1. TBI and Behavioral Health Challenges
Carolyn Lemsky, Ph.D., C.Psych

2. Disclosures and Acknowledgements

3. Defined TBI and Severity
Review John Corrigan, Ph.D. Director, Ohio Valley Center for Brain Injury Prevention and Rehabilitation
-webinars
Defined TBI and Severity
Mild no or LOC < 30 min.)
Moderate (LOC 30 min – 24 hr.)
Severe (LOC > 24 hours)
Temporary or permanent effects
TBI’s may have a cumulative effect
TBIs a young age may affect development
At Risk Populations
Substance Users
Military
Domestic Abuse Survivors
Athletes (boxers, football players hockey players)
People with a previous TBI
Finger print of TBI
Frontal and temporal lobes
Emotional and Behavioural Regulation
Back in October, John Corrigan introduced brain injury and co-occurring disorders to us.
I’m going to give a quick overview of the content of that webinar, but it is available online using the link on this slide.
Started out by defining brain injury as a blow to the brain (not just the head) that leads to an alteration of consciousness…Yes a concussion is a TBI.
Main Indicator LOC.
Gave some great information about why so many of the clients we serve are affected by TBI.
At risk populations for one or more TBIs
There is a finger print of TBI
All of the things that help both to avoid problems with substance use and mental health, but also allow one to benefit from treatment

4. A history of TBI with LOC is common among the clients you serve
Non-institutionalized adults
1 in 5
People seeking treatment for SUD
2 - 3 in 5
Psychiatric Inpatients
Dr. Corrigan reviewed some interesting demographic data…and this is a quick and dirty summary. Life time history
He talked about a few population based studies that showed…
Co-occurring Disorders
3-4 in 5

5. Moderate to Severe TBI Non-institutionalized adults 3-6%
People seeking treatment for SUD 15-20%
Psychiatric Inpatients
20 %
But in some of the data from Toronto here, and in a few other jurisdictions that looked at folks who are chronically homeless and have co-occurring addictions and mental health issues, the numbers are more like 3-4 in 5.
Homeless
12 to 15 %

6. Clinical Observations
An even bigger gap between what a client intends to do and what they are able to do
More likely to have difficulty engaging in treatment and leaving treatment early
Finding services
Making and keeping appointments
Keeping up with program requirements
More likely to be seen as non-compliant or unmotivated
We know that making any health related changes are difficult, and particularly in addictions care there may be difficulty…

7. Recommendations for service providers
Routine Screening for brain injury and other sources of neurocognitive impairment
Learning to recognize when behaviors are the result of neurological challenges
Making programs more accommodating
Viewing complexity as a rule and develop programming accordingly
Care plans that include long-term supports
Recommendations for service providers

8. Overview How and why mental health problems and TBI interact
Accommodating Neurobehavioural Impairment
Accommodating Cognitive Impairment
Universal Accommodations
Programming considerations

9. The Finger print of TBI Pattern of Injury Neuroanatomy of Reward
Because of the bony ridges in the skull the pattern of injury isn’t random, The frontal lobes and the tips of the temporal lobes are most at risk.

10. The Finger print of TBI Pattern of Injury Neuroanatomy of Reward
Because of the bony ridges in the skull the pattern of injury isn’t random, The frontal lobes and the tips of the temporal lobes are most at risk. As Dr. Corrigan discussed these are the areas of the brain that responsible for behavioural regulation.

11. Shearing of Axons deep in the brain may create problems with functional communication between brain structures
Because of the twisting that can occur when there is a concussion, or more severe brain injury there is often a shearing of axons—the connecting fibers between nerve cells that are responsible for the transmission of information between nerve cells. And there’s a predictable pattern here too…and that is it tends to be the junction between the grey and white matter that is effected. That’s because these types of tissues have different densities so the shake at different speeds and separate.
Now in very mild concussion there may be axonal shearing and it doesn’t show up on imaging, and a person may recover. This is a picture of more severe axonal injury. These lesions only show up on imaging when they are fairly severe

12. Control Brain Injury TBI is a disorder of disrupted brain connectivity
(Hayes, Bigler, & Verfaellie, 2016)
This is a newer kind of image that actually watches the brain at work. Diffuser tensor imaging. It gives the investigators, (mostly used in research) So it can tell if things that might look okay are not working properly.
Major tracts that frequently have abnormal mean diffusivity (MD), suggesting axonal injury or demyelination, or altered fractional anisotropy (FA), indicative of reduced neuronal integrity after TBI, include the genu of the corpus callosum, the cingulum bundle, and the uncinate fasciculus (Hulkower, Poliak, Rosenbaum, Zimmerman, & Lipton, 2013).
Resting state fMRI. When a person rests and is not engaged in a task, brain regions in the default mode network (DMN) are activated. The DMN consists of regions (e.g., posterior cingulate cortex, medial prefrontal cortex, lateral parietal cortex, temporal parietal junction) that exhibit synchronous activation at rest, that is, are functionally connected (Fox et al., 2005). In contrast, these regions normally deactivate during performance of an external task. DMN dysfunction,suchasfailuretodeactivatewhenanunexpected external event demands cognitive control, may result from (1)altered within-networkfunctionalconnectivity(FC),asin
reduced connectivity between posterior cingulate cortex with ventromedial prefrontal cortex (Sharp, Scott, & Leech, 2014) or (2) alteration of between-network FC, such as increased connectivity between one or more DMN regions and ventrolateral prefrontal cortex, a task-related region (Figure 1; Newsome et al., 2016). Emerging evidence indicates that failure of task-related regions to deactivate during rest or of DMN regions to deactivate during task performance are related to residual cognitive dysfunction (Sharp et al., 2014). TBI may also produce aberrant connectivity between the DMN and the
salience network (i.e., anterior insula and dorsal anterior cingulatecortex),anetworkthatunderpinsselectiveattention to relevant stimuli and switching between attention to internally generated mental activity and external events, However, the long range implications of aberrant FC following TBI remain to be elucidated. Longitudinal imaging is necessary to elucidate the long-term effects on connectivity, evaluatewhetherDMNstatusisausefulprognosticbiomarker, and determine if measurement of FC is useful for evaluating interventions in TBI patients
Control
Brain Injury
(Hulkower, Poliak, Rosenbaum, Zimmerman, & Lipton, 2013).

13. To have a well functioning brain it has to communicate well from the inside out.
This is a simplified illustration of three major divisions of the brain. The brain evolved from the inside out with the simple functions occurring in the older portions of the brain, and then the middle brain where the emotional machinery is, and also memory…and then the outer layer which is the most recently evolved and responsible for conscious thought.
So for our conscious thinking to influence the more automatic aspects of our brain there has to be good connectivity.
Our brains use a disproportionate amount of energy. And the brain, like all of the rest of our organs evolved to be as energy efficient as possible. Its energy intensive to think things through, and it’s also relatively slow process. Like everything in nature survival value determined how we evolved, and it had survival value to make cognitive processing as automatic as possible—as efficient as possible. Which means that most of what determines our behavior occurs below the level of conscious thought, but can also be influenced by conscious thought if everything is working properly.
Recall that we’ve been talking about a greater gap between what a person thinks about and says and what they do…that’s because after brain injury, our conscious brains seem to have less influence over the automated /automatic aspects of our brain.
As well get to later, if a person can’t influence these automatic processes well, they need more help from the environment.

14. The gap between what a person says and what they do is related to poor connections with the brain.
Depression and anxiety are the most common difficulties that can occur after brain injury,
And they’re also the most common in the general population.

15. Having a mental health disorder is a risk factor for poorer recovery and long-term outcome after TBIs of all severities.
Depression and anxiety are the most common difficulties that can occur after brain injury,
And they’re also the most common in the general population.

16. Altered Connectivity in Depression
We’re short on time, so I’ll just give the examples of depression and PTSD, since I believe that’s an area of interest for a lot of people who listened to the previous webinar.
So what does this have to do with mental health? The structural disconnection leads to a functional disconnection and the large scale networks of the brain may work differently after brain injury. The same types of disruption in functional connections occurs in mental health problems, although the cause of the problem may be physiological rather than structural.
Figure 1. Schematic overview of the key brain regions that show abnormal long-range connectivity patterns in subjects with MDD. Here, we only show areas for which evidence has been confirmed across at least MEG and fMRI modalities. Orange arrows represent altered connection between two brain regions that has been confirmed using both MEG and fMRI resting-state paradigms. Red arrow represents altered resting-state connectivity between two regions that has been confirmed across MEG, EEG, and fMRI. Abbreviations: MEG, magnetoencephalography; EEG, electroencephalography; fMRI, functional magnetic resonance imaging; dlPFC, dorsolateral prefrontal cortex; mPFC, medial prefrontal cortex; sgACC, subgenual anterior cingulate cortex; PCC, posterior cingulate cortex; MDD, major depressive disorder. (Green–blue striped area represents dlPFC shown here from a medial view perspective for convenience.)
Alamian G, Hincapié A-S, Combrisson E, Thiery T, Martel V, Althukov D and Jerbi K (2017) Alterations of Intrinsic Brain Connectivity Patterns in Depression and Bipolar Disorders: A Critical Assessment of Magnetoencephalography- Based Evidence. Front. Psychiatry 8:41. doi: /fpsyt
Alamian G, Hincapié A-S,
Combrisson E, Thiery T, Martel V,
Althukov D and Jerbi K (2017)

17. Common Symptoms between Depressed mood and TBI
May range from mild (trouble getting started) to needing direction for all behavior
Apathy
Frontal Lobe and underlying structures
Blunted or Labile affect
Hypothalamus
Changes in Appetite
Areas of the brain stem responsible for sleep initiation and maintenance.
Sleep Disturbance
Both mental and physical fatigue
Fatigue
Memory, poor problem-solving, attention and concentration
Cognitive Impairment

18. PTSD the result of a neurobiological process that results in an error in processing the context of a memory.
What is the difference between TBI and PTSD…
TBI is the result of a mechanical force, and whereas PTSD
Now going back to the idea that our brains were designed to increase survival…
It makes sense to write down something that is dangerous very clearly so that you can avoid it, and to remind the brain’s owner about the existence of the threat and to be vigilent.
When there is an extreme stress or danger, the brain has mechanisms, like the fast release of catecholamines to get the brain to write down—so memories are written with very strong sensory and emotional cues. In the circumstances in which our brains evolved, it made sense to have a nervous system that erred on the side of caution…having a lot of false positives made sense because failing to regard a stick as a potiental snake or a russle in the woods as a preditor could be a fatal mistake.

19. Pattern of Traumatic Injury
Emotional Regulation in PTSD
Pattern of Traumatic Injury
PTSD is really a disorder of emotional processing.
Yehuda, R., Hoge, C., McFarlane, A. et al. Post-traumatic stress disorder (2015)

20. Common Symptoms PTSD and mTBI
Poor concentration
Irritability
Anger
Sleep disturbance
Fatigue
Impairments of executive functioning

21. mTBI PTSD Axonal shearing Diffuse white matter lesions Neurobiological
Reduced hippocampal volume in more severe injuries
Some frontal regions with reduced activity
White matter abnormalities associated with chronic symptoms (PCS)
mTBI may make it harder to benefit from fear extinction
Neurobiological
Specific areas of white matter lesions (medical pre- frontal/sub cortical tracts)
More grey matter lesions
Reduced hippocampal volume
Increased frontal activity
mTBI is a risk factor for developing PTSD
Both disorders make an independent contribution to the post-concussive symptoms that are experienced—but parcing that apart is difficult.
High rate of co-morbidity.

22. Lessons for treatment
Cognitive processing and exposure based treatments work equally well with and without mTBI.
A modified therapy that includes treatment for problems with working memory, verbal memory and problem solving had increased benefits (Jak, 2019).
In most cases there is limited benefit to knowing whether mTBI or PTSD is causing a given symptom (Hayes, 2019)

23. Anger/Irritability Damage to the orbital-frontal cortex
Wood and Thomas (2013) two types
Irritable
Episodic (possible association with epileptiform activity in the temporal lobe)

24. Suicidality/Self-Harm
Increased risk for survivors of all ages (22% to 28%)
Co-occurring substance use disorder
PTSD symptoms
Depression, Anxiety and other psychiatric symptoms.
Impulsivity (emotional dysregulation)
(Simpson and Tate, 2005)

25. Some studies suggest high rates of personality disorders after TBI
Kaponen, 2002: 23% had a personality disorder 30 years post- ABI (avoidant > paranoid > schizoid)
Hibbert et al., 2002: 65% have a personality disorder (borderline > avoidant > paranoid > obsessive compulsive > narcissistic)
Streeter et al., 1995: 40% of men presenting with borderline personality disorder had a history of head injury compared to 4% of controls

26. Psychotic Disorders
Apparently paranoid ideation as the result of poor memory for events
Poor reasoning and perseveration resulting in thought-processes that seem delusional
Negative symptoms such as flat affect, and reduced initiation

27. Summary
Functional connectivity (large brain circuits functioning together) enable healthy brain functioning.
Both brain injury and mental health disorders may alter how the brain communicates.
Many symptoms of mental health disorders overlap with symptoms of brain injury.
Often, the source of a particular problem will be impossible to determine
Evidence-based mental health therapies are effective for people living with the effects of TBI.

28. 1. Could this be related to a neurological problem?
When a client is having trouble engaging in or benefitting from your intervention, ask yourself two questions.
1. Could this be related to a neurological problem?
2. What can I do to accommodate?

29. Accommodating cognitive impairment
No two injuries are alike.
It isn’t only the injury but the person who has been injured.
Changing the way that services are delivered can reduce the impact of cognitive impairment
Reduce cognitive load
Encouraging cognitive compensation

30. The flow of cognition Executive Functioning Memory
Alertness
Attention
Processing of information
Memory
Executive Functioning
The flow of cognition
This is model of cognitive functioning that was developed to formulate plans for cognitive rehabilitation. The ideas is that cognitive functions build on each other from basic to more complex. When there’s a problem a problem toward the beginning of the flow, everything above it suffers.

31. Executive Function Planning Mental Control Initiating activity
Switching tasks
Emotional Control
Self-Awareness
Behavioural Self-management

32. Accommodating cognitive impairment
Showing up
Paying attention
Remembering What to do
Deciding what to do
Planning
Starting
Evaluating

33. Cognitive Load (Sweller)
Example of cognitive load
Cognitive Load (Sweller)

34. Reducing cognitive load
Slow down
Break down tasks
Use routines
Create reminders and teach clients to use them
Set clear goals and agendas
Remove Distractions
The term cognitive load actually refers to the fact that our working memory (the process of taking in and manipulating information) before its sent to long term memory. There’s a whole active area of cognitive neuroscience that digs into the details of this, but a bit of common sense can actually go a long way to helping all of our clients profit from traetment

35. Accommodating neurobehavioural impairments
Changing the nature of services offered may be needed to address neurobehavioural impairments (gap between say and do).
Emphasizing behavioural rehearsal and routines
Case management
Longer periods of treatment
Supported housing
Use of incentives

36. What allows people to be successful?
Good Judgement
Daily routines/habits

37. Many mental health therapies have the goal of harnessing conscious cognitive processing (executive functioning) to better manage the automatic thought and behavior processes that are governed by the limbic system.

38. Feldstein, Filbey, Hendershot, McEachern & Hutchison, 2011

39. Longer-term options such as sober homes may help clients learn and remember productive routines. Access to support for problem-solving difficult situations

40. Behavioural strategies that emphasize skill building and positive routines
DBT skills training (DBT-Informed skills training)
Behavioural Activation
Incentives and short term goals
Cognitive Adaptation Training
Community Reinforcement Approach

41. Awareness (Neurological)
Capacity to recognize a weakness or difficulty
Reasoning
Attention
Memory
Emotional processing
Insight (Psychological) Willingness to address a perceived weakness or difficulty
Self-concept
Optimism
Coping strategies

42. Intellectual Awareness Anticipatory Awareness
Insight and Awareness
No awareness
I don’t see a problem
Intellectual Awareness
Other people say I have a problem
Emergent Awareness
OOPS, I think I have a problem
Anticipatory Awareness
I know I tend to do this, so I better do something about it

43. Collaborative Interventions
Engagement
Persuasion
Active Treatment
Relapse Prevention
Anticipatory Awareness
Emergent Awareness
Intellectual Awareness
Unaware
Client-centered/collaborative goal setting
Motivational Interviewing
Supported trials
Client education
Cognitive/behavioural interventions
Cognitive compensation
Collaborative Interventions
Supervision/structured activity
Trustee/Legal system
Reduce exposure to substance
Support to reduce harms/attend treatment
Family intervention/education
Environmental Supports
Community Head Injury Resource Services of Toronto

44. Individualizing Cognitive compensation
Observe
Observe the behavioural difficulty
Consider
Consider possible cognitive problems that may be contributing, including level of awareness
Compensate
Work with the client to consider alternative compensations

45. Example: Andy’s attendance is poor
Observe
Misses sessions and is often late
Assess
Ask what’s happening
Ask what the client has done in the past that was helpful.
Consider
Doesn’t remember appointments
Trouble leaving on time
Compensate
Reminders
Appointment Card
Calendar
Help the client plan
Organizational Reminders

46. Example: Amelia has trouble taking turns speaking in groups
Observe
Talkative in groups
Interrupting others
Assess
Ask what’s happening
Ask what the client has done in the past that was helpful.
Consider
Impulsivity
Isn’t noticing cues that other’s might like to speak Loses track of the topic
Compensate
Non-judgmental feedback
Agree on a cue
Structure requests for comments

47. Programming modifications
Low-Barrier intake processes
Drop-in /single appointment
Support with paperwork
Smaller groups
Flexible schedules
Availability of case management services
Don’t assume that skills developed in one setting will be delivered in another setting.

48. Summary
There are many simple things that you can do to accommodate clients with neurocognitive impairment. Increasing emphasis on behavioural strategies including the use of treatment incentives may be useful after brain injury Environmental supports, such as case management, reminders, assistance in developing structured routines, support with financial management, etc. are most valuable when a person has limited awareness and poor self regulation

51. Things to remember
Each client will have a unique combination of difficulties
A problem that you observe may have several different causes—requiring different strategies.
Many of the strategies are helpful for different problems.

52. Recommended Practices
Screening for brain injury
Cross trained staff members
Smaller caseloads
Programs of care that are not time limited
Low threshold to service entry (and re- entry)
Flexible schedules
Case management supports
Options for small group and individual therapy

53. Find community partners

54. Webinar 2: Substance use Disorders and Brain Injury April 8 at 12 PM PST
Evidence based practices
Modifications for common interventions (MI)
Model of case management for complex problems