BrainLine talks with Dr. Maria Mouratidis about the treating the patient and avoiding stove piping.
One of the advances in science and practice that has become more evident. It's not necessarily new, but more in the forefront is how are we understanding overlapping disorders and problems? Our patients are coming back with complicated injuries that are both physical, psychological, and brain injury oriented. Trying to understand what are the relationships between brain injury, for example, and post-traumatic stress disorder, for example. And post-traumatic stress disorder is only one of several psychological consequences of exposure to trauma or stress. For example, the incidence of depression is as high or higher than post-traumatic stress disorder. Substance abuse is fairly prevalent, especially for untreated PTSD or depression. And the person resorts to using substances to deal with emotional pain. Any by trying to understand and create programs that are integrated, that integrate both the psychological health aspect of injuries and illnesses and well-being-- because we're also focusing on the patient's strengths and well-being. That's why we use the term psychological health. In addition to their brain injuries, and trying to understand that relationship and create an assessment and treatment program that mirrors the patient, that mirrors that integration. So for example, stovepiping--which is a term that is used to explain when everything is cut off and is separate. So we would have the PTSD or the psychological health over here. Or we'd have the TBI traumatic brain injury over here and they wouldn't integrate. So a common example that most people can probably relate to is the problem of the depressed alcoholic. Depression and alcoholism co-exist often. There could be a variety of biological, psychological, and social explanations of why that might be--and genetic, as well. However, treatment programs that don't deal with both problems simultaneously, can often result in patients not getting care or not getting optimal care. So, for example, if the depressed alcoholic patient goes to the mental health department, and the mental health department says, "Well, of course, you're this depressed. Look at how much you're drinking. Please go to the substance abuse treatment program, and when your drinking is under control, if you're still depressed, please come and see us." So the patient goes to the substance abuse clinic, and the substance abuse clinic says, "Well, of course, you're drinking this much. Look at how depressed you are. Please go to the mental health clinic, and once your depression is under control, if you're still drinking this much, please come back and see us." And so that patient, as you might imagine, doesn't get care, doesn't get very much care. Similarly, trying to understand that psychological injuries and brain injuries are interwoven and that it is important to provide education and treatment and assessment, in a coordinated fashion that takes into account their brain injuries. So, for example, being able to modify existing treatments for post-traumatic stress disorder for patients that have a brain injury might mean the patient may do better in individual therapy than in group therapy. It may mean that he or she may need 3 20-minute sessions over the course of a week instead of one one-hour session. They might need the same assignment gone over several times and work on the same assignment for several weeks. And the same thing would be true for substance abuse programs. Modifying existing programs that patients who have cognitive deficits, can succeed in them. And, in the absence of that, when the patient attempts those treatments and fails, it contributes really to more symptoms because they feel demoralized, more hopeless. And that is one of the challenges that our field--it is incumbent upon us to move that forward, so that patients can benefit from treatments as we continue to do research. And it helps us want to understand the mechanisms of those disorders better, but it's important to keep in mind that we are treating a patient. We are not treating a disorder, so by having an integrated plan that identifies the patient's strengths, as well as their areas of difficulty, and a plan for remediating ameliorating those difficulties is what is more important than so much what we happen call it.
Posted on BrainLine March 4, 2009.
Dr. Mouratidis is a licensed neuropsychologist and currently the command consultant and subject matter expert for Traumatic Brain Injury and Psychological Health at the National Naval Medical Center.