2. Introduction to conceptualizing suicide risk in those with TBI Part 1 of 4 Beeta Y. Homaifar, PhD Melodi Billera, LCSW Where we discuss: TBI Basics Impact of TBI on Suicide Risk

3. Disclosure This presentation is based on work supported, in part, by the Department of Veterans Affairs, but does not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

4. Disclaimer Information during this presentation is for educational purposes only – it is not a substitute for informed medical advice or training. You should not use this information to diagnose or treat a mental health problem without consulting a qualified professional/provider

5. What we hope Is that you will find this presentation: Immediately useful Engaging Respectful of your experiences

6. What we really, really hope image: www.fordyceletter.com

7. What we believe Conceptualizing suicide risk Empathy Anxiety

9. Objective 1 TBI Basics

10. TBI Definition A blow or jolt to the head or a penetrating head injury that disrupts the function of the brain CDC 2005 Does every blow or jolt to the head result in a TBI?

11. Leading causes of TBI

12. TBI Severity CriteriaMildModerateSevere Structural imagingNormalNormal or abnormal Loss of consciousness (LOC)0–30 min> 30 min and < 24 hrs > 24 hrs Alteration of mental state (AMS)A moment up to 24 hrs > 24 hours. Severity based on other criteria Post-traumatic amnesia (PTA)0–1 day> 1 and < 7 days> 7 days Glasgow Coma Scale (best available score in first 24 hours) 13-159-12< 9

13. How the brain works…

14. How the brain might look after a TBI…especially if it’s moderate-severe

15. TBI in the Post 9-11 Era Reported rates of TBI in deployed OEF/OIF service members have ranged from 15.2% to 22.8% Majority of TBIs sustained are mild TBI Hoge et al. 2008; Terrio et al., 2009

16. Re-injury statistics Risk of Repeat Brain Injuries – After 1 st TBI, risk of second injury is 3 times greater – After 2 nd, risk of third injury is 8 times greater – Why is this so? Slowed reaction time Judgment off Impulsive Inattention Slide: Mary Hibbard, PhD, ABPP

17. Repeat injuries – what do you notice about these categories?

18. TBI CAN IMPACT COGNITION Attention Processing Speed Learning & Memory Communication Executive Functions

19. What is Executive Functioning? Lezak, 2004; Bechara et al., 2000 A set of cognitive processes involved in goal-directed behavior

20. Executive Dysfunction Impulsivity Difficulty problem solving Difficulty with insight

21. TBI Can Affect Mood Apathy/Depression

22. TBI Can Affect Behavior Aggression

23. TBI and Systems Issues TBI can affect problem solving abilities re: accessing resources – Meeting basic needs – Employment/job retention

24. Take Home Message TBI → Cognition TBI → Mood TBI → Behavior TBI → Systems issues Direct result from the injury Reaction to life experiences after TBI Pre-existing vulnerabilities Any combination of these

25. Objective 2 Impact of TBI on Suicide Risk

26. Self Directed Violence After TBI Individuals with TBI are more likely to Think about suicide Attempt suicide Die by suicide Bahraini et al 2013; Simpson & Tate, 2002

27. How long does the risk of suicide persist after a TBI?

28. TBI Shared Risk Factors Suicide Age Gender Substance Use Psychiatric Illness Aggression

29. Psychosocial stressors Social isolation, loneliness Loss of self, lack of purpose Problem solving deficits secondary to executive dysfunction Relationship of TBI to Suicide

30. Implications of Problem Solving Deficits Distress TIME Threshold may be lower in TBI---problem solving may break down at lower levels of distress than you might expect Threshold of distress for those with no TBI- related impairment is higher---can tolerate more before problem solving breaks down

31. TBI as a “Disease Process” For some, TBI is a lifelong process that may be both disease and Masel & DeWitt, 2010

32. Optimal Health Trajectory Suicide Risk Trajectory TBI Can Shift the Health Trajectory Time TBI Depression Executive Dysfunction Risky Behaviors Relationship problems

33. Optimal Health Trajectory Suicide Risk Trajectory Timing Matters Time TBI

34. This Wraps up Part 1 of the Conceptualizing Suicide Risk in those with TBI beeta.homaifar@va.gov melodi.billera@va.gov Please continue to Part 2 and/or 3