Brain injury may go undetected

Prevalence of a traumatic brain injury (TBI) among individuals in the substance use treatment population has been estimated to be as high as the 60% range in some research studies. Yet in the real world of clinical practice, the complexities around diagnosing TBI and differentiating it from other disorders often make it difficult for professionals to isolate the effects of a disorder that threatens to sabotage progress in addiction treatment.

“We're not asking the right questions,” says Bryon Adinoff, MD, professor of alcohol and drug abuse research at the University of Texas Southwestern Medical Center and a staff psychiatrist at the VA North Texas Health Care System. “There is no good agreement on what is the best way to diagnose TBI. The findings can be very subtle; you might not see them on an MRI.”

Adinoff says that unlike the case with substance abuse assessment, where professionals have several validated questionnaires at their disposal, the healthcare community still is looking for effective screening tools for TBI. One of the mental health colleagues at his institution recently sent him a screen that the school is looking closely at, he says.

UT Southwestern now also houses the Texas Institute for Brain Injury and Repair, an entity that has received millions in state funding to explore what happens when the brain is damaged and how it can be fixed.

Undiagnosed TBI certainly “could be getting in the way of substance abuse treatment,” says Adinoff, primarily because a key component of substance abuse treatment involves the patient's ability to abstract ideas and concepts related to their illness and recovery.

Bidirectional relationship

Comorbidity of a substance use problem and TBI can be common in part because the presence of each one can increase the risk of incurring the other. “People with brain damage have problems with impulsivity, and that poses a risk factor for using a legal or illegal drug,” says Adinoff. “That creates a problem for first use, problem use, or continued use.”

According to a 2010 substance abuse treatment advisory from the federal Center for Substance Abuse Treatment (CSAT), there is evidence that TBI, especially when the brain's frontal cortex is affected, may generate deficits in cognitive processes that exacerbate the risk of problematic substance use.

On the other hand, substance abuse also makes an individual a likelier candidate to sustain a brain injury from an accident or a physical altercation with another person, says Adinoff.

The CSAT treatment advisory, Treating Clients with Traumatic Brain Injury, states, “Brain imaging studies and neuropsychological testing indicate that [a substance use disorder] and TBI compound the negative effects each has on brain structure and function. A substance abuse history is associated with worse outcomes from TBI including greater likelihood of mortality, complications, and poorer hospital or emergency department discharge status, as well as ongoing disability and nonproductivity a year or more after brain injury.”

Yet assessment remain challenging when it comes to differentiating TBI from other conditions where symptoms can appear similar. “They used to ascribe to [post-traumatic stress disorder] a lot of what is now seen as part of TBI,” Adinoff says. Variability in cognitive deficits can point to a number of possible causes.

“Something that is diagnosed as bipolar disorder could actually be affective disturbance due to brain trauma,” Adinoff adds.

Counselors' role

Adinoff says that if an addiction treatment program or clinician suspects that a patient might have a brain injury, an appointment to obtain an MRI and/or visit a neurologist should be pursued for that patient. The CSAT advisory states that some of the substance use patient behaviors that could be most indicative of TBI include consistent failure to complete tasks, lack of interest, inappropriate social behavior, lack of self-awareness, and frequency of irrelevant statements in one's speech. Again, however, many of those issues also can be manifestations of problems other than brain injury.

The publication suggests direct, simple questioning to the patient if TBI is suspected, with queries such as, “Have you ever been knocked out?” or “Did you lose any memory after being hit?”

The advisory recommends a number of possible approaches counselors can take to assist substance use treatment clients with TBI-related limitations. These include:

• Creating a low-stimulus counseling environment with frequent rest breaks, and repetition of information in concise segments.

• Facilitating recovery from TBI by communicating an overall positive message to patients. “The client who is frustrated and discouraged can be helped by knowing that the head will continue to 'clear' and his or her ability to adhere to the recovery plan will improve with time and practice,” the advisory states.

• Emphasizing the importance of abstinence from substances to avoid the damaging cognitive and emotional consequences of a relapse.

• Encouraging patients to join a support group for individuals with TBI, or establishing an in-house group or pairing patients with peer mentors who also have experienced the illness.

• Offering modest incentives, such as small gift cards, to individuals in order to encourage completion of intake, early attendance in treatment, or treatment retention.

• Supporting the patient's building of effective coping skills by incorporating factors such as humor and enjoyable activities into the overall treatment process. These efforts are seen as assisting the patient in coping with the distress that comes with decreased functional ability.