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Adjustment following Brain Injury

Approximately 50% of people who acquire a brain injury will go on to develop chronic anxiety and/or depression (Anson & Ponsford, 2006). Thus there has been a focus on understanding this process in order to help. However, adjustment is a complex process. For a start Impairment does not linearly equate to disability, because disability has a social context, hence it is socially constructed (see Johnston, 1996). Therefore, the process of adjustment to brain injury is mitigated by internal and external, controllable and uncontrollable cognitive, emotional, social, and psychological factors. The literature on adjustment diverts down many lines of enquiry. There is of course the founding theories of Kubler-Ross (1969) on the stages of grief. This model has undergone many updates moving away from a linear stage model of grief to an acceptance model describing the common feelings of loss in a wider context. This model has great therapeutic use in brain injury, but it still lacks the specificity in predicting positive adjustment and coping. Of course, brain injury carries with it an increased likelihood of specific cognitive factors that may affect coping. For example, reduced problem solving ability, mood dysregulation, lability, memory difficulties, reduced concentration and so on. However, researchers now believe the impact of this is less obvious than one might assume. For instance, although these cognitive dysfunctions are more prevalent in severe brain injuries, adjustment appears to be inversely correlated to severity self awareness and insight is not always a good thing (see Brown & Vandergoot, 1998 ‘quality of life’ studies). Poor adjustment has often been associated with self-blame, excessive worry, ruminative thoughts, wishful thinking, misuse of drugs and alcohol and general avoidance (Anson & Ponsford, 2006). In addition there appears to be a significant gender divide with females more likely to seek systemic support and males more likely to cope in isolation. Researchers have managed to specify positive predictors of adjustment. Some of these include: a problem solving approach, low expectation of outcome and realistic hopes & goals, an internal locus of control, healthy levels of self esteem, use of humour, personal resilience, high premorbid intelligence, and supportive families/home environments. But perhaps, one quotation defines adjustment best by summarising three wishes:

“People want something to do, somewhere to live and someone to love” (McColl et al. 1998).

Cognitive Rehabilitation Treatment

Following an acquired brain injury, often a client experiences changes in cognition, emotion, personality and behaviour.

Cognitive rehabilitation is a treatment for acquired brain injury clients to help improve everyday function.

It involves specialist assessment in order to specify skills and strategies for the ABI client and their carers/family.

It may involve behavioural advice, pen and paper tasks to practice, psychoeducation, computer programs and apps, or skills to use in everyday life.

For many it is a vital part of the rehabilitative process alongside physical forms of rehabilitation. It provides a way of reaching optimal trajectories of recovery and can improve client insight, wellbeing and safety.

Unfortunately the health system is limited with regards to access to cognitive rehabiliation, length of cognitive rehabilation and resources for cognitive rehabilitation.

Dr Moore can provide bespoke cognitive rehabilitation assessment and treatment within the South West of England in cases where funding is approved by solicitors.

Email psychologyassessment@yahoo.co.uk for for information of to make an enquiry.

 

 

EMDR Treatment

EMDR treatment is NICE and WHO endorsed for the treatment of psychological trauma and PTSD. Evidence suggests it is not only effective but highly efficient and cost effective at not only reducing symptomatology but often completely alleviating the symptoms of trauma: hyperarousal, intrusive memories and avoidance behaviours.

It involves target memory assessment, coping skills teaching, controlled exposure and bilateral eye stimulation to help a client re-process traumatic target memories.

Dr Moore provides EMDR treatment in addition to his existing broad Clinical Psychology training for clients with insurance funded treatments following traumatic experiences. This treatment is limited to the South West of England to help manage costs.

For more information on EMDR- visit: http://www.getselfhelp.co.uk

Orientating the Brain

The following technical terms are used to orientate around and within the brain and its structures:

 

Top=dorsal/superior

Bottom=ventral/inferior

Front=rostral/anterior

Back=caudral/posterior

Medial=mid-line

Lateral=away from mid-line

Contralateral=opposite side as

Ipsilateral=same side as

Unilateral=one side only

Bilateral=both sides

Proximal=close

Distal=distant

Communicating Scores

In order to assert clinical opinion toward a patients raw data test results from varying sources should be assimilated into a common metric (standardisation). Percentiles tell us the rarity or abnormality of an individual’s score. They are easily understandable and communicable but are not linear and so the difference between the 10-20th percentile in comparison to the 20-30th percentile is not necessarily the same. Z scores on the other hand, are linear transformations. They indicate with positive and negative values how many standard deviations a score is away from its mean. However, working in negative can present communication problems and z scores tend to get lost in translation when communicating with non-neuropsychologists. A common alternative is to use T scores (mean=50, SD=10) which offers a balanced level of incrementation. Others prefer index scales (mean 100, SD 15) which are often received with familiarity as they are used in the measurement if IQ. However, the fact that they are used in IQ can bring unwanted misconception when communicating interpretation and opinion. Descriptive ranges are often used to reflect where a score falls within words not numbers.

Mental Capacity: Cognitive Deficit and Neurological Assessment.

There are occasions when a person’s cognition is compromised to the extent that their mental capacity to make specific decisions may be impaired. Such scenarios sometimes occur when a person acquires a brain injury, degenerative condition or neurological disease or when the person has a severe learning disability or mental illness. 

Assessments of capacity can be conducted by the carer or health professional who initially raises concerns, however, what is often required is a thorough neuropsychological assessment including a measure of the person’s current cognitive status conducted by a clinical psychologist/neuropsychologist. 

Neuropsychological assessment involves the integration of theoretical and clinical knowledge accrued from the study of brain behaviour relationships and information gleaned from the review of individual patient’s medical records, patient presentation, patient interview, carer/relative assessment and the administration of standardised psychometric assessments.
It is important to note that capacity cannot be inferred solely from standardised psychometric assessment but it is much more holistic. There are no performance cut-offs or black-and-white guidelines for assessing capacity. Psychometric tests will be chosen on the basis of the tests own reliability and validity credentials; on the basis of the anticipated cognitive deficits implicated by the pathology of the disease or insult; and often based upon the type of decision that has been examined. For example if the decision is one that involves the examination of ability to use judgement, executive tests measuring judgement may be chosen. Each neuropsychological assessment is therefore tailored to the situation. There are however certain helpful things to think about when conducting an assessment of capacity:
1. Start off by thinking that everyone can make their own decisions.
2. Give a person the support he/she needs to make decisions before concluding that he/she cannot make his/her own decisions.
3. Nobody should be stopped from making a decision just because others may think it is unwise or eccentric.
4. Anything done for, or on behalf of, a person without capacity must be in his/her “best interests” – a decision which is arrived at by working through a checklist.
5. When anything is done or decided for a person without capacity, it must be the least restrictive of his/her basic rights and freedoms.
There is a duty by the assessor to ensure every avenue has been exhausted to facilitate a persons ability to make decisions, however following this, someone will fail to meet the requirements of capacity if they cannot fulfil all these prerequisites:
1: understand the information relevant to the decision
2: retain that information
3: use or weigh up the information
4: communicate the decision
Often a clinical psychologist/neuropsychologist will be instructed by the court of protection or a solicitor to conduct a neuropsychological assessment and produce a report to help the court make a decision as to a person’s capacity and best interests. The instruction of these expert witnesses will offer an independent, evidence-based, reliable and valid opinion as to persons mental capacity on a specific decision(s). As well as being decision-specific, assessments are also time bound and subject to review depending on the prognosis and changeability of the person’s cognitive status. For example, when a person recovers from severe mental illness /brain injury or where a person has periodically lucid periods within a neurological disease (sometimes seen in Parkinson’s disease for instance).
Psychologyassessment@yahoo.co.uk

TBI and a walk in the woods

Whilst walking Archie the labrador through the woods this morning I noticed the distinctive pecking sound of a woodpecker. Why doesn’t the woodpecker get concussion I wondered? With a quick google I discovered that their heads move at 20 feet per second at each peck enduring a deceleration of more than 1000 times that of gravity. As like many of the conundrums in nature, the answer lies in evolution. Onwards I walked with Archie through the Devon woodlands. I noticed many of the terrains we negotiate are man made. Even the dug out kilns within the woods provide steep drops to avoid. Buildings, bridges, roads all pose threats for head injury in humans that evolution has simply not had chance to equip us for the requisite forces involved when things go wrong.  If we assume evolution ended at the discovery of contraception, or perhaps ground to a snails pace, then we are simply not built for falling off buildings or getting struck by motorised vehicles. Where the woodpecker has evolved to cope with impressive forces, humans remain vulberable to the forces beyond the natural scope of the cave dweller.42-28707768

Apparently the woodpecker has 3  useful physiological attributes. Firstly, its skull has a safety belt looping structure to protect it. Secondly, it has upper and lower beak discrepancies to help lower the load upon the beak. Thirdly, its skull has plate like bones with a spongy structure to finalise the protection. So next time you hear a woodpecker, think to yourself what an amazing thing evolution is.