Neurobehavioral Based Problems in TBI: clinical, behavioral, and caregiver approaches to managing
same D. Bradley Burton, Ph.D.
Hannah Kersting, B.A., B.S.
The impact of brain injury can take three broad forms:
1. Neurocognitive
2. Neurobehavioral
3. Psychological
Neurocognitive entails changes in cognitive and cognitive related
capacities,
e.g., learning, language, reasoning, organization and control functions.
Psychological is defined as the individual’s psychological/emotional
reaction to having sustained brain injury and all that implies.
Neurobehavioral involves changes in the individual’s capacity to accurately
perceive, monitor, plan, and control their internal and external behavior.
Neurobehavioral disorders
1. Hypoactivity/dysbulia vs Hyperactivity/lability
2. Anosognosia vs full insight
Treatment Modalities
• Cognitive Behavioral: procedural memory / environmental engagement
• Pharmacological – mood / behavior stabilizer vs stimulant
• Natural recovery process
-2
-1
0
1
22.
2.16
2.3.
16
2.4.
16
2.5.
16
2.8.
16
2.9.
16
2.10
.16
2.11
.16
2.12
.16
2.15
.16
2.16
.16
2.17
.16
2.18
.16
2.19
.16
2.22
.16
2.23
.16
2.24
.16
2.25
.16
ST OT PT
Affective Instability Scale
l
Shunt Placement
-2
-1
0
1
22.
2.16
2.3.
16
2.4.
16
2.5.
16
2.8.
16
2.9.
16
2.10
.16
2.11
.16
2.12
.16
2.15
.16
2.16
.16
2.17
.16
2.18
.16
2.19
.16
2.22
.16
2.23
.16
2.24
.16
2.25
.16
2.26
.16
ST OT PT
Affective Instability Scale
Decreased Keppra
0
50
100
150
200
1/24/1
5-1/27
/15
2/4/15
-2/8/1
5
2/16/1
5-2/22
/15
3/9/15
-3/15
/15
4/1/20
15-4/
7/201
5
4/22/1
5-4/28
/15
5/27/1
5-6/2/
15
6/10/1
5-6/16
/15
6/24/1
5-6/30
/15
7/8/15
-7/14
/15
7/22/1
5-7/28
/15
8/5/15
-8/11
/15
8/19/1
5-8/25
/15
9/2/15
-9/8/1
5
9/16/1
5-9/22
/15
9/30/1
5-10/6
/15
10/14
/15-10
/20/15
10/28
/15-11
/3/15
11/11
/15-11
/17/15
11/25
/15-12
/1/15
12/11
/15-12
/15/15
12/23
/15-12
/29/15
1/6/16
-1/12
/16
1/20/1
6-1/26
/16
2/3/16
-2/9/1
6
2/17/1
6-2/23
/16
Verbal Outbursts Physical Outbursts Physcial Threats Verbal Threats cursing others Property Dest. Suicidal Verbal. Suicidal GestureSelf-abuse physical/sexual verbal/sexual attempt elopeactual elope test limits attempts to trip others attempts to get out of bed spitting steals food and drink releases seat belt beats on chair or wall resistive to care bite himself gets into staffs belongings attempts to go to courtyardinstances of orality goes into other pts rooms pressured talking restless behaviorreactive negative affect harms or destroys property perseverations
Behavior Tracking increased respiradol and prn ativan
increased ativan
A special Case
• Anosognosia perceptual unawareness of neurocognitive deficit
• Alien limb syndrome • Anton’s syndrome • Denial of neurocognitive deficit “your all
crazy”. More likely with nondominant hemi process
Treatment Modalities
• Procedural memory – redundant re-conceptualization / cognitive rehearsal
• Daily orientation exercises • Environmental alteration – structured
daily activities / schedule • Insight oriented psychotherapy • Natural recovery process
OQ Tracking Data
65
45
7
11
13 1314
15
18 1819
20
1011
1213
1514
1314
16
1817
20 20
12
0
5
10
15
20
12/14
/2012
12/19
/2012
12/20
/2013
1/21/2
013
1/24/2
013
1/29/2
013
1/30/2
013
2/1/20
13
2/4/20
13
2/8/20
13
2/25/2
013
2/28/2
013
2/29/1
3
2/30/1
3
OQ W/O cues OQ W/ cues
Functional Convergence
OQ Tracking Data
10
21 1
0 0 0
4
8
6
1011
0
8 8
2
10
14
18
14
18
0
3
0 0
2
0
17
11
1615
0
17
12
14
16
2019
20
10
5
10
15
20
2/28/2
014
3/1/20
14
3/4/20
14
3/5/20
14
3/6/20
14
3/7/20
14
3/8/20
14
3/12/2
014
3/13/2
014
3/14/2
014
3/19/2
014
3/20/2
014
3/22/2
014
3/25/2
014
3/26/2
014
3/27/2
014
4/1/20
14
4/2/20
14
4/4/20
14
4/5/20
14
4/8/20
14
4/9/20
14
OQ W/O cues OQ W/ cues
The rubric of recovery
Insight
Compliance with treatment
Emotional/behavioral stability
Psychological adjustment
Recovery