Dr Nigel S King Consultant Clinical Neuropsychologist

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1 Dr Nigel S King Consultant Clinical Neuropsychologist Oxford Institute of Clinical Psychology Training University of Oxford, UK nigel.king@hmc.ox.ac.uk & Community Head Injury Service Bucks Healthcare NHS Trust Jansel Square, Aylesbury, Bucks, UK 1

2 1. Early Interventions 2. Interventions for prolonged and long-term PCS 3. How this might be applied in practice 4. Other models that may be useful 5. Conclusions 2

3 Sayegh, A., Sandford, D., Carson, A., (2011) Psychological approaches to treatment of post concussion syndrome: a systematic review. Journal of Neurology, Neurosurgery & Psychiatry: 81: Snell, D.L., Surgenor, L.J., Hay-Smith, E.J.C., Siegert, R.J. (2009). A systematic review of psychological treatments for mild traumatic brain injury: An update on the evidence. Journal of Clinical & Experimental Neuropsychology; 31 (1): Ponsford, J. (2005). Rehabilitation interventions after mild head injury. Current opinion in Neurology; 18:

4 Comper, P., Bischop, S.M., Carnide, N., Tricco, A. (2005). A systematic review of treatments for mild traumatic brain injury. Brain injury; 19 (11): Borg, J., Holm, L., Peleso, P.M., Cassidy, J.D., Carroll, L.J., von Holst, H., Paniak, C., Yates, D. (2004). Non-surgical intervention and cost of mild traumatic brain injury: results of the WHO collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine; Suppl. 43:

5 Vast majority of literature focuses on early intervention Only one or two well conducted RCTs for prolonged/long-term PCS Supportive evidence for: a) Brief written information for everyone following MTBI in first few days and weeks b) Tailored education, reassurance and CBT available to those with persisting PCS in first few weeks and months 5

6 Primary deficit after MTBI is a shaken sense of self If this occurs in a context where there is little or no validation or understanding of this perceptions of predictability and stability are disrupted This can lead to a cycle of fear, failure, avoidance, anxiety, depression, loss of self esteem and alienation (particularly if self esteem is heavily related to high levels of achieving or other vulnerable personality styles are present perfectionism, obsessivecompulsive traits). Psychological overlay accumulates with time These combine with physical (e.g. pain, fatigue, sensory deficits, reduced balance/dizziness, medication) and neurological factors (e.g. age, previous MTBIs) to cause the presenting PCS. 6

7 1 Education/Information 82% 2 Support/Reassurance 74% } Mittenburg & Burton (1994) 3 Graded Exposure to Avoided Activity 56% 4 Antidepressant Medication 45% } Middleboe et al (1992) 5 Cognitive therapy 44% 7

8 Main interventions are psychological Predominately attempt to minimise vicious cycle: PCS Stress PCS 8

9 1. Validate and explain the experience of the person 2. Do not prematurely confront any emotional factors as primary 3. Re-establish shaken sense of self e.g. with small successful challenges to achieve 4. Rebuild internal and external support systems 5. Help the family 6. Then treat emotional factors 9

10 1. Early engagement helping client to develop an open mind to alternative explanations for PCS which can be directly tested in therapy, i.e. avoiding debate about reality of PCS and aetiology 2. Identifying factors that improve or worsen PCS (e.g. poor sleep fatigue, concentration problems) 3. Using Lishman s 1988 model to explain reducing organic factors and increasing psychological factors 10

11 11

12 4. Minimising boom-bust oscillations between high & low levels of activity to establish sustainable level of activity to be built upon 5. Build on this level to aim for sustainable, graded increases in activity (in intensity and/or duration) 6.? Focus on how patients respond differently to symptoms rather than dwelling on good old days biases 7.? Use of models of perfectionism 8.? Reattribution of symptoms to take into account nonorganic factors 12

13 9. Use of Yerkes-Dodson curve to illustrate non-linear relationship between effort/arousal and performance, e.g. trying harder on a task because you think you will struggle with it may harm the performance behavioural experiment of putting less effort and concentration into a task 10.? Use of re-investment ideas automatic skills becoming deautomised particularly when under stress/pressure, e.g. behavioural experiment of focussing on walking 11.? Negative automatic thoughts regarding expectations or perceptions of performance failures 12.Combine with cognitive rehabilitation strategies but be careful they don t become safety behaviours 13

14 Preliminary investigations (e.g. Neuropsychological assessment, results feedback) Session 1 1. Agenda setting 2. CBT rationale for persistent PCS 3. Discussion of CBT format (collaborative, goal-focused, homework, focus on links between thoughts and feeling) 4. Problem and goal list 5. Homework: read Recovery from Post-concussion Syndrome: A Guide for Patients (adapted from Mittenberg et al., 1993) Session 2 1. Agenda setting 2. Review of previous session and homework 3. Discuss probable treatment techniques 4. Identify initial problem area and initiate appropriate techniques 5. Review and homework 14

15 Session 3 1. Agenda setting 2. Review previous session and homework 3. Identify the day s problems area(s) and initiate/develop appropriate techniques 4. Review and homework Session s As with session 3 3. Summarise techniques that have worked, and clarify reasons why 4. Summarise techniques that have not worked, and clarify reasons why 5. Introduce other problem areas as applicable Sessions Increasing focus on relapse prevention/coping with possible symptom flare-ups in final quarter of session series ( What happens if...? ) 2. Focus on continuation of therapy beyond final sessions: Devising action plans/behavioural experiments for the future 3. Review what has and has not helped, and discuss why 15

16 24% significant improvement (RPQ <13 points) 44% moderate improvement (reduction of 8 points) 56% little to no improvement on RPQ scores Overall effect sizes: Large QOLAS (Quality of life) Hedges g=0.95 Moderate RPQ (PCS symptoms) Hedges g=0.54 Moderate C15 20R (Fatigue) Hedges g=

17 Main limitations: o N = 45 (25 treatment, 20 waiting list control) o 28% PTA > 1 day, 20% PTA > 1 week. 17

18 The other RCT (Tiersky et al 2005) Archives of Physical Medicine & Rehabilitation (86), o o o 1 20 years post injury (mean = 5 6 years) 50 mins CBT + 50 mins cognitive rehabilitation, 3x week for 11 weeks Significant improvements in anxiety and depression and scoring on PASAT and Ray Auditory Verbal Learning Task 18

19 o Small sample size (N = treatment, 9 waiting list control) o Included patients with GCS 9 12 and LOC up to 4 hours o Very high levels of input o Mixed input o Cognitive rehabilitation involved both compensatory and remediation approaches o Only brief description of interventions 19

20 Early Symptoms Assessment 1. Severity of head injury Post traumatic amnesia Loss of consciousness Glasgow Coma Scale Neurological investigations, e.g. CT, MRI 2. Extent and severity of post concussion symptoms e.g Rivermead Post Concussion Symptoms Questionnaire (RPQ King et al 1995) 3. Emotional status e.g. Hospital Anxiety & Depression Scale (HADS Zigmond & Smith, 1983), Impact of Event Scale-Revised (IES-R Weis & Marmar, 1997) 20

21 Intervention Education/Reassurance 1. Normality of symptoms & non malignant nature 2. Likely recovery time & optimistic prognosis 3. Reduced speed of information processing 4. Graduated return to work 5. Symptoms as temperature gauge re: doing too much 6. Minimizing vicious circle: PCS Stress PCS 21

22 a) Common problems following mild head injury b) Reduced speed of information processing c) Memory problems d) Post traumatic stress reactions (King et al 1997) 22

23 1. Full assessment of symptoms vs symptoms via expectation 2. Realistic and optimistic prognosis vs bland reassurance (if unrealistic anger, worry & disillusionment) 3. Using symptoms as temperature gauge vs over- focusing on symptoms 23

24 Late Symptoms Assessment 1. Severity of head injury Post traumatic amnesia Loss of consciousness Glasgow Coma Scale Neurological investigations, e.g. CT, MRI 2. Extent and severity of post concussion symptoms e.g Rivermead Post Concussion Symptoms Questionnaire (RPQ King et al 1995) 3. Emotional status e.g. Hospital Anxiety & Depression Scale (HADS Zigmond & Smith, 1983), Impact of Event Scale-Revised (IES-R Weis & Marmar, 1997) 4. Pre-morbid factors (family, psychological, educational, occupational and clinical history). 5. Detailed chronological development of symptoms 6.?? Neuropsychological assessment 24

Intervention Formulation Accident Post traumatic stress Mild head injury and post

Anxiety near reminders of accident Avoidance of reminders Flashbacks Depression

safety/ vulnerability Agoraphobia/ panic attacks Reduced: concentration, stress

manage daily demands leading to reduced confidence ++ Reduced quality/ quantity of

close relationships Loss of life: structure/routine/ purpose/meaning Loss of job

25 Intervention Formulation Accident Post traumatic stress Mild head injury and post concussion symptoms Neck injury Nightmares Increased arousal/ jumpiness Flashbacks Anxiety near reminders of accident Avoidance of reminders Flashbacks Depression Irritability Life assumptions changed regarding: control, predictability, purpose, safety/ vulnerability Agoraphobia/ panic attacks Reduced: concentration, stress tolerance, multi-tasking, day-to-day memory, speed of processing Decreased ability to manage daily demands leading to reduced confidence ++ Reduced quality/ quantity of sleep Fatigue Stress ++ Pain Reduced mobility Compensation claim Reduced quality of close relationships Loss of life: structure/routine/ purpose/meaning Loss of job Financial difficulties I m going mad ; I m a different person ; Why am I like this? ; Something serious has been missed 25

26 Neuropsychological rehabilitation principles and treatment to slowly reclaim normality CBT principles to minimise emotional sequelae CBT models from other areas 26

27 Cognitive Behavioural Model of Chronic Fatigue I must rest to get better I should try harder Burst of activity Avoid activity Some achievement but fatigue Reduction in fatigue but failure to live up to expectations Surawy et al

28 1. Pain depression cycle Pain Social withdrawal Decreased Activity Depression 28

29 2. Pain agitation cycle Pain Sleeplessness Muscle Tension Anger Hardin

30 Characteristics of trauma / sequelae / prior experiences / beliefs / coping state of the individual Cognitive Model of PTSD (Ehlers & Clark 2000) + Cognitive processing during trauma Matching Triggers Nature of Trauma Memory Negative Appraisal of Trauma and/or sequelae Current Threat (Intrusions, arousal symptoms, strong emotions) Strategies intended to control threat / symptoms 30

31 Examples Irritability, anger outbursts Neuropsychological problems My personality has changed for the worse My marriage will break-up I can t trust myself with my own children My brain has been damaged I ll lose my job I m going mad I can t cope with stress anymore 31

32 Functional symptoms: Generalized pain Fatigue Predominant interference with real-life multi-tasking? Excessive / misdirected attention Reduced attentional reserve Slow information processing Cognitive symptoms (e.g. memory lapses, distractibility and word-finding difficulties) Illness experience Controlled (effortful) / automatic cognitive processing? High cognitive effort Heightened self-monitoring of cognitive processes and errors Memory perfectionism Over-interpretation of cognitive failures abnormal beliefs 32

33 1. One size fits all early interventions may be adequate for providing effective initial information and reassurance, with tailored reassurance and CBT for persisting symptoms. 2. Individualised formulations and interventions essentials for prolonged/long-term PCS. 3. Emerging evidence that CBT can be an effective treatment for some patients with permanent PCS, but not for all. 4. Formulation normally to include all potential non-organic factors alongside the possibility of brain injury factors 5. Emphasis that problems and symptoms are real regardless of cause 33

34 6. Emphasis that the more they are due to non-organic factors the better as greater scope for successful treatment and full recovery 7. Treat all non-organic factors maximally e.g minimising boom-bust approach to symptom management, establish a baseline activity level and increase it in a graduated way (including physical exercise), emphasis that worsening symptoms do not mean physical harm is occurring, attend to threatened sense of self, minimise hyper-attention to deficits. 8.? Treat residual cognitive difficulties with cognitive rehabilitation approaches 9.? Postpone judgement regarding contribution of organic factors until all non-organic factors have been maximally addressed 34

35 Overcoming Mild Traumatic Brain Injury and Post-concussion Symptoms: A self-help guide using evidencebased techniques King 2015 Constable & Robinson. London 35

Mild Brain Injury & Post-Concussion Syndrome. Patient Information Booklet. Talis Consulting Limited

Mild Brain Injury & Post-Concussion Syndrome Patient Information Booklet Talis Consulting Limited What is Minor Head Injury? Minor Head Injury is one of the most common neurological conditions seen in