Cognitive behavioral therapy for social anxiety, TBI, PTSD (7/8/21 newsletter)

Jul 9

We are halfway finished with our summer 2021 Concussion Education & Advocacy Internship Program! This year, our internship cohort consists of 18 interns from 5 different colleges, four in the US and one in Ireland.

We would like to acknowledge our interns who wrote for this newsletter:

Writers: Lori Mae Yvette Calibuso Acob, Melissa Brown, Julia Brzac, Nathan Campbell, Emma Chin, Christine Hau, Wyatt Hill, Karina Suwal, and Chelsea Ryan.

Editors: Conor Gormally and Malayka Gormally.

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Opportunities

Conor Gormally, Concussion Alliance Co-founder, will give a presentation about our internship program

July 28-30: 2021 Virtual World Congress on Brain Injury, a joint initiative of the International Brain Injury Association (IBIA), the North American Brain Injury Association (NABIS), Acquired Brain Injury Ireland, and other organizations. Register in advance.

At the conference, Conor Gormally, Co-founder of Concussion Alliance, will give a pre-recorded oral presentation of an abstract, Bringing Concussion Education and Advocacy to the Next Generation of Healthcare and Public Health Professionals: Concussion Alliance’s Novel Service Learning Undergraduate Internship.

Co-authors are Malayka Gormally, Executive Director of Concussion Alliance, and Elizabeth Sandel, MD, who is on our professional advisory board.

Education

University of Georgia program helps students with concussion symptoms find support

A recent press release from the University of Georgia announced the successful funding and establishment of an experimental peer mentoring program for students who have suffered a concussion. Led by Katy O’Brien, an assistant professor in the college’s education department, the program pairs students with mentors based on the students’ reported symptoms and a few personal preferences. The goal is to match students with peer mentors who have suffered a concussion with similar symptoms in the past to create a supportive atmosphere in which the student feels free to speak openly about their situation.

In the press release, O’Brien mentioned that analysis of the mentor-mentee interactions has allowed her to better understand what students require to get the most out of the program. From her experience so far, she’s seen that “when students have the resources they need during recovery—including support and understanding—they tend to recover more quickly. Through the program, we’ve also learned that by giving back, mentors feel they have a greater understanding of what they went through.”

A Concussion Alliance blog post covers another study highlighting how social support, particularly from peers, supports recovery.

Sports

Majority of high school athletic sport-related concussion protocols found not fully compliant with state law and best practices

A recent qualitative document analysis of Pennsylvania high school sports-related concussion (SRC) protocols found that most protocols were not fully compliant with all mandatory state law requirements. The study included 184 Pennsylvania high schools, who voluntarily provided copies of their SRC protocol from the 2018-2019 academic year. Four athletic trainers then analyzed these protocols, using the frequency of state law components to determine the level of compliance in each school’s protocol. These components included preparticipation and prevention, recognition and assessment, and management of SRCs related to state law and athletic participation.

Researchers found that only 23.4% included all mandatory state law tenets. While many included return-to-play protocols (74.5%), return-to-classroom or return-to-learn protocols were notably absent (32.4%), especially considering the impact school-based athletics can have on students’ academic performance. However, schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers.

This finding led researchers to conclude that employing full-time athletic trainers may help establish high school SRC protocols that include state law requirements more closely and provide additional advice for best SRC practices. This article was published in the Journal of Athletic Training.

Diagnostics

Updates to the audiologist’s guide for TBI assessment, treatment & recovery

A recent article published in The Hearing Journal restructures both patient history-taking and auditory assessment procedures, allowing hearing specialists to incorporate possible post-TBI effects in their patient assessment and treatment plans. Hearing loss has been noted as a common consequence of traumatic brain injuries (TBIs) regardless of severity. Specifically, sensorineural hearing loss (SNHL), often caused by damage to the inner ear or the auditory nerve, is the most common form of auditory impairment associated with post-TBI consequences.

Bojana Šarkić, Dr. Jacinta Mary Douglas, and Dr. Andrea Simpson, authors of the present article, offer reconstructions of patient diagnosis and auditory assessment based on patient TBI history. Suggested changes to diagnostic methodology focus on investigating patient history for signs of previous head traumas or injuries to determine whether an audiologist should use a standard or TBI-recommended test battery during patient assessment. The article also lays out a suggested auditory assessment procedure (see Figure 2) in the presence of possible TBIs in patient history. The recommended assessment procedure provides a standardized method of evaluating auditory dysfunction following TBIs, which was previously lacking in the world of audiology.

Self-care

Managing post-brain injury anger: tips for friends and family providing support

Anger is a common response after a brain injury, and this reactionary behavior can be challenging to manage. An article published in Headway: the Brain Injury Association discusses nine tips for anger management. Headway articles address issues for those with mild to severe TBI; we think this article includes valuable information for those with a concussion and those who support them.

For support figures, often receiving or helping to manage anger, it’s better to allow the concussed person to come to an understanding of their behavior. Despite this, helping them identify possible triggers can be helpful, and doing small experiments to determine the anger level response may help with the identification process. If these triggers, once known, arise in a public setting, having a nonverbal sign for identifying increased anger levels can help those experiencing it take a moment or remove themselves from the situation.

It is essential to be clear and understanding when communicating with one another. Having patience and addressing when the anger is directed at those closest to the patient can also help with anger management. If managing the anger through identification, patience, and good communication isn’t providing any improvement, seeking a neuropsychologist to help advise can be a practical next step. The Headway fact sheet is another excellent resource for helping with anger management.

Therapies Currently Available

Cognitive behavioral therapy as treatment for PTSD and effects of TBI

An article on Brainline describes how cognitive behavioral therapy (CBT) can be an effective treatment for symptoms caused by post-traumatic stress disorder (PTSD) as well as traumatic brain injury (TBI).

CBT focuses on the interrelated causal relationships between thoughts, feelings, and behaviors, where modification of one component can subsequently affect others. For example, those with PTSD can have negative thought patterns about themselves caused by negative emotions from trauma. CBT can change unhealthy thought patterns, which consequently change one’s emotional experience. TBI patients can also use this approach, especially those experiencing depression, anxiety, and fear of an injury resulting in further impairment. CBT could help these individuals recognize the cognitive, affective, and behavioral components of depression, anxiety, and fear – allowing them to implement positive strategies.

Two common CBT strategies are identifying unhealthy thoughts and relaxation tactics. One way to deal with harmful thoughts is reframing, which involves looking at situations from a different perspective. An example of this would be interpreting another’s actions as caused by factors that have nothing to do with oneself. Another strategy is positive self-talk, which focuses on changing individuals’ views of themselves from negative to positive.

The American Psychological Association recognizes CBT as being equal to or more effective in treating symptoms than medication or other forms of psychotherapy. The U.S Department of Veterans Affairs also recommends forms of CBT as therapy for military veterans with PTSD.

See our page Cognitive Behavioral Therapy for more information, including finding providers, options for CBT online, and CBT apps.

Therapies Under Research

Understanding traumatic brain injury through the inflammatory response

A review article by Colleen M. Bodnar et al., published in Frontiers in Immunology, discusses deficits in inflammatory response to understand pathologies of traumatic brain injury (TBI) on the brain’s protective barriers. The causes of post-TBI symptoms have been thought to be linked to the dysregulation of inflammatory markers in important brain barriers: the blood-brain barrier, the blood-cerebrospinal fluid barrier, the meningeal barrier, the blood-retina barrier, and the brain-lesion border. The authors focus on a marker of particular note – the inflammatory “master cytokine” interleukin-1 (IL-1), which is responsible for initiating inflammatory responses.

One of the most well-studied barriers is the blood-brain barrier (BBB), which separates the central nervous system (CNS) from the surrounding flow of blood in the skull. It is highly regulated and has selective permeability to small lipid molecules, blood, and gases. Larger, polar molecules are blocked by the tight junction cells that line the BBB. These cells play a crucial role in protecting the brain from foreign substances. When one suffers a TBI, these tight junction cells become lesioned, and the BBB increases its permeability and also activates neuroinflammatory cascades.

The authors point to numerous studies that have reported increased levels of IL-1 post-TBI, even lasting years after injury. The sustained elevation of IL-1 suggests that inflammation and increased permeability of the brain can be chronic if TBI is severe enough and may put the brain at risk for infections or toxic substances. Further, some studies have found that high levels of IL-1 are associated with a higher risk of epilepsy, neurodegenerative diseases, and weaker immune responses.

Although still a novel field, current immunological research suggests that the dysregulations of the body’s inflammatory response can help us understand post-TBI symptoms. The review authors highlight the need for further study into the differing effects of two kinds of IL-1 cytokines, IL-1α and IL-1𝛽. Looking into the future, the researchers suggest that "IL-1 is an attractive target for CNS barrier targeted interventions."

Mental Health

Therapist-guided internet-delivered cognitive behavior therapy (ICBT) exhibits efficacy in treating social anxiety disorder (SAD) in children and sdolescents

A study by Martina Nordh, PhD et al. found therapist-guided ICBT to be an efficacious and cost-effective treatment for social anxiety disorder (SAD), compared to an active comparator. The treatment devised by the research group consisted of “psychoeducation about SAD, gradual exposure to social situations, social skills training, focus shifting (from internal to external attention), reduction of safety behaviors and avoidance, replacement of overly negative thinking with adaptive thoughts, and construction of a plan for relapse prevention.” The comparator ISUPPORT, a treatment currently in use, notably lacked the theoretically active components of CBT for SAD (gradual exposure to social situations, for example).

“To our knowledge, no study evaluating ICBT for SAD has yet used an active comparator,” researchers wrote, stressing that comparing methods to treatments actively in use is “essential to distill the true effect of a behavioral intervention beyond the effects of practitioner attention and frequent monitoring and reporting of symptoms.”

Therapy participation consisted of 103 self-referred children (mean age 14, 77% girls), with 51 randomly assigned to 10 weeks of therapist-guided ICBT and 52 to ISUPPORT. The researchers note self-referral and ISUPPORT’s perceived lack of credibility as limitations and recommend modifying treatment length and therapist support in the future.

Concussion Alliance stresses the relevance this study holds for mTBI patients, as research has shown that “children who have suffered from a TBI (mild, moderate or severe) are at a higher risk of developing subsequent anxiety disorders.”

Youth

Studies find that children who experience a concussion are four times more likely to sustain another concussion

A study by Jacqueline van Ierssel et al. examined the “risk of concussion in children with a previous history of concussion” through a systematic review and meta-analysis from four electronic databases. The authors compared children ages 5-18 with and without a previous history of concussion. Overall, repeat concussion was evaluated using the Newcastle-Ottawa Scale.

From 732 identified studies, the authors selected seven to include in their analysis, representing approximately 3,000 children who had sustained a concussion and over 20,000 who did not. The authors found that a child who had suffered a concussion was four times more likely to sustain another concussion.

The study, published in the British Journal of Sports Medicine, concludes that “Children with a previous concussion are at a greater risk of concussion after returning to sport compared with children with no history of concussion.” Additionally, “clinicians should consider managing children with concussion more conservatively than adults as the increased risk of concussion is even more concerning given children’s previously established potentially increased vulnerability to concussion, potentially longer recovery times and potential for adverse long-term consequences during a sensitive period of neurodevelopment growth.”

Childhood is a time of rapid development, which means that executive function (self-regulation skills) and metacognitive skills (the capacity to understand and regulate their thoughts – memory, planning) may be more vulnerable to the deficits resulting from a concussion. Interestingly, a study by Heather T. Keenan et al., published in JAMA Network Open Pediatrics, suggests that a child’s executive function worsens from baseline concussion to 36 months post-concussion. Future research should explore the difference in concussion risk, stratified by sex, and evidence-based prevention measures.

CTE and Neurodegeneration

Study shows a link between repetitive traumatic brain injury and development of neurodegenerative diseases.

Eric N Anderson et al. performed a study, published in eLife, exploring how repetitive traumatic brain injury (TBI) may lead to neurodegenerative diseases such as amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD), Parkinson's disease (PD), and chronic traumatic encephalopathy (CTE).

The authors analyzed 2000 proteins in the brain tissues of animals (fruit flies and rats) exposed to repeated TBI. The researchers also studied brain tissue from 18 patients with either mild (9) or severe (9) CTE and age-matched controls (8). The study identified 361 proteins that significantly changed following TBI exposure. They particularly noted the upregulation of the nuclear pore complex (NPC), which regulates the transport of essential proteins. Any dysregulation of the NPC will affect transport efficiency and cell functionality.

Researchers also noted altered protein levels of TDP-43. Anderson explains that "although TDP-43 is a known indicator of neurodegeneration, it wasn't clear how repeated trauma promotes the build-up of TDP-43 in the brain."

As researchers further examined the connection between the NPC alterations and abnormal TDP-43 aggregation in TBI, they found an increase in nucleoporins (Nups). Changes in Nups production lead to impaired protein transportation, impaired communication, and decreased motor function.

Overall, this study demonstrates that TBI can lead to an over-accumulation of "neurodegenerative hallmark proteins." Hence, with repeated trauma to the brain, the likelihood of developing ALS, AD, PD, or CTE is heightened. Researchers are hopeful that we can develop therapeutic strategies to prevent TBI-induced neurological disorders with this knowledge.