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New research sheds light on alcohol use after brain injury
Traumatic Brain Injury Rehabilitation Update, Summer 1998
Those who do resume drinking may be compounding their problems rather than simply adding to them. Studies have suggested that the use of alcohol after TBI —even in “normal” amounts—is associated with poor neurological outcomes, including cerebral atrophy, poor performance on neuropsychological tests, deterioration of emotional and behavioral functioning during post-acute recovery, and the development of postconcussive symptoms after mild TBI.
The reason for these poorer outcomes is not known for certain, said Charles H. Bombardier, PhD, a rehabilitation psychologist at Harborview Medical Center in Seattle. One theory blames alcohol’s inhibiting effect on a process called neuronal sprouting.
“After injury, the brain reorganizes itself to compensate for the area that’s been damaged,” Bombardier said. “The cells don’t regenerate, but connections may reoccur between surviving nerve cells.” Alcohol interferes with neuronal sprouting, so it may therefore interfere with the brain’s reorganization process after TBI.
Some also believe that alcohol use contributes to seizures and may predispose a person with TBI toward getting another brain injury, Bombardier said. “Alcohol in large quantities definitely causes neurological impairment on its own,” he added. The brain tissues of alcoholics undergo a process of atrophy, in which the valleys on the surface of the brain become larger and the mountains become smaller. Also, drunkenness can mimic brain injury, impairing a person’s complex attention, memory, judgment, and balance.
“In persons who drink heavily, these impairments can last at least six weeks after the person stops drinking,” Bombardier said. “Alcohol can also have permanent effects on the brain, especially in people who are over 40 years old or those who have more than 10 drinks a day.”
Window of Opportunity
There is evidence that traumatic injury creates a window of opportunity in which survivors are more motivated to change their drinking behavior. This seems to be especially true for injuries that are alcohol-related, perhaps because such injuries force survivors to face the inescapable consequences of their drinking.
In a study published last year, Bombardier and two colleagues administered questionnaires to 50 patients with recent TBI who admitted using alcohol(3). The results indicated that these patients were more ready to change their drinking habits than general medical patients who were heavy drinkers. The highest “readiness to change” scores were found among subjects who had histories of alcoholism, higher daily consumption of alcohol, or whose accidents involved alcohol.
These higher scores do not mean that rehabilitation professionals should confront patients about their problem drinking during acute rehabilitation, however. “Resistance and denial are not so much personality traits of someone with an alcohol problem as the results of counterproductive behavior by the therapist, especially confrontational behavior,” Bombardier said.
His study was based on a model that divides behavior change into five stages: precontemplation, contemplation, preparation, action, and maintenance (see Stages of Change). To be effective, interventions should be tailored to the patient’s present stage on this continuum.
One way to accomplish this is to administer a readiness to change measure along with alcohol screening tests, and base any further assessment or intervention on the result, Bombardier said. Patients in the precontemplation stage may benefit most from nonconfrontational consciousness-raising strategies such as informing them of how their self-reported alcohol consumption compares to national norms, while those in the contemplation stage primarily need help exploring the pros and cons of change in order to resolve their ambivalence about taking action.
Motivational Interviews
Under a grant funded by the National Center for Injury Prevention and Control and the National Center for Environmental Health’s Disabilities Prevention Program, Bombardier is studying the effectiveness of a brief intervention during acute rehabilitation for preventing return to alcohol abuse after TBI. The intervention uses motivational interviewing(4), a treatment technique that assumes that the responsibility and capability for change lie within the patient, and that the therapist’s task is to enhance the patient’s motivation and commitment to change.
Bombardier’s intervention consists of two sessions. The first is a face-to-face interview in which numerous alcohol-related factors, including quantity and frequency of alcohol consumed and psychosocial consequences, are assessed. During the second session, the therapist provides the patient with personalized feedback that includes information on the impairment or risks associated with past and future drinking.
The therapist explicitly emphasizes the patient’s personal responsibility for change, provides clear advice to make a change in drinking, and gives the patient a menu of alternative strategies for changing problem drinking. “This information is provided with empathy and understanding, not confrontation, and in such a way as to reinforce the patient’s optimism about changing the behavior,” Bombardier said.
Bombardier and his colleagues have modified the standard motivational interviewing protocol to accommodate patients with recent brain injury. The intervention is usually carried out within a few days of discharge in order to maximize the patient’s cognitive recovery, and feedback given orally is backed up with simple written and graphic representations of the data. Feedback also routinely includes information on the increased risk of sustaining another TBI, increased risk of posttraumatic seizures, and the possibility that alcohol use may suppress cognitive recovery after TBI, and subjects are given the clear recommendation that they should consider abstaining from alcohol for at least one year after injury to facilitate recovery.
Preliminary results from a pilot study indicate that motivational interviewing may significantly improve the spontaneous trend toward reduced drinking after TBI, and may be especially valuable in the inpatient rehabilitation setting because it can be taught to nonspecialists and is brief enough to be integrated into increasingly short hospitalizations.
References
- Corrigan J, Lamb-Hart G, Rust E. A programme of intervention for substance abuse following traumatic brain injury. Brain Inj 1995;9:221-36.
- Kreutzer JS, Doherty K, Harris J, Zasler N. Alcohol use among persons with traumatic brain injury. J Head Trauma Rehabil 1990;5:9-20.
- Bombardier CH, Edhe D, Kilmer J. Readiness to change alcohol drinking habits after traumatic brain injury. Arch Phys Med Rehabil 1997;78(6):592-6.
- Miller WR, Zweben A, DiClemente CC, et al. Motivational enhancement therapy manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence. National Institute on Alcohol Abuse and Alcoholism Project MATCH Monograph Series, Vol. 2.
Sidebar:
The stages of change: how people change addictive behaviors
In their studies of how people change addictive behaviors, James O. Prochaska and his colleagues have identified five progressive stages of change:
Precontemplation: the person has no intention to change his or her behavior in the foreseeable future, and may be unaware of the problems it causes, although family members, friends, coworkers, etc. are often well aware of them. When persons in this stage seek help with their problem behavior, they usually do so because of pressure from others, and often feel coerced into changing. They may even demonstrate change as long as the pressure is on, but often quickly return to their old ways once the pressure is off.
Persons in the precontemplation stage can wish to change, but this is different from intending or seriously considering change in the next six months.
Contemplation: the person is aware that a problem exists and is seriously thinking about overcoming it, but has not yet made a commitment to take action. People can remain stuck in this stage for long periods, weighing the pros and cons of the problem and the solution.
Preparation: the person intends to take action in the next month and may have already taken some action toward modifying the problem behavior, such as attempting to limit the number of drinks. Although individuals in this stage may have made some reduction in the problem behavior, they have not yet reached the point of taking effective action, such as abstaining from alcohol abuse. However, they do intend to take such action in the very near future.
Action: the person modifies his or her behavior, experiences, or environment in order to overcome the problem. This is the stage at which change is most easily recognized and acknowledged by others, and it requires considerable commitment of time and energy.
Many people erroneously equate action with change, overlooking the important preparatory work done during the earlier stages and the effort necessary to maintain change after the action stage.
Maintenance: the person works to prevent relapse and consolidate the gains attained during the action stage. For addictive behaviors, this stage can last from six months to a lifetime.
Spiral Progression
Most people taking action to modify addictions do not succeed on their first attempt. Relapse and recycling through the stages occur quite frequently. Some people, discouraged by a sense of failure and shame, relapse all the way to the precontemplation stage. However, many cycle back to the contemplation or preparation stage, where they begin to consider plans for their next action attempt while trying to learn from their recent efforts.
Because most relapsers do not revolve endlessly in circles or regress all the way back to where they started, Prochaska et al. visualize their stages of change as a spiral rather than a linear or circular progression (see figure).
This diagram shows how a person might cycle through the stages of change in a spiral pattern.
Source
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol 1992;9:1102-1114.