Psychiatric Problems Following TBI

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Psychiatric Problems Following TBI

• Jesse R. Fann, MD, MPH
• Departments of Psychiatry and Behavioral
  Sciences, Rehabilitation Medicine, Epidemiology
• University of Washington
• Seattle, Washington

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Domains of TBI

• Neurobiological Injury
• Consequences of direct injury to brain
• Traumatic Event
• Risk for Post-traumatic Stress Disorder,
  Depression
• Chronic Medical Illness
• May lead to long-term symptoms disability

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TBI as Neurobiological Injury

• Primary effects of TBI
• Contusions, diffuse axonal injury
• Secondary effects of TBI
• Hematomas, edema, hydrocephalus, increased
  intracranial pressure, infection, hypoxia,
  neurotoxicity, inflammation
• Can affect mood modulating systems including
  serotonin, norepinephrine, dopamine,
  acetylcholine, and GABA

(Hamm et al 2000 Hayes Dixon 1994)
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Non-penetrating TBI
Diffuse Axonal Injury Contusion Subdural
Hemorrhage
Taber et al 2006
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Examples of Neuropsychiatric Syndromes Associated
with Neuroanatomical Lesions

• Leteral orbital pre-frontal cortex
• Irritability - Impulsivity
• Mood lability - Mania
• Anterior cingulate pre-frontal cortex
• Apathy - Akinetic mutism
• Dorsolateral pre-frontal cortex
• Poor memory search - Poor set-shifting /
  maintenance
• Temporal Lobe
• Memory impairment - Mood lability
• Psychosis - Aggression
• Hypothalamus
• Sexual behavior - Aggression

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Mayberg et al, J Neuropsychiatry Clin Neurosci
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TBI as Traumatic Event

• PTSD Prevalence 11-27
• Possibly more prevalent in mild TBI
• Mediated by implicit memory or conditioned fear
  response in amnestic patients?
• PTSD Phenomenology
• Intrusive memories 0-19
• Emotional reactivity 96
• Intrusive memories, nightmares, emotional
  reactivity had highest predictive power
• Anxiety often comorbid with / prolongs depression
• Warden 1997, Bryant 1995, Flesher 2001,
  Bombardier 2006
• Warden et al 1997, Bryant et al 2000

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Psychiatric Illness in Adult HMO Enrollees (N939
with TBI, 2817 controls)
Fann et al. Arch Gen Psychiatry 2004 6153-61
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Psychiatric Disorder MTBI
Bryant et al., Am J Psychiatry, in press
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Neuropsychiatric Sequelae

• Delirium
• Depression
• Mania
• Anxiety
• Psychosis
• Cognitive Impairment
• Aggression, Agitation, Impulsivity
• Insomnia

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Examples of Neuropsychiatric Syndromes Associated
with Neuroanatomical Lesions

• Leteral orbital pre-frontal cortex
• Irritability - Impulsivity
• Mood lability - Mania
• Anterior cingulate pre-frontal cortex
• Apathy - Akinetic mutism
• Dorsolateral pre-frontal cortex
• Poor memory search - Poor set-shifting /
  maintenance
• Temporal Lobe
• Memory impairment - Mood lability
• Psychosis - Aggression
• Hypothalamus
• Sexual behavior - Aggression

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Neuropsychiatric Evaluation and Treatment
Etiologies

• Psychiatric Neurologic/Medical Social
• Premorbid Neurologic illness Social, family,
  vocation
• Psych disorders sxs. Lesion location,
  size, Rehabilitation situation
• Personality traits pathophysiology and
  stressors
• Coping styles Other medical
  illness Functional impairment
• Substance Abuse Other indirect
  sequelae Medicolegal
• Medication side effects (e.g., pain, sleep
  disturb)
• interactions Medication side effects
• Psychodynamic signif. interactions
• of neurologic illness
• Family psych. history
• Roy-Byrne P, Fann JR. APA Textbook of
  Neuropsychiatry, 1997

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Neuropsychiatric Evaluation and Treatment Workup

• Psychiatric Neurologic/Medical Social
• Psychiatric history Medical history and
  Interview family, friends,
• examination physical examination
  caregivers
• Neuropsychological Appropriate lab tests Assess
  level of care
• testing e.g., CBC, med blood
  supervision available
• Psychodynamic signif. of levels, CT/MRI,
  EEG Assess rehab needs
• neuropsychiatric sxs., Medication allergies
  progress
• disability and treatments

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Neuropsychiatric History

• Psychiatric symptoms may not fit DSM-IV criteria
• Focus on functional impairment
• Document and rate symptoms (use validated
  instruments)
• Assess pre-TBI personality, coping, psychiatric
  history
• Talk with family, friends, caregivers
• Explore circumstances of trauma
• LOC, PTA, hospitalization, medical complications
• Subtle symptoms - may fail to associate with
  trauma
• How has life changed since TBI?
• Thorough review of medical and psychiatric sxs.
• Assess level of care and supervision available
• Assess rehabilitation needs and progress

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Neuropsychiatric Treatment

• Use Biopsychosocial Approach
• Treat maximum signs and symptoms with fewest
  possible medications
• TBI patients more sensitive to side effects
• START LOW, GO SLOW, BUT GO
• May still need maximum doses
• Therapeutic onset may be latent
• Some medications may lower seizure threshold
• Some medications may slow cognitive recovery
• Monitor and document outcomes
• Few randomized, controlled trials

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Delirium

• Acute disturbance of consciousness, cognition
  and/or perception
• Increased risk in patients with TBI
• Undiagnosed in 32-67 of patients
• Often missed in both inpatient and outpatient
  settings
• Associated with 10-65 mortality
• Can lead to self-injurious behavior, decreased
  self-management, caregiver management problems
• Associated with increased length of hospital stay
  and increased risk of institutional placement
• Other terms used to denote delirium acute
  confusional state, intensive care unit (ICU)
  psychosis, metabolic encephalopathy organic brain
  syndrome, sundowning, toxic encephalopathy

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Delirium

• Identify and correct underlying cause
• TBI increases a persons vulnerability
• e.g., seizures, hydrocephalus, hygromas,
  hemorrhage, drug side effect or interactions,
  endocrine (hypothalamic, pituitary dysfunction),
  metabolic (e.g., sodium, glucose), infections
• Pharmacologic management
• Antipsychotics
• Haloperidol (e.g., IV), droperidol, risperidone,
  olanzapine, quetiapine (taper 7 10 days after
  return to baseline)
• Benzodiazepines (combined with antipsychotics),
  alcohol or sedative withdrawal
• lorazepam
• Minimize polypharmacy
• Medical management
• Frequent monitoring of safety, vital signs,
  mental status and physical exams
• Maintain proper nutritional, electrolyte, and
  fluid balance
• Behavioral Management safety, orientation,
  activation

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Depression / Apathy

• Prevalence of major depression 44.3
• Assess pre-injury depression and alcohol use
• Use inclusive diagnostic technique
• May occur acutely or post-acutely
• Not directly related to TBI severity
• Apathy alone - prevalence 10
• disinterest, disengagement, inertia, lack of
  motivation, lack of emotional responsivity
• van Reekum et al. J Neuropsychiatry Clin
  Neurosci 200012316-327

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DSM-IV Major Depressive Disorder (MDD)

• Depressed mood
• Loss of interest/pleasure
• Sleep disturbance
• Poor energy
• Motor change agitation or slowness
• Weight/appetite change increase/decrease
• Impaired concentration or indecision
• Excessive worthlessness or guilt
• Recurrent thoughts of death or suicide
• At least one of the essential criteria and a
  total of at least 5 symptoms endorsed most of the
  day most days for at least 2 weeks
• Must cause clinically significant impairment

APA, Diagnostic Statistical Manual of Mental
Disorders, 4th ed, 2000
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Transdiagnostic Symptoms

• TBI
• Depressed mood
• Anhedonia
• Weight loss/gain
• Insomnia/hypersomnia X
• Psychomotor changes X
• Fatigue X
• Worthlessness/guilt
• Poor concentration X
• Thoughts of death/suicide

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Patient Health Questionnaire - 9
Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed, or hopeless 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 0 1 2 3
7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving .around a lot more than usual 0 1 2 3
9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3
Spitzer et al. JAMA 1999
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Rates Of Major Depression After TBI
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N 559
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Point Prevalence of MDD
Range 21-31, no trend
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Cumulative Rate of MDD as a Function of
Depression History
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69
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P lt .001 independent predictors after adjusting
for all other variables
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Rate of MDD by History of Lifetime Alcohol
Dependence
70
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P lt .001 independent predictor after adjusting
for all other variables
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Cumulative Rate of MDD by PTSD History
81
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Univariate predictor, not significant after
adjusting for other variables
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Comorbidity of Anxiety and MDD
Any comorbid anxiety disorder in MDD vs. MDD-
(60 vs. 7 RR, 8.77 CI, 5.56-13.83)
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Depression / Apathy

• Selective serotonin re-uptake inhibitors (SSRIs)
• sertraline - paroxetine - fluoxetine
• citalopram - escitalopram
• venlafaxine, duloxetine (may help with pain)
• bupropion (may decrease seizure threshold)
• nefazedone (may be too sedating, liver toxicity)
• mirtazapine (may be too sedating)
• Tricyclics nortriptyline, desipramine (blood
  levels)
• methylphenidate, dextroamphetamine
• Electroconvulsive Therapy consider less
  frequent, nondominant unilateral
• Apathy Dopaminergic agents - methylpyhenidate,
  pemoline, bupropion, amantadine, bromocriptine,
  modafinil

Fann et al, J Neurotrauma 2009
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Number of Postconcussive Symptoms
p.05
All symptoms
Depressive symptoms excluded
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PCS Depression Study(Baseline and Week 8)





plt.05 plt.01
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Treatment options

• Antidepressant medications
• Particularly for major depression and dysthymia
• Psychotherapy for all forms of depression (esp.
  CBT)
• Pro no side effects, may last longer (learning
  effect), addresses interpersonal / real life
  problems, flexible delivery options
• Con may need to adapt for cognitive impairment,
  may cost more and take longer to work, more time
  consuming, may not be as effective for severe
  major depression
• Other psychosocial interventions (e.g.,
  educational support groups)
• Support and watchful waiting
• Often optimal treatment with combination of
  antidepressants and psychotherapy

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Modifiable Risk Factors
Depression
Cognitive Distortions
Neurobiological Factors
No Pleasant Activities
Sedentary Lifestyle
Psychosocial Adversity
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LifeImprovement Following Traumatic Brain
InjuryA Trial of Cognitive-Behavioral Therapy
for Depression after TBI

• Charles H. Bombardier, PhD
• Steven Vannoy, PhD
• Peter Esselman, MD
• Kathy Bell, MD
• Nancy Temkin, PhD
• University of Washington
• Evette Ludman, PhD
• Group Health Research Inst

• Jesse R. Fann, MD, MPH
• Departments of Psychiatry Behavioral Sciences
  and Rehabilitation Medicine
• School of Medicine
• Department of Epidemiology
• School of Public Health
• University of Washington

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Reason Accommodations
Slowed information processing responding Present information at slower rate Allow client more time to respond Provide written summary of session beforehand
Impaired attention concentration Minimize environmental stimulation and distractions during session Focus on one topic at a time, Use shorter sessions Avoid need for multi-tasking e.g., no note taking while listening
Impaired learning recall Provide written summary of session (patient workbook) Assign simple written homework Provide written educational materials or workbook Plan additional practice of CBT skills within session (over-learn skills)
Impaired verbal abilities Minimize emphasis on verbally mediated aspects of CBT Emphasize behavioral activation and pleasant events scheduling
Impaired initiation generalization Include family or friend in treatment planning and homework assignments Provide 2 sessions devoted to generalization and relapse prevention at end
Impaired motivation Use motivational interviewing techniques to engage subjects in therapy Provide care management activities aimed at return to work, school or other meaningful roles and finding effective rehabilitation resources

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Mania

• Prevalence of Bipolar Disorder 4.2 after TBI
• Look for
• elevated, expansive or irritable mood
• grandiosity
• decreased need for sleep
• pressured speech
• flight of ideas, distractability
• impuslivity
• High rate of irritability, emotional
  incontinence
• May be associated with epileptiform activity
• Potential interaction of genetic loading, right
  hemisphere lesions, and anterior subcortical
  atrophy
• van Reekum et al. J Neuropsychiatry Clin
  Neurosci 200012316-327

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Mania

• Acute
• Benzodiazepines
• Antipsychotics
• olanzapine, risperidone, quetiapine, clozapine
• Anticonvulsants
• valproate
• Electroconvulsive Therapy
• Chronic
• valproate
• carbamazepine
• lamotrigine
• lithium carbonate (neurotoxicity)
• gabapentin, topiramate (adjunctive treatments)

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Pseudobulbar Affect

• A neurologic condition characterized by episodes
  of crying or laughing that are sudden, frequent,
  and involuntary
• Occurs in patients with TBI, MS, ALS, stroke, and
  certain other neurologic conditions
• FDA-approved in 2011 Nuedexta
• Dextromethorphan (20mg) modulates glutamate
• Quinidine (10mg) metabolic inhibitor

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Anxiety Disorders

• Adjustment Disorder
• Posttraumatic Stress Disorder
• Panic Disorder
• Generalized Anxiety Disorder
• Specific Phobia e.g., medical procedures
• Obsessive-Compulsive Disorder
• Anxiety Disorder due to General Medical Condition
  (e.g., hypoxia, sepsis, pain)
• Substance-induced Anxiety Disorder

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Rates of Anxiety Disorders (civilians)
GAD PTSD OCD Panic Phobias Sample  
24 NA NA 4 2 Agoraphobia 50 patients diagnosed with TBI seen at a rehabilitation clinic -mean 32.5 months post injury Fann et al., 1995
8 17 14 11 7 100 patients with TBI - mean 7.6 years post injury Hibbard et al., 1998
3 3 2 9 1 100 patients hospitalized for TBI - 1 year post injury Deb et al., 1999
17 14 1 6 7 Specific Phobia 6 Social Phobia 1 Agorophobia 100 patients hospitalized for TBI - assessed 0.5 - 5.5 years post injury Whelan-Goodinson et al., 2009
13.4 13 4 7.5 12.8 Agoraphobia 9 Social Phobia 817 patients hospitalized for traumatic injury (40 TBI) - assessed 1 year post injury Bryant et al., 2010
NA Not Assessed.
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Anxiety

• Often comorbid with and prolongs course of
  depression in TBI
• Posttraumatic Stress Disorder Prevalence 14.1
• Reexperience, Avoidance, Hyperarousal
• gt 1 month, causes significant distress or
  impairment
• Possibly more prevalent in mild TBI
• Panic Disorder Prevalence 9.2
• Generalized Anxiety Disorder Prevalence 9.1
• Obsessive-Compulsive Disorder Prevalence 6.4
• van Reekum et al. J Neuropsychiatry Clin
  Neurosci 200012316-327

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Adjustment Disorders

• Clinically significant symptoms of depressed
  mood, anxiety, or both
• Occurring within 3 months in response to an
  identifiable stressor(s) once the stressor has
  terminated, the symptoms do not persist for more
  than an additional 6 months
• Causing marked distress that is in excess of what
  would be expected from exposure to the stressor
  and significant impairment in social or
  occupational (academic) functioning
• The stress-related disturbance does not represent
  bereavement or meet the criteria for another Axis
  I disorder.

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PTSD Criteria

• CLUSTER A Stressor
• A. Experience/witness threat
• Respond with fear/helplessness
• CLUSTER B Reexperiencing
• At least 1 of
• A. Intrusive memories
• B. Nightmares
• C. Flashbacks
• D. Psychological distress to reminders
• E. Physiological reactivity to reminders

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PTSD Criteria (contd)

• CLUSTER C Avoidance
• At least 3 of
• A. Avoid thoughts, feelings
• Avoid places, activities
• -----------------------------------------
• C. Dissociative amnesia
• Diminished interest
• Detachment from others
• Restricted affect
• Foreshortened future
• CLUSTER D Arousal
• At least 2 of
• A. Sleep disturbance
• B. Anger
• Concentration difficulties
• Hypervigilence
• Elevated startle response

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PTSD Criteria (contd)

• CLUSTER E Symptoms last at least 1 month
• CLUSTER F Causes impairment
• CLUSTER H Not due to medical condition or
  substance abuse

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PTSD Risk Factors

• Trauma
• Level of threat
• Exposure to grotesque events
• Fatality/injuries
• Uncontrollable event
• Duration of disaster
• Peri-Trauma
• Panic
• Dissociation
• Catastrophic appraisals

• Post-Truama
• Low social support
• Coping style
• Community reaction
• Ongoing stressors
• Comorbidity
• Secondary symptoms

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Psychiatric Disorder Prior Sleep Problems
Bryant et al., Sleep, in press
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Role of Trauma Memories

• One study reported that confidence in memory for
  traumatic experience inversely related to PTSD
  development

Gil et al., (2007), Am J Psychiatry
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Interface of PTSD Persistent PCS
Stein McAllister, AJP 2009
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Brain regions implicated in PTSD and vulnerable
to TBI
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Implications

• Mild TBI patients need to be monitored for stress
  reactions
• Do not confuse effects of Mild TBI with effects
  of stress
• Interaction of the two factors suggest that
  optimal intervention for PCS will focus on stress
  reactions

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Panic Attack

• Intense fear or discomfort
• At least 4 symptoms peak in 10 min
• palpitations, pounding heart, or accelerated
  heart rate
• chest pain or discomfort
• shortness of breath or smothering
• feeling of choking
• feeling dizzy, unsteady, light-headed, or faint
• paresthesias (numbness or tingling sensations)
• chills or hot flashes
• trembling or shaking
• sweating
• derealization or depersonalization
• fear of losing control or going crazy
• fear of dying
• nausea or abdominal distress

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Panic Disorder

• Recurrent unexpected panic attacks for 1
  month (or more
• either persistent concern about having additional
  attacks or worry about the implications of the
  attack or its consequences (eg, losing control,
  having a heart attack, going crazy) or a
  significant change in behavior related to the
  attacks.

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Generalized Anxiety Disorder

• A. Excessive anxiety and worry, occurring more
  days than not , for at least 6 months, about a
  number of events of activities
• B. Difficult to control the worry
• C. Associated with 3 or more symptoms (some
  present more days than not for at least 6 months)
• Restless, keeyed up, or on edge
• Easily fatigued
• Difficult concentrating or mind going blank
• Irritable
• Muscle tension
• Difficulty falling or staying asleep, or restless
  sleep
• D. Focus of anxiety / worry not confined to
  features of another Axis I disorder
• E. Clinically significant distress or impairment
• F. Not due to substance or general medical
  condition and does not occur exclusively during a
  Mood, Psychotic, or Pervasive Dev Disorder

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Anxiety

• Medications
• Benzodiazepines use lower doses (50 typical
  dose)
• e.g., clonazepam, lorazepam, alprazolam
• Watch for cognitive impairment, disinhibition,
  dependence
• Buspirone (for Generalized Anxiety Disorder)
• Antidepressants
• SSRIs, venlafaxine, nefazedone, mirtazapine, TCAs
• Beta-blockers, verapamil, clonidine
• Anticonvulsants Valproate gabapentin have
  some anxiolytic effects
• Psychosocial
• Individual (CBT, Behavioral Activation), couples,
  family, group

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Psychosis

• Hallucinations, delusions, thought disorder
• Immediate or latent onset
• Symptoms may resemble schizophrenia prevalence
  0.7 in TBI
• Schizophrenics have increased risk of TBI
  pre-dating psychosis
• Patients developing schizophrenic-like psychosis
  over 15-20 years is 0.7-9.8
• Look for epileptiform activity and temporal lobe
  lesions
• Treatment Antipsychotic medications (referral)
• van Reekum et al. J Neuropsychiatry Clin
  Neurosci 200012316-327

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Psychosis

• Antipsychotics
• First generation e.g. haloperidol,
  chlorpromazine (seizures)
• Second generation e.g., risperidone
• Third generation e.g., olanzapine, quetiapine,
  ziprasidone, aripiprazole, clozapine (seizures)
• Start with low doses (e.g., Risperidone 0.5mg
  qHS)
• TBI pts have high risk of anticholinergic and
  extrapyramidal side effects
• May cause QTc prolongation, increased sudden
  death in elderly
• Use sparingly - may impede neuronal recovery
  acutely (from animal data)

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Cognitive Impairment

• Common problems after TBI
• Concentration and attention
• Memory
• Speed of information processing
• Mental flexibility
• Executive functioning
• Neurolinguistic
• Association with Alzheimers Disease suggested
• Cognitive Rehabilitaiton may help
• May be associated with other psychiatric
  syndromes (e.g., depression, anxiety, psychosis)
  treating these may improve cognition

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Cognitive Impairment

• May improve recovery
• Stimulants
• methylphenidate, dextroamphetamine, caffeine
• Nonstimulant dopamine enhancers
• amantadine, bromocriptine, pramipexole,
  L-dopa/carbidopa
• Acetylcholinesterase inhibitors
• physostigmine, donepezil, rivastigmine,
  galantamine
• Antidepressants
• sertraline, fluoxetine, milnacipran (SNRI)
• Others
• CDP Choline, gangliosides, pergolide, selegiline,
  apomorphine, phenylpropanolamine, naltrexone,
  atomoxetine, vasopressin

Writer Schillerstrom, J Neuropsychiatry Clin
Neurosci 2009
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Cognitive Impairment

• May impede recovery
• haloperidol
• phenothiazines
• prazosin
• clonidine
• phenoxybenzamine
• GABAergic agents
• benzodiazepines
• Phenytoin
• carbamazepine
• phenobarbital
• idazoxan

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Aggression, Irritability, Impulsivity

• Up to 70 within 1 year of TBI
• May last over 10-15 years
• Interview family and caregivers, if possible
• Characteristic features
• Reactive - Explosive
• Non-reflective - Periodic
• Non-purposeful - Ego-dystonic
• Treat other underlying etiologies (e.g., bipolar)
• Treatment Medications and behavioral
  interventions

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Pilot study of sertraline (N15)Brief Anger /
Aggression Questionnaire (BAAQ)
Fann et al. Psychosomatics 2001 4248-54
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Aggression, Agitation, Impulsivity(none FDA
approved for this indication)

• Acute
• Antipsychotics (e.g., Quetiapine 25-50mg bid)
• Benzodiazepines (e.g., Clonazepam 0.5mg bid)
• Chronic
• Beta-blockers (e.g. propranolol may need up
  to 200mg/d in some cases, pindolol, nadolol)
• valproate, carbamazepine, gabapentin
• Lithium (narrow therapeutic window)
• buspirone
• Serotonergic antidepressants (e.g., SSRIs,
  trazodone)
• tricyclic antidepressants (e.g., nortriptyline,
  desipramine)
• Antipsychotics (esp. second and third
  generation)
• amantadine, bromocriptine, bupropion
• clonidine, methylphenidate, naltrexone, estrogen

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Non-Pharmacologic Interventions

• Behavioral Modification
• Based on operant learning principles, e.g.,
  managing environmental contingencies
• Require high degree of environmental control
  consistency therefore, difficult in outpatient
  settings
• Typically amplify or suppress behaviors, rathern
  than teach new responses to triggers or
  antecedents
• Psycho-educational (small RCT, N16)
• Based on Novacos Stress Innoculation Training
  (SIT)
• Based on CBT principles
• Heighten awareness of cognitive distortions that
  fuel inappropriate emotional reactions
• Teach more adaptive responses
• May be difficult for people with cognitive
  impairment
• Anger Self-Management Training (ASMT) Moss UW
  Study
• Based on Self-Care and Problem-Solving Training
• Improves awareness and ability to attend to anger
  signals
• Establishes new, constructive habits for coping
  with threat

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Treatment Insomnia

• Treat underlying etiology (e.g., pain, anxiety,
  depression, sleep apnea)
• Emphasize sleep hygiene, Cognitive Behavioral
  Therapy
• Medications often dependence-forming
• Benzodiazepines (fast-acting)
• lorazepam (Ativan), temazepam (Restoril),
  alprazolam (Xanax)
• Non-benzodiazepines
• short-acting zolpidem (Ambien), zaleplon
  (Sonata), ramelteon (Rozerem)
• Longer acting zolpidem CR (Ambien CR), Lunesta
• Antihistamines diphenhydramine (Benadryl)
• Antidepressants trazodone (Desyrel),
  amitriptyline

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Sleep Hygiene Principles

• Sleep/wake principles
• Maintain habitual bed and rise times
• Restrict time in bed
• Explore the usefulness / detriment of napping
• Environmental principles
• Ensure bedroom is sufficiently dark
• Minimize disturbing noise (use earplugs, if
  needed)
• Ensure bedding, temperature and airflow are
  consistent with quality sleep
• Ensure a nightlight does not illuminate the eyes
  while in bed
• Eliminate or place bedroom clocks so that they
  cannot be viewed from bed
• Eliminate other distractions, e.g., pets
• Diet and drug use principles
• Avoid rich food late in the evening
• Explore the usefulness of a late bedtime snack
• Try snacking on foods that promote sleep
• E.g., milk, bananas, turkey, cheese, peanut
  butter
• Avoid caffeine, alcohol and tobacco, esp. in the
  evenings
• Be aware that OTC and Rx medications may
  adversely affect sleep

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Proposed Model
TBI Severity ,-
Cognition

Functioning/ QOL
Neurosychiatric Symptoms
/-
TBI
Health Care Utilization
/-
Postconcussive Symptoms
Psychiatric Vulnerability
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The significant problems we face cannot be
solved at the same level of thinking we were at
when we created them
Albert Einstein