Psychiatric Problems Following TBI

Jesse R. Fann, MD, MPH

Departments of Psychiatry and Behavioral Sciences, Rehabilitation

Medicine, & Epidemiology

University of Washington

Seattle, Washington

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

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)(Hamm et al 2000; Hayes & Dixon 1994)

Non-penetrating TBI

Diffuse Axonal Injury

Contusion

Subdural Hemorrhage

Taber et al 2006

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

Mayberg et al, J Neuropsychiatry Clin Neurosci

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

Psychiatric Illness in Adult HMO Enrollees (N=939 with TBI, 2817 controls)

0.000.100.200.300.400.500.600.700.800.90

0.000.100.200.300.400.500.600.700.800.90

6 12 18 24 30 36 6 12 18 24 30 36Month

Pred

icted

Cum

ulat

ive In

ciden

ce

Psychiatric Illness by TBI*nonemild

mod./severe

No Prior Psychiatric Illness Prior Psychiatric Illness

* Predicted proportions for a women of age 40-44 with median index month (6), median log cost and no comorbid injuries

Fann et al. Arch Gen Psychiatry 2004; 61:53-61

Psychiatric Disorder & MTBI

02468

101214161820

MDD GAD Agora PTSD Social Ph Panic

MTBI

No TBI

Bryant et al., Am J Psychiatry, in press

Neuropsychiatric Sequelae

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

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

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

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

Neuropsychiatric HistoryPsychiatric 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

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

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

Delirium• Identify and correct underlying cause

– TBI increases a person’s 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

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 2000;12:316-327

DSM-IV Major Depressive Disorder (MDD)1. Depressed mood*

2. Loss of interest/pleasure*

3. Sleep disturbance

4. Poor energy

5. Motor change agitation or slowness

6. Weight/appetite change increase/decrease

7. Impaired concentration or indecision

8. Excessive worthlessness or guilt

9. 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

Transdiagnostic SymptomsTBI

1. Depressed mood

2. Anhedonia

3. Weight loss/gain

4. Insomnia/hypersomnia X

5. Psychomotor changes X

6. Fatigue X

7. Worthlessness/guilt

8. Poor concentration X

9. Thoughts of death/suicide

Patient Health Questionnaire - 9 Over the last 2 weeks, how often have you been bothered by any of the

following problems?Not at all

Severaldays

Morethan

half thedays

Nearlyevery 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

Rates Of Major Depression After TBI

N = 559

53%

Point Prevalence of MDD

Range 21-31%, no trend

Cumulative Rate of MDD as a Function of Depression History

73%*69%*

41%

*P < .001; independent predictors after adjusting for all other variables

Rate of MDD by History of Lifetime Alcohol Dependence

70%*

45%

*P < .001; independent predictor after adjusting for all other variables

Cumulative Rate of MDD by PTSD History

51%

81%

Univariate predictor, not significant after adjusting for other variables

Comorbidity of Anxiety and MDD

1

27

6

54

0

10

20

30

40

50

60

70

80

90

100

Cu

mu

lati

ve

Pe

rce

nt

Panic Disorder Other Anxiety Disorder

MDD-

MDD+

Any comorbid anxiety disorder in MDD+ vs. MDD- (60% vs. 7%; RR, 8.77; CI, 5.56-13.83)

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

Number of Postconcussive

Symptoms 7

3.93.5

2.2

0

1

2

3

4

5

6

7

# of symptoms

All symptoms Depressive symptoms excluded

Current Depression No current Depression

* p=.05

*All symptoms * Depressive symptoms excluded* p=.05

PCS – Depression Study(Baseline and Week 8)

0 2 4 6 8 10 12 14 16

Headache

Dizziness

Blurred Vision

Bothered by Noise

Bothered by Light

Loss of Temper

Fatigue

Trouble Concentrating

Irritability

Memory Difficulties

Anxiety

Sleep Disturbance

Improving

Worsening

Same

**

**

*

*

**p<.05**p<.01

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

Modifiable Risk Factors

NeurobiologicalFactors

CognitiveDistortions

No PleasantActivities Sedentary LifestylePsychosocial

Adversity

Depression

LifeImprovement Following Traumatic Brain Injury:A Trial of Cognitive-Behavioral Therapy for Depression after TBI

Charles H. Bombardier, PhDSteven Vannoy, PhDPeter Esselman, MDKathy Bell, MDNancy Temkin, PhD University of WashingtonEvette Ludman, PhD Group Health Research Inst

Jesse R. Fann, MD, MPHDepartments of Psychiatry & Behavioral

Sciences and Rehabilitation Medicine

School of MedicineDepartment of EpidemiologySchool of Public HealthUniversity of Washington

Reason Accommodations

Slowed information processing & responding

Present information at slower rate Allow client more time to respondProvide written summary of session beforehand

Impaired attention & concentration

Minimize environmental stimulation and distractions during sessionFocus on one topic at a time, Use shorter sessionsAvoid 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 therapyProvide care management activities aimed at return to work, school or other meaningful roles and finding effective rehabilitation resources

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 2000;12:316-327

Mania• Acute

– Benzodiazepines– Antipsychotics

» olanzapine, risperidone, quetiapine, clozapine– Anticonvulsants

» valproate – Electroconvulsive Therapy

• Chronic– valproate – carbamazepine – lamotrigine – lithium carbonate (neurotoxicity)– gabapentin, topiramate (adjunctive treatments)

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

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

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.

Rates of Anxiety Disorders (civilians)

Anxiety• Often comorbid with and prolongs course of

depression in TBI

• Posttraumatic Stress Disorder: Prevalence 14.1% *– Reexperience, Avoidance, Hyperarousal

– > 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 2000;12:316-327

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.

PTSD Criteria

CLUSTER A: StressorA. Experience/witness threatB. Respond with fear/helplessness*

CLUSTER B: ReexperiencingAt least 1 of:• A. Intrusive memories*• B. Nightmares*• C. Flashbacks*• D. Psychological distress to reminders*• E. Physiological reactivity to reminders*

PTSD Criteria (cont’d)CLUSTER C: AvoidanceAt least 3 of:A. Avoid thoughts, feelingsB. Avoid places, activities -----------------------------------------C. Dissociative amnesia*D. Diminished interestE. Detachment from othersF. Restricted affect*G. Foreshortened future

CLUSTER D: ArousalAt least 2 of:A. Sleep disturbance*B. Anger*C. Concentration difficulties*D. HypervigilenceE. Elevated startle response

PTSD Criteria (cont’d)

CLUSTER E: Symptoms last at least 1 month

CLUSTER F: Causes impairment

CLUSTER H: Not due to medical condition or substance abuse*

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

Psychiatric Disorder & Prior Sleep Problems

Bryant et al., Sleep, in press

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

Interface of PTSD & Persistent PCS

Stein & McAllister, AJP 2009

Brain regions implicated in PTSD and vulnerable to TBI

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

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

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.

Generalized Anxiety DisorderA. Excessive anxiety and worry, occurring more days than not ,

for at least 6 months, about a number of events of activitiesB. Difficult to control the worryC. 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 impairmentF. Not due to substance or general medical condition and does

not occur exclusively during a Mood, Psychotic, or Pervasive Dev Disorder

AnxietyMedications

• 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

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 2000;12:316-327

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)

Cognitive Impairment• Common problems after TBI

– Concentration and attention– Memory– Speed of information processing– Mental flexibility– Executive functioning– Neurolinguistic

• Association with Alzheimer’s Disease suggested• Cognitive Rehabilitaiton may help• May be associated with other psychiatric syndromes (e.g.,

depression, anxiety, psychosis) – treating these may improve cognition

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

Cognitive ImpairmentMay impede recovery

haloperidolphenothiazinesprazosinclonidinephenoxybenzamineGABAergic agentsbenzodiazepinesPhenytoincarbamazepinephenobarbitalidazoxan

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

Pilot study of sertraline (N=15)Brief Anger / Aggression

Questionnaire (BAAQ)

01234567

89

10

baseline week 8

p=.05

Fann et al. Psychosomatics 2001; 42:48-54

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

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, N=16)– Based on Novaco’s 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

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

Sleep Hygiene PrinciplesSleep/wake principles• Maintain habitual bed and rise times• Restrict time in bed• Explore the usefulness / detriment of nappingEnvironmental 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., petsDiet 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

Proposed Model

TBI

PsychiatricVulnerability

PostconcussiveSymptoms

Cognition

NeurosychiatricSymptoms Health Care

Utilization

Functioning/QOL

+

+/-

+/-

TBI Severity+,-

“The significant problems we face cannot be solved at the same level of thinking we were at when we created them”

Albert Einstein