Table Of ContentNeuropsychological Management of
Mild Traumatic Brain Injury
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Neuropsychological
Management of
Mild Traumatic
Brain Injury
Edited by
SARAH A. RASKIN, PH.D.
Department of Psychology and Neuroscience Program
Trinity College
Hartford, Connecticut
CATHERINE A. MATEER, PH.D.
Department of Psychology
University of Victoria
Victoria, British Columbia
Canada
New York Oxford
OXFORD UNIVERSITY PRESS
2000
Oxford University Press
Oxford New York
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Copyright © 2000 by Oxford University Press, Inc.
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All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
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without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Raskin, Sarah A.
Neuropsychological management of mild traumatic brain injury /
Sarah A. Raskin, Catherine A. Mateer.
p. cm. )
Includes bibliographical references and index.
ISBN 0-19-508527-2
1. Brain damage—Patients—Rehabilitation.
2. Clinical neuropsychology.
I. Mateer, Catherine A. n. Title.
[DNLM: 1. Brain Injuries—rehabilitation. 2. Brain Injuries— complications.
3. Brain Injuries—psychology.
WL 354 R225n 2000] RC387.5.R37 2000 617.4'81044—dc21
DNLM/DLC for Library of Congress 99-13808
1 2 3 4 5 6 7 8 9
Printed in the United States of America
on acid-free paper
To Brian and Julian
SR
To Kim
CM
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Preface
This book is intended for use by rehabilitation professionals, including
neurologists, psychologists, neuropsychologists, counselors, speech
pathologists, occupational therapists and physical therapists, and voca-
tional counselors who are already familiar with the sequelae and treat-
ment of various forms of brain injury. Its aim is to present guidelines for
the application of rehabilitation techniques to the cognitive and emotional
effects of mild traumatic brain injury (MTBI). It is not intended to be an
academic review of either MTBI or cognitive rehabilitation; many such
works are already in print. Instead, we believe there is a need for a clear,
pragmatic guide to the actual practice of rehabilitation with this popula-
tion.
The techniques and approaches we describe are derived from the lit-
erature and from our own experience in working with individuals who
have sustained MTBI. We have focused on theories and strategies of treat-
ment that are well-founded in research. This has been a challenge as the
great majority of research in the area of MTBI is on issues related to as-
sessment rather than treatment.
Preparation of a book about treatment strategies has also been chal-
lenging in light of the pervasive questions about the nature and origins
of persistent symptoms after what appear to be relatively mild injuries.
We take no exception to the well-documented finding that the great ma-
jority of individuals who sustain MTBI go on to make essentially full re-
covery and return to their former levels of work, daily living, and leisure
activity. It is equally well-documented, however, that a small minority of
individuals who sustain MTBI, estimated from between 5 and 20 percent,
do not make full recovery and report disruptive symptoms for many
months, or even years, after injury. While the reasons for this are un-
doubtedly multifaceted, there are no simple explanations that can account
for the findings across all affected individuals. Possible explanations in-
clude more severe injury than was initially diagnosed, MTBI complicated
by other injuries, or greater individual vulnerability. Many of these indi-
viduals have been shown to benefit from structured rehabilitation pro-
grams that address changes in cognitive ability, alterations in mood, and
vii
viii Preface
problems with adjustment and reintegration to home, work, and social
activity. It is for these individuals that this book is intended.
We acknowledge that, in some cases, symptoms seen after accident or
injury are exaggerated in response to various forms of conscious and un-
conscious secondary gain. We support careful evaluation and diagnosis
to identify such situations. While overt malingering is not a target for
treatment, psychologists and other rehabilitation professionals can play
an important role in working with individuals who are demonstrating
conversion or psychosomatic disorders. Careful investigation of the na-
ture of persistent symptoms following MTBI is necessary and applauded,
failure to find convincing "organic" underpinnings has too often resulted
in a minimization of the need to develop effective interventions to assist
affected individuals. Indeed, acknowledgment of psychological correlates
of the disorder should not cause rehabilitation specialists, and especially
psychologists to abandon efforts to provide effective interventions.
This book is intended to be an integrated guide to dealing with both
cognitive and emotional sequelae, and with the beliefs about and reac-
tions to these sequelae that often serve to exacerbate and maintain these
sequelae. Presenting symptoms are commonly cognitive and physical in
nature but often are shaped by depression, anxiety, frustration, and feel-
ings of anger. In assessment, there is usually an attempt to dissociate these
various factors and to identify specific impairments in different cognitive
and emotional domains. This is appropriate and useful in the diagnostic
process but may be only partially valid in treatment. Cognitive and emo-
tional factors interact with each other and with the injured person's own
history, background, personality, and social context. While we have writ-
ten separate chapters on specific cognitive and emotional domains, we
recognize their complex interactions and the need to address these inter-
actions in treatment. The rehabilitation specialist and/or team working
with individuals who have sustained MTBI should be versed in or have
available an eclectic mix of treatment strategies.
Throughout the book we have tried to provide enough theory, infor-
mation, and case examples so that trained professionals can begin to un-
derstand and use the intervention techniques in their practices. As will
be emphasized throughout, these techniques work best when individu-
alized for each client. This can be done with regard not only to the indi-
vidual's unique constellation of cognitive and emotional strengths and
deficits, but also to their life experiences, goals, and interests. The form,
time frames, and settings for rehabilitation of individuals with MTBI need
to be variable and flexible.
Each chapter follows approximately the same general format. First,
there is a review of the relevant theories and research findings for the var-
ious cognitive and emotional processes with respect to MTBI. This is fol-
lowed by suggestions for assessment, including questionnaires and stan-
dard neuropsychological and psychological measures. The primary focus
Preface ix
of each chapter will be on treatment strategies, augmented by case ex-
amples and treatment materials. Materials can be copied or adapted as
appropriate to the reader's setting.
The first section of the book deals with concepts of MTBI and its ef-
fects, neurological and medical aspects, and assessment. Chapter 1 gives
an overview of various factors that may contribute to persistent disabil-
ity following MTBI and their interactions. Problems of definition and di-
agnosis are discussed. Chapter 2, written by a neurologist, covers med-
ical aspects of the syndrome, including visual and vestibular disturbances,
headache, and chronic pain. It provides information on the diagnosis of
physical signs and symptoms and on current treatment approaches. Chap-
ter 3 focuses on issues of assessment, and includes a discussion of vari-
ous challenges in the selection and interpretation of assessment tools in
this population. The chapter stresses issues in the assessment of cognitive
and emotional functioning and includes a discussion of problems related
to assessment of motivation and symptom validity.
The next section deals with cognitive symptoms common to individu-
als with MTBI. The chapters are divided by type of cognitive process—
attention, memory, and executive functions. Research has shown that each
of these areas is commonly affected by MTBI. Each chapter begins by re-
viewing the relevant research literature and then discusses specific treat-
ment strategies. These include techniques for demonstrating generaliza-
tion of training to everyday activities. The strategies we describe represent
a mix of process-specific interventions, compensation strategies, and psy-
chological interventions to assist clients in gaining a sense of mastery and
control over their cognitive performance.
The next section of the book addresses the emotional sequelae of MTBI.
It begins with a discussion of principles of psychotherapy that empha-
sizes how they can be used with this population. The following four chap-
ters cover management strategies for dealing with depression, anxiety,
and irritability and anger. They review relevant research on MTBI in each
of these emotional domains. The treatment strategies presented are eclec-
tic but for the most part build on empirically validated cognitive behav-
ioral principles and strategies.
Posttraumatic stress disorder is far more prevalent in individuals with
MTBI than in those with more severe brain injuries, and its evaluation
and treatment are discussed in the chapter on anxiety disorders. The chap-
ter on irritability and anger points out the subtle interactions between
brain injury, which often results in diminished self-control, and the emo-
tional response, manifested in frustration, blame, and diminished coping
ability.
Chapter 11 deals with the effects of MTBI on work performance and
discusses the critical elements of vocational rehabilitation in this popula-
tion. Vocational outcomes are reviewed with emphasis on integrating vo-
cational skills and skill training with other areas of rehabilitation.
