L8: Non Motor Impairments After ABI II (Behavior, Emotion, Motivation)

% of pts diagnosed with neuropsychiatric disorders after stroke

33-50%

% of pts with one diagnosis after TBI

40

% of pts with 2 diagnoses after TBI

40

In patients with neuropsychiatric disorders post ABI, there is an increased likelihood of

• Functional impairment

• Decreased social function

• Poorer health-related QOL

Neuropsychiatric disorders are more ________ than cognitive and physical impairments

Troubling

Neuropsychiatric disorders are associated with

Primary and secondary etiologies

What are primary and secondary etiologies

• Primary = brain area directly impacted by ABI

• Secondary = downstream effect (may be from decreased ability to interact with environment)

There is ________ evidence on intervention efficacy

Limited

(no clear consensus on treatment approach)

What is pseudobulbar affect?

Sudden, uncontrollable outbursts of laughter or crying

Behavioral dyscontrol is the ________

Tendency for impulsive reactions toward internal/external stimuli

How might behavior dyscontrol present

• Agitation

• Disinhibition

• Aggression

• Perseveration

What areas of the brain might be affected to cause neuropsychiatric disorders

• Emotional areas

  • Cingulate gyrus

• Higher cognitive function areas

  • Frontal lobe

What is agitation

A state of restlessness and increased psychomotor activity reflecting underlying emotions

Agitation often linked to?

Confused states early after injury

Agitation can also be associated with?

Long-term behavioral presentation

What is disinhibition

Inappropriate, nonaggressive response reflecting an inability to appreciate behavioral norms

Physical disinhibition might look like

• Sexual advances

• Impulsivity

Impulsivity more often occurs in

Right sided frontal lobe strokes

Verbal disinhibition might look like

• Poorly considered utterances (mumbling)

• Breaking rules of discourse

• Egocentric perspective

What is aggression

Verbal outburst or physical violence directed at objects or people

Risk factors for aggression

• Emotional dyscontrol

• Major depression

• Frontal lobe damage

• Pre-injury aggression

Medical treatment for aggression

• Valproate

• Beta blockers

• Psychostimulants

• Selective serotonin-reuptake inhibitors (SSRIs)

What behaviors are more associated with TBI

• Aggression

• Disinhibition

Reactive aggression is triggered by

Modest or trivial stimuli

Nonreflective aggression typically doesn’t involve

Premeditation or planning

what is non-purposeful aggression

Aggression that serves no long-term aims or goals

What is explosive aggression

• Buildup is not gradual

  • no redirection/de-escalation

What is periodic aggression

Brief outbursts of rage and aggression punctuated by long periods of relative calm

What is ego-dystonic aggression

After outbursts, patients are upset, concerned, and/or embarrassed, as opposed to blaming others or justifying behavior

What is perseveration

Repetitive thoughts and/or behaviors after brain injury

What are the 3 most common types of perseveration after brain injury

• Stuck in set

• Recurrent perseveration

• Continuous perseveration

Perseveration is caused by damage to the

Frontal lobe

What is stuck in set perseveration

Uncontrolled or extended maintenance of a thought, or topic in conversation, despite the situation changing

What is recurrent perseveration

• The unintentional and unfocused repetition of a behavior

  • ex: a person with recurrent perseveration might write the same word or letter multiple times for no reason

What is continuous perseveration

• The uncontrollable repetition of an impression or feeling

  • ex: someone who continues to dwell on their anger longer than the situation warrants

What is the best treatment for persveration?

Cognitive Behavioral Therapy (CBT)

What are mood disorders

Sustained, pervasive shift in emotion and/or feeling

How might mood disorders present

• Depression

• Anxiety

• Apathy

How prevalent is mood disorder with ABI

• 1/3 will have

• 30-50% depending on reference

What is depression

Depressed mood, decreased capacity for pleasure

Depression is the ________ neuropsychiatric diagnosis in CVA & TBI

Most common

Depression might cause/lead to in someone with ABI

Social isolation and emotional distress

Social isolation and emotional distress contribute to

• Increased disability

• reduced QOL

• increased risk of mortality

Risk Factors of depression

• Older age

• Female

• Lower education

• Prior psychiatric disorder

• Stroke severity

TBI specific factors that can lead to depression

• Frontal lobe injury

• Left injury lateralization

• Serotonergic dysfunction

Medical treatment for depression

• Selective serotonin-reuptake inhibitors

• Tricyclic antidepressants

• Neuromodulation (CVA)

PT considerations for exercise for pt with depression

• Exercise is moderately more effective than control intervention on depression

  • Not more or less effective than psychological or pharmacological treatments

PT considerations for socialization/group treatment

Interventions combining social support and exercise improve social participation > social support alone

What is the effect of MULT-I (music upper limb therapy-integrated) intervention for depression

Effectively reduced depression symptoms and increased BDNF levels as compared to the HEP intervention

What is anxiety

Excessive worry, nervousness or unease about an anticipated event or situation

Anxiety might be classified as

• Generalized

• Associated with PTSD

CVA Risk Factors for anxiety

• Increased severity

• Premorbid depression

• Early anxiety

• Cognitive impairment

TBI Risk Factors for anxiety

• Older age

• Female

• Prior psychiatric disorders

• Longer loss of consciousness

• Shorter post-traumatic amnesia

Treatments for anxiety

• Selective serotonin-reuptake inhibitors

• Benzodiazepines

What is apathy

Decrease in motivation

Apathy is associated with a

Dysfunctional reward network and/or co-morbid depression

Apathy can be related to

• Cognition

• Behavior

• Emotion

• Social interactions

Treatment for apathy

• Dopamine-agonists

• Psychostimulants

• Acetylcholinesterase inhibitors

What is memory

The ability to recall information

Brain regions involved in memory

• Hippocampus

• Amygdala

• Neocortex

• Basal ganglia

• Cerebellum

Implicit memory is

Muscle memory or "second nature"

Explicit memory is

Verbal retrieval, remembering specific events

Episodic memory is

Memory from first person experience

Semantic memory is

Facts about the general world

What is executive function

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

What is the brain region associated with executive function

Prefrontal cortex

Implications in therapy or at home for executive function

• Cues to initiate tasks

• External reminders for time to leave

• Sticky notes for the order to dress

• Supervision level

Outcome measures that could be used

• Mini-mental state examination

• Montreal cognitive assessment (MOCA)

• Clock draw

Using the ________ is better to do a quick screen of cognitive function for anyone over 70 years old

MOCA