10/3/2019
Psychological & Therapeutic Interventions for Treating Acquired Brain Injury in an Outpatient Setting
CHRIS GILYARD, LMFT, IBH STAFF PSYCHOTHERAPIST CENTRACARE HEALTH, PHYSIATRY & REHAB
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ABI (Acquired Brain Injury)
. Definitions:
. Acquired Brain Injury (types acquired post-birth): mTBI, anoxia, stoke, brain bleed, tumor resection, “chemo brain”, others
. Traumatic Brain Injury (External): Severe, Moderate, MILD. . Referring to the initial injury itself – not the symptoms or outcome that an individual with TBI may experience. . “mild”- misleading, not referring to the degree or longevity of symptoms . mTBI – often called concussion . mTBI: Cognitive deficits, not intellectual or developmental
. Metaphors: snow globe, old cell phone, worst hangover ever
. Mild TBI’s often don’t show up on scans
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1 10/3/2019
ABI (Acquired Brain Injury)
Somethings definitely show up on a scan…
Mild TBI’s oftentimes don’t
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ABI (Acquired Brain Injury)
. ABI is a hidden disability . Often misunderstood, ignored or missed due to the invisibility of ABI
. ABI & Mental Illness: Differences . Mental illness has changes in the brain resulting from . Genetic, environmental and social factors . ABI is injury or damage that is done to the brain . MH issues may co-occur with a brain injury as a result of:
. Damage to visual, auditory, vagal, cognitive, nervous or other systems
. Psychological & emotional response to the brain trauma & related life changes
. ABI is different from Mental illness . The challenge is knowing what symptoms belong to which diagnosis and how to treat them
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ABI (Acquired Brain Injury)
. Challenges:
. Some MH & BI issues look and appear the same, but are strongly BI based: ANXIETY
. Some MH & BI issues look and appear the same, but tend to be an emotional response to the circumstances: DEPRESSION
. Some can be both, like PTSD: sympathetic nervous system is activated due to trauma, as well as visual processing damage
. BI issues can exacerbate pre-morbid MH issues, & Pre-morbid MH issues can complicate BI Issues
. ABI is often mistaken for mental illness and people may be treated with drugs that don’t help recovery. **
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ABI (Acquired Brain Injury)
. Symptom Overlap:
ABI & PTSD ABI & Depression
. Feelings of anxiety . Depressed mood . Disordered sleep (insomnia/hypersomnia) . Sleep disturbance . Difficulty concentrating . Diminished interest or participation . Irritability or angry outbursts . Trouble recalling important details of traumatic event . Fatigue . Diminished interest or participation in significant . Diminished ability to think or concentrate activities . Psychomotor retardation that may present similar to . Feeling of detachment from others apathy
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ABI (Acquired Brain Injury)
. Be Aware:
. MI and ABI are not the same
. Symptoms can overlap, intertwine & complicate one another
. Need to treat both for optimal recovery
. Be aware of misdiagnosis
. Vison and sight are not the same
. Suicide Risk…. Up to seven times higher risk (Teasdale & Engberg, 2001)
. An ABI is a hidden disability
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ABI (Acquired Brain Injury)
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ABI (Acquired Brain Injury)
. Common Symptoms:
. Headache . Severe brain fatigue
. Irritation/Agitation . Multi-tasking issues **
. Light sensitivity . Mood dysregulation
. Noise sensitivity . Word finding problems
. Dizziness & balance problems . Reading difficulties
. Memory, focus, concentration issues ** . Impulse control **
. Sleep disruption/Insomnia . Feeling “not like myself”
. Visual processing issues (not sight) . High stimulation intolerance
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ABI (Acquired Brain Injury)
. Emotional Changes . Consequences of brain trauma and life changes
. Common emotional reactions to an ABI include: . Depression . Anxiety and fear . Anger . Frustration . Mood swings . Grief and loss . Feeling alone . Guilt and SHAME . Self Criticism
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ABI (Acquired Brain Injury)
. Behavioral Changes . Consequences of brain trauma and life changes
. Common behavior changes include: . Apathy or reduced motivation . Problems with decision making and initiation . Emotionally labile . Short tempered and agitated . Remembering . Difficulties engaging with others . Restlessness/agitation . Isolation and avoidance . Rumination . Suicidal Ideation
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ABI (Acquired Brain Injury)
. Relationships
. Possible sources of stress for family members:
. Lack of understanding & education about ABI . Financial issues . Increased conflict . Potential new chores of partner and children . Social isolation . “Caregiver” role . GRIEF OR LOSS of “the person they knew before” the ABI . PTSD
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ABI (Acquired Brain Injury)
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ABI (Acquired Brain Injury)
. Changes in sexual functioning and desire
. Sexual functioning issues can result from physical, medical, cognitive or emotional factors . Impotence: brain based, medicine based, emotionally based . Pain during sexual interaction . Fatigue . Relational tension . Caregiver fatigue . Increases symptoms such as headaches, ear ringing, pain . Decrease in sexual desire and response can result from an ABI
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7 10/3/2019
mTBI: 101
. Social Work Considerations:
. Social Work provides support to patients in our care: • Transportation, paperwork, questions about processes, education, coordination of services, problem solving, financial resources, navigating benefits (work or public) . In absence of social work two good resources are: DISABILITY HUB and United Way 211 . If MA insurance, consider ARMHS worker (Nystrom has taken an interest in BI individuals) . If certified disabled and under 65 – consider county Waivers
. County financial workers are NOT social workers!
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ABI (Acquired Brain Injury)
. Insurance:
. Workman’s Compensation:
. Often a great source of distress for patients
. Invalidating, confusing, anxiety-producing
. A QRC (Qualified Rehab Counselor) is a legal right; encourage your client to have one
. Work with the QRC to ensure coverage
. IME’s (Independent Medical Evaluator): in depth medical assessment to evaluate TBI status; hired by insurance company. Very stressful for the client.
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8 10/3/2019
mTBI: 101
. Assessment & Intake Questions:
. Ask about symptoms; clients may not say, identify or be aware . Have you ever had a head injury? . “Seen stars”, “had your bell rung”, felt dazed after a head bang? . Have you ever lost consciousness after hitting your head . Even momentarily or . Felt dizzy &/or nauseated, had headaches, been irritable, had memory problems . Have you ever had a stroke, surgery on your head/brain, or surgery where you were deprived of air or couldn’t breath . Have you ever been diagnosed with a brain injury, concussion, whiplash or neck injury
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ABI (Acquired Brain Injury)
. Diagnosis:
. Mood disorder due to physiological condition (TBI/PCS) with anxiety/depression . Mild cognitive disorder . Adjustment Disorder
. PTSD . Anxiety/depression . Pre-morbid diagnosis
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9 10/3/2019
ABI (Acquired Brain Injury)
. Diagnosis:
. You may see from others:
. Major Depressive disorder
. Generalized Anxiety disorder
. Bipolar
. PTSD
. Borderline
. Personality Change secondary to TBI
. Intermittent Explosive Disorder
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ABI (Acquired Brain Injury)
. Assessment Tools:
. PHQ9 . GAD7 . CSSRS (Columbia Suicide Severity Rating Scale) . PCL (Post-traumatic Checklist for PTSD) . Rivermead Post Concussive Symptoms Questionnaire
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Distress & Fatigue Management
. The more distress &/or fatigue the more symptoms
. Increased stimulation = increased symptoms
. Stores, concerts, places of faith, schools, restaurants, workplace
. Need for constant reminders and in-session practice
. Low & slow: Low gear and slow down
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ABI (Acquired Brain Injury)
. Things That Worsen Symptoms:
. Activity level that day or days before . STRESS . Lack of sleep . Emotional events (good or bad) . “Pushing through” . Visual activities (ex. driving, screens, reading, writing) . Multi tasking . Time of day . Brain fatigue
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ABI (Acquired Brain Injury)
High distress 10 High symptoms - - - - 5 Distress & Symptom awareness - - - - No distress No or few symptoms 0
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ABI (Acquired Brain Injury)
. Interventions & Considerations:
. Lights: may need to be low or off . Sunglasses . Stairs: some patients cannot maneuver stairs . Oils: check regarding smell sensitivities . Sounds: sound machines, clocks, etc, can be overstimulating . Time of day: Be aware of issues due to brain fatigue, sleep problems, etc . Intake: may need assistance due to visual processing issues . Color paper helps with visual stress (blue/green/purple) . Assessments: may need to read the questions
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Energy Management . Low & slow . Ear plugs, ear buds, visors, baseball hats . Every morning: . No screen time initially . 3 gratitudes . 3 prayers or hopes . 1-3 to-do’s for the day
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ABI (Acquired Brain Injury)
. Symptoms Management Strategies:
. Calming distress:
THE BEST TOOL YOU HAVE IS YOU
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ABI (Acquired Brain Injury)
. How people get meaning out of communication:
. 7% → words
. 38% → voice
. 55% → non-verbal
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ABI (Acquired Brain Injury)
. Interventions to calm distress
. Voice: Slow, calm, relaxed, soft tone . Facial gestures: softened features, non-stressed . Eye contact . Tempo of body: relaxed, slow, calm . Touch: appropriate, with permission . Language: basic, easy, non-complicated
DO YOU CALM STRESS OR CREATE IT ?!
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ABI (Acquired Brain Injury)
. Mirror Neurons:
. Neurons that specifically work to mirror what it sees . Yawning, body positioning . Encourage breath work . Relationally: helps us to understand and connect
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ABI (Acquired Brain Injury)
. Mirror Neurons:
. What does it say about how we can influence pts? . That we have the ability to help them begin to de-stress by just behaving in a certain way . If we can practice calmness, we can influence calmness
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Calming Techniques
. Relaxation: practice in session, colored breath
. Breathing: 4 square, Breathing App , Phone app
. Mindfulness: chocolate
. Talking slow
. Weighted blanket/vest
. Story Telling
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Normalization & education . Validation . Invisible Injury . Affirmation . “Your brain vs your mind” . “You still remember who you are and how you were” . Constant comparing . They feel crazy, people don’t believe them, they look normal . They feel alone, misunderstood, and scared . “You have such a smart brain”
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Psychoeducation : Social skills
. 5¢ or 5$ story
. Rehearsed responses (I.e. Are you back to work yet?)
. How to be proactive in self care: assertiveness
. How family can help identify symptoms & take brain breaks
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Activity Management . Plan for success:
. Prepare for activities
. Utilize energy management during activities
. Triggers vs Cues: help client to understand and use
. Prepare for post-activity recovery
. Activity strategies:
. Safe person: code words, touch, eye contact (regulator)
. Bathroom and car breaks
. Sitting facing away from crowd, on outer perimeter
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ABI (Acquired Brain Injury)
. Therapeutic Strategies:
. Grief and loss . Family/Couples therapy . Group Therapy/support
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ABI (Acquired Brain Injury)
- Toyota commercial
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ABI (Acquired Brain Injury) RESOURCES
. ABI.com . Amy's TBI Tribe Public Group | Facebook (Amy Zellmar) . Disability hub 1-866-333-2466 ; https://disabilityhubmn.org/ . Finding the Road Back to Normal by Amy Zellmar . Ghost In My Brain by Clark Elliott . Guidebook for Psychologists: Working with Clients w/TBI. Psych_TBI_Manual_FINAL129.pdf . Minnesota Brain Alliance (612) 378-2742 www.braininjurymn.org . Project BrainSafe: www.brainsafemn.com . TBI Guide. Com
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References
. Teasdale., T. & Engberg., A. (2001). Suicide after traumatic brain injury: a population study, 71: 436-440. doi: 10.1136/jnnp.71.4.431
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ABI (Acquired Brain Injury)
Thank you!
Chris Gilyard, LMFT Staff Psychotherapist, Integrated Behavioral Health [email protected]
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