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Neuropsychiatric disorders after ABI

Disorders involving behavior emotion and/or psychiatric function that occur after acquired brain injury

they are common and can worsen functional impairment social function and quality of life

Neuropsychiatric disorders after stroke

Occur in approximately 33-50% of patients after stroke

Neuropsychiatric disorders after TBI

Occur in approximately 65% of patients with one diagnosis and 40% with two diagnoses

Silent epidemic

Description of neuropsychiatric disorders after ABI because they are common and often more troubling to patients than cognitive or physical impairments

Primary and secondary etiologies

Neuropsychiatric disorders after ABI can result from both primary brain injury effects and secondary factors

Behavioral dyscontrol

Tendency for impulsive reactions toward internal or external stimuli

Major forms of behavioral dyscontrol

Agitation disinhibition aggression and perseveration

Agitation

State of restlessness and increased psychomotor activity reflecting underlying emotions

Agitation after brain injury

Often linked to confused states early after injury and can also be associated with long-term behavioral presentation

Disinhibition

Inappropriate nonaggressive responses reflecting an inability to appreciate behavioral norms

Physical disinhibition

Inappropriate physical behaviors such as sexual advances or impulsive actions

Verbal disinhibition

Inappropriate verbal behaviors including poorly considered utterances and breaking rules of discourse

Disinhibition characteristics

May include impulsivity limited patience limited awareness egocentric perspective and inappropriate responses to motor or speech demands

Aggression

Verbal outburst or physical violence directed at objects or people

Risk factors for aggression

Emotional dyscontrol major depression frontal lobe damage and pre-injury aggression

Medical treatment for aggression

May include valproate beta-blockers psychostimulants and selective serotonin-reuptake inhibitors

Perseveration

Repetitive thoughts and/or behaviors after brain injury

Cause of perseveration

Associated with frontal lobe damage

Mood disorder

Sustained pervasive shift in emotion and/or feeling

Major mood disorders in ABI

Depression anxiety and apathy

Depression

Depressed mood and decreased capacity for pleasure

Depression after CVA and TBI

Most common neuropsychiatric diagnosis in patients with CVA and TBI

Effects of depression after CVA

Social isolation and emotional distress contribute to increased disability reduced quality of life and increased risk of mortality

Depression risk factors

Older age female sex lower education prior psychiatric disorder and greater stroke severity

TBI-specific depression risk factors

Frontal lobe injury left injury lateralization and serotonergic dysfunction

Medical treatment for depression

Selective serotonin-reuptake inhibitors tricyclic antidepressants and neuromodulation for CVA

PT considerations for depression

Exercise socialization/group treatment music and MULT-I intervention may be incorporated

MULT-I intervention

Intervention that effectively reduced depression symptoms and increased BDNF levels compared with the HEP intervention

BDNF

Brain-derived neurotrophic factor

Anxiety

Excessive worry nervousness or unease about an anticipated event or situation

Types of anxiety after ABI

Anxiety may be generalized or associated with posttraumatic stress disorder

CVA risk factors for anxiety

Increased severity premorbid depression early anxiety and cognitive impairment

TBI risk factors for anxiety

Older age female sex prior psychiatric disorders longer loss of consciousness and shorter post-traumatic amnesia

Medical treatment for anxiety

Selective serotonin-reuptake inhibitors and benzodiazepines

Apathy

Decrease in motivation

Can be related to cognition behavior emotion or social interactions

Medical treatment for apathy

Dopamine agonists psychostimulants and acetylcholinesterase inhibitors

Brain regions involved in memory

Hippocampus amygdala neocortex basal ganglia and cerebellum

Implicit memory

Memory for skills or actions that become second nature such as muscle memory

Explicit memory

Memory involving verbal retrieval and remembering specific events

Episodic memory

Memory from first-person experiences

Semantic memory

Memory involving facts about the general world

Executive function

Functions that enable a person to engage successfully in independent purposive self-serving behavior

Brain region associated with executive function

Prefrontal cortex

Executive function in therapy

Impairment may require cues to initiate tasks external reminders for time to leave sticky notes for the order to dress and appropriate supervision level

Supervision level

The amount of assistance or monitoring needed based on the patient's cognitive and executive-function abilities

Quick outcome measures for cognition

Mini-Mental State Examination (MMSE)

Montreal Cognitive Assessment and Clock Draw (MoCA)

Neuropsychiatric symptoms compared with physical/cognitive impairments

Patients may report neuropsychiatric symptoms as more troubling than cognitive or physical impairments

Treatment evidence for neuropsychiatric disorders

There is limited evidence regarding intervention efficacy and no clear consensus on a single treatment approac

Rancho Levels of Cognitive Functioning Scale

Scale used to describe cognitive and behavioral functioning during recovery after brain injury

No Response

Individual appears to be in a deep sleep and is unresponsive to any stimuli

Generalized Response

Inconsistent and non-purposeful reaction to stimuli

responses are limited and often the same regardless of the stimulus and may include gross movement vocalization or physiologic change

Generalized Response timing

Response time is delayed and the earliest response may be to deep pain

Localized Response

Responses are specific but inconsistent to direct stimuli and are directly related to the type of stimulus presented

Localized Response abilities

May follow simple commands and may respond better to familiar people

Confused-Agitated

Heightened state of activity with severely decreased ability to process information

Confused-Agitated behavior

Behavior is not related to the immediate environment and hostility attempts to climb out of bed or remove restraints are common

Confused-Agitated mobility

May sit reach and walk but not necessarily upon request

Confused-Agitated self-care

Requires maximal assistance for self-care

Confused-Inappropriate

Individual appears alert and responds to simple commands consistently but may demonstrate agitation directly related to and out of proportion to stimuli

Confused-Inappropriate behaviors

Inappropriate verbalizations and high distractibility are common

Confused-Appropriate

Goal-directed behavior is present but dependent on external direction

Response to discomfort is appropriate and responses may be incorrect because of memory problems while still being appropriate to the situation

Confused-Appropriate commands

Follows simple commands consistently

Confused-Appropriate orientation

Orientation is inconsistent but awareness of self family and basic needs is increased

Automatic-Appropriate

Individual appears to act appropriately in the hospital and at home but moves through daily routines automatically in a robot-like manner

Poor judgment and problem-solving are common and unrealistic future plans may occur

Purposeful-Appropriate

Individual is alert and oriented and recalls and integrates past and recent events

Purposeful-Appropriate learning

Carryover for new learning is present without need for supervision once an activity is learned

Challenging behaviors after TBI

Approximately 30-70% of patients with TBI exhibit challenging behaviors in the inpatient setting

Agitation after TBI prevalence

44% of hospitalized patients with TBI during the early recovery phase

Emotional distancing

Maintaining appropriate emotional distance can help the therapist manage challenging behavior without taking it personally

ICAR model

Model for understanding and managing behavior involving Information Contingencies Self-awareness and Relationships

ICAR Information

Neuropsychological assessment of cognitive abilities and neuropsychiatric dysfunction

Individualized behavior analysis

Process of defining qualifying and quantifying a specific behavior rather than using vague descriptions

Define the behavior

Identify exactly what the patient is doing

Qualify the behavior

Describe the behavior specifically rather than using a vague label such as patient is agitated

Quantify the behavior

Measure characteristics of the behavior such as frequency duration and intensity

Examples of measurable behaviors

Yelling picking standing rocking refusing and self-harm are examples of behaviors that can be specifically identified and measured

Antecedent

Event or condition that occurs before a behavior and may trigger the behavior

Goal of antecedent analysis

To reliably predict stressors and behavioral responses

Behavioral antecedent factors

Time of day specific activity lack of control environmental issues caregiver behavior specific language changes in routine and physical needs

ABC behavior analysis

Behavior analysis based on the sequence Antecedent Behavior Consequence

Reinforcement

Consequence that can increase the likelihood that a behavior will occur again

Goal of antecedent control

Modify triggers or conditions that occur before the behavior by changing your own behavior or the environment

Positive reinforcement

Providing a consequence following a desired behavior that supports the continuation of that behavior

Shaping

Gradually developing a desired behavior through appropriate consequences

Extinction

Behavior management approach involving removal of reinforcement that maintains a behavior

Effective behavior rules

Should include a specific description of the behavior you want to see or not see

Rule circumstances

Rules should specify the circumstances under which the rule should be followed

Realistic consequences

Consequences should be realistic and achievable

Meaningful consequences

Consequences should be meaningful to the individual

Deadline for reward

A behavior management plan should establish a deadline for when the reward will be provided

Rule setting

Process of establishing specific behavioral expectations and consequences

Anosognosia

Lack of physical or cognitive self-awareness

Anosognosia after stroke

More frequently associated with right cortical damage

Anosognosia after TBI

Approximately 52-68% of individuals demonstrate some lack of self-awareness

Physical self-awareness

Lack of awareness of one's physical impairments or limitations

Cognitive self-awareness

Lack of awareness of one's cognitive impairments or limitations

Pyramid model of self-awareness

Model describing levels of awareness that progress from recognizing that something is generally wrong to recognizing that something is wrong now and that something could go wrong

Pyramid model level 1

Something is generally wrong

Pyramid model level 2

Something is wrong right now

Pyramid model level 3

Something could go wrong