Neuropsychological Disorders: Part I

Acquired Brain Injuries (ABI)

When someone’s brain was developing and functioning as expected, before some insult or event that disrupted this functioning

• Symptoms and outcome depend on the cause and severity of the brain injury

• Can also depend on pre-existing factors and the post-injury environment

• Sudden onset

Common causes of ABI

• TBI

• Stroke

• Infection and diseases

• Brain tumour

• Epilepsy

• Alcohol related brain injury

• Drug abuse

• Poisoning/inhalation of organic solvents

• Hypoxia/anoxia (lack of oxygen)

Neurodevelopmental Conditions

Occur due to brain differences occurring prior to birth

• Often diagnosed in children, but can be later detected in adults

• Assessment and intervention follow the same protocols as clinical neuropsychology

Neurological disorders can be due too…

• Developmental factors

• ABI

True or False: Brain injury conditions are always overt

False

What is the most typical external causes of acquired brain injury?

• Motor vehicle and traffic accidents

• Falls

• Hit by an object

• Assault

• Sports related (particularly in USA)

• Work related or industrial accidents

• Blast injuries

% of ABI caused by sports related injuries in USA

20%

What are some causes of ABI that are not caused by traumatic injury?

• Poisoning

• Inhalation of organic solvents

• Substance use

• Infections

Describe some sources of ABI caused by infection

• Bacterial (i.e. meningitus and brain abscesses)

• Viral (i.e. herpes)

• Parasitic (e.g. cerebral malaria)

• Encephalitis (inflammation of CNS due to infection)

• COVID-19 complications

What did Ellul et al. find in relation to COVID-19 and neurological associations?

• Linked to increased risk of strokes

What are the internal causes of ABI?

• Strokes and aneurisms

• Tumours

• Epilepsy

• Metabolic disturbance (i.e. diabetic coma)

• Dementia

What are the secondary effects of TBI?

• Haemorrhage or haematoma

• Intracranial pressure

• Oedema or brain swelling

• Post-traumatic epilepsy

Progressive Neurological Conditions

• Alzheimer’s disease

• Parkinson’s

• Multiple sclerosis

• Huntington’s

• Wernicke Korsakoff’s syndrome

Describe the ABI prevalence rates across Australia

• Most people with ABI reside in Queensland, where numbers are significantly above average

• 41% of people aged under 65 with ABI live outside of major cities, which is higher than the proportion of people with disabilities and the population of Australia within this age group

Important note: Doesn’t include people above 65

Source: AIHW, 2007

Describe the rates (per 100 000) of different types of ABI in Australia and the number of new cases each year

TBI:

• Significantly higher for men (150) than women (65)

• Lowest increase rate per year, with 22 000 new cases each year

Stroke

• Non-significant difference between men (175) and women (172)

• Increasing at a rate of 50 000 new cases per year

Dementia

• Higher for women (449) than men (325)

• Highest rate of increase with 93 000 new cases per year

Paints the picture that dementia is a growing issue!!

True or False: The prevalence of ABI increases with age

True

• People 65 or older are more than twice as likely to have ABI with participation restrictions/activity limitations

What are some areas of assistance often required by people who have ABI?

• Self-care

• Mobility

• Communication

• Cognitive/emotional support

• Health care

• Housework

• Property maintenance

• Paperwork

• Meal preparation

• Transport

Open Head Injury

Penetration of skull and protective membrane

• I.e. gunshot, sharp objects

Symptoms include:

• Often no loss of consciousness

• Localised symptoms

• Relatively rapid and spontaneous recovery

Think: Phineas Gage

Closed Brain Injuries

No penetration of skull or protective membrane

• Damage results from mechanical forces (i.e. concussion)

• Diffuse axonal injury and focal lesion (contusions) in frontal and temporal areas

  • Think: Axons and neural connections are impacted and can spread basically

• Caused by things like car accidents, falls, assaults and sport

Coup

Brain damage at the site of impact

Think: Running into a pole and getting brain damage to your frontal cortex (pink)

Contracoup

Brain damage that occurs on the opposite side of the brain to where the impact occurred

Think: Contradiction - you think the injury is where the impact is but it’s actually the opposite (blue)

How do you measure the severity of TBI?

• Glasgow Coma Score

• Post traumatic amnesia

• Results of neuroimaging

Glasgow Coma Score (GCS)

Measures the presence and depth of a coma

• Can be used to measure severity of TBI

• Assesses eye opening, motor response and verbal responses

• Lower score (or absence of these things) indicates a more severe coma

Post-traumatic Amnesia

Can be used to measure severity of TBI

• Refers to the period of time prior to return of ongoing memory after an injury

• If less than 5 minutes, very mild

• When more than 1 more, it is looking more severe

• Greater than 4 weeks is extremely severe

Think: When dad was knocked off his bike and started taking pictures of the scene, but can’t remember a thing

What tends to happen to GCS’s when post traumatic amnesia gets higher?

They tend to decrease

• Greater absence of things like eye opening, motor responses and verbal responses

Think: Greater amnesia = greater severity. It is unlikely that a severe brain injury will not be overt

What neuroimaging techniques can be used to assess TBI severity?

• Computed tomography (CT)

• Magnetic resonance imaging (MRI)

Computed Tomography (CT)

Useful to detect skull fracture, haematomas, large contusions, abscesses, swelling, infraction ventricular enlargement and atrophy

• Quicker than MRI and easier to monitor patient

Magnetic Resonance Imaging (MRI)

More sensitive than CT with greater resolution

• Takes longer and has greater incompatibilities

Characteristics of TBI:

Mild TBI/Concussion

Assessment Results:

• Loss of consciousness < 30 minutes

• Pst-traumatic amnesia < 24 hours

• GCS = 13-15 (most things intact)

Symptoms

• Typically no neurological deficits

• Symptoms resolve within days-weeks

• 15-25% of cases experience ongoing symptoms (few)

Repeated head injury can lead to chronic traumatic encephalopathy (progressive neurodegenerative disease - common with athletes)

Mild TBIs and concussions, when repeated, are linked to

Chronic traumatic encephalopathy and mental health problems

Think: Rugby/AFL players and heightened suicide risk

Characteristics of TBI:

Moderate/Severe TBI

Assessment Results:

• Coma > 1hr

• Post traumatic amnesia > 1 day

Characteristics/Symptoms

• Varies according to site and extent of injury

• Sensorimotor deficits

  • Motor weakness or paralysis

  • Incoordination

  • Loss of motor skills and dexterity

  • Poor balance

  • Reduce physical endurance

• Speech issues

• Swallowing issues

• Impacts on smell, sight, hearing, taste, pain, temperature, texture and proprioception

Also associated with ongoing symptoms

Ongoing Symptoms of moderate/severe TBI

• Difficulties with fatigue, attention, memory, EF and behavioural regulation

• Focal impairments (language, perception and praxis)

• Cognitive and behavioural issues

• Psychological issues

Think: Everything that happened with Phineas Gage basically

What are the negative psychosocial outcomes that can follow after moderate/severe TBI?

• Unemployment or changed duties

• Reduced participation in activities

• Reduced leisure activities

• Social isolation

• Difficulty with new/existing personal relationships

• Depression, anxiety and loss of self-worth

• Sexuality issues

Think: Life is changed dramatically because they either don’t have the physical capabilities they once did, or they are facing social stigma and issues. How can you engage in the things you were once passionate about? Things would be incredibly difficult and overwhelming, especially with compounding factors such as fatigue and behavioural regulation deficits

What are the causes of psychological problems following TBI?

• Directly related to brain injury

• Secondary factors associated with brain injury

• Premorbid factors

How can psychological factors occur after brain injury that are directly related to the injury?

• Site of damage may be localised to areas involved in behavioural and affective regulation, such as frontal, limbic and right hemispheric regions.

• This would lead to disruptions to neural networks and neurotransmitter systems involved in emotion regulation, initiation, motivation etc.

What secondary factors associated with brain injury can cause psychological issues?

• Social isolation

• Reduced independence

• Change of identity and roles

• Grief and loss reactions

• Increasing insight into changed future

• Cognitive flexibility and concrete thinking style

• Body image changes

• Medication side effects

Think: The social and ecological consequences requiring interaction with environment and introspection

What premorbid factors associated with brain injury can cause psychological issues?

• Previous psychological problems, personality factors or coping styles

• Substance abuse

• Lack of family/social supports

Think: Things that were already there before the injury occurred, or prognostic variables

What are common family issues in families facing TBI?

• Frequent initial denial

• Families usually left with long-term responsibility for practical, social and emotional needs of injured person

• Behaviour change causes greatest distress

• Different burden upon parents vs spouses

• Significant long-term effects upon siblings/children

• Stress more apparent 1-5 years post injury

• Healthy family functioning and family support is associated with resilience and better psychosocial adjustment

When is family stress most apparent post TBI?

1-5 years

Healthy family functioning and family support post TBI is associated with…

• Resilience

• Better psychosocial adjustment

What is the role of a psychologist in managing clients with TBI?

• Investigating history of concussion or mild TBI that was not investigated

• Not generally involved in the initial weeks/months following severe TBI (medical intervention and stabilisation first)

• Assess the extent of persisting symptoms in cognitive and behavioural domains, and infer their impact on functioning

• Educate clients and families about expected outcomes and management

• Design and implement strategies to assist clients to manage their deficits in daily life

Case Study: Robert

Describe his case

• 51yo M

• Former cabinet maker

• Single and living with mother

  • Had caretaking role following her stroke

• Wide circle of friends pre-injury, with interests in car restoration, music and golf

Injury

• Sustained TBI in motor vehicle accident

• GCS score at accident: 14 (not comatosed basically)

• Post-traumatic amnesia: 24hrs

• Initial CT revealed left frontal haematoma

• Small fractures to the face and cervical vertebrae

Case Study: Robert

What was his situation 4 years post injury?

• Resumed driving, but not returned to work

• Lost contact with most friends

• Not participating in hobbies

• Providing care to mother, but extremely stressful due to functional and cognitive limitations

  • Very forgetful - problem for administering medication

  • Troubles with manual handling

Case Study: Robert

What were his activity limitations and restrictions, as identified by a functional assessment by his OT?

• Difficulties in initiating and following through with everyday task (think: EF deficits)

  • Could only reliably complete daily care activities and walking his dog

  • Made easier by routine and procedural nature of tasks, and behavioural expression of expectation from dog

• Overwhelmed by unstructured and open-ended tasks that requires more complex planning and flexibility and goal setting (i.e. gardening, shopping for new clothes, etc)

  • Could do these things (i.e. going to the gym) if it became a part of his routine, however he required support to reinitiate the task if the routine was disrupted.

• Errors and difficulties in managing groceries and cooking

  • E.g. when cooking steak and vegetables, he would return home with several kilograms of meat and no vegetables, then forget to cook the steak

  • E.g. returning milk to the fridge before making coffee

• Extremely forgetful

  • E.g. forgetting his mum was admitted to hospital hours after he took her there

• Difficulty in making decisions

  • Needs more time to consider decisions, but is overwhelmed by more thinking

  • Would instead react impulsively and make serious errors

• Reduced mobility and persistent pain

• Behavioural and affective regulation issues

  • E.g. Responding angrily and swearing at people with low frustration tolerance

• Social integration issues with communication difficulties

  • E.g. not being able to ‘get his point across’

• Depression, anxiety and suicidal thoughts

• Sleeping approximately 15 hours per day

Case Study: Robert

Describe his cognitive assessment results

National Adult Reading Test: High Average

WAIS-V:

• Strengths: Problem solving, visual abstract reasoning

• Weaknesses: Psychomotor processing speed, working memory, verbal abilities when responding to questions of social convention and verbal fluency

• Notes:

  • Sometimes demonstrated rigidity in his approaches towards tasks, and learning curve plateaued early, indicating he could not apply new learned strategies

  • Demonstrated difficulties with learning and memory due to attentional demands (easily overwhelmed by lengthy verbal information)

  • Memory was poor, but assisted by recognition cues

  • High variability in subscales and tasks indicate overall scores of IQ may be misleading

Executive Functioning

• Strengths: Complex visuospatial problem solving and visuo-constructional tasks

  • Could monitor his own performance and change strategies when needed, particularly for structured, untimed tasks (think: less cognitive load and ambiguity in planning)

  • Demonstrated in good performance on Winsconsin card sorting test

• Weaknesses: Inhibition, self-monitoring, strategy utilisation, planning, following rules, thinking flexibly, shifting attention

  • Demonstrated in difficulties with Hayling Sentence completion test, Stroop test and Trail Making Test part B

Case Study: Robert

Summarise Robert’s neurocognitive assessment

Relative to premorbid functioning (estimated high-average) and several superior scores on the performance index of the WAIS-IV, the following conclusions can be made:

• Reduced immediate and working memory capabilities

• Slowed processing speed of information

• High levels of cognitive fatigue

• Word-finding difficulties

• Deficits in planning, organisation and problem solving in UNSTRUCTURED tasks

• Difficulties with initiation and motivation in everyday life were not evident in formal assessment, but this may also be a validity issue of the testing environment which is more structured and supportive

Case Study: Robert

How does the region of Robert’s brain injury explain some of the cognitive deficits he experiences?

Injury to frontal lobes

• Causing subtle intellectual deficits

• Severe changes in regulation of attentional states and initiation and control of responses (EFs)

• Mood instability, reduced frustration tolerance, impulsive aggression

These executive functioning deficits therefore cause significant disruption to Robert’s relationships, everyday function and ability to engage in his premorbid roles as friend, worker, carer and home maintainer.

Case Study: Robert

What initial intervention was implemented to support Robert to participate in his role as home maintainer? How did it go?

• Robert was supported to identify a ‘to-do’ list of tasks he wished to get done at the commencement of intervention.

• Neuropsychological counselling sessions and techniques:

  • Schedule one activity from the list in her diary per week to complete

  • Create a job list of the fridge with the first step of each job written out

  • Using sticky notes and phone alarms around the house to ‘prompt’ him to commence the job.

These strategies were NOT successful due to his executive functioning deficits, and the OT recommended a paid support worker who could provide external structuring and provision would be beneficial.

Case Study: Robert

How did a support worker help Robert?

• Role was to facilitate Robert’s involvement in tasks, not to complete them for him

• Worked side by side with Robert in both planning and physical aspects of tasks

• SW would ask Robert what tasks from his list he would like to complete upon arrival and provided prompts in the form of questions

  • “what will you do first? Do you have all the tools needed for this job?”

• When Robert could not provide an answer, the SW would generate an idea and seek Robert’s input to instil agency and empowerment

• They would write a written plan, and the SW would refer to the written plan as much as personal as to not make Robert overly reliant on them.

• They would tick off jobs when complete, make note of difficulty or safety issues, and invite Robert to reflect

This assistance improved his mood, motivation and initiation of routine tasks outside of session to make the most of his support hours. Due to permanent cognitive deficits, it is likely that SW involvement will be ongoing.

What is involved in early management and acute rehabilitation following strokes?

• Standardised and evidence-based acute stroke unit care

• MDT

• Education and support

• Goal setting and monitoring using SMART goals

• Discharge planning

SMART Goals

• Specific

• Measurable

• Achievable

• Relevant

• Timely

Important in early management and acute rehabilitation following strokes, especially to keep people motivated.

A patient has a left-sided stroke. What symptoms are they likely to experience?

• Right sided weakness

• Language difficulties

Think: Left = language

A patient has a right-sided stroke. What symptoms are they likely to experience?

• Left-sided weakness

• Visuo-perceptual deficits

  • Problems interpreting and making sense of visual information

What common symptoms post-stroke are often missed?

• Cognitive deficits

• Mood impairment

This is important because they are predictors of long term outcomes

Think: If you can’t interact with people without yelling at them and can’t fulfil your usual roles because you are forgetful, you’re probably going to be depressed and unmotivated to carry out treatment.

What is most important for positive long term outcomes following a stroke?

Early intervention

A patient describes they had a stroke, and they have since experienced weakness on one side of their body and visuoperceptual deficits. What side would the stroke have occurred on, and what side of their body would be weak?

Right side stroke

Left side weakness

A patient describes they had a stroke, and they have since experienced weakness on one side of their body and language deficits. What side would the stroke have occurred on, and what side of their body would be weak?

Left Side Stroke

Right side weakness

What are examples of focal cognitive issues that can occur after a stroke?

• Perception

• Agnosias

• Language

• Neglect

• Apraxia

What are examples of generalised impairments that can occur after a stroke?

• Memory impairment

• Executive dysfunction

• Attentional difficulties

• Problems with social and emotional perception

What is post stroke cognitive impairment associated with?

• Poorer compliance with treatment

  • Think: Can’t engage in treatment if you can’t remember what the strategies are

• Dependent living

• Mood disorders

• Reduced QOL

Think: More impairment = more psychosocial and treatment issues

How can cognitive issues post-stroke be managed or treated?

• There is evidence for memory rehabilitation, including memory skills group

• Case formulation and interventions aimed to improve individual’s SMART goals

• Designing, implementing and evaluating individual and group-based cognitive rehabilitation interventions basd on individual goals

Describe common emotional issues after stroke

These are very common and can significantly affect functional outcome

• Includes depression, anxiety and PTSD-like problems

• Mental fatigue and sleep disturbance

• Emotional lability

• Difficulty with coping and adjustment

What is a consideration with stroke patients when assessing emotional/affective problems?

One of the most common symptoms post-stroke is aphasia which impairs one’s ability to process, produce and/or comprehend language

• It is therefore important that non-verbal assessments are used where appropriate

• Examples include:

  • SADQ-10

  • Depression Intensity Scale Circles

2 Examples of Non-verbal Emotional assessments and why they might be used

• Stroke Aphasic Depression Questionnaire (SADQ-10)

• Depression Intensity Scale Circles (DISCs)

Used when a stroke patient has aphasia, which leads to language processing deficits.

What are some challenges in applying psychological interventions to stroke patients?

• Their degree of cognitive impairment, potentially making language processing difficult

• Fatigue

• Lack of motivation to engage in treatment

True or False: Psychological therapies can be adapted to effectively treat depression, anxiety, sleep disturbance and fatigue post-ABI?

True

What therapeutic skills/techniques are applicable for stroke patients?

• Pleasant activity scheduling/behavioural activation for someone with major physical disability

• Challenging automatic thoughts/core beliefs in someone with impaired reasoning/rigidity of thought

• Exposure therapy in someone with significant memory problems

• Mindfulness in someone with attentional disturbance

A stroke patient presents with memory problems. What technique would you recommend?

Exposure therapy

A stroke patient presents with attentional problems. What technique would you recommend?

Mindfulness

A stroke patient with major physical disability presents with depression. What technique would you recommend?

Pleasant activity scheduling or behavioural activation

A stroke patient presents with rigid beliefs and impaired reasoning about themself and their abilities. What technique would you recommend?

Cognitive restructuring through challenging automatic thoughts and core beliefs

According to Kneebone and Jefferies (2013), how effective are modified CBT anxiety interventions for people who have had a stroke?

There is evidence that they are effective.

• They used mCBT due to executive dysfunction, memory problems and communication difficulties

• The modified interventions led to significant clinical improvement in both cases (N=2), and results were maintained at 3 months follow up.

In Kneebone and Jefferies (2013) study, what were the modifications made to the CBT interventions?

Part of treating Ned’s anxiety that was related to his cognitive deficits was cognitive rehabilitation with strategies such as:

• Paraphrasing to slow down conversations

• Answering the phone with a preparatory statement to gather his thoughts (“Could you just hold on one moment?”)

• Encouragement of the use of self-coping statements (“OK the anxiety is there, but it’s part of the deal now. If I relax I will absorb more of what they are telling me.”)

Modifications to Myrtle’s intervention included:

• Discussion about fear/anxiety hierarchies instead of writing them due to difficulties with reading and writing (also made the TA collaborative, and the Tx was not just an educator)

• Tx let Myrtle take the lead in sessions due to lack of control in her everyday life

• Cognitive disputation of negative predictions Myrtle had were used

• Psychoeducation about stroke reoccurrence to challenge fears about another stroke occurring

• Tx used more summaries in session to help with communication difficulties

• Slowed pace of conversations

In a general sense, how can interventions be modified for patients who have had a stroke according to Kneebone and Jefferies (2013)?

• Incorporating cognitive rehabilitation strategies

  • I.e. encouraging client to use summaries in conversation to slow down conversation and ensure understanding

• Incorporating education about stroke

• Behavioural strategies

  • Using more summaries in session

  • Using verbal instructions or imagery to present information, depending on the type of impairment

  • Slowing pace of conversations

  • Revisiting topics

  • Letting client take the lead in session, given lack of control outside of session