Transcript Clinical Neuropsychology

Neuropsychological Evaluation of
Mild Traumatic Brain Injury (Concussion)
Nathaniel W. Nelson, Ph.D., ABPP-CN1,2
1University
of St. Thomas, Graduate School of Professional Psychology
2Private Practice
Outline
1.
Clinical Neuropsychology: Who We Are and What We Do
2.
Assessment of Mild Traumatic Brain Injury (Concussion)
3.
Natural History of Neuropsychological Recovery
4.
Factors that May Extend Recovery
5.
Treatment Considerations
Clinical Neuropsychology:
Domains of Assessment
• Hundreds of standardized neuropsychological measures available to evaluate
cognitive/psychological function
Basic Domains of Assessment:
• Intellectual Function
• Attention/concentration
• Language
• Visual-spatial Function
• Motor Function
• Executive Function
• Learning/Memory (Visual and Auditory)
• (Personality/Emotional)
• (Effort/Motivation)
Holistic Approach to the Individual Patient
• Case Conceptualization in Clinical Neuropsychology
• Incorporates Information from Multiple Aspects of Patient Function:
• Cognitive
• Physical and Behavioral
• Psychological/Emotional
The Clinical Neuropsychologist:
Thumbnail Sketch
Who are we?
~80% doctoral-level Clinical/Counseling Psychologists with 2-year post-doc in Clinical Neuropsychology
~80% work with adults, at least for part of their practice
~42% institution-based, ~23% private practice, ~25% both institution/private practice, ~10% post-doctoral
What do we do?
~85% clinical/administrative, 8% teaching/training, 7% research
When are we consulted (primary reasons for referral)?
Determination of diagnosis (inpatient and outpatient)
Treatment planning (inpatient and outpatient)
Establish baseline of cognitive and/or psychological functioning
Educational evaluation
Forensic evaluation
Where do our referrals come from (top 8 referral sources)?
(1)
Neurology
(2)
Psychiatry
(3)
Rehabilitation
(4)
Law (Attorney)
(5)
Neurosurgery
(6)
Internal Medicine
(7)
School System
(8)
Physiatry
Adapted from:
Sweet, Nelson, & Moberg (2006);
Sweet, Giuffre Meyer, Nelson, & Moberg (2011);
Sweet, Benson, Nelson, & Moberg (in preparation)
Top 5 Conditions Referred for
Neuropsychological Evaluations*
Rank
2005
2010
2015
1
Traumatic Brain Injury
Traumatic Brain Injury
Traumatic Brain Injury
2
ADHD
ADHD
ADHD
3
Learning Disorder
Elderly dementias
Elderly dementias
4
Elderly dementias
Learning Disorder
Seizure Disorder
5
Stroke
Other
medical/neurological
Other medical/neurological
*Includes respondents who evaluate patients across the full lifespan (i.e., pediatric and adult)
Adapted from: Sweet, Nelson, & Moberg (2006); Sweet, Giuffre Meyer, Nelson, & Moberg (2011);
Sweet, Benson, Nelson, & Moberg (in preparation)
Mild TBI (Concussion) Most Frequent Level of Severity in Medical Settings
Incidence rates of TBI-related hospitalizations in the United States by
category of severity (1980-1995).
Adapted from: Thurman, D., & Guerrero, J. (1999). Trends in hospitalization associated with traumatic brain injury. JAMA, 282, 954-957.
Frequency of TBI-Related
Neuropsychological Evaluation (By Severity)
TBI Severity Assessed
% Mild
% Moderate
% Severe
Institution
69
19
18
Private Practice
75
18
11
Institution/
Private Practice
67
21
16
Pediatric
67
19
20
Adult
71
19
15
Lifespan
69
20
15
Work Setting
Identity
From: Sweet, Benson, Nelson, & Moberg (in preparation)
Outline
1.
Clinical Neuropsychology: Who We Are and What We Do
2.
Assessment of Mild Traumatic Brain Injury (Concussion)
3.
Natural History of Neuropsychological Recovery
4.
Factors that May Extend Recovery
5.
Treatment Considerations
Assessing TBI Severity
• Glasgow Coma Scale (GCS; Teasdale & Jennet, 1974)
• 15-point scale that measures depth of coma according to post-injury
responses to stimuli:
• Eye opening (1-4),
• Verbal responsiveness (1-5)
• Motor response (1-6)
• Composite score within 24-hours of resuscitation typically determines injury
severity:
• Mild (13-15)
• Moderate (9-12)
• Severe (3-8)
Assessing TBI Severity
• TBI Severity Parameters:
• Loss of Consciousness (LOC) and Duration
• Alteration of Consciousness (AOC) and Duration
• Post-traumatic Amnesia (PTA) and Duration
• Evidence of brain injury disclosed on neuroimaging
• Glasgow Coma Scale (GCS) Status
• “Measures of duration of impaired consciousness typically are better predictors
of outcome than measures of depth of coma such as the GCS” (Dikmen,
Machamer, & Temkin, 2009, p. 600).
Mild TBI (Concussion):
Diagnosis From Acute-Injury Parameters
Criteria
Structural imaging
Loss of Consciousness
(LOC)
Alteration of
consciousness/mental state
(AOC)
Post-traumatic amnesia
(PTA)
Glasgow Coma Scale (best
available score in first 24
hours)
Mild
Moderate
Severe
Normal*
Normal or abnormal
Normal or abnormal
0 – 30 minutes
>30 minutes and < 24
hours
> 24 hours
A moment up to 24 hours
>24 hours. Severity based
on other criteria.
>24 hours. Severity based
on other criteria.
0-1 day
>1 and < 7 days
> 7 days
13-15
9-12
<9
Note. *Indisputable evidence of positive brain MRI finding may result in assignment of mild ‘complicated’ TBI.
Adapted from: Corrigan et al. (2010); VA/DoD (2009); New Zealand Guidelines Group (2006).
Outline
1.
Clinical Neuropsychology: Who We Are and What We Do
2.
Assessment of Mild Traumatic Brain Injury (Concussion)
3.
Natural History of Neuropsychological Recovery
4.
Factors that May Extend Recovery
5.
Treatment Considerations
Cognitive Recovery by TBI Severity (One-Year Post-Injury)
2.5
2
1.5
1
0.5
0
<1 Hour
1-24 Hours
2-5 Days
6-13 Days
14-28 Days
>29 Days
Time from Injury to Follow Verbal Commands
Note. The figure depicts overall impairment in neuropsychological performance at one-year post injury by TBI severity (the amount of
time after injury until victim could follow verbal commands). Results from Dikmen et al. (1995) as summarized by Larrabee (2012).
Effect sizes represented as Cohen’s d with positive values representing greater impairment
From McCrea, M. (2001). Standardized mental status testing on the sideline after sport-related concussion. Journal of
Athletic Training, 36, 274-279.
From Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301-317.
From Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301-317.
Mild Traumatic Brain Injury (Concussion):
Favorable Course of Cognitive Recovery
Mild TBI Meta-Analyses:
• Binder et al. (1997a, b)
• Beyond acute stage of recovery, small effect size on cognitive performance (d = -.12)
• Schretlen and Shapiro (2003)
• Moderate effect size for cognitive impairment in acute stage of injury (d = -.41)
• Across all follow-up stages, small overall effect size for cognitive impairment (d = -.24)
• Full cognitive recovery typically attained after 1-3 months (d = -.08)
• Frencham et al. (2005), follow-up to Binder et al. (1997)
• Small effect sizes across all stages post-injury
• Effect tends toward zero at 3 months post-injury
• Belanger et al. (2005)
• No residual neuropsychological impairment after 3 months post-injury (d = .04).
• Large effect sizes for clinic-based samples (d = .74) and litigants (d = .78)
• Litigation associated with stable or worsening of cognitive functioning over time.
• Iverson (2005, p. 311)
• “Under most circumstances, we should anticipate good recovery following an MTBI. Patients and athletes should be
reassured.”
“The natural history of MTBI is reasonably well
understood. For most people, regardless of age, the
injury is self-limiting and follows a generally
predictable course.”
“Permanent cognitive, psychological, or psychosocial
problems due to the biological effects of this injury
should be considered uncommon in trauma patients
and rare in athletes” (p. 301).
From Iverson, G. L. (2005). Outcome from mild traumatic brain injury. Current Opinion in Psychiatry, 18, 301-317.
Outline
1.
Clinical Neuropsychology: Who We Are and What We Do
2.
Assessment of Mild Traumatic Brain Injury (Concussion)
3.
Natural History of Neuropsychological Recovery
4.
Factors that May Extend Recovery
5.
Treatment Considerations
Factors that May Extend Cognitive Recovery Following MTBI
• Premorbid/Co-Morbid Psychopathology
• Chronic Pain
• Misattribution, False Expectations, &
Self-Report Bias
• Secondary Gain & Symptom Exaggeration
Concussion and Premorbid/
Co-morbid Psychopathology
• Premorbid psychopathology is prevalent among claimants with persisting
cognitive difficulties post-MTBI
• Greiffenstein and Baker (2001)
• Co-morbid depression, anxiety, and coincident stressors may contribute to, or
largely account for, late-stage ‘post-concussion’ symptoms
• Fann et al.(1995); Fenton et al. (1993); Polusny et al. (2011)
• Maladaptive personality traits (‘Axis II’ pathology) may also contribute to poor
outcomes for select TBI samples, particularly among those with Axis I and Axis II
conditions
• Hibbard et al. (2000); Evered et al. (2003)
Concussion and Premorbid/
Co-morbid Psychopathology
Overall Cognitive Performance
1
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
Control
MTBI Only
Axis I Only
Co-Morbid Axis I/MTBI
Adapted from:
Nelson, N. W., Hoelzle, J. B., Doane, B. M., McGuire, K. A., Ferrier-Auerbach, A. G., Charlesworth, M. J., Lamberty, G. J.,
Polusny, M. A., Arbisi, P. A., & Sponheim, S. R. (in press). Neuropsychological outcomes of U.S. veterans with report
of remote blast concussion and current psychopathology. Journal of the International Neuropsychological Society.
Chronic Pain
• Iverson & McCracken (1997)
• Significant minority (39%) of chronic pain patients (without history of head
injury) reports ‘post-concussive symptoms’
• 42% reported at least one cognitive complaint, forgetfulness being the most
common
• Paniak et al. (1998)
• Injuries that commonly co-occur with MTBI (e.g., orthopedic; musculo-skeletal;
whiplash-associated) “usually present a more pressing need for treatment
than do MTBI sequelae” (p. 1020).
• Sheedy et al. (2006, 2009)
• Pain symptoms identified acutely (i.e., in ER settings) may for a minority of
individuals predict chronic symptoms 3-months post-injury
Misattribution, False Expectations, & Self-Report Bias
• “Expectation as Etiology”
• Mittenberg et al. (1992)
• “Diagnosis Threat”
• Suhr & Gunstad (2002, 2005); Ozen & Fernandez (2011)
• “Good Old Days Bias”
• Gunstad & Suhr (1992); Iverson et al. (2010); Lange, Iverson, & Rose (2010)
Secondary Gain, Disability, and Persisting Symptoms
• WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury
(Carroll et al., 2004, p. 102):
“Although the evidence indicates good recovery for most adults sustaining MTBI,
where symptoms and disability are persistent, compensation and litigation
factors are important, and exploratory studies suggest that prior health, age and
life stressors are also determinants of poorer outcome.”
Secondary Gain & Symptom Exaggeration:
Trends in Malingering Research
Berry, D. T. R., & Nelson, N. W. (2010). DSM-5 and malingering: A modest proposal. Psychological Injury & Law, 3, 295-303.
Secondary Gain and
Symptom Exaggeration
• Base rates of insufficient effort and malingering increase dramatically in workers’ compensation and other
secondary gain contexts
• Mittenberg et al. (2002)
• Survey of 388 U.S. neuropsychologists regarding 33,531 annual cases. Estimated rates of
probable malingering:
• Based on referral:
• Personal injury litigation = 29%
• Disability = 30%
• Criminal = 19%
• Medical considerations = 8%
• Based on condition:
• Mild head injury = 39%
• Fibromyalgia/chronic fatigue = 35%
• Chronic pain = 31%
• Neurotoxicity = 27%
• Electrical Injury = 22%
Outline
1.
Clinical Neuropsychology: Who We Are and What We Do
2.
Assessment of Mild Traumatic Brain Injury (Concussion)
3.
Natural History of Neuropsychological Recovery
4.
Factors that May Extend Recovery
5.
Treatment Considerations
Treatment Considerations
• Psychoeducation; Early Reassurance of Recovery
• Pre-discharge therapy session diminishes duration and extent of post-injury
symptoms
• Single session (SS) of education/reassurance within 3 weeks of injury is as
effective as conventional ‘treatment-as-needed’ (TAN) with few symptoms
reported 3 and 12 months post-injury
• Paniak et al. (1998, p. 1020):
• “Education/reassurance should be provided, preferably in both oral and
written forms, in the acute care setting.”
Adapted from:
Mittenberg et al. (1996); Paniak et al. (1998, 2000); WHO MTBI Task Force (Borg et al., 2004)
Treatment Considerations
• Cognitive Behavioral Psychotherapy (CBT) and Other Psychological Treatments
• CBT may be particularly effective in treatment of post-concussive symptoms
• Treated MTBI patients show diminished symptom complaints after three months;
overall symptoms are comparable with matched control groups
• Limited evidence that multifaceted rehabilitation programs that include a
psychotherapeutic element are of benefit in management of persisting
symptoms
• Available research in treatment of MTBI is limited by small samples and lack of
randomized trials. Further, more rigorous randomized control are trials needed.
Adapted from:
Al Sayegh et al. (2010); Kashluba et al. (2004)
Treatment Considerations
• Hospital-Based Model for Clinical Management of MTBI (McCrea, 2008)
• Multidisciplinary Approach
• Emergency Medical Providers
• Physiatrist
• Neuropsychologist
• Nurse coordinator
• Based on the principle that effective intervention is ideally:
• Early (i.e., within 1-5 days of injury)
• Easily accessible and supportive
• Educational (e.g., review common symptoms of time-limited duration)
• Anchored in Empirical Literature
• Not Intensive (in terms of sophisticated neurologic workup, neuroimaging, or medical treatment)
• Primary intervention is educational and psychological in most cases
• Follow-up sessions (as needed)
• Continued reassurance and education
• Address factors that may potentially interfere with recovery
Summary
1.
Concussion diagnosis is made on the basis of acute-injury parameters
LOC and duration; PTA and duration; GCS status; Neuroimaging findings
2.
Concussion typically results in time-limited symptoms and impairments
Great majority attains rapid recovery in function that approaches baseline within days, weeks, to no more than a few months post-injury
3.
Symptoms months/years after concussion (akin to “Post-Concussive Syndrome”) cannot be reliably linked with remote concussion
4.
Non-concussion-related factors often account for persisting complaints
Premorbid/Co-morbid psychopathology
Chronic Pain
Misattribution
Secondary Gain/Exaggeration
5.
Early interventions may prevent persisting symptoms
Psychoeducation, Reassurance
CBT, other Supportive Counseling