John D. Corrigan, Ph.D, ABPP
Professor at Ohio State University and Director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation. Editor-in-Chief, Journal of Head Trauma Rehabilitation.
Dr. Corrigan has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational or other activity other interests in any commercial companies pertaining to this educational activity.
CATR: A lot of patients struggling with addiction have a history of head trauma. How would I go about knowing whether the person had an actual traumatic brain injury (TBI)? Dr. Corrigan: The only way to know is to ask in a systematic way. You can’t count on behavioral manifestations or on seeing a scar on the head. It might be a quite remote injury; maybe one that was experienced in childhood, so there is really no substitute for asking. And it makes a difference how you ask. There have been several attempts in research and clinical practice to use questions like “Have you ever had a traumatic brain injury?” which is essentially asking the person to self-diagnose.
CATR: What approach do you recommend instead? Dr. Corrigan: There are standardized measures that you can use, including one we have developed called Ohio State University TBI Identification Method (OSU TBI-ID). It is available for free and includes online training (See: http://ohiovalley.org/tbi-id-method/).What we first do is ask about a lifetime history of injuries by reminding people about hospitalizations; emergency room visits; and times they fell, were in a fight, or in a car crash. All this to remind them of ways they might have gotten a TBI. And if they say, “Oh yeah, I had one of those injuries.” Then you say, “Now remember the bike crash you said you had in 8th grade, were you knocked out or did you lose consciousness from that?” So, you systematically interview to get at the data. It does sound a little long, but a typical administration of the OSU TBI-ID is about three to five minutes. So the bottom line is that you need to ask, and the way you ask makes a difference in terms of what you are going to find out.
CATR: What other sources of information do you find useful? Dr. Corrigan: Well, if you have collateral input from someone who knows the person then you can include them in the interview. And, of course, you can review medical records. You cannot trust medical records, however, because there are so many TBIs that are untreated or undocumented. And what we’re learning is that you should think about TBI less like a broken bone and more like lead paint. It is lifetime exposure that makes the difference, and we don’t really have medical records that go for your entire lifetime.
CATR: What about imaging or neuropsychological testing? Dr. Corrigan: They can be useful, but the thing to remember is that they have attenuated sensitivity. So a “yes” on one of those methods is a “yes.” but a “no” is actually a “maybe.” In other words, you can have a history that you should be concerned about along with a perfectly clean-looking MRI, fMRI, or even neuropsychological assessment. They are sensitive to more severe or specific kinds of injuries, but they don’t get the full lifetime exposure. The starting point really needs to be a systematic interview.
CATR: Could you tell us about the intersection with addiction—how common is TBI in people who misuse substances? Dr. Corrigan: We don’t have definitive general population rates, but several statewide surveys suggest that perhaps 20% of adults have had at least one TBI with loss of consciousness in their lifetime. In studies done in addiction treatment settings, that number is more like 50%. And the prevalence is greater among clients in higher levels of care. We did a large study in dual-diagnosis programs and found that 80% of those individuals had a history of TBI with loss of consciousness (McHugo GJ et al, J Head Trauma Rehabil 2016). And if you consider moderate and severe TBI, so at least 30 minutes loss of consciousness, then you’d expect a prevalence of 2% to 3% in the general population and about 20% in treatment settings—that’s one in five with at least moderate to severe TBI. Another issue is that if you have both addiction and TBI, then you can expect to have some other psychiatric disorders as well, which makes treatment even more complicated.
CATR: Is it fair to say that the relationship is bidirectional—that substance misuse can lead to trauma, and that, in turn, TBI is a risk factor for addiction? Dr. Corrigan: Systematic reviews have typically concluded that substance misuse leads to TBI. That’s because if you take a population of folks who are in treatment for TBI, there’s a large number who have had substance misuse prior to that. And it’s because intoxication leads to injury, and there is evidence that the more intoxicated the person is at the time of an injury, the more likely it is to involve a TBI (Savola O et al, Alcohol Alcohol 2005;40(4):269-273). So, no question, misusing substances leads to TBI. And we have some of the population data I mentioned comparing general population rates to persons in addiction treatment, and once you see substance use kicking in, the prevalence rates just skyrocket. So that direction is pretty much unequivocal.
CATR: What about the other direction—TBI leading to addiction? Dr. Corrigan: The other direction has been harder to get our arms around. For one, there are folks who have a bad injury and stop drinking. They are scared out of it or have insight into what it can mean. Plus, you have folks whose injury is so devastating that they may be in an environment where they don’t have easy access to alcohol or drugs. A very interesting part of this question involves looking at childhood TBI and whether or not that may predispose to adult substance misuse. This has been demonstrated in animal studies, and eventually led us to start looking at human data—and there are similar trends in some birth cohorts and large population studies that are finding this relationship between childhood injury and adult substance misuse.
CATR: Very interesting. Do we know the reasons for this predisposition? Dr. Corrigan: There are a couple of plausible mechanisms. One is neuroinflammation, which is a natural and needed response to acute injury. But that heightened inflammatory state can persist beyond the short term. This is something that is observed in all neurotrauma, not just TBI, and it may be part of what triggers later consequences, like a predisposition to drinking alcohol, which then helps the inflammatory state persist (Weil ZM & Karelina K, Front Behav Neurosci 2017;11;135). So, it ends up being kind of a vicious cycle.
CATR: What about the neuropsychiatric consequences of TBI—can they also be a factor in why people misuse substances? Dr. Corrigan: Yes. TBI can lead to the disruption of the dopaminergic circuitry that plays a part in the development of addiction. And there’s also a mechanical effect. What is sometimes not known about TBI is that wherever the blow to the head comes, there typically is contusion in the frontal areas. And that’s because once you get enough force that the brain is essentially jiggling within the cranial vault, there is a tendency to scrape across some of the bony ridges in the frontal areas. You also get heightened shearing and tearing in the dense circuitry going from the midbrain and basal ganglia to the frontal lobes. So the frontal lobes are particularly vulnerable, which has a lot to do with not being able to put the brakes on impulsive or disinhibited behavior, and may predispose the person to misuse substances.
CATR: It seems that this may impact treatment, which often is about restoring those brakes. Dr. Corrigan: Yes, and one of the reasons to screen for TBI in addiction treatment is that it provides another hypothesis about possible causes of behaviors. So, if you know somebody has a history of TBI then you might be looking for problems around attention or processing speed or initiation or impulsivity. And one of my takeaways from years of working in addiction and TBI is that, compared to others in addiction treatment, patients with TBI have a greater disconnect between intention and actual behavior change. Obviously, there is a disconnect for everybody or we wouldn’t have so many people in treatment for addiction. But the distance from the intent to change behavior and actual successful behavior change is a bigger for clients with TBI.
CATR: Sounds like this can explain why patients with TBI drop out of treatment. Dr. Corrigan: True. And if you look at it from the providers’ side they will say “They’re not compliant.” If you ask the patient, they will say, “They don’t get me.” And I think there are reasons for that. For one thing, we underestimate that treatment has a cognitive load. Whether that’s something as simple as participating in groups where there are multiple people to pay attention to or being able to keep something in your head while somebody else is talking. And there are a lot of didactics in treatment, without much attention to the person’s learning capacity.
CATR: What are practical ways to address this problem? Dr. Corrigan: One of the things that we do in our program is to insert people we are working with into the right levels of care and educate their clinicians about TBI. We will get a patient into an IOP, for example, and the second or third day they don’t show up or show up late, and the staff ream them for not being motivated. Well, if you have a neurologic injury, missing or being late could be because you forgot to set an alarm, or you weren’t organized enough to make your bus. In brain injury rehab, we expect people to miss appointments, so we look for ways that we can assure they attend, like using reminders or setting an alarm in a calendar on their phone. What we look at is as a neurologic issue. While in addiction treatment, it’s often looked at as a psychological or motivational issue. This happens so frequently that we try to immunize staff against it. If we know that a patient is disorganized or has a tendency to be hyper-verbose, we try to get staff ready for those behaviors, so they are treated as neurologic, not just psychologic issues.
CATR: That’s very interesting. What techniques can clinicians use to work with these neurologic aspects? Dr. Corrigan: We end up having the conversation so often that we’ve developed a reference booklet for addiction clinicians and any professionals working with persons with TBI (See: http://ohiovalley.org/informationeducation/accommodatingtbi/). Basically, it helps you recognize some of these executive function impairments and then gets you thinking about ways you might accommodate them, either in the relationship or in your treatment planning. For instance, some of the simple things we suggest the counselor try with clients who have attention problems is to use short communications, ask the client to summarize what they just heard, or use written cues. These accommodations add to the skill set of the provider to be able recognize some of these neurologic deficits and then have some ideas about how to compensate.
CATR: This is a very hands-on approach. Do you also recommend engaging the family and other supports to compensate for the patient’s deficits? Dr. Corrigan: Yes, definitely. One of my rules of thumb is that the more severe the brain injury, the less you can count on insight alone resulting in success, and the more you have to use other tools for that individual. So, the professional should think about environmental factors like family, living situation, and relapse prevention medications (though disulfiram is best avoided in people who might impulsively drink on it). Another part of this is that the more severe the brain injury the more time is required for cravings to subside. It simply is going to take longer before you can be confident that the person with TBI is not going to relapse. And, again, that’s because their insight alone will not assure abstinence. Their conscious commitment to sobriety may be just as good as the person beside them without TBI; but, they are going to be more vulnerable to relapse and have more problems staying sober for a longer time. The professionals must assist them to put more supports in place, like medication, family, living environment, and time.
CATR: Can this knowledge about TBI lower frustration among clinicians? Dr. Corrigan: I think that when clinicians start to recognize that behavior can come from a neurologic basis, not just a psychological basis, their frustration level does go down. For instance, it’s not uncommon that a person with a brain injury can be overly talkative, which can be a problem in a milieu-based treatment setting. Hyper-verbosity can bring out the worst in that environment. And not only will the therapist become frustrated because the client is dominating group time, but the other clients can become frustrated as well. Throw in a little social disinhibition and it’s easy to see why clients with TBI often get into trouble in treatment settings. But just knowing that this behavior has a neurological source makes hyper-verbosity something to be dealt with therapeutically, not to become frustrated with. It’s important that the professional know it is not going to offend a person by pointing out these behaviors—indeed, professionally delivered feedback is often welcome. It is a problem if professionals say nothing and come to the conclusion that the client is doing something intentionally to be irritating.
CATR: You mentioned that groups can be challenging in patients with TBI. Is there a way around this issue? Dr. Corrigan: In this day and age, if you say no groups then you’ve really limited a person’s access to treatment. There also are benefits of groups, such as hearing other peoples’ stories and getting peer feedback. There are simple things you can do to accommodate the person with brain injury in group treatment. I generally recommend that there be some post-group processing, even brief, just to say to the client with a TBI, “Here are the big things I saw go on in the group today. What did you see?” And, if there’s homework, seeing if they’re using some compensatory strategy to remind themselves, like writing it down or putting a reminder in their phone. So, it doesn’t take much, and these strategies are more about an informed and creative therapist who can do a lot for somebody with TBI without expensive bells and whistles.