TBI and PTSD among OEF/OIF Veterans and UNC Cognitive Rehabilitation Research

1. TBI and PTSD among OEF/OIF VeteransandUNC Cognitive Rehabilitation Research James Wolfe, M.S., NCC Erin Clevenger, M.A. Eric B. Elbogen, Ph.D. UNC-Chapel Hill School of Medicine Dept. of Psychiatry

2. Mental Health Needs of Iraq and Afghanistan Veterans • Over one million currently active military personnel have served in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) • Estimates vary, but about 15-20% of troops returning show some symptoms of posttraumatic stress disorder (PTSD) • 15%-20% of all returning veterans have experienced some type of traumatic brain injury (TBI), often associated with IEDs (improvised explosive devices) • Some veterans have both TBI + PTSD

3. Mental Health Needs – Trend of PTSD Diagnoses

4. Mental Health – Trend of TBI Diagnoses

5. Mental Health Needs of Iraq and Afghanistan Veterans • Both TBI and PTSD can lead to a lifetime reduction in social, cognitive, and vocational functioning • The sooner the assessment of TBI and PTSD, the sooner rehabilitation plans can be implemented, which will dramatically improve effectiveness of these efforts • One report indicated that more North Carolinians have served in Iraq and Afghanistan than any other state; thus, we can anticipate a huge demand for allied health services in the upcoming decade

6. What is TBI? • Traumatic brain injury (TBI) occurs when a sudden trauma causes damage to the brain

7. What is TBI? • TBI can also result from a blast. Shockwaves from explosions can damage the brain through the skull or can cause small objects such as shrapnel to pierce the head 

8. What is TBI? • A person with a mildTBI (mTBI) may remain conscious or may experience a loss of consciousness for a few seconds or minutes • Other symptoms of mild TBI:

9. What is TBI? • A person with a moderate or severe TBI may show symptoms of mTBI as well as: • Worsening/persistent headache • Nausea or vomiting • Convulsions or seizures • Inability to awaken from sleep • Dilation of one or both pupils • Slurred speech • Weakness/numbness in the extremities • Loss of coordination • Increased confusion, restlessness, or agitation

10. What is TBI? • Prognosis of a TBI depends upon the severity of the injury, the location of the injury, and the age and general health of the person. Problems with the following are common: • cognition (thinking, memory, and reasoning), • sensory processing (sight, hearing, touch, taste, and smell), • communication (expression and understanding), and • behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).

11. What is PTSD? • PTSD first presumes that a person has experienced a traumatic event involving actual or threatened death or injury to themselves or others -- and where they felt fear, helplessness or horror. • Diagnostic criteria: Three symptom clusters must persist for more than a month after the traumatic event and cause clinically significant distress or impairment.

12. What is PTSD? Symptom clusters of PTSD: • Intrusions- such as flashbacks or nightmares, where the traumatic event is re-experienced • Avoidance - when the person tries to reduce exposure to people or things that might bring on their intrusive symptoms • Hyperarousal - meaning physiologic signs of increased arousal, such as hypervigilanceor increased startle response

13. TBI/PTSD Overlap TBI PTSD Flashbacks Irritability Memory Decision- making Inhibition Emotional regulation Anxiety Avoidance Learning new things Shame Motor Skills Guilt

14. TBI/PTSD Overlap % Having trouble making plans, decisions, learning new things % Experiencing violence control issues N= 568 % of veterans

15. How to Assess for TBI TBI is the result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: • Any period of loss of or a decreased level of consciousness • Any loss of memory for events immediately before or after the injury (posttraumatic amnesia) • Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.) • Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient • Intracranial lesion

16. How to Assess for Impairments in Functioning Neuropsychological Assessment Tests: • Attention – ability to focus and concentrate on verbal and visual information for a short or long period of time at a given processing speed • Memory – ability to recognize and recall verbal and visual information short-term and long-term • Executive Functioning – ability to have higher order thinking and problem solve; ability to think flexibly; ability to inhibit behaviors and responses

17. Cognitive Task • Please memorize the following words: • Cup • Elbow • Sailboat • Broom • Pear • Building • Tornado • Pencil

18. Cognitive Task PINKBLUEGREEN GREENPINKBLUE PINKGREENPINK BLUEPINKBLUE GREENBLUEGREEN BLUEPINKBLUE PINKGREENGREEN

19. Cognitive Task BLUEPINK BLUE PINK GREENPINK GREENPINKGREEN PINKBLUEPINK BLUEGREENBLUE GREENBLUEGREEN BLUEPINKPINK

20. Attention vs. Executive Functioning • The first color-word task involves straight attentional abilities and taps into processing speed • The second task is harder because it involves the ability to inhibit the overlearned response to read the word • This exercise measures executive functioning because it involves higher order ability to keep a rule in mind, to inhibit initial responses, and to instead execute the new rule

21. Cognitive Task • Remember the list of words you were asked to memorize? • Please write down as many of the words from the previous list as you can.

22. Cognitive Task • Now, we’re going to list words, some were on the original list and others weren’t. Which ones were on the list? Cap? Elbow? Umbrella? Hat? Sailboat? Building? Broom? Zebra? Apple? Pencil?

23. Free Recall vs. Recognition • The first task is much harder because it involves retrieval of encoded information without cues (free recall) • The second task is easier because it assists retrieval of encoded information with cues (recognition) • Many people with TBI do poorly on the first and not the second, which signals that the information was encoded but that there is a problem retrieving the information

24. Neurocognitive Effects of TBI and PTSD • Literature agrees that attentional impairments are associated with PTSD • With respect to TBI, depends on type of injury (focal or diffuse) • Attention is generally affected with reduced working memory and slower processing speed • Memory retrieval often affected, but recognition remains intact • Executive dysfunction, typically disinhibition, is related to TBI

25. Rehabilitation of Trauma-Related Disability • Cognitive Remediation • Help improve attention, memory, or problem solving • For veterans who’ve experienced a TBI, research shows most improvement in cognitive functioning comes in the first 18 months • Speech Therapy • Retrain injured veteran if needed • Basic communication skills may also need to be addressed

26. Rehabilitation of Trauma-Related Disability • Vocational Rehabilitation • Match job with cognitive strengths or weaknesses • Provide employment support on an ongoing basis if necessary • Occupational Therapy • Modify living or work environment to compensate for deficits (e.g., cues) • Help structure veteran’s time and schedule to achieve realistic life goals

27. PTSD Treatment • Posttraumatic stress disorder is usually treated with a combination of medications and counseling • The medications are designed to reduce anxiety and to help patients overcome depression • Common types of counseling for veterans with PTSD include cognitive-behavior therapy, exposure therapy, group therapy, and family therapy.

28. PTSD Treatment • Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy • There is preliminary evidence that aerobic exercise may have a calming effect • Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided

29. Summary • Thousands of Iraq and Afghanistan veterans are returning to North Carolina and have suffered a trauma resulting in social, cognitive, or vocational deficits • The most prevalent issues are traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), which can lead to a lifetime reduction in basic functioning • Comprehensive assessment of TBI and PTSD give information about the accuracy of the diagnosis and about which types of rehabilitation strategies will be effective • To address these trauma-related disabilities, allied health professionals will be critical in developing rehabilitation plans to help veterans reintegrate and readjust to civilian life

30. UNC StudyBrain Functioning and Cognitive Rehabilitation In Veterans • Aimed at improving brain function of veterans with TBI and PTSD • Involves participation for six months • Use an iPod Touch to practice techniques for improving memory and planning skills • Data collection at the beginning and end of study including interview, testing of memory and attention, EEG, and MRI • Three in-home support sessions involving a family member or friend • Veteran will be paid $500, participating family member or friend will be paid $200, and veteran will keep iPod

31. UNC Study Eligibility requirements to participate: • Served in a branch of the military since Oct. 2011 • Has had a head injury that meets diagnostic criteria for TBI (had the head injury while in the military) • Has military-related PTSD • Can have an MRI and EEG

32. Recruitment Area (within 125 miles of Chapel Hill)

33. UNC Study • If you know of a veteran who might be interested in participating in the study, please have them call for more information: Dr. Eric Elbogen UNC Forensic Psychiatry 919-972-7459