1、THE TRAUMATIC BRAIN INJURY AND CHEMICAL DEPENDENCY CONNECTION,ADDICTION MEDICINE EDUCATIONAL SERIES WORKBOOK,2,THE TRAUMATIC BRAIN INJURY AND CHEMICAL DEPENDENCY CONNECTION,STEVEN KIPNIS, MD, FACP, FASAM OASAS MEDICAL DIRECTORMARYANN Y. FOSTER, LCSW-R ELISE GROSSMAN, MA CRC SHELLY LEVY, PSY.D EDWARD
2、 ROSS, LCSW-R ICD-INTERNATIONAL CENTER FOR THE DISABLEDROBERT KILLAR, CASAC DIRECTOR OASAS COUNSELOR ASSISTANCE PROGRAMPATRICIA LINCOURT LCSW OASAS BUREAU OF TREATMENTCHRISTINE SUTTER CASAC STEPHEN OSWALD CASAC TBI Specialists BLAISDELL ADDICTION TREATMENT CENTER,3,THE HEALTHY BRAIN,The brain can be
3、 considered the computer of the human body. It is enclosed inside the bony skull, which acts as a protective covering. On the inside of the body, it is protected by the blood-brain barrier, a protective barrier that keeps out toxic substances and allows fat (lipid) soluble substances through.,4,THE
4、HEALTHY BRAIN,The basic functional unit of the brain is the neuron, a cell that is specialized to send information. The brain uses these neurons to communicate with other parts of the brain, the spinal cord and ultimately with the rest of the body. Movement, cognition and emotional expression are ju
5、st some of the functions. There are 100 billion of these in the normal brain. The parts of the neuron are: Cell body Maintenance of cell life Nutrition, waste removal, manufacturing of chemicals Dendrite Receive information from other cells or stimuli Up to 10,000 in one cell Axon Main pathway to ot
6、her cells Usually one main axon Myelin Protective wrapping around cells Speeds nerve impulses,5,THE HEALTHY BRAIN,Drawing of a neuron,6,THE BRAIN IS DIVIDED INTO LOBES, THE CEREBELLUM AND THE BRAIN STEM,7,THE HEALTHY BRAIN,The Frontal Lobe is involved in the following functions: Initiation Problem s
7、olving Judgment Inhibition of behavior Planning and anticipation Self monitoring Motor planning Personality Emotions Awareness of abilities and limitations Organization Attention and concentration Mental flexibility Speaking (expressive language),8,THE HEALTHY BRAIN,Temporal Lobe functions: Memory H
8、earing Understanding language Organization Sequencing Parietal Lobe functions: Sense of touch Differentiation of size, shapes, and colors Spatial perception Visual perception,9,THE HEALTHY BRAIN,Occipital Lobe functions: Vision Cerebellum functions: Balance Coordination Skilled motor ability Brain S
9、tem functions Breathing rate Heart rate Arousal and consciousness Sleep and wake cycles Attention and concentration,10,Each year in America, one million people are seen by medical doctors due to a blow to the head. Of that number, 50,000 to 100,000 have prolonged problems that will affect their abil
10、ity to work and/or affect their daily lives.,Data compile and arranged by the Brain Injury Association of America based on date from the Centers for Disease Control and Prevention, American Cancer Society and National Multiple Sclerosis Society.,11,Every 21 Seconds One Person In The U.S. Sustains A
11、Brain Injury Source: Brain Injury Association of New York State www.bianys.org,The majority of people are injured in car accidents. It is important to note that you do not have to be traveling at a high rate of speed to get a head injury. Nor do you have to hit your head on an object (steering wheel
12、, windshield) to injure the brain. Even at moderate rates of speed, traumatic brain injuries can and do occur,12,TRAUMATIC BRAIN INJURY (TBI),TRAUMATIC BRAIN INJURY (TBI) is an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce
13、a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment. *Brain Injury Association, 1986,13,ACQ
14、UIRED BRAIN INJURY (ABI),The term Acquired Brain Injury refers to TBI, as well as other types of brain injuries occurring after birth, such as stroke, near suffocation, infections in the brain, anoxia. TBI/ABI is not due to an inherited, degenerative or congenital problem. The effects of a brain inj
15、ury depend on the cause, the location of the injury and the severity of the injury. Brain injury is an invisible disability.,14,TRAUMATIC BRAIN INJURY,Traumatic brain injury can cause death.,15,ACQUIRED BRAIN INJURY,Acquired brain injury can be due to trauma, such as an open or closed trauma, or due
16、 to infections, medical problems such as stroke or substance effects. Brain tumor Meningitis Seizure disorder Hepatic encephalopathy (seen in liver failure) Heart attack Anoxia Near drowning Choking Strangulation Electrical shock Lightening strike Exposure to toxins or chemicals CVA/Stroke Aneurysm
17、Alcohol and drugs,16,TRAUMATIC BRAIN INJURIES: OPEN AND CLOSED BRAIN INJURY,Open,Closed,MAY NOT BE AS APPARENT AS AN OPEN INJURY,17,LEVELS OF BRAIN INJURY,Mild TBI Loss of consciousness is very brief, usually a few seconds or minutes Loss of consciousness does not have to occur the person may be daz
18、ed or confused Testing and scans of the brain may appear normal Most common: 75%-85% of all brain injuries are mild 90% of individuals recover within 6-8 weeks, often within hours or days, but 10% experience deficits, which may not be evident immediately More than one mild brain injury over time (e.
19、g., sports injuries or domestic violence) increases the chance of deficits,18,LEVELS OF BRAIN INJURY,Moderate TBI Loss of consciousness lasts from a few minutes to a few hours Confusion lasts from days to weeks Physical, cognitive, and/or behavioral impairments last for months or are permanent EEG/C
20、AT/MRI are positive for brain injury,19,LEVELS OF BRAIN INJURY,Severe TBI Prolonged unconscious state or coma lasts days, weeks, or months Categories include: Coma Vegetative State Persistent Vegetative State Minimally Responsive State Locked-in Syndrome,20,LEVELS OF BRAIN INJURY,Severe TBI Categori
21、es Coma Unconscious state from which the individual cannot be awakened with minimal or no meaningful response to stimuli Vegetative State Arousal is present but cannot interact with environment Eye opening can be spontaneous or in response to stimulation Persistent Vegetative State Vegetative state
22、lasting for more than one month Minimally Responsive State No longer in coma or vegetative state with primitive reflexes and inconsistent ability to follow simple commands, though an awareness of the environment Locked in Syndrome Rare neurologic condition in which a person cannot physically move an
23、y part of the body except the eyes. The person is conscious and able to think.,21,GLASGOW COMA SCALE The Glasgow Coma scale provides an objective way to evaluate a patients level of consciousness and to detect changes from baseline functioning.,22,AN INJURED BRAIN,Changes are noted to thought proces
24、ses: Memory Decision making Planning Sequencing Judgment Attention Communication Reading and writing skills Thought processing speed Problem solving skills Organization Self perception Perception Thought flexibility Safety awareness New learning,23,AN INJURED BRAIN,Physical Changes are seen: Muscle
25、movement Muscle coordination Sleep Hearing Vision Taste Smell Touch Fatigue Weakness Balance Speech Seizures Sexual functioning,24,AN INJURED BRAIN,Personality and Behavioral Changes Social skills Emotional control and mood swings Appropriateness of behavior Reduced self-esteem Depression Anxiety Fr
26、ustration Stress Reduced Self Awareness (often misunderstood as denial) Self-centeredness Anger management Coping skills Self-monitoring remarks or actions Motivation Irritability or agitation Excessive laughing or crying,25,AN INJURED BRAIN,Right sided injuries Visual-spatial impairment Visual memo
27、ry deficits Decreased awareness of deficits Altered creativity and music perception Loss of “the big picture” type of thinking Decreased control over left sided body movements Left sided injuries Difficulties in understanding language (receptive language) Difficulties in speaking or verbal output (e
28、xpressive language) Depression Anxiety Verbal memory deficits Impaired logic Sequencing difficulties Decreased control over right sided body movements,26,ACQUIRED BRAIN INJURY,Alcohol and drugs can cause brain injury directly or indirectly. Alcohol is a neurotoxin, though its effect and extent of da
29、mage depends on the amount of alcohol consumption, the age and sex of the consumer, genetic vulnerability and other factors. Binge drinkers may be less prone to alcohol related cognitive deficits than heavy daily users, though they are still vulnerable to alcohol intoxication related events.,27,ACQU
30、IRED BRAIN INJURY,Alcohol can cause Direct brain damage (alcohol dementia, Wernicke Korsakoffs Syndrome, and atrophy of the cerebrum and cerebellum. There can be some improvement in deficits with abstinence Indirect damage can be associated with Falls and accidents Intracerebral bleeds due to alcoho
31、l effect on platelets and blood pressure Hepatic encephalopathy due to alcohols effect on the liver,28,ACQUIRED BRAIN INJURY,Solvents such as glue can lead to ataxia (impaired gait) and cognitive problems. Metabolic syndromes can also be seen especially with inhalation of substances that effect the
32、kidney. Cannabis dependence is associated with impaired attention, concentration and motivation,29,ACQUIRED BRAIN INJURY,Stimulant use can be associated with strokes (as seen here), seizures and long term memory and concentration problems.,30,ACQUIRED BRAIN INJURY,Sedative effects are not well studi
33、ed in the long term, though overdose can lead to respiratory compromise and oxygen deprivation. Oxygen deprivation can also be seen in opiate overdose as pictured here, where the overdose victim developed noncardiogenic pulmonary edema* and intubation and respirator care was needed.,* NONCARDIOGENIC
34、 PULMONARY EDEMA A Condition whereby the lungs fill up with fluid (PULMONARY EDEMA) but the cause is not heart failure (CARDIOGENIC) in origin, the usual cause of PULMONARY EDEMA is congestive heart failure, where the heart is not pumping properly and the blood backs up into the lungs.,31,The CDC es
35、timated that 5.3 million Americans live with disabilities due to brain injury and that 67% of people in rehabilitation for brain injury have a previous history of substance abuse (Thurman, 1998). 50% of these people will return to using alcohol and drugs after the injury (Corrigan, 1995).,32,20% of
36、persons with brain injuries who did not use alcohol or drugs prior to the injury, were vulnerable to alcohol and drug use after the injury (Corrigan, 1995). 50% of clients enrolled in OASAS Programs were affected by probable TBI (N=647) (Fenske, Gordon, Perez, Hibbard, Brandau, submitted for publica
37、tion).,33,ASSESSMENT OF THE TBI PATIENT SHOULD INCLUDE:,Biopsychosocial as the standard in chemical dependence treatment Screening tool Cognitive assessment Emotional assessment Physical assessment Description of injury/illness/etc Concrete needs assessment Review of medical/neurological records,34,
38、ASSESSMENT,Screening Tool: ICD HELPS,H Did you ever HIT your head? Were you ever HIT on the head?E Were you ever seen in an EMERGENCY room, by a doctor or hospitalized? For what reason?L Did you ever LOSE consciousness? For how long? For what reason?P Did you have any PROBLEMS after you were hit on
39、the head? Headache? Dizziness? Anxiety? Depression? Difficulty concentrating? Difficulty Remembering?Difficulty reading, writing or calculating? Difficulty performing your old job at work? Difficulty with school work? Poor judgment? Poor problem solving?S Any other SIGNIFICANT SICKNESS? Look for hos
40、pitalizations for brain cancer,meningitis, stroke, heart attack, diabetes. Screen for domestic violence and child abuseICD-International Center for the Disabled: Picard, Scarisbick, Paluck, 1993,35,ASSESSMENT,ICD Cognitive assessment Does patient have problems with memory Difficulty managing day-to-
41、day tasks? Does patient forget appointments? Does patient have difficulty paying attention or concentrating on a task? Does the patient get overwhelmed by too much information if given at once? Is the patient able to understand what is said to him/her? Do others tell him/her that they notice problem
42、s? If the patient denies problems, ask if others tell him/her that they are observing problemsICD-International Center for the Disabled, 2004,36,ASSESSMENT,ICD Cognitive assessment Some questions: What is todays complete date? Do you know what agency you are in? Do you know who I am or why you are s
43、eeing me? Do you have problems with memory? Do you have problems remembering day to day tasks? Do you have problems paying bills? Do you have problems taking medications? Do you have problems eating meals? Do you forget to turn off the stove? Do you use a date book or other techniques for rememberin
44、g?ICD-International Center for the Disabled, 2004,37,ASSESSMENT,ICD Cognitive assessment Some questions: Is there someone who helps to remind you about appointments? Who ? Do you have difficulties paying attention or concentrating on a task? Do you have any difficulties with reading? Do you get over
45、whelmed by too much information being given to you at one time? Are you able to understand what is said to you? Do you have difficulties at times finding the right words to say? Do you have difficulties organizing you thoughts and communicating them?ICD-International Center for the Disabled, 2004,38
46、,ASSESSMENT,Emotional assessment Do you feel: Depressed Anxious Do you have trouble sleeping? Do you have loss of appetite? Do you get frustrated easily? Do you have difficulty controlling anger? Do you often act without thinking?ICD-International Center for the Disabled, 2004,39,ASSESSMENT,Physical
47、 Assessment Does the patient have left or right-sided weakness? Does the patient have difficulties with balance? Does the patient complain of frequent headaches? Does the patient get fatigued easily? Are there noticeable scars from trauma or operations? Is the speech easily understood?ICD-Internatio
48、nal Center for the Disabled, 2004,40,ASSESSMENT,Description of injury/illness/etc Date Describe event with details of the trauma/illness, results of the trauma/illness, hospitalizations, rehabilitation treatments Loss of consciousness? Duration Was coma initially present? How long did it last? Did s
49、eizures occur after the incident? Type of seizure When did they start? How often do they occur? Date of last seizure? Physician following the problem? Medications being used?ICD-International Center for the Disabled, 2004,41,ASSESSMENT,Concrete Needs Assessment Can you travel by public transportation? If yes, do you need assistance with writing out the route to travel? If no, do you need someone to go with you? Do you need an ambulette? Do you need assistance registering or checking in at appointments?ICD-International Center for the Disabled, 2004,
