Fundamentals of Traumatic Brain Injury: Overview and Treatment Considerations for Mental Health Professionals

[00:00:00] Opening --- [00:00:00] Renee Madathil, PhD: One thing that kind of breaks my heart sometimes is when I hear people, say they got referred for, you know, mental health, Mental health services and they were told like we don't work with people with brain injury because you can't do therapy with people with brain injury, or you can't do people, you can't do therapy with people with like cognitive social disorders or speech language disorders. [00:00:19] And that that does break my heart a little bit because it means that we're really not thinking outside the box. And, you know, can, does my therapy look like the manualized treatment of, you know. the general psychiatry clinic? No, it absolutely does not. So, but we can be creative, right? We can absolutely be creative. [00:00:38] And to me, that's the difference between a technician and a clinician [00:00:41] Meghan Beier, PhD (2): Welcome to the find empathy, behavioral medicine webinars series. I'm excited to introduce Dr. Madathil, who will be speaking about the fundamentals of traumatic brain injury? Dr. Madathil currently serves as an outpatient rehabilitation neuropsychologist at University of Rochester medical center. She received her doctorate in clinical psychology from the University of Montana and went on to complete her residency and postdoctoral fellowship in both rehabilitation, psychology and neuropsychology at the University of Washington medical center and Harbor view trauma center. In addition, she completed a one-year research fellowship at the Seattle VA examining the effects of repeated blast related, mild traumatic brain injury and veterans. Dr. Madathil provides psychological services with the goal of increasing function and quality of life for persons living with chronic illness, injury, and or disability. Her current clinical practice focuses on assisting individuals and their support systems and coping with and adapting to the effects of injury or illness during and after hospitalization. She also specializes in brain behavior relationships and the neuropsychological assessment and treatment of neurologic disorders. Thank you to the Rowan center for behavioral medicine for hosting live webinars. If you would like to stay informed about future webinar topics, please sign up for our monthly newsletter at findempathy.com/learn. The recorded audio and video content is eligible for continuing education. But please be aware that we do not offer CEs for the live presentations. To earn continuing education for the recorded presentations professionals are required to listen or watch the complete recorded talk via the find empathy learning platform. For more information and to get your CEs, click the link in the show notes or visit find empathy.com. Now onto the presentation. [00:02:45] Presentation --- [00:02:45] Renee Madathil, PhD: Thanks so much, Dr. Beier. So happy to be here, everyone. Um, Like it was mentioned, feel free to just jump in with questions or if there's something that needs clarification. [00:02:56] Um, this certainly you don't have to wait until the end, although I'm happy to take questions at the end as well. Um, brain injury is certainly an area that I'm pretty passionate about. Um, and. Excuse me, and I, I think as I was doing this talk, you know, I could go down so many different rabbit holes, but I really tried to keep it kind of at the 10, 000 foot level. [00:03:19] We are focusing on traumatic brain injury and I'll get into some of the definitions a little bit about, you know, language when it comes to language and terminology around brain injury in the population. But, um. If there are certain, uh, uh, aspects of brain injury or working with people who have traumatic brain injury that you want a little bit more kind of in depth, um, information on, I'm, I'm happy to take those questions, have those discussions as we go along. All right, so without hesitation here, I'm going to keep going. Um, so today we're going to talk about some fundamentals of traumatic brain injury. Um, just an overview of our objectives. We're going to learn about what actually qualifies as a diagnosis of TBI. That term, those letters, get thrown out, uh, thrown around a lot, and anyone who knows me in this space, I get a little bit nitpicky about jargon and terminology, um, because I really think when it comes to brain injury, Um, we all have different lenses and different approaches to brain injury, but we really should try to kind of speak the same language. [00:04:22] Um, and, uh, I think it also helps better understand the people that we're working with. Um, I want to just do a review of injury characteristics and classifications of severity and how brain injuries, traumatic brain injuries are, um, defined in terms of their level of severity. Um, I also thought we would kind of touch on the stages of recovery because that's often the question people have is, um, you know, when does this get better? [00:04:54] How does brain injury, um, look in, you know, a few months, a few years, et cetera. And then the role of, um, interdisciplinary professionals at the table. Um, and then also, of course, I, because this is a talk. Uh, around centered around people who are mental health professionals. I want to talk about therapy interventions at the various stages of recovery levels of functioning. [00:05:20] Okay, so starting at the top, just getting all on the same page when it comes to terminology, and I want to put a disclaimer that there are absolutely I'm sure some. Fellow brain injury nerds out there who would disagree slightly with some of these, um, terms and definitions as I, as I go on, but for the most part, I'm doing kind of an overview of what the general consensus is. [00:05:44] Um, so when it comes to brain injury, and we use the term brain injury, um. We can't use the words traumatic brain injury or TBI for all kinds of brain injury. So whenever we're talking about a brain injury that occurs outside the womb after birth, we're talking about kind of this umbrella of what's called acquired brain injury. [00:06:08] So any kind of injury to the brain that occurs after birth is considered an acquired brain injury. includes traumatic brain injury, but it also includes things like hypoxic brain injuries, strokes, tumors, infections, et cetera. So that is kind of the large, um, umbrella term for any injury that happens, um, after birth traumatic. [00:06:29] brain injury, like I mentioned, is kind of subsumed under acquired brain injury. And the, uh, the standard, the standardized definition for a traumatic brain injury is a disruption in the normal functioning of the brain that can be caused by a bump, a blow, a jolt to the head, or a penetrating head injury. [00:06:50] You can further classify a traumatic brain injury using some of these subcategories. So is it a focal injury? Um, like that's confined to one area of the brain? Um, so something like we would say a, a contusion, a a or a bruise on the brain in one, like localized area, or is it a diffuse brain injury, um, where you can see damage kind of. [00:07:15] read throughout. Um, is it an open or a closed injury? Meaning closed brain injuries that are happening without the presence of a skull fracture, right? Where the brain is kind of able to expand outside the skull. Um, we're going to talk a little bit about the levels of severity. Um, and then there's also classifications around primary versus secondary, uh, injuries. [00:07:38] So the primary injury is the initial trauma. We get that blow to the head. Secondary injuries can result as a result of that initial insult. So things like the swelling that occurs, um, the loss of oxygen that might occur, um, metabolic changes that might occur. So looking at this definition of traumatic brain injury, um, and like I said, different disciplines, you know, do think differently. [00:08:02] Even though we have standardized definitions in medicine and healthcare, um, we can still each bring our own kind of lens based on our own disciplines. So When we think about tumor resection, for example, this is a question that I like to ask my residents a lot, um, is would you consider a tumor resection a traumatic brain injury? [00:08:26] Feel free to [00:08:27] Meghan Beier, PhD: jump in. [00:08:33] Renee Madathil, PhD: Any opinions? [00:08:38] Oh, Lillian? I think yes. Yes. Okay. And why would you consider it a traumatic brain injury? Um, I think because of the procedures that they have to go through, um, and, uh, sometimes we see significant even decline. Whenever we do the kind of testings, uh, WISC and other like kind of deep testings and stuff like that. [00:09:05] Yeah. So oftentimes after a tumor removal, we are going to see a disruption in normal functioning of the brain, right? We might see difficulties with mental status orientation. We might see difficulties with cognition and technically. When you use the knife, right? Whether it was a planned procedure or something spontaneous, right? [00:09:27] Even though it's a, it's a, um, a planned procedure, it's still kind of controlled trauma, right? And that's kind of how I view it, right? As a. As a neuropsychologist, there are some people, you know, when I ask this question that the room can get a little bit divided at times, um, on whether or not, well, you're kind of controlling it under certain conditions and there's anesthesia and things like that. [00:09:49] But for my purposes as a neuropsychologist, as a rehab psychologist. I do consider this a traumatic brain injury because particularly if there is a disruption, um, in terms of functioning of the brain, which I often see, um, and then, you know, it is a penetrating head wound. So just something to think about. [00:10:07] Before [00:10:08] Meghan Beier, PhD: you move on, um, Courtney, um, or Anne Marie, did you want to say anything? I know you put something in the chat. If not, [00:10:14] Renee Madathil, PhD: that's okay. And you are welcome to disagree. That's absolutely fine. I, I absolutely agree. Sorry, my video is off. That's okay. I'm having a hard time figuring out what's going on. Um, however, I just, I said the same thing pretty much, just depending on the result of the resection. [00:10:35] Yes, it is, um, considered an injury because of the impact on cognition or other functions that are controlled by the brain. Yeah, yeah. And I, I think that, um, you know, again, I, you know, I'm not going to throw any colleagues under the bus, but I do think that, you know, sometimes in, in health care, when we're talking about medical intervention, we don't think about it as traumatic, but you all know, right? [00:11:01] And I use the word trauma pretty loosely, right? That, but. There's the thing that landed you in the hospital, and then there's the interventions and hospitalization itself, right, that by the time people come to see us, maybe on the outpatient side, or even on the inpatient side, um, we're kind of considering it all, you know, as part of the traumatic experience, right? [00:11:21] Thank you for your participation on that. All right. So, alteration in brain functioning, what counts? Again, there are definitions for this, right? So, um, alteration in brain function or disruption to normal brain functioning includes any period of loss or decreased consciousness. It also includes any loss of memory. [00:11:44] Marie for events immediately before. So retrograde amnesia or after the injury, which is post traumatic amnesia. It also includes neurologic deficits, right? So things like muscle weakness, loss of balance, coordination, disruption of vision, changes in speech and language, which we often see in severe. [00:12:04] moderate and severe injuries, um, or sensory loss, um, so any alteration in the mental state at the time of injury, such as confusion, disorientation, slow thinking, or difficulty with concentration. So, I imagine some of you might be thinking, you can experience some of these things outside a traumatic brain injury, right? [00:12:22] Um, especially things like alteration in mental state or confusion, disorientation, right? Um, and so it becomes really important to, again, Yeah, and come back to that initial definition of traumatic brain injury, where there has to be some blow or jolt to the head in, in, you know, conjunction with this alteration and brain functioning. [00:12:44] All right. So other things to think about with brain injury. So we want to think about location, right? So a lot of you, I'm sure, are familiar with kind of the real estate of the brain, right? And we've learned, we all learned about like the different lobes of the brain and that there are different structures that, you know, when they get affected, they affect certain functions, et cetera. [00:13:05] But it's important to keep in mind that that lesion location doesn't give us all the information about a functional deficit. So that's part of why we're important, I like to say, is that, you know, you can take that picture of that, uh, that brain on an MRI or a CT scan, but, you know, one person's lesion in the frontal lobe is may, it may not look the same functionally as another person's lesion, right? [00:13:30] I had a mentor during, uh, when I was at Washington who liked to say that not all brains read the same textbook, right? So it is important to get as much data as possible, and I do think that's where we come in as mental health professionals as well, to kind of evaluate the whole person, um, that it's not enough. [00:13:47] Right now, we do not have, um, tools that can just capture both lesion, you know, severity and location, plus the attached functional deficit, right? We have to have imaging, plus neuropsychological or cognitive testing, plus psychological evaluations, and kind of, you know, we are still in this place of needing multiple data points. [00:14:12] Um, it's also important to remember that injuries cause damage to both structures and systems, and so We've really, in the last decade or so, moved away from, um, kind of this language around, uh, an injury to this particular spot in this structure means X, and that's all it means. But remembering that that structure, right, um, let's say the caudate nucleus of the basal ganglia, right, isn't just doesn't have one job. [00:14:42] It's also part of a system. It's part of a network, right? So when we're thinking about brains and networks and channels of communication that are, you know, incredibly complex, um, an injury to one spot, a focal injury can cause a lot of difficulties or deficits, um, that maybe aren't associated with that one structure. [00:15:03] So, for example, um, a lot of times, you know, people think of the cerebellum and they think of movement disorders, right? But people with cerebellar strokes or brain injuries, um, can often have, um, difficulties with affect and cognition and things that you wouldn't normally associate with the cerebellum. [00:15:22] And that's because of the network that the cerebellum is part of and the projections to various parts of the brain, including the frontal lobe. So I like to just kind of remind Folks that, um, we don't want to get too hyper focused on, you know, one structure and that that function of that one structure. [00:15:39] But think about the brain as a whole network. Um, and this is one of my pet peeve things. This is probably not as relevant, but there was like a movie. Years ago called Lucy that came out because I don't know if anybody remembers it but me, but it drove me absolutely bananas But it was all built around this premise of like humans only use 10 percent of our brains, right? [00:16:02] and was it Scarlett Johansson like who like You know, unlocked the 90 percent and all of a sudden she was like this badass chick who got like super fit and sexy and like super smart and could speak a million languages on the spot and that kind of thing and if only right like if only I could find the magic key but the truth is of course that We use 100 percent of our brains. [00:16:27] And yes, there's a lot that we don't know, perhaps, about our brains, and there continues to be some mystery around it, but we certainly are using 100 percent of our brains at all times. All right. So that was my soapbox. I have many, but that's one of them. Um, so just thinking about kind of, again, like when we're thinking about measurement and how do we classify brain injuries, you know, one of the things you might come across right in reviewing medical records is this Glasgow Coma Scale, right? [00:16:58] And I touch on this because the Glasgow Coma Scale does play into that classification of severity. So when somebody is, um, you know, uh, in the field, right, somebody's injured, paramedics come, they come to the E. D. Um, this is the initial measurement of function. This is the first sort of, um, uh, thermometer, so to speak, of rain functioning and level of severity. [00:17:28] Um, so you, as you can see, it is pretty basic, right? So thinking just about Eye opening, verbal response, motor response, and getting a sum total of that. So theoretically, um, all of us on this call are 15, maybe on our best day. Um, but really it's that quick and dirty kind of in the field look. It's what happens also in the ED when people come to the ED, um, and that gives us our first kind of gauge of, of level of severity for, for brain injury in terms of functioning. [00:18:04] So, the Glasgow Coma Scale, as I mentioned, kind of gets, uh, included, that measurement gets included into TBI severity as a whole. Um, and so, when we think about TBI severity, I like to remind folks about what that means, because there are standardized definitions. When you say mild, moderate, and severe, Severe that is defined in some ways. [00:18:29] Um, so when we are thinking about those definitions, the criteria include that Glasgow Coma Scale score, that post-traumatic amnesia. That loss of consciousness and structural imaging, MRI, CT, et cetera. So when we're looking at TBI severity and talking about a mild TBI, a mild TBI is the same thing as a concussion. [00:18:56] For concussion, imaging is mostly clear. Usually we are not seeing anything on MRI or CT. I have an asterisk there because If there is evidence of of a finding on imaging and everything else in this column is the is this is the same. We call that a complex or complicated concussion. So like I said, in most cases, imaging is normal. [00:19:26] The loss of consciousness is less than 30 minutes. You don't have to lose consciousness at all, but you do have to have an alteration again in in mental status. So you can have, you know, people call it like getting their belt wrong. They're a little bit dazed. They see stars, et cetera, right? Um, that post traumatic amnesia is somewhere it's either not happened, um, or it's less than a day. [00:19:50] And that Glasgow coma scale score is 13 to 15. So pretty high functioning on that globe, the Glasgow coma scale, the jump from mild to moderate and severe in terms of, um, what this looks like from a recovery trajectory. Um, standpoint and severity standpoint, um, is pretty large. And we'll talk a little bit about the recovery and the differences, but once you get into moderate and severe, as you can see, you're starting to get, um, some more, um, imaging findings. [00:20:21] Um, it's rare not to catch anything on MRI for especially a severe tube. Um, you know, it's possible that someone only had a CT, which is not as sensitive, and so we try to push for MRI when we have traumatic brain injury cases. That loss of consciousness is greater than a half an hour. Um, for a moderate, it's 24 hours. [00:20:44] For severe, it's greater than a day. Um, that post traumatic amnesia, again, that's that kind of, um, you know, loss of memory after the event and it's kind of patchy islands of memory. The person can kind of be in and out. It's a little bit like a delirium, um, where there's kind of fluctuating orientation and the memory is not continuous. [00:21:04] It lasts, uh, for moderate injuries about, you know, somewhere between, uh, a day and a week, um, and severe. It's greater than a week. And then that Glasgow coma scale is obviously a lot worse as well. So again, when we're talking about our categories of severity, when it comes to brain injury, it is referring to specific things, right? [00:21:26] So somebody says to you, I had a severe concussion. I hear that a lot. I had a severe concussion. That does not mean they had a severe TBI. It means that they had a mild TBI and perhaps the way they experienced it, the symptoms might be severe. Right? It's important to know in these definitions, there is no criteria for cognition, right? [00:21:48] And so that is, is purposeful, um, in that, you know, when we look at cognitive difficulties, cognitive difficulties can be experienced in all three of these categories. And there's not really a way to, um, say a mild injury. Leads to mild cognitive impairment or cognitive difficulty. Like, we, we want to say that, but those of us who work in this space know that the presentation, um, of a, of symptoms in mild, uh, brain injury or in concussion can look sometimes like, like severe. [00:22:28] Memory difficulties and same with moderate and severe. So it's a much harder thing to classify. Um, and so, you know, it's understandable that we, we want it to correlate with the level of symptom presentation, but it doesn't always. And then those cognitive symptoms can change over time. Whereas if someone has had. [00:22:49] You know, a classification of a severe brain injury, they will always have had a severe brain injury, but their symptoms may not be as severe as time goes on. [00:23:02] I also like to include, um, in terms of that initial, um, that initial measurement, you know, even if you don't work inpatient or in a hospital, I think when it comes to a brain injury, particularly, I think it's just really important to understand kind of, the phases that people have been through by the time they get to you. [00:23:24] Um, the Ranchos Los Amigos scale, um, of cognitive recovery is used very widely in the field of rehab medicine. And really what it does, it's not an outcome measure, but it's a, it's an index to describe awareness. Um, and just monitor recovery in a functional way. So we're really, when we look at these categories, we're talking at those low levels about just general response, right? [00:23:52] And I like to tell people, you know, when I'm working with them, having a brain injury is a lot like getting born again, right? And going through the developmental stage. ages kind of at a faster rate. So initially, we're just looking for things like eye opening, right? And, um, you know, just command following, right? [00:24:10] Just those basic things, sleep wake cycles. And then over time, we see, right, that there, um, this level of agitation that is inherent to brain injury recovery. So, um, on the inpatient side, you're going to get these, um, calls for help from medical units. This patient is really agitated and we in brain injury world say, yay, that's great. [00:24:33] That means they're progressing, right? Um, so as systems are turning on, they might be going into hyper drive a little bit. They're not, uh, you know, your executive functioning isn't there to kind of filter things out. So we kind of progress through these phases of agitation and inappropriateness and confusion and altered mental status. [00:24:51] Um, and then. Hopefully over time we progress, um, towards, um, being more purposeful and aware of our environment and interact more appropriately. Okay. So the magic question, like I mentioned, um, oftentimes is when am I going to get back to normal? I think someone had a question. Yes, absolutely. Hi. This is Janelle. [00:25:18] Hi, Janelle. What is the difference between the level eight and nine? They're named the same? Sure. We're the Rancho Los. Yeah, so purposeful, appropriate. Yeah, so I don't know why this one says purposeful. There might be a hyphen missing, um, but this, um, if you look up, um, Rancho Sos Amigos scale, um, you, you'll find the titles. [00:25:41] There's also, I actually use a, there's a Rancho Sos Amigos scale for families that I use really, really often. Um, It, because the language is, is a lot less jargony. And I actually use it for other professionals as well, because not everyone uses this, but I'm sorry, I don't know why that says purposeful appropriate for both level eight and nine. [00:26:02] Okay. [00:26:06] Yeah. Okay. Okay. Thank you. All right. So like I said, the, when am I going to get back to normal, the recovery trajectory, this tends to be the crystal ball question, right? Um, so I often, um, you know, try to, in conversation with folks, try to go back to that. Let's talk about your level of severity, right? When it comes to the injury itself. [00:26:32] So when it comes to mild injuries or concussions, most often when we're talking about one concussion, right? So I'm not talking about like multiple concussions. We're not going to talk about CTE and football players and, you know, concussion after concussion without getting healed. But one concussion, in most cases, in 90 percent of the cases, you're going to see full recovery back to baseline in days to weeks. [00:26:57] There are some exceptions to that in older adults. and, um, in Children. So the recovery trajectories are a little bit slower. Anything outside, any lingering symptoms outside of three months is considered prolonged or persistent. So, um, we, again, with one concussion, we expect full recovery, and we expect that to happen in three months. [00:27:22] At least at the very least within that first three month window, um, when we see symptoms linger, right, we get into what's called, um, prolonged post concussive syndrome. And I'll talk about that in a little bit. So that's for mild or, uh, TBI or concussion. Moderate to severe, um, we have kind of a little bit of a spiel that we talk about with, um, uh, with patients, is you'll see the fastest gains in the first six months. [00:28:00] So in the first six months, you're going to see changes week to week to week, and then recovery starts to slow as you hit that kind of one year mark, but it'll continue up to 18 months and beyond. It's just that the rate of recovery slows down. There will be a time where recovery kind of plateaus. Um, and so we usually tell people when it comes to milestones, think of it as, you know, Month 1 is a milestone, month 6, month 12, and then things will slow down, but you'll still see some recovery. [00:28:37] The general trend, the good news for most traumatic brain injury is the general trend is up from the day of injury, provided there are no complications such as seizures or other medical complications. Um, that also includes psychological complications, so things like depression, anxiety can slow that recovery trajectory down. [00:28:58] Um. Substance use can certainly slow that recovery trajectory down as well. We typically recommend, after TBI, no alcohol use for at least a year. Um, and no other substance use. Alcohol in particular is considered a depressant, right? It slows us down, slows things down, and that's not what we want in, um, in brain injury recovery. [00:29:22] Is that, is that, um, upward trend of recovery consistent across age, across aged cohorts? Or are there differences, um, like with mild recovery? Is there differences like with children and older adults? So, yeah, so it tends to be the, it tends to be pretty, um, the, this, the rate of recovery tends to be pretty consistent. [00:29:46] The, the caveat to that is actually pediatrics. So it used to be that we thought children Um, because they were so young, right? Um, that they are, they had better prognostic outcomes, um, when it comes to traumatic brain injury, and that is not true. So what we tend to see with, with children is that you've got a traumatic brain injury that's now super imposed onto development, right? [00:30:13] So it's sort of, this spiel does not apply as Um, and it works well to Children because you might have, let's say, um, a five year old with a traumatic brain injury. They might look appropriate and look okay compared to their peers. But where you're going to start to see deficits is, uh, when they when it's time for them to hit their milestones. [00:30:43] So you, so the, the monitoring becomes really important, um, because children as they're trying, as they're approaching those milestones may fall behind those peers, so early intervention is still relevant and important for them, even if at the time they look like they're doing okay. So thank you for asking that there is that caveat for pediatrics. [00:31:06] Okay, thank you. [00:31:10] Okay, so special cases. So we talked a little bit about that post concussive syndrome syndrome, right? So we're talking about and I'm not talking about like three months in one day, right? Um, so we talked about, you know, symptoms should be resolved in a matter of weeks, certainly in a matter of three months or less. [00:31:28] But what happens when those symptoms linger? Those symptoms tend to be things like fatigue, headache, oftentimes patients will complain of dizziness and vertigo. So we have to start thinking about other kinds of, um, Other etiologies at play, other causes, other factors, we have to get back to some differential diagnostics as well, which can be both physiologic and psychologic. [00:31:55] Um, so we think about things like headache. We think, think about things like, um, vertigo and postural vertigo. We think about pain. Um, you know, certainly, uh, there's a lot of literature, um, Around the comparison of post concussive syndrome to like functional neurologic disorders, um, formerly known as conversion disorders in which, um, you know, perhaps the symptoms started out with this, you know, concussion organic cause, but then there was, um, some sort of, you know, Uh, you know, trauma experience in conjunction in conjunction with that, and those trauma symptoms sort of lingered and took over. [00:32:34] We know that anxiety, depression, um, PTSD can also result in feeling foggy and we could and headache and pain and insomnia, that type of thing as well. So we really have to start looking at other contributors to the picture. Um, and we often. discuss with patients kind of that difference between a hardware problem and a software problem. [00:33:01] So the good news in concussion is that there is not a hardware problem, right? There's nothing that is structurally damaged, but that doesn't mean that there's not something glitchy happening, right? And so we can utilize, um, sort of other interventions, right? Uh, psychotherapy, behavioral interventions, certainly P. [00:33:26] T. O. T. Speech. Um, and, uh, and, uh, and medicine to try and get people back on track. The prognosis is is good for most people with P. C. S. provided that they're in treatment, but it does often take, um, interdisciplinary care. So I'm happy to talk more about this population. I feel like this could be a whole separate talk, to be honest. [00:33:50] Um, this is a, a really interesting, um, population when it comes to, to brain injury. Oftentimes, um, you'll even see people who maybe didn't meet criteria for a full traumatic brain injury, or there was a question around whether or not there was maybe a loss of consciousness or maybe a blow to the head. Um, so it's always good to kind of keep in mind as you're going along, you know, that differential diagnosis and, and kind of digging into symptoms, um, and, and designing a solid plan with other providers at the table. [00:34:27] Other special cases that don't quite fit the trajectory spiel, um, lack of oxygen to the brain. So hypoxic ischemic encephalopathy, anoxic brain injuries, um, and diffuse axonal injuries. So with hypoxia, um, you know, obviously our, our brain is highly dependent on oxygen. It uses about 25 percent um, of oxygen that comes into, um, the body. [00:34:52] the brain is highly vascularized, um, and the cells are highly metabolic. So when we have a lack of oxygen to brain areas, um, the cells get overexcited and they actually start to die off, which is different than getting a blow to the head and having some bleeding and having that blood be reabsorbed. So, um, you know, a cell death is, you know, from a prognostic standpoint, is it's. [00:35:17] It's much slower in recovery, um, because we're having to kind of detour around areas of damage. And in cases of severe hypoxia, we can see, certainly see permanent, um, uh, permanent impairment, um, and much more severe impairment than with traumatic brain injury. Um, in diffuse axonal injury, sort of similarly, um, you know, we see this in kind of, um, um, Cases where there's, uh, let's see, high acceleration and then a sudden stop, the brain, you know, is floating in cerebrospinal fluid and kind of bangs around, um, and the gray and white matter start twisting, the brain is Twifting on itself. [00:36:01] The, um, the, the constitution of your brain is a little bit like jello. Um, and so we get this axonal shearing, right? And those axons are, of course, important, um, for communication for one cell to communicate with the other. So, um, the most common presentation with somebody who has a severe diffuse axonal injury is, um, is that they start in coma, right? [00:36:25] Um, and so we can't, um. Necessarily apply the same recovery trajectory when we've actually cut those axons and shared those axons. So it's considered more severe. [00:36:44] So looking at those phases of recovery, right? We've got those ranchos levels, those, those low levels of injury, right? That some of your, uh, brain injury survivors that you're seeing and treating may have started in. And that's where we are talking about things like coma or vegetative states, minimally conscious states where there's just very little interaction. [00:37:05] Um, then we're talking about, um, kind of the what we call sort of, again, if you're kind of comparing it to the developmental trajectory, that sort of toddler stage, right? That post traumatic amnesia, that agitation, inappropriate behavior, poor judgment and insight. Um, and then as we kind of think about treatment, our patients may have, you know, are likely to have gone through some kind of rehabilitative, um, treatment format. [00:37:35] So whether that be the inpatient side, you know, so the inpatient level of acute inpatient rehabilitation, which is hospital based, they're doing intensive therapies, or perhaps they're doing something more subacute at a skilled nursing facility, um, you know, or at Uh, maybe they've discharged home and they're receiving services within their home setting and then outpatient visits occurring in the clinic. [00:38:01] Um, so there's lots of different phases to rehabilitation and the intensity of, of rehabilitation. Um, but likely people with brain injuries that you have, um, been treating have interfaced with rehab at some point. [00:38:16] Okay. When it comes to later stages, um, we can start to differentiate what is permanent deficit, right? What is cognitive deficit versus post traumatic amnesia? We want to think about continued strengthening, return to lifestyle and activities, possibly, um, you know, increase their independence. Um, that's always the goal. [00:38:40] And When we look at, you know, outcomes for people a couple years after moderate to severe traumatic brain injury, most people continue to show decreases in level of disability, increased levels of functioning. Um, a good number of people still require some level of supervision. Um, but, uh, but certainly in terms of hope and keeping hope for recovery, many are able to live in a private residence. [00:39:04] perhaps with some distant supervision or check ins. Um, some certainly benefit from having, um, more supervision from a significant other or care partner. And many people go back to work. Um, there's certainly some who are not able to return to the same job, but maybe require a different career path or some modifications. [00:39:33] I do like to talk a little bit about this word recovery because I, I don't always know if we're all talking about the same thing when it comes to recovery, right? What's your patient talking about when they're saying recovery? What's the family talking about? What's the doctor physician talking about? So you know, there's, there's multiple perspectives and it does obviously tend to be a very emotionally laden question of when do I, when do I. [00:40:01] reach recovery. So I, I tend to approach this, um, conversation with a little bit of, of, um, curiosity in mind because I want to know what does recovery mean to you, right? Um, so certainly, you know, a lot of folks, um, a lot of brain injury survivors are thinking more about my previous self, you know, when do I get back to all the things that I did before? [00:40:26] Um, You know, from a neurosurgeon's perspective, it might be, you know, when you've reached that kind of medical stability from like a surgical intervention standpoint. From a rehab professional, it might be, when are you able to be functionally independent and groom yourself, bathe yourself, um, you know, get back to driving, things like that. [00:40:46] From a, you know, my perspective as a psychologist, um, when are you thinking, when are you feeling, um, Emotionally stable, um, in your mood and, you know, uh, independent in your ability to cope. Um, we also have to think about this as, you know, are you talking about acute recovery and like survival? Are we talking about, um, kind of the long term, right? [00:41:10] Because The other thing we have to think about with brains is that we're all aging, right? And as much as we would love to drink from the fountain of youth and stay young forever, um, you know, we have to think about brain injury as a chronic condition and the evolution of, you know, those symptoms, um, in the context of an aging brain as well. [00:41:30] So certainly things to think about, um, over the lifespan. [00:41:40] So when it comes to that psychological and emotional recovery, we've got to think about some common presentations. So certainly about half of people with traumatic brain injuries are affected by depression and anxiety within the first year of injury. Um, and even more. Perfected years out as well. Um, anger and irritability is often a common complaint. [00:42:02] Um, that can be kind of manifest itself as anxiety or vice versa. Anxiety manifests as irritability or depression. Some research suggests up to two thirds of people within the first year or so experience those difficulties with anger and irritability. Intributing factors to that, those psychological difficulties, response to injury, right, the, just the emotional, um, you know, response to the injury itself and the changes that come with that, um, the neurologic changes, right, to brain structures and symptoms because emotions are, they are coming from here, right? [00:42:38] And so we have to think about kind of those neurologically based, um, factors that, that affect our, um, ability to regulate our emotions. Um, sleep and fatigue is often something that is affected by, um, brain injuries. So we want to be thinking about, um, you know, how our, how our survivors are, are sleeping. [00:43:00] We want to think about things like acquired sleep disorders, um, such as obstructive sleep apnea, et cetera. Uh, we want to be thinking about pain and physical discomfort, spasticity, um, as well as overstimulation, which can also kind of manifest in that sort of anxious or panic, um, kind of experience. [00:43:22] Certainly the other aspect of that psychological recovery, that adaptation or adjustment of, you know, who am I now, right? Um, I often talk about, um, with my patients, kind of pre, pre brain injury was, Version 1. 0, right? And post brain injury was version 2. 0. And so it's really not about going back, right? [00:43:44] Because there really isn't going back. Even if after you're able to achieve all the goals you want to achieve, this experience has inherently changed you, right? When we go through some kind of medical event or trauma, it's inherently changed you. So who are you now? How are we going to build 2. 0? And what, what does that look like going forward? [00:44:04] Beyond the usual measurement of, you know, whatever it is you use for, for depression, anxiety, PHQ, GAD, whatever it may be, there are also some measures available that I find helpful in working with this population. Um, I often, uh, will, uh, reference the Center for Outcome Measurement. And brain injury, which has some scales that you don't need to be a neuropsychologist to use. [00:44:28] So, um, even, you know, self report measures, um, like the apathy evaluation scale or the awareness questionnaire is one that I'll use often, which has a version for the brain injury survivor, as well as a version for either a clinician or, um, a loved one. Um, and kind of that acts as a measure of insight and kind of compares the scores and just kind of gives some good information. [00:44:55] Can you tell me a little bit more about what type of information the awareness questionnaire gives? Sure. Yeah. So the questions tend to be, um, again, oriented towards level of insight. So it can be practical things like, um, so it'll, it'll kind of, uh, it sets the context of, um, compared to before my injury. [00:45:19] You know, compared to now I can even something as basic as manage my money independently. Um, my memory is just as good as it was before my, um, you know, I can regulate my emotions just as well as I did before. So it asks the brain injury survivor to compare themselves pre and post injury. And then those questions are asked of. [00:45:46] someone else, like either a clinician or a loved one that knows the survivor well, and then you compare and contrast how they rate it. Do you compare and contrast during session, or how do you administer? How do I incorporate it? Mm hmm. Yeah, so, um, so sometimes I, it sort of, Is contextually dependent for me. [00:46:11] Um, I think sometimes, you know, I will include it just depending on who I'm seeing and kind of where they're at in their recovery trajectory. I might use it as part of my intake paperwork if they're coming with a loved 1. And kind of talk through because sometimes what happens is the loved one is the person who's pushing, um, the brain injury survivor towards therapy and the person, the survivor feels like everything's fine. [00:46:40] Um, so I might use it as a reflection of perspectives and just kind of talk about it seems like, you know, you both have different perspectives and then pull out a couple of practical. Uh, our questions and see if that yields some practical examples and kind of generate some discussion and I'd like to kind of observe, you know, what examples are brought out and like how each person kind of reacts to that just to sort of see, does the intervention need to be, you know, focused on 1 person. [00:47:10] Does it need to be focused on the spouse? Does it need to be together? Um, am I going to need to resort to, um, other disciplines like OT to do like a med assessment? You know, if there's a question about being able to do your medications independently. So for me, it's really a, it's a tool to start generating some conversation, um, and then observing where am I going to go from there in terms of appropriate intervention. [00:47:35] Thank you. Thank you. Yeah, sure. It sounds like including the family members is often a big part of this. Yeah. Mm hmm. Yes, absolutely. Yeah. Thank you for saying that out loud. Um, yeah. So some considerations, right? So this is one that I can also soapbox about a little bit because I do think, you know, one thing that kind of breaks my heart sometimes is when I hear people, um, say they got referred for, you know, mental health, um, Mental health services and they were told like we don't work with people with brain injury because you can't do therapy with people with brain injury, or you can't do people, you can't do therapy with people with like cognitive social disorders or speech language disorders. [00:48:21] And that that does break my heart a little bit because it means that we're really not thinking outside the box. And, you know, can does my therapy look like the manualized treatment of, you know. the general psychiatry clinic? No, it absolutely does not. So, but we can be creative, right? We can absolutely be creative. [00:48:40] And to me, that's the difference between a technician and a clinician, right? Um, so when it comes to psychotherapy with this population, we absolutely want to get a sense of cognition and language. Um, we absolutely want to take into consideration if this person has short term memory difficulties, we're going to have a notebook, right? [00:49:00] Or a binder that comes to every session. We're going to take notes. We're going to put phone reminders in there. Um, we're going to tailor the therapy to be more behavioral. Maybe, um, you know, just again, kind of depending on the, on the person, you know, when it comes to language, our, um, You know, my folks who are struggling with aphasia or expressive language disorders, um, they need to get that stuff out, right? [00:49:25] It can't be that we say, oh, well, that just, you know, not being able to verbalize just somehow means that you can't benefit from therapy. We've got to find alternative ways of expression, right? I can understand It's a Receptive aphasias or global aphasias where, you know, the language going in isn't getting understood, but the language coming out, we can't be so dependent on verbal skills, right? [00:49:48] We can do better than that. We certainly need to be also thinking about that level of insight, which is why I use tools like the awareness questionnaire of like, where is this person's understanding of their deficits and how do they. Perceive that in terms of their own functioning in the world. Right? [00:50:04] Because one of the things I explained to families is our ability to perceive ourselves comes from here, right? Like, there's nothing. This thing doesn't take control. Um, so when we're talking about insight and trying to do insight oriented therapy, there's, there might be a problem with that, right? Um, so I have to consider level of insight. [00:50:27] I have to consider things like pacing, knowing that people with traumatic brain injuries and especially like severe, moderate to severe injuries get incredibly cognitively fatigued, right? We can't just talk about the physical fatigue, but there's emotional fatigue and Cognitive fatigue. And so we got to think about pacing, you know, am I the fourth appointment they've had in that day? [00:50:47] Like that's not gonna work, right? Um, you know, thinking about getting realistic goals and therapy as well. Like, what is it going to be that we work on? And, you know, how do we know when we've gotten there? How do we track that progress? Um, Involving care partners, such a huge one, right? Um, and a lot of times, you know, helping those care partners understand it's okay. [00:51:14] To, um, not know what to do right and not know how to respond. It's okay to make mistakes. It's okay to not understand something. Um, I particularly love working with, uh, with spouses and parents around like role modeling. Um, I work with a mother and adults, her adult 29 year old son, and I was teaching her about. [00:51:38] You know, just communication and how when you say something, he might not along, but he might not understand what you're saying. Right. So just those kinds of techniques where you can kind of role model in person and then communication with other providers. I'm an interdisciplinary kind of. Provider at heart, so certainly keeping up that channel of communication. [00:52:02] Um, another big point of mine. I always try to emphasize social communication is not adequate cognitive assessment. Excuse me. I think most of, you know, this, but the number of times. You know, somebody will say, Oh, I talked to that person for 10 minutes and it seemed fine, right? Like, no, like social conversation is something that as is automatic, right? [00:52:25] And automatic language is not at all, um, an assessment of, um, someone's cognition, right? I have a lot of, a lot of folks who can carry on it. Good conversation with good social cues and eye contact and head nodding. Um, but can't explain back to you what you just said, right? Um, so enlisting the help of other providers, getting that neuropsych evaluation or speech language pathology cognitive evaluation. [00:52:52] Um, and then, you know, understanding like who in your area, who are your community based partners? Because really, once people are out of the system or out of your office, they are living in the community and this doesn't turn off. Right. So who is it that you have as allies in your community, um, to help support, um, patients and their families. [00:53:18] And then certainly psychotherapy approaches that tend to be most commonly used, certainly CBT behavioral activation, behaviorally based tends to be popular, um, especially in moderate to severe. or TBI. Um, and then mindfulness based approaches because they emphasize paying attention on purpose, right? And a lot of times with people who have attentional difficulties, that's what we're trying to retrain them to do, right? [00:53:43] Is pay attention, slow down on purpose, certainly emphasizing skill training for that emotion regulation. Um, and, and similar, I think across actually the severity trajectory, even with concussion or post concussive syndrome, I use a lot of those. DBT kind of emotion regulation, distress tolerance skills certainly use exposure, um, as well for, um, kind of distress tolerance and, and tolerance of physical symptoms in that population. [00:54:11] Um, but a lot of kind of behaviorally based interventions, um, tend to, to work nicely with this population. And then lastly, I just wanted to throw up some resources that I use pretty often. Um, Brain Injury Association of America is the oldest advocacy, brain injury advocacy group in the nation, and every state has a chapter. [00:54:33] Um, those advocates work tirelessly, um, and act as, as shepherds to kind of guide people within their communities and connect them with resources. They've been very helpful for, in my experience at least. Um, and then certainly just some online resources, um. As well, fact sheets, things like that. So I don't want to, um, go over time. [00:54:54] So I'll end here, but certainly, um, if anybody has questions, I'm happy to, to take them or comments. [00:55:02] Q & A --- [00:55:02] Renee Madathil, PhD: Lillian. Uh, hi. Uh, I have a question, uh, regarding the exposure. If you can briefly give, uh, if you can, it's very interesting. I, uh, never heard that before. Yeah. So, uh, like I said, like post concussive syndrome can be its own talk, right? But I actually do use exposure, um, with this population, um, and so depending on presentation, right, so what tends to happen is I'll get somebody who has become kind of withdrawn and socially isolated in their home because they are so Um, they anticipate such distress from the symptoms they might get. [00:55:46] I might have pain. I might have a headache. I might have vertigo. Um, and so I kind of approach it like I would like a functional neurologic disorders in some ways, and we design a little bit of a hierarchy and we work on some in vivo exposure, um, in the clinic setting. Um, so, you know, whether that looks like. [00:56:09] Going to the lobby and exposing ourselves to some stimu like overstimulation, right? In a controlled environment, doing some relaxation in the moment of that lobby, right? Um, going outside. A lot of my, uh, folks in New York have, um, difficulty with the fall because the leaves, the colors on the ground. Um, so things like that, you know, going outside, taking a little bit of a walk, working through the distress versus escaping it, right? [00:56:35] Wow. Thank you so much. Yeah, sure. Other questions, comments. [00:56:47] I'll just say, um, so although I don't have any patients with. Uh, TBI currently, this talk really kind of broadened my perspective on what to look for, like post surgery. Yeah. And what types of interventions are available post surgery. So I have a, um, a couple of patients and one in particular who, um, has a stage four, um, what, liver cancer and just, just underwent a surgery. [00:57:18] And the, the, the idea of, of, Recovery and getting back to normal that was, um, that was described to her by her. Her surgeon. Her surgeon, right? Right. Yes. He was going at it from a very medical perspective. Yes. Yes. You'll be fine in a month. That's what they all say. You'll be fine in a month. Yes. Yes. And so he gave her this four to six weeks and immediately That's something that we started to kind of dismantle and kind of rework for her because from a medical perspective, she was back to normal, normal. [00:57:55] Her, her wounds were heal, healing externally. Right. And, and so We really had to kind of rework that. Absolutely. Absolutely. And again, it's not about throwing our colleagues under the bus, but just understanding we all define that differently. When are you going to be better? Yeah. Cause the surgeon isn't wrong. [00:58:17] Like surgically, she probably was fine. Right. And four to six. weeks for everything else. Right. Absolutely. From a PT perspective, relearning, um, how to walk, uh, retraining her muscles and body to sit upright. Um, she was trying to get back on the treadmill at, at the six week mark. And it's like, let's, let's slow ourselves down. [00:58:39] Let's pace ourselves. And let's talk about what is, um, What is reasonable for, for, for full body, full system recovery. And so, yes, yes, exactly. Exactly. I like that because it's, it's a bit of a broadening moment for me. I'm glad. Yeah. Thanks for sharing that. Norena. Yeah, I mean, I just wanted to make a comment. [00:59:08] Let's not forget that a lot of these patients with. That don't have a direct impact to the brain. I know Renee saw my traumatic brain injury and gave an example of like how to define that earlier. A lot of these patients with liver, uh, cancers, cancers, kidney cancers have quite a bit of like toxicity issues going on that has significant impact on the brain as well. [00:59:30] So I think sometimes those things are significantly overlooked. So even though we may not be seeing. You know, direct, you know, cognitive impact as a result of a, either tumor resection or sort of a head injury itself, uh, there are significant medical issues that can cause, uh, Yeah, absolutely. Especially, like, the, the biggest one for me is cardiac conditions, too. [00:59:54] Like, we get so focused, I think, on, like, Hearts and oh my gosh, you had a heart attack. And in my head, I'm like, oh, crap, you had a heart attack. That means there was a lack of like blood supply and oxygen, right? Um, so yeah, it's all connected, right? It's all connected. [01:00:07] And I did find purposeful appropriate is the right, it's right, but they all have different caveats for like standby assistance, standby assistance on request, or modified independent. So, yes, it's appropriate, but definitely shouldn't be. Yeah, sorry, that was going to bother me, Janelle. I'm sorry. No, no, I'm glad you asked. [01:00:33] All right. Thanks everybody so much for your questions and participation. I really appreciate it. for coming. Thank you. All right. Take care. [01:00:42] [01:00:42] Conclusion --- [01:00:42] Meghan Beier, PhD: if you would like continuing education credits for listening to this episode, go to findempathy. com backslash learn. [01:00:54] Our goal is to help people living with challenging medical conditions find the mental health providers who understand their diagnosis. Our education and this podcast is focused on increasing the number of mental health providers who can help. [01:01:08] If you are a psychologist or a mental health provider that specializes in health populations, please consider signing up on the free Find Empathy directory. Go to find empathy.com and select get listed. We would love to connect with you on social media. Look for us on Facebook, LinkedIn, Twitter, and Instagram. [01:01:28] If you have suggestions for topics you would like covered by this podcast, let us know. Our email is info at findempathy. com. Finally, please know that the opinions expressed by the experts today are their own. We are not financially supported by any of the businesses or resources described in today's podcast. [01:01:47] Also, remember that the content provided today is for educational purposes only. Please seek the guidance of your doctor or mental health provider for any questions you might have regarding your own health or medical condition. Thank you so much for listening, and we look forward to you joining us in the next episode.