VISN 6 MIRECC: Mental Illness Research, Education, & Clinical Center Robin A. Hurley, MD, FANPA Professor, WFUSM Katherine H. Taber, PhD, FANPA Professor, VCOM Disclaimer: The views expressed in this session are strictly those of the presenters (RAH & KHT). They do NOT represent those of the Veteran’s Health Administration, the Department of Defense, or the United States Government. Windows To The Brain: Neuropsychiatry of Brain Injury
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VISN 6 MIRECC: Mental Illness Research, Education, & Clinical Center Robin A. Hurley, MD, FANPA Professor, WFUSM Katherine H. Taber, PhD, FANPA Professor,
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VISN 6 MIRECC:Mental Illness Research, Education, & Clinical Center
Robin A. Hurley, MD, FANPAProfessor, WFUSM
Katherine H. Taber, PhD, FANPAProfessor, VCOM
Disclaimer: The views expressed in this session are strictly those of the presenters (RAH & KHT). They do NOT represent those of the Veteran’s Health Administration, the Department of Defense, or the United States Government.
Windows To The Brain: Neuropsychiatry of Brain Injury
•Neuropsychiatric symptoms in TBI
•Functional anatomy of emotion, memory, and behavior circuits as it relates to TBI
•VA Polytrauma system of screening, care, and clinical practice guidelines
•Current assessment and treatment advice for TBI-PTSD within VA
•Current VISN 6 MIRECC projects and suggestions for the future
Today’s Discussion
Reported TBI in DoD
TBI Exposures entering VA Healthcare System
15%-20% entering VHA have + TBI screen (Carlson et al, 2010; Pietrzak et al, 2009)
April 2007 - FY2009, 66,023 Veterans identified as possibly having a TBI through outpatient screening of individuals presenting to VA from OIF/OEF. Of those screened positive, 24,559 were confirmed to have sustained a TBI (37%). (Veteran’s Health Initiative: Traumatic Brian Injury, released April 2010. http://www.publichealth.va.gov/docs/vhi/traumatic-brain-injury-vhi.pdf)
Neuropsychiatry post-TBI: What do we see in clinic?
• Impulsivity: common reason family brings patient to MD
• Disinhibition: no “filter” on thoughts or actions (misses social cues)
• Balance/dizziness/vertigo
• Headaches
• Visual changes
(e.g. sensitivity to bright lights, decreased accommodation, convergence, and reading, oculomotor dysfunction )
• Memory/cognitive deficits
• Irritability and aggression
• Sleep disturbances
• Ringing in ears/decreased hearing• Substance Abuse
• Partial Complex Seizures (especially frontal)
• Verbal and social interactions & history of physical aggression• Substance abuse, cognition, and living environment• PTSD and chronic pain
• Imaging when history and clinical presentation do not match
Dilemma Clinicians Now FaceDilemma Clinicians Now Face
• No treatment trials with FDA approved medications for co-morbidities
• Current guidance: separate Clinical Practice Guidelines Management of Post-traumatic Stress Management of Concussion/mild Traumatic Brain Injury Pain Management Directive 2009
• Clinicians needed information to guide clinical practice for co-morbidities
• TBI-PTSD Consensus Conference held to provide clinical guidance to the field.
www.ptsd.va.gov
2009 Practice Recommendations for the Treatment of Veterans with
Co-morbid PTSD, mild TBI, and Pain:
SystemsSystems
EducationEducation
Assessment/Assessment/TreatmentTreatment
Coordinate careProvider incentives Use of resources
• New Evidence-Based Synthesis Report – Assessment and Treatment of Individuals with History of TBI and PTSD (August, 2009) at www.hsrd.research.va.gov/publications/esp/
• PTSD and mild TBI online course at www.ptsd.va.gov
• Information about exemplary programs such as Phoenix, San Diego, and Salisbury available.
• MIRECC’s and Centers of Excellence at www.mirecc.va.gov
Our MIRECC is organized as a translational medicine multi-site center focused on post deployment mental health issues. The overarching goals are improving clinical assessment and treatment and development of novel interventions through basic and clinical research.
Research labs include: imaging, neuroscience, neuropsychology, genetics, epidemiology/health services, and clinical interventions.
Research and Clinical hubs are located at the Durham VAMC
Education hub is located at the Salisbury VAMC
Objectives:
Investigations of tissue-level mechanisms of primary blast injury through modeling, simulation, neuroimaging & neuropathological studies
JIEDDO, $800,000 annually 2007-2010, Collaboration with MITKatherine Taber and Robin Hurley, VISN 6 MIRECC
Elucidate tissue and cell-level brain injury mechanisms due to primary blast effects
Develop validated models of brain response to blast informed with realistic tissue mechanical properties
Correlate simulations with neuroimaging and clinical studies on returnees and derive blast TBI injury criteria including pertinent metrics and thresholds.
Effects of feeling Dazed and Confused
• Whole brain analysis of primary and crossing fibers measures of white matter integrity.
• Widely distributed pattern of white matter differences between mild TBI and non-TBI control group.
• Significant association of duration of LOC and feeling dazed and confused with white matter integrity
• PTSD did not modulate white matter integrity
• Post-9/11 veterans with mild TBI (n=30) and controls (n=42)
• Clinical variables :
• Age
• PTSD
• Number of TBI events
• Duration of loss of consciousness (LOC)
• Feeling dazed and confused
• Posttraumatic amnesia
Effects of mild TBI and PTSD on white matter integrity in post-9/11 veteransRaj Morey, VISN 6 MIRECC
Morey et al, 2011, under review
RESULTS
y=20 y=-20 y=-40 y=-60 y=-80y=0
y=40 y=20 y=0 y=-20 y=-40
y=40 y=20 y=0 y=-20 y=-60y=-40 y=-80
Effects of Loss of Consciousness
TBI vs. controls
y=20 y=-20 y=-40 y=-60 y=-80y=0
y=40 y=20 y=0 y=-20 y=-40
y=40 y=20 y=0 y=-20 y=-60y=-40 y=-80
Effects of Loss of Consciousness
TBI vs. controls
Magnetoencephalography (MEG) in PTSD and TBIJared Rowland and Jennifer Stapleton, VISN 6 MIRECC
Dwayne Godwin, WFSM
• Neurocognitive sequelae of mTBI and PTSD.
• MEG investigation of effects of PTSD on inhibitory processes and decision making.
• Individual and interactive effects of time and probability on the discounting of rewards.
• Cognitive processes associated with impaired decision making with & without blast related TBI.