JV Caprez Social Work Field Day

1. JV Caprez Social Work Field Day Differentiating between Traumatic Brain Injury (TBI) and mental disorders that share symptomology: Trauma Disorders, Anxiety, Depression, Bipolar Disorder, Autism, Substance Use Disorders and ADHD

2. Dr. Tami Radohl, PhD, LSCSW Dr. Radohl is a Licensed Clinical Social Worker (KS) who specializes in Behavioral Health.  She worked in community mental health, schools, hospitals, criminal justice, adoption, and private practice settings before completing her PhD in Social Work.  At present, she is the Director of Field Education at Park University (Parkville, MO) and teaches Behavioral Health, DSM V, and Social Work with Children and Families to MSW students. Past research focuses on mental health including family therapy and recovery with those who have serious mental illness. Current research involves partnering with community agencies and higher education to house and educate homeless youth, field education pedagogy, interdisciplinary behavioral health education, and social work advocacy.  Current volunteer activities include the Board of the Directors for the National Association of Social Workers, Kansas Chapter and the Board of Directors for the Junior League of Johnson and Wyandotte Counties.  

3. Rhonda Weimer, LCSW, LSCSW Rhonda Weimer, received her MSW from the University of Kansas in 1993 with a concentration in Clinical Social Work.  From 1993 through 2004 Rhonda worked as a Clinical Social Worker; first at Northeast Kansas Mental Health and Guidance Center (now known as the Guidance Center), and then through her private practice.  She continues to maintain licensure in both Kansas and Missouri and serve as a clinical supervisor for candidates seeking advanced licensure.  Although she has been teaching in higher education since 2002, she also remains active working part time as a Military Family Life Counselor with active duty and National Guard troops to address pre and post deployment difficulties. 

4. Section 1 intro 8:30-10:00 • Greetings & Nuts & bolts • Overview & define TBI • The process of diagnosing TBI • Tools used in assessment of TBI

5. Why is differential diagnosis in this area important? • How do we know if the TBI occurred before mental illness OR occurred after already having a mental health disorder (perhaps an undiagnosed disorder)? • Why should we care? • What implications do these answers have? • Insurance • Correct treatment • Other ideas? • All in all, mental illness and TBI are NOT a “dual diagnosis.” Why?

6. Traumatic Brain Injuryeffects over 2 million people in the U.S. • “Transient or persistent brain dysfunction occurring as a result of head movement and/ or collision between the head and an object or surface that causes suprathreshold loading to the brain,” • Zollman, 2016, p 10

7. TBI injury • Classification of TBI by mechanism: • Closed head injury/ blunt force • Direct force to the head such as falls, assaults, and motor vehicle collisions • Blast injury • Overpressure waves generated from explosives • Penetrating injury • Gunshot, shrapnel, knife, other object • Clinical classification of TBI: • Mild • GCS 13-15; awake, confused but can communicate and follow commands • Moderate • GCS 9-12 drowsy but not comatose, eyes open, note pain stimuli • Severe • GCS 3-8 comatose, high risk of deterioration

8. Beware: TBI can be defined differently based on location • In Kansas, strokes and aneurisms do not qualify as TBI • However, in other states, they do! • Schools may provide services based on current state statute, regardless of “TBI definition” at the professional or federal level

9. Mild TBI: concussion • About 75% of all brain injuries are Mild TBI (MTBI) • Most do not cause permanent disability: most have complete resolution of symptoms by 3 months • Symptoms include: • Headache • Dizziness • Inability to concentrate • Nausea • Fatigue

10. thank you to NBC Learn Higher Ed • 2016 1:55 • Brandi Chastain • https://highered.nbclearn.com/portal/site/HigherEd/browse?cuecard=105785#.WpiDu28ghs4.email • TBI films • 2018 2:32 parents saying no to football • https://highered.nbclearn.com/portal/site/HigherEd/browse?cuecard=114367#.WrP08jO71wU.email

11. Moderate to severe TBI • May have significant impairments – although up to 90% will be able to live independently • May need assistance with finances, transportation, and complex tasks • Prediction of outcomes is based on many variables including specifics of the injury • Better outcomes for: • Younger • Insured • Caucasians • Less severe injuries • Fewer injuries

12. Blast injured veterans 2011 2:27 • https://highered.nbclearn.com/portal/site/HigherEd/browse?cuecard=53977#.WpiC7uWDCSU.email • PTSD in Iraq & Afghanistan veterans 2008 1:58 • https://highered.nbclearn.com/portal/site/HigherEd/browse?cuecard=33732#.WpiBJOhUp18.email

13. Common symptoms associated with TBI • Fatigue – 21% of persons with MTBI report, and this may persist after other symptoms have resolved • Described as both physical and mental fatigue • Balance deficits - 80% of military members with MTBI report • Dizziness – 20%-50% of persons with MTBI • Headache • Nausea • Visual disturbance • Tinnitus • Slurred speech • Memory deficits

14. TBI risks vary by age, gender, behavior • Children 1-4, and adults over 75 at highest risk for TBI due to a fall • Across all ages males are at higher risk for TBI (up to 7X) • Motor vehicle accidents are the highest cause of mortality due to TBI • Persons of color and lower socioeconomic status 30%-50% higher risk • Alcohol involved in 50% of TBI • Driving/ pedestrian/ falls/ suicide attempt/ violence

15. Diagnosis of TBI • Is a medical diagnosis: • If someone you are working with has not yet seen a physician prioritize this immediately • Caused by impact to the head or movement of the brain within the skull • Symptoms are present immediately after the injury

16. Assessment of TBI • Breakthrough in diagnosing 2013 2:37 • https://highered.nbclearn.com/portal/site/HigherEd/browse?cuecard=62753#.WpiAeYH4Qks.email

17. TBI referral—what should you expect from Neurology: The neurological examination is divided into several components, each focusing on a different part of the nervous system: • Mental status • Cranial nerves • Motor system • Sensory system • The deep tendon reflexes (e.g. infant) • Coordination and the cerebellum and nerves of brain (e.g. optical, oculomotor, olfactory) • Gait/Coordination • What do these things tell us? • Great resource: https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/neurological_examination_85,P00780

18. TBI referral—what should you expect from neuropsychology? • A neuropsychologist uses a series of tests to assess various areas of cognition and behavior, such as memory, attention, learning, processing speed and abstract reasoning • Neuropsychological tests (unlike bedside cognitive and behavioral neurologic screens) are standardized, meaning that they are given in the same manner to all patients and scored in a similar manner time after time.  • A typical evaluation may take 6-8 hours • Exams may include, but are not limited to: • intelligence, executive functions (such as planning, abstraction, conceptualization), attention, memory, language, perception, sensorimotor functions, motivation, mood state and emotion, quality of life, and personality styles

19. Glasgow Coma Scale (GCS)(Teasdale and Jennett 1974 in Zollman, 2016) • There is no universally accepted classification system, but the GCS is the most commonly used assessment for TBI • Assess 3 domains: • Eye opening • Motor response • Verbal response

20. Glasgow Outcome Scale (GOS) • One of the earliest scales to record outcomes from moderate or severe TBI • 5 categories from dead to good recovery: GOS-E is the extended version that increases the categories to 8 • Severe disability (2 levels) • Moderate disability (2 levels) • Good recovery (2 levels)

21. Rancho Los Amigos Levels of Cognitive Functioning (LCFS) Hagen, Malkmus & Durham 1972 in Zollman 2016 • Describes cognitive functioning after TBI on the basis of the interaction with the environment • Often used as a descriptive tool between professionals or for family education

22. Mayo Portland Adaptability Inventory (MPAI-4) Malec 2005 in Zollman 2016 • Measurements in 3 subsets • Ability • Sensory, motor, cognitive • Adjustment • Mood, interpersonal interactions • Participation • Social contacts, initiation, money management • Post hospital evaluation of physical, cognitive, emotional, behavioral and social issues • Can be performed by professionals, caretakers or the patient/ client • May identify barriers to community reintegration

23. Comprehensive Neuropsychological Assessment (NPA) Zollman 2016 • To evaluate: • Cognitive deficits • Emotional changes • To determine: • Need for treatment and to develop an individualized treatment plan • Assess efficacy of treatments • Both immediate and long-term improvements • Inform return to work and return to learn timing

24. NPA data quantifies cognitive, emotional & behavioral functioning • Domains assessed • Attention/ concentration • Speed of info processing • Learning/ encoding of new info • Motor speed • Memory and learning • Reading speed and comprehension • Verbal fluency and language use • Intellectual function • Executive functions • Problem solving, planning, organization, decision making, prioritizing Dysexecutive behaviors should also be assessed: Impulsivity, apathy, risk taking, irritability and daily blunders

25. With NPA also assess mood • Emotional distress can exacerbate cognitive functioning deficits • Common symptoms of TBI include depression, anxiety, and emotional dysregulation • Persons may also meet the criteria for PTSD depending on the circumstances of the injury

26. NPA interpretation • Absolute impairments • Low scores on testing data from a testing instrument (typically paper/ pencil or on screen administration) • Relative impairments • Reductions in functioning compared to their prior abilities • Assess functional relevance • Select tests to evaluate what is important to the person: reading comprehension vs calculating skills vs sustained attention, etc.

27. Section 2 10:15-11:45 • Differential diagnosis of Major Depression, Anxiety Disorders, Trauma Disorders, Bipolar Disorder, Autism, ADHD and Substance Use Disorders • Symptom overlap with TBI

28. Confounding factors attributed to symptom persistence in TBI • Personality traits • Five personality traits vulnerable to poor outcomes: • Overachieving, dependent, insecure, grandiose, borderline • Affective disorders • Pain disorders • Medication side effects • Sleep disorders • PTSD

29. Additional factors • Migraine: history of pre-injury migraines is a risk factor for prolonged post-concussion symptoms • Dizziness: presence of dizziness may predict a longer recovery phase • ADHD: student athletes had higher rates of concussion (if ADHD), and athletes with concussions had higher rates of ADHD, AND concussed athletes with ADHD had more severe impairments in concentration and fatigue • Mood disorder: history (or family history) associated with prolonged post concussion symptoms AND associated with development of post injury psychiatric disorder • Genetics: the ApoE-4 allele associated with Alzheimer's may be associated with chronic cognitive symptoms post TBI

30. Symptoms specific to mental health • Anxiety • Changes in expressive/receptive language • Diminished functioning when tired or overstimulated • Fluctuations in mood • Diminished tolerance for social activity • Sleep disturbance • Apathy and/or depression • Verbal/behavioral impulsivity • Changes in attention (divided attention)

31. Behavioral impairment • Deficits often observed in TBI: • Agitation • Restlessness, aggression • Irritability • Anger, aggression • Impulsivity and disinhibition • Sexually intrusive behavior • Not in line with the context, relationship or social conventions • Lack of initiation • Difficulties starting an action despite a desire to do so

32. Behavioral disturbances due to TBI= up to 96% of patients • Acute • Agitation • Disinhibition • Emotional lability • Apathy • Aggression • Chronic • Executive dysfunction • Complex, goal directed behavior • Among the most disabling consequences of TBI • Emotional dysregulation • Impaired appraisal of emotional valence • Attractiveness or aversiveness of a stimulus • Impaired response modulation • Can’t inhibit or amplify their emotional responses • Impaired facial expression matching experience • Anosognosia – failure to recognize impairments and functional consequences

33.  Louis Theroux: A Different Brain 09/09/2017 5:55 Louis Theroux meets with several patients afflicted with traumatic brain injury (TBI). Earl Linton sustained a serious head injury after a fatal crash two years ago and was given a supervision order. Linton and his mother describe his rehabilitation process. A BBC Production http://ezproxy.fhsu.edu:2048/login?url=http://fod.infobase.com/PortalPlaylists.aspx?wID=96215&xtid=128905

34. Screening for emotional distress following TBI • Standard criteria for depression and anxiety should be applied • Do not subtract any criteria due to overlap • Self-report can be impacted • Re-screening may be indicated at intervals during recovery • Impaired attention and memory can affect screening

35. Executive functioning • There is no universal definition/ agreement of what constitutes executive functioning • Deficits include: • Difficulties with problem solving • Problem solving is impacted by emotional states • Attentional process serve as a foundation for executive functions, emotional regulation and learning

36. 3 areas to cover during mental status exam • Pre-injury history • May need family member due to amnesia symptoms, or over/ under reporting • Behavioral observations • Are they fidgeting? Is it actually agitation? • Cognitive functions • Compared to their individual baseline

37. Neurocognitive disorder due to TBIpage 624 DSM-5 • Criteria met for Major or Mild Neurocognitive disorder Pages 602/605 DSM 5 (2013) • Significant or modest cognitive decline • Symptoms impact everyday activities • Not a delirium • Not another mental disorder • Evidence of TBI • Symptoms begin immediately after TBI and persist

38. Emotional and behavioral functioning/ dysfunctioning TBI is known to cause/ impact • Behavioral • Personality change • Impulsivity • Disinhibition • Reduced frustration tolerance • Decreased motivation • Sleep disturbance • Emotional • Mood dysregulation • Depression • Irritability • Anxiety • Apathy

39. Differential diagnosis post TBI:Depression • Begin with considering if the symptoms are BEST described by Adjustment Disorder (with depressed mood) (TBI is the identified stressor) • OR • Adjustment to new physical/ cognitive/ lifestyle deficits and limitations

40. Major Depressive Disorder/ Major Depression p 160 DSM-5 • Delineate normal sadness and grief from a depressive episode • Judgment of the clinician • Rule out substance use including prescriptions • A large number of substances cause depressive symptoms: during intoxication or withdrawal • Rule out medical conditions • Direct physiological effect • Psychological result especially with new diagnoses/ disability • When did the mood episode begin • What is the intensity and duration • When eliminating substances do symptoms resolve (DSM suggests sobriety for at least one month) • When has the client last seen a physician • What physiological conditions are present • What happened first

41. Is there cognitive impairment ? • Cognitive impairment can occur that is severe solely due to the depressive episode • Cognitive impairment can also be an indication that the brain is being directly affected by the TBI • During assessment note if clients appear frustrated with testing or task completion*

42. Is this a mood episode? Or TBI? • Will be accompanied by 4 additional symptoms if mood episode: • Loss of interest or pleasure in activities • Changes in sleep • Changes in appetite • Changes in weight • Changes in psychomotor activity • Presence of symptoms at the same time/ in the same time period • Duration of 2 weeks • Symptoms present every day/ most of the day • Mood may be irritable instead of sad • Rule out premenstrual dysphoric disorder p 171

43. Solely Major Depressive Disorder? • Have they been through a trauma? • Consider ASD/ PTSD • Is there evidence of manic or hypomanic episodes? • Consider Bipolar I or Bipolar II diagnosis • Are hallucinations or delusions present? • Consider schizophrenia, schizoaffective, or delusional disorder • Did the difficulties in concentration and thinking start before the mood episode? • Consider neurocognitive disorder

44. Final diagnostic decisions for Major Depressive Disorder • Single episode Vs • Recurrent • Severity • Mild • Moderate • Severe • With psychotic features • In partial remission • In full remission • unspecified • Specifiers • Anxious distress • Mixed features • Melancholic features • Atypical features • Mood-congruent psychotic features • Mood-incongruent features • Catatonia • Peripartum onset • Seasonal pattern • Panic attacks?

45. Half (50%) of TBI patients will develop depression during the first year post injury • Physical and cognitive symptoms associated with TBI should not be ignored as potential symptoms of depression also • Personal history of mood disorder increases risk • Poor social functioning increases risk • History of alcohol misuse increases the risk

46. Overlapping symptoms from both TBI and Major Depression • Fatigue • Sleep disturbance • Apathy or amotivation • Impaired concentration • Irritability

47. Relative to the general population increased rates of: • Suicidal ideation • Suicide attempts • Completed suicide • Evaluation of family relationships, support systems, coping mechanisms is crucial. • Families experience changes in: • Stress • Roles • Social isolation • Schneider 1998

48. Differential diagnosis post TBI: Bipolar disorder • Only 9% of TBI patients may develop bipolar disorder in the first year post injury; but the lifetime risk is similar to the general population • First task is to identify if the elevated/ expansive/ or irritable mood occurred pre-injury • Is it abnormally elevated/ expansive/ irritable?

49. To meet the diagnostic criteria for manic episode p124 DSM 5 • The elevated/ expansive/ irritable mood will be accompanied by 3-4 of the following: • Inflated self-esteem • Reduced need for sleep • More talkative • Flight of ideas • Distractibility • Increased goal-directed activities • Excessive involvement in risky activities

50. Building blocks for bipolar disorder • Both a manic or hypomanic episode AND a depressive episode • Manic episode lasts 1 week OR hypomanic episode lasts 4 days AND depressive episode lasts 2 weeks • Any personal or family history of these mood episodes? • Do the symptoms ONLY occur in the context of the medical condition? • Is this a response to the life changes caused by the TBI?