NeuroNeuro--rehabilitation & Emotionrehabilitation & Emotion

Huw WilliamsHuw WilliamsCCNRCCNR

School of PsychologySchool of PsychologyUniversity of ExeterUniversity of Exeter

& & Emergency Dept, Emergency Dept,

Royal Devon & Exeter HospitalRoyal Devon & Exeter Hospitaly py pw.h.williams@exeter.ac.ukw.h.williams@exeter.ac.uk

Centre for Clinical Neuropsychological Research (CCNR)

NHS

With thanks to: With thanks to: Profs Barbara Wilson OBE & Jonathan EvansProfs Barbara Wilson OBE & Jonathan EvansW & JW & J

staff and clients at staff and clients at --

Thanks to:Thanks to:Thanks to:Thanks to:

James Tonks, Phil Yates, Ian Frampton, Alan James Tonks, Phil Yates, Ian Frampton, Alan J pJ pSlater, Luke Mounce, Sarah Wall, Helen RylandSlater, Luke Mounce, Sarah Wall, Helen Ryland

Adrian Harris, Adam Reuben, Jonathan BengerAdrian Harris, Adam Reuben, Jonathan Benger, , J g, , J g

Alex Haslam, Janelle Jones, Catherine Haslam, Alex Haslam, Janelle Jones, Catherine Haslam, Jolanda JettenJolanda JettenJolanda JettenJolanda Jetten

Penny Weeks consulting, CBIT, Encephalitis Penny Weeks consulting, CBIT, Encephalitis Society Headway Devon Headway UKSociety Headway Devon Headway UKSociety, Headway Devon, Headway UK, Society, Headway Devon, Headway UK, UKABIF, OZCUKABIF, OZC

Patients/clients/members who participated inPatients/clients/members who participated inPatients/clients/members who participated in Patients/clients/members who participated in projectsprojects

Brain Injury: Scale of problemBrain Injury: Scale of problem

WHO: “Brain Disease” = WHO: “Brain Disease” = 35% of Europe’s total 35% of Europe’s total disease burden disease burden

Head Injury is the leading cause of Head Injury is the leading cause of death and disability in children & death and disability in children & working age adults working age adults

“TBI [Traumatic Brain “TBI [Traumatic Brain Injury] Injury] -- among young adults, among young adults, j y]j y] g y g ,g y g ,account[s] for a quarter to a account[s] for a quarter to a third of trauma deaths and third of trauma deaths and for a much larger proportion for a much larger proportion

f lif l di bili ” Mf lif l di bili ” Mof lifelong disability” Maas of lifelong disability” Maas et al., (2006)et al., (2006)

All brain injuries 1998-2003 by gender(Suspected & Moderate-Severe)

140

160( p )

100

120

ndan

ces

40

60

80

No.

atte

n

0

20

40N

0

0-405

to 09

10 to

1415

-1920

-2430

-3435

-3940

-4445

-4950

-5455

-5960

-6465

-6970

-7475

-7980

-84 85+

Age groupAge groupMales Females

Yates, Williams et al. 2006, JNNP

Brain Areas that typically Injured…

frontalfrontal--tempotempo--limbic systemslimbic systems are crucial for are crucial for Monitoring arousal level & control of behaviour Monitoring arousal level & control of behaviour t d “ l t t ”t d “ l t t ”towards “goal states”towards “goal states”

Injury often leads to:Injury often leads to:

impulsivity, poor planning, inadequate impulsivity, poor planning, inadequate response inhibition and inflexibility (Milders, response inhibition and inflexibility (Milders, Fuchs & Crawford, 2003).Fuchs & Crawford, 2003).

&&

““poor anger managementpoor anger management (reactive), (reactive), irritability irritability p g gp g g ( ),( ), yyand impulse controland impulse control are common” (Hawley et al. are common” (Hawley et al. 2003).2003).

li d i l d fi ili d i l d fi i dd ddpersonality and emotional deficits personality and emotional deficits –– due to due to dede--coupling of cognition and emotioncoupling of cognition and emotion has been has been described by Damasio (1994), as “acquired described by Damasio (1994), as “acquired sociopathy”” sociopathy”” --

…is there a case for Neuro…is there a case for Neuro--rehab “OF rehab “OF EMOTION”EMOTION”EMOTION”…EMOTION”…

A h l h l h bl ?A h l h l h bl ?Are there mental health problems?Are there mental health problems?Are such MHPs related to psychological or Are such MHPs related to psychological or –– proportionally proportionally --“biological” factors“biological” factorsgg

Are there cognitiveAre there cognitive--behavioural phenomena that may behavioural phenomena that may be amenable to CBT?be amenable to CBT?

Related to moodRelated to mood? pain, sleep and other “health” issues? pain, sleep and other “health” issues

What about neurologically based emotional deficits?What about neurologically based emotional deficits?What about neurologically based emotional deficits?What about neurologically based emotional deficits?How can CBT be delivered? And does it work?How can CBT be delivered? And does it work?

Considering cognitive systems and neuroConsidering cognitive systems and neuro--affective systems affective systems g g yg g y yythat may be affected…that may be affected…

NeuroNeuro--rehabilitation and emotionrehabilitation and emotionNeuroNeuro rehabilitation and emotionrehabilitation and emotion

Typically referring issues for Typically referring issues for services involves mood services involves mood problems, breakproblems, break--ups, ups, drink/drugs..etc…drink/drugs..etc…

See Williams & Evans, 03See Williams & Evans, 03Special Issue of Special Issue of Neuropsychological Neuropsychological RehabilitationRehabilitation on Biopsychosocial on Biopsychosocial Issues in NeuroIssues in Neuro--RehabRehab

Suicidality…Suicidality…Simpson & Tate (2007) review:

Suicides account for 1-7% of deaths - over medium to long term in mortality studies – and ? Under-rep

Teasdale et al (2001)SMR (Standardised Mortality Ratios) of:

4.05 TBI3.02 Concussion

(also see Fleminger et al 2003)

•SUICIDE RISK:Call for better & management of

Mental health issues for survivors of neurological trauma

See editorial, JNNP, Sept, 01

Mood disorders post TBIMood disorders post TBIMood disorders post TBIMood disorders post TBI

Silver, Kramer, Greenwald, & Weissman (BI 2001)Silver, Kramer, Greenwald, & Weissman (BI 2001) community community sample of over 5,000 adults 361 (i.e. 7.2%) had suffered TBI sample of over 5,000 adults 361 (i.e. 7.2%) had suffered TBI (with LoC) and of this sub(with LoC) and of this sub--sample (versus non TBI)sample (versus non TBI)(with LoC) and of this sub(with LoC) and of this sub--sample (versus non TBI)sample (versus non TBI)

11% suffered major depression (5.2)11% suffered major depression (5.2)11% ph bi di rd r11% ph bi di rd r (7 4)(7 4)11% phobic disorders 11% phobic disorders (7.4)(7.4)5% OCD 5% OCD (2.3)(2.3)3% panic disorder.3% panic disorder. (1.2)(1.2)

24.5% Alcohol dependence 24.5% Alcohol dependence (10.1)(10.1)10% Drug dependence 10% Drug dependence (5.2)(5.2)

Depression post TBI Depression post TBI Causes:Causes:H l iH l i t l (2002)t l (2002)Biological “gradient”?Biological “gradient”?

HolsingerHolsinger et al. (2002)et al. (2002)oo Lifetime risk (general Lifetime risk (general population) of depression population) of depression

Levin et al (01)Levin et al (01) no consistent no consistent pattern of focalised lesionspattern of focalised lesions

ll (04)(04) d d ld d l

highest in head injuredhighest in head injuredGarske & Thomas (92) Garske & Thomas (92)

55% mild55% mild--severe depressionsevere depressionJorge et al Jorge et al (04)(04)–– reduced volume reduced volume in ventroin ventro-- and dorsolateral and dorsolateral prefrontal regionsprefrontal regions

Bowen et al. (99)Bowen et al. (99)35% “caseness”35% “caseness”

Therefore consider role of:Therefore consider role of:••PrePre--injury copinginjury coping••Identity crisesIdentity crises

Iowa study (03):Iowa study (03):33% "major depressive 33% "major depressive disorder" during the first yeardisorder" during the first year Identity crises Identity crises

••Lack of support & treatmentLack of support & treatmentSee: See: Rogers & Read Rogers & Read -- Review Review

disorder during the first year.disorder during the first year.

BPAD BPAD –– Bipolar AffectiveBipolar AffectiveVan Reek m (00)Van Reek m (00) BPAD in 4% (5xBPAD in 4% (5x (2007)(2007)Van Reekum (00)Van Reekum (00) BPAD in 4% (5x BPAD in 4% (5x population)population)

AnxietyAnxietyAnxietyAnxiety -- all elevated all elevated

Van ReekumVan Reekum (00) - GADGAD (9.1%)/(9.1%)/Panic Panic (9.2) (9.2) OCDOCD 6.4%)6.4%)

PTSD:PTSD:Bryant et al. (00)Bryant et al. (00) -- 27%27%

Williams et al. (03)Williams et al. (03) -- 18% rate of symptoms 18% rate of symptoms –– (of which a third severe)(of which a third severe)

Greenspan et al. (06)Greenspan et al. (06)PTS t 11% t 6 th &PTS t 11% t 6 th & 16% t 1616% t 16 ththPTS at 11% at 6 months & PTS at 11% at 6 months & 16% at 1616% at 16 monthsmonths

[Bruggimann (06)[Bruggimann (06)Of 49 nonOf 49 non--severe stroke ptntssevere stroke ptnts -- 31% had significant PTSD symptoms31% had significant PTSD symptoms]]Of 49 nonOf 49 non--severe stroke ptnts severe stroke ptnts -- 31% had significant PTSD symptoms31% had significant PTSD symptoms]]

Lack of natural recovery compared to other groups Lack of natural recovery compared to other groups ((Mayou et al, 00Mayou et al, 00))(( y ,y , ))

Pain maintaining PTSDPain maintaining PTSD((Bryant, 99; see McMillan, Williams and Bryant, 2003Bryant, 99; see McMillan, Williams and Bryant, 2003))

…LOTS OF MENTAL HEALTH …LOTS OF MENTAL HEALTH ISSUES…more focus on “how to treat”ISSUES…more focus on “how to treat”ISSUES…more focus on how to treat ISSUES…more focus on how to treat

neededneeded“Evidence documenting the presence of these“Evidence documenting the presence of theseEvidence documenting the presence of these Evidence documenting the presence of these

disorders in significant proportions of those with disorders in significant proportions of those with TBI is sufficient….[however there is ] TBI is sufficient….[however there is ] [ ][ ]insufficient evidence available to guide insufficient evidence available to guide effectiveeffective practicepractice to provide a basisto provide a basiseffectiveeffective practicepractice…to provide a basis …to provide a basis for …more for …more targeted interventionstargeted interventions,”,”

Gordon et al (p. 28, AJPMR:06) emphasis mineGordon et al (p. 28, AJPMR:06) emphasis mine

Mood problems…pragmatic view Mood problems…pragmatic view d p p gd p p g

“a “a paucity of data continue to preclude the paucity of data continue to preclude the formulation of a definitive account of the formulation of a definitive account of the aetiologyaetiology… post… post--TBI psychiatric TBI psychiatric syndromes syndromes gg pp pp yymay be may be phenomenologically phenomenologically similarsimilar to their idiopathicto their idiopathic counterparts [whichcounterparts [whichsimilarsimilar to their idiopathicto their idiopathic counterparts…[which counterparts…[which suggests they] suggests they] may be amenable to standard may be amenable to standard therapeutic interventionstherapeutic interventions” Rogers and Read” Rogers and Read (2007:(2007:therapeutic interventionstherapeutic interventions Rogers and Read Rogers and Read (2007: (2007: Brain Injury)Brain Injury). . emphasis mineemphasis mine

Coherence of mood disorders and Coherence of mood disorders and TTschemas postschemas post--TBITBI

Do survivors of TBI have the cognitiveDo survivors of TBI have the cognitive--emotionalemotional--motivational motivational “architecture” consistent with mood disorders that can be targeted?“architecture” consistent with mood disorders that can be targeted?architecture consistent with mood disorders that can be targeted?architecture consistent with mood disorders that can be targeted?

Sufficient Sufficient memory of what has happenedmemory of what has happened (& does it matter)?(& does it matter)?WhWh ki d f i l hki d f i l h d di i bd di i bWhat What kinds of coping styles, schemaskinds of coping styles, schemas and distortions get set up by and distortions get set up by trauma & aftermath?trauma & aftermath?

A ib i f• Attributions for trauma event

• Mood induced compromised access to autobiographical memory (ABM)memory (ABM)

• Coping styles

• Rumination (over trauma) that might contribute to ABM problems & suggest negative automatic thoughts

Memory of the event: a risk factor? Memory of the event: a risk factor?

Gil et al (2005) (Am Gil et al (2005) (Am hh 40

4550

J Psychiatry)J Psychiatry)120 TBI hospitalised 120 TBI hospitalised for obs for obs –– BUT BUT mostlymostly MILDMILD 25

303540

recallno recallmostly mostly MILDMILD

14% PTSD (full) at 6 14% PTSD (full) at 6 monthsmonthsMemory of event Memory of event

lik l hlik l h5

101520

no recall

more likely to have more likely to have PTSD esp. rePTSD esp. re-- rere--experiencing cluster experiencing cluster of symptomsof symptoms

0no.

Williams, Evans, Needham & Wilson 03 Williams, Evans, Needham & Wilson 03 Memory WITHIN Memory WITHIN 24 hours predicting 24 hours predicting PTSD at 6 monthsPTSD at 6 months

(Brain Injury and J. Traumatic Stress)(Brain Injury and J. Traumatic Stress)

••Up to a third had some recall Up to a third had some recall ••( Forrester, Encel & Geffen, (1994) ( Forrester, Encel & Geffen, (1994) ••IES (PTSD) mean scores: IES (PTSD) mean scores: ( )( )••Recall group: Recall group: 12.612.6••no recall group no recall group 12.712.7••no difference…no difference…

Causal Attributions as predictor of PTSD Causal Attributions as predictor of PTSD (Severe TBI group)(Severe TBI group)(Severe TBI group)(Severe TBI group)

(Williams, Evans, Needham & Wilson, 03 (Brain Injury))(Williams, Evans, Needham & Wilson, 03 (Brain Injury))

60

70

40

50

percent

10

20

30percent

0

10

my fault ?my fault no-one ?other other

positive correlation between attribution of external control for the event and severity of PTSDpositive correlation between attribution of external control for the event and severity of PTSD

Turnbull et alTurnbull et al (BI: 2001) TBI “remembering” the emotional tone… (BI: 2001) TBI “remembering” the emotional tone… M iM i S d lS d l (JAP i ) bj i f h i f(JAP i ) bj i f h i fMeiserMeiser--Stedman et al.Stedman et al. (JAP: in press) greater subjective sense of threat at time of (JAP: in press) greater subjective sense of threat at time of traumatraumafear … a Near Death Experience (N D E)fear … a Near Death Experience (N D E)

“Appraisal at injury” may be key “Appraisal at injury” may be key pp j y y ypp j y y ypredictor of PTSD…predictor of PTSD…

f d ff d fExamples of Islands of (periExamples of Islands of (peri--traumatic) memoriestraumatic) memories

HT: no PtSDHT: no PtSD“ emergency workers freeing me from the wreckage police“ emergency workers freeing me from the wreckage police..emergency workers freeing me from the wreckage, police ..emergency workers freeing me from the wreckage, police talking to me…talking to me…feelingfeeling I’ll survive…”I’ll survive…”

KE: severe PtSDKE: severe PtSDKE: severe PtSDKE: severe PtSD“[I was] coming around for a short period…[I] “[I was] coming around for a short period…[I] felt I was dying…Ifelt I was dying…Iwas in the car. Smoke … blood…I couldn’t see…I reached for was in the car. Smoke … blood…I couldn’t see…I reached for my girlfriend she was dead ”my girlfriend she was dead ”my girlfriend... she was dead.. .my girlfriend... she was dead.. .

Trauma causality, stress and autobiographical Trauma causality, stress and autobiographical memory (ABM)memory (ABM)memory (ABM) memory (ABM)

Williams, Williams & Ghadiali,( 1998: Neuropsych Rehab)Williams, Williams & Ghadiali,( 1998: Neuropsych Rehab)

18 participants, TBI18 participants, TBIM C l Di i HADSM C l Di i HADSMeasures: Causal Dimension, HADS, Measures: Causal Dimension, HADS, ABM taskABM task

Both Internal and external: (N: 6)Both Internal and external: (N: 6)"I was at [the] races. I "I was at [the] races. I b k d t ib k d t i 12

14backed two winners..my backed two winners..my friend lost [and asked for friend lost [and asked for money]..we argued..I refused money]..we argued..I refused him the money..[we] ended him the money..[we] ended up fighting he wasup fighting he was 8

1012

othersb thup fighting..he was up fighting..he was

responsible [but] I’d said he responsible [but] I’d said he wouldn't get the lend".wouldn't get the lend".

External: (N: 12)External: (N: 12) 246 both

selfExternal: (N: 12)External: (N: 12)

"We were...[outside a "We were...[outside a nightclub]waiting for a nightclub]waiting for a taxi...[taxi came] a lad said it taxi...[taxi came] a lad said it was his...after anwas his...after an

02

N bwas his...after an was his...after an argument...he punched me..I argument...he punched me..I banged my head [on the banged my head [on the kerb]... I collapsed..." kerb]... I collapsed..."

Number

E ternali ing ca sal attrib tion predicti e of Depression & An iet• Externalizing causal attribution predictive of Depression & Anxiety

• Depression and anxiety predictive of poorer autobiographical recall (controlling for cognitive problems)

Rumination & overgeneral MemoryRumination & overgeneral Memory Bessell, Watkins & Williams (2008: JINS)Bessell, Watkins & Williams (2008: JINS)

Rumination =Rumination =

repeated dwelling on the self, depressed symptoms, upsetting events, and personal problems-and personal problems

e.g. “Why did this happen to me? Why do I feel like this? Why do I always react this way?” (see Nolen-Hoeksema y y y ((1991))

Predicts:

onset & increased duration of depression (see Watkins, pc)

Rumination & overgeneral MemoryRumination & overgeneral Memory Bessell, Watkins & WilliamsBessell, Watkins & Williams

Participants:(45 m 16 f), MILD and SEVERE impairments due to ABI

dMeasures & Procedure:•Autobiographical Memory Test (AMT) •Neuropsych tests, mood measures (Beck) and “Rumination Q”

•Matched pairs PPS assigned (random) to one of two different attention tasks (rumination or distraction) lasting less than 10 minutes.

Conditions:Rumination: items like - “think about why you react the way you do””. Distraction: items like - “think about and imagine a boat slowly crossing the Atlantic””.g y g

Post-intervention:PPS asked to carry out a second AMT to assess the level of change in overgeneral memory from baseline.

Results0.60

s • Rumination significantly

0.40

0.50

al M

emor

ies

Mildly Impaired /Distraction

Rumination significantly increased overgeneral memory, for BOTH

(S & Mild)0.30

Ove

rgen

era Distraction

Mildly Impaired /RuminationSeverely Impaired /Distraction

groups (Severe & Mild)

• Distraction did not

0.10

0.20

ropo

rtio

n of

Severely Impaired /Rumination

Distraction did not influence over-general recall in either group

0.00Time 1 Time 2

Pr

Figure: Mean Proportion of Overgeneral Memories across Conditions by Time

Psychological adjustment & Psychological adjustment & coping stylescoping stylesM & St b kM & St b k (1995)(1995) Finset & Andersson (2000)Moore & StambrookMoore & Stambrook (1995)(1995)131 Participants, TBI131 Participants, TBI? predictors of long term outcome, ? predictors of long term outcome, IQ/M /C i St lIQ/M /C i St l

Finset & Andersson (2000)•70 ABI (& 70 1 controls)•COPE

•lack of active approach oriented coping style IQ/Memory/Coping StylesIQ/Memory/Coping Styles

Group 1:Group 1:l l f l “hi hl l f l “hi h

pp p g yassociated with apathy•Avoidant coping assoc. with depression

external locus of control, “high external locus of control, “high variety” of strategies & variety” of strategies & poor poor outcomeoutcome

“I’d do anything to top the “I’d do anything to top the i Lif d I' b ii Lif d I' b i

•Williams & Dunt: pilot…(29 ABI pps)•Depression LESS problem-focused coping.A i id i lpain...Life stopped…I'm being pain...Life stopped…I'm being

punishedpunished””Group 2:Group 2:

rere--appraised control for life eventsappraised control for life events

•Anxiety & avoidant coping style

50

60

rere--appraised control for life events, appraised control for life events, Problem solving strategy & Problem solving strategy & good good outcomeoutcome

“terrible day…I appreciate life and “terrible day…I appreciate life and f il t k d tf il t k d t 20

30

40

percent

family more... take a day at a family more... take a day at a timetime””

0

10

De An D&A Pain

Psychological adjustment & coping stylesPsychological adjustment & coping stylesPsychological adjustment & coping stylesPsychological adjustment & coping stylesLosses & GriefLosses & Grief: cognitive, physical, social roles & : cognitive, physical, social roles &

l ti hi (l ti hi (S C t t l (03)S C t t l (03)relationships (relationships (See Coetzer et al. (03) See Coetzer et al. (03) Complex process of adjustmentComplex process of adjustment and Roundhill & and Roundhill & Williams (2008)Williams (2008)( )( )

Avoidance of loss (early phases)Avoidance of loss (early phases)“You don’t want to remember that life, “You don’t want to remember that life, ,,how it was, and how it is now.”how it was, and how it is now.”

Anti ip ti n f in (l t r phAnti ip ti n f in (l t r phAnticipation of gain (later phases Anticipation of gain (later phases ----especially if supported)especially if supported)

“There is a lifetime of recovery. You’ve “There is a lifetime of recovery. You’ve got to be positive about these things.”got to be positive about these things.”

Mood related Schemas* Mood related Schemas* and Coping Responsesand Coping Responses

AnxietyAnxiety DepressionDepressionAnxietyAnxietythemes of threat and themes of threat and vulnerability vulnerability

““stuck in traumastuck in trauma” ”

Depression Depression themes of loss and devaluation of themes of loss and devaluation of the self the self ––cognitions invariably focus upon cognitions invariably focus upon

d i i id i i i lflfrumination rumination Trepidation and fear in Trepidation and fear in anticipation of the future anticipation of the future

ExternalisedExternalised “sense” of“sense” of

regrets and recriminations regrets and recriminations –– selfself--focussed negative ruminationfocussed negative ruminationLess adaptive coping stylesLess adaptive coping stylesCompromised autobiographicalCompromised autobiographicalExternalisedExternalised sense of sense of

control control Avoidant coping styleAvoidant coping styleCompromised autobiographical Compromised autobiographical

Compromised autobiographical Compromised autobiographical accessaccess

See: See:

Moore & StambrookMoore & Stambrook (1995)(1995)p g pp g paccessaccess

* note: co* note: co--morbidity very high for morbidity very high for mood disorders so overlappingmood disorders so overlapping

Moore & StambrookMoore & Stambrook (1995) (1995) Finset & Andersson (2000)Curran, Ponsford & Crowe (2000) Curran, Ponsford & Crowe (2000) re: coping styles after Brain Injuryre: coping styles after Brain InjuryL D (AJP 2003)L D (AJP 2003)mood disorders, so overlapping mood disorders, so overlapping

schemasschemasLe Doux (AJP: 2003) re: Le Doux (AJP: 2003) re: overcoming fear and active copingovercoming fear and active coping

Affective processingAffective processing

"Brains become minds when they learn to "Brains become minds when they learn to dance with other brains"dance with other brains" W J FW J Fdance with other brains"dance with other brains" W.J. Freeman W.J. Freeman

Being in a role involves Being in a role involves emotional stability & synchrony emotional stability & synchrony WITH others…WITH others…

Cognition can be deCognition can be de--coupled from “basic” emotion inputscoupled from “basic” emotion inputs

Emotion unavailable for decision making/setting Emotion unavailable for decision making/setting goals…goals…

Specific deficits e.g. ability to process socioSpecific deficits e.g. ability to process socio--emotional cues emotional cues

Intrinsic emotional arousal/ control system.Functional at birth Enables

External stimuli

Thalamo amygdala pathway.

Tonks et al, 2007/2008: A HEURISTIC FOR SOCIO-EMOTIONAL PROCESSING IN THE BRAIN

Amygdala.Emotion Recognition.Eye gaze detection/reading

HippocampusExternal context information

Functional at birth. Enablesassociation learning.

Sensory/ spatial analysis system.Develops rapidly during the 18 months following birth, with an

Emotional response

Face expression analysis

Eye Configurationanalysis

Vocal Analysis

months following birth, with an identifiable further significant stage of improvement at around 11 years old

Executive system synthesis.Develops throughout childhood

Executive functioning

Emotion regulation controlAffect perception

Develops throughout childhood and adolescence, assuming increasing executive control over emotions.

(Le Doux, 1999; Rolls, 1999; Hornack, Rolls & Wade 1996; Jackson& Moffat, 1987; Baron-Cohen, 2000; Evans, 2003)

Male or FemaleMale or Female Mean Time Mean Time Lapse Since Lapse Since

Mean Injury Mean Injury AgeAge

Nature/ Frequency of Nature/ Frequency of Insult.Insult.

Tonks, Williams et al - Emotion processing post ABI

Age groupAge group TotalTotal

ppInsult (yrs)Insult (yrs)

gg(yrs)(yrs) (M=Male, F=Female)(M=Male, F=Female)

malemale femalefemale

Nine to tenNine to ten22 11 33

2.172.175.35.3 M= 1 Severe TBI, 1 Stroke. M= 1 Severe TBI, 1 Stroke.

F 1 S TBIF 1 S TBI22 11 33 5.35.3 F= 1 Severe TBIF= 1 Severe TBI

Ten to elevenTen to eleven11 11 22

.88.889.89.8 M= 1 Heamorrage (AVM).M= 1 Heamorrage (AVM).

F= 1 MeningitisF= 1 Meningitis

Eleven to twelveEleven to twelve 5 45 4 M= 1 mild TBI 2 TumourM= 1 mild TBI 2 TumourEleven to twelveEleven to twelve33 11 44

5.45.45.175.17 M= 1 mild TBI, 2 Tumour.M= 1 mild TBI, 2 Tumour.

F= 1 moderate TBIF= 1 moderate TBI

Twelve to thirteenTwelve to thirteen22 00 22

6.466.466.336.33 M= 2 Severe TBI.M= 2 Severe TBI.

Thirteen to fourteenThirteen to fourteen22 11 33

6.146.147.177.17 M= 1 Severe TBI, 1 mod M= 1 Severe TBI, 1 mod

TBI. F= 1 Severe TBI.TBI. F= 1 Severe TBI.

Fourteen to Fifteen Fourteen to Fifteen 44 00 44

2.892.8911.4211.42 M= 1 Severe TBI, 1 mod M= 1 Severe TBI, 1 mod

TBI 1 mild TBI 1 StrokeTBI 1 mild TBI 1 StrokeTBI. 1 mild TBI. 1 Stroke.TBI. 1 mild TBI. 1 Stroke.

Fifteen Plus*Fifteen Plus*11 11 22

2.332.3313.7913.79 M= 1 Severe TBI.M= 1 Severe TBI.

F= 1 Severe TBIF= 1 Severe TBI

Group TotalGroup Total TBI=14 M i iti =1TBI=14 M i iti =1

Table 5: Summary and injury profiles for the ABI participants in the study

pp

1515 55 2020TBI=14, Meningitis=1, TBI=14, Meningitis=1, Tumour=2, Tumour=2, Heamorrage=1, Stroke=2.Heamorrage=1, Stroke=2.

Tonks, Williams et al - Emotion i t ABI t lt lprocessing post ABI controlscontrols

67 (age matched)67 (age matched) children were recruited fromrecruited from primary and secondary schools. These were given the b tt i f t tbatteries of tests.

How do ABI children How do ABI children compare to noncompare to non injuredinjuredcompare to noncompare to non--injured injured

children? children? 82

80

F(1 85) 14 227 000

amin

g

78

76

F(1,85)=14.227 p<.000

ANCOVA (FAS): F(1,84)=10.992 p<.001

B ex

pres

sion

na

74

72

HealthyABI

Mea

n FA

B

70

68

Group

How do ABI children compare How do ABI children compare to nonto non--injured children (“Mindinjured children (“Mindto nonto non injured children ( Mind injured children ( Mind

in the Eyes”)?in the Eyes”)?

70 80

test

60 est

70

60

nd in

the

eyes

d in

the

eyes

te50 Group

HealthyABI

Mea

n m

in

50

12 Plus11 to 12up to 11

Mea

n m

in

40

ABI

Healthy

Group PIAGROUP

Problems in emotion processing in Problems in emotion processing in children with ABIchildren with ABIchildren with ABIchildren with ABI

••Group trends:Group trends:••those withthose with difficulties with angry faces experienced peer problemsdifficulties with angry faces experienced peer problems••those with those with difficulties with angry faces experienced peer problemsdifficulties with angry faces experienced peer problems

•• poor at identifying expressions reported less propoor at identifying expressions reported less pro--social.social.

••Specific deficitsSpecific deficits

••KL KL -- not recognise sad facesnot recognise sad faces•• MN MN –– not “getting” emotional tone. He could not “getting” emotional tone. He could not understand not understand sarcastic remarkssarcastic remarkssarcastic remarkssarcastic remarks••OPOP-- reads all “eyes” reads all “eyes” as hostileas hostile. increasingly violent. increasingly violent

[also see: Milders Fuchs and Crawford 2003 re: adults with TBI;[also see: Milders Fuchs and Crawford 2003 re: adults with TBI;[also see: Milders, Fuchs and Crawford 2003 re: adults with TBI; [also see: Milders, Fuchs and Crawford 2003 re: adults with TBI; Skye MacDonald & colleagues re: TASIT (awareness of social inference)]Skye MacDonald & colleagues re: TASIT (awareness of social inference)]

Theory of Mind & Empathy in TBI (in press) : Theory of Mind & Empathy in TBI (in press) : S h W ll H Willi & I F tS h W ll H Willi & I F tSarah Wall, Huw Williams, & Ian Frampton Sarah Wall, Huw Williams, & Ian Frampton

ToMToMToM ToM A Test of Social Processing (Turkstra et al., 2001)A Test of Social Processing (Turkstra et al., 2001)Faux Pas test (BaronFaux Pas test (Baron--Cohen et al., 1999) Cohen et al., 1999) (( ))

EmpathisingEmpathisingSocioSocio--Emotional Questionnaire for ChildrenEmotional Questionnaire for Children

“I (he/she) notice(s) when other people are “I (he/she) notice(s) when other people are happy”happy”“I (he/she) prefer(s) being alone than with“I (he/she) prefer(s) being alone than withI (he/she) prefer(s) being alone than with I (he/she) prefer(s) being alone than with others”others”

+ Strengths and Difficulties Q & DEX+ Strengths and Difficulties Q & DEX--C C (Dysexecutive)(Dysexecutive)

Empathy in non-injured children in early adolesence

42

p y y(100+ boys and girls)

39

40

41&

Em

p (I

) co

re GirlsBoys

37

38

39

Emot

Rec

og

subs

cale

s c Boys

35

36

11 12 13 14

SEQ

11 12 13 14

Age

boys tended to show a decrease in positive social-emotional functioning, alongside self-reports of increased anti-social behaviour.Those with a history of MTBI rated particularly low

18

Theory of Mind (complex) & Critical age of injuryTheory of Mind (complex) & Critical age of injuryWall, Williams, Frampton (in prep)Wall, Williams, Frampton (in prep)

25 young adolescents (10 to 25 young adolescents (10 to 15yrs) with a history of ABI, 15yrs) with a history of ABI, 50 typically50 typically--developing (TD) developing (TD) 13

14

15

16

17

nd m

ean

scor

e

Boys

Girls yp yyp y p g ( )p g ( )matched controlsmatched controlsGlobal impairmentsGlobal impairments

Poorer empathic respondingPoorer empathic responding8

9

10

11

12

Theo

ry o

f Mi

p p gp p gLess accurate ToMLess accurate ToMParental reports of poor Parental reports of poor emotion recognition and emotion recognition and empathyempathy

BI TD

90

100

empathyempathySelfSelf--reports of poor emotion reports of poor emotion recognition and empathyrecognition and empathy+ executive impairments + executive impairments 50

60

70

80

% pp(DEX(DEX--C + EF measures), C + EF measures), increased daily difficulties and increased daily difficulties and impact (SDQ)impact (SDQ)

10

20

30

40

%

0

Birth to 2 2 to 6 6 to 12 +Age at injury (years)

Average

Borderline/impaired

What is Rehabilitation?What is Rehabilitation?What is Rehabilitation?What is Rehabilitation?

“Rehabilitation is a process whereby people who are “Rehabilitation is a process whereby people who are disabled by injury or disease work together with disabled by injury or disease work together with professional staff, relatives and members of the wider professional staff, relatives and members of the wider p ,p ,community to community to achieve their optimum physical, psychological, achieve their optimum physical, psychological, social and vocational wellsocial and vocational well--beingbeing” (McLellan 1991)” (McLellan 1991)

“…[aims at] supporting survivors to become more independent and achieve meaningful goals that are self-sustaining and self-rewarding” (Williams, Evans & Fleminger, 03)

37

g , )

BioBio--psychopsycho--social formulations & CBTsocial formulations & CBTComplex forms of emotional Complex forms of emotional disturbancedisturbance

CBT to:CBT to:•Identify triggers for -

mood/behaviour••dysexecutive and amnestic dysexecutive and amnestic syndromes syndromes

••INSIGHT!INSIGHT!

mood/behaviour

•Do behavioural experiments••INSIGHT!INSIGHT!

••Possible deficits in emotional Possible deficits in emotional processing processing

•Challenge ‘negative thoughts’

••in in a “mix” with reactive a “mix” with reactive mood disordersmood disorders

•Reappraise negative attributions

•Challenge unhelpful self-views

••Additional health issues, & Additional health issues, & eg paineg pain See Williams & Evans (2003) Special issue of

Challenge unhelpful self views •DEVELOP INSIGHT!

eg paineg pain••Possible alcohol/drug issuePossible alcohol/drug issue••Poor sleepPoor sleep

( ) pNeuropsychological rehabilitation on Biopsychosocial approaches…

PTSD & TBI: CMPTSD & TBI: CM(Williams, Evans & Wilson, 2003: in Cognitive Neuropsychiatry)(Williams, Evans & Wilson, 2003: in Cognitive Neuropsychiatry)

B k dB k dBackgroundBackground26 yr, Arts & Education officer26 yr, Arts & Education officer

Injury:Injury:j yj ystabbed with a knife in the headstabbed with a knife in the headright temporalright temporal--parietal areaparietal areaclear narrative of the eventclear narrative of the event

NeuroNeuro--cognitivecognitivehemianopiahemianopiahemianopiahemianopiafatiguefatigueattention (coping w/ distraction/switching)attention (coping w/ distraction/switching)reduced speed of processingreduced speed of processing

Narrative of event: CMNarrative of event: CMNarrative of event: CMNarrative of event: CM

“... People got off [the train], and I was alone. I [was] engrossed “... People got off [the train], and I was alone. I [was] engrossed p g [ ], [ ] gp g [ ], [ ] gin a book ...I saw a man go past...he smiled and went to the next in a book ...I saw a man go past...he smiled and went to the next carriage. He came back two minutes later ... after 30 seconds I carriage. He came back two minutes later ... after 30 seconds I felt pain in my head and weight as if the carriage had fallen ontofelt pain in my head and weight as if the carriage had fallen ontofelt pain in my head and weight as if the carriage had fallen onto felt pain in my head and weight as if the carriage had fallen onto me. I got up and realized something terrible had happened...I me. I got up and realized something terrible had happened...I went into the next carriage... another man told me to sit down, went into the next carriage... another man told me to sit down, and that he would get help ...I put my hand up and felt the knife. and that he would get help ...I put my hand up and felt the knife. I asked if I had been stabbed, I asked if I was to die. He said no, I asked if I had been stabbed, I asked if I was to die. He said no, he’ll get help. At the next stop an ambulance arrived and took he’ll get help. At the next stop an ambulance arrived and took g p pg p pme to hospital.”me to hospital.”

PTSD & TBI: CM, assessment, 1.5 yrs postPTSD & TBI: CM, assessment, 1.5 yrs postHYPERAROUSALHYPERAROUSAL

daily panic attacks & hyperdaily panic attacks & hyper--vigilantvigilantclaustrophobia & social fearsclaustrophobia & social fears

INTRUSIONS: INTRUSIONS: b i db i dupset by reminders upset by reminders

frequent unwanted memories and nightmares (2frequent unwanted memories and nightmares (2--3 a night) 3 a night) seeing the man who stabbed herseeing the man who stabbed hervisual images of people being stabbedvisual images of people being stabbed

AVOIDANT & DEPRESSED:AVOIDANT & DEPRESSED:id bli “b ” lid bli “b ” lavoids public transport or “busy” placesavoids public transport or “busy” places

depresseddepressednot involved in art/educationnot involved in art/education

CM: Rehabilitation StagesCM: Rehabilitation StagesCM: Rehabilitation StagesCM: Rehabilitation Stagesunderstand cognitive and emotional issuesunderstand cognitive and emotional issues

i “i “ i l i ” f hi l i ” f he.g. attention system, “overe.g. attention system, “over--inclusive” for threatinclusive” for threatdevelop cognitive/emotion control skills in “safety”develop cognitive/emotion control skills in “safety”

relaxation skills relaxation skills for graded desensitizationfor graded desensitization

guided visual imagery guided visual imagery to tolerate & switch between images (e.g. make “cartoonto tolerate & switch between images (e.g. make “cartoon--like”)like”)g ( gg ( g ))

develop use of memory (filofax) system develop use of memory (filofax) system e.g. plan for travel/cue cards/ pleasant scenese.g. plan for travel/cue cards/ pleasant scenes

l ti l t l kill i til ti l t l kill i tiapply emotional control skills in practiceapply emotional control skills in practicework through “hierarchies” of avoided situationswork through “hierarchies” of avoided situations

PTSD & TBI:CMPTSD & TBI:CMPTSD & TBI:CMPTSD & TBI:CM

•traveled by train on two short routes, independently

•engaged in social activities (eating out cinema)•engaged in social activities (eating out, cinema)

•managing “A” level Art,

• less severe intrusive thoughts

l f l d (2 3 i ht t 1 f t i ht)•less frequent unpleasant dreams (2-3 a night to 1 a fortnight)

Outcome: CM Outcome: CM Scores on CAPS:Scores on CAPS:(Cli i i Ad i i d PTSD S l )(Cli i i Ad i i d PTSD S l )(Clinician Administered PTSD Scale)(Clinician Administered PTSD Scale)

35

25

30

35

15

20

25intrusionavoid

5

10

15 hyper

0

5

assess end int dischargeg

[[*M: Memory (RA: Retograde, AA: Anterograde), Dx: Dysexecutive, A: Attention, V: Visuospatial, L: Language, S: Speed]

CaseCase CogCog EmotionEmotion NeuroNeuro--rehabrehab CBT e.g.CBT e.g. OutcomeOutcome

KEKE:: MM PTSDPTSD PalmPalm--top (pacingtop (pacing “Stop Think“Stop Think PTSD symptoms sigPTSD symptoms sig reduced)reduced)KEKE::TBI,TBI,RTARTA(death)(death)

M,M,Dx,Dx,SS

PTSD, PTSD, Alcohol misuseAlcohol misuseAngerAnger

PalmPalm top (pacing, top (pacing, planning> self planning> self monitoring)monitoring)ABC diary>ABC diary>

Stop, Think, Stop, Think, Relax, Do”Relax, Do”Imaginal Imaginal --exposureexposure

PTSD symptoms sig. PTSD symptoms sig. reduced)reduced)

No anger No anger –– 3 mths3 mthsAlcohol reduced 50%Alcohol reduced 50%PT work/ New relationshipPT work/ New relationship

DC:DC:

TBITBIRTARTA

M, M, (RA/(RA/AA)AA)

OCDOCDDepressionDepressionHealth worriesHealth worries

VoiceVoice--cordercorderPlanning diaryPlanning diaryManMan--U “ABMU “ABM--

hierarchical expbehavioural expts “doubt-reduction”

HADs nonHADs non--clinicalclinicalnot “checking”not “checking”Socially engagedSocially engaged

thread”thread” “over-attending” PT studentPT student

SRSR

TBITBIMMDXDX

“Capgras”“Capgras”DepressionDepression

Neuropage &Neuropage &DiaryDiary

BeliefBelief--evidence?evidence?Behav exptsBehav expts

time with kidstime with kidssocialisingsocialising

RTA RTA (P)(P)

ppisolatedisolated

yy pp“think into feeling”“think into feeling”

gg

MTMT MM DepressionDepression Diary with Diary with “SUDS” ti“SUDS” ti

Small Small di t >di t >

Mood “+” & stableMood “+” & stableTBITBIRTARTA

VV Mood swingsMood swings “SUDS” ratings “SUDS” ratings p.dayp.day

disagreements => disagreements => angerangerMisMis--reading faces?reading faces?

Full time at workFull time at workImproved relationshipsImproved relationships

KE: Monitoring, Relaxation KE: Monitoring, Relaxation T i i i lT i i i lTraining & Imaginal exposureTraining & Imaginal exposure

D iti & i h t tDesensitize & gain coherent story•monitoring for intrusions

“watched TV programme with a crash in it & had breathing problems”problems

•reporting, in detail, following relaxation “[from above]...its happening again, ..imagining where [she was].. [ o bove]... s ppe g g , .. g g w e e [s e w s]..the steering wheel against my chest] couldn't scream...that’s what it is.. can’t breathe, crushing..blood in my eyes”

•prompted re: use of calming breaths, orientate to surroundings

•Go though hierarchy of avoided activities

Graded Hierarchy & “doubt Graded Hierarchy & “doubt d i ” i h i l id i ” i h i l ireduction” with visual imageryreduction” with visual imagery

910“Meeting friends in a pub/club”“Meeting friends in a pub/club”

4567891. leaving house 1. leaving house

check breathing & listen to door check breathing & listen to door “click” “click” -- “burn in” current task“burn in” current task

2. Worry over leg2. Worry over leg

012342. Worry over leg2. Worry over leg

“how likely…what was the “how likely…what was the explanation from physio…”explanation from physio…”

3. Unable to keep track of 3. Unable to keep track of i / li / l buses town city

6789

10

week 1

conversations/plansconversations/plansquiet area quiet area –– USE voiceUSE voice--cordercorder, , then fthen f--faxfax

20

123456 week 1

dischargefollow up

8101214161820

assessdischarge

01

calls pubclubbing0

246

HAD: Ax HAD: Dp M: OCD

MT: reMT: re-- “reading” emotion as part of “reading” emotion as part of changing NATschanging NATschanging NATschanging NATs

CBT & RehabilitationCBT & RehabilitationIdentify triggers for mood (mood diary)Identify triggers for mood (mood diary)y gg ( y)y gg ( y)

small disagreements become hugesmall disagreements become huge“confirm” that “not liked or wanted” “confirm” that “not liked or wanted”

Eg Pub with workEg Pub with work matesmatesEg Pub with workEg Pub with work--matesmatesFacial recognition & expression??Facial recognition & expression??

“Re“Re--read” emotions read” emotions --tone/proximity/posturetone/proximity/posture

Interested--- sceptical?

He looks like hes a little bit cross

CBTCBT –– further developmentsfurther developmentsCBT CBT further developmentsfurther developments

Need Need --Single case design studiesSingle case design studiesRCT diRCT di bb

Ensure interdisciplinary Ensure interdisciplinary training for CBT training for CBT principles as “a way ofprinciples as “a way ofRCT type studies RCT type studies –– maybe maybe

with “staggered” waitwith “staggered” wait--listslistsSpecific formats for subSpecific formats for sub--

principles as a way of principles as a way of working” in neuroworking” in neuro--rehab rehab (see Gracey et al 05)(see Gracey et al 05)Spec c o ats o subSpec c o ats o sub

groups with particular groups with particular needsneeds Use of CBT for enabling Use of CBT for enabling

adaptive coping:adaptive coping:For:For:MoodMoodEmotion regulationEmotion regulation

adaptive coping:adaptive coping:PartnersPartnersParentsParentsEmotion regulationEmotion regulation

Health & habit issuesHealth & habit issues significantsignificant--othersothers

So, Why do CBT in Neuro-rehab?

at least its one way, that has some evidence, of instilling hope in realistic manner that canof instilling hope, in realistic manner, that can encourage positive change …

DC: “…I spent all the time..afraid that if I do DC: “…I spent all the time..afraid that if I do something I’d look foolish… [now] every something I’d look foolish… [now] every

k d [I’ i h] f i d [ h h] ik d [I’ i h] f i d [ h h] iweekend, [I’m with] friends…[through] using weekend, [I’m with] friends…[through] using strategies... that was confusing [but] strategies... that was confusing [but] you get you get

d t th h bit dd t th h bit d t t t tt t t tused to the new habits… and used to the new habits… and you get to trust you get to trust [yourself].. get confident[yourself].. get confident..[but] ..[but] you’ve got to watch you’ve got to watch

for that vicious cycle of withdrawalfor that vicious cycle of withdrawal ””for that vicious cycle of withdrawalfor that vicious cycle of withdrawal....

References…References…*Judd, T (1999) Neuropsychotherapy and Community Integration. Brain Illness, Emotions and*Judd, T (1999) Neuropsychotherapy and Community Integration. Brain Illness, Emotions andJudd, T (1999) Neuropsychotherapy and Community Integration. Brain Illness, Emotions and Judd, T (1999) Neuropsychotherapy and Community Integration. Brain Illness, Emotions and Behaviour. Kluwer press. AND SEE NRSI 2003Behaviour. Kluwer press. AND SEE NRSI 2003*Lishman, L (1998) Organic Psychiatry, Oxford Press*Lishman, L (1998) Organic Psychiatry, Oxford Press*Ponsford, J (1995) Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living, *Ponsford, J (1995) Traumatic Brain Injury: Rehabilitation for Everyday Adaptive Living, Laurence Erlbaum Associates Hove. & SEE RECENT BOOKLaurence Erlbaum Associates Hove. & SEE RECENT BOOKLaurence Erlbaum Associates, Hove. & SEE RECENT BOOKLaurence Erlbaum Associates, Hove. & SEE RECENT BOOKPowell, T (1992) Head Injury a Practical Approach. Headway.Powell, T (1992) Head Injury a Practical Approach. Headway.Prigatano, G et al (1989) Neuropsychological Rehabilitation, FA Davis Philadelphia (updated in Prigatano, G et al (1989) Neuropsychological Rehabilitation, FA Davis Philadelphia (updated in 2000)2000)Ramachandran V S and Blakeslee S (1999) Phantoms in the Brain 4Ramachandran V S and Blakeslee S (1999) Phantoms in the Brain 4thth estestRamachandran. V.S. and Blakeslee, S. (1999) Phantoms in the Brain. 4Ramachandran. V.S. and Blakeslee, S. (1999) Phantoms in the Brain. 4thth est.est.Damasio, A. (2003) Looking for Spinoza. Vintage. Damasio, A. (2003) Looking for Spinoza. Vintage. Halligan, P, et al. (2003) Handbook of Clinical NeuropsychologyHalligan, P, et al. (2003) Handbook of Clinical NeuropsychologyWilliams, W.H. and Evans, JJ (2003) Biopsychosocial Approaches in Williams, W.H. and Evans, JJ (2003) Biopsychosocial Approaches in N h ili i S i l I f N h l i l R h bili i P h lN h ili i S i l I f N h l i l R h bili i P h lNeurorehailitation:…Special Issue of Neuropsychological Rehabilitation, Psychology Neurorehailitation:…Special Issue of Neuropsychological Rehabilitation, Psychology Press.Press.Yates, Williams, Harris, et al (in press) Incidence of Brain Injury in an Emergency Dept. Journal Yates, Williams, Harris, et al (in press) Incidence of Brain Injury in an Emergency Dept. Journal of Neurology, Neurosurgery and Psychiatry.of Neurology, Neurosurgery and Psychiatry.Iddon, J. & Williams W.H. (2003) Memory Booster Workout. Hamlyn. (or in 2005 as Iddon, J. & Williams W.H. (2003) Memory Booster Workout. Hamlyn. (or in 2005 as “Memory Boosters”)“Memory Boosters”)Tonks et al (2007) Brain Injury Tonks et al (2007) Brain Injury –– (a) and (b) and Brain Impairment(a) and (b) and Brain Impairment

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