PTSD, TBI & LEGAL CLAIMS

December 6, 2021

We know that a significant number of people with a TBI have PTSD / trauma. The essence of treating PTSD is equipping the person with skills, supporting them in confronting the original threat and reducing avoidance. What is not recognised so much are the embedded and ongoing activating 'threats' presented by a TBI (cognition, employment, family, social and financially) and the case itself (assessment interviews requiring re-telling the story, adversarial experts, confronting impairment etc.). The 'threats' must be dynamically addressed before exposure and behavioural change can be sustained. In interview, dissociation can be mistaken for an absence of distress. All this takes time, and does not fit with 8-10 sessions of TFCBT or EMDR, the NICE suggestion for a 'simple' trauma treatment programme! Hopefully, medico-legal experts on both sides of cases can become better informed regarding the complexity and challenge in treating these clients.


Dr David Quinn

Clinical Neuropsychologist

Halliday Quinn Limited, Apr 25 2019

By PH757046 December 6, 2021
Three All in the Mind podcasts related to Covid-19, and its oblique links with boredom There are lots of interesting and useful podcasts out there. I’d like to share 3. The first podcast discusses the psychological and neural impact of lockdown: https://www.abc.net.au/radionational/programs/allinthemind/the-brain-in-isolation/12201054 One contributor at the start of lockdown estimated that most people can cope with 3 months of social distancing. It’s not clear to me if that prediction has been confirmed for the vulnerable group he identified. Another contributor focused on the fact that our brain quickly adapts to events of the previous day. He looked at adaptive processes at the neural level. It is often said that the cells that fire together wire together. Certainly, we know that the synaptic junctions between neurons grow every day. The growth appears to be greatest for the most active synapses. Increased activity strengthens connections. Synaptic junctions reduce in size when we sleep. These reductions do not eliminate the relative increases arising from the previous day’s activity. Repeating activity in the same subset of synapses over time builds up connection in the long term. This fits with the growing body of evidence showing that our experience reshapes our brain. For example, learning to juggle increases the volume of parietal cortex over a 3-month training period and right hippocampal volume increases during the course of training for London taxi drivers. The podcast points out that though we are still talking with people, we are not using the full range of social behaviours – no touching, less reliance on facial expressions etc. This implies that the neural mechanisms regulating these components of social behaviour become less active and their interconnections weaken. The short-term impact of this is probably unclear but, theoretically, the contributor suggested that the connectivity of our brains has probably changed somewhat over the last 3 months. There is other evidence that repeated social isolation over the longer term alters brain connectivity. The podcast describes the case of an American prisoner who was in solitary confinement for many years. He had lost the ability to recognise faces by the time he was released. However, freedom enabled him to restore that capability because his daily experiences required him to develop that skill. A couple of podcasts noted that people sometimes complain of increased boredom during the Covid-19 lockdown. It turns out that the following 2 podcasts review interesting research on boredom: https://www.abc.net.au/radionational/programs/allinthemind/the-benefits-of-boredom:-part-1/12249300 https://www.abc.net.au/radionational/programs/allinthemind/the-benefits-of-boredom:-part-2/12270824 I’ll indicate some of the research that particularly interested me. · In the first podcast, 5 boredom categories were identified, 2 of which can be beneficial. · Boredom is hypothesised to be triggered by failure to see value in an activity and/or overload. · It was argued that boredom has a biological value in triggering activity and certain types can stimulate creativity. · One study found a link between the following personality traits and boredom-stimulated creativity: openness to new experiences, internal locus of control, love of learning and interest in ideas. Lots of people complain of boredom after sustaining a brain injury, so I’ve been wondering about potential ways of using these ideas to respond more creatively to clients’ boredom complaints. Dr Rodger Weddell Senior Consultant Clinical Neuropsychologist Halliday Quinn Limited, Jul 13 2020
By PH757046 December 6, 2021
Many studies have shown that traumatic brain injury can result in difficulties with recognising emotions (39%), particularly fear and sadness and also in reduced empathy (60%). As therapists we are aware of the impact of these changes on relationships: when loved ones need comforting the most i.e. when they are frightened or upset, they are unlikely to get it from their injured partner who can appear detached and uncaring - often very different from how they used to be. In treatment, a relational approach to this difficulty is essential (Neumann et al 2017) (Kreutzer (2015) so that those around the client as well as clients themselves are assisted to understand, adjust and adapt to such profound changes. After all, empathy’s social role is to serve as the origin of the motivation for cooperative and pro-social behaviour as well as effective social communication. Empathy as a concept links loosely to both Tom and Lauren’s earlier blogs….. Empathy seems to be associated with activity in the ventro-medial pre-frontal cortex (the VMPFC), the area that may hold the key to the so-called executive paradox (Lauren’s topic). The executive paradox complicates assessment of capacity in many highly intelligent people. The VMPFC seems to contribute importantly to decision making where multiple factors apply and when situations are uncertain, ambiguous or specifically financial. These ingredients are often present in the decision making scenarios that prompt the need for capacity assessments. In a 2018 study (Beadle et al), people with VMPFC injuries behaved with little empathy in a financial context towards a man who was in a state of suffering compared to matched uninjured controls. The choices made by people with VMPFC injuries were also more likely to contribute to negative social impacts and evaluations. Andrew Worthington argues in the April edition of The Neuropsychologist that attention should be directed a bit less when assessing capacity at dorso-lateral pre-frontal cortex (DLPFC) related skills and more at ventro-medial function i.e. everyday tasks, social function and pre-injury behaviour as Lauren has pointed out. The overlap with empathy deficits may be relevant. Moving to Tom’s musical theme……A study reported in Nature last month by Novembre et al suggests that there may be some mileage in musically based tasks to promote cooperation in those who have difficulty with empathic perspective taking (EPT). When asked to be the leader of a pair engaged in synchronising musical output using e-music boxes, low EPT as well as higher EPT individuals were able to modify their movements and speed to make it easier for their musical partner to synchronise with them. Does this finding support the idea of a relational approach to treating reduced empathy? It is not clear whether treatment approaches alter only the cognitive aspect of empathy (the capacity to understand another's perspective or mental state). The emotional aspect (the capacity to respond with an appropriate emotion to another's mental state) may be more elusive. Is it the same missing ingredient that applies in the executive paradox where decision making needs the additional input of more emotional, “gut instinct” reasoning? Louise Russell Senior Consultant Clinical Neuropsychologist Halliday Quinn Limited, Sep 13 2019
By PH757046 December 6, 2021
Research shows the benefits of using music as a tool for improving various mental health conditions, including depression, trauma, and schizophrenia (to name a few). Music acts as a medium for processing emotions, trauma, and grief - but music can also be utilised as a regulating or calming agent for anxiety or for dysregulation. Active Music Listening Music can be utilised to regulate mood. Because of its rhythmic and repetitive aspects, music engages the neocortex of our brain, which calms us and reduces impulsivity. We often utilise music to match or alter our mood. While there are benefits to matching music to our mood, it can potentially keep us stuck in a depressive, angry or anxious state. To alter mood states, play music to match the current mood of the person and then slowly shift to a more positive or calm state. It has been generally accepted that both listening to and creating music can have various positive effects on mood and mental health. Incorporating music into your everyday life can help to: ▪elevate your mood and motivation ▪aid relaxation ▪increase the efficiency of your brain processing. Tom Hughes Practice /Business Manager Halliday Quinn Limited, Jul 3 2019
By PH757046 December 6, 2021
Research shows the benefits of using music as a tool for improving various mental health conditions, including depression, trauma, and schizophrenia (to name a few). Music acts as a medium for processing emotions, trauma, and grief - but music can also be utilised as a regulating or calming agent for anxiety or for dysregulation. Active Music Listening Music can be utilised to regulate mood. Because of its rhythmic and repetitive aspects, music engages the neocortex of our brain, which calms us and reduces impulsivity. We often utilise music to match or alter our mood. While there are benefits to matching music to our mood, it can potentially keep us stuck in a depressive, angry or anxious state. To alter mood states, play music to match the current mood of the person and then slowly shift to a more positive or calm state. It has been generally accepted that both listening to and creating music can have various positive effects on mood and mental health. Incorporating music into your everyday life can help to: ▪elevate your mood and motivation ▪aid relaxation ▪increase the efficiency of your brain processing. Tom Hughes Practice /Business Manager Halliday Quinn Limited, Jul 3 2019
December 6, 2021
We know that a significant number of people with a TBI have PTSD / trauma. The essence of treating PTSD is equipping the person with skills, supporting them in confronting the original threat and reducing avoidance. What is not recognised so much are the embedded and ongoing activating 'threats' presented by a TBI (cognition, employment, family, social and financially) and the case itself (assessment interviews requiring re-telling the story, adversarial experts, confronting impairment etc.). The 'threats' must be dynamically addressed before exposure and behavioural change can be sustained. In interview, dissociation can be mistaken for an absence of distress. All this takes time, and does not fit with 8-10 sessions of TFCBT or EMDR, the NICE suggestion for a 'simple' trauma treatment programme! Hopefully, medico-legal experts on both sides of cases can become better informed regarding the complexity and challenge in treating these clients. Dr David Quinn Clinical Neuropsychologist Halliday Quinn Limited, Apr 25 2019
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