10/3/2019

Psychological & Therapeutic Interventions for Treating Acquired Brain 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

. (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 . 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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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

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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

. , 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 . . 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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mTBI: 101

. Social Work Considerations:

. Social Work provides support to patients in our care: • Transportation, paperwork, questions about processes, education, coordination of services, , 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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mTBI: 101

. Assessment & Intake Questions:

. Ask about symptoms; clients may not say, identify or be aware . Have you ever had a ? . “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 , 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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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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