Management of the emotional and behavioral challenges after Traumatic Brain Injury with Cognitive Behavioral Therapy

1. RECENT ADVANCES
in
Managing Emotional and Behavioral
Challenges of Traumatic Brain Injury
with Cognitive Behavioral Therapy
Approach
Presentation by: Purva Pai
MPT 2nd year

2. INTRODUCTION
Traumatic Brain Injury
Traumatic brain injury (TBI) is a leading cause of morbidity,
mortality, disability, and socioeconomic loss with a global annual
incidence estimated at 69 million.
Causes that lead to TBI include road traffic accidents, falls, and
violence.

3. It can have debilitating effects on the person as well as caregivers
due to changes occurring in physical, behavioral, psychosocial, and
cognitive aspects of the person’s life.
The changes affect the person’s ability to continue with their
routine activities with some occurring immediately after the injury
such as the physical and cognitive symptoms and some emotional
and behavioral symptoms which affect in the long term.

4. Emotional and behavioral changes can significantly affect the physical recovery of patients
with TBI. These changes, including anxiety, depression, sleep disturbances, and medication
non-compliance, can hinder the healing process and impact outcomes.
They also affect appetite and social relationships, influencing nutrition and social support, both
vital for recovery and can alter pain perception, potentially diminishing tolerance for
discomfort during rehabilitation.
Addressing these emotional and behavioral changes through appropriate interventions,
including counseling and support, is essential for optimizing physical recovery in TBI patients.

5. Signs and Symptoms
• Pain
• Headache (PTH)
• Seizures
• Double vision
• Nausea, vomiting
• Confusion
• Disorientation
• Altered consciousness
• Weakness in arms and legs
• Slurred speech
• Loss of balance
• Loss of coordination
• Sensory disturbances
• Aphasia
• Difficulty in ADL’s

6. • Difficulty with communication
• Memory problems
• Attention and concentration issues
• Difficulty with planning and
execution
• Sleep disturbances
• Fatigue
• Mood swings, Agitation
• Anxiety and Depression
• Lack of motivation
• Mood lability, Impulsivity
• PTSD
• Stress
• Sexuality Problems

7. Interventions available till 2018
• Physical activity and Exercise
• Emotional support
• Counselling
• Relaxation techniques
• Sensory Integration
• Psychotherapy
• Medications

8. Pharmacological Intervention
• Anti-depressants
• Anti-anxiety – Benzodiazepines
• Antipsychotic – Risperidone
• Mood Stabilizers – Valproate, Carbamazepine
• Stimulants – Methylphenidate
• Hypnotics
• Sedatives

9. Need for Recent Studies
There are various interventions available for the treatment of
physical and cognitive impairments seen in individuals who have
sustained Traumatic Brain Injury.
Though these treatments are effective, there are emotional and
behavioral factors which can hinder the recovery of the individual.
Hence there is a great need to work on a more holistic approach
for improving the overall quality of life of the patients.

10. CBT has shown promising results in managing emotional and behavioral
symptoms in various populations.
Therefore, there is a need for recent research in order to provide more
insights in tailoring individualized interventions using CBT to meet the
unique needs of TBI patients and should consider both the physical and
emotional aspects of TBI rehabilitation to enhance overall outcomes.

11. CBT
Cognitive-Behavioral Therapy (CBT) is a structured and evidence-based
therapeutic approach that focuses on identifying and changing negative thought
patterns and behaviors contributing to emotional distress or mental health issues. It
can be adapted and modified as per requirement.
It's particularly effective for addressing specific symptoms, offers skill
development and problem-solving techniques, and emphasizes measurable
progress.
It is preferable to choose CBT over general counseling or psychotherapy for a
goal-oriented, shorter-term, and symptom-focused approach with practical tools to
manage specific issues efficiently, while still allowing for integration with other
therapeutic approaches when needed.

12. Search Strategies
• Database searched: PubMed, Google Scholar, Science Direct.
• Key words: Traumatic Brain Injury, Cognitive Behavioural Therapy, Modified
CBT, Behavioral and Emotional Symptoms, Neurobehavioral symptoms,
Neuropsychological symptoms.
• Selection Criteria:
1) The search was limited to data published between 2019-2023 and only English-
language articles were included with full-text or abstract of the articles.
2) Articles before 2019 were excluded.

13. Title Year
Level Of
Evidence
1) A Pilot Randomized Controlled Trial of
Cognitive-Behavioral Therapy for Insomnia in
Adolescents With Persistent Postconcussion
Symptoms
2019 1b
2) Promoting mental health in traumatic brain
injury using single-session Behavioural Activation
and SMS messaging: A randomized controlled trial
2019 1b

14. Title Year
Level Of
Evidence
3) An acceptance and commitment therapy-
based intervention for PTSD following traumatic
brain injury: a case study
2019 4
4) The effectiveness of cognitive behaviour
therapy for reducing anxiety symptoms
following traumatic brain injury: A meta-
analysis and systematic review
2021 1a

15. Title Year
Level Of
Evidence
5) Experience of adapted cognitive behaviour
therapy to address sexuality problems after
traumatic brain injury: A qualitative study
2023 4

16. 1) A Pilot Randomized Controlled Trial of Cognitive-
Behavioral Therapy for Insomnia in Adolescents With
Persistent Postconcussion Symptoms (2019)
Authors - Lianne Tomfohr-Madsen; Joshua W. Madsen; Dominique
Bonneville; Shane Virani; Vickie Plourde; Karen M. Barlow; Keith Owen
Yeates; Brian L. Brooks
Alberta Children’s Hospital, Calgary, Canada
Journal of Head Trauma Rehabilitation
(Impact Factor – 3.11)

17. Patient Population Intervention
• 24 participants with persistent post-
concussion symptoms and sleep
disruption
• 12-18 years old
• Between 1-12 months post-injury
(Avg 15.1 weeks)
• CBT-I Intervention (n=12)
• 45 mins assessment
• 7 days online sleep diary before randomization
• 6 sessions, 1 per week
Comparison Outcomes
• TAU (Treatment As Usual) Control
Group (n=12)
• Primary outcome measure – Insomnia Severity Index (ISI)
• Online daily sleep diaries, average total sleep time, wake
after sleep onset, sleep-onset latency, and sleep efficiency
were calculated.
• The 24-Hour Sleep Patterns
• Pittsburgh Sleep Quality Index
• Dysfunctional Beliefs and Attitudes about Sleep Scale
• Patient Reported Outcomes Measurement Information
System (PROMIS) Anxiety and Depression
• Health and Behavior Inventory

18. Baseline
Post
Treatment
4 weeks
post Rx

19. Result
CBT-I demonstrated large and clinically significant improvements in
insomnia ratings in adolescents with persistent post concussion symptoms, at
posttreatment, which were maintained at the 4-week follow-up.
CBT-I also resulted in improved sleep quality, fewer dysfunctional beliefs
about sleep, better sleep efficiency, shorter sleep-onset latency, and longer
sleep time compared to the treatment-as-usual control group.
CBT-I had a large effect size in reducing Insomnia Severity Index (ISI) scores,
as well as significant reductions in Pittsburgh Sleep Quality Index (PSQI) and
Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) scores.
However, CBT-I did not have significant effects on secondary outcomes such as
child-reported depression and anxiety.

22. Possible Mechanism
CBT-I is a well-established treatment for insomnia and is believed to
work by addressing maladaptive thoughts and behaviors related to
sleep, promoting relaxation techniques, and implementing strategies to
improve sleep hygiene

23. Conclusion
 CBT-I may be a promising treatment option for insomnia in
adolescents with persistent post concussion symptoms.

24. 2) Promoting mental health in traumatic brain
injury using single-session Behavioural Activation
and SMS messaging: A randomized controlled trial
(2019)
Authors - Tessa Hart, Monica Vaccaro, George Collier, Inna Chervoneva &
Jesse R. Fann
Moss Rehabilitation Research Institute, Elkins Park, USA
Neuropsychological Rehabilitation
(Impact Factor – 2.92)

25. Patient Population Intervention
• 65 chronic moderate to severe
TBI patients (6 months prior to
enrolment) with depression
and/or anxiety.
• 2:1 Randomization
• Implementation Intention (INT) intervention
• 1 session of Behavioral Activation (BA) + 8 weeks of
daily SMS messages with implementation intentions.
Comparison Outcomes
• Motivation (MOT)
intervention
• 1 session on importance of
Motivation + 8 weeks of
motivational SMS
messages.
• Primary Outcome measures - Environmental Reward
Observation Scale (EROS).
• Behavioural Activation for Depression Scale (BADS).
• Brief Symptom Inventory Global Severity Index (BSI
GSI) for emotional status.
• Participation Assessment with Recombined Tools-
Objective (PART-O) 3 subscales - Productivity, Out
and About, Social Relations.
• Likert-type scale

26. Reason for 2:1 Randomization
1) When evidence for a
treatment is strongly showing
effectiveness – to provide more
people with the benefit of
Treatment
2) Better statistical efficiency
when a small sample size is
present

28. Result
Study results showed that both, the Implementation Intention (INT) and Motivation (MOT)
interventions resulted in modestly improved emotional status in participants with chronic
moderate to severe traumatic brain injury (TBI) and depression and/or anxiety.
The INT condition led to more exposure to environmental reward and greater productivity
compared to the MOT condition.
The delivery of frequent text messages proved to be a very feasible means of supporting treatment
in this population.
There were significant differences within each condition for certain outcome measures, such as
EROS, BADS, and BSI GSI as well as in PART-O Productivity subscale, but PART-Soc and
PART-Out showed no significant changes for either condition.
Participants in both conditions reported high scores on Likert-type questions regarding the
helpfulness of the messages, personal relevance, and recommendation of the program to others.
Both groups also reported improved mood since the start of the study.

31. Presumed mechanism
One mechanism - Increased exposure to environmental reward via increased
pleasurable activity and decreased avoidance of activity.
Second mechanism – Based on the literature, periodic alerting, even with a
“content-free” signal such as a tone delivered at random intervals, can lead to
improvements in goal-directed behavior among people with acquired brain
injury.
It increases the activation of mental representations and strengthens the link
between cues and specified responses, leading to more automatic execution of
desired behaviors.
This works by interrupting goal neglect and promoting re-orientation to what
the recipient intends to do.

32. Conclusion
Study findings conclude that BA-based interventions may be effective
for treating depression and/ or anxiety and increasing productive
activity in chronic, moderate to severe TBI.
The use of SMS-enhanced treatment appears to be feasible and
represents a promising avenue for use in community-dwelling persons
with severe TBI.

33. 3) An acceptance and commitment therapy-based
intervention for PTSD following traumatic brain
injury: a case study (2019)
Authors - Lauren Roche
Lincolnshire Partnership Foundation NHS Trust, Lincoln, UK
Brain Injury
(Impact Factor – 2.16 )

34. Patient Population Intervention
• 48-year-old female
• With cognitive difficulties,
significant distress, and PTSD
symptoms following a car accident
on 29th December 2017.
• Acceptance and Commitment Therapy (ACT) based
intervention for PTSD
• 12 sessions from 29th August to 29th December 2018
• 90 mins/ session every 2-3 weeks
Comparison Outcomes
• Hospital anxiety and depression scale (HADS)
• The impact of events scale revised (IES-R)
• PTSD symptom scale – interview for diagnostic
statistical manual (DSM)-5 (PSS-I-5)
• Valued living questionnaire (VLQ)
• Cognitive fusion questionnaire (CFQ)
• Quality of life (QoL)

36. Possible mechanism
• Psychological flexibility, a key concept in ACT, refers to the ability to
regulate behavior based on individual values and goals, persisting or
changing actions depending on the situation.
• ACT is said to help improve psychological flexibility through interventions
that help individuals acknowledge and accept powerful thoughts and
emotions associated with trauma, while still engaging in behaviors that
align with their values and lead to meaningful outcomes.

37. Result
• The case study presented positive outcomes post-intervention and at follow-up,
indicating that the Acceptance and Commitment Therapy (ACT) based
intervention may be a feasible intervention for PTSD post TBI.
• The client showed improvements in ACT outcome measures, psychological
measures, and quality of life ratings, which were consistent with subjective
reporting.
• After 12 intervention sessions, the client reported functional improvements such
as reducing time spent on YouTube and referencing the man involved in the
accident, completing activities on the exposure program independently, and
engaging in more activities with her family.
• The client demonstrated the use of ACT techniques, such as "letting go" of
thoughts, self-talk about the importance of her values, and acknowledging the
need for self-compassion.
• Progress was noted post-intervention on all mood measures used and
subjectively reported, which further improved at 3- and 12-month follow-ups,
even without further clinician intervention.

39. Conclusion
• This case study is supportive for the application of a
pragmatic ACT-based intervention for addressing PTSD
following TBI.

40. 4) The effectiveness of cognitive behaviour therapy
for reducing anxiety symptoms following traumatic
brain injury: A meta-analysis and systematic
review (2021)
Authors - Alice Little, Christopher Byrne, Rudi Coetzer
North Wales Brain Injury Service, Colwyn Bay Hospital, UK
NeuroRehabilitation
(Impact Factor – 2)

41. Patient Population Intervention
• Patients with Mild-Moderate-
Severe TBI ages >18 years
• At least 6 months prior to study.
(10 RCTs, 698 participants)
• Cognitive Behavioral Therapy (with adaptations)
(n=359)
• 5-33 weeks interventions, between 5 weeks and 6
months
Comparison Outcomes
(n=342)
• Supportive Psychotherapy (1)
• Psycho-education (2)
• Supportive counseling (1)
• Treatment as usual (TAU) (3)
• Waitlist control (WLC) (3)
(Anxiety-related outcome measures)
• Hospital Anxiety and Depression Scale (HADS)
• State Trait Anxiety Inventory (STAI)
• Beck Anxiety Inventory (BAI)
• Symptom Checklist-90-R (SCL-90- R)
• PTSD checklist-military version (PCL-M)
• Depression Anxiety Stress Scale (DASS)

43. Result
The meta-analysis found a small overall effect size (SMC=-0.26) for
CBT interventions in reducing anxiety symptoms for the TBI
population which were smaller than those reported for non-TBI
clinical populations.
The meta-analysis tentatively supports the view that CBT
interventions may be effective in reducing anxiety symptoms in some
patients following TBI.

44. SMC=-0.26 showing small effect size overall
No evidence of publication bias with a
relatively symmetrical pattern

47. Conclusion
As the results of this meta-analysis indicate that CBT results in a
small, but potentially significant reduction in anxiety symptoms for
individuals who have sustained a TBI, it provides tentative support for
the use of CBT to treat anxiety symptoms following TBI, also
considering the easy-to-administer nature and negligible side effect
profile of CBT, compared to stand-alone pharmacological
interventions.

48. 5) Experience of adapted cognitive behaviour
therapy to address sexuality problems after
traumatic brain injury: A qualitative study (2023)
Authors - Elinor E. Fraser, Marina G. Downing, Kerrie Haines, Linda
Bennett, John Olver & Jennie L. Ponsford
Epworth Healthcare, Monash-Epworth Rehabilitation Research Centre,
Richmond, Victoria, Australia
Neuropsychological Rehabilitation
(Impact Factor – 2.92)

49. Patient Population Intervention
• 8 Individuals with traumatic brain
injury (TBI)
• 4 male, 4 female
• 18-65 years, mild-very severe
• >3 months post-injury
• Adapted cognitive behavior therapy (CBT) for
addressing sexuality problems after TBI
• 8, 60 minute sessions, weekly once
• 1 booster session after 2 months
• Individualized semi-structured interviews (2 weeks
post 8th session ranging from 38-49 mins)
Comparison Outcomes
• Patient Experience and Improvement in sexual
well-being after TBI

53. Result
• Participants with TBI reported a positive treatment journey characterized by high levels
of satisfaction and understanding. Participants with TBI considered the treatment
experience to be beneficial, regardless of variations in age, sex, marital status, injury
severity, time post-injury, and type of sexuality problem.
• The experience of the intervention was characterized by four themes (and sub-themes):
(1) Context preceding treatment
(2) Factors facilitating engagement
(3) Outcomes derived from experience
(4) Feedback on reflection.
• The results provided an enriched understanding of the client’s experience of the
intervention as well as the effectiveness of this novel CBT intervention in addressing
complex and persistent sexuality problems after TBI.

55. Conclusion
• Failure to address sexuality is a significant gap in healthcare that not only prevents
service providers from meeting the holistic needs of this clinical population but
abandons individuals and couples to “sorting it out” without any professional
support or guidance.
• The qualitative study supports the efficacy and perceived helpfulness of a novel,
individualized CBT intervention for individuals with TBI who have experienced
complex and persistent post-injury changes in sexuality.
• The findings suggest that a tailored CBT intervention may have multiple benefits
for individuals and couples who experience sexuality difficulties after TBI,
providing them with a safe space to talk as well as understanding to deal with the
situations, acceptance, confidence, and communication.

56. Clinical Implications
1) CBT-I Intervention for TBI patients with Insomnia
6 sessions, once per week
(1) introduction
(2) relaxation training
(3) stimulus, sleep consolidation, and medication use
(4) cognitive therapy
(5) sleep hygiene
(6) mindfulness and relapse prevention.
Sleep Diary
Targeting the maladaptive beliefs and attitudes about sleep as well as sleep-
disruptive behavioral practices.

57. 2) Behavioral Activation Therapy ( a form of CBT) for Anxiety, Depression, and overall Productivity
in post-TBI patients
Implementation Intention (INT) intervention
1 Session of Behavioral Activation Therapy + Daily SMS messages with implementation intentions
of Action Plans and Coping Strategies
Generating activities important to the patient, which are realistic and can be repeated over the
therapy period.
3) Acceptance and Commitment Therapy for PTSD following TBI
12 sessions of 90 minutes each
1 session every 2-3 weeks
(1) Psycho-education of ACT framework – finding out key values, noticing thoughts, behaviors,
outbursts, anger.
(2) Acceptance – responses of relaxation and acceptance with breathing exercises and positive self-
talk
(3) Commitment – Hierarchical Behavior Exposure Program with activities the person finds
difficult, with strategies, reflections, and more positive self-talk.

58. Future Recommendations
 Studies with larger sample sizes are needed for better generalizability of
the population as well as for obtaining a larger effect size which increases
the statistical significance of the studies.
Instead of providing just one session of BA, a structured treatment protocol
with more sessions might be more beneficial and may have more significant
and longer-lasting effects of the intervention.
Study (1a) showed a small effect size for the treatment of anxiety due to the
smaller sample sizes of most studies and the heterogenicity of the various
conditions they targeted along with anxiety such as various levels of
cognitive impairments. Hence for future studies, it is recommended to
specifically target anxiety for better efficacy and homogeneity across
studies.
Larger trials and better study designs are needed to show the efficacy of
adapted CBT to address sexuality problems.

59. References
1) Tomfohr‐Madsen L, Madsen JW, Bonneville D, et al. A pilot randomized controlled trial of Cognitive-
Behavioral therapy for insomnia in adolescents with persistent postconcussion symptoms. Journal of Head
Trauma Rehabilitation. 2020;35(2):E103-E112. doi:10.1097/htr.0000000000000504
2) Hart T, Vaccaro M, Collier G, Chervoneva I, Fann JR. Promoting mental health in traumatic brain injury
using single-session Behavioural Activation and SMS messaging: A randomized controlled trial.
Neuropsychological Rehabilitation. 2019;30(8):1523-1542. doi:10.1080/09602011.2019.1592761
3) Roche L. An acceptance and commitment therapy-based intervention for PTSD following traumatic brain
injury: a case study. Brain Injury. 2019;34(2):290-297. doi:10.1080/02699052.2019.1683896
4) Little A, Byrne C, Coetzer R. The effectiveness of cognitive behaviour therapy for reducing anxiety
symptoms following traumatic brain injury: A meta-analysis and systematic review. NeuroRehabilitation.
2021;48(1):67-82. doi:10.3233/nre-201544
5) Fraser EE, Downing MG, Haines K, Bennett L, Olver J, Ponsford JL. Experience of adapted cognitive
behaviour therapy to address sexuality problems after traumatic brain injury: A qualitative study [published
online ahead of print, 2023 Jun 12]. Neuropsychol Rehabil. 2023;1-28.
doi:10.1080/09602011.2023.2221858

60. THANK YOU