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 1 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 2 1 10/3/2019 ABI (Acquired Brain Injury) Somethings definitely show up on a scan… Mild TBI’s oftentimes don’t 3 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 4 2 10/3/2019 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. ** 5 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 6 3 10/3/2019 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 7 ABI (Acquired Brain Injury) 8 4 10/3/2019 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 9 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 10 5 10/3/2019 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 11 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 12 6 10/3/2019 ABI (Acquired Brain Injury) 13 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 14 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! 15 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. 16 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 17 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 18 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 19 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 20 10 10/3/2019 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 21 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 22 11 10/3/2019 ABI (Acquired Brain Injury) High distress 10 High symptoms - - - - 5 Distress & Symptom awareness - - - - No distress No or few symptoms 0 23 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 24 12 10/3/2019 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 25 ABI (Acquired Brain Injury) . Symptoms Management Strategies: . Calming distress: THE BEST TOOL YOU HAVE IS YOU 26 13 10/3/2019 ABI (Acquired Brain Injury) . How people get meaning out of communication: . 7% → words . 38% → voice . 55% → non-verbal 27 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 ?! 28 14 10/3/2019 ABI (Acquired Brain Injury) . Mirror Neurons: . Neurons that specifically work to mirror what