Mitigating Potential Bias 9/13/2018. Reducing Emotion Dysregulation After TBI

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1 Reducing Emotion Dysregulation After TBI Dawn Neumann, PhD Associate Professor and Research Director Indiana University, Physical Medicine & Rehabilitation Rehabilitation Hospital of Indiana Faculty/Presenter Disclosure Relationships with commercial interests: Grants/Research Support: NIH NICHD/ NCMRR STTR Phase I grant 1R41HD A1 Former business owner App: My Emotional Compass Indiana University Funding Opportunities for Research Commercialization and Economic Success (FORCES) Mitigating Potential Bias The company, EmotEd, dissolved November Pursuing academically. I do not/ will not be receiving any royalties for the resulting App that is a product of that research I will be discussing. 1

2 Emotional Disorders & Deficits after TBI Up to 70% have deficits Alexithymia Problems with: Emotional self-awareness Interoceptive / body state awareness Labeling emotions Differentiating 30-61% emotions of people with TBI!! Unlikely to think about emotions Does NOT mean no emotions. Can t control what you don t know! Don t know you re having an emotional response Don t know what emotion you re feeling Poor emotion regulation 2

3 Alexithymia Associated with Anxiety and Depression Alexithymia associations with: Anxiety (r=.668, p<.001) Depression (r=.558, p<.001) Post-TBI Alexithymia associated with Negative Behaviors & Psychosocial Outcomes Poor coping skills Substance abuse, Suicidal ideation Poor recognition of others emotions Lower Empathy Poor Relationship Quality Quality of life 3

4 The Different Case Presentations of Alexithymia Unaware of emotions Not expressed I don t have emotions Awareof emotions, lacks labels Not expressed Unaware of emotions Inappropriately expressed I m not angry! Aware of emotions, lacks labels Inappropriately expressed I m fine. or I feel confused I m flooded by negative feelings I can t describe Can alexithymia be reduced with targeted treatment after TBI, and if so, will other aspects of emotion dysregulation also be improved? This work is supported by: NIH NICHD/ NCMRR STTR Phase I grant 1R41HD A1 Indiana University Funding Opportunities for Research Commercialization and Economic Success (FORCES) Design Baseline Treatment Posttest Alexithymia (TAS-20) Emotional labeling (LEAS) Difficulty with Emotion Regulation (DERS) Positive Affect (PANAS) Trait Anxiety (STAI) Depression (PHQ9) Anger (STAXI) 8 Sessions hrs 2x / week Same as baseline 2 mo FUP Same as baseline 4

5 Toronto Alexithymia Scale (TAS-20) Total Score: subjective; range ; 61 = high alexithymia Difficulty Identifying Feelings Difficulty Describing Feelings Externally Oriented Thinking Levels of Emotional Awareness Scale (LEAS) Objective measure 10 hypothetical scenarios How would you feel How would other person feel Parallel forms Scored on discreteness of emotional words and emotional range (Lane et al) Difficulty with Emotion Regulation Scale (DERS) Subjective measure of emotion regulation Total Score and 6 subscales: Lack of emotional awareness Lack of emotional clarity Difficulty controlling impulsive behaviors when distressed Difficulty engaging in goal-directed behaviors when distressed Nonacceptance of negative emotional responses Limited access to effective emotion regulation strategies. 5

6 17 enrolled 13 completed Participant Characteristics (mod-severe TBI) Age (11.41) Sex (male) 76.5% Education (2.36) Cause of Injury MVA Fall 94.1% 5.9% Time post-injury (yrs) 8.73 (8.10) PTA days LOC Abnormal Neuroimaging Cerebral Contusion Hematoma Post-traumatic Hemorrhage (187.45) (25.39) 23% 46% 77% Alexithymia Treatment 1:1 Therapist-guided, web-based training Lessons 1-4: educational information, skill building, and interactive exercises. Emotional Awareness: Emotional arousal; sensations/ body cues Describe & Differentiate: Vocabulary; Emotions vs thoughts, acts and sensations, differentiating emotions Lessons 5-8: Virtual Scenario Exercises using 1 st person video simulations of emotional situations. Take home exercises Emotions that generally feel bad Emotions that generally feel good 6

7 What is / was your emotional arousal (emotional energy/ charge)? o At or only slightly higher than baseline o A lot higher than baseline Did you feel one of these emotions? 7

8 Example Virtual Scenario Alexithymia Outcomes Severe alexithymia ( 61) *p=.004 *p=.02 Mod alexithymia (52-60) 62% less severe 6 normal 5 stayed normal at 2- month f/up. T1 T2 ES: T1 T3 ES:.953 TAS Subscale Outcomes p=.004 * * p=.009 * * p=.018 * 8

9 Emotional Labeling Outcomes (LEAS) *p<.001 *p=.013 T1 T2 ES:.928 T1 T3: ES:.674 Secondary Outcomes Emotion Regulation Post-test 1 (E.S.) 2 month f/u (E.S.) Positive Affect Emotion Dysregulation ( (-.488) Anxiety (-.597) Anger (- (.013) Depression (- (.095) Significant after correcting for multiple comparisons No longer sig after correcting for multiple comparisons (trend) Not significant Satisfaction 9

10 Case Study: Jennifer Thank you for making me feel optimistic again I m like a different person. Things that I would normally blow up about, I now can let go. It helps slow me down and think through my emotions. Neurologist, psychiatrist and friends noticed a marked difference in me I m calmer and my speech is better. Changes maintained. > 1 yr post-treatment: your program gave me my words & emotions back I can NEVER Thank You enough for giving me my words back Summary of Alexithymia Alexithymia appears to be treatable Improved emotion regulation, anxiety, positive affect observed. Improved identification and description of emotions may be associated with better emotion regulation Emotion regulation improvements appear to wane when not directly trained. More research needed (larger, rigorous trials) My Emotional Compass App 10

11 Multisite RCT ASMT vs PRE Intermediate Test (T2) After session 4 ASMT: 3 dropouts (n=57) PRE: 3 dropouts (n=27) 11

12 ASMT Treatment Components: Self-Awareness ASMT Treatment Components- Problem Solving Anger Results- % Tx Responders Posttest Follow-up PRE ASMT PRE ASMT STAXI- Trait Anger 47% 68%* 40% 60% BAAQ (extreme behavior) 17% 12% 13% 12% Overall (response on at least 1 of the above) 63% 71% 57% 77% *=significance; bold = 20% greater response rate than PRE Over half who responded at posttest showed at response at the intermediate test [after session 4]. 12

13 Objective: Preliminary evaluation of the efficacy of a web-based group intervention (Online EmReg) to improve Emotion Regulation after TBI. Online EmReg Study Design: Pre-posttest design Subjects: 91 participants TBI & emotion regulation deficits across 33 States & 5 Countries Online EmReg treatment components Group therapy using video conferencing application Sessions 1-8: Psychoeducation Teach awareness for triggers, sensations, emotions, & thoughts surrounding behavior Skills to modify/ regulate autonomic responses and reduce emotional and behavioral dysregulation. Sessions 9-24: Skill Practice 13

14 Emotion Dysregulation Results (DERS) * p<.001 *p=.04 (p<.001) Identifying the Common Denominator Emotional Self-Awareness Clinical Take Home Points Evaluate patients with TBI and emotion dysregulation for alexithymia Treatment teaching emotional awareness can reduce alexithymia and emotional control Consider emotional self-awareness training as a precursor or supplement to emotional therapy 14

15 Reductions in Alexithymia and Emotion Dysregulation after Training Emotional Self-Awareness Following TBI: A Phase I Trial Effectiveness of a Treatment for Impairments in Social Cognition and Emotion Regulation (T-ScEmo) after TBI: A RCT Anger Self-Management Training for Chronic Moderate to Severe TBI: Results of an RCT Potential Impact of Amantadine on Aggression in Chronic TBI Sertraline for Major Depression Year following TBI: An RCT The relations of cognitive, behavioral, and physical activity variables to depression severity in TBI: Reanalysis of data from an RCT Improving Emotion Regulation Following Web-based Group Intervention for Individuals with TBI Thank you! Questions? Contact: dmneuman@iupui.edu 15