Neuropsychological Interventions

Brain Tumour

AKA neoplasm

• Cluster of tumour cells

Symptoms/Diagnosis

• Headache

• Vomiting

• Mental dullness

• Seizures

• Increase in ICP

• Brain scans

Biopsy and histopathology determine grade and type of tumour

Prognoses vary as a function of age, type, grade, treatment regime and genetics

Benign/Non-Malignant Tumours

• Not likely to reoccur after removal

  • With exception of lower grade gliomas

• Encapsulated or distinct border

• Compression/displacement effects

• Can still be very serious depending on size and location (e.g. brain stem, midline or medial)

Roughly 2000 new cases per year

Examples of benign/non-malignant tumours

• Meningioma

• Pituitary tumour

• Colloid cyst

• Oligodendroglioma*

• Astrocytoma*

*Lower grade gliomas

What is unique about lower grade gliomas

Ologiodendrogliomas and astrocytomas can progress or recur at a higher rate

Meningiomas

Most common type of non-malignant brain tumour that develops in the meninges or protective membranes surrounding the brain and spinal cord

• Slow growing

• Growth compresses and displaces brain tissue and spinal cord; causing issues

• Most often effect the frontal lobes, but can also occur in the optic nerve sheath that protects the nerve connecting the eye to the brain

• Increase with age

• 3 grades depending on

  • Mitotic rate

  • Brain invasion

  • Specific histological features

Pituitary Tumours

A mass of abnormal cells that grows on the pituitary gland

• Most are benign and slow growing, and most common in young or middle/aged adults

• Account for about 17% of all primary brain tumour

Pituitary glands regulate the activity of other glands in the endocrine system and keeps hormone levels balanced to help control and regulate growth and body functions (e.g. sexual functions and fertility)

2 Categories of tumours:

• Secreting: Can release excess amount of any pituitary hormones

• Non-secreting: Not producing hormones

Malignant Brain Tumours

• Cancerous and high grade (3-4)

• Likely to reoccur after removal

• Fast growing, lack a distinct border and infiltrate surrounding tissue

• Complete removal is not possible and may metastasize because microscopic cancer cells extend beyond the tumour edge

2 types

1. Primary: gliomas start growing within the brain

2. Metastatic: Originate in other parts of the body

Think: Like looking for melanoma - lacking distinct border, weird shape, etc

A glioblastoma is an example of

A malignant tumour

Glioblastoma IDH-Wildtype, grade 4

The most aggressive and most common type of primary brain tumour

• Has an irregular contour

• Own blood supply

• Area of necrosis or cell death

• Usually occurs in older adults

Worst prognosis of any CNS malignancy (6.8% 5 year relative survival, 8 months median survival time)

• Treatment usually involves surgery, radiation and chemo with adjuvant temozolomide

  Think: Death sentence basically. If you get rid of it, it will probably come back

Astrocytoma, IDH-mutant, grades 2, 3, 4

Diffuse, infilitrating astrocyte tumours where there isno identifiable border between the tumour and normal brain tissue, even though the borders appear relatively well-marginated on imaging.

• Graded based on histological and molecular features

• Aggressive

• Occurs mostly in younger adults

• high recurrence

• Treated with surgery, radiation and chemotherapy

Oligodendroglioma

Type of diffuse infiltrating glioma with IDH mutation and 1p19q codeletion

• Commonly present in cerebral hemispheres

• Occurs primarily in 40-50yos

• High rate of reoccurrence

• Often increase in grade over time

• 10 year survival rate 50%

Tumour-Related Brain Damage

Caused by compression and displacement effects which result in:

• Raised intracranial pressure

• impaired CSF flow

• Swelling (steroid effects)

• Bleeding

Can lead to infiltration or invasion of surrounding brain tissue and cell necrosis

Two effects:

• Mass effects: Widespread damage or disruption to brain functioning - more generalised impairment

• Focal effects - more localised damage and specific cognitive impairments (think: vision loss)

Can also occur due to neurotoxic effects of treatment

• Damage to healthy tissue or white matter caused by chemo or radiation for eg

Themes of unmet support needs for caregivers

• information

• practical

• emotional

Describe existing caregiver’s focused interventions

• Typically perceived as outside of routine practice

• Scarce

• Typically comprise nurse-led support with focus on needs assessment, psychoeducation, coping and problem-solving soon after Dx.

Describe Lion et al’s (2023) Themes of Caregiver Care Model

There are two main themes:

• The theme that ‘it was never about me’ and that caregiver’s priorities were mismatched between needs and support

  • This means the caregiver prioritises the support for the person with high-grade glioma over themself

  • Their meeds are overlooked and unmet

  • Their perceived need for and acceptance of support changes

  • Caregiving is a lonely experience

• The theme of continuous, coordinated and personalised support as helpful to the experience and wellbeing of caregivers

  • Coordination of care and support services

  • The value of palliative care

  • Practical support impacts caregiver well-being (e.g. a cleaner or gardener to offload tasks)

  • Brain tumour-specific psychological support (rather than generalised support - it is a lonely experience and they want to be understood! takes away from that cognitive load of the caregiver being the only advocate/educator too)

Takeaway: Change the bad, maximise the good

Caregiver support needs need to be met, and they need help in also accepting support because current themes and perceptions are not helpful. We need to provide more coordinated, specialised services for caregivers so they are not overlooked.

What are the attitudinal barriers to psychological support-seeking among carers of people with different chronic physical health conditions according to Banks et al., 2025?

1. Carers held pre-existing beliefs about the validity of accessing support for themselves, often devaluing their personal needs to prioritise the patient.

   • I am the support GIVER not RECEIVER

2. Stigmatised metal health beliefs meant that psychological support was not only seen as a luxury by some, but also contradictory to carer’s perceived strength role as pillars of emotional stability and strength

   • If I need services myself then I am not the strong person I need to be for this person.

3. These beliefs were shaped and reinforced in patient-centric healthcare systems where there was a perceived lack of carer recognition and carer-informed support and services.

   • Going to the doctor for support and instead getting homework.

Think: Caregiver’s are the bank, not the person getting the loan

Stiekema et al. (2020)

Describe the model of perceived long term needs of people with acquired brain injury and their partners

There are 3 categories of needs that are divided over 4 ecological levels

• Adaptation

• Understanding

• Timely and individualised care

The levels are:

• Intrapersonal (coming to terms within themselves)

• Immediate social environmental (needs from friends and family)

• Healthcare (needs from their health team)

• Society (needs from society and institutions)

Stiekema et al. (2020)

What are the perceived intrapersonal long term needs of people with ABI and their partners?

• Awareness of consequences

• Process of acceptance

• Dealing with consequences in daily life

Think: Basically facing reality and not being in denial about the situation and outcomes

Partner focus groups also identified the need for:

• Personal time

Stiekema et al. (2020)

What are the perceived immediate social environment long term needs of people with ABI and their partners?

• Understanding from relatives and friends

• Role changes in relationship/family

Think: The people around them need to accept and understand that things are not going to be the same and manage their expectations

Stiekema et al. (2020)

What are the perceived long term health care needs of people with ABI and their partners?

• Understanding from professionals

• Information

• Transition to home

• Searching for help and support

• Peer support

• Support for partner/family

Unique to people in brain injury focus groups:

• Acknowledgement of individual differences

• Acknowledgment of small improvements

Unique to people in partner focus groups:

• Case manager

Think: DON’T BE A FUCKING GP ABOUT IT

Stiekema et al. (2020)

Who is primarily responsible for meeting the adaptation needs of individuals with ABI?

Themself and their immediate social environment

Stiekema et al. (2020)

Who is primarily responsible for meeting the understanding needs of individuals with ABI?

• Immediate social support

• Medical professionals

• Society and institutions

Stiekema et al. (2020)

Who is primarily responsible for meeting the timely and individualised care needs of individuals with ABI?

• Health care team

• Society and institutions

Stiekema et al. (2020)

What source is embedded in all themes and categories of long term needs for people with ABI?

Society and institutions

• Think about how government messaging, policy and funding has a trickle down effect on how people with brain injury are perceived and treated

Think: America must fucking hate people with ABI because they cut all their healthcare, limiting their access to timely and individualised care, embedding social norms that limit understanding of their experience, and in turn make it harder to adapt.

Stiekema et al. (2020)

According to this model, what needs are uniquely important for people in brain injury focus groups?

• Acknowledgement of individual differences

• Acknowledgement of small improvements

Think: Each brain injury is so unique in its presentation - stop treating people like textbook cases and start getting to know them for who they are, not what criteria they tick.

Ownsworth et al. (2011)

Personal and Social Processes of Adjustment Model

There are 3 different factors that implicate how people make sense of their experience and situation

• Interactions with people in the health system

• Reactions and support of personal support network

• Diverse coping reactions

These are all connected - think about how a lack of support for caregivers from the health care system might impact how the caregiver can show up to support the patient, especially if maybe the person has a rejection sensitivity profile.

This will change their appraisals and understanding of the situation

Ownsworth (2014)

Biopsychosocial Framework of Factors that Influence Outcomes

Outcomes: Functional well-being, emotional well-being, QOL

4 Factors:

• Pre-injury characteristics

• Neuropathology

• Psychological factors

• Social environment

Ownsworth (2014)

Biopsychosocial Framework of Factors that Influence Outcomes

Pre-injury characteristics

• Genotype

• Age

• Sex

• Ethnicity

• Occupation

• Cognitive Reserve + physical abilities

• Psychological and social resources

Think: Perhaps a younger sportsperson with a supportive family prior to injury might have better outcome than an 85yo frail man who acquired BI after a fall.

Ownsworth (2014)

Biopsychosocial Framework of Factors that Influence Outcomes

Neuropathology

• Causes and mechanisms

• Severity, location, recurrence, onset/course

• Treatment options

• Direct effects on functioning (i.e. aphasia)

Think: When you look at the brain scan, is it good news or bad news? Bad news probably means worse outcomes.

Ownsworth (2014)

Biopsychosocial Framework of Factors that Influence Outcomes

Psychological Factors

• Personal appraisals and reactions

  • Personality

  • Outlook

  • Self-awareness

  • Coping strategies

  • Motivation

  • Goals

Think: They are depressed, unmotivated and experience high rejection sensitivity so they are not coping or engaging in rehab.

Ownsworth (2014)

Biopsychosocial Framework of Factors that Influence Outcomes

Social Environment

• Concurrent stressors

• Access to resources (physical, financial, information, social support and rehab)

• Societal reactions

Think: The person is experiencing financial stress because they can’t work or drive, and they can’t get to appointments because no one is around to take them

Describe the Adaptation-Coping Model to help understand behaviour in dementia

• Personal, disease related and material and social factors directly impact their cognitive appraisal of their situation

• But the way they approach the adaptation process (or don’t) depends on internal and external factors

  • Internal: are they engaging in adaptive tasks? are they using coping strategies (i.e. exercise vs drinking)? are they engaging in coping behaviours? or are they just accepting their fate and miserable.

    • This feeds back to their appraisal and can either improve or make it worse.

  • External: do they have materials and social support to adapt? such as access to care, transport, additional social support

The result can either be a healthy adaptation process, balance, or disruptions in mood and behaviour.

Think: You could really put this into the context of mother

Neuroplasticity

Brain ability to reorganise its structure, function and connections in response to life experiences

• The lifelong potential of the brain to change in response to learning and experience

• Occurs in response to positive and adverse life experiences

• Can occur through synaptogenesis or neurogenesis

• This is leveraged in neuropsychological interventions

• Greatest evidence exists for motor and sensory function

2 processes of neuroplasticity leveraged in neuropsychological interventions

• Neurogenesis - creation of new neurons

• Synaptogenesis - creation of new synapses between neurons

Does neuroplasticity vary with age?

No

• Mice experiment showed that mice of all ages experienced neuroplasticity

• however this is less known in humans

What factors influence neuroplasticity in humans?

• Timing of injury

• Timing of intervention (want it to be soon after!)

• Brain maturation issues

• Function to be changed:

  • Motor and sensory function has most evidence

  • Preliminary evidence for language

  • Little evidence for cognitive and behavioural functions

• Changes at a structural level do not always have corresponding changes in behaviour or functions

Key implications of neuroplasticity

• Recovery

• Maintenance and further gains

• Lack of activity and stimulation (i.e. over-dependence on support) may result in secondary functional impairments

When is the optimal window of neuroplasticity to achieve the greatest benefits of rehabilitation?

Soon after the injury

Think: Don’t let it marinate

Neuroplasticity: what does participation in rehab and meaningful activities prevent?

Atrophy and functional decline

Think: Use it or lose it - that’s neuroplasticity baby

Dixon & Backman (1999)

Process of Compensation Model

The need for compensation arises when there is a disparity between the skills a person has relative to the demands of the environment and expected performance

• General aim of compensation is to close the gap between:

  • Expected performance

  • Environmental demands

  • Level of skill

• Participants must be aware of the mismatch (builds motivation to engage in rehabilitation)

  • First step of the process can be increasing self-awareness and motivation building

• 4 mechanisms of compensation

Think: If I need to move furniture (expected performance) to clean my space and it is really heavy (environmental demands), I need to build my strength (compensate)

COMPENSATION

A process through which deficits or losses are moderated.

Think: If I am broke and can’t (don’t want to) work, I will compensate with a rich partner 🙂

What is poor self-awareness related to in the context of rehabilitation?

• Reduced engagement

• Unrealistic goals (because you’re not really understanding the problem)

• Lack of strategy use

• Failure to benefit from rehab

• Poor long-term outcomes

Think: Someone with anorexia going to the gym to lose weight (incorrect strategy). They don’t understand the mismatch, they just spend hours on the treadmill, they don’t find any benefit from it. They should be aware of the mismatch between their body weight and self-concept.

4 mechanisms of compensation

• Remediation

• Self-adjustment

• Substitution

• External adjustment

Mechanisms of compensation

Substitution

Using previously developed skills or new skills to take over the performance of absent, lost or declining skills

Think: Riding a bike instead of driving a car

Mechanisms of compensation

Remediation

Investing more time and effort through repeated training and practice on a specific task

Think: Stretching to regain flexibility

Mechanisms of compensation

Self-adjustment

Adjusting goals and expectations of performance to match environmental demands to one’s skill level

Think: Accepting that burn out is hard, and expecting 100% for my thesis is unreasonable

Mechanisms of compensation

External adjustment

Modifying and selecting environments and adjusting expectations of others

Tele-MAST: Making Sense of Brain Tumour

RCT of a 10-week home-based therapy program

Person centred focus on sense of coherence

• Understanding their illness

• Managing its effects

• Ability to find meaning

Tele-MAST: Making Sense of Brain Tumour

Evidence for efficacy

RCT with 50 people and family members found:

• Significantly greater reduction in depressive symptoms

• Improvement in existential well-being

• Improvement in QOL

Compared to WLC

Tele-MAST: Making Sense of Brain Tumour

What populations benefit from this?

Treating depression in adults with glioma (brain tumour)

• Not for caregivers

MAST Individualised Psychotherapy

Making sense of brain tumour intervention for patients AND caregivers

• Up to 10 sessions via telehealth

• Tailored to goals, concerns and family needs

  • Understanding and management of effects of brain tumour (i.e. memory, concentration, motivation, fatigue)

  • Coping skills and management of low mood and anxiety

  • Support to plan for the future and decision making

  • Support for family regarding their fears/concerns

  • Improving couple relationship functioning

  • Legacy making projects

Think: BASICALLY QPMS

Meeting Centres Support Program

Program for individuals with dementia to promote and support adaptive tasks, but can be used across many different brain injuries

Addresses 3 domains of adaptation by supporting with adaptive tasks:

• Practical/cognitive adaptation (re-activation)

• Emotional adaptation (optimising affective functioning)

• Social adaptation (re-socialisation)

Meeting Centres Support Program -

Practical/Cognitive Adaptation Domain + Support strategies

• Dealing with disabilities

• Develop an adequate care relationship with professional carers

Strategies:

• Cognitive stimulation

• Physical fitness

• Optimising choice and control

Meeting Centres Support Program

Emotional Adaptation Domain + Support strategies

• Preserving an emotional balance

• Maintaining a positive self-image

• Preparing for an uncertain future

Support strategies:

• Improving emotional well-being

• Relaxation and fun

• Building confidence

• Opportunities to talk to others who understand

Meeting Centres Support Program

Social Adaptation Domain + Support strategies

• Stay in contact with family and friends

• Dealing with care environments

Support strategies:

• re-building social opportunities

• promoting engagement with others in a relaxed atmosphere

• Supporting others going through similar experiences

• Effective help seeking