Assessment and Treatment of TBI for Mental Health Practitioners

1. Assessment and Treatment of TBI for Mental Health Practitioners Jim Messina, Ph.D. Assistant Professor, Troy University, Tampa Bay Site

2. Goal of Workshop Help you better understand • What is TBI • How TBI is assessed • What the issues are facing clients with TBI • Mental Health Tools to be utilized with patients with TBI

3. What is a TBI? • TBI occurs when a sudden trauma such as a blow or jolt causes damage to the brain • There are two types: • Focal: damage to one area of brain • Diffuse: damage in more than one area of brain

4. Categories of TBI • Closed head injury: results from any trauma that causes the brain to be violently shaken inside of the skull such as a “blast” injury • Penetrating injury: when object goes through the skull & enters the brain.

5. Skull fracture Brain contusion DAI (Diffuse axonal injury) over 50% of TBI Primary lesions HEAD INJURY Intracranial hemorrhages Brain edema Increase of ICP (Intracranial pressure) Infections Delayed lesions Long term effects Resultant concerns

6. Results of TBI • Can cause nerve cells in brain to stretch, tear, or pull apart, making it difficult or impossible for cells to send messages from one part of brain to another & to rest of body • Can interfere with how brain works, including thinking, remembering, seeing & controlling movements

7. Causes of TBI • Brain injuries can occur when the head strikes an object such as a windshield or the ground at a fast rate of speed • When a flying or falling object strikes the head • Can occur without a direct blow to head as in cases of severe "whiplash"

8. Most Common Causes of TBI for Military • Bullets, fragments, blasts • Motor vehicle-traffic crashes • Falls • Assaults Blasts are a leading cause of TBI for active duty military personnel in war zones.

10. Resultant injury from explosive devices • Primary Injury–overpressure • Secondary injury–secondary wave-shrapnel • Tertiary injury-person blown into objects • Quaternary-heat and gas

12. Ranges of TBI • Traumatic brain injury can range from mild to very severe depending on many things including: • Force of the trauma • Previous brain injuries • How quickly emergency medical treatment is given

13. TBI Definitions:Concussion/Mild TBI • A confused or disoriented state lasting 24 hours or less • Loss of consciousness for up to 30 minutes • Memory loss lasting less than 24 hours.

14. Moderate TBI: • A confused or disoriented state that lasts more than 24 hours • Loss of consciousness for more than 30 minutes, but less than 24 hours • Memory loss lasting greater than 24 hours but less than seven days

15. Severe TBI • A confused or disoriented state that lasts more than 24 hours • Loss of consciousness for more than 24 hours • Memory loss for seven days or more

16. Penetrating TBI or Open Head Injury • The outer layer of the brain is penetrated by a foreign object

17. DoD Numbers on TBI 2000-2011 Mild: 175,647 76% Moderate: 38,235 16.7% Severe: 2,360 1% Penetrating: 3,378 1.6% Not Classifiable: 9,099 4% Total: 229,106

18. TBI By Military Service2000-2011 Army 57% • Active: 100,373 • Guard: 22,489 • Reserves: 9,415 Navy 13.9% • Active: 29,597 • Reserves: 2,325 Air Force 13.8% • Active: 27,305 • Guard: 2,659 • Reserves: 1,611 Marines 14.5% • Active: 30,473 • Reserves: 2,859

19. Who are Highest Risk for TBI? • Males are about 1.5 times as likely as females to sustain a TBI • Military duty increases risk of sustaining a TBI

20. Signs & symptoms of mild TBI or concussion • Headaches • Dizziness • Excessive fatigue (tiredness) • Concentration problems • Forgetting things (memory problems) • Irritability • Sleep problems • Balance problems • Ringing in the ears • Vision changes

21. Signs & symptoms of moderate and severe TBI • coma • severe headaches • seizures/convulsions • nausea/vomiting • inability or difficulty speaking, understanding &concentrating • confusion, restlessness or agitation • loss of or changes in coordination • memory loss/amnesia • vision changes or loss of vision • paralysis and/or muscle spasticity • chronic pain • sleep disturbances • inability or changes in ability to use senses of taste, touch, sight, sound, smell & taste • loss of bowel and/or bladder control

22. Common Late Symptoms of Concussions • Persistent Headache • Lightheadedness and/or dizziness • Decreased attention and concentration • Poor memory • Easy fatigability • Anxiety or depressed mood • Sleep disturbance

23. How long do Symptoms Last? • Symptoms of mild TBI or concussion often resolve within hours to days & almost always improve over 1-3 months • Patients with moderate to severe TBI often have long-term medical problems requiring specialized attention • Symptoms & effects will vary greatly from one patient to another, depending on severity of TBI & location of injury

24. Long Term Impact of Single Concussion or mTBI • A single traumatic brain injury may prompt long-term neurodegeneration (Johnson, V.E., Stewart, W. & Smith, D.H. (2011). Widespread Tau and Amyloid-Beta Pathology Many Years After a Single Traumatic Brain Injury in Humans. Brain Pathology (22) 142-149) • Tau tangles & amyloid-beta plaques were present years (1-47 years) after just one Traumatic Brain Injury (concussion) so could be precursor to Alzheimer's or other neurodegenerative conditions

25. Do Disabilities Come from TBI? Disabilities from a TBI depend upon • Severity of injury • Location of the injury • Age & general health of the patient

26. What are the Possible Disabilities? • Problems with cognition (thinking, memory, and reasoning) • Sensory processing (sight, hearing, touch, taste, and smell), • Communication (expression and understanding) • Behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness)

27. What Measures are used to assess for TBI • Military Acute Concussion Evaluation (MACE) • Brief Traumatic Brain Injury Screen (BTBIS) • Glasgow Coma Scale

28. Military Acute Concussion Evaluation (MACE) Who should be evaluated with the MACE? • Any one dazed, confused, “saw stars” or lost consciousness even momentarily, as a result of an explosion, blast, fall, motor vehicle crash, or other event • In such event involving abrupt head movement, a direct blow to head, or other head injury

29. MACE Components Standardized Assessment of Concussion (SAC): • Total possible score = 30 • Orientation = 5 • Immediate Memory = 15 • Concentration = 5 • Memory Recall= 5

30. Orientation (1 point per question) • Orientation: Assess patients awareness of the accurate time • WHAT MONTH IS THIS? • WHAT IS THE DATE OR DAY OF THE MONTH? • WHAT DAY OF THE WEEK IS IT? • WHAT YEAR IS IT? • WHAT TIME DO YOU THINK IT IS?

31. Immediate Memory (up to 15 points, 5 points per trial) • 3 Trials with 5 words: candle, paper, sugar, sandwich, wagon • For each trial: I’M GOING TO TEST YOUR MEMORY, I WILL READ YOU A LIST OF WORDS AND WHEN I AM DONE, REPEAT BACK AS MANY WORDS AS YOU CAN REMEMBER, IN ANY ORDER.

32. Concentration (5 points) • I’M GOING TO READ YOU A STRING OF NUMBERS AND WHEN I AM FINISHED, REPEAT THEM BACK TO ME BACKWARDS, THAT IS, IN REVERSE ORDER OF HOW I READ THEM TO YOU. FOR EXAMPLE, IF I SAY 7-1-9, YOU WOULD SAY 9-1-7. 5-2-6 4-1-5 (1 point) 1-7-9-5 4-9-6-8 (1 point) 4-8-5-2-7 6-1-8-4-3 (1 point) 8-3-1-9-6-4 7-2-4-8-5-6 (1 point) • NOW TELL ME THE MONTHS IN REVERSE ORDER, THAT IS, START WITH DECEMBER AND END IN JANUARY (1 point)

33. Delayed Recall (5 points) • DO YOU REMEMBER THAT LIST OF WORDS I READ A FEW MINUTES EARLIER? I WANT YOU TO TELL ME AS MANY WORDS FROM THE LIST AS YOU CAN REMEMBER IN ANY ORDER. • One point for each word remembered for a total of 5 possible points. • Lastly a neurological screening is done:

34. Neurological Screen • Eyes: check pupil size & reactivity. • Verbal: notice speech fluency & word finding • Motor: pronator drift- ask patient to lift arms with palms up, ask patient to then close their eyes, assess for either arm to “drift” down. Assess gait & coordination if possible Document any abnormalities • No points are given for this section

35. Results on MACE • Non-concussed patients, the mean total score was 28 • Scores below 25 may represent clinically relevant neurocognitive impairment and require further evaluation for the possibility of a more serious brain injury.

36. Brief Traumatic Brain Injury Screen (BTBIS) • The Defense and Veterans Brain Injury Center (DVBIC) has developed a simple TBI screening device also called the Brief Traumatic Brain Injury Screen (BTBIS) • The questions quickly help us to assess if the person in front of us is possibly suffering from TBI

37. First Question Did you have any injury(ies) during your deployment from any of the following: • Fragment • Bullet • Vehicular (any type of vehicle, including airplane) • Fall • Blast (Improvised Explosive Device, RPG, Land mine, Grenade) • Other: specify

38. Second Question Did any of the injury received during your deployment result in any of the following? • Being dazed, confused or “seeing stars” • Not remembering the injury • Losing consciousness (knocked out) for less than a minute • Losing consciousness for 1-20 minutes • Losing consciousness for longer than 20 minutes • Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.) • Head injury • None of the above

39. Third Question Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? Headaches Ringing in the ears Dizziness Irritability Memory Problems Sleep problems Balance Problems Other-specify

40. Glasgow Coma Scale Is used to help determine severity of TBI • Responses are scored using three measures which are scored separately & then combined • Eye opening • Best verbal response • Best motor response

41. Glasgow Coma Scale Items Eye Opening (E) • Spontaneous 4 • To speech 3 • To pain 2 • No Response 1 Best Motor Response (M) • To verbal command: obeys 6 • To painful stimulus: localizes pain 5 • Flexion-withdrawal 4 • Flexion-abnormal 3 • Extension 2 • No response 1 Best Verbal Response (V) • Oriented and converses 5 • Disoriented and converses 4 • Inappropriate Words 3 • Incomprehensible sounds 2 • Makes no sounds 1 Scoring: Eye Score (E) + Motor Score (M) + Verbal Score (V) = 3-15

42. Classifications of TBI by GCS • Mild TBI/Concussion GCS Score of 13-15 • Moderate TBI GCS score of 9-12 • Severe TBI GCS score of 8 or less

43. Mental Health Treatments for Clients with TBI Goal is to: • Reduce stress, overcome common co-occurring conditions such as post-traumatic stress disorder, depression, chronic opioid therapy, and substance use. • Handle their states of anxiety, anger or depression by use of Handbooks Tools for Coping on www.coping.us

44. Get yourself two apps to help Your Clients with TBI • mTBI Pocket Guide • Co-Occurring Conditions Toolkit • Both available as free apps from the National Center for Telehealth and Technology

45. Teach Clients with TBI to use Apps on their phones • Breath2Relax • Tactical Breather • Mood Tracker • LifeArmor • PTSD Coach • Available through The National Center for Telehealth and Technology

46. Use the Tools for Coping Series on www.coping.us • Tools for Handling Loss • Tools for Personal Growth • Tools for Relationships • Tools for Communications • Tools for Anger Workout • Tools for Handling Control Issue • Growing Down-Healing the Inner Child • Balanced Lifestyle-Weight Management

47. Treat Co-Morbid PTSD if present • Utilize the Evidenced Based Treatment for PTSD outlined in the VA-DOD Clinical Guidelines of 2010 • Cognitive Processing Therapy • Prolonged Exposure Therapy • EMDR

48. To wrap it up we looked at: • What is TBI • How TBI is assessed • What the issues are facing clients with TBI • Mental Health Tools to be utilized with patients with TBI

49. Thank you for your attention and interest. I hope you are motivated to get out and learn more about TBI and utilize the resources identified today

50. Short Course on TBI for Mental Health Counselors at:http://coping.us/introtoneuroscience/tbicourseforcounselors.html