What email address or phone number would you like to use to sign in to Docs.com?
If you already have an account that you use with Office or other Microsoft services, enter it here.
Or sign in with:
Signing in allows you to download and like content, and it provides the authors analytical data about your interactions with their content.
Embed code for: MVA to TBI
Select a size
MVA leads to TBI and CR placement in an aggressive middle-aged woman. Interesting issues include: Carbamazepine titration, hydrocephalus
Patient Name: MVA leads to TBI and CR placement in an aggressive middle-aged woman
Identifying Data: Ms. Xxxx is a 53-year-old, white, single woman who sustained a severe traumatic brain injury (TBI) in a 19XX motor vehicle accident (MVA) which left her severely disabled. She currently resides in an OMRDD operated group home (IRA) in xxxxx, New York. She was referred for evaluation by her primary care physician, Dr. K.
Clinical Summary, K, M.D. 1-16-98
Psychological Assessment M Ph.D. 7-25-95
Neuropsychological Evaluation, H Ph.D. 3-30-92
OMRDD Individualized Service Plan, 11-13-97
OMRDD Residential Habilitation Plan, 11-13-97
OMRDD Psychiatric/Mental health Worksheet, 1-29-98
Lab Data and CT Scans
Psychiatrist reports from the patient’s chart
Overt Aggression Scale (OAS), 1-29-98
Galveston Orientation Test, 1-29-98
Group Home staff interview, S, RN, 1-29-98
Clinical interview, patient, 1-29-98
Reason for Referral: During the past three months, Ms. Axxx has had increasingly frequent and more intense episodes of verbal and physical aggression. These episodes and other recent problems have been characterized by staff as follows: “yelling, screaming, swearing, making derogatory statements about other residents, staff and family…outbursts seem to have no identifiable precipitants…frustrated over minor situations like trying to put on her shoes…hoarding items…discovered during the middle of the night emptying of the contents of her closet and dresser onto her bed…redirection and humor seldom works to change her tone anymore…more irritable and verbal threats are more common…throws things during these episodes…in recent months her gait problems have increased and led to numerous falls; As a consequence, she is now confined to a wheelchair.” This evaluation was requested for treatment recommendations.
History of Present Illness: In 19XX when Ms. Axxx was 15 years old she sustained a TBI in a motor vehicle accident (MVA). Following the MVA, she was comatose for 2 months. Her injuries were described in the chart as follows: “contusion of the brain stem involving the reticular formation”; “contusion of the right cerebrum associated with left sided spastic hemiplegia”. “Damage to the left hemisphere, suspected secondary to marked spasticity of the right arm and leg.” Ms. Axxx was in her freshman year of high school when the accident occurred. Before the accident, she was “an average student academically, who participated in all sports and was considered an expert swimmer”.
Ms. Axxx was discharged home after the accident to live with her parents and sister. By April of 19XX the family concluded “they were unable to meet her needs at home” and Ms. Axxx was admitted to the XXX Developmental Center. In July of that year, Ms. Axxx was transferred to the XXX Developmental Center and 10 years later she was placed in family care where she managed more or less successfully until 19XX when “she had to be moved to a more restrictive level of care (ICF) (XXXX Group Home in xxxxx) because she was having frequent falls and emotional outbursts”. Six months later she was transferred to the XXXX Group Home in xxxxx in order to “be with a more appropriate peer group”.
Longstanding symptoms and problem behaviors have been described as follows: “frequent outbursts of swearing at and insulting others…overly demanding attitude for attention, smoking and falling…problems processing new memories…easily frustrated and will yell at peers showing a total disregard for their feelings (“I don’t belong with these retards; it’s all because of that stupid accident.”)…gentle and good natured one moment and explodes in a fit of temper the next…upset by loud noises, being rushed and being reminded that her skills are not what they use to be…a perfectionist…frustrated if things aren’t just right…unable to stop a task once she starts it until the task is complete…continues cleaning her face until told to stop…thinks about what happened 30 or 40 years ago as if they are happening now…wants to relate only to staff and seems obsessed with cigarettes…difficulty coordinating her movements and her memory is significantly impaired especially for short-term information.”
Ms. Axxx’s strengths, interests and character traits include the following: “honest…likes shopping and going to shows…particular about her appearance…important to look nice…values and protects her possessions…loves to help…happy when she accomplishes her work with precision…values her family…likes people who will listen and understand…sensitive and understanding…excellent sense of humor…would like to do everything by herself and not need help…wants a place to herself…has a private room and redecorated it to make the room hers…enjoys knitting and listening to 60’s music…does not want to stop smoking.” Family is very interested in her care and visit often.
CT Scans of Head: 1988 - “cortical atrophy associated with marked dilatation of the entire ventricular system”. 1995 - “hydrocephalus with dilatation of the lateral, 3rd and 4th ventricles, old right occipital infarct, no change from 1988 CT scan”
Current Medications: Atenolol 100mg qd at hs, Estrace 0.5mg qd, Provera 2.5mg qd, Accupril 40mg qd, Catapres-TTS #3 patch q 1 week and Calcium Carbonate 650mg bid.
Carbamazepine (Tegretol) 200mg tid since 1993, prescribed by Dr. F., psychiatrist at the County Mental Health Center, for agitation and aggression. Benefit from Tegretol has been limited. Prior to 19XX, she took Trilafon for two years without benefit.
Medical History: Significant for hypertension, hydrocephalic dementia, TBI, R/O CVA.
Laboratory Results:11-20-97 CBC without differential-WNL, Carbamazepine level 6.4.
Current Neuropsychological Test Results:
IQ borderline to mild MR
Left visual field cut
Left auditory dysfunction
Poor verbal memory
Poor ability to plan, execute, monitor and correct behavior
Impoverished ability to learn new material
Emotional lability is probably a disinhibition phenomenon
Rigid with perseverative qualities
No evidence of decline in cognitive functioning
Impaired attention, auditory comprehension, recall and recent memory
Speech fluent but flat and slow
Poor self esteem
Mental Status Examination: Ms. Axxx was a moderately obese, wheelchair bound woman with short but well styled red gray hair, blue eyes, a hirsute, chubby face and a ruddy complexion which flushed frequently. She wore large stylish glasses and a natty burgundy and green corduroy outfit. Her eyes were downcast until I asked her to look up at me. She was pleasant and cooperative and seemed to enjoy the give and take of the interview. At times her affect was flat and at other times full and appropriate. She told jokes and enjoyed a hearty laugh. She spoke in short simple sentences. Her speech was fluent, relevant and coherent but soft and dysarthric. About the Home, she said “not good; too many bosses; I don’t like people telling me what to do; they won’t let me smoke cigarettes when I want to.” She doesn’t know what causes her angry outbursts; “usually it feels like nothing”. Her free time is spent “spoon knitting” cords of yarn which are later made into afghans and blankets. She enjoys attending the Sheltered Workshop “because it’s a place to go and something to do and I earn some money”. Her dissatisfaction could be distilled into this one sentence; “I’m an adult and I don’t want to be treated like a child”. There were no signs of psychosis or delirium. She was neither hallucinated nor delusional. She was alert and her sensorium was clear but she was grossly confused and disoriented. Although she could provide many accurate details of her childhood, she was oriented only to name and date of birth; she did not know the time, day of week, month or year and could describe her current location only as “a doctor’s office somewhere”. Her insight and judgment were severely impaired.
Conclusions: Based upon a review of Ms. Axxx’s history, CT scan findings, neuropsychological signs, symptoms, test results and problem behaviors, the following conclusions can be drawn directly and by inference:
Neuropathology: MVAs are the most common cause of TBI. TBI sustained in an automobile accident usually leads to a characteristic pattern of neuropathological changes due to the dynamics of an auto accident and the physics of the injury:
Diffuse axonal injury, a disruption in the connections between the brain stem reticular formation and the cortex
Because of their vulnerability, cortical contusions involving the temporal and frontal lobes.
There is a rough correlation between length of coma and the severity of TBI. Ms. Axxx was comatose for two months which suggests severe head injury. Severe TBI usually causes loss of neurons in the form of diffuse cerebral atrophy, demunition of white matter and hydrocephalus ex vaccuo (ventricular enlargement due to loss of cerebral tissue). Hydrocephalic dementia can be seen in her brain CT scans. She has never been seen by a neurosurgeon for evaluation of her hydrocephalus.
Ms. Axxx’s injuries are consistent with all of the above.
The right occipital infarct seen on Ms. Axxx’s CT scans may have been caused by the rupture of capillaries during the accident or by a subsequent stroke. The infarct caused her left visual field cut. These lesions can also cause alexia, agraphia and constructional apraxia. Victims of severe TBI are 10 times more likely to develop progressive, degenerative dementia than the general population.
Episodes of Verbal and Physical Aggression: Frontal lobe dysfunction often causes behavioral and/or emotional disinhibition syndrome. Disinhibition is a disorder of the expression of emotion not a disorder of emotion. Angry outbursts are sparked by trivial stimuli and do not reflect extreme feelings of rage. Patients with disinhibition syndrome are unable to control or modulate the expression of emotion. These patients often make vulgar or socially inappropriate remarks, show poor judgment and display rapidly shifting moods and irritability. Damage to the inferior orbital surface of the frontal lobes can lead to outbursts of rage and violent behavior.
Deficits in self-awareness commonly seen in victims of severe TBI are also contributing to this problem. The patient shows an inability to: 1) perceive herself as others perceive her, 2) recognize her internal motivations, 3) critique her own behavior 4) accurately identify her strengths and limitations. Most patients with deficits in self-awareness lose the ability to learn from experience, develop a generally more demanding attitude and exhibit reduced frustration tolerance. Deficits in self-awareness worsen over time. Denial of deficits in TBI patients is commonly manifested as anger towards family members because of institutional placement which the patient believes is unnecessary.
Impaired Memory Orientation and Concentration: Impaired Reticular Activating System functioning seen in diffuse axonal injury leads to unstable levels of arousal, which in turn causes the following:
Interpersonal relationships are more difficult because the patient tires easily and cannot follow conversations well.
Adjustment to increased stimulation such as noise or confusion is prolonged and, as a consequence, minor frustrations and loud noises trigger angry outbursts.
Difficulty switching and dividing attention. This is one of the causes of Ms. Axxx’s behavioral perseveration (“inability to stop a task once she starts it until the task is complete”; “extended face washing”).
Poor concentration and memory.
Fluctuating levels of arousal is probably the explanation for Ms. Axxx’s nocturnal episodes of “emptying the contents of her closet and dresser onto her bed”.
Temporal lobe damage is responsible for Ms. Axxx’s inability to lay down new memories and poor auditory comprehension. Damage to the frontal lobes has also contributed to her memory problems and caused impairment in Executive Functions (the ability to organize, plan, monitor and correct behavior, carry out purposeful action and solve problems). Impaired executive functions is another factor causing Ms. Axxx’s behavioral perseveration and also leads to frustration which acts as a trigger for her emotional outbursts.
Depression: Ms. Axxx is clearly suffering from mild to moderate depression. Depression is common in TBI patients and caused by “mourning the loss of former self” and compromised anterior cerebral functioning. Poor self-esteem is evident in Ms. Axxx’s attempts to differentiate herself from the other residents, perfectionism, desire “to help” and identification with staff members. She tries to compensate for poor self-esteem in adaptive ways such as: (1) paying attention to her appearance, (2) using her intact skills (i.e. knitting), (3) reaching out socially.
Medications: Two of Ms. Axxx’s current medications may be contributing to her cognitive impairment. She takes Atenolol 100mg qd. Atenolol is a beta blocker which can cause depression and cognitive impairment. Its use is generally avoided in patients with dementia. Catapres (Clonidine) is an Alpha 2 antagonist and can cause confusional states. Also, dosing Carbamazepine is tricky: Carbamazepine induces its own metabolism. Over an 8-week period the half-life declines from about 36 hrs. to between 10 & 20 hrs. Consequently, the dose must be adjusted upward after the first 8 weeks of treatment, sometimes to twice the dose arrived at during the first 2 to 3 weeks of treatment. Steady state is reached over a period of about 4 to 5 - ½ lives. Because Carbamazepine metabolizes itself, this period changes over time. Assuming a ½ life of 15 hrs., after 8 weeks of treatment, steady state would be achieved every 4 days or so. When increasing the dose after the first 8 weeks of treatment, a level should be obtained every week until a known effective level is achieved for three consecutive weeks
Because Ms. Axxx’s cognitive dysfunction is variable, behavioral approaches should be tailored to her specific deficits and strengths. A behavioral plan designed for her would differ from a plan developed for a mentally retarded individual. The plan should be presented to her as a means of reducing staff control and increasing her autonomy. She should be an active participant in its development and she should agree to its terms. She should be given a copy of the final plan.
Personality change due to traumatic brain injury, disinhibited/aggressive type
Antipsychotics, anticonvulsants, antidepressants and, during the acute phase of TBI, beta blockers have all been used successfully in the treatment of agitation and aggression associated with disinhibition in TBI patients.
Several antidepressants have a direct effect on emotional disinhibition as well as an antidepressant effect. In descending order, relative to the direct effect on emotional disinhibition, these drugs are: (1) TCA’s, Nortriptyline and Desipramine, (2) Trazadone (starting at 25mg qd and increasing by 25mg every 5 days), (3) Sertraline (Zoloft) (starting at 25mg qd titrating to 100mg or more qd).
I suggest Dr. K reconsider her antihypertensive medication regimen. We could start her on Sertraline (Zoloft) 50mg qd titrating up to 150mg qd for depression and disinhibition and titrate up her Carbamazepine to a dose where we see a blood level of 8 for a full 8 weeks. I will speak with Drs. F and K about these recommendations.
In order to improve Ms. Axxx’s self-awareness and reduce denial, provide her with continuous feedback concerning how her behavior affects others. For example, audiotape one of her verbal outbursts and at a later time when she is calm play the tape for her while explaining the impact her behavior had on others. She must perceive this feedback as non-judgmental.
When she expresses anger towards her family about institutional placement, ask her why she thinks her family placed her in institutional care and have her put her response in writing, if she can. Review her answer with her and help her to internalize this new understanding.
Explain the mechanism of denial of deficits to the family so they will not respond to her criticism with guilt and resentment and reduce visitation.
Stability and predictability will limit frustration and emotional outbursts. Establish a predictable and consistent daily routine for Ms. Axxx.
Staff should always try to communicate important information using the same language. Staff might consider creating a list of sentences to use when responding to Ms. Axxx’s questions.
When Ms. Axxx is agitated, communicate with her using the following techniques:
Give one direction or ask one questions at a time.
Use short, simple sentences with familiar words.
Use no choice directions.
Use touch and eye contact to calm her.
Announce any physical contact before touching her.
Always approach her from the front.
When she is agitated, tell her you understand that she is frightened and frustrated and you wish to help her overcome these feelings.
Staff who have the best relationship with Ms. Axxx should be designated to intervene and help calm her when she is agitated.
Develop a consistent plan for intervening when Ms. Axxx becomes agitated and insure that all staff are aware of the plan.
To mediate arousal problems, establishing her baseline arousal cycle by recording arousal level every 30 minutes each day for one week using a simple numerical rating system such as: 4 = fully alert, 3 = somewhat somnolent, 2 = tends to drift into sleep on and off, 1 = barely arousable. Once a pattern has been identified, provide rest breaks but not naps during the periods of greatest fatigue. Schedule the most enjoyable activities for periods when Ms. Axxx is not at peak arousal but slightly fatigued. The task will act as a reward or incentive to persist when tired. Schedule the most demanding activities after a period of sleep. Do not schedule hours of unbroken activity.
To improve awareness of deficits, with Ms. Axxx’s participation, create a list of her most serious deficits, their impact on her daily life and methods she can use to compensate for each deficit. Review this list frequently. Again, this must be non-judgmental and presented with a positive slant.
To limit perseveration, pause for several minutes between activities; the next activity should be completely unrelated to the previous one.
Provide Ms. Axxx with tools to compensate for memory deficits:
Teach her to use:
paired associate learning
help her create a memory log including:
facts about the facility
information about her brain injury
a detailed daily schedule
a calendar with scheduled appointments, activities, etc.
things to do list
list of important names with identifying information.
Repeat all important information/instructions many times each day.
When Ms. Axxx makes a provocative remark, try to be matter of fact in your response. Avoid any statements which she could perceive judgmental or moralistic.
When she becomes verbally aggressive, respond as follows:
Do not take her anger and hostility personally.
Ignoring the overt content of her remarks and respond to the underlying feeling: “Your anger is probably caused by your frustration about not being able to do things for yourself.”
She responds to humor. Try to defuse a tense situation with humor.
A special relationship with one staff member would go a long way towards improving Ms. Axxx’s self-esteem.
Staff should emphasize Ms. Axxx’s achievements, skills and interests in frequent, brief contacts to subtly bolster her self-esteem.
Try to identify events and interactions which seem to improve her mood and weave more of them into her daily routine.
At all times, treat Ms. Axxx with respect and as a responsible adult. She is highly sensitive about this subject. Given the overall context, I would allow her to make her own decisions about the extent of her smoking.
Encourage as much autonomy, independence and self-reliance as possible. Comment frequently on Ms. Axxx’s ability to care for herself.
Engage her in as many self-esteem enhancing activities as possible.
Staff should avoid appearing directive with Ms. Axxx. She will see this as a threat to her self-esteem and become oppositional as a means of asserting her autonomy.
Mental tasks beyond Ms. Axxx’s capacity may produce frustration and aggression. Although this does not mean that new things should not be tried, be sensitive to her response to new tasks and backtrack if necessary (maybe try again later). Avoid confronting her with tasks which stress her areas of weakness.
Ask family members to visit at regular and predictable intervals.
It may be possible to teach Ms. Axxx to use visual imagery to control emotional disinhibition. When she feels she’s about to explode into a rage, she should visualize a situation which has the opposite affective content (i.e. a happy family occasion or an amusing anecdote).
Engage her in simple failure free activities.
Contacts with staff should be frequent and include the following:
Opportunities to vent anger and grief.
Assistance with grooming and other activities which will enhance and maintain her self-respect and self-esteem.
Encouragement of autonomy by respectfully placing responsibility for the outcome of her care in her hands.
Assistance with orientation.
Staff, other residents and family members should be made aware of the fact that Ms. Axxx’s emotional outbursts are manifestations of disinhibition syndrome caused by cerebral impairment. They are involuntary. The thoughts and feelings she expresses are not genuine.
Don’t ask for or expect Ms. Axxx to explain her feelings when she is upset. Simply allow her to discharge her feelings verbally.
Avoid ambiguity, and do not present her with unnecessary choices or decisions. Use statements such as “Now it is time to take a shower”.
Ms. xxx enjoys the attention of others, particularly those in positions of authority (i.e. staff). Staff should reinforce her positive behaviors with attention, and to the extent possible, extinguish negative behaviors by withholding attention.
Attempt to set limits on Ms. Axxx’s behavior without limiting her ability to express feelings. For example, when she is angry with another resident, tell her it is okay to have these feelings while simultaneously indicating that confronting another resident in an aggressive way is not acceptable and probably does not reflect her true feelings.
Limit confusion and confusing stimulation. Family visits may be overwhelming at times and some recreational activities may not be well tolerated
An effective behavior management plan must begin with a system of tracking which can shed light on the following:
What happened before the behavior occurred, what triggered or precipitated the behavior. Antecedents can be internal (i.e. frustration or anxiety) or external (i.e. conflict with roommate or interaction with staff.)
What need is the patient attempting to satisfy through the behavior or what goal is the patient trying to reach through the behavior.
Did the behavior result in the satisfaction of a need or was a goal met. Were the consequences reinforcing or non-reinforcing.
An outline of the tracking process is attached.
She has hydrocephalus; my wish to have her evaluated for placement of a VP shunt by a neurosurgeon.
Drew Chenelly, Psy.D. Date:
1s and interests in frequent, brief contacts to subtly bolster her self-esteem.