1. 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

2. 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

3. 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

4. What are neuropsychiatric vs psychosocial symptoms?

5. Common Symptoms
Disorders of…
Mood
Cognition
Behavior
Other
Physical

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

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

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

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

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

11. 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

12. 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

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

14. DBT
Disclaimer

15. Acceptance and change model
DBT
Acceptance and change model

16. DBT
What are "dialectics"?

17. DBT
Acceptance and change skills:
Mindfulness
Distress tolerance

18. DBT Acceptance and change skills: Emotion regulation
Interpersonal effectiveness

19. 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

20. DBT
Adapting DBT

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

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

23. 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…