TBI, CBT, DBT? What to do? Psychological and neuropsychiatric care of the patient with TBI. Margo Lauterbach, MD Sarah Loeffler, LCSW-C Andrea Gottlieb, PhD Sheppard Pratt Health System Concussion Clinic at the Neuropsychiatry Program at Sheppard Pratt

Disclosures Dr. Gottlieb and Sarah Loeffler have no financial disclosures Dr. Lauterbach is 1/3 owner of Brain Educators, LLC, publishers of The Brain Card®, a neuropsychiatry pocket reference

Objectives: (1) To understand neuropsychiatric and psychological symptoms that can accompany TBI (2) To understand the psychotherapy approaches to illness (3) Have an understanding of the adaptation of traditional modalities of psychological treatment for use with patients with TBI

What are neuropsychiatric vs psychosocial symptoms?

Common Symptoms Disorders of… Mood Cognition Behavior Other Physical

Disorders of Mood Depression Dysphoria Elation Hostility Agitation/Irritability "Mania" "Bipolar" Lability Apathy

Disorders of Cognition Motivation Impulsivity * Attention Memory Language Processing Speed Cognitive Flexibility Abstract Thinking Planning Organization

Disorders of Behavior Personality Changes Impulsivity * Interpersonal Skills Substance Use Changes in Sexuality * Aggression Disinhibition Impaired Judgement

Other Disorders Anxiety Psychosis Sleep Disorders * Safety Concerns * PTSD Generalized Worry (GAD) Panic Disorder Psychosis Hallucinations Delusions Sleep Disorders * Safety Concerns * Suicidal Violent

Physical Disorders Seizure Disorders Sleep Disorders * Movement Disorders Vestibular Disorders Headaches Chronic Pain Visual Changes Energy/Fatigue

The Importance of “Individual Brains” Psychotherapy + psychopharmacology Adapting modalities of treatment Adapting modalities of treatment is essential to providing individualized care that matches the heterogeneous brain injury population. This adaptive approach is often required to provide thorough treatment of complex cognitive and interpersonal symptoms

Relevant Information for Consideration Litigation Third Parties Workers Compensation Insurance Companies Presence/Absence of Supports Multidisciplinary Providers – Pros and Cons Work/School Potential Finances Spiritual/Religious/Cultural

Examples of Therapies Supportive Counseling Cogntive Behavioral Therapy (CBT) Cognitive Rehabilitation Therapy (CRT) Self-Awareness Training Dialectical Behavioral Therapy (DBT)

DBT Disclaimer

Acceptance and change model DBT Acceptance and change model

DBT What are "dialectics"?

DBT Acceptance and change skills: Mindfulness Distress tolerance

DBT Acceptance and change skills: Emotion regulation Interpersonal effectiveness

DBT Why DBT for TBI? DBT is designed for those with symptoms that sometimes overlap with post-TBI emotional symptoms and social impairments Mood: irritability, lability, emotional dysregulation Social judgment/interpersonal relatedness and skills Tolerance of distress/frustration Safety concerns

DBT Adapting DBT

DBT Acceptance skills: Mindfulness ("wise mind") Emotion regulation (skill: observe and describe emotions)

DBT Change skills: Distress tolerance Interpersonal effectiveness (ex: "distracting skills") Interpersonal effectiveness ("GIVE" skills)

DBT Why DBT and SP Concussion Clinic: Matches the emotional needs we see for many of our patients. Creates a language and a new frame for treatment. It is adapted, hence flexible It is working for many…