Presentation on theme: "Assessment and Treatment of TBI for Mental Health Practitioners"— Presentation transcript:
1 Assessment and Treatment of TBI for Mental Health Practitioners Jim Messina, Ph.D.Assistant Professor, Troy University, Tampa Bay Site
2 Goal of Workshop Help you better understand What is TBI How TBI is assessedWhat the issues are facing clients with TBIMental Health Tools to be utilized with patients with TBI
3 What is a TBI?TBI occurs when a sudden trauma such as a blow or jolt causes damage to the brainThere are two types:Focal: damage to one area of brainDiffuse: damage in more than one area of brain
4 Categories of TBIClosed head injury: results from any trauma that causes the brain to be violently shaken inside of the skull such as a “blast” injuryPenetrating injury: when object goes through the skull & enters the brain.
5 Skull fractureBrain contusionDAI (Diffuse axonal injury) over 50% of TBIPrimary lesionsHEADINJURYIntracranial hemorrhagesBrain edemaIncrease of ICP (Intracranial pressure)InfectionsDelayed lesionsLong term effectsResultantconcerns
6 Results of TBICan cause nerve cells in brain to stretch, tear, or pull apart, making it difficult or impossible for cells to send messages from one part of brain to another & to rest of bodyCan interfere with how brain works, including thinking, remembering, seeing & controlling movements
7 Causes of TBIBrain injuries can occur when the head strikes an object such as a windshield or the ground at a fast rate of speedWhen a flying or falling object strikes the headCan occur without a direct blow to head as in cases of severe "whiplash"
8 Most Common Causes of TBI for Military Bullets, fragments, blastsMotor vehicle-traffic crashesFallsAssaults Blasts are a leading cause of TBI for active duty military personnel in war zones.
12 Ranges of TBITraumatic brain injury can range from mild to very severe depending on many things including:Force of the traumaPrevious brain injuriesHow quickly emergency medical treatment is given
13 TBI Definitions: Concussion/Mild TBI A confused or disoriented state lasting 24 hours or lessLoss of consciousness for up to 30 minutesMemory loss lasting less than 24 hours.
14 Moderate TBI:A confused or disoriented state that lasts more than 24 hoursLoss of consciousness for more than 30 minutes, but less than 24 hoursMemory loss lasting greater than 24 hours but less than seven days
15 Severe TBIA confused or disoriented state that lasts more than 24 hoursLoss of consciousness for more than 24 hoursMemory loss for seven days or more
16 Penetrating TBI or Open Head Injury The outer layer of the brain is penetrated by a foreign object
17 DoD Numbers on TBIMild: 175,647 76% Moderate: 38, % Severe: 2,360 1% Penetrating: 3, % Not Classifiable: 9,099 4% Total: 229,106
18 TBI By Military Service 2000-2011 Army 57%Active: 100,373Guard: 22,489Reserves: 9,415Navy 13.9%Active: 29,597Reserves: 2,325Air Force 13.8%Active: 27,305Guard: 2,659Reserves: 1,611Marines 14.5%Active: 30,473Reserves: 2,859
19 Who are Highest Risk for TBI? Males are about 1.5 times as likely as females to sustain a TBIMilitary duty increases risk of sustaining a TBI
20 Signs & symptoms of mild TBI or concussion HeadachesDizzinessExcessive fatigue (tiredness)Concentration problemsForgetting things (memory problems)IrritabilitySleep problemsBalance problemsRinging in the earsVision changes
21 Signs & symptoms of moderate and severe TBI memory loss/amnesiavision changes or loss of visionparalysis and/or muscle spasticitychronic painsleep disturbancesinability or changes in ability to use senses of taste, touch, sight, sound, smell & tasteloss of bowel and/or bladder controlcomasevere headachesseizures/convulsionsnausea/vomitinginability or difficulty speaking, understanding &concentratingconfusion, restlessness or agitationloss of or changes in coordination
22 Common Late Symptoms of Concussions Persistent HeadacheLightheadedness and/or dizzinessDecreased attention and concentrationPoor memoryEasy fatigabilityAnxiety or depressed moodSleep disturbance
23 How long do Symptoms Last? Symptoms of mild TBI or concussion often resolve within hours to days & almost always improve over 1-3 monthsPatients with moderate to severe TBI often have long-term medical problems requiring specialized attentionSymptoms & effects will vary greatly from one patient to another, depending on severity of TBI & location of injury
24 Long Term Impact of Single Concussion or mTBI A single traumatic brain injury may prompt long-term neurodegeneration (Johnson, V.E., Stewart, W. & Smith, D.H. (2011). Widespread Tau and Amyloid-Beta Pathology Many Years After a Single Traumatic Brain Injury in Humans. Brain Pathology (22) )Tau tangles & amyloid-beta plaques were present years (1-47 years) after just one Traumatic Brain Injury (concussion) so could be precursor to Alzheimer's or other neurodegenerative conditions
25 Do Disabilities Come from TBI? Disabilities from a TBI depend uponSeverity of injuryLocation of the injuryAge & general health of the patient
26 What are the Possible Disabilities? Problems with cognition (thinking, memory, and reasoning)Sensory processing (sight, hearing, touch, taste, and smell),Communication (expression and understanding)Behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness)
27 What Measures are used to assess for TBI Military Acute Concussion Evaluation (MACE)Brief Traumatic Brain Injury Screen (BTBIS)Glasgow Coma Scale
28 Military Acute Concussion Evaluation (MACE) Who should be evaluated with the MACE?Any one dazed, confused, “saw stars” or lost consciousness even momentarily, as a result of an explosion, blast, fall, motor vehicle crash, or other eventIn such event involving abrupt head movement, a direct blow to head, or other head injury
29 MACE Components Standardized Assessment of Concussion (SAC): Total possible score = 30Orientation = 5Immediate Memory = 15Concentration = 5Memory Recall= 5
30 Orientation (1 point per question) Orientation: Assess patients awareness of the accurate timeWHAT MONTH IS THIS?WHAT IS THE DATE OR DAY OF THE MONTH?WHAT DAY OF THE WEEK IS IT?WHAT YEAR IS IT?WHAT TIME DO YOU THINK IT IS?
31 Immediate Memory (up to 15 points, 5 points per trial) 3 Trials with 5 words: candle, paper, sugar, sandwich, wagonFor each trial: I’M GOING TO TEST YOUR MEMORY, I WILL READ YOU A LIST OF WORDS AND WHEN I AM DONE, REPEAT BACK AS MANY WORDS AS YOU CAN REMEMBER, IN ANY ORDER.
32 Concentration (5 points) I’M GOING TO READ YOU A STRING OF NUMBERS AND WHEN I AM FINISHED, REPEAT THEM BACK TO ME BACKWARDS, THAT IS, IN REVERSE ORDER OF HOW I READ THEM TO YOU. FOR EXAMPLE, IF I SAY 7-1-9, YOU WOULD SAY(1 point)(1 point)(1 point)(1 point)NOW TELL ME THE MONTHS IN REVERSE ORDER, THAT IS, START WITH DECEMBER AND END IN JANUARY (1 point)
33 Delayed Recall (5 points) DO YOU REMEMBER THAT LIST OF WORDS I READ A FEW MINUTES EARLIER? I WANT YOU TO TELL ME AS MANY WORDS FROM THE LIST AS YOU CAN REMEMBER IN ANY ORDER.One point for each word remembered for a total of 5 possible points.Lastly a neurological screening is done:
34 Neurological Screen Eyes: check pupil size & reactivity. Verbal: notice speech fluency & word findingMotor: pronator drift- ask patient to lift arms with palms up, ask patient to then close their eyes, assess for either arm to “drift” down. Assess gait & coordination if possible Document any abnormalitiesNo points are given for this section
35 Results on MACE Non-concussed patients, the mean total score was 28 Scores below 25 may represent clinically relevant neurocognitive impairment and require further evaluation for the possibility of a more serious brain injury.
36 Brief Traumatic Brain Injury Screen (BTBIS) The Defense and Veterans Brain Injury Center (DVBIC) has developed a simple TBI screening device also called the Brief Traumatic Brain Injury Screen (BTBIS)The questions quickly help us to assess if the person in front of us is possibly suffering from TBI
37 First QuestionDid you have any injury(ies) during your deployment from any of the following:FragmentBulletVehicular (any type of vehicle, including airplane)FallBlast (Improvised Explosive Device, RPG, Land mine, Grenade)Other: specify
38 Second QuestionDid any of the injury received during your deployment result in any of the following?Being dazed, confused or “seeing stars”Not remembering the injuryLosing consciousness (knocked out) for less than a minuteLosing consciousness for 1-20 minutesLosing consciousness for longer than 20 minutesHaving any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)Head injuryNone of the above
39 Third QuestionAre you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion?Headaches Ringing in the earsDizziness IrritabilityMemory Problems Sleep problemsBalance Problems Other-specify
40 Glasgow Coma Scale Is used to help determine severity of TBI Responses are scored using three measures which are scored separately & then combinedEye openingBest verbal responseBest motor response
41 Glasgow Coma Scale Items Eye Opening (E)Spontaneous 4To speech 3To pain 2No Response 1Best Motor Response (M)To verbal command: obeys 6To painful stimulus: localizes pain 5Flexion-withdrawal 4Flexion-abnormal 3Extension 2No response 1Best Verbal Response (V)Oriented and converses 5Disoriented and converses 4Inappropriate Words 3Incomprehensible sounds 2Makes no sounds 1Scoring:Eye Score (E) +Motor Score (M) +Verbal Score (V) = 3-15
42 Classifications of TBI by GCS Mild TBI/Concussion GCS Score of 13-15Moderate TBI GCS score of 9-12Severe TBI GCS score of 8 or less
43 Mental Health Treatments for Clients with TBI Goal is to:Reduce stress, overcome common co-occurring conditions such as post-traumatic stress disorder, depression, chronic opioid therapy, and substance use.Handle their states of anxiety, anger or depression by use of Handbooks Tools for Coping on
44 Get yourself two apps to help Your Clients with TBI mTBI Pocket GuideCo-Occurring Conditions ToolkitBoth available as free apps from the National Center for Telehealth and Technology
45 Teach Clients with TBI to use Apps on their phones Breath2RelaxTactical BreatherMood TrackerLifeArmorPTSD CoachAvailable through The National Center for Telehealth and Technology
46 Use the Tools for Coping Series on www.coping.us Tools for Handling LossTools for Personal GrowthTools for RelationshipsTools for CommunicationsTools for Anger WorkoutTools for Handling Control IssueGrowing Down-Healing the Inner ChildBalanced Lifestyle-Weight Management
47 Treat Co-Morbid PTSD if present Utilize the Evidenced Based Treatment for PTSD outlined in the VA-DOD Clinical Guidelines of 2010Cognitive Processing TherapyProlonged Exposure TherapyEMDR
48 To wrap it up we looked at: What is TBIHow TBI is assessedWhat the issues are facing clients with TBIMental Health Tools to be utilized with patients with TBI
49 Thank you for your attention and interest Thank you for your attention and interest. I hope you are motivated to get out and learn more about TBI and utilize the resources identified today
50 Short Course on TBI for Mental Health Counselors at: http://coping