments of Psychiatry and Behavioral Sciences, Rehabilitation Medicine, & Epidemiology University of Washington Seattle, Washington Domains of TBI • Neurobiological Injury –Consequences of direct injury to brain • Traumatic Event –Risk for Post-traumatic Stress Disorder, Depression • Chronic Medical Illness –May lead to long-term symptoms & disability TBI as Neurobiological Injury • Primary effects of TBI – Contusions, diffuse axonal injury • Secondary effects of TBI – Hematomas, edema, hydrocephalus, increased intracranial pressure, infection, hypoxia, neurotoxicity, inflammation • Can affect mood modulating systems including serotonin, norepinephrine, dopamine, acetylcholine, and GABA (Hamm et al 2000; Hayes & Dixon 1994) Non-penetrating TBI Diffuse Axonal Injury Contusion Subdural Hemorrhage Taber et al 2006 Examples of Neuropsychiatric Syndromes Associated with Neuroanatomical Lesions • Leteral orbital pre-frontal cortex – Irritability - Impulsivity – Mood lability - Mania • Anterior cingulate pre-frontal cortex – Apathy - Akinetic mutism • Dorsolateral pre-frontal cortex – Poor memory search - Poor set-shifting / maintenance • Temporal Lobe – Memory impairment - Mood lability – Psychosis - Aggression • Hypothalamus – Sexual behavior - Aggression Mayberg et al, J Neuropsychiatry Clin Neurosci TBI as Traumatic Event • PTSD Prevalence: 11-27% * – Possibly more prevalent in mild TBI – Mediated by implicit memory or conditioned fear response in amnestic patients? • PTSD Phenomenology: ** – Intrusive memories: 0-19% – Emotional reactivity: 96% – Intrusive memories, nightmares, emotional reactivity had highest predictive power • Anxiety often comorbid with / prolongs depression * Warden 1997, Bryant 1995, Flesher 2001, Bombardier 2006 ** Warden et al 1997, Bryant et al 2000 Psychiatric Illness in Adult HMO Enrollees (N=939 with TBI, 2817 controls) Psychiatric Illness by TBI* Predicted Cumulative Incidence 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 none mild mod./severe No Prior Psychiatric Illness 6 12 18 24 30 36 Prior Psychiatric Illness Month 6 12 18 24 30 36 * Predicted proportions for a women of age 40-44 with median index month (6), median log cost and no comorbid injuries Fann et al. Arch Gen Psychiatry 2004; 61:53-61 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 Psychiatric Disorder & MTBI 20 18 16 14 12 10 8 6 4 2 0 MTBI No TBI MDD GAD Agora PTSD Social Ph Panic Bryant et al., Am J Psychiatry, in press Neuropsychiatric Sequelae • • • • • • • • Delirium Depression Mania Anxiety Psychosis Cognitive Impairment Aggression, Agitation, Impulsivity Insomnia Examples of Neuropsychiatric Syndromes Associated with Neuroanatomical Lesions • Leteral orbital pre-frontal cortex – Irritability - Impulsivity – Mood lability - Mania • Anterior cingulate pre-frontal cortex – Apathy - Akinetic mutism • Dorsolateral pre-frontal cortex – Poor memory search - Poor set-shifting / maintenance • Temporal Lobe – Memory impairment - Mood lability – Psychosis - Aggression • Hypothalamus – Sexual behavior - Aggression Neuropsychiatric Evaluation and Treatment: Etiologies Psychiatric Premorbid Psych disorders & sxs. Personality traits Coping styles Substance Abuse Medication side effects & interactions Psychodynamic signif. of neurologic illness Family psych. history Neurologic/Medical Social Neurologic illness Lesion location, size, pathophysiology Other medical illness Other indirect sequelae (e.g., pain, sleep disturb) Medication side effects & interactions Social, family, vocation Rehabilitation situation and stressors Functional impairment Medicolegal Roy-Byrne P, Fann JR. APA Textbook of Neuropsychiatry, 1997 Neuropsychiatric Evaluation and Treatment: Workup Psychiatric Neurologic/Medical Psychiatric history & Medical history and examination physical examination Neuropsychological Appropriate lab tests testing e.g., CBC, med blood Psychodynamic signif. of levels, CT/MRI, EEG neuropsychiatric sxs., Medication allergies disability and treatments Social Interview family, friends, caregivers Assess level of care & supervision available Assess rehab needs & progress Neuropsychiatric History Psychiatric symptoms may not fit DSM-IV criteria Focus on functional impairment Document and rate symptoms (use validated instruments) Assess pre-TBI personality, coping, psychiatric history Talk with family, friends, caregivers Explore circumstances of trauma LOC, PTA, hospitalization, medical complications Subtle symptoms - may fail to associate with trauma How has life changed since TBI? Thorough review of medical and psychiatric sxs. Assess level of care and supervision available Assess rehabilitation needs and progress Neuropsychiatric Treatment • Use Biopsychosocial Approach • Treat maximum signs and symptoms with fewest possible medications • TBI patients more sensitive to side effects START LOW, GO SLOW, BUT GO • May still need maximum doses • Therapeutic onset may be latent • Some medications may lower seizure threshold • Some medications may slow cognitive recovery • Monitor and document outcomes • Few randomized, controlled trials Delirium • Acute disturbance of consciousness, cognition and/or perception • Increased risk in patients with TBI • Undiagnosed in 32-67% of patients – Often missed in both inpatient and outpatient settings • Associated with 10-65% mortality • Can lead to self-injurious behavior, decreased selfmanagement, caregiver management problems • Associated with increased length of hospital stay and increased risk of institutional placement • Other terms used to denote delirium: acute confusional state, intensive care unit (ICU) psychosis, metabolic encephalopathy organic brain syndrome, sundowning, toxic encephalopathy Delirium • Identify and correct underlying cause – TBI increases a person’s vulnerability – e.g., seizures, hydrocephalus, hygromas, hemorrhage, drug side effect or interactions, endocrine (hypothalamic, pituitary dysfunction), metabolic (e.g., sodium, glucose), infections • Pharmacologic management – Antipsychotics » Haloperidol (e.g., IV), droperidol, risperidone, olanzapine, quetiapine (taper 7 – 10 days after return to baseline) – Benzodiazepines (combined with antipsychotics), alcohol or sedative withdrawal » lorazepam • Minimize polypharmacy • Medical management – Frequent monitoring of safety, vital signs, mental status and physical exams – Maintain proper nutritional, electrolyte, and fluid balance • Behavioral Management – safety, orientation, activation Depression / Apathy • Prevalence of major depression 44.3% * – Assess pre-injury depression and alcohol use – Use ‘inclusive’ diagnostic technique – May occur acutely or post-acutely – Not directly related to TBI severity • Apathy alone - prevalence 10% – disinterest, disengagement, inertia, lack of motivation, lack of emotional responsivity * van Reekum et al. J Neuropsychiatry Clin Neurosci 2000;12:316-327 DSM-IV Major Depressive Disorder (MDD) 1. 2. 3. 4. 5. 6. 7. 8. 9. • • Depressed mood* Loss of interest/pleasure* Sleep disturbance Poor energy Motor change agitation or slowness Weight/appetite change increase/decrease Impaired concentration or indecision Excessive worthlessness or guilt Recurrent thoughts of death or suicide At least one of the essential criteria* and a total of at least 5 symptoms endorsed most of the day most days for at least 2 weeks Must cause clinically significant impairment APA, Diagnostic & Statistical Manual of Mental Disorders, 4th ed, 2000 Transdiagnostic Symptoms TBI 1. 2. 3. 4. 5. 6. 7. 8. 9. Depressed mood Anhedonia Weight loss/gain Insomnia/hypersomnia Psychomotor changes Fatigue Worthlessness/guilt Poor concentration Thoughts of death/suicide X X X X Patient Health Questionnaire - 9 Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving .around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 Over the last 2 weeks, how often have you been bothered by any of the following problems? Spitzer et al. JAMA 1999 Rates Of Major Depression After TBI 53% N = 559 Point Prevalence of MDD Range 21-31%, no trend Cumulative Rate of MDD as a Function of Depression History 73%* 69%* 41% *P < .001; independent predictors after adjusting for all other variables Rate of MDD by History of Lifetime Alcohol Dependence 70%* 45% *P < .001; independent predictor after adjusting for all other variables Cumulative Rate of MDD by PTSD History 81% 51% Univariate predictor, not significant after adjusting for other variables Comorbidity of Anxiety and MDD Cumulative Percent 100 90 MDD- 80 MDD+ 70 60 54 50 40 27 30 20 10 1 6 0 Panic Disorder Other Anxiety Disorder Any comorbid anxiety disorder in MDD+ vs. MDD(60% vs. 7%; RR, 8.77; CI, 5.56-13.83) Depression / Apathy • Selective serotonin re-uptake inhibitors (SSRIs) - sertraline - citalopram • • • • • • - paroxetine - escitalopram - fluoxetine venlafaxine, duloxetine (may help with pain) bupropion (may decrease seizure threshold) nefazedone (may be too sedating, liver toxicity) mirtazapine (may be too sedating) Tricyclics: nortriptyline, desipramine (blood levels) methylphenidate, dextroamphetamine Electroconvulsive Therapy – consider less frequent, nondominant unilateral • Apathy: Dopaminergic agents - methylpyhenidate, pemoline, bupropion, amantadine, bromocriptine, Fann et al, J Neurotrauma 2009 modafinil Number of Postconcussive Symptoms 7 7 6 5 3.9 # of symptoms 3.5 4 3 2.2 2 1 * p=.05 * p=.05 0 symptoms * All All symptoms * Current Depression Depressive symptoms excluded Depressive symptoms excluded No current Depression PCS – Depression Study (Baseline and Week 8) ** Headache Dizziness Blurred Vision Improving Worsening Same Bothered by Noise Bothered by Light Loss of Temper ** Fatigue Trouble Concentrating * * Irritability Memory Difficulties Anxiety * Sleep Disturbance *p<.05 **p<.01 0 2 4 6 8 10 12 14 16 Treatment options • Antidepressant medications: – Particularly for major depression and dysthymia • Psychotherapy: for all forms of depression (esp. CBT) – Pro: no side effects, may last longer (‘learning effect’), addresses interpersonal / real life problems, flexible delivery options – Con: may need to adapt for cognitive impairment, may cost more and take longer to work, more time consuming, may not be as effective for severe major depression • Other psychosocial interventions (e.g., educational & support groups) • Support and watchful waiting • Often optimal treatment with combination of antidepressants and psychotherapy Modifiable Risk Factors Neurobiological Factors No Pleasant Activities Depression Psychosocial Adversity Cognitive Distortions Sedentary Lifestyle Life Improvement Following Traumatic Brain Injury: A Trial of Cognitive-Behavioral Therapy for Depression after TBI Jesse R. Fann, MD, MPH Departments of Psychiatry & Behavioral Sciences and Rehabilitation Medicine School of Medicine Department of Epidemiology School of Public Health University of Washington Charles H. Bombardier, PhD Steven Vannoy, PhD Peter Esselman, MD Kathy Bell, MD Nancy Temkin, PhD University of Washington Evette Ludman, PhD Group Health Research Inst Reason Slowed information processing & responding Impaired attention & concentration Accommodations Present information at slower rate Allow client more time to respond Provide written summary of session beforehand Minimize environmental stimulation and distractions during session Focus on one topic at a time, Use shorter sessions Avoid need for multi-tasking e.g., no note taking while listening Impaired learning Provide written summary of session (patient workbook) & recall Assign simple written homework Provide written educational materials or workbook Plan additional practice of CBT skills within session (over-learn skills) Impaired verbal abilities Impaired initiation & generalization Impaired motivation Minimize emphasis on verbally mediated aspects of CBT Emphasize behavioral activation and pleasant events scheduling Include family or friend in treatment planning and homework assignments Provide 2 sessions devoted to generalization and relapse prevention at end Use motivational interviewing techniques to engage subjects in therapy Provide care management activities aimed at return to work, school or other meaningful roles and finding effective rehabilitation resources Mania • Prevalence of Bipolar Disorder 4.2% * after TBI • Look for: – elevated, expansive or irritable mood – grandiosity – decreased need for sleep – pressured speech – flight of ideas, distractability – impuslivity • High rate of irritability, “emotional incontinence” • May be associated with epileptiform activity • Potential interaction of genetic loading, right hemisphere lesions, and anterior subcortical atrophy * van Reekum et al. J Neuropsychiatry Clin Neurosci 2000;12:316-327 Mania • Acute – Benzodiazepines – Antipsychotics » olanzapine, risperidone, quetiapine, clozapine – Anticonvulsants » valproate – Electroconvulsive Therapy • Chronic – valproate – carbamazepine – lamotrigine – lithium carbonate (neurotoxicity) – gabapentin, topiramate (adjunctive treatments) Pseudobulbar Affect A neurologic condition characterized by episodes of crying or laughing that are sudden, frequent, and involuntary Occurs in patients with TBI, MS, ALS, stroke, and certain other neurologic conditions FDA-approved in 2011 – Nuedexta ® Dextromethorphan (20mg) – modulates glutamate + Quinidine (10mg) – metabolic inhibitor Anxiety Disorders • • • • • • • Adjustment Disorder Posttraumatic Stress Disorder Panic Disorder Generalized Anxiety Disorder Specific Phobia – e.g., medical procedures Obsessive-Compulsive Disorder Anxiety Disorder due to General Medical Condition (e.g., hypoxia, sepsis, pain) • Substance-induced Anxiety Disorder Rates of Anxiety Disorders (civilians) GAD PTSD OCD Panic Phobias 24% NA NA 4% 2% Agoraphobia 8% 17% 14% 11% 3% 3% 2% 17% 14% 13.4% 13% NA = Not Assessed. Sample 50 patients diagnosed with TBI seen at a rehabilitation clinic -mean 32.5 months post injury Fann et al., 1995 7% 100 patients with TBI - mean 7.6 years post injury Hibbard et al., 1998 9% 1% 100 patients hospitalized for TBI - 1 year post injury Deb et al., 1999 1% 6% 7% Specific Phobia 6% Social Phobia 1% Agorophobia 100 patients hospitalized for TBI assessed 0.5 - 5.5 years post injury WhelanGoodinson et al., 2009 4% 7.5% 12.8% Agoraphobia 9% Social Phobia 817 patients hospitalized for traumatic injury (40% TBI) - assessed 1 year post injury Bryant et al., 2010 Anxiety • Often comorbid with and prolongs course of depression in TBI • Posttraumatic Stress Disorder: Prevalence 14.1% * – Reexperience, Avoidance, Hyperarousal – > 1 month, causes significant distress or impairment – Possibly more prevalent in mild TBI • Panic Disorder: Prevalence 9.2% * • Generalized Anxiety Disorder: Prevalence 9.1% * • Obsessive-Compulsive Disorder: Prevalence 6.4% * * van Reekum et al. J Neuropsychiatry Clin Neurosci 2000;12:316-327 Adjustment Disorders • Clinically significant symptoms of depressed mood, anxiety, or both • Occurring within 3 months in response to an identifiable stressor(s); once the stressor has terminated, the symptoms do not persist for more than an additional 6 months • Causing marked distress that is in excess of what would be expected from exposure to the stressor and significant impairment in social or occupational (academic) functioning • The stress-related disturbance does not represent bereavement or meet the criteria for another Axis I disorder. PTSD Criteria CLUSTER A: Stressor A. Experience/witness threat B. Respond with fear/helplessness* CLUSTER B: Reexperiencing At least 1 of: • A. Intrusive memories* • B. Nightmares* • C. Flashbacks* • D. Psychological distress to reminders* • E. Physiological reactivity to reminders* PTSD Criteria (cont’d) CLUSTER C: Avoidance At least 3 of: A. Avoid thoughts, feelings B. Avoid places, activities ----------------------------------------C. Dissociative amnesia* D. Diminished interest E. Detachment from others F. Restricted affect* G. Foreshortened future CLUSTER D: Arousal At A. B. C. D. least 2 of: Sleep disturbance* Anger* Concentration difficulties* Hypervigilence PTSD Criteria (cont’d) CLUSTER E: Symptoms last at least 1 month CLUSTER F: Causes impairment CLUSTER H: Not due to medical condition or substance abuse* PTSD Risk Factors Trauma • Level of threat • Exposure to grotesque events • Fatality/injuries • Uncontrollable event • Duration of disaster Peri-Trauma • Panic • Dissociation • Catastrophic appraisals Post-Truama • Low social support • Coping style • Community reaction • Ongoing stressors • Comorbidity • Secondary symptoms Psychiatric Disorder & Prior Sleep Problems Bryant et al., Sleep, in press Role of Trauma Memories • One study reported that confidence in memory for traumatic experience inversely related to PTSD development Gil et al., (2007), Am J Psychiatry Interface of PTSD & Persistent PCS Stein & McAllister, AJP 2009 Brain regions implicated in PTSD and vulnerable to TBI Implications • Mild TBI patients need to be monitored for stress reactions • Do not confuse effects of Mild TBI with effects of stress • Interaction of the two factors suggest that optimal intervention for PCS will focus on stress reactions Panic Attack • Intense fear or discomfort • At least 4 symptoms peak in 10 min – – – – – – – – – – – – – palpitations, pounding heart, or accelerated heart rate chest pain or discomfort shortness of breath or smothering feeling of choking feeling dizzy, unsteady, light-headed, or faint paresthesias (numbness or tingling sensations) chills or hot flashes trembling or shaking sweating derealization or depersonalization fear of losing control or going crazy fear of dying nausea or abdominal distress Panic Disorder • Recurrent unexpected panic attacks for 1 month (or more • either persistent concern about having additional attacks or worry about the implications of the attack or its consequences (eg, losing control, having a heart attack, “going crazy”) or a significant change in behavior related to the attacks. Generalized Anxiety Disorder A. Excessive anxiety and worry, occurring more days than not , for at least 6 months, about a number of events of activities B. Difficult to control the worry C. Associated with 3 or more symptoms (some present more days than not for at least 6 months) – – – – – – Restless, keeyed up, or on edge Easily fatigued Difficult concentrating or mind going blank Irritable Muscle tension Difficulty falling or staying asleep, or restless sleep D. Focus of anxiety / worry not confined to features of another Axis I disorder E. Clinically significant distress or impairment F. Not due to substance or general medical condition and does not occur exclusively during a Mood, Psychotic, or Pervasive Dev Disorder Anxiety Medications • Benzodiazepines: use lower doses (~50% typical dose) – e.g., clonazepam, lorazepam, alprazolam – Watch for cognitive impairment, disinhibition, dependence • Buspirone (for Generalized Anxiety Disorder) • Antidepressants – SSRIs, venlafaxine, nefazedone, mirtazapine, TCAs • Beta-blockers, verapamil, clonidine • Anticonvulsants: Valproate & gabapentin have some anxiolytic effects Psychosocial – Individual (CBT, Behavioral Activation), couples, family, group Psychosis • Hallucinations, delusions, thought disorder • Immediate or latent onset • Symptoms may resemble schizophrenia: prevalence 0.7%* in TBI • Schizophrenics have increased risk of TBI predating psychosis • Patients developing schizophrenic-like psychosis over 15-20 years is 0.7-9.8% • Look for epileptiform activity and temporal lobe lesions • Treatment: Antipsychotic medications (referral) * van Reekum et al. J Neuropsychiatry Clin Neurosci 2000;12:316-327 Psychosis • Antipsychotics – First generation: e.g. haloperidol, chlorpromazine (seizures) – Second generation: e.g., risperidone – Third generation: e.g., olanzapine, quetiapine, ziprasidone, aripiprazole, clozapine (seizures) • Start with low doses (e.g., Risperidone 0.5mg qHS) • TBI pts have high risk of anticholinergic and extrapyramidal side effects • May cause QTc prolongation, increased sudden death in elderly • Use sparingly - may impede neuronal recovery acutely (from animal data) Cognitive Impairment • Common problems after TBI – Concentration and attention – Memory – Speed of information processing – Mental flexibility – Executive functioning – Neurolinguistic • Association with Alzheimer’s Disease suggested • Cognitive Rehabilitaiton may help • May be associated with other psychiatric syndromes (e.g., depression, anxiety, psychosis) – treating these may improve cognition Cognitive Impairment May improve recovery • Stimulants – methylphenidate, dextroamphetamine, caffeine • Nonstimulant dopamine enhancers – amantadine, bromocriptine, pramipexole, L-dopa/carbidopa • Acetylcholinesterase inhibitors – physostigmine, donepezil, rivastigmine, galantamine • Antidepressants – sertraline, fluoxetine, milnacipran (SNRI) • Others – CDP Choline, gangliosides, pergolide, selegiline, apomorphine, phenylpropanolamine, naltrexone, atomoxetine, vasopressin Writer & Schillerstrom, J Neuropsychiatry Clin Neurosci 2009 Cognitive Impairment May impede recovery haloperidol phenothiazines prazosin clonidine phenoxybenzamine GABAergic agents benzodiazepines Phenytoin carbamazepine phenobarbital idazoxan Aggression, Irritability, Impulsivity • • • • Up to 70% within 1 year of TBI May last over 10-15 years Interview family and caregivers, if possible Characteristic features – Reactive – Non-reflective – Non-purposeful - Explosive - Periodic - Ego-dystonic • Treat other underlying etiologies (e.g., bipolar) • Treatment: Medications and behavioral interventions Pilot study of sertraline (N=15) Brief Anger / Aggression Questionnaire (BAAQ) 10 9 8 7 6 5 4 3 2 1 0 p=.05 baseline Fann et al. Psychosomatics 2001; 42:48-54 week 8 Aggression, Agitation, Impulsivity (none FDA approved for this indication) • Acute Antipsychotics (e.g., Quetiapine 25-50mg bid) Benzodiazepines (e.g., Clonazepam 0.5mg bid) • Chronic Beta-blockers (e.g. propranolol – may need up to 200mg/d in some cases, pindolol, nadolol) valproate, carbamazepine, gabapentin Lithium (narrow therapeutic window) buspirone Serotonergic antidepressants (e.g., SSRIs, trazodone) tricyclic antidepressants (e.g., nortriptyline, desipramine) Antipsychotics (esp. second and third generation) amantadine, bromocriptine, bupropion clonidine, methylphenidate, naltrexone, estrogen Non-Pharmacologic Interventions • Behavioral Modification – Based on operant learning principles, e.g., managing environmental contingencies » Require high degree of environmental control & consistency; therefore, difficult in outpatient settings » Typically amplify or suppress behaviors, rathern than teach new responses to triggers or antecedents • Psycho-educational (small RCT, N=16) – Based on Novaco’s Stress Innoculation Training (SIT) » Based on CBT principles » Heighten awareness of cognitive distortions that fuel inappropriate emotional reactions » Teach more adaptive responses » May be difficult for people with cognitive impairment • Anger Self-Management Training (ASMT) – Moss + UW Study – Based on Self-Care and Problem-Solving Training – Improves awareness and ability to attend to anger signals – Establishes new, constructive habits for coping with threat Treatment: Insomnia • Treat underlying etiology (e.g., pain, anxiety, depression, sleep apnea) • Emphasize sleep hygiene, Cognitive Behavioral Therapy • Medications often dependence-forming • Benzodiazepines (fast-acting) – lorazepam (Ativan), temazepam (Restoril), alprazolam (Xanax) • Non-benzodiazepines – short-acting: zolpidem (Ambien), zaleplon (Sonata), ramelteon (Rozerem) – Longer acting: zolpidem CR (Ambien CR), Lunesta • Antihistamines: diphenhydramine (Benadryl) • Antidepressants: trazodone (Desyrel), amitriptyline Sleep Hygiene Principles Sleep/wake principles • Maintain habitual bed and rise times • Restrict time in bed • Explore the usefulness / detriment of napping Environmental principles • Ensure bedroom is sufficiently dark • Minimize disturbing noise (use earplugs, if needed) • Ensure bedding, temperature and airflow are consistent with quality sleep • Ensure a nightlight does not illuminate the eyes while in bed • Eliminate or place bedroom clocks so that they cannot be viewed from bed • Eliminate other distractions, e.g., pets Diet and drug use principles • Avoid rich food late in the evening • Explore the usefulness of a late bedtime snack – Try snacking on foods that promote sleep » E.g., milk, bananas, turkey, cheese, peanut butter • Avoid caffeine, alcohol and tobacco, esp. in the evenings • Be aware that OTC and Rx medications may adversely affect sleep Proposed Model TBI Severity +,- Cognition + TBI +/- Neurosychiatric Symptoms +/- Postconcussive Symptoms Psychiatric Vulnerability Functioning/ QOL Health Care Utilization “The significant problems we face cannot be solved at the same level of thinking we were at when we created them” Albert Einstein