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 assessed
What the issues are facing clients with TBI
Mental 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 brain
There are two types:
Focal: damage to one area of brain
Diffuse: damage in more than one area of brain

4. Categories of TBI
Closed head injury: results from any trauma that causes the brain to be violently shaken inside of the skull such as a “blast” injury
Penetrating injury: when object goes through the skull & enters the brain.

5. Skull fracture
Brain contusion
DAI (Diffuse axonal injury) over 50% of TBI
Primary lesions
HEAD
INJURY
Intracranial hemorrhages
Brain edema
Increase of ICP (Intracranial pressure)
Infections
Delayed lesions
Long term effects
Resultant
concerns

6. Results of TBI
Can 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 body
Can interfere with how brain works, including thinking, remembering, seeing & controlling movements

7. Causes of TBI
Brain injuries can occur when the head strikes an object such as a windshield or the ground at a fast rate of speed
When a flying or falling object strikes the head
Can occur without a direct blow to head as in cases of severe "whiplash"

8. Most Common Causes of TBI for Military
Bullets, fragments, blasts
Motor vehicle-traffic crashes
Falls
Assaults Blasts are a leading cause of TBI for active duty military personnel in war zones.

10. Resultant injury from explosive devices
Primary Injury–overpressure
Secondary injury–secondary wave-shrapnel
Tertiary injury-person blown into objects
Quaternary-heat and gas

12. Ranges of TBI
Traumatic brain injury can range from mild to very severe depending on many things including:
Force of the trauma
Previous brain injuries
How quickly emergency medical treatment is given

13. TBI Definitions: Concussion/Mild TBI
A confused or disoriented state lasting 24 hours or less
Loss of consciousness for up to 30 minutes
Memory loss lasting less than 24 hours.

14. Moderate TBI:
A confused or disoriented state that lasts more than 24 hours
Loss of consciousness for more than 30 minutes, but less than 24 hours
Memory loss lasting greater than 24 hours but less than seven days

15. Severe TBI
A confused or disoriented state that lasts more than 24 hours
Loss of consciousness for more than 24 hours
Memory 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 TBI
Mild: 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: 100,373
Guard: 22,489
Reserves: 9,415
Navy 13.9%
Active: 29,597
Reserves: 2,325
Air Force 13.8%
Active: 27,305
Guard: 2,659
Reserves: 1,611
Marines 14.5%
Active: 30,473
Reserves: 2,859

19. Who are Highest Risk for TBI?
Males are about 1.5 times as likely as females to sustain a TBI
Military duty increases risk of sustaining a TBI

20. Signs & symptoms of mild TBI or concussion
Headaches
Dizziness
Excessive fatigue (tiredness)
Concentration problems
Forgetting things (memory problems)
Irritability
Sleep problems
Balance problems
Ringing in the ears
Vision changes

21. Signs & symptoms of moderate and severe TBI
memory loss/amnesia
vision changes or loss of vision
paralysis and/or muscle spasticity
chronic pain
sleep disturbances
inability or changes in ability to use senses of taste, touch, sight, sound, smell & taste
loss of bowel and/or bladder control
coma
severe headaches
seizures/convulsions
nausea/vomiting
inability or difficulty speaking, understanding &concentrating
confusion, restlessness or agitation
loss of or changes in coordination

22. Common Late Symptoms of Concussions
Persistent Headache
Lightheadedness and/or dizziness
Decreased attention and concentration
Poor memory
Easy fatigability
Anxiety or depressed mood
Sleep 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 months
Patients with moderate to severe TBI often have long-term medical problems requiring specialized attention
Symptoms & 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 upon
Severity of injury
Location of the injury
Age & 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 event
In 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 = 30
Orientation = 5
Immediate Memory = 15
Concentration = 5
Memory Recall= 5

30. Orientation (1 point per question)
Orientation: Assess patients awareness of the accurate time
WHAT 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, wagon
For 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 finding
Motor: 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 abnormalities
No 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 Question
Did you have any injury(ies) during your deployment from any of the following:
Fragment
Bullet
Vehicular (any type of vehicle, including airplane)
Fall
Blast (Improvised Explosive Device, RPG, Land mine, Grenade)
Other: specify

38. Second Question
Did any of the injury received during your deployment result in any of the following?
Being dazed, confused or “seeing stars”
Not remembering the injury
Losing consciousness (knocked out) for less than a minute
Losing consciousness for 1-20 minutes
Losing consciousness for longer than 20 minutes
Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)
Head injury
None of the above

39. Third Question
Are 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 ears
Dizziness Irritability
Memory Problems Sleep problems
Balance 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 combined
Eye opening
Best verbal response
Best motor response

41. Glasgow Coma Scale Items
Eye Opening (E)
Spontaneous 4
To speech 3
To pain 2
No Response 1
Best Motor Response (M)
To verbal command: obeys 6
To painful stimulus: localizes pain 5
Flexion-withdrawal 4
Flexion-abnormal 3
Extension 2
No response 1
Best Verbal Response (V)
Oriented and converses 5
Disoriented and converses 4
Inappropriate Words 3
Incomprehensible sounds 2
Makes no sounds 1
Scoring:
Eye Score (E) +
Motor Score (M) +
Verbal Score (V) = 3-15

42. Classifications of TBI by GCS
Mild TBI/Concussion GCS Score of 13-15
Moderate TBI GCS score of 9-12
Severe 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 Guide
Co-Occurring Conditions Toolkit
Both available as free apps from the National Center for Telehealth and Technology

45. Teach Clients with TBI to use Apps on their phones
Breath2Relax
Tactical Breather
Mood Tracker
LifeArmor
PTSD Coach
Available through The National Center for Telehealth and Technology

46. Use the Tools for Coping Series on www.coping.us
Tools for Handling Loss
Tools for Personal Growth
Tools for Relationships
Tools for Communications
Tools for Anger Workout
Tools for Handling Control Issue
Growing Down-Healing the Inner Child
Balanced 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 2010
Cognitive Processing Therapy
Prolonged Exposure Therapy
EMDR

48. To wrap it up we looked at:
What is TBI
How TBI is assessed
What the issues are facing clients with TBI
Mental 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