Traumatic Brain Injury: Definition, Classification, and Management
We hear a lot about traumatic brain injury (TBI) nowadays: among NFL players (as in the movie ‘Concussion’), and as a signature diagnosis among recent combat veterans. What doesn’t get as much press coverage is the impact of TBI on those suffering from addiction. Having an alcohol or other substance use disorder greatly increases the risk of TBI. But what is TBI? How do I diagnose it? How does it manifest? How do I manage it?
Although there is no universally accepted definition for TBI, recently updated guidelines from the Department of Veterans Affairs (VA/DoD Clinical Practice Guideline for the Management of Concussion-mild Traumatic Brain Injury, 2016; https://tinyurl.com/y8e6owdx) state that a TBI is an injury to the brain caused by an external force accompanied by one of several clinical signs following the event). These signs can be an intracranial lesion, loss of consciousness, amnesia, confusion, slowed thinking, muscle weakness, sensory loss, or another neurological deficit. The severity of a TBI (mild, moderate, or severe) is determined by the symptoms immediately following the injury (see the VA TBI severity table below). If the patient meets different ratings for the different criteria, go with the more severe rating. The lay term “concussion” equates to a mild TBI. In addition to the neurological symptoms, patients may experience cognitive problems affecting their attention, memory, processing speed, and executive function. Mental health effects include irritability, impulsivity, depression, and anxiety. However, these symptoms can be an effect of the TBI or part of a comorbid, major depressive disorder, posttraumatic stress disorder (PTSD), or substance use disorder.
Table: Classification of TBI Severity
Assessment and treatment
But what symptoms should I really be concerned about? For any TBI that is associated with progressively declining neurological function or worsening headache, pupil asymmetry, seizures, intractable vomiting, ongoing disorientation or neurological deficit, slurred speech, or new bizarre behavior, you should immediately refer for emergency evaluation.
The good news is that the vast majority of mild TBI cases resolve without any intervention. It’s important for the physician to provide education and reassurance to the patient and family. Any interventions should be tailored to the specific symptoms while reinforcing good sleep hygiene, relaxation techniques, and limiting use of caffeine, tobacco, and alcohol. Return to normal functioning at work or school should be encouraged in a gradual, monitored fashion. Patients with a TBI who report ongoing symptoms need appropriate referral and a comprehensive treatment plan (Silver JM et al, Textbook of Traumatic Brain Injury, American Psychiatric Publishing, Inc; 2nd ed;2011).
Cognitive rehabilitation therapy (CRT)
You may have heard of cognitive rehabilitation therapy (CRT) as a treatment for TBI. But what exactly does it involve? And does it work? After a TBI there may be functional deficits that are both physical and mental in nature. CRT is a therapeutic process structured to improve the patient’s functioning in their daily lives. Patients are first guided through recognizing their strengths, weaknesses, and what deficits they want to improve. Then techniques are relearned when possible (solve the problem), or compensatory strategies are identified (work around the problem). The last step is to incorporate these relearned or new skills into daily life. This process can be applied to both physical and cognitive deficits that arise from a TBI.
CRT sessions should be tailored to the individual but most incorporate memory compensation techniques. Such techniques include having the patient write down at each session what was important to them, then reviewing their notes and memory of what was said during the next session. This method not only increases their participation in the therapy sessions but teaches them how to use the memory compensation techniques in their daily lives.
The evidence for CRT after stroke and moderate to severe TBI has long been established, showing improvement in the domains of memory, attention, and communication (Cicerone KD et al, Arch Phys Med Rehabil 2005;86(8):1681-1692). However, for mild TBI, CRT remains more controversial as there isn’t strong evidence for improved functional outcomes. The 2016 VA clinical guidelines recommend short-term CRT for moderate to severe TBI and discourages prolonged treatment courses without measurable improvements.
Sometimes the most concerning symptoms the patient will come to us for are the cognitive deficits and they may press for neuropsychological (NP) testing early. However, NP testing should not be done in the first 30 days. Most cognitive deficits of mild TBI will improve within this time period. And if the problems last longer than 30 days, NP testing may be helpful. Whenever referring for NP testing, be specific in why you are making the request. A targeted referral allows the NP examiner to choose the right tests to provide the most useful information.
When considering medication treatment for symptoms following a TBI, there are several general guidelines to follow (Silver JM et al, Neurology 2006;67(5):748-755.2011). Again, most symptoms of a mild TBI will abate within a month, so watchful waiting and reassurance are important. Symptom improvement may continue throughout the first year as the brain continues to heal, so be sure to reassess the need for the medication intervention. Many times, the neuropsychiatric symptoms after a TBI can be complicated by concurrent major depressive disorder, PTSD, or a substance use disorder. Untreated depression can be the root cause of cognitive problems, irritability, sleep disturbance, fatigue, and headache. Be sure to perform a thorough psychiatric assessment so that you can tailor the treatment plan accordingly. Target specific symptoms or concurrent conditions with your medication choices. After a TBI the brain can be more susceptible to side effects of medications, underscoring the importance of “starting low, and going slow.”
Here are a few specific medication recommendations to target neuropsychiatric symptoms (Silver JM et al, 2011). For improving processing speed, methylphenidate has the most evidence. Donepezil and rivastigmine also may have some utility for treating memory impairment. When targeting depression and anxiety, SSRIs are first-line and choose a specific SSRI based on side effect profile and limiting medication interactions (sertraline, citalopram, and escitalopram are favorable choices) (Salter DL et al, J Head Trauma Rehabil 2016;31(4):E21-32). Be cautious with bupropion due to increased seizure risk. Caution is also advised with typical antipsychotics as they may inhibit neuronal recovery, and also benzodiazepines due to the memory impairment effects. For controlling mania or irritability, valproate is preferred due to its anti-seizure effect as well as having less cognitive side effects in long term treatment than other mood stabilizers (carbamazepine or lithium). Atypical antipsychotics may also be helpful in controlling irritability especially when combined with psychosis, and are preferred over typical antipsychotics. More recent research shows beneficial effects of amantadine in treating aggression from TBI even 6 months post-injury and more studies are evaluating its use in the acute phase after a severe TBI (Hammond FM et al, J Head Trauma Rehabil. 2017;32(5):308-318).
CATR Verdict: When treating patients with TBI, always remember that the brain has a great capacity for plasticity and recovery. Encourage patients to see their treatment as a process and journey. Take care to evaluate for comorbid mental health disorders, and handle accordingly. Those with substance use disorders, whether existing pre-TBI or newly occurring, should be encouraged to enter into treatment promptly. With the right combination of cognitive rehabilitation, pharmacotherapy, and a good therapeutic alliance, your patients can make great strides in recovery after a TBI.
Alcohol use and TBI are closely related. Up to two-thirds of people with TBI have a history of alcohol abuse or risky drinking. Between 30-50% of people with TBI were injured while they were drunk and about one-third were under the influence of other drugs. Around half of those who have a TBI cut down on their drinking or stop altogether after injury, but some people with TBI continue to drink heavily, which increases their risk of having negative outcomes.
After TBI, many people notice their brains are more sensitive to alcohol. Drinking increases your chances of getting injured again, makes cognitive (thinking) problems worse, and increases your chances of having emotional problems such as depression. In addition, drinking can reduce brain injury recovery. For these reasons, staying away from alcohol is strongly recommended to avoid further injury to the brain and to promote as much healing as possible.
Facts about TBI and alcohol
Alcohol and brain injury recovery
- Recovery from brain injury continues for much longer than we used to think possible. Many people notice improvements for many years after injury.
- Alcohol slows down or stops brain injury recovery.
- Not drinking is one way to give the brain the best chance to heal.
- People’s lives often continue to improve many years after brain injury. Not drinking will increase the chance of improvement.
Alcohol, brain injury and seizures
- Traumatic brain injury puts survivors at risk for developing seizures (epilepsy).
- Alcohol lowers the seizure threshold and may trigger seizures.
- Not drinking can reduce the risk of developing seizures.
Alcohol and the risk of having another brain injury
- After a brain injury, survivors are at higher risk (3 to 8 times higher) of having another brain injury.
- Drinking alcohol puts survivors at an even higher risk of having a second brain injury. This may be because both brain injury and alcohol can affect coordination and balance.
- Not drinking can reduce the risk of having another brain injury.
Alcohol and mental functioning
- Alcohol and brain injury have similar negative effects on mental abilities like memory and thinking flexibility.
- Alcohol magnifies some of the cognitive problems caused by brain injury.
- Alcohol may affect brain injury survivors more than it did before their injury.
- The negative mental effects of alcohol can last from days to weeks after drinking stops.
- Not drinking is one way to keep your mental abilities at their best and stay sharp and focused.
Alcohol and mood
- Depression is about 8 times more common in the first year after TBI than in the general population.
- Alcohol is a “depressant” drug, and using alcohol can cause or worsen depression.
- Alcohol can reduce the effectiveness of anti-depressant medications. People who are taking antidepressants should not drink alcohol.
- One way to improve problems with sadness or depression after TBI is to stop or cut down on the use of alcohol.
Alcohol and sexuality
- Lowered desire is the most common effect of TBI on sexuality.
- Alcohol reduces testosterone production in males.
- Alcohol reduces sexual performance (erection and ejaculation) in men.
- Alcohol reduces sexual satisfaction in men and women.
- Avoiding alcohol improves sexual ability and activity in men and women.
How much alcohol is “safe” after TBI?
After TBI the brain is more sensitive to alcohol. This means that even one or two drinks may not be safe, especially when you need to do things that require balance, coordination and quick reactions, such as walking on uneven surfaces, riding a bicycle or driving a car. The fact is, there is no safe level of alcohol use after TBI.
Alcohol and medications
Alcohol is especially dangerous after TBI if you are taking certain prescription medications. Alcohol can make some medicines less effective and can greatly increase the effects of others, potentially leading to overdose and death. Using alcohol along with anti-anxiety medications or pain medications can be highly dangerous because of the possible multiplying effect.
What about using other drugs?
Alcohol is a drug. Almost everything mentioned above about alcohol applies equally to other drugs. If your drug of choice is something other than alcohol-such as marijuana, cocaine, methamphetamine or prescription drugs, anti-anxiety medications (benzodiazepines such as Ativan, Valium, or Xanax), or pain medication (opioids like Percocet, Oxycodone or Oxycontin)-many of the same principles apply. In addition, use of illegal drugs or misuse of prescription drugs can lead to legal problems.
If you use multiple drugs like alcohol and marijuana, or alcohol and pain pills, there is a higher risk of addiction and overdose. Using alcohol and pain medications together, or alcohol and anti-anxiety medications, has killed many people. Contact your doctor if you are drinking and using prescription drugs.
What should you do?
The stakes are higher when people choose to use alcohol after having a TBI. Some people continue drinking after a TBI and don’t have any desire to change that behavior. Others know they probably should stop or reduce alcohol use, but don’t know how or have tried in the past and not been successful.
There are many ways to stop using alcohol or other drugs and many ways to reduce the potential for harm. The great majority of people who have stopped having alcohol problems did it on their own. They got no professional help or counseling and did not use Alcoholics Anonymous (AA). Don’t underestimate your ability to change if you want to.
There are many ways to change, cut down or stop drinking
The key ingredients to changing your drinking are: (1) find people who will support your efforts to change your drinking; (2) set a specific goal; (3) make clear how you will meet your goal; (4) identify situations or emotions that can trigger drinking, and figure out ways to cope with those triggers ahead of time; and (5) find ways to reward yourself for sticking to your plan and meeting your goals.
If you have questions or concerns about your drinking, there are many ways to get information or help:
- Take a confidential on-line drinking assessment: http://www.alcoholscreening.org/.
- Talk to your physician about your concerns, and ask about medications that can help you resist relapse or reduce cravings for alcohol, such as naltrexone (Revia).
- Psychologists or other counselors in your brain injury rehabilitation program can help you get started on a treatment program that is right for you.
- Alcoholics Anonymous (AA) has helped millions of people. There are meetings in most towns and cities (http://www.aa.org/).
- Moderation Management (http://www.moderation.org/) and Smart Recovery (http://www.smartrecovery.org/) are alternatives to AA that do not use the 12-step model.
- Substance Abuse and Mental Health Services Administration (SAMHSA) is a federal program that can help you find a treatment facility wherever you live (http://findtreatment.samhsa.gov/; 800-662-4357).
- Private treatment: look in the Yellow Pages under substance abuse, chemical dependency counselor, or addiction treatment.
Reduce the harm from drinking
For those who don’t want to stop drinking, it is still possible to reduce some harm from drinking:
- Eat food and drink water before you drink alcohol. This will help reduce the sharp spike in blood alcohol level that can cause nausea, vomiting, falls, blackouts and alcohol poisoning.
- Plan your transportation so you don’t drink and drive: have a non-drinking designated driver; plan to spend the night where you are doing your drinking; or drink only at home.
- To avoid dangerous peaks in blood alcohol concentrations, drink beer rather than hard liquor, or mix hard liquor with water instead of with sweet, carbonated beverages.
- Sip your drinks slowly (no more than one per hour). Drinking too fast can make the pleasant feelings of alcohol go away.
- Drinking in bars slows some people down because of the expense. However, be sure you do not drive after drinking.
- Take vitamins B1 (thiamine), B12 and folate to reduce the chances of alcohol-related brain damage.
- Keep your drinking to no more than two drinks per day. Or cut back on certain days of the week, such as weeknights.
- Take a drinking “holiday” (days or weeks when you decide not to drink at all). This can remind you of some of the benefits of being sober.
How family members can help
No one can force another person to stop using alcohol or drugs, but you can have an influence. Attending Al Anon meetings can be a good source of support for a friend or family member of someone who abuses alcohol or drugs, and it can help promote change. Planning an “intervention” where family and friends confront the person may help.
A program called Community Reinforcement and Family Training (CRAFT) has been found to work best. CRAFT takes a more positive, motivational approach that helps loved ones make not drinking more rewarding for the person with the alcohol problem. Research has shown that alcoholics are more likely to go into treatment if their loved ones follow the CRAFT method. To learn about CRAFT, see the book Get Your Loved One Sober in the Resources section below, or find a counselor familiar with this approach.
Bombardier, C.H. & Turner, A. (2009). Alcohol and traumatic disability. In R. Frank & T. Elliott (Eds.), The Handbook of Rehabilitation Psychology, Second Edition (pp. 241-258). Washington, DC: American Psychological Association Press.
- Brown, J., Corrigan, J., & Hammer, P. (2010). “Substance Abuse and TBI.” Brainline Webcast #4, Defense and Veterans Brain Injury Center. (http://www.brainline.org/webcasts/4-TBI_and_Substance_Abuse/index.html)
- Corrigan, J., & Lamb-Hart, G. (2004). Alcohol, Other Drugs, and Brain Injury. Columbus, Ohio: Ohio Valley Center for Brain Injury Prevention and Rehabilitation, Ohio State University Dept. of Physical Medicine and Rehabilitation. (Available from the Brain Injury Association, http://www.biausa.org/LiteratureRetrieve.aspx?ID=43235. )
- Meyers, R.J., & Wolfe, B.L. (2004). Get Your Loved One Sober: Alternatives to Nagging, Pleading, and Threatening. Center City, MN: Hazelden Publications.
- Substance Abuse Resources and Disability Issues (SARDI); http://www.med.wright.edu/citar/sardi/index. html.
This information is not meant to replace the advice from a medical professional. You should consult your health care provider regarding specific medical concerns or treatment.
Our health information content is based on research evidence whenever available and represents the consensus of expert opinion of the TBI Model System directors.
Alcohol Use After Traumatic Brain Injury was developed by Charles Bombardier, PhD, in collaboration with the University of Washington Model Systems Knowledge Translation Center.