Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process Rodney D. Vanderploeg, Ph.D. Tampa.

Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA May 18, 2007

Objectives Provide an overview of the TBI Clinical Reminder screening process Describe a model follow-up evaluation and treatment process Describe when and how neuropsychological evaluations should be completed Describe other roles of psychology following positive TBI Clinical Reminders

Although I love Harry Potter

There is No Magic!

And, things like this are Pseudo-Magic
“Automatic Clock Drawing Test” Featured in the Journal of the American Geriatrics Society, NIH, and the American Bar Association ElderLAW E-NEWS. New! 5 minute evaluation

If you want to know if someone had a Traumatic Brain Injury (TBI)
ASK THEM: Did you experience a physical trauma or injury that resulted in your being: Knocked out / Rendered unconscious, Dazed and confused for several minutes, and/or With memory gaps for some or all of the immediate period after the event If the answer is “yes”, then they had a TBI

TBI Screening Reminder
That is what the “TBI Screening Reminder” Does TBI Screening Reminder April 2007

So, what really are the issues?
Who has ongoing symptoms and problems? What are these symptoms and problems due to (TBI, PTSD, Depression, Anxiety, Somatoform Disorder, malingering, combinations of conditions)? What is the appropriate treatment for any identified problems/conditions? Who is responsible for providing the assessment and treatment? Who is responsible for coordinating this process? When should this be done locally, and when should it be done by regional specialists? What are the roles of psychology in points 3-6?

“TBI Screening Reminder” Functions
Identify possible OIF/OEF Participants Confirm deployment to OIF/OEF Theatres of Deployment Screen for TBI if deployed in OIF/OEF Theatres Identify those with an OIF/OEF-related history of TBI

Criteria for Severity of TBI
Mild Moderate Severe LOC < 30 min with normal CT &/or MRI LOC < 6 hours with abnormal CT &/or MRI LOC > 6 hours with GCS 13-15 GCS 9-12 GCS < 9 PTA < 24hr PTA < 7days PTA > 7days Don’t confuse combat-trauma psychological confusion with post-TBI PTA (i.e., inability to lay down new memories and therefore having post-TBI “memory gaps”)

Screening Questions: 4 Sections
Section 1: Trauma Events Section 2: Immediate Disturbance of Consciousness Symptoms after Events Section 3: New or Worsening Symptoms after the event Section 4: Current Symptoms

Screen Interpretations
A “no” response to any of the sections terminates screening and is a “negative screen” A “yes” response to ALL FOUR sections is a “positive screen”

Section 1: Trauma Events

Section 2: Immediate Symptoms

Section 3: New/Worsening Symptoms

Section 4: Current Symptoms

Positive TBI Screen: Follow-up
Positive replies in all four sections constitute a positive screen Positive screens automatically generate a consult to a TBI specialist or clinic This specialist/clinic has 1 week to initiate contact with patient for more detailed follow-up evaluation Initial treatment trial is based on positive problems on this follow-up evaluation

What to Know: Relevant Background (1)
Mild TBI Symptoms There is no symptom that is unique to or diagnostic of mild TBI Many postconcussion symptoms occur in normal healthy individuals All symptoms/problems overlap with one or more other conditions (PTSD, Depression, Anxiety, Chronic Pain, Somatoform Disorder, chronic health conditions)

In prospective cases (non-clinical, non-legal) virtually all symptoms of mild TBI resolve within months Cognitive Emotional Physical Yet, a subgroup (about 10-15%) continue to experience a postconcussive syndrome Psychological factors play a large role in symptom presence in this subgroup

In this subgroup (of about 10-15%) There is no relationship between symptom complaints and objective findings on: Neuropsychological Testing Physical Examination Neurological Examination Again, this is because psychological factors play a large role in symptom complaints

Predisposing Factors. Causative Factors
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors Self-Expectation mTBI Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Demographic Characteristics Medical Iatrogenesis Litigation Iatrogenesis Acute Symptoms Chronic Symptoms Coping Abilities Social Support

Psychological Contributions
Predisposing Factors Causative Factors Perpetuating and Mitigating Factors Self-Expectation mTBI Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Demographic Characteristics Medical Iatrogenesis Litigation Iatrogenesis Acute Symptoms Chronic Symptoms Coping Abilities Social Support Psychological Contributions

Issue One Who has ongoing symptoms and problems?
Anyone who responds positively to all four of the TBI Clinical Reminder sections Section 1: Trauma Event(s) Section 2: Immediate Disturbance of Consciousness after Event(s) Section 3: New or Worsening Symptoms after the event(s) Section 4: Current Symptoms

Issue Two: Symptom Etiologies
2. What are these symptoms and problems due to (TBI, PTSD, Depression, Anxiety, Somatoform Disorder, malingering, combinations of conditions)? Initial post-TBI Clinical Reminder Assessment (at Tampa and elsewhere) Telephone Administration of: History Questions (e.g., confirmation of exposure, details of TBI severity, history of symptom course), Review of bodily systems and associated complaints, etc. Neurobehavioral Symptom Inventory (22 items rating postconcussive symptoms) PTSD Checklist (PCL) Pain symptoms

Interpretation of Initial Assessment Findings What are the most likely etiologies for the symptoms? What etiology(s) is/are primary? (Does PTSD, chronic pain, sleep disturbance likely explain the cognitive symptoms?) Would successful treatment of the primary etiology likely resolve most or all of the symptoms? Referring and Triaging: Refer accordingly for further evaluation and/or treatment

When to Refer Refer if the evaluation/referral will: Tell you something you don’t already know Make a difference in the patient’s treatment or management

Turning Down a Consult for Neuropsychological Assessment
Referral received and chart reviewed. Veteran currently has severe symptoms of PTSD and chronic headaches. Given this, his cognitive complaints of memory and concentration problems are expected. If testing were performed in this situation, any cognitive impairments would likely be attributed to the severity and extent of the mental health problems. Testing would not clarify diagnostic issues nor guide treatment -- because mental health and pain management treatment should to be the main focus at this time. Once his mental health and pain symptoms are better managed, and rated as no worse than mild to moderate, if cognitive symptoms remain, a re-referral at that time may be clinically useful.

Follow-up Additional Specialized Assessments (and then treatment) TBI: PNS or PSCT (PM&R, (Neuro)Psychology, Speech, Psychiatry) PTSD: PTSD Program Chronic Pain: Pain Program or PM&R Somatoform Disorder(s): ????? Depression, Anxiety, Stress: MHC Seizures, Neurologic Conditions: Neurology

Issue Three: Appropriate Treatment(s)
Treat the primary condition(s), the one(s) that explains most or all of the symptoms Don’t invest time and effort in conditions that account for only small amounts of symptom variance Just because a condition was/is present (e.g., history of mild TBI), doesn’t mean it should be the focus of further assessment or treatment if other conditions are primary

Difficulty with decisions
+ PTSD Re-experiencing Avoidance Social withdrawal Memory gaps Apathy Arousal Sensitive to noise Concentration Insomnia Irritability ? Mild TBI Residual Difficulty with decisions Mental slowness Concentration Headaches Dizzy Appetite changes Fatigue Sadness + Depression

Issue Four: Who is Responsible?
TBI Clinical Reminder: Primary and Specialty Clinics (including Urgent Care, MHC, PTSD, Dental, etc.) Initial Follow-up Assessment: Polytrauma Program staff (Level II: PNS or Level III: PSCT), SCI Program staff, or Local Designated Specialist(s) - Physician (e.g., Neurologist, PM&R physician)

Issue Four: Who is Responsible? (cont.)
Subsequent Evaluations/Treatments: TBI: PNS or PSCT (PM&R, (Neuro)Psychology, Speech, Psychiatry) PTSD: PTSD Program Chronic Pain: Pain Program or PM&R Somatoform Disorder(s): ????? Depression, Anxiety, Stress: MHC Seizures, Neurologic Conditions: Neurology

Primary & Specialty Clinics

Polytrauma Program staff, SCI Program staff, or
Designated Specialist(s)

Programs / Clinics for Identified Conditions

Issue Five: Coordination of Care Responsibilities
If a Level I, II, or III Polytrauma Program, then the polytrauma team If not, the system is not clear who is responsible for making sure evaluations are completed, treatments are initiate, and symptoms/problems are resolving But, if treatment is not successful within a reasonable time (e.g., 90 days), patients should to be referred to a PNS or PRC

Issue Six: Local versus Regional Care
If the facility has a designated TBI specialist who is assigned to respond to the TBI Clinical Reminders, then initial assessment and treatment should be local If not, assessment should be done by the nearest PNS or PSCT staff If that assessment indicates that local resources can provide the treatment, fine; if not, and the problems are deemed to be TBI-related, then the nearest PNS

Issue Seven: Role(s) of Psychology / Neuropsychology
Members of the PNS or PSCT staff Assessment and treatment if indicated Neuropsychological Evaluations (15% of cases) Psychological Assessments (15-75+% of cases) TBI Rehab Interventions Mild TBI Education & Support Compensatory Training / Cognitive Remediation Stress Management, Education, Support Specialty Treatment PTSD, Depression, Anxiety, Chronic Pain

Important Mild TBI Facts

Causes of Persistent Postconcussion Symptoms

“Expectation as Etiology” and/or “The Good Old Days”
Symptom Mis-Attribution Willey Mittenberg, Ph.D. “Diagnostic Threat” Julie Suhr, Ph.D.

Expectation as Etiology
Controls asked to imagine symptoms of a mild TBI “expected” symptom presence and severity very similar to mild TBI patients’ actual symptoms Mild TBI patients “under-estimated” the frequency and severity of pre-MTBI symptoms and problems Athletes “expected” lower levels of post-concussion problems than non-athletes Athletes with a concussion “over-estimated” pre-concussion levels of symptoms

Mild TBI “Diagnostic Threat”
Non-clinical evaluations of college students with a remote history of mild TBI (many months earlier) Neuropsychological Test Performance If told they are participating in a study of the effects of mild TBI, their performance is worse than, If told they are simply participating in a study of cognitive functioning in college students The “context” of the evaluation matters!

Mild TBI Treatment Change expectation and attribution of symptoms
Provide education Education regarding mild TBI Education regarding symptoms and their course Provide Support/Treatment Stress management Psychological and cognitive coping strategies and resources Cognitive-Behavioral therapy

If There is Time which there will not be

What to Expect: Literature Review Findings
Mild TBI Findings Neuropsychological Test Performance Postconcussion Symptoms Causes of Postconcussion Symptoms Treatment of Mild TBI

Neuropsychological Test Performance

Mild TBI: Neuropsychological Meta-analytic Studies (1)
(Schretlen & Shapiro, 2003) A second recent meta-analytic study found that overall neuropsychological effect size (d) for MTBI in prospective studies was 0.24 Categorized into 4 time-since-injury intervals the effect sizes were: < 7 days 7-29 days 30-89 days > 89 days 0.41 0.29 0.08 0.04

Mild TBI: Neuropsychological Meta-analytic Studies (2)
(Belanger, Curtiss, Demery, Lebowitz, & Vanderploeg, in press) A third recent meta-analytic study found the following, categorized into two time-since-injury intervals and three types of studies: Time Post-Inj. Litigation Based Clinic Based Unselected Samples < 90 days 0.52 No studies 0.63 > 90 days 0.78 0.74 0.04

Vietnam Experience Study (VES)
Neuropsychological and Postconcussive Symptom Findings

Subjects Vietnam Experience Study Data/Center for Disease Control Vietnam Experience Study 1988a, 1988b JAMA 4,462 randomly selected male US Army vets (community dwelling, not clinic-referred or self-referred) Entered military between 1/ /71 Minimum of 4 months active duty Served only one tour of duty

Subjects cont’d Racial makeup of the 4,462 participants:
81.9% Caucasian 11.8% African-American 4.5% Hispanic 1.9% Other Mean age = years (SD = 2.53) Mean level of education = years (SD = 2.3) Mean IQ = 105 (SD = 20.32) (based on GTT) This was during the period of the draft, so these veterans represent the population of the United States at that time quite well.

Subjects cont’d Participants underwent a 3 day evaluation including:
extensive medical, psychological, and neuropsychological examination included were questions regarding MVA, head injury, loss of consciousness, and subsequent hospitalization Evaluations took place approximately 16 years post-military discharge

Measures Diagnostic Interview Schedule (DIS-III-A)
Extensive surveys of physical functioning and symptoms Battery of neuropsychological tests

Groups and Sample Sizes
Since your discharge from active duty have you been injured in a motor vehicle accident? Since your discharge from active duty have you injured your head? Did you lose consciousness (black out) as a result of the head injury?

Neuropsychological Measures
Multivariate analysis of variance (MANOVA) was conducted with 14 neuropsychological measures, which cover the domains of: Complex Attention Psychomotor Speed & Coordination Verbal Abilities Executive Abilities Non-Verbal Abilities (visuospatial) Verbal Memory Visual Memory Measures included the General Technical Test, parts of the Wechsler Adult Intelligence Test - Revised, the Wisconsin Card Sorting Test, Verbal Fluency Measures, and other neuropsychological tests commonly used in brain injury settings.

MANOVA was not significant F(30,7620) = 1.28, p = 0.14,
Statistical Analyses: Neuropsychological Measures (Matching groups on premorbid IQ) MANOVA was not significant F(30,7620) = 1.28, p = 0.14, eta squared = 0.005 On average, the MTBI group performed 0.03 of a standard deviation more poorly than either control group The eta squared measure of .005 indicates that across the four groups the variation in neuropsychological performance accounted for 0.5% of variations in levels of performance. That is, virtually no differences were present across the groups on cognitive measures.

Current Cognitive Functioning: Examples of the 14 Measures
This slide shows some representative cognitive test performance patterns across the four groups on measures of verbal fluency, visuospatial abilities, and memory functioning. As you can see, raw score differences on the neuropsychological measures were less than one point. Groups are virtually identical, and mild head injury, with or without loss of consciousness, has no long-term adverse effects of cognitive abilities.

Postconcussion Symptoms

Postconcussion Symptoms
Physical Headache, dizziness, fatigue, noise/light intolerance, insomnia Cognitive Memory complaints, poor concentration Emotional Depression, anxiety, irritability, mood lability

PCS Diagnostic Criteria
ICD-10 Three or more of: Headache, dizziness, malaise, fatigue, or noise intolerance Irritability, depression, anxiety, or emotional lability Subjective concentration, memory, or intellectual difficulties Insomnia or affective lability DSM-IV Three or more of: 1. Fatigue 2. Disordered Sleep 3. Headache 4. Dizziness 5. Irritability 6. Anxiety, depression, or affective lability

(Controlling for Demographics, Medical, & Prior Psychiatric Symptoms)
Odds-Ratios for Occurrence of the Postconcussion Symptom Complex over Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Diagnosis Normal Control MVA Control Mild TBI DSM-IV Postconcussion Syndrome 1.0 (20.6%) 1.04 ( ) (25.2%) 2.00 ( ) (40.9%) ICD-10 (19.1%) 1.13 ( ) (24.9%) 1.80 ( ) (37.4%)

Odds-Ratios for Various Physical/Neurological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control MVA Control Mild TBI Balance Problems 1.0 (3.4%) 1.58 (1.02 – 2.45) 2.43 (1.48 – 3.97) Sensitivity to Light 1.0 (3.6%) 1.14 (0.72 – 1.80) 1.92 (1.15 – 3.20) Headache Problems 1.0 (13.0%) 1.15 (0.89 – 1.50) 1.94 (1.42 – 2.68) Trouble Sleeping 1.0 (24.9%) 1.22 (1.01 – 1.51) 1.85 (1.39 – 2.45) Double Vision 1.0 (5.7%) 1.10 (0.75 – 1.61) 1.81 (1.17 – 2.79) Fatigue Easily 1.0 (20.9%) 1.00 (0.80 – 1.26) 1.42 (1.05 – 1.91)

Odds-Ratios for Various Cognitive/Neuropsychological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control MVA Control Mild TBI Periods of Memory Loss or Confusion 1.0 (4.4%) 1.14 (0.76 – 1.72) 2.80 (1.83 – 4.28) Memory Problems 1.0 (13.7%) 1.13 (0.87 – 1.46) 1.75 (1.28 – 2.41) Concentration Problems 1.0 (13.4%) 1.40 (1.10 – 1.80) 1.28 (0.91 – 1.80)

Odds-Ratios for Various Emotional/Psychological Postconcussion Symptoms During the Past Year (Controlling for Demographics, Medical, & Prior Psychiatric Symptoms) Symptom Normal Control MVA Control Mild TBI Irritability or Short Temper 1.0 (26.5%) 1.10 (0.89 – 1.35) 1.36 (1.02 – 1.81) Aggressive and Angry Behavior 1.0 (10.2%) 1.34 (1.02 – 1.77) 1.32 (0.91 – 1.91) Sadness and Depression 1.0 (11.2%) 1.28 (0.97 – 1.69) 0.92 (0.62 – 1.37) Anxious 1.0 (13.8%) 1.29 (0.99 – 1.65) 1.10 (0.77 – 1.56)

Causes of Persistent Postconcussion Symptoms

“Expectation as Etiology” and/or “The Good Old Days”
Symptom Mis-Attribution Willey Mittenberg, Ph.D. “Diagnostic Threat” Julie Suhr, Ph.D.

Expectation as Etiology
Controls asked to imagine symptoms of a mild TBI “expect” symptom presence and severity very similar to mild TBI patients’ actual symptoms Mild TBI patients “under-estimate” the frequency and severity of pre-MTBI symptoms and problems Athletes “expect” lower levels of post-concussion problems than non-athletes Athletes with a concussion “over-estimate” pre-concussion levels of symptoms

Mild TBI “Diagnostic Threat”
Non-clinical evaluations of college students with a remote history of mild TBI (many months earlier) Neuropsychological Test Performance If told they are participating in a study of the effects of mild TBI, their performance is worse than, If told they are simply participating in a study of cognitive functioning in college students The “context” of the evaluation matters!

Other Factors Influencing the Development and Persistence of Persistent Postconcussion Symptoms

Predictors of Persistent PCS: Vietnam Experience Study Data
Examine the influence of the following predictors on the presence of a persistent Postconcussion Symptom Complex (PPCS) following mild head injury Predictors: demographic variables early life psychiatric difficulties social support variables loss of consciousness In this component of the study, we sought to examine the influence of a number of variables such as these listed here on the persistence of PCS in a mild head injured sample. pause

Results Overall model was significant MTBI R2 = 33.0
MTBI 2 (26, N = 532) = , p < .001 Unique Variance per predictor MTBI demographic variables (9.2%) early life psychiatric symptoms (6.3%) Internalizing (e.g., depression/anxiety) (4.9%) Externalizing (ASP, alcohol, drugs) (0.9%) social support (4.9%) LOC / MVA (1.4%) 2-way Interactions (5.4%) 3-way Interactions (0.1%) As you can see here, the overall model was significant accounting for 14.3% of the variance. We then examined the potential contribution of each predictor by partitioning out the unique variance (entered each predictor last). As you can see, the subject characteristics accounted for the largest amount of variance (6.7%), followed by early life psychiatric symptoms (2.4%). Social support accounted for 2.1% of the variance. Surprisingly, Adverse events and Loss of Consciousness accounted for almost no variance. Because of the lack of relationship with these two variables, we wanted to replicate these findings to increase our confidence in their validity. Therefore we decided to use an experimental rather than a statistical method of control. However, first we needed to determine which subject characteristics were salient predictors.

Contribution of Demographic Variables in MTBI
Overall Demogr. Variance 9.2% unique variance Variable MTBI Age at evaluation 0.9% Level of education 0.2% Race % Intelligence 3.3% Therefore, we did another LR on subject characteristics to determine the unique contribution of each of these variables. This would allow us to control for those confounds in a re-examination of odds ratios across groups for persistent PCS. As you can see on the slide, employment (full, multiple jobs, part-time or unemployed) accounted for the largest portion of the unique variance 2.2% Intelligence was next (1%)

MTBI: Intelligence by LOC (1.8%)

MTBI: Intelligence by Social Support (1.2%)

MTBI: Internalizing by Social Support (1.0%)

PCS Conclusions LOC is only a small factor in predicting the presence of PPCS (1.4% unique variance) in MHI Multiple factors and their interactions accounted for approximately 33% of the variance in PPCS status in the sample with MHI

PCS Conclusions Within a MTBI sample: Lower pre-injury intellectual ability, Less poor social support, and More early life emotional problems (e.g., depression, anxiety) were associated with higher frequencies of Persistent PCS Loss of consciousness (MTBI) interacts with cognitive reserve in influencing the development or persistence of PCS

Treatment of Mild TBI

Mild TBI Treatment Change expectation and attribution of symptoms
Provide education Education regarding mild TBI Education regarding symptoms and their course Provide Support/Treatment Stress management Psychological and cognitive coping strategies and resources Cognitive-Behavioral therapy

References Belanger, H. G., Curtiss, G., Demery, J. A., Lebowitz, B. K., & Vanderploeg, R. D. (2005). Factors moderating neuropsychological outcomes following mild traumatic brain injury: A Meta-analysis. Journal of the International Neuropsychological Society, 11, Belanger, H.G., & Vanderploeg, R.D. (2005). The Neuropsychological Impact of Sports-Related Concussion: A Meta-Analysis. Journal of the International Neuropsychological Society, 11, Luis, C. A., Vanderploeg, R. D., Curtiss, G. (2003). Predictors for a postconcussion symptom complex in community dwelling male veterans. Journal of the International Neuropsychology Society, 9, Miller, L.J. & Mittenberg, W. (1998). Brief cognitive behavioral interventions in mild traumatic brain injury. Applied Neuropsychology, 5, Mittenberg, W., Tremont, G., Zeilinski, R., Fichera, S., & Rayls, K. (1996). Cognitive behavioral prevention of postconcussion syndrome. Archives of Clinical Neuropsychology, 11, Mittenberg, W., Zielinski, R.E., & Fichera, S. (1993). Recovery from mild head injury: A treatment manual for patients. Psychotherapy in Private Practice, 12,

References Schretlen, D. J., & Shapiro, A. M. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International Review of Psychiatry, 15, Suhr, J.A. & Gunstad, J. (2005). Further exploration of the effect of “diagnosis threat” on cognitive performance in individuals with mild head injury. Journal of the International Neuropsychological Society, 11, Vanderploeg, R. D., Curtiss, G., & Belanger, H. G. (2005). Adverse long-term neuropsychological outcomes following mild traumatic brain injury. Journal of the International Neuropsychological Society, 11, Vanderploeg, R.D., Belanger, H.G., & Curtiss, G. (2006). Mild Traumatic Brain Injury: Medical and Neuropsychological Causality Modeling. (pp ). In Young, G., Kane, A. & Nicholson, K. (Eds.), Psychological Knowledge in Court: PTSD, Pain and TBI. New York: Springer-Verlag. Vanderploeg, R.D. (2004). Veterans Health Initiative: Traumatic Brain Injury. (Editor). VA Employee Education System. Web-based physician, psychologist, & other health care professionals CME/CEU training program. [ ] Vanderploeg, R. D., Curtiss, G., Luis, C. A., & Salazar, A. M. (in press). Long-term morbidity and quality of life following mild head injury. Journal of Clinical and Experimental Neuropsychology.

Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process Rodney D. Vanderploeg, Ph.D. Tampa.

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Roles of Neuropsychology and Psychology following Positive TBI Clinical Reminders: The Evaluation and Treatment Process Rodney D. Vanderploeg, Ph.D. Tampa.

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