The Role of Premorbid Factors and Awareness in Patients With Neurobehavioural Problems.

1. Shona McIntosh: consultant clinical psychologist/ senior clinical tutor. “…it’s not only the kind of injury that matters its the kind of head” Symonds 1937 The Role of Premorbid Factors and Awareness in Patients With Neurobehavioural Problems.

2. Summary • Why don’t interventions work? • Ethics… • The difficult to work with/help patient. • Case example. • Awareness, anosognosia, denial, intention & habit. • What might affect oral care for people with ABI and neurobehavioural problems?

3. Ethical issues in changing behaviours… What is “challenging behaviour”, who decides and why? Plato 427BC – 347BC “there is a single general pure idea of goodness that all good things possess.” Aristotle 384BC – 322BC “there is no completely universal idea of ‘The good’”

4. Similarities & differences with learning disability population. • Complex presentation may include physical, cognitive, emotional and psychosocial impairments. • ABI presentation may vary over time depending on stage of recovery. • Often global cognitive impairments but may be lesion specific impairments too. • Developmental issues in both. • Premorbid factors influence behaviour and interact with cognitive abilities.

5. The Difficult to Help Patient 1 • ABI affecting cognitive functions; memory, executive functioning and metacognitions. • Behaviour control poor. • Understanding short/long term consequences poor. • Loss of empathy. • Impaired ability for new learning. • Procedural learning only. • Few interests or “rewards” applicable.

6. Premorbid and/or habitual behaviours: repeated, rewarding behaviours. • Use of drugs/alcohol • Culture or experience of violence. • Forensic history. • Psychosocial difficulties contributing to low self esteem. • Poor socio-economic background. • Psychiatric history / previous head injury. • Poor self care.

7. What do we mean by awareness? • Complex: different levels, uses feedback, neurological and psychogenic components. Anosognosia = unawareness or imperception of disease. Anosodiaphora indifference, lack of concern. Motivated or defensive denial, lack of insight.

8. Current model of Insight/Awareness in Clinical Psychiatry (Markova 2003)

9. Neurological Model of Disorders of Self Awareness (Prigatano)1999) • Frontal: impaired self awareness as a social being, inappropriate, cannot anticipate. • Occipital: No awareness of cortical blindness. • Temporal: No awareness of memory impairment. Visual auditory problems are distorted. Problems explained on the basis of external causes, may lead to paranoid thinking.

10. Parietal: No awareness of impaired sensorimotor function; hemiplegia, hemi-inattention, reduced balance, reduced capacity to navigate freely and safely in space. Anton Roderscheidt (Right parietal damage) Neurological Model of Disorders of Self Awareness continued...

11. Self Awareness Theory: Carver & Sheier 1981 (image from Aronson et al 1999)

12. Biopsychosocial model of factors relevant to awareness (Clare in press 2003)

13. Denial: implies awareness and understanding of consequences. • Good rehabilitation prospects: Realistic self appraisal confronts impairments. • Poor rehabilitation prospects: Protective mechanism maintaining hope, self constructs and self esteem. Avoids a grief response to loss.

14. Intention and Awareness Ouellete & Wood 1998 • Behaviour is guided by intentions. • Past behaviour (and a person’s beliefs and attitudes) contribute to intentions. • Intentions require understanding of consequences of an act. • Understanding of consequences = awareness. “intentions reflect attitudes towards the behaviour defined as the favourability of the consequences of an act and the importance of these effects…”. • Intentions need to be more powerful than existing well practised behaviours. Azjen (1987) Theory of planned behaviour. Intentions reflect: attitude toward the behaviour, subjective experiences (what’s usual for a person) and perceived behavioural control norms.

15. Anosognosia is organic but psychological coping mechanisms may also present, e.g. denial. Feedback is essential for awareness. Acquired brain injury can damage many areas and mechanisms required for awareness. Without awareness there will be no understanding of needs to change intentions and behaviours.

16. You can take a horse to water…. • The importance of intention….

17. Factors which influence oral health for people with mental health problems/learning disabilities • Type severity and stage of mental illness. • Mood, motivation and self esteem. • Perception of oral health problems. • Habits, lifestyle and ability to sustain self-care and dental attendance. • Attitudes to oral care. • Griffiths,Jones et al 2000 Oral Health for People with Mental Health Problems Guidelines and Recommendations. Report of the BSDH working group.

18. Factors which influence oral care for people with acquired brain injury and neurobehavioural problems • Nature, severity and subsequent cognitive, physical and neurobehavioural impairments. • Premorbid and current perception of oral health problems. • Mood, executive functioning and stage of adjustment to impairments. • Premorbid and current habits, lifestyle, ability and intention to sustain self-care and dental attendance. • Oral side effects of medication on physical and cognitive functions. • Premorbid and current attitudes to oral care.

19. Possible CPD or professional training requirements for working with people with ABI and neurobehavioural problems. • Pharmacological risks and complexity of drug interactions of drugs used. • An understanding of cognitive and communication impairments including anosognosia. • Behavioural management techniques. • Understanding the roles of the multidisciplinary team.

20. Issues…

21. How not to get bitten… • Ask the right questions • Work with person before appointment • double appointment • risk assessment • get info: cognitive, language, physical abilities (comprehension,memory, bite reflex, self control, anxiety) • Keep it short and simple. • Check drug side effects

22. Managing disinhibited or challenging behaviour. • Give information; before, during, after. To patient, to carer/relative. • Allow time; warn patient of intervention, leave alone and go back if necessary. • Desensitise bite response.