Tbi essentials wsu

Traumatic Brain Injury (TBI) Essentials: workshop at Worcester State University

1. Traumatic Brain Injury (TBI) Essentials

2. Today’s Schedule 8-8:30 Registration What is Traumatic Brain Injury & Screening for TBI-related deficits 10-10:15 Break How TBI Impacts Executive Functioning & Populations at Greater Risk for Brain Injury 12-1 Lunch Locating Community Supports and Services for Head Injured Clients 2:15-2:30 Break Counseling Brain Injury Survivors and Their Families 3:45-4:00 Question and Answer

3. Overview Epidemiology Mechanisms of Injury Deficits Associated with TBI Identification Treatment Special cases

4. # tbiwsu

5. Epidemiology

6. National prevalence rates of various disabilities 400,000 with Spinal Cord Injuries 500,000 with Cerebral Palsy 2.3 million with Epilepsy 3.0 million with Stroke-related Disabilities 4.0 million with Alzheimer’s Disease 5.3 million with Traumatic Brain Injury 5.4 million with persistent Mental Illness 7.2 million with Mental Retardation

7. In the United States, at least 1 million sustain a TBI each year Incidence

8. Causes of TBI

9. Who is at Highest Risk for TBI? Males 1.5 times as likely as females to sustain a TBI Two age groups most at risk are 0-4 year olds and 15-19 year olds, and The elderly, frequently from falls African Americans have the highest death rate from TBI

10. Incidence of TBI x Age and Gender

11. Mechanisms of injury

12. Types of Brain Injuries Acquired Brain Injuries Traumatic Brain Injuries Other Brain Injuries: Strokes Hydrocephalus Tumors Demyelinating disorders Infections Toxic encephalopathy Anoxic/hypoxic injury Penetrating Closed Head Injury

13. Causes of TBI

14. Mechanisms of Injury Primary mechanisms of injury Contusions Small vessel disruption Diffuse axonal injury

15. Coup-Contra Coup

16. Hematoma

17. Mechanisms of Injury Secondary mechanisms of injury Edema Evolving hematoma Hydrocephalus

18. Normal ventricles

19. Managing intracranial pressure

20. Introduction to Neuroanatomy

21. Introduction to Neuroanatomy What’s different about the brain?

22. Neuron

23. Synapse

24. Peripheral and Central Nervous System

25. Introduction to Neuroanatomy Front – back x Top – bottom Left - right

26. what IS … 4/27/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 33

27. … what COULD BE 4/27/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 34

28. Introduction to Neuroanatomy Front – back Top – bottom Left – right x

29. ?

30. Frontal Lobe

31. Temporal Lobe

32. Parietal Lobe

33. Occipital Lobe

34. Limbic System

35. Cerebellum

36. The Ventricles

37. Normal ventricles

38. Deficits associated with tbi

39. Medical Physical stamina Pain Headaches Seizures (within 2 years of injury) Bowel/bladder continence

40. Motor Functioning Paresis or spasticity Gross motor strength Fine-motor speed and dexterity Motor coordination and planning Spatial-based movement Oculomotor Balance

41. Sensory-Perceptual Abilities Tactile, visual, and auditory modalities Sometimes, olfaction

42. Attention Alertness and arousal. Selective or focused attention. Modality specific Sustained attention (vigilance). Span of attention. Hemi-neglect (ignoring one side of the body).

43. Receptive Language Word and phrase comprehension Conflictual and comparative statements Vocal tone and prosody Speed of processing Pragmatics (social meaning in language)

44. Expressive Language Fluency Naming Word and phrase repetition Organization of output (e.g., spontaneous versus confrontational speech) Vocal tone and prosody Pragmatics (social use of language)

45. Memory and Learning

46. The Executive Functions X

47. Places San Jose Aberdeen Paris Hattiesburg

48. Places San Jose Aberdeen Paris Hattiesburg

49. Boys’ Names Dante Pete Jordan Elvis

50. Boys’ Names Dante Pete Jordan Elvis

51. “a healthy well-adjusted 26 year old”

52. The Executive Functions Inhibition Shift Regulation Initiation Working memory Planning / organizing Self-monitoring

53. The Executive Functions Bridging the now with the past Bridging the now with the future

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55. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 69 1-step errands Chores with cues Basic inhibition Age-appropriate Expectations Preschool

56. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 70 2-3 step directions Bring papers home 20-30 minute assignments Simple spending decisions Follow rules/inhibit/no grabbing Age-appropriate Expectations Kindergarten - 2 nd Grade

57. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 71 Simple shopping list Keep track of personal items Longer homework assignments Simple project planning Keep track of variable daily schedule Save money Inhibit and regulate even without teacher present Manners Simple delayed gratification (phone) Age-appropriate Expectations 3 rd -5 th Grade

58. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 72 Complex chores Babysitting Organizing system Complex schedule Longer term projects Time management Self soothe Manage conflict Age-appropriate Expectations 6 th – 8 th Grade

59. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 73 Independent with assignments Make adjustments based on feedback Longer term goal setting Manage leisure time Inhibit reckless behavior Easily walk away from provocation Say “no” to fun activity if other plans already made Take others’ perspective Age-appropriate Expectations Teenage-mid 20’s

60. School and Vocational Outcomes Problems initiating and completing work. Slowed work pace. Increased impulsivity. Trouble navigating physical surroundings. Decreased productivity.

61. School and Vocational Outcomes Confusion and increased stress. Resistance to change. Trouble with generalization of new learning. Distractible. May resent special assistance.

62. Social-Behavioral Outcomes Loss of friends and social circles. Decreased affective regulation. Increased impulsivity. Increased agitation.

63. Social-Behavioral Outcomes Poor perspective taking. Comparison to preinjury level of functioning. Poor understanding of TBI and recovery. Premature return to school/work. Unrealistic predictions.

64. Emotional Dependent behaviors / amotivation Irritability / emotional lability / anger Depression Disinhibition Denial/lack of insight At risk for substance abuse

65. Who Gets Better? Predictors of Positive Outcome x

66. Preinjury Predictors of Positive Outcome History of good academic achievement Good social relationships No history of learning, attention, or behavioral difficulties No history of substance abuse No significant family problems

67. Preinjury Predictors of Positive Outcome Strong-willed and determined Under 21 years of age No previous neurological history (e.g., a prior TBI) Good self regulation skills

68. Preinjury Predictors of Positive Outcome No criminal history Good relationships with family members Warm and supportive family No psychopathology

69. Behavioral Predictors of Positive Outcome Motivated and persistent Optimistic Has the capacity to recognize errors and self-correct Aware of behavioral deficits Ambulatory

70. Behavioral Predictors of Positive Outcome Relatively independent with activities of daily living Initiates tasks with no/minimal assistance Preserved perspective-taking capacity Relatively preserved neurocognitive abilities

71. Environmental Predictors of Positive Outcome Individual treatment plans Continuity and coordination of treatment throughout the recovery process Structure, consistency, and repetition in daily activities Good , stable resources (e.g., financial, family, friends, community, etc.)

72. Environmental Predictors of Positive Outcome Presence of “key” person in the family Family involved in the treatment plan Family realistic about individual’s status Presence of “key” person on team

73. Neurological Predictors of Positive Outcome Coma < 6 hours PTA < 24 hours GCS > 7 Normal EEG and MRI Normal intracranial pressure Normal ventricle size No intracranial hematoma

74. Indices of Severity of TBI Intracranial Pressure Retrograde Amnesia Anterograde Amnesia/Post-traumatic Amnesia Duration of Loss of Consciousness (LOC) Glasgow Coma Scale score Rancho Los Amigos Scale (1 to 10)

75. Indices of Severity of TBI

76. Mild injury 0-30 minute loss of consciousness Moderate injury 3 minutes to 24 hours LOC Severe injury > 24 hours LOC

77. Identification of tbi

78. Identification of TBI Obtain the medical records if possible Interview family/friends for collaboration Arrange for a neuropsychological evaluation Refer to a neurologist or psychiatrist for medication and behavioral consultation Consider referral to a brain injury rehabilitation program

79. Inquiry Regarding TBI Any history of concussion or head injury? Ever been knocked out? Note: this question may lead to discussion of Alcohol abuse Domestic violence Postconcussive symptoms? Return to work/school?

80. When did you wake up from the head injury? Do you remember being transported to the hospital? Do you remember being in the trauma unit? Being transferred to the rehab unit? PTA : period of time after the CHI for which the patient has no memory “Getting at” PTA in the clinical interview

81. Comprehensive Mental Status Examination Behavior Emotion Cognition

82. ABC STAMPLICKER

83. ABC STAMPLICKER appearance

84. ABC STAMPLICKER behavior

85. ABC STAMPLICKER cooperation

86. ABC STAMPLICKER speech

87. ABC STAMPLICKER thought Form Content

88. ABC STAMPLICKER affect

89. ABC STAMPLICKER mood

90. ABC STAMPLICKER perception

91. TO ORIENT To understand one’s relationship to the environment

92. ABC STAMPLICKER level of arousal

93. ABC STAMPLICKER insight

94. Judgment The ability to weigh and compare the relative values of different aspects of an issue.

95. ABC STAMPLICKER cognition

96. ABC STAMPLICKER knowledge

97. ABC STAMPLICKER endings

98. Risk Assessment Protocol Identify predisposing factors Examine potentiating factors Conduct a specific suicide inquiry Ideation? Plan? Intent? Determine level of intervention Documentation

99. ABC STAMPLICKER reliability

100. Diagnostic Issues Cognitive Disorder NOS Dementia Due to Head Trauma

101. Diagnostic Issues Distinguishing psychiatric from TBI-related impairment Insight/denial/ anosagnosia Explosive behavior disorders Pseudodementia “Acquired ADHD”?

102. TBI treatment

103. Considerations in TBI Recovery What constitutes “recovery” Will he/she be 100%? It takes a year? “Plateaus” The normal neurological evaluation Independence and modified independence No magic bullets Meds Rehab technologies

104. Medical Management: Acute TBI Airway Close monitoring for edema Seizure control Close monitoring for increased intracranial pressure

105. Normal ventricles

106. Increased intracranial pressure

107. ICP monitor

108. Pharmacological Treatments Amantadine x Anti-seizure agents Antipsychotics Antidepressants Stimulants

109. Pharmacological Treatments Amantadine x Anti-seizure agents Antipsychotics Antidepressants Stimulants

110. Early Rehabilitation Efforts : Formal family meetings Use of an interdisciplinary team approach in overall treatment Discharge planning by team members, family, and community services

111. Referrals

112. Referrals Brain Injury and Statewide Specialized Community Services

113. Referrals Assistive technologies Independent living skills training Speech therapy Occupational therapy Physical therapy Neurology Psychiatry Physiatry Substance abuse treatment

114. Referrals Case management Home modifications Transportation Cognitive rehabilitation Counseling Financial management Respite care Neuropsychological evaluation

115. Goals of Neuropsychological Assessment Determine spared versus impaired abilities. Understanding impact of injury and/or a neurodevelopmental problem (e.g., LD). Assist in localization of function and dysfunction.

116. Goals of Neuropsychological Assessment Assist in determining whether to remediate or to compensate. Generate suggestions for remediation and compensation. Suggestions for monitoring and tracking of progress in school setting.

117. When to Consider a Referral to Neuropsychology Documented brain injury/insult Suspected brain injury or insult Neurodevelopmental disorder Unusual psychological profile Positive neurological findings Severe behavior problems Treatment needs

118. Cognitive Rehabilitation 4 ways our patients “get better” Brain healing Brain re-organization / plasticity Compensatory skills Restructuring the environment

119. Cognitive Rehabilitation: Specific Approaches Psychometric approach (healing/plasticity) Stimulus-based approach (restructuring the environment) Developmental approach (plasticity and compensatory) Behavioral engineering approach (compensatory skills)

120. Cognitive Rehabilitation Research challenges Cognitive orthotics and prosthetics

121. Yoga / read Staff meeting Planning session Phone calls billing

122. Vh : jeff w/ puritan oil Vc : kate re: brimfield TC umass dermatology. Spoke w/ cindy 508 8564000

123. Learn French Stop smoking Be a better spouse

124. Vh : jeff w/ puritan oil Vc : kate re: brimfield TC umass dermatology. Spoke w/ cindy 508 8564000

125. Learn French Stop smoking Be a better spouse Call umass dermatolody - cindy 508 8564000

126. Yoga / read Staff meeting Planning session Phone calls billing

127. The “Good-Fit” Personal Organizer for the Client with Executive Dysfunction 2 pages per day 7 am to 9 pm Contains a master to-do list With the client at all times Use for work and home Have only one system

128. Use of the personal organizer or PDA Move it from your head to your calendar Break long term goals into action items The organizer is your budget – how you “spend” your time Use your organizer for every part of your life

129. Use of the personal organizer or PDA Use your organizer for every part of your life Your to-do list should contain things you have to do, but also things you want to do, or to be, or to have. You make appointments with your doctor or insurance agent, because they’re important. You can make appointments with yourself as well. “Hi Cindy, this is David…..” (win friends and influence people with your amazing phone log)

130. easy hard 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 162

131. “error-free learning”

132. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 165

133. Psychotherapy with the brain-injured client Mild TBI interventions Severe TBI interventions

134. Psychotherapeutic Interventions Individual Therapy Permitting appropriate expression of emotional reaction to TBI and loss Patient education Social skills training Family/spouse involvement Impact of memory problems and decreased insight

135. Psychotherapeutic Interventions Individual Therapy Critical for the therapist to be TBI-savvy Consider the environment in which the person functions “ Lieben und arbeiten ”

136. Psychotherapy with the brain-injured client Develop routines Energy conservation

137. Psychotherapy with the brain-injured client Values and motivators

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139. Psychotherapy with the brain-injured client Self-esteem

140. Self - esteem

141. Activity Scheduling

142. Psychotherapy with the brain-injured client Substance abuse and dependence

143. Psychotherapeutic Interventions Group Therapy Modeling Problem solving Peer feedback Social skills practice

144. Behavioral Therapies Very few people with TBI have fully lost the ability to learn new behaviors Structure , consistency, and repetition Role of cognition in self regulation External feedback

145. This requires a measurable and precise definition of the target behavior Always get specific examples Cross check across settings “Pick your battles”? Inquire about the antecedents and consequences Behavioral Strategies: Defining the Problem

146. Behavioral Strategies: Identifying the Function Everybody’s doing the best he/she can Every behavior serves a function Every behavior problem is either A skills deficit, or A contingency problrm

147. Behavioral Strategies: Identifying Resources Personal resources: Memory? Flexibility? Persistence? Motivation? Social / family / peer resources Organizational resources

148. Behavioral Strategies: Guidelines Skills Safety Least restrictive Managing the antecedent: Set me up for success!

149. Examples of Behavioral Strategies Antecedents Does not understand Does not begin task Unable to do task Is not motivated Interventions Provide clear, concrete instructions; notes Give prompts; reinforce initiative Simplify task; provide skill-based training Increase interest or relevance; reward for task completion

150. Examples of Behavioral Strategies Consequences Avoids failure by not complying Gets out of work Receives attention for not doing task Gets to assert independence/control Interventions Alternate difficulty tasks with easy ones Premack principle Time out or ignoring; reinforce for attention Offer choices when appropriate

151. Behavior Management Strategies: X

152. Behavior Management Strategies: Agitation and Irritability

153. Behavior Management Strategies: Agitation and Irritability Redirection Offer an alternative activity Relaxation strategies Recognize antecedent conditions Speak calmly Use key familiar phrases

154. Behavior Management Strategies: Apathy

155. Behavior Management Strategies: Apathy Give choices between doing one thing or another; not between doing and not doing Activity scheduling, in advance

156. Behavior Management Strategies: Denial/Lack of Insight

157. Behavior Management Strategies: Denial/Lack of Insight Have ongoing discussions of “ strengths and needs ” Create discrepancy This may be the most difficult problem to address

158. Behavior Management Strategies: Impulsivity/Disinhibition

159. Behavior Management Strategies: Impulsivity/Disinhibition Structured and organized daily routine Rewarding/praising impulse control and inquiring “how exactly did you do that?” “Talking stick”

160. Behavior Management Strategies: Depression/Withdrawal

161. Behavior Management Strategies: Depression/Withdrawal Help students identify preserved abilities and strengths - rather than focusing on their deficits Keep TBI survivor involved in the present rather than dwelling on the past Use active listening techniques, but focus on positive feelings

162. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 199 A antecedents B behavior C consequences

163. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 200 A antecedent B behavior C consequences

164. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 201 A antecedent B behavior C consequences

165. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 202 A antecedents B behavior C consequences

166. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 203

167. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 204 A antecedent B behavior C consequences metacognition

168. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 205 B eginning Middle End

169. 4/26/2012 © 2011 David D. Nowell, Ph.D. All rights reserved. 206 A antecedent B behavior C consequences

170. Treating Sensory Defensiveness

171. Addressing Visuomotor Problems with Reading

172. What’s the kid’s deal? Greene, Ross. The Explosive Child.

173. Family Issues and Needs Family stress related to severity of TBI The family’s resilience may be key to a brain injured child’s successful rehabilitation Divorce rates range from 15% to 54%

174. Sources of Family Stress Uncertainty about recovery Cognitive and personality changes Financial strain Transitions to “new” settings Lack of respite care

175. Family Definition of the Event

176. Family Issues and Needs Family’s adaptation may take years Any change may trigger emotional response Watch for signs of grieving

177. Return to School Accommodations and Modifications IDEA and Section 504

178. IDEA Definition of TBI: An acquired injury to the brain caused by an external physical force resulting in functional disability or psychosocial impairment that adversely affects a child’s educational performance.

179. School Re-Entry Issues Educational consultation should begin before return to school Continuity of care between school and rehabilitation services Prepare for multiple transitions Re-entry should include interdisciplinary support

180. Percentage Referred for Services

181. Basic Criteria for School Re-Entry Attends to a task for 10 to 15 minutes Adjust for age Can tolerate 20 to 30 minutes of classroom stimulation Can function adequately in a group of 2 or more students Engages in meaningful communication Follows simple directions accurately Gives some evidence of learning potential

182. School Re-Entry Procedures Assess needs Adaptive domain Cognitive domain Communication domain Sensorimotor domain Social-emotional-behavioral domain Transportation needs Family needs

183. School Re-Entry Procedures Identify the best setting for intervention Outpatient counseling? Home-based family interventions? School-based SLP / OT? Buddy system at school? In-service for school staff? Modified school day? In-school breaks? “Study halls” with resource teacher? Pre-vocational training? Regular re-evaluation for change over time

184. Developing IEP Goals Focus on 2 or 3 priority issues Identify metacognitive & organizational strategies Write measurable goals that incorporate the strategies Include specific information about how the strategy should be taught and implemented across settings Write short-term goals that are truly short-term

185. TBI Impact at School Problems initiating and completing work. Slowed work pace. Increased impulsivity. Topographical disorientation Distractible Difficulty generalizing new learning

186. Classroom Management Two key factors : Structure Motivation Explicitly teach rules & expectations Establish prompts or cues, such as gestures and reminder cards

187. Classroom Management Can students answer the following questions: What do I have to do? How much do I have to do? When am I finished? What do I do next ?

188. Classroom Management Use repetition & feedback Avoid multi-step instructions Supplement verbal instructions with nonverbal / modeling Provide additional time for information processing Assist with organization of materials and schedule

189. Classroom Management To be motivating, a task must be interesting Intersperse difficult or novel tasks with easy or previously learned ones Distinguish cognitive factors from other issues (impact of headache, or depression)

190. Specific Classroom Strategies: Attentional Processes Reward on-task behavior ; Use novel, unusual, relevant or stimulating activities Redirect Remove unneccessary distractors Explore a variety of cueing systems Verbal cues Physical prompts Gestural cues

191. Specific Classroom Strategies: Attentional Processes Reduce the number of individual tasks on a printed page Reduce the amount of copying from the board Provide a ruler or EZ-Reader to focus visual attention Avoid asking a student to multi-task Chunking / Pomodoro

192. Specific Classroom Strategies: Memory and Learning Enhance the saliency of material Regularly summarize information as it is being taught Dry-erase board Use overlapping techniques, such as repetition and rehearsal

193. Specific Classroom Strategies: Memory and Learning Couple new information with previously learned information Identify in advance the key information to be learned Make use of over-learning

194. Specific Classroom Strategies: Language Limit length and complexity of communication Do not use figurative speech Recognize the student may not understand humor or sarcasm

195. Specific Classroom Strategies: Language Reminders to start, end, or repair a conversation Use question prompts to help the student share more information, especially in groups Allow for slowed information processing

196. Specific Classroom Strategies: Language Speak slowly Reduce background noise

197. Specific Classroom Strategies: Visual Processing Provide longer viewing times or repeat viewings when using visual instructional materials Facilitate a systematic approach to reading and math by covering parts of the page Provide support for orientation to building and grounds Limit visual distractions (web page, handouts, text, desk)

198. Specific Classroom Strategies: Executive Functions Problem Solving Processes Develop a problem-solving guide to help student through the stages of problem solving Identifying the problem Acquire relevant information Generate several possible solutions List pros and cons for each solution Identify best solution Create a plan of action Evaluate the effectiveness of the plan Encourage generalization

199. Specific Classroom Strategies: Executive Functions Raise questions about alternatives and consequences Provide ongoing, non-judgmental feedback Provide part of a sequence and have the student finish it Frequent cues re: main topic vs. supporting ideas

200. Specific Classroom Strategies: Executive Functions Note impact of fatigue on cognition Note impact of some medications Consider reduced workload Consider note-taker “How exactly did you do that?”

201. Special cases

202. Special cases Domestic violence Shaken baby syndrome Combat trauma Alcohol abuse/dependence Mild TBI

203. Special cases Domestic violence

204. In women reporting to ERs for injuries associated with DV: 30% of battered women reported a loss of consciousness at least once . 67% reported residual problems that were potentially head-injury related. (Corrigan 2003)

205. Domestic Violence… Greater than 90% of all injuries secondary to domestic violence occur to the head, neck or face region. (Monahan & O’Leary 1999)

206. Special cases Shaken baby syndrome

207. American Academy of Pediatrics-Committee on Child Abuse and Neglect Pediatrics 2001 “ … 95% of serious intercranial injuries and 64% of all head injuries in infants younger than 1 year were attributable to child abuse ” Pediatrics, 2001

208. Shaken Baby Syndrome

209. Shaken Baby Syndrome Rotational, acceleration, deceleration forces There may or may not be impact trauma Brain rotates inside the skull Bridging veins in the brain may be stretched or torn Subdural hematoma may develop

210. Shaken Baby Syndrome Kirschner & Wilson’s “dirty dozen” 1. Child fell from a low height 2. Child fell and struck head on floor or furniture, or hard object fell on child 3. Child unexpectedly found dead (age and/or circumstances not appropriate for SIDS) 4. Child choked while eating and was therefore shaken or struck on back

211. Shaken Baby Syndrome Kirschner & Wilson’s “dirty dozen” 5. Child suddenly turned blue or stopped breathing, and was then shaken 6.Sudden seizure activity 7. Aggressive or inexperienced resuscitation 8. Alleged traumatic event one day or more before death

212. Shaken Baby Syndrome Kirschner & Wilson’s “dirty dozen” 9. Caretaker tripped or slipped while carrying child 10. Injury inflicted by sibling 11. Child left in dangerous situation (e.g. bathtub) for just a few moments 12. Child fell down stairs

213. Shaken Baby Syndrome Symptoms Apnea Listlessness Lethargy Poor feeding Irritability Vomiting Seizures

214. Special cases Combat trauma

215. Combat Trauma TBI as “signature wound” of Iraqi conflict USA Today 9/07

216. Combat Trauma Iraq characterized by different kind of weaponry: explosive munitions. 15% of soldiers returning from Iraq may have sustained at least mild TBI ( Hoge et al 2008) 36% may have been exposed to blasts ( Maguen et al 2012)

217. Combat Trauma Comorbid PTSD Headache Sensory impairment Alcohol use

218. Special cases Alcohol abuse/ dependenc y

219. Alcohol Abuse May increase morbidity of MVA-related TBI (Cunningham et al 2002) Although low amounts may be protective Chronic alcohol abuse associated with falls, assaults, multiple head injuries Overlay of alcohol-related impairment

220. Special cases Mild TBI

221. TBI Severity: Mild TBI (mTBI) Concussion signs and symptoms include ANY changes in behavior such as: Cognitive impairments Physical symptoms (e.g., headaches, blurry vision, diplopia , dizziness) Emotional symptoms (e.g., irritability, volatility) Sleep difficulties Not “feeling like themselves.”

222. TBI Severity: Mild TBI (mTBI) Persistent symptoms following the concussion is often referred to as Post-Concussive Syndrome . Cumulative effect

223. TBI Severity: Mild TBI (mTBI) Chronic traumatic encephalopathy

224. Psychotherapy with the persistent post-concussive client Perfectionistic tendencies Somatic focus Poignancy Secondary gain “old me / new me” Check to see whether you are working at cross-purposes

225. The “Big 5” (plus 1) The “Big 5” Daily planner Daily organization time Movement Nutrition Connection Sleep

226. Let’s stay in touch! Join my e-newsletter list: Fill out a card today and drop it in the box. Text to join: text DNSEMINARS to 22828 Sign up on my web site or Facebook page Visit us on the web : www.DrNowell.com davidnowell David Nowell Seminars