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Kristine Burkman, Ph.D.Staff PsychologistSan Francisco VA Medical Center
ASAM Disclosure of Relevant Financial Relationships
Content of Activity: ASAM Medical –Scientific
Conference 2013
Name Commercial Interests
Relevant Financial
Relationships: What Was Received
Relevant Financial
Relationships: For What Role
No Relevant Financial
Relationships with Any
Commercial Interests
Kristine Burkman, Ph.D.
X
Definitions
Assessment
Prevalence
Overlapping Symptoms
Treatment Considerations
Suggested Strategies
a traumatically induced physiologic disruption of brain
function, as manifested by one of the following:
Loss of consciousness
Loss of memory for events immediately before or after
the accident Alteration of mental state at the time of the accident
(e.g., feeling dazed, disoriented, or confused)
Focal neurological deficit(s) that may or may not be
transient
KEEP IN MIND: TBI refers to original injury or etiology, there are no symptoms for this diagnosis
American Congress of Rehabilitation Medicine (ACRM)
Specifiers: Mild, Moderate, Severe
Refers to 24-48 hours following injury.
Severity of initial injury ≠ impairment in functioning
Prognosis often related to: Length of loss of consciousness Length of post traumatic amnesia
Verbal response Oriented to person, place & date
= 5 Converses but is disoriented = 4 Says inappropriate words = 3 Says incomprehensible sounds =
2 No response = 1
Eye opening Spontaneous = 4 To speech = 3 To painful stimulation = 2 No response = 1
Motor response • Follows commands = 6 • Makes localizing movements to pain = 5 • Makes withdrawal movements to pain =
4 • Flexor (decorticate) posturing to pain = 3 • Extensor (decerebrate) posturing to pain
= 2• No response = 1
SCORING
Specifier is based on score within 48 hrs
of injury:
Severe = 1 - 8 Moderate = 9 - 12
Mild = 13 - 15
Not routinely assessed in combat situations
VA assesses via self-report months, even years after the event
Screen (4 items, sensitive not specific) Second level eval (22 items)
Often not documented and military culture may encourage minimization
91% of OEF/OIF casualties survive1
Compared to 84% of Vietnam, 80% WWII
Estimated 22% of returning servicemembers have reported experiencing TBIs and concussions2
Of those injured, approximately 31% diagnosed w/ TBI3
77% of all head injuries are mild TBI4
1Holcomb et al., 2006, 2Terrio et al., 2005, 3Hayward, 2008, 4Fischer, 2010
Persons w/ TBI more likely to have 2nd and 3rd TBI1
Repeat TBIs increase severity and chronicity of symptoms1
Twice as likely to screen positive for PTSD or depression2
Increased risk for suicide3
1Center for Disease Control (CDC); 2Maguen, Lau, Madden & Seal, 2012; 3Brenner, Ignacio & Blow, 2011
Complicated literature Bi-directional relationship between TBI and SUD Pre-injury pattern of substance use predicts post-
injury pattern of use
Substance use impairs rehabilitation and exacerbates symptoms
Increased risk of additional injury
Co-Occurring Disorders SUD + Depression, 3-5 time more likely to relapse1
SUD + PTSD relapse more quickly 2,3
Co-occurring patterns of relapse 2, 4
Exposure to Trauma Probability of relapse increases as the # of traumas
types increase 5
1Curran et al., 2000; 2Brown et al., 1996; 3Ouimette et al., 1997; 4Curran & Booth, 1999; 5Fraley et al., 1998
Feeling dizzy Loss of balance Poor coordination, clumsy Headaches Vision Problems Sensitivity to Light Nausea Hearing difficulties Sensitivity to noise Numbness Change in taste and/or smell
Loss/increase in appetite Difficulty concentrating Forgetfulness Difficulty making decisions Slowed thinking, disorganized Fatigue, loss of energy Feeling depressed or sad Difficulty falling or staying asleep Feeling anxious or tense Irritability, easily annoyed Poor frustration tolerance, easily overwhelmed
Re-experiencingIntrusive images, memories, thoughtsNightmaresFlashbacksEmotional distress at remindersPhysical reaction to reminders
AvoidantAvoiding thinking/talking about traumaAvoiding situationsTrouble remembering aspects of traumaLoss of interest in activities used to enjoyFeeling distant/ cut-off from othersEmotionally numbForeshortened sense of future
HyperarousalInsomniaIrritabilityDifficulty concentratingHypervigilenceStartle response
Limbic System Activated
Common Challenges
Frontal Lobe Inhibited
Impulse Control
Planning
Abstraction
Judgment
EmotionMemory
Maguen, Lau, Madden, Seal, 2012
Dizziness Headaches Memory
problems Light
sensitivity
Irritability Emotional numbing
Sleep problems
Loss of interest Feeling down,
hopeless
Avoidance Nightmares Hypervigilence
Missed appointments Avoidance, memory problems, difficulty w/
initiation, inability to organize effectively, relapse
Difficulty tracking or recalling skills Frustrated w/ pace, embarrassment in session
Crisis-prone Relationships, work/school, legal, psychiatric
crises
Distorted expectations and beliefs
Phase Based Model of Recovery
Titrate level of emotional content re: trauma material
Assess level impairment re: memory and emotion regulation to inform when and how to approach trauma processing
Reconnect with others/lifeMeaning of experience
-Interpersonal work-Insight/existential-Symptom maintenance
Integration
Consolidation of memory Habituation of
fear response
-Construction of narrative-Cognitive restructuring-Exposure
Processing
Establish “safety”Improve self-
regulation
-Psychoeducation-Coping skills-Psychopharmacology
Stabilization
Fear of symptoms exacerbation
Drop out rates
Insufficient training for protocol among clinicians
“Fragile” patients
Chaotic/ high risk situationsKEEP IN MIND: Mild TBI should resolve fully within 6 months, debate over cause of ongoing symptoms
Integrated treatment of TBI, PTSD and SUD is recommended!
Flexibility
Persistent outreach
Validate, reassure, challenge Acknowledge problems as real to veteran Education re: relapse, heterogeneity of injuries,
expectation of recovery from mTBI Goal of recovery not adjustment to permanent disability
Multidisciplinary team
Harm reduction
Write it down
Organize
Visualize Info
Attach emotion
Repetition
MEMORY & LEARNING
Plan Ahead
Allow extra time
Accuracy over speed
Avoid multitasking
Flexible deadlines
PROCESSING SPEED
Include support members
Emotional awareness & management
Routine
Encourage persistence
FRONTAL LOBE DAMAGE
Keep it simple
Go slow
Write it down
Encourage veteran to communicate back what he/she understands
Repeat
