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Toolkit for Providers of Clients with Co-occurring TBI and Mental Health Symptoms

Rocky Mountain MIRECC for Veteran Suicide Prevention

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Traumatic Brain Injury

The Traumatic Brain Injury ToolkitAs of 2008, an estimated 320,000 Veterans of the wars in Iraq and Afghanistan experienced a traumatic brain injury (TBI) during deployment (Tanielian and Jaycox, 2008). Members of the general population acquire TBI as well. According to the Centers for Disease Control and Prevention (CDC) (2014) an estimated 1.7 million Americans sustain a traumatic brain injury (TBI) each year. This section provides information on TBI screening, assessment and intervention.

Reference

Tanielian, T., & Jaycox, L. H. (Eds.). (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.

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TBI: Background Information

Definition of TBI

The CDC (2014) defines TBI as “a bump, blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. More information can be found at the CDC website on TBI.

The severity of a TBI may range from “mild,” i.e., a brief change in mental status or consciousness to “severe,” i.e., an extended period of unconsciousness or amnesia after the injury.”

TBI severity is classified as mild, moderate or severe using criteria described in the table below. If a client meets criteria in more than one category of severity, the higher severity level is assigned.

TBI Severity Classification

CriteriaMildModerateSevere
Structural imaging Normal Normal or abnormal Normal or abnormal
Alteration of consciousness (AOC)* a moment to 24 hours >24 hours. Severity based on other criteria Alteration of consciousness (AOC)*
Loss of Consciousness (LOC) 0-30 min >30 min and <24 hours >24 hours
Post-Traumatic Amnesia (PTA) 0-24 hours >24 hours and <7 days >7 days
Glascow Coma Scale (GCS) (best available score in first 24 hours) 13-15 9-12 <9
Table adapted from Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline, as found in the Textbook of Traumatic Brain Injury, 2nd Ed. 2011, p. 5
* AOC must be immediately following the injury event. Symptoms may include: feeling dazed, confusion, difficulty thinking clearly or responding appropriately, and being unable to describe events immediately before or after the injury event.

Reference

Centers for Disease Control and Prevention. (2011). Injury prevention and control: Traumatic brain injury. Retrieved from Centers for Disease Control and Prevention website on August 20, 2014.

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Traumatic Brain Injury (TBI) Sequelae and Symptoms

Mild injuries are typically associated with short-term difficulties that resolve in 3 months to one year following injury.The majority of military and civilian TBIs sustained, approximately 75%, are mild in nature (CDC, 2014). The definition for Mild Traumatic Brain Injury (mTBI) as defined by the American Congress of Rehabilitation Medicine (ACRM) (1993) includes presence of at least one of the following:

  1. any period of Loss of Consciousness (LOC);
  2. any loss of memory for events immediately before or after the event;
  3. any Alteration of Consciousness (AOC) at the time of the event (e.g., feeling dazed, disoriented, or confused); and
  4. focal neurological deficit(s) that may or may not be transient, but where severity of the injury does not exceed the following:
    • loss of consciousness of approximately 30 minutes or less;
    • a Glasgow Coma Sale (GCS) of 13-15 after 30 minutes; and
    • Post Traumatic Amnesia (PTA) of 24 hours.

Mild, moderate, or severe TBI can cause a wide range of functional short- or long-term changes affecting thinking, sensation, language, or emotions. Common TBI sequelae are listed below. Mild injuries are typically associated with short-term difficulties that resolve in 3 months to one year following injury. Those with moderate to severe injuries may experience longer-term difficulties.

Reference

Centers for Disease Control and Prevention. (2011). Injury prevention and control: Traumatic brain injury. Retrieved from Centers for Disease Control and Prevention website on August 20, 2014.

Common mTBI sequelae

Post-concussion syndrome is a complex disorder in which a combination of symptoms after a concussion (or, mTBI), last for weeks to months after the injury (Mayo Clinic, n.d). Symptoms generally present within the first 7-10 days and go away within three months, though they can persist for a year or more.

Symptoms may include:

  • headaches,
  • dizziness,
  • fatigue,
  • irritability,
  • anxiety,
  • insomnia,
  • loss of concentration and memory, and
  • noise and light sensitivity

Please visit the Mayo Clinic website for more information about post-concussion syndrome

Reference

Mayo Clinic. (n.d.). Diseases and Conditions: Post-concussion syndrome. Retrieved here on August 20, 2014.

Common Moderate to Severe TBI Sequelae

The symptoms of moderate to severe TBI are serious and can have an effect on many aspects of a person’s life (The Center of Excellence for Medical Multimedia, n.d.). Symptoms may include:

  • A headache that gets worse or does not go away
  • Dizziness
  • Pain
  • Fatigue
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • The inability to wake up from sleep
  • Dilation of one or both pupils of the eyes
  • Problems speaking
  • Weakness or numbness in the hands and feet
  • Loss of coordination or balance
  • Confusion, restlessness, or agitation
  • Problems sleeping
  • Memory, language, and attention difficulties
  • Unpredictable mood, aggressive outbursts, or inappropriateness
  • Depression, anxiety and personality changes

Another symptom of TBI is memory loss, called post-traumatic amnesia, or PTA. During this time, individuals are unable to form accurate and consistent memories of information and events. How long the amnesia lasts helps determine how badly the brain is injured. If PTA lasts for more than one week, long-term problems with thinking, planning, behavior and personality are more likely.

For more information about mild, moderate and severe TBI

Reference

The Center of Excellence for Medical Multimedia. (n.d.). Symptoms of Moderate to Severe TBI. In the Traumatic Brain Injury website. Retrieved here on August 20, 2014.

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TBI: Screening

Traumatic Brain Injury-4 (TBI-4)

1. Have you ever been hospitalized or treated in an emergency room following a head or neck injury? (Yes/No)

2. Have you ever been knocked out or unconscious following an accident or injury? (Yes/No)

3. Have you ever injured your head or neck in a car accident or from some other moving vehicle accident? (Yes/No)

4. Have you ever injured your head or neck in a fight or fall? (Yes/No)

Brenner et al., 2013

Screening for TBI is the first step in gathering information regarding probable injury. The TBI-4 and the first five questions of the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are two examples of questions that can assist providers with screening.

A “yes” response to any of the questions is indicative of a probable TBI and warrants further assessment to confirm or deny previous injury. A positive response to question 2 is the most likely indicator of probable TBI when using the TBI-4.

If a client answers “no” to all of the questions, no further assessment is needed.

Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID)

Ohio State University Traumatic Brain Injury Identification MethodThe first five questions from the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) (Corrigan and Bogner, 2007; Bogner and Corrigan, 2009) are listed below:

  1. In your lifetime, have you ever been hospitalized or treated in an emergency room following an injury to your head or neck? Think about any childhood injuries you remember or were told about. (Yes/No)
  2. In your lifetime, have you ever injured your head or neck in a car accident or from crashing some other moving vehicle like a bicycle, motorcycle, or ATV? (Yes/No)
  3. In your lifetime, have you ever injured your head or neck in a fall or from being hit by something (for example, falling from a bike or horse, rollerblading, falling on ice, being hit by a rock?) Have you ever injured your head or neck playing sports or on the playground? (Yes/No)
  4. In your lifetime, have you ever injured your head or neck in a fight, from being hit by someone, or from being shaken violently? Have you ever been shot in the head? (Yes/No)
  5. In your lifetime, have you ever been nearby when an explosion or a blast occurred? If you served in the military, think about any combat-or training-related incidents. (Yes/No)

 

If an individual responds yes to any of these questions, further assessment can be completed using the rest of the OSU TBI-ID.

Download the OSU TBI-ID and view an instructional video from The Ohio Valley Center for Brain Injury Prevention and Rehabilitation.

References

Corrigan, J. D., & Bogner, J. A. (2007). Initial reliability and validity of the OSU TBI Identification Method. Journal of Head Trauma Rehabilitation, 22(6), 318–329.

Bogner, J. A., & Corrigan, J. D. (2009). Reliability and validity of the OSU TBI identification method with prisoners. Journal of Head Trauma Rehabilitation, 24(6), 279–291.

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TBI: Assessment

Diagnosis of TBI and its associated comorbid symptoms and disorders present unique challenges to reliably making a diagnosis of TBI. As such, no screening instruments available can reliably make the diagnosis. Instead, full assessment should be implemented when screening results indicate probable TBI. It should be noted that assessment via brain imaging is not useful in detecting history of mTBI. As such, structured clinical interview is considered the gold standard assessment approach for diagnosing TBI. Assessment using a structured clinical interview will help to clarify the nature of the injury, confirm injury events, determine if a TBI was sustained, and if so, the severity of injury. The Ohio Valley Center for Brain Injury Prevention and Rehabilitation offers training regarding assessment of TBI history and related symptoms using the gold-standard Ohio State University TBI Identification Method (OSU TBI-ID). Although structured interview relies on verbal history which may be difficult to obtain, this approach provides a means for clinicians to elicit and obtain as much detailed injury history as possible in order to make a diagnosis.

TBI Assessment Tools

After information regarding TBI history has been gathered and a history of probable injury or injuries has been confirmed to establish diagnosis, it can be helpful to assess if and how symptoms associated with TBI may be impacting the client's life. Several tools are available to facilitate this process.

Symptoms

Neuro-behavioral Symptom Inventory (NSI)

The NSI (Cicerone & Kalmar, 1995) is a 22-item self-report measure of post-concussive (PC) symptoms that commonly occur after mild TBI, including affective, somatic, sensory and cognitive complaints. It can be used as part of a larger assessment battery.

Reference
Cicerone, K. D., & Kalmar, K. (1995). Persistent postconcussion syndrome: The structure of subjective complaints after mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 10, 1–17.

Functioning

Craig Handicap Assessment and Reporting Technique (CHART)

The CHART (Whiteneck et al., 1992) is a 32-item interview based assessment which was developed to measure the degree to which impairments and disabilities result in handicaps years after initial rehabilitation. It can be used for individuals with a history of moderate to severe TBI. The CHART assesses functioning in six domains:

  1. Cognitive Independence — the ability to “orient”;
  2. Physical Independence — the ability to sustain a customarily effective independent existence;
  3. Mobility — the ability to move about effectively in surroundings;
  4. Occupation — ability to occupy time in the manner customary to that person’s sex, age, and culture;
  5. Social Integration — the ability to participate in and maintain customary social relationships; and
  6. Economic Self-Sufficiency — the ability to sustain customary socioeconomic activity and independence.

 

In addition to the 32-item measure, a short form comprised of 19 questions is also available. The measure can be accessed here.

Reference
Whiteneck, G.G., Charlifue, S.W., Frankel, M.H., Gardner, B.P., Gerhart, K.A., Krishnan, K.R., Menter, R.R., Nuseibeh, I., Short, D.J., et al. (1992). Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Paraplegia,30(9), 617-30


World Health Organization Quality of Life (WHOQOL)

The WHOQOL is available in a 100 item measure (WHOQOL-100: WHO, 1995) and an abbreviated 26-item version (WHOQOL-BREF; WHO, 1996). The instrument assesses a client’s perceived functioning in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. Quality of life is determined by assessing the following domains:

  1. Physical Health;
  2. Psychological;
  3. Level of Independence;
  4. Social Relationships;
  5. Environment; and
  6. Spirituality/Religion/Personal Beliefs.

 

It can be used on individuals with history of mild and moderate to severe TBI. This measure is available in more than 20 languages. Information about the measure can be found here. The WHOQOL-100 can be downloaded directly. The WHOQOL-BREF can be downloaded here.

References
World Health Organization Quality of Life Group. (1995). The World Health Organization quality of life assessment (WHOQOL): Position paper from the World Health Organization. Social Science & Medicine, 41(10), 1403-1409.

WHOQOL-BREF. (1996). Introduction, administration, scoring and generic version of the assessment—field trail version. Geneva: World Health Organization.


Daily Living Activities-20 (DLA-20) (for mental health)

The DLA-20 (Scott & Presmanes, 2001) is a 20-item measure used to assess functioning in daily living areas that may be impacted by mental illness or disability. The measure is available upon completion of online training by MTM Services. Information regarding the measure and training can be found here. This measure can be used on individuals with mild and moderate to severe TBI.

Reference
Scott, R.L., Presmanes, W. (2001). Reliability and validity of the Daily Living Activities Scale: a functional assessment measure for severe mental disorders. Research on Social Work Practice: 11(3), 373-389.


Participation Assessment with Recombined Tools-Objective (PART-O)

The PART-O (Whiteneck, et al., 2011) is a 24-item measure that was developed to measure the objective participation of persons with moderate to severe TBI. In addition to the 24-item measure, a short form comprised of 17 items (PART-O-17) is also available (Bogner, Whiteneck, Corrigan, et al., 2011).

References
Whiteneck G, Dijkers M, Heinemann AW, Bogner J, Bushnik T. Cicerone K, Corrigan JD, Hart T, & Malec J. Development of the Participation Assessment with Recombined Tools-Objective for use with individuals with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 2011;92:542-51.

Bogner JA, Whiteneck G, Corrigan JD, Lai JS, Dijkers MP, Heinemann AW. Comparison of scoring methods for the Participation Assessment with Recombined Tools–Objective. Archives of Physical Medicine and Rehabilitation. 2011;92:552-63.


The results from these assessments, in conjunction with other diagnostic information (e.g., mental health diagnoses and symptoms and medical diagnoses and symptoms), can facilitate comprehensive case conceptualization, identification of client-specific needs and related treatment planning.

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TBI: Intervention

Clinical Practice Guidelines

The following provide links to clinical practice guidelines for mild TBI and persistent symptoms. These guidelines offer information and direction to providers managing clients’ recovery from mTBI:

  • VA and DoD worked together to create the Clinical Practice Guidelines for mTBI to facilitate consistent and beneficial treatment. Download the guidelines.
  • The Ontario Neurotrauma Foundation also created Guidelines for Concussion/Mild TBI and Persistent Symptoms, which include information about the treatment of persistent symptoms. Download the guidelines.

Strategies to Facilitate EBP

There are currently no widely established evidence-based practices (EBPs) focused on TBI. Those with a history of mTBI may benefit from any number of EBPs and may or may not require modifications to treatment delivery. Those with a history of moderate to severe TBI are most likely to require modifications to treatment delivery. For information regarding recommendations in this regard, please see Olson-Madden, Brenner, Matarazzo, Signoracci, and Expert Consensus Collaborators (2013).

Below are examples of several challenges clinicians often face when providing EBPs to individuals with a history of TBI. Specific strategies are provided with each question. Please also see Signoracci, Matarazzo, Bahraini (2012).

Question: Do you ever notice your client having a difficult time learning or remembering information they hear?

  • Strategy: Slow pace of conversation
    • Function: Facilitate learning and memory for individuals who may become overwhelmed with auditory information
      • Example: N/A

Question: Do you and your client have difficulties with miscommunication?

  • Strategy: Use client’s language
    • Function: Reduce miscommunication while facilitating establishment of rapport
      • Example: Clinician uses same language as an individual who refers to a difficult experience with a particular term or phrase (e.g., "the accident", "when I got hurt", etc)

Question: Does it seem like your client gets overwhelmed with information?

  • Strategy: Take short breaks
    • Function: Prevent cognitive overload. Increase opportunities for consolidation of information
      • Example: Input from individual will be helpful to determine length of breaks needed and when breaks should be implemented to be most helpful

Question: Does your client struggle with staying organized in session?

  • Strategy: Write things down/draw things out collaboratively with the client
    • Function: Facilitate organization
      Facilitate learning and  memory for individuals who may become overwhelmed by auditory information
      Facilitate understanding of circumstances and events that may precede distress, conflict, or crisis (i.e., suicidal ideation, amd/or engagement in self-directed violence)
      • Example: Write down key points/information/examples when in session
        Draw timelines to capture sequence of events that may have preceded distress, conflict, or crisis

Question: Does your client need reminders to help them function daily?

  • Strategy: Utilize visual cues
    • Function: Create environmental prompts to engage in coping strategies and engagement in activities of daily living (ADLs)
      • Example: Posting pictures representing coping skills, tasks to complete, and inspirational quotes in easy to see/highly used areas

Question: Does your client tend to isolate?

  • Strategy: Incorporate supports proactively in activity planning
    • Function: Consistently engage social supports to reduce isolation and increase active engagement in coping strategies and ALDs
      Educate social supports about the plan and incorporate them in a proactive and meaningful way may increase likelihood of successful implementation of activity plans/schedules
      • Example: Regularly scheduled check-ins with social supports
        Appointments (medical, mental health, social support groups, community activities)
        Sharing activity plans/schedules with social supports identified in the plan

Question: Does your client have difficulty remembering what was discussed in session?

  • Strategy: Ask the client to provide summaries
    • Function: Provide opportunity for individuals to consolidate and articulate their understanding of information
      • Example: Individual provides a summary of self-assessment (e.g., When I am by myself for long periods of time, I am more likely become sad, unmotivated, anxious)
        Individual provides a summary of planning strategies (e.g., After I have been by myself for more than 3 hours, I will call someone listed on my activity plan/schedule and make arrangements to spend time together)

Question: Does your client seem to understand how to complete tasks, but still have difficulty completing things on their own?

  • Strategy: Role-play
    • Function: Practice engaging in coping strategies and ADLs with support and opportunities for modification to reduce challenges/barriers and increase problem solving
      • Example: Practice engaging in coping strategies and ADLs
        Practice using the activity plan/schedule (calling supports, engaging in self-care activities, etc)

Question:Does your client sometimes not engage in coping strategies you may have provided?

  • Strategy: Utilize client identified coping strategies and work collaboratively to design implementation
    • Function: Increase likelihood of implementation of activity plans/schedules by planning engagement in meaningful activities that facilitate coping and pleasure
      • Example: Provider facilitates planning for meaningful activities as identified by the client (e.g., working out, calling a support, spending time with favorite pet)

References

Olson-Madden, J., Brenner, L., Matarazzo, B., & Signoracci, G. (2013). Identification and treatment of TBI and co-occuring psychiatric symptoms among OEF/OIF/OND veterans seeking mental health services within the state of Colorado: Establishing consensus for best practices. Community Mental Health Journal, 49(2), 220-229.

Signoracci, G.M., Matarazzo, B.B., Bahraini, N.H. (2012). Traumatic Brain Injury and Suicide: Contributing Factors, Risk Assessment and Safety Planning. In J. Lavigne & J. Kemp (Eds.), Frontiers in suicide prevention and risk research, treatment and prevention. Hauppauge, NY: Nova Science Publishers, Inc.

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Additional Helpful Information about Brain Injuries

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Your Feedback

 

Your feedback is tremendously important to keeping this toolkit up to date and relevant. If you find broken links, out of date information, or you have questions, suggestions or quibbles please contact Joe Huggins at joe.huggins@va.gov.

Thanks!

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