robert walker, m.s.w., l.c.s.w. university of kentucky department of behavioral science and center...

Brain Injury: types and severity in

domestic violence victimization

Robert Walker, M.S.W., L.C.S.W.University of Kentucky Department of Behavioral Science andCenter on Drug and Alcohol Research

PREVALENCE OF Brain Injury AMONG dv VICTIMS

Injuries to the head from domestic violence are far more common than thought.

Estimates of prevalence range from 18% -90% of DV victims having brain injuries ((Jackson, 2002;Valera, 2003).

Clearly different kinds of DV populations account for much of the variation in prevalence.

Among those with brain injuries, approximately half experienced unconsciousness.

Specific proximal causes

Battery to the head

Falls

Suffocation, Submersion in water (hypoxic injury)

Drug overdose (hypoxic injury)

Auto accidents

Sports injuries (soccer, football)

ALCOHOL ABUSE

ABIDEPRESSION

ANXIETY DISORDER

DRUG ABUSE

PERSONALITY DISORDER

SLEEP DISORDER

CHRONIC PAIN

The typical cluster of problems related to TBI/ABI

Understanding brain injuryEvery brain injury is different.

Every person with a brain injury will present differently.

However, most experience frontal lobe injury with negative effects on: thinking emotion regulation and control of impulsivity

Understanding Brain Injury

Brain injury can result in a wide range of physical and mental problems and symptoms.

In addition, there is a wide range in the severity of injury.

Understanding Brain Injury

This diversity of symptoms and problems makes it imperative that advocates learn how a brain injury has affected the individual.

Safety plans must take into account these individual differences if they are to succeed.

Major Types of Brain Injury

There are two major ways to define brain injury: “Traumatic brain injury” refers to blunt force trauma to the head resulting in injury to the brain. This used to be called “closed head injury”.

“Acquired brain injury” is a broader term that includes various insults to the brain including lack of oxygen, bleeding in the brain, infection, or exposure to toxins.

TRAUMATIC BRAIN INJURY: A definition

Traumatic brain injury is an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.

Adopted by the Brain Injury Association Board of Directors, February 22, 1986.

TRAUMATIC BRAIN INJURY: Symptoms soon after an injury

Symptoms of a traumatic brain injury can include a wide range of physical and mental problems that are likely to be present immediately after an injury:

- Spinal fluid (thin water-looking liquid) coming out of the ears or nose

- Loss of consciousness; however, loss of consciousness may not occur in some concussion cases

- Dilated pupils or pupils appear of unequal size

- Loss of eye movement

- Respiratory failure

- Semi comatose state

Adapted from the Brain Injury Association of America


- Coma

- Impaired muscle tone and impaired muscle movements

- Paralysis – particularly on one side of the body

- Slow heart rate

- Slow respiration rate, with an increase in blood pressure

- Vomiting

- Lethargy

- Headache



Confusion

Inefficient thinking/ impaired cognition

Inappropriate emotional responses


TRAUMATIC BRAIN INJURY:Long after the injury

DepressionAnxietyPossible hallucinationsMemory problemsProblems controlling impulsesDifficulty solving problemsChronic pain, headachesInappropriate behaviorLearning difficultiesProblems with physical coordinationFatigue


TRAUMATIC BRAIN INJURY: Long after the injury

If these problems were present BEFORE the injury, the injury may make them worse.


TYPES OF TRAUMATIC BRAIN INJURY

Diffuse Axonal InjuryConcussionContusionCountre-coupShaken-baby syndrome

Diffuse Axonal Injury

A Diffuse Axonal Injury can be more wide-spread throughout the brain than a specific or focal injury to one part of the brain.

It can be caused by shaking or by strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as can occur when a body is thrown around in a car accident.


Injury occurs because the brain inside the skull case lags behind the movement of the skull, causing brain structures to tear.

It’s somewhat like having a jello-like substance in a pail, then sloshing the pail back and forth. The soft material is thrown around against the hard containing surface. This can create shearing effects and tearing of nerve cells.


There can be extensive tearing of nerve tissue throughout the brain. This trauma triggers the release of brain chemicals (cortisol) that can cause further damage. (Cortisol stops cell metabolism of glucose, thus resulting in cell death).


The tearing of the nerve tissue disrupts the brain’s regular communication networks and normal chemical processes.

This disturbance in the brain can produce temporary or permanent widespread brain damage, coma, or death OR, it can result in moderate global impairments that can be misunderstood as other disorders (MS).



A person with a diffuse axonal injury can present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.

The impairments may be better described as “global” because they include a wide range of physical and mental functions.


Concussion

A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.

Concussions can be mild, moderate or severe.

A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change like sudden crash or acceleration during a car wreck.

The blood vessels in the brain may stretch and cranial nerves may be damaged.


Concussion

A person may or may not experience a brief loss of consciousness (not exceeding 20 minutes). A person may remain conscious, but feel “dazed” or “punch drunk”.

A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan. Skull fracture, brain bleeding, or swelling may or may not be present.

Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome


Concussion

A concussion can cause diffuse axonal type injury (see above) resulting in permanent or temporary damage.

A blood clot in the brain can also develop from a concussion and can even be fatal.


Concussion

It may take a few months to a few years for a concussion to heal and many individuals have life-long consequences of these injuries.

Recently, a form of progressive dementia has been identified among football players who sustained multiple injuries years ago.


ContusionA contusion is a bruise on the brain; It is where blood vessels have been ruptured in brain tissue.

A contusion can be the result of a direct impact to the head.

Large contusions may have to be surgically removed


Other Specific Types of Traumatic Injury

Contre-coup Where injury occurs on both sides of the brain Reverberation injury

Shaken baby syndrome Brain tissue can be torn apart Blood vessels in the brain may be ruptured and bleed

This causes swelling and pressure damage to neurons


Acquired Brain Injury

An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth.

An acquired brain injury commonly results in a change in neuronal activity, which effects the physical integrity, the metabolic activity, or the functional ability of the cell. An acquired brain injury may result in mild, moderate, or severe impairments in one or more areas, including cognition, speech-language communication; memory; attention and concentration; reasoning; abstract thinking; physical functions; psychosocial behavior; and information processing.

Adopted by the Brain Injury Association Board of Directors, March 14, 1997.

Acquired Brain Injury: CausesAcquired brain injury is generally related to decreased oxygen to the brain and this is defined in two ways: Anoxic events where the brain has lost its oxygen supply and

nerve cells die;

Hypoxic events where the brain has experienced a reduced supply of oxygen and nerve cells can be impaired.

Acquired Brain Injury: General Characteristics

Tends to be more global and less specific in location

Impairment in thinking and memory is likely

Mental health problems are likely

Movement disorders are likely

Conditions/situations that can lead to acquired brain injury

Near drowning Drug or alcohol overdose Heart attack Stroke, aneurysm Meningitis Dementias

Severity of Brain InjuryHaving reviewed different types of brain injury, it is also important to understand that there are different levels of severity as well. Typically, injuries are classified into three groups:

Severe

Moderate

Mild

Severity of Brain Injury Although the severity of the injury may predict the level

of impairment, there are many factors which influence the long-term outcome of the injury.

Prior TBIs, history of substance abuse, age, quality of rehabilitation and environmental supports are some major factors that can affect long-term outcomes.

Mild Brain Injury: Typical Signs/Symptoms

Headache

Fatigue

Sleep disturbance

Irritability

Sensitivity to noise or light

Balance problems

Decreased concentration and attention span

Mild Brain Injury: Typical Signs/Symptoms

Decreased speed of thinking

Memory problems

Learning problems

Poor social skills

Nausea

Depression and anxiety

Emotional mood swings

Possible motor coordination problems (typically mild)

Mild Brain Injury: Clinical Issues

Major depression is prevalent among persons with mild to moderate brain injury, with between 14% and 29% experiencing it (Jorge, Robinson, Arndt, et al., 1993; Rapoport, McCullagh, Streiner, et al., 2003).

These rates are 3-5 times greater than for the general population.

It is now recognized that PTSD and TBI can be co-occurring conditions with each complicating the other.


Depression is associated with worse performance across a wide array of cognitive domains.

Yet depression among persons with ABI can be treated, thus opening the possibility of improvement across cognitive areas (Rapoport, McCullagh, Shammi, & Feinstein, 2005).

A stronger case can be made for using SSRIs with these persons as they cause increased brain-derived growth factor (BDNF) which can reduce inflammation effects in the central nervouse system.


Memory deficits and associated attentional problems are not always associated with severe and overt brain injury,

but can result from mild to moderate injury even when there has been no loss of consciousness with the injury (Kelly 1999; Malec 1999; National Institutes of Health 1999; Dixon, Taft & Hayes 1993).

Frontal Lobe Injury

Most individuals entering shelters or treatment form trauma-related problems will have frontal lobe injury.

Individuals with frontal lobe injuries share problems with executive functioning – planning for the future, inhibiting impulses, and regulating emotion.

Frontal Lobe Injury

Individuals with injury to the frontal lobes can have increased difficulty reading social cues and emotional cues (Mah, Arnold, & Grafman, 2004).

Frontal lobe injury is associated with deficits in detecting lies and forming a mental picture of how others think or feel about situations (Stone, Baron-Cohen, & Knight, 1998; Stuss, Gallup, & Alexander, 2001).

Frontal Lobe Injury

Injury to specific regions of the frontal lobes may result in different kinds of memory encoding and retrieval processes (Stuss & Alexander, 2005).

Storing of new information may be less accurate and less complete.

Ready retrieval of remembered information may be impaired and slower.


Apathy and indifference have also been associated with frontal lobe injury (Stuss, Van Reekum & Murphy 2000; Edwards-Lee & Saul 1999; Litvan 1999).

The apathy may be associated with a reduced emotional responsivity – even in startle situations and in novel situations (Van Reekum, Stuss, & Ostrander, 2005).

It may be important to differentiate apathy from depression.


In some cases, persons with frontal lobe injury can have both indifference characterized by minimization of symptoms,

Or they may show emotional placidity and inappropriate joking or social disinhibition (Edwards-Lee & Saul 1999).

Their traits can easily be misunderstood in intervention settings as resistance or transference issues.

In fact, the reasons for the behavior may include cognitive impairment secondary to brain injuries that may be mild, but significant.


Generalized Anxiety Disorder, PTSD, and Obsessive-Compulsive Disorder have also been found among individuals following a traumatic brain injury (Van Reekum, Cohen, & Wong, 2000).

In general, the prevalence of these disorders greatly exceeded the rates for the population at large.

Be sensitive to the likelihood of multiple mild injuries.

Cumulative effects over time matter.

BRAIN INJURY AND SUBSTANCE ABUSE

Traumatic brain injury has been associated with alcohol and drug use both as a contributing factor to the injury and as a complicating factor for rehabilitation (Hested et al. 1995; Miller 1992; Boyle, Vella & Moloney 1991).

Up to two-thirds of brain injury cases have been found to have histories of substance use before the injury (Corrigan 1995).

Among those with injuries the probability of having a TBI tripled when BAC was .15-.20, then increased 9-fold when BAC exceeded .20 (Savola, Niemela & Hillbom, 2005 )


The high prevalence of drug and alcohol problems among traumatic brain injured individuals suggests that drug abusers might be at high risk for brain injury and vice versa.

Being intoxicated at the time of injury predicts greater severity and poorer outcomes.

This relationship between ABI and substance use fits in the picture of DV as well.


Individuals may not “get it” about their risks and safety needs because of denial.

BUT - may not get it because they really just do not get it, due to cognitive impairments secondary to brain injury, substance use, PTSD or the combination of all three.

It is easy to read brain injury victims as resistive to new information and to safety planning.

How to screen for TBI/ABI John Corrigan’s work at Ohio State is very helpful.

Search for his work.

Ohio State University TBI Identification Method Short Form

1. Have you ever been hospitalized or treated in an emergency room following an injury to your head or neck? Think about any childhood injuries you remember or were told about.

Yes

No

2. Have you ever injured your head or neck in a car accident or from some other moving vehicle accident?

Yes

No

3. Have you ever injured your head or neck in a fall or from being hit by something?

Yes

No

Bogner, J.A., Corrigan, J.D. (2009). Reliability and validity of the OSU TBI Identification Method with Prisoners. Journal of Head Trauma Rehabilitation, 24(6), 279-291. Corrigan, J.D., Bogner, J.A. (2007). Initial reliability and validity of the OSU TBI

4. Have you ever injured your head or neck in a fight, from being hit by someone or being shaken violently?

YesNo

5. Have you ever been nearby when an explosion or a blast occurred? If you served in the military, think about any combat-related incidents.

YesNo

If all above are “no” then stop. If answered “yes” to any of the questions above, ask:

6. Were you knocked out or unconscious following the injury(ies) you mentioned above? DO NOT INCLUDE LOSING CONSCIOUSNESS DUE TO DRUG OVERDOSE OR FROM BEING CHOKED (see #8, below).

YesNo

If answer to #6 is “No”, ask:

7A. Were you dazed or have a gap in your memory from the injury(ies) you mentioned above? [RULE OUT ALCOHOL BLACKOUTS]

YesNo

If answer to #6 is “Yes”, ask:

7B. How long were you knocked out? (If identified multiple injuries with loss of consciousness, ask for each. If not sure of the time frame, encourage them to make their best guess.)

For How long ________ How old were you? _____For How long ________ How old were you? _____ For How long ________ How old were you? _____ For How long ________ How old were you? _____ For How long ________ How old were you? _____

If more than 5, how many times more?______

Longest time knocked out?_____ How many ≥ 30 mins.?_____ Youngest age?____

8. Have you ever lost consciousness from a drug overdose or being choked?

Number of times from a drug overdose

Number of times from being choked

Bogner, J.A., Corrigan, J.D. (2009). Reliability and validity of the OSU TBI Identification Method with Prisoners. Journal of Head Trauma Rehabilitation, 24(6), 279-291. Corrigan, J.D., Bogner, J.A. (2007). Initial reliability and validity of the OSU TBI

Scoring

_________# TBI-LOC (number of TBI’s with loss of consciousness from #7B)

_________# TBI-LOC ≥ 30 (number of TBI’s with loss of consciousness ≥ 30 minutes from #7B)

_________age at first TBI-LOC (youngest age from #7B)

_________TBI-LOC before age 15 (if youngest age from #7B < 15 then =1, if ≥ 15 then = 0)

_________Worst Injury (1-5):

If responses to #1-5 are “no” classify as 1 “improbable TBI”.

If in response to #6 reports never being dazed or having memory lapses classify as 1 “improbable TBI”.

If in response to #7A reports being dazed or having a memory lapse classify as 2 “possible TBI”.

If in response to #7B loss of consciousness (LOC) does not exceed 30 minutes for any injury classify as 3 “mild TBI”.

If in response to #7B LOC for any one injury is between 30 minutes and 24 hours classify as 4 “moderate TBI”.

If in response to #7B LOC for any one injury exceeds 24 hours classify as 5 “severe TBI”.

________# anoxic injuries (sum of incidents reported in #8)

https://osuwmcdigital.osu.edu/sitetool/sites/psychiatry2public/documents/Psychiatry_Documents/corrigan.pdf

If the person is positive for TBI/ABI

Then, plan for shorter sessions.

Use visual, auditory, and written materials and media – multi-sensory.

Have the person write down safety planning steps and actions.

Have the person report back what key assignments are (if there are assignments).

Watch for signs of “forgetting to remember.”

Conclusions Brain injuries can take many forms depending on the type and

severity of injury.

Also, pre-existing conditions can affect the clinical manifestations of brain injury in both the long and short term after an injury.

Examine whether persons get it versus being resistant to new information. At the end of safety planning sessions, have the person report

back what the plan consists of;

Put situations to the person and ask her to describe the safety actions;

If these steps are carried out well, then comprehension is relatively intact.

If not, repeat everything using smaller chunks of info.

Conclusions Many mental health problems emerge following a brain

injury and these conditions may actually mask a brain injury.

Substance abuse is a likely contributor to the risk for brain injury and increased substance use may be a consequence of the injury.

Safety planning should always consider the possibility of neurocognitive problems secondary to ABI.

robert walker, m.s.w., l.c.s.w. university of kentucky department of behavioral science and center...

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