Alcohol abuse and traumatic brain injury

Gregory A. Jones

Alcohol Abuse and Traumatic Brain Injury

The role of alcohol and other drug abuse in traumatic brain injury is well documented, with an incidence of intoxication at injury of approximately 50 percent. Because of cognitive, behavioral, and functional deficits, brain injury survivors pose unique challenges to the alcoholism treatment field.

Head Injury and Alcohol Abuse

Alcohol consumption is a strong predisposing factor in traumatic brain injury (Kerr et al. 1971; Field 1976; Parkinson et al. 1985). In studies addressing head injury and alcohol use specifically, elevated blood alcohol levels were present in more than 40 percent of the patients seen in emergency rooms or admitted to hospitals because of traumatic head injury (Galbraith et al. 1976; Rutherford 1977; Brismar et al. 1983; Parkinson et al. 1985). In the most recent study of head-injured patients at a North American trauma center, 67 percent of those tested for blood alcohol levels showed evidence of alcohol use and more than one-half (51 percent) were intoxicated, using a definition of 100 mg/100 ml (100 mg/dl) (Sparadeo and Gill, in press). This is consistent with a Swedish study showing a 58-percent rate of intoxication among those tested (Brismar et al. 1983).

In a study of neuropsychological deficits in alcoholics, psychometric test performance was significantly lower among head-injured alcoholics than among those who had not experienced head injuries (Hillbom and Holm 1986). Both groups scored lower than the general population on most test items. Results of the study also suggest that the incidence of head injury in alcoholics is two to four times higher than in the general population.

Other studies have documented the role of alcohol and other drug abuse in traumatic brain injury. Alterman and Tarter (1985) found the risk for head injury in patients with familial alcoholism to be almost twice that of patients without such history. In a study of 75 severely brain-injured patients (Tobis et al. 1982), 51 had histories of alcohol abuse and 29 had histories of illicit drug use. The number of patients using both alcohol and other drugs was not specified. Sparadeo and Gill (in press) found that 25 percent of their sample had alcohol histories documented in their medical records. A recent survey of brain injury rehabilitation programs around the country reported that approximately 55 percent of patients had some alcohol or other drug abuse problems before the brain injury and 40 percent had abuse problems described as moderate to severe (NHIF 1988).

Psychosocial Consequences of

Head Injury

Traumatic brain injury can mean many long-term psychological and behavioral difficulties. Because every head injury is different, it is impossible to predict the exact outcome for the survivor. While generalizations can be made, it is important that treatment professionals and other concerned persons note that individuals may present few problems or a combination of several problems. Some deficits following head injury are painfully obvious; others are extremely subtle and become evident only during intensive clinical evaluation (Lezak 1978b). Alcohol and other drug abuse professionals working with head injury survivors commonly deal with clients who appear to function normally in most settings but who are unable to understand the concepts of alcohol or other drug addiction or to benefit from traditional treatment modalities.

To work effectively with survivors of traumatic brain injury, it is vital that alcohol and other drug abuse professionals acquaint themselves with the unique problems these clients present. The following discussion of the more common consequences of head injury is drawn from general knowledge in the field of brain injury rehabilitation. For more detailed information, the reader is directed to Levin and colleagues (1982), Edelstein and Couture (1984), Lezak (1978a, 1978b, 1983), and Brooks (1984).

Impairment of memory-Post-traumatic amnesia is one of the most common consequences of head injury. For many survivors, memory for events and conditions prior to their injury is generally intact while short-term memory for recent events is disrupted. In practical terms, this means that brain injury survivors might remember the events of their high school prom in great detail but forget what was served for breakfast this morning. Some survivors may try to fill in the gaps with confabulation, a usually sincere attempt to mask memory deficits that is sometimes misinterpreted as dishonesty. Impairment of recent memory makes it difficult for many survivors to retain information and generalize new learning from one setting to another.

Decreased self-awareness and insight - Many survivors of traumatic brain injury experience a reduced capacity for insight, self-monitoring, and awareness. They may have difficulty seeing the relationship between their behavior and the resulting consequences and may experience confusion or frustration in their attempt to understand situations.

Impairment of abstract reasoning - The ability to integrate information and to reason in the abstract are vital skills in our "information age." Unfortunately, many brain injury survivors experience a reduction in these skills and a corresponding increase in concrete thought. In assessment, these problems are sometimes detected in proverb interpretation tasks, where clients may be unable to move beyond the concrete content of a simple saying to its more abstract meaning (Lezak 1983).

Deficits of attention and concentration - Many brain injury survivors have difficulty attending to complex tasks. They are more easily distracted by extraneous stimuli and have a reduced ability to concentrate and focus.

Inappropriate social behavior - Problems with impulsiveness and disinhibition are common among survivors of traumatic brain injury. They may giggle or make inappropriate comments; they may interact in a rude or aggressive manner. Excessive flirting or more overt sexual gestures are sometimes observed. Some survivors become withdrawn and isolated; others demonstrate behavior that is self-centered and perceived as immature. They may have a low tolerance for stress and be easily frustrated.

Changes in mood and affect - Some brain injury survivors experience changes in emotional responses. Affect may become flat or blunted with little expression of either joy or sadness. Emotions may become labile, with broad swings of mood. Anger, along with feelings of profound grief, may be accompanied by a clinical depression.

Language and communication deficits - Damage to the brain may result in oral-motor problems, such as slurring of speech and difficulty forming words (dysarthria). Of a more serious nature are deficits of comprehension or language disorders known as aphasia. The brain injury survivor may not understand everything heard and may not be able to find the words or formulate the sentences necessary to respond. These problems may result in increased frustration or confusion for survivors and concerned persons like.

Sensory deficits - There is a high incidence of visual-perceptual problems following head injury; reading and writing abilities may be impaired. Tinnitus (ringing in the ears) or other disorders may affect hearing.

Goal-formulation and problem-solving difficulties - Unrealistic or undefined goals are common among brain injury survivors. When they do have clear and reasonable objectives, many survivors have a reduced ability to solve problems and to achieve their goals without sufficient structure and support.

Vocational/educational problems - Because of the permanence of brain damage and the long-term nature of its consequences, few head injury survivors are able to return to their premorbid (preinjury) level of vocational or educational placement. Those who have survived mild injuries often retain the cognitive skills necessary to return to work but may experience reduced tolerance for stress and increased fatigue.

Impact on the family and community - The functional impairments from traumatic brain injury, though serious, do not usually require that survivors be institutionalized. In their study of severely brain-injured patients, Tobis and colleagues (1982) reported that 72 percent had been discharged to return home; the rate of community discharge is even higher among survivors of moderate and mild injuries. As a result, families and communities must face the issue of the reintegration of survivors who may have experienced profound changes in their abilities and personalities.

There is a high incidence of divorce following head injury. Reports of depression and somatic disorders among spouses or children of survivors are common. Many survivors experience social isolation and marginalization as a result of their injuries; peer relationships and support systems are often radically altered.

ALCOHOL AND OTHER DRUG ABUSE

FOLLOWING HEAD INJURY

When the complex variable of alcohol or other drug abuse is considered within the context of the social reintegration of brain injury survivors, the potential for serious problems seems clear. Given that the population as a whole has a high rate of documented alcohol abuse prior to injury (and that alcohol abuse is a key factor in the etiology of brain injury), it is reasonable to suggest that alcohol consumption following injury would also be a problem. This is especially so, considering that the great majority of brain injury survivors are discharged into the community, where alcohol and other drugs are readily accessible. Reilly and colleagues (1986) have identified four factors that increase the risk of alcohol abuse after traumatic injury: 1) increased discretionary time and boredom, 2) increased enabling from family and friends, 3) uncertainty over the ability to return to work or to function effectively at work, and 4) physical limitations and posttraumatic mood change. All of these factors can be found among most brain injury survivors.

While anecdotal reports are numerous, there are few data on the incidence of alcohol and other drug abuse after brain injury. In one of the first attempts to document postinjury use patterns, Sparadeo and Gill (1988) found that 54 percent of the survivors they surveyed had returned to alcohol use after completion of rehabilitation. This was in spite of the fact that the majority had been injured in motor vehicle accidents while under the influence of alcohol or other drugs. The two major factors influencing abstinence in the remaining 46 percent were the presence of a seizure disorder or placement in long-term, supervised living situations.

CLINICAL CONSIDERATIONS FOR ALCOHOL

AND OTHER DRUG ABUSE PROFESSIONALS

Brain injury survivors present unique problems for counselors and other professionals because the psychosocial and functional consequences of brain injury complicate the already difficult tasks of evaluation and treatment. Given what is known about traumatic brain injury and alcohol abuse, it is likely that most professionals will occasionally encounter brain injury survivors; those practicing in urban areas or among minority populations should give special attention to the incidence and consequences of brain injury. Cognitive and neurobehavioral problems may have an impact on the following areas of practice:

Assessment and diagnosis - Memory deficits tend to make brain injury survivors poor historians, and subjective reports of alcohol or other drug use patterns may be inaccurate. Impaired insight may keep survivors from recognizing that their use patterns are problematic. Because many mild head injuries go unreported (Hillbom and Holm 1986), it is recommended that evaluators inquire about previous accidents or injuries. A simple question such as "Have you ever been knocked unconscious?" may be helpful in a preliminary screening for possible head injury status.

Because brain injury survivors sometimes have difficulty with abstract thought and more complex concepts, long or complicated assessment tools may be ineffective. Consideration should be given to the use of a brief diagnostic tool such as the CAGE Questionnaire (Ewing 1984). Utilization of data from neuropsychological or rehabilitation evaluations is also suggested.

Changes in functional abilities are often the most reliable and measurable symptoms of alcohol or other drug abuse by head injury survivors. Once the practitioner has determined that such changes are not the result of other medical conditions and can be associated with known incidents of consumption, decreasing skills or increasing patterns of maladaptive behavior may provide observable diagnostic criteria for alcohol abuse. For the survivor, these declines in functional ability can be devastating, limiting involvement in rehabilitation or vocational programming. Threatening to discontinue essential services may motivate the brain injury survivor to respond to intervention.

Intervention and treatment - Insight-oriented approaches are prevalent among treatment models for alcohol and other drug abuse (Logan et al. 1987). However, the usefulness of psychodynamic approaches with brain injury survivors is questionable because of the high incidence of cognitive deficits, such as impaired abstract reasoning and decreased insight. Behavioral difficulties of survivors, such as impulsiveness and disinhibition, may cause conflict or tension in group sessions, reducing the effectiveness of the sessions. Rather than receiving support and affirmation from group members, brain injury survivors may be stigmatized or characterized as disruptive. These problems also may be experienced in meetings of self-help groups, such as Alcoholics Anonymous, where significant neurobehavioral problems attributable to head injury may be viewed as "character defects."

In the case of brain injury rehabilitation, the prevailing behavioral model of intervention relies on achieving positive long-term outcomes through a series of short-term goals (Goldstein and Ruthven 1983; Wood 1987). This approach may be more effective with inpatients than with alcohol-or other drug-abusing outpatients who live in community settings where factors influencing behavior cannot be as easily monitored.

In a manual examining methods of counseling head injury survivors in the community, Blanchard (1984) emphasizes the need for practitioners to understand the cognitive and behavioral consequences of head injury and to rely more on such basic counseling techniques as respect, authenticity, and empathy.

Case management - Agencies and individual practitioners serving brain injury survivors who abuse alcohol or other drugs are responsible for addressing their often complex needs and either providing necessary services or making appropriate referrals. Effective case management usually requires an interdisciplinary approach involving social workers, psychologists, occupational and physical therapists, vocational counselors, and specialists in community reentry. Professionals must acquaint themselves with available programs, since referrals to economic or housing assistance programs and consultation with medical or public health professionals may be necessary. Services for spouses or families of clients also should be considered, because the dual problems of disability and alcohol or other drug abuse put intense pressure on family systems.

FUTURE DIRECTIONS

The outlook for future development in the area of alcohol or other drug abuse and brain injury is mixed but hopeful. There remains a troubling avoidance of the problem on the part of clinicians who provide acute care to brain-injured persons. In a recent and quite revealing survey of 154 trauma centers in 43 States, only 55.2 percent regularly measured blood alcohol levels upon admission (Soderstrom and Cowley 1987). In a retrospective chart review of 379 trauma patients seen in the emergency room of an urban teaching hospital, Chang and Astrachan (1987) found that although 43 patients were suspected or known to have used alcohol or other drugs, none was referred for further evaluation.

Rehabilitation providers, on the other hand, have responded to the problem of alcohol abuse and brain injury with a positive initiative. In 1987, the Professional Council of the National Head Injury Foundation convened a Substance Abuse Task Force. The work of this group, though preliminary, has helped to define the problem from both an etiological and clinical perspective and to suggest potential solutions. A positive finding of the task force is that "50 percent of acute and 83 percent of the postacute rehabilitation programs surveyed are addressing alcohol and other drug abuse within their range of services (NHIF 1988).

Better identification and intervention strategies for those with traumatic brain injury will succeed only if a corresponding initiative is undertaken within the alcohol and other drug abuse treatment field. Recommendations for development of effective services for brain injury survivors include improvement in the following areas:

Research - The number of brain injury survivors being served within the current alcohol and other drug abuse treatment system is not documented. To determine the effectiveness of current programs and methods, it is essential that this population be profiled. While it may be reasonable to suppose that brain-injured persons who abuse alcohol or other drugs have a high incidence of discharge from treatment centers for failure to meet treatment goals and are more prone to relapse than those without brain injuries, this has not been established.

Education - Perhaps the greatest barrier to the effective identification and treatment of brain injury survivors with alcohol or other drug abuse problems is the continued lack of awareness among professionals. Medical and rehabilitation professionals would benefit from additional training in assessing alcohol and other drug abuse. Professionals treating clients who abuse alcohol and other drugs need more information about brain injury and its consequences. Alcohol and other drug abuse counselors should be encouraged to familiarize themselves with the brain injury rehabilitation programs and services in their communities.

Interdisciplinary dialogue and cooperation - Communication between the rehabilitation and alcohol and other drug abuse fields merits further development, especially where brain injury is concerned. Professionals in both fields have much to learn from each other.

Preliminary attempts to examine and integrate information from various fields have contributed much to the effort. With additional research, education, and improved interdisciplinary cooperation, the outlook is hopeful.

REFERENCES

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BLANCHARD, M.K. Counseling Head Injured Patients. Albany, NY: New York State Head Injury Association, 1984.

BRISMAR, B.; ENGSTROM, A.; AND RYDBERG, U. Head injury and intoxication: A diagnostic and therapeutic dilemma. Acta Chirurgica Scandinavica 149:11-14, 1983.

BROOKS, N. Closed Head Injury: Psychological, Social and Family Consequences. Oxford: Oxford University Press, 1984.

CHANG, G., AND ASTRACHAN, B. Identification and disposition of trauma patients with substance abuse or psychiatric illness. Connecticut Medicine 51:4-6, 1987.

EDELSTEIN, B.A., AND COUTURE, E.D. Behavioral Assessment and Rehabilitation of the Traumatically Brain-Damaged. New York: Plenum Press, 1984.

EWING, J.A. Detecting alcoholism: the CAGE questionnaire. Journal of the American Medical Association 252(14):1905-1907, 1984.

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LOGAN, S.L.; MCROY, R.G.; AND FREEMAN, E.M. Current practice approaches for treating the alcoholic client. Health and Social Work 12(3):178-186, 1987.

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The author thanks Francis R. Sparadeo, Ph.D., for generously providing information and manuscript material necessary to the completion of this article.

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