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Untitled Prezi

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Heather Liddiard

on 2 December 2016

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TBI and Anxiety Disorders

Common after TBI
Often social phobia
Fear of goiung out, interacting with other people
Avoidance of anxiety provoking sitautions
Rolefor medication - few studies
Significant role for Psychology and OT led treatments
Depression
Common 27-61%
Frontal - striatal-thalamocortical circuits
Key NT systems in depression altered by the TBI
Who was speaking
Dr Mayur Bodani, Consultant Psychiatrist

Dr Marc Loewer, Consultant Psychiatrist

Dr Anita Rose, Consultant Psychologist

Dr Jyoti Evans, Consultant Psychologist
Aims for today
Prevalence and types of psychiatric disorders following TBI
Pharmcological treatments
Behavioural approaches
Environmental approaches
Types of Psychiatric Disorders following TBI

Psychosis 0.1- 9.8 % (David and Prince 2007)
Anxiety Disorders
Depressive Disorders 18.3%- 61% (Kim et al 2007)
Bipolar Disorder
Obsessive Compulsive Disorder 1.6% -15% (Hibbard 1998, Deb et al 1999)
Post Traumatic Stress Disorder 3- 27.1% (Bryant et al 2000)
Personality Disorders
Dr Bondani
Specilaises in neuropsychiatry
Sleep disorders and fatigue
West Kent and Medway NHS Trust
Expresses the importance of pre-morbid information
Dr Marc Loewer
Trained in Germany and Switzerland
Fachklinik Sonneneck, Germany
Specialises in psychiatry and psychotherapy/CBT
Interest in Mindfulness for TBI
Dr Anita Rose
Raphael Medical Centre
Specialises in MS
Interested in analysing behavious and impact of ecological factors
Dr Jyoti Evans
Medium Secure Unit
TBI and forensic needs
Sex offender treatment programme
Interventions used to manage behaviour - life maps, body maps, environmental controls
Anxiety Disorders

Panic Attacks
Agoraphobia
Specific phobia
Social phobia
Acute Stress Disorders
Generalised Anxiety Disorder

TBI and Anxiety Disorders

Common after TBI
Often involve social phobia
Fear of interacting with others
Avoidance of certain environments
Few studies- role for medication
Most research suggests significant role for psychology and OT led interventions
Depressive disorders
Frontal striatal thalamocortical circuits
Key NT systems in depression altered by TBI

Risk factors
Pre-injury depression
Co-morbid psychiatric disorders
Substance misuse
Unemployment (Seel et al 2004)
Female
Loss and stress
Social isolation (Gomez et al 1997)
Cognitive difficulties
Lower economic status (Jorge et al 2004)
Post Traumatic Stress Disorder

E
xperiencing; recollections of the event, thoughts and perceptions
A
voidance; of thoughts, feelings,conversations
A
rousal; falling and staying asleep, anger, hyper-vigilance

(East African Airways)

Acute < 3 months
Chronic > 3 months

PTSD can occur in individuals with amnesia for the trauma

Protective Factors
PTA (Gill et al 2005)
Lack of insight (Williams et al 2002)

Psychopharmacology

Antidepressants
Mood stabalisers
Anti psychotics
Neuroleptics
Hypnotics
Antidepressants

SSRI
SNRI
TCA
MAOI
MARI
Atypicals
SSRI/SNRI
Citalopram/escitalopram
Sertraline
Fluoxetine
Venlafaxine
Duloxetine
Mirtazeoine

Action
Inhibition of serotonin re-uptake
SSRIs act on serotonin only
SNRIs act on serotonin and norepinephrine
Usually first choice of medication due to fewer side effects
Not dangerous if OD

Monoamine Oxidase Inhibitors MAOI
Moclobemide
Tranylcypromine
Phenelzine

Action
Inhibit the activity of monoamine oxidase, prevents the breakdown of monoamine neurotransmitters and therefore increases their availability

Historically dietary and drug interactions and therefore not first choice of treatment

Psychological Approaches

No standardised recommendations of guidance
Family and social support
Psychotherapy adapted to cognitive limitations
Relaxation
Psycho-education
CBT
Problem solving training
EMDR for PTSD - only if have access to the traumatic event
Somatic Experiencing for PTSD


Psychotherapy

Clearly structured treatment
Goal setting
Clear treatment
expectations
Written reminders
Repetition
Mindfulness and TBI

Number of recent studies on this
Reducing depression after stroke (Johaansson et al 2012)
Improving fatigue after stroke /TBI (Bedford et al 2012)

What is mindfulness?

Paying attention in a particular way
In the present moment
Non judgmental


Evidence for changes in the brain after mindfulness
Striatum/amygdala (Tang et al 2015)
Hypothesis is that mindfulness helps with attentional control, self regulation, self awareness; all of which play a significant role in many psychiatric presentations.

There is evidence to suggest that mindfulness can reduce the risk of relapse.
What does it involve?

(Williams et al 2000)

Course of at least 8 weeks
2.5 hours per day
Homework assignments
45 mins practice each day
Behavioural Approaches
Positive reinforcement
Negative reinforcement
Punishment (no longer in use)
Extinction
Differential reinforcement of other behaviour
Time out
Response cost
Overcorrection
Types of behavioural issues

Personality change 57%
Inappropriate laughing 24%
Pathological crying 19%
Aggression 38%
Impaired social judgement 38 %

Max et al 2011)
CAUSES

Organic
Frontal lobe
Orbio-frontal structures = disinhibition of emotional behavior
Dorso-lateral = arousal and emotional responsiveness

Premorbid Personality

Cognitive changes

Environment
Assessment

When
does it occur?
Where
does it occur?
Who
does the behaviour occur with?
Did it start suddenly or build up
gradually
?
How long
does it last?
What is the
history
of the problem?
What
solutions
have been tried in the past?
How are other
people reacting
?
Other factors in analysis

Physical factors;noise, overcrowding,
Respect
Choices
Communication
Current coping skills
Loss
Cognitive changes




Ecological Factors
Remember!!

Behaviours with similar topography can have different functions across different situations
Questions?
Assessment

History
Understand the nature and severity of the TBI
Assessment of mental state
Assessment of cognitive ability
Formulation
Treatment Plan
Changes at TCT
Ongoing work - Additions to INRA: Social, education, psychological, premorbid factors
Behavioural approaches - discussions re: behaviour pathways
Environmental approaches - how to adapt the environment to manage behaviours
Environmental treatments

Sensory modulation -
Minimise chance of risky behavior occurring
Calming colours and minimal clutter to aid reduction in stress for someone in mania
Bright colours and stimulating environment to enhance a persons mood when in low mood

Minimise/remove stressors

Manipulate the environment - (high tables and sides and large tools could frighten a child)

Lifestyle changes are the first choice before psychiatric medications.

Thank you!!!
How this can relate to children with TBI

Many children are prescribed with psychiatric medications
Psychiatric disorders can interfere with recovery
Family support is essential - BIE for parents, siblings and the child
Play therapy for the child to express the difficulties they have in a forum that they can access
Behavioural issues are the same for children, although you also have to bare in mind their
Mindfulness for children - http://www.huffingtonpost.com/sarah-rudell-beach-/8-ways-to-teach-mindfulness-to-kids_b_5611721.htmlhttp://annakaharris.com/mindfulness-for-children/
Psychiatric Effects of TBI

Heather Liddiard
Debbie Lantsbury

There could be a number of reasons as to why a person does not want to engage - e.g. lack of sleep, pain, sensory sensitivities etc
Communication is key - a person wants to be able to understand and to be understood by you
Disorientation!
Management:
Stay calm & speak quietly
Keep your distance
Open body language
Full transcript