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Humanistic and Biological Interface in Brain Injury Rehabilitation
Anjum BashirLeyla Ziyal
Tim Warren www.partnershipsincare.co.uk
The enigma of Brain InjuryThe enigma of Brain Injury
• Brain Injury: a complex condition
• Not an illness
• Disease model not suitable
• Pathology obscure
• Psychopathology multifactorial
What is the Pathology?What is the Pathology?
• Pituitary Tumour excised• Tuberculous Abcess in temporal
region treated• Epilepsy and fronto temporal
scarring• RTA and subdural haematoma in
frontal region• Heroin overdose and found
unconscious anoxia of brain• Diabetic and found unconscious
possibly low blood sugar• Cerebral atrophy with large
ventricles• And so on
What is the Pathology?What is the Pathology?
• Complex and varied• Regional injury rather than focal• Events before and after:• Brain oscillates 3000 times before
coming to rest when in an accident with a car at 60mph
• Loss of oxygenation or over • Biochemical imbalance
Biological Dilemma Biological Dilemma
• Take example of an essential cognitive function:
Memory • Memory systems in brain• Regional distribution
Brain RegionsBrain Regions
• Hippocampus is the key area• Involved in declarative, anterograde
or new knowledge or information• Right Hippocampal complex (non
verbal)• Specialize in faces, geographical
routes, melodies, spatial information
• Left Hippocampal complex• Verbal language
Non medial Temporal regionNon medial Temporal region
• Same Right (non verbal) and left (verbal) specialisation
• Retrograde or past memories
Other regionsOther regions
• Ventromedial frontal lobe:• Emotion/feelings and Memory• Prospective memory;
remembering to do things in future
• Dorsolateral frontal lobe:• How many times and how
along ago an event has occurred
Brain RegionsBrain Regions
Basal Ganglia• Procedural memory (riding a
bike, swimming, habits, seeking automatic support and encouragement
Thalamus• Acquisation of factual information
and main transmitter or memory related information
Dilemma of Pathology?Dilemma of Pathology?
• Biological Explanations incomplete or vague
• Scientific advancement imprecise
• Some key laboratory tests only for research
Patients our best GuidesPatients our best Guides• TO THOSE WHO CANNOT ACCEPT MY CHANGE•
People change over time and most change is by choice.The person I am is not the person I was.Not over time, but in an instant, it all changed.I am different.It wasn't my choice, it wasn't my fault, but you treat me like it was.The person I was died and I went to my own funeral. I am different.You didn't like the person you saw in front of you.The person in the mirror wasn't me and I didn't like her either.But, I looked beyond the mirror and slowly became the person I am.If you hang on to the past, you die a little each day;once was enough for me.I am different, but not by choice, so don't reprimand me for being me.I am different.If you can't accept that, you can't accept me and I can't accept that.
• Sandee Rager
Listening to relativesListening to relatives
• He is not the person I knew• She is self centred• He is unpredictable• She cannot decide what to do• Oh those mood swings• Memory is so poor• Gets angry and can be so unkind
What ICD says?What ICD says?
• Organic Personality Disorder
• A category for all disorders
Discovering the person?Discovering the person?
Behind the organic fog
• A lost person• New fantasies• New realities• A new personality• Can s/he rediscover themselves
Biological PromiseBiological Promise
• Is it limited?• Goal: recreate availability to self
discovery
• Treat as whole:
Illness vulnerability increased
Mental dis- ease a challenge
Brain Dysfunction a challenge
No head injury is too serious to despair of, nor too trivial to ignore“
In order to be walked on, you have to be lying down."
No way! Be stubborn! The greatest indicator of success in TBI recovery is said by some professionals to be how stubborn you can be:
Persist! Brian Weir,TBI survivor
Thank you for ListeningThank you for Listening
Now our next speaker
Leyla Ziyal
BIOLOGICAL AND HUMANISTIC INTERFACE
IN BRAIN INJURY REHABILITATION
LEYLÂ ZIYAL M Phil AFBPsS C PsycholChartered Consultant Clinical Neuropsychologist
31 03 2010
A. INTRODUCTIONA. INTRODUCTION
Aim Share our practice at Elm Park BIS – Clinical
Neuropsychology Perspective
This paper: Practice overview1. How we do what we do
2. Why we do what we do – rationale
3. Illustrative case study
4. Next step in practice development
Next paperA further illustrative case study
A.1 Setting the sceneA.1 Setting the scene
Male patients
Severe acquired brain injury
Present with complex challenging
behaviours
Our shared goal:
Mobilise the potential of our patients to attain the maximum level of independence and quality of life that is possible for them to
achieve
A.2 Setting the sceneA.2 Setting the scene
Multidisciplinary work
Discharge objectives
Home-based reintegration within the community
Community Assisted Living Facilities,
Through to probably long-term step down
Facilities in residential contexts
1 HOW WE DO THE THINGS WE DO 1 HOW WE DO THE THINGS WE DO
Accessing the person behind the injury
‘’the human being is first and last…a subject, not an object”
Sacks, O. (1984) A leg to stand on Duckworth, London
1 HOW WE DO WHAT WE DO1 HOW WE DO WHAT WE DO
Neuropsychological Assessment
Cognitive Retraining (CRt)
Self repair (SR)
Attention
Memory
Information Processing
Executive Function
Life narrative (LNar)
Emotion Management (EMg)
Awareness Training (Aw)
Systemic/corrective Interventions
Behaviour Modification (BM)
as a means to relationship maintenance and
enhancement
1 HOW WE WHAT WE DO1.1 neuropsychological assessment helps us to:1 HOW WE WHAT WE DO1.1 neuropsychological assessment helps us to:
Generate a functional map of the
brain
Contribute to the multi-
disciplinary enterprise of setting
first stage discharge planning
goals
Develop a needs-analysis that
prioritises needs in terms of
these discharge goals
Formulate a rehabilitation
strategy in light of these goals
within the compass of the
patient’s current level of mastery
Pitch the level of
intervention to the
patient’s current level
of capability and
receptivity
Open a window of
understanding into
what and how the
patient is construing
his situation and
what/how he is feeling
1 HOW WE DO WHAT WE DO1 HOW WE DO WHAT WE DO
1.1 Neuropsychological assessment
a continuous process
repeat neuropsychological assessmentsrehabilitation performance recordsbehaviour records
1 HOW WE DO WHAT WE DO1 HOW WE DO WHAT WE DO
Cognitive RetrainingMemoryAttentionInformation processingExecutive function
Self Repair TherapiesLNarEMgAwCorr T
Behaviour Modificationas appropriate and only as means of replacing disruptive or undesirable behaviours with new more adaptive responses, and of selectively reinforcing desired behaviours whilst discouraging maladaptive ones.
1.2 cognitive retraining and self repair[and behaviour modification]
1 HOW WE DO WHAT WE DO1.2 cognitive retraining and self repair
Intervention format:
1 HOW WE DO WHAT WE DO1.2 cognitive retraining and self repair
Intervention format:
Groups - MetacognitionDevelops self-concept and self-efficacy in a supportive and safe milieu that promotes sense of self discovery and control
Enables Self evaluation through other observation and self-prediction
Facilitates multi-sourced Constructive feedback
Offers 0pportunity to further understand the nature of injury and its effects in the roles that the patient had adopted until now and may be likely to adopt from now onwards
Inter-session and modular Cross fertilisation
Individual – one to oneReinforces group work
Addresses special needs: anxiety/depression, OCD, SOT
Trouble shoots
Builds therapeutic alliance and facilitates engagement
Affords the opportunity to develop special relationship
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT) 2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)Key concepts
The way we think determines the way we behave.
Identity is a unifying construct
The approach must be capable of encompassing the cognitive, emotional and psycho-social domains of functioning
Task is to help our patients to reconnect with their pre-injury identity in their journey of readjustment to the post ABI order through developing a sense of self efficacy and locus of and through locating the locus of control within themselves
Key methodMobilisation of the Core-belief – Life rule system
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)Mobilisation of the Core-belief – Life rule system
Belief system
about me
about others
about the word
Rule system
conditional beliefs: ‘if – then’ statements
Life rules: Injunctions
Protective behaviours
Enforce the rule
Keep the core belief below the level of awareness
Maintains emotional balance
2 WHY WE DO WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)2 WHY WE DO WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)Mobilisation of the Core-belief – Life rule system
SCHEMA
RULE
RULE
RULEPROTECTIVE BEHAVIOURS
PROTECTIVE BEHAVIOURS
PROTECTIVE BEHAVIOURS
DISTORTED AUTOMATIC THOUGHTS NEGATIVE EMOTION
2 WHY WE WHAT WE DO: RATIONALECognitive Behaviour Therapy (CBT)
What happens when our protective behaviours break down
2 WHY WE WHAT WE DO: RATIONALECognitive Behaviour Therapy (CBT)
What happens when our protective behaviours break down
SHATTERED LIFE RULES
ACTIVATEDCORE BELIEFS
NEGATIVE EMOTION LOSS
OF IDENTITY
INERT PROTECTIVE BEHAVIOURS
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)ABI: What happens when
protective behaviours break down?
loss of self self-knowledgeself by comparison self in the eyes of the world
impaired sense of identity
impaired sense of continuity ‘me before/me after’
grief
2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)2 WHY WE WHAT WE DO: RATIONALE
Cognitive Behaviour Therapy (CBT)
Reconstituting personal meaning an identity
Develop self-efficacy; self control
Access and repair self-identity
Re-align the belief-rule system to post-injury reality
Re-align the belief-rule system to pre-injury reality
Promote acceptance, adjustment and reconstitution of personal meaning and identity
BIOLOGICAL AND HUMANISTIC INTERFACE
IN BRAIN INJURY REHABILITATION
part 2
LEYLÂ ZIYAL M Phil AFBPsS C PsycholChartered Consultant Clinical Neuropsychologist
31 03 2010
3 ILLUSTRATIVE CASE STUDY3 ILLUSTRATIVE CASE STUDY
HistoryLate 40s sustained severe head injury in age 16. Depressed right frontal skull fracture. unconscious for 6 weeks with slow recovery
DiagnosisOrganic personality disorder (F07.0)Frontal Lobe Syndrome (secondary to acquired brain injury)
Forensic historySexual offending history of dating back to age 21. Onset soon after head injury listed as a schedule 1 Offender
3 ILLUSTRATIVE CASE STUDY3 ILLUSTRATIVE CASE STUDY
AdmissionEarly 2008 on section 37 but this was allowed to lapse: currently informal
BehaviourDisplays of inappropriate sexual behaviours, making inappropriate sexual comments, touching females and wearing sexually revealing garments.
Intervention Intermittent forensic counselling aimed at inculcating in him the idea that he was a criminal and that any further offending would put him behind bars. This led to no significant reduction in his displays of unacceptable sexual behaviours
3 ILLUSTRATIVE CASE STUDYReferral to Clinical Neuropsychology and goals
3 ILLUSTRATIVE CASE STUDYReferral to Clinical Neuropsychology and goals
February 2009 Reduce inappropriate sexual behaviours totally
Consolidate the gains he makes during his stay
at the Unit
Facilitate his integration within a setting commensurate
with his progress and with his cognitive potential as
part of discharge planning
MethodologyConduct neuropsychological assessment
Develop formulation
Determine therapeutic strategy and criteria of success
Determine method of evaluation
3 ILLUSTRATIVE CASE STUDY3 ILLUSTRATIVE CASE STUDY
Clinical Neuropsychological assessment
CHART 1: COMPARISON OF COGNITIVE AND EXECUTIVE FUNCTIONS
0
20
40
60
80
100
perc
enti
le s
core
s
EXECUTI VE
COGNI TI VE
3 ILLUSTRATIVE CASE STUDYFormulation
3 ILLUSTRATIVE CASE STUDYFormulation
RTA – FRONTAL LOBE INJURY
AVALANCHE OF SEXUAL IMPULSES
IMPAIRED IMPULSE CONTROL RESPONSE INHIBITION RULE ATTAINMENT
3 ILLUSTRATIVE CASE STUDYTherapeutic strategy and criteria of success
3 ILLUSTRATIVE CASE STUDYTherapeutic strategy and criteria of success
Therapeutic strategyCorrective therapy of SOT individual format - CBT
CRt in information processing and Executive functions in group format
SR therapies in group format
Criteria of successZero display of sexual behaviours – behaviour charts
Development of insight – therapeutic assignments in SOT and SR
Increased competence in CRt – performance evaluation
3 ILLUSTRATIVE CASE STUDYIndividual CBT
3 ILLUSTRATIVE CASE STUDYIndividual CBT
Figure 1: Possible thought sequence triggered by an activating event
ACTIVATING EVENT
PROTECTIVE BEHAVIOURS
RULES
THIS IS DIFFERENT
IF NOT NOW WHENI AM DEPRIVED
INAPPROPRIATE BEHAVIOURS
3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes
3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes
CHART 01 'A': I NAPPROPROPRI ATE SEXUAL BEHAVI OURS J AN - J UN 2009
therapy begins end February 2009
0
1
2
3
4
SE
XU
ALL
Y
SU
GG
ES
TIV
E
CO
MM
EN
TS
TO
UC
H B
OT
TO
M
TO
UC
H H
AIR
NIP
PLE
TA
LK
WE
AR
ING
RE
VE
AG
AR
ME
NT
S
TO
UC
HH
AN
D
JAN
FEB
MAR
APR
JUNE
3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes
3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes
Figure 2: touching hand cognitive sequence
ACTIVATING EVENTS:1. ASKED TO HELP WITH
DINING ROOM 2. HANDED WIPING CLOTH
AUTOMATIC THOUGHTSI AM IMPORTANTTHEY NEED ME
SHE CAN TRUST ME TO DO ITSHE THINKS WELL OF ME
I AM GRATEFULI FEEL WARM TOWARDS HER
I WANT TO SHOW MY APPRECIATIONI WANT TO HOLD HER HAND
RULES/CONSEQUENCESUNAWARE
BEHAVIOURHOLDS HER HAND TOO LONG
3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes
3 ILLUSTRATIVE CASE STUDYIndividual CBT: outcomes
0
1
2
3
4
5
6
7
8
9
JULY AUG SEPT OCT NOV DEC JAN FEB
CHART 02: ‘A’ INAPPROPRIATE SEXUAL BEHAVIOURS
JULY 2009 - FEBRUARY 2010
Standing too close to female
staff/attempting to touch
Brushing past / touching female
staff
Looking for long periods at female
staff
Complimenting female staff
Sexual comments/inappropriate
comments
Drawing sexually explicit pictures &
showing it to staff
Sleep walking in the Nude/Boxers
4 THE NEXT STEP IN THE DEVELOPMENT OF OUR PRACTICE4 THE NEXT STEP IN THE DEVELOPMENT OF OUR PRACTICE
Develop our work in awareness training
Improve change-readiness through the incorporation of Prochaska, Norcross & DeClemente’s 05-stage change theory
Improve engagement levels through incorporation of motivational interviewing
CASE STUDY OF PATIENT SK
By Tim Warren Assistant Psychologist
31st March 2010
SummarySummary
• Background of SK• History of SK• Injury Details• Post Injury• Admission to Elm Park• Treatment plan• Groups and therapy• Planning for Discharge• Questions
Patient Details:Patient Details:• SK• Gender: Male• Age: 57 years old• Profession: Milkman• Marital Status: Divorced• Children: 2 Daughters• Lives alone in a first floor flat• History of alcoholism
SK ChildhoodSK Childhood
• All normal Milestones Reached• Normal early childhood• Normal primary school education• Mother died during high school• Was bullied at high school• Reported to have fallen in with the
wrong crowd • No qualifications gained from high-
school
Injury DetailsInjury Details• Injury sustained on 09.06.2008 from a
fall down the stairs of his flat• GCS = 3• CT scan showed the following:
• Sub gleal haematoma in left occipital lobe• Contusions to right inferior frontal and temporal
lobes• Contusions to left temporal lobes• Evidence of traumatic subarachnoid blood in right
hemisphere• No mid-line shift or fracture to skull• Minimal cerebral swelling
• CT repeated several days later with no change.
Post injuryPost injuryBehaviours:• Sexual disinhibition• Physical aggression toward objects• Verbal aggression towards others• Prone to self harm • Suicidal ideationCognitive:• Dis-orientated to time and place• Confabulation and memory deficits• Lack of insight and awareness• Depression and anxiety
Admission To Elm ParkAdmission To Elm Park
• Admitted on 11/8/08• Baseline of Behaviours• Assessment of function
• Identify strengths and weaknesses
• Target areas of treatment
• Streamline into appropriate group for cognitive re-training
• Identify goals and care pathway
• Goal setting and planning MDT & SK
Treatment PlanTreatment PlanBehaviours:• Sexual comments – TOOTS and feedback
• Verbal Aggression – TOOTS and feedback
• Self Harm – One to One therapy
• Aggression against objects – Verbal de-escalation with feedback
• Positive Reinforcement of appropriate behaviours
Treatment plan (psychology)Treatment plan (psychology)Cognitive:
• Neuropsychological assessment• WAIS III
• WMS III
• WTAR
• DKEFS
• 1:1 therapy for anxiety and depression• Therapy for alcoholism• Cognitive re-training in groups• Unit sessions• Community access programme
Cognitive assessment (WAIS III):Cognitive assessment (WAIS III):
0
20
40
60
80
100
120
SCORE 95 91 100 86 107 86 88
CENTILE 37 27 50 18 68 18 21
FSIQ VIQ PIQ VCI POI WMI PSI
Cognitive function:Cognitive function:Summary:• SK is at the AVERAGE range of cognitive
function• His non-verbal abilities are significantly
superior to his verbal abilities• Significant impairment in working memory• His non-verbal abilities are significantly
higher than WTAR predicted scores
Memory assessment (WMS III)Memory assessment (WMS III)
0
10
20
30
40
50
60
70
80
90
100
Score 65 67 100 75 62 63 69 85
Percentile 1 1 50 5 1 1 2 16
AI AD ARD VI VD IM GM WM
Memory function:Memory function:
Summary:• Impairment in memory in both visual
and verbal modalities• Impaired immediate and delayed recall
of information• Impaired working memory confirmed• Average level of recognition memory• Results suggest a retrieval deficit
within memory function
Executive Function (DKEFS)Executive Function (DKEFS)Tests used: Trail Making, Verbal Fluency, Design
Fluency, Sorting Test (Free and recognition).
0
5
10
15
20
25
Score 6 3 7 5 8
Percentile 9 1 16 5 25
TM VF DF Sf Sr
Executive function continued:Executive function continued:
Summary:• On the baseline conditions SK’s
performance ranged between the 62nd to 38th percentile
• On the conditions designed to tap into executive function he ranged between the 16th and 1st percentile
• His performance was consistent with that of dysexecutive syndrome
• More pronounced in left frontal lobe abilities
Psychological Interventions:Psychological Interventions:
• Assessment showed no evidence of diffuse cognitive impairment
• Main areas of impairment are within the domains of Memory and executive function
• Put into Attention, Memory and Life Narrative groups
• 1:1 sessions for anxiety and memory strategies
SK Attention SK Attention
• Targeting: 1. Sustained
2. Selective
3. Alternating
4. Divided
• Exercises Auditory and Visual
• Accuracy Rating
• Self Rating
SK Attention:SK Attention:
Mean accuracy score across all attention exercises
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
1 2 3 4 5
Exercise number
scor
e Self mean
Obj mean
SK Memory:SK Memory:
• Develop insight through practice
• Understanding
• Internal strategies
• External strategies
• Ecological exercises
• 1:1 sessions feedback
SK Memory:SK Memory:Memory Percent Accuracy
69.6
82.5
60 65 70 75 80 85
NO STRATEGY
STRATEGY
SK Life NarrativeSK Life Narrative
• Means of linking self pre-injury to now
• Looking at attributes of person
• Linking attributes to behaviour
• Significant life events
• Developing insight into self
SK life narrative Example 1:SK life narrative Example 1:
• Identified self as Introverted, Flexible,
Belief focused and creative
• Didn’t organise or structure self
• Spare time Depression
Drinking
• Lead to significant sad events
SK Life narrative Example 1:SK Life narrative Example 1:
• Behaviour Experiment• What I feel when I have nothing
planned: Bored
Lonely• What I feel when I have things
structured and Planned:
Active
Engaged
Happier
SK Life Narrative Example 2:SK Life Narrative Example 2:
• Looking at core beliefs
• Early childhood
• Significant life event
• Leading to behaviour
• Altered core belief
Core BeliefCore Belief
Must be clean and presentable:
Mother / acceptance
Good behaviour
Life events:
Bullied at high school
Mothers death
Maladaptive core belief:
Not accepted if clean and presentable
Acceptance if rebellious & unstructured
“Wrong crowd”
Core belief continued:Core belief continued:
Maladaptive core belief: Need to be rebellious
Behaviour: Unkempt
Protective behaviours
Wrong crows
Drinking
Consequences: Loss of job
Loss of family
Challenging behaviour
Injury
InterventionIntervention• Change maladaptive core belief
Behaviour experiments
cumulative insight
cost benefit analysis
Therapeutic trust
• Alteration of core belief
Discharge Planning:Discharge Planning:• Identification of needs:
– Structured day
– Continuation of Alcohol therapy
– Need for check ups
– Care package
• Graded Discharge – Day visits home
– Over night stays
– Discharge
• Successful Discharge
Closing remarksClosing remarks
• Holistic approach
• Knowing patient
• Structure therapy
• Application to everyday
• Successful discharge