Presentation on theme: "Wounds of War: Traumatic Brain Injury"— Presentation transcript:
1Wounds of War: Traumatic Brain Injury Rex M. Swanda, Ph.D., ABPP-CNNeuropsychology ProgramNew Mexico VA Healthcare System
2Traumatic Brain Injury (TBI) Brain injury caused by an external mechanical force such as a blow to the head, concussive forces, acceleration-deceleration forces, or projectile missile (e.g., bullet).
3CONCLUSIONS TBI does not typically occur in isolation Emotional and psychosocial stressorsReported TBI most frequently involves mild TBICredible research indicates that full cognitive recovery is the norm in mild TBI (e.g., LOC < 30 minutes)Important to identify TREATABLE symptomsNo direct treatments for TBIAssociated psychological symptoms are associated with subjectively reported TBI symptoms that ARE highly treatableDepression, PTSD, Substance Abuse
4Incidence of TBI 500,000 to 2,000,000 per year (civilian) Poorly definedPoorly documented
5Risk Factors Associated with TBI Age15 to 24 years of ageFirst 5 years of lifeElderlyMales outnumber Females 2:1Except over age 75
6Risk Factors Associated with TBI Lower Socio-Economic StatusUnemploymentLower EducationPrior History of a Medical Condition Affecting the Central Nervous SystemAlcoholism or Substance AbuseHistory of Prior Head Injury
7Frequent Causes of TBI Falls Motor Vehicle Accidents Interpersonal Violence
8Classification of TBI Closed Head Injury Skull intact, Brain tissue not exposed90% of civilian head injuryDiffuse effects are commonAttention / ExecutivePenetrating Head Injury (Open Head Injury)Skull and dura are penetratedFocal injury is more common
10Long-Term Consequences of TBI Cognitive consequencesEmotional consequencesSocial consequences
11Indicators of Severity for all types of head injury Loss of Consciousness (Loss of Awareness)Coma(operationalized by Dikmen, et al. as Time to Follow Commands)Post Traumatic Amnesia (PTA)Signs of Intracranial Injury
12Glasgow Coma Scale15 point scale measures presence, degree, and duration of comaBased onEyes Opening response (1 – 5 pts)Best Verbal response (1 – 5 pts)Best Motor response (1 – 6 pts)
13Post-traumatic Amnesia A period of anterograde amnesia in which new memories cannot be consistently made and recalled that follows recovery of consciousness in head injury or other neurological trauma.The duration of PTA is often used as a predictor of the degree of recovery.
14Classification of Head Injury Mild Head InjuryGlasgow Coma Scale 13 – 15PTA 5 – 60 minutesModerate Head InjuryGlasgow Coma Scale 9 – 12PTA up to 24 hoursModerate to Severe Head InjuryGlasgow Coma Scale 3 – 8PTA 1 to 7 days or longer
15What does empirical research tell us about the consequences of Traumatic Brain Injury Dikmen, S.S., Machamer, J.E., Winn, R., & Temkin, N.R. (1995). Neuropsychological outcome at 1-year post head injury. Neuropsychology, 9,Dikmen, S., Machamer, J., & Temkin, N. (2001). Mild Head Injury: Facts and Artifacts. Journal of Clinical and Experimental Neuropsychology, 23,
16What does empirical research tell us about the consequences of Traumatic Brain Injury Hoge, C.W., McGurk, D., Thomas, J.L., et al (2008) Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine. 358, no. 5,
17Outcome Research: Mild TBI Appropriately designed research studies indicate that virtually 100% mild head injured subjects show no cognitive impairment within about 3 months to a year (outside) post-injuryEXCELLENT Prognosis for Mild Head Injury
18TBI Outcome Research: Surreya Dikmen, Ph.D. Studies date from 1986Follow patients and controls over timeProspective DesignConsecutive hospital admissions of well-defined Head Injury patientsHarborview Medical Center (Seattle, WA), a Level I Trauma Center
19TBI Outcome Research: Dikmen Study minimized selection biasLarge demographically representative groupEnglish-speaking only (for testing criteria)Did NOT screen out preexisting conditionsUnusually high rates of follow-up85% followed up after one year
20Outcome Research: Dikmen Pre-existing conditions included:Prior significant head injuryAlcoholism receiving treatmentHistory of cerebral diseasePsychiatric disorder (schizophrenia, bipolar disorder)
21Outcome Research: Dikmen Broad spectrum of head injury severityMinimum injury criteria include:Any period of loss of consciousnessPost-traumatic amnesia of at least 1 hourOther objective evidence of head trauma (e.g., hematoma)Injury severe enough to hospitalizeSurvival to complete at least 1 month follow-up for neuropsychological assessment baseline
22Outcome Research: Dikmen Trauma Control Subjectsrecruited from ER after trauma to parts of body, other than headControls matched head-injured onagesexeducation
23Outcomes Following TBI Dose-Response RelationshipDikmen, et al. (1995) found a significant relationship between length of coma (Time to Follow Commands) and level of performance on sensitive neuropsychological measures at 1 year post-injuryGreater cognitive impairment is associated with longer periods of coma
24Outcomes Following TBI Mild head injured patients (TFC < 1 hour) were indistinguishable from trauma controls at one year post-injury on sensitive measures of cognitive functioning
25Outcomes Following TBI Although there were no significant differences on cognitive testing, premorbid characteristics and risk factors were more powerful than head injury in explaining persistent psychosocial symptoms at one year post-injury (Dikmen, et al. 2001)
26Contributing Risk Factors Account for Persistent Symptoms in cases of Mild Closed Head Injury AgeEducationPre-existing conditionsTreatment for alcohol or substance abuseCNS disorder (prior head injury)Psychiatric condition (including PTSD)Somatoform-Spectrum diagnoses
27Dikmen’s Conclusion“It is equally unusual for mild head injury to produce deficits after 1 year as it is for severe head injury to produce no deficits after 1 year.”(Dikmen, et al., 1995)
28Recent Study of Soldiers Returning from Iraq Hoge, et al (2008, in NEJM) studied 2525 U.S. soldiers returning from Iraq.124 (4.9%) reported injuries with LOC43% of these met criteria for PTSD260 (10.3%) reported altered Mental Status27.3% of these met criteria for PTSD435 (17.2%) reported other injuries16.2% of these met criteria for PTSD1760 reported no injury9.1% of these met criteria for PTSD
29Recent Study of Soldiers Returning from Iraq Although the relationship is associative and not necessarily causal………“after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headaches.”Consistent with Dikmen’s research
30So, how do we account for subjective complaints of lasting symptoms following TBI ?
31Postconcussion Syndrome ICD-10 Diagnostic Criteria A. History of head trauma with loss of consciousness precedes symptoms onset by maximum of four weeks
32Postconcussion Syndrome ICD-10 Diagnostic Criteria B. Symptoms in 3 or more of the following categories:Headache, dizziness, malaise, fatigue, noise toleranceIrritability, depression, anxiety, emotional labilitySubjective concentration, memory, or intellectual difficulties without neuropsychological evidence of marked impairmentInsomniaReduced alcohol tolerancePreoccupation with above symptoms and fear of brain damage with hypochondriacal concern and adoption of sick role.
33Misattribution of Symptoms Why do patients, families – even providers – “misattribute” symptoms, such as memory problems, “loss” of cognitive abilities, or declining cognitive performance – to brain injury?
34Psychological Theories for Understanding Postconcussion Syndrome and “Misattribution of Symptoms” “Good Old Days” Hypothesis“Nocebo” EffectDiathesis-Stress ModelExpectation as Etiology
35“Good Old Days” Hypothesis Gunstad & Suhr (2001)Tendency of people to recall past symptoms and functioning more favorably than was actually the caseSuggests that, following any negative event, people tend to attribute all symptoms to that negative event, regardless of a preexisting history of that very problem or any other factors that may be influencing that problem.
36Nocebo EffectHahn (1997)The notion that expectations of sickness and associated emotional distress cause the sickness in questionSuggests that response expectations are “anticipations of automatic reactions to particular situational cues” and are outside both volition and conscious thought.
37Diathesis-Stress Model Wood (2004)Examines the interaction between physiologic and psychological factors that generate and maintain postconcussional symptoms.Suggests that iatrogenic forces can influence a patient’s recovery after MTBI, especially if health care providers inadvertently reinforce misperceptions of symptoms or insecurities about recovery
38Diathesis-Stress Model In McCrea (2008, p. 176)“an unfortunate scenario unfolds when a patient with vague symptom complaints and no clear indication of significant head trauma is told he has “brain damage” and will never make a complete neurologic, symptom, or functional recovery.”“The long-term damage of creating that perception for a patient is most difficult to undo.”
39Expectation as Etiology Mittenberg et al (1992)Suggests that the incidence and persistence of PCS may be explained by the degree to which an individual misattributes common complaints to a prior head injuryExamine in detail as an example of “normal” tendencies to misattribute symptoms
40Misattribution of Symptoms Poor understanding that many common symptoms represent a “final common endpoint” of many overlapping diagnoses and disordersPoor understanding of mechanisms of brain processing, injury, and recoveryPoor understanding of base rates of symptoms among “normal” individuals
41Symptoms Overlap Across Diagnoses From: McCrea (2007) Mild Traumatic Brain Injury and Postconcussion Syndrome p. 160, Table 161HeadacheDizzinessIrritabilityMemory ProblemsAttention ProblemsCollegeStudents36 %18%36%17%42%Chronic Pain80%67%49%33%63%Depressed37%20%52%25%54%Non-TBI Personal Inj77%41%46%71%Mild TBI26%28%
42Poor Understanding of Brain Mechanisms Involved in Memory “Memory” complaints are among most common symptoms associated with postconcussion syndromeInformation Processing Model of Memory helps clarify the role that “psychological factors” can play in memory complaintsExample of the important role that basic education plays as a therapeutic intervention
44Base Rates and Misattribution of Symptoms Base Rates: The frequency with which abnormal neuropsychological findings are observed among “normal” individuals.It is “normal” to perform in the impaired range on some cognitive measuresHeaton, Grant, and Matthews norms indicate that very few healthy individuals complete a neuropsychological protocol without any impaired scores, while as many as 38% of “normals” perform in the impaired range on 6 or more discrete scores in a 40-score battery.
45Percent of “normal” individuals who score in the impaired range on 0 to 6 or more measures in a battery of 40 measures
46Expectation as Etiology Mittenberg, et al. (1992)223 volunteers100 pts with closed head injuriesAverage 1.7 years after injuryAverage reported LOC = 23 minutes30-symptom checklist of itemsAffectiveSomaticMemory
47Examples of symptom checklist Forgets where car is parkedForgets why they entered a roomLoses items around the houseSensitivity to bright lightBlurry or double visionConcentration difficultyDepression
48Control SubjectsWhich symptoms do you (healthy volunteers) currently experience?….Now imagine an MVA-related head injury 6 months before, in which you were knocked out, hospitalized for a week or two. Respond to the symptoms that you think you would have after an accident like this.
49Patients with head injuries Identify the symptoms you think you would have had before the accident (how you used to be)Then identify symptoms that you notice now, after the accident (how you are now)
50No difference between the incidence of Post-concussion Symptoms expected by controls and those reported by head injury patients. Control Group M = s.d. = Head Injured M = s.d. = 8.3
51Incidence of Expected and Actual Postconcussion Symptoms % controls% patientsHeadache80.059.1Anxiety68.158.3Concentration difficulty66.870.5Irritability50.065.9Forgets why entered room34.850.6Loses items around house28.528.1
52However, Head Injury patients significantly underestimated symptoms prior to injury, compared to normal base ratesHead injury patients underestimated premorbid frequency of 21 specific symptoms compared to base rates of normal controls
53Normal Base Rates of normal controls compared to head injury patient’s premorbid estimates of symptoms% controls% patientsForgets where car parked32.07.0Loses car keys31.06.0Forgets groceries28.39.0Concentration difficulty13.55.0Forgets appointment dates20.2Loses items around house17.04.0
54“Results suggest a tendency for patients with head injuries to attribute [normally occurring] premorbid symptoms to head trauma.”
55Neuropsychological Assessment of Effort and Motivation
56Malingering (DSM-IV)…the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs.
57Diagnoses Involving Symptom Exaggeration or Unfounded Physical or Psychological Symptoms Malingering – intentional feigning or exaggerating symptoms of illness or injury for external gain.
58Intentional Production of Symptoms Obvious External Incentives Symptoms Satisfy Psychological NeedsSomatization DisorderAbsentNot ObviousLikelySomatoform DisorderConversion DisorderSymptoms worsened by stress and conflictHypochondriasisMisinterpretation of Physical SymptomsFactitious DisorderPresentNeed to Maintain the “Sick” RoleMalingering
59Base Rates of Malingering and Symptom Exaggeration Mittenberg, Patton, Canyock, & Condit (2002)Surveyed ABCN diplomatesRates of cases involving “probable malingering” and “symptom exaggeration”19% personal injury30% disability19% criminal8% general criminal cases
60Base Rates of Malingering and Symptom Exaggeration Larrabee, G. (2003)Reviewed 11 studies1363 consecutively evaluated mild traumatic brain-injury litigants.Found a rate of about 40% symptom exaggeration or malingering among the sample
61Base Rates of Malingering and Symptom Exaggeration Chafetz & Abrahams (2005)Adults seeking Social Security disability13.8% met criteria for definite malingering58.6% met criteria for probable malingering (two or more failed validity indicators)Combined definite/probable base rate of malingering of 72.4%
62Base Rates of Malingering and Symptom Exaggeration Bush, et al (2005)Likely rates of malingering or symptom exaggeration – and potential costs to the system (SSD, VA, personal injury litigation) – are significant enough that National Academy of Neuropsychology recommends that symptom validity testing be included as part of comprehensive neuropsychological test battery.
63What Makes Sense “Neuropsychologically” in a Specific Case? Circumstances of the Alleged InjuryReported Changes in Functioning Over TimeConsideration of Brain – Behavior RelationshipsPattern of Neuropsychological Performance
64Documented Evidence of Injury versus Patient’s Account of the Injury Consider subjective reports ofLOCForce of CollisionLevel of toxic exposureIn light of documentationAmbulance / Police ReportsMedical RecordsLaboratory Reports
65Reported Changes Over Time versus Natural Course of Recovery Mild head injury symptoms should improve over time – not worsen“It is equally unusual for mild head injury to produce deficits after one year as it is for severe head injury to produce no deficits after one year.” Dikmen, et al., 1995
66The pattern of neuropsychological performance should be consistent with the reported symptoms and circumstances of the alleged injury
67“Odd” complaints for mild head injury without signs of focal neuroanatomical injury StutteringLoss of vocabularySevere self-neglectwith preserved ability to driveLoss of autobiographical memoryLoss of developmentally overlearned skillsTying one’s shoesSpelling
68Two Main Approaches to Detect Poor Effort or Malingering Identification of motivationally-impaired patterns of performance on traditional neuropsychological testsUse of specific measures of effort
69Deviations from Expected Patterns of Functioning VIQ vs. PIQ differences on WAIS testingStrengths on “Hold” vs. “Don’t Hold” MeasuresUnexpected pattern of Index ScoresVerbal Comprehension IndexPerceptual Organization IndexWorking Memory IndexProcessing Speed IndexWorse performance on easier vs harder items
70Specific Measures of Effort and Validity MMPI-2 Personality Self-Report“F” family (F, Fb, Fp, F – K)FBSVRIN Variable Response indicatorsTRIN True Response Set
71Forced Choice Recognition Techniques Many types of StimuliPictures, Faces, Words, Numbers, TexturesExpectation for high levels of Success, even among significantly impaired individualsChance rules
73Outright “Malingering” is Rare Malingering is only one point on a diagnostic continuum of poor effort and symptom exaggeration
74Outright “Malingering” is Rare Poor effort and symptom exaggeration are most frequently associated with:Chronic illness behaviorSignificant emotional symptomsDepressionAnxietyPTSDPoor expectations for one’s own performance (Nocebo effect)
75Effort and Motivation are best assessed in light of: Objective Records and DocumentationKnown brain-behavior relationshipsNatural history of recovery from injuryUnusual pattern of performance on standard materials
76CONCLUSIONS TBI does not typically occur in isolation Emotional and psychosocial stressors are typically significant
77CONCLUSIONSReported TBI most frequently involves mild TBI
78CONCLUSIONSCredible research indicates that full cognitive recovery is the norm in mild TBIDuration of documented Loss Of Consciousness is most frequently subtle, or less than 30 minutes
79CONCLUSIONS Important to identify TREATABLE symptoms No direct treatments for TBI, BUTHighly successful treatment programs forDepressionPTSDSubstance AbuseFamily/Couples Therapy
80CONCLUSIONS TBI does not typically occur in isolation Emotional and psychosocial stressorsReported TBI most frequently involves mild TBICredible research indicates that full cognitive recovery is the norm in mild TBI (e.g., LOC < 30 minutes)Important to identify TREATABLE symptomsNo direct treatments for TBIAssociated psychological symptoms are associated with subjectively reported TBI symptoms that ARE highly treatableDepression, PTSD, Substance Abuse