Category: Education

Behavioral Changes After a Traumatic Brain Injury

In a previous blog post, I discussed the emotional changes that may result from traumatic brain injury (TBI). Another consequence of TBI that patients may not recognize themselves are behavioral changes. It is crucial that loved ones pay attention to shifts in behavior in order to provide support and connect patients with the care they need. It is important to note that behavioral changes resulting from brain injury can vary significantly, given that no two brain injuries are identical. In this post, I outline several changes that survivors and their loved ones or caregivers may benefit from understanding.

Changes in Personality After a TBI

Brain injury survivors may display the same personality traits as prior to their injury; however, these traits may be amplified. For instance, an individual who was calm and not easily excitable prior to their brain injury may come across as apathetic or aloof post-injury. There may even be instances where the individual displays traits that are conflicting with their pre-injury temperament, as in the case of someone who was demure but becomes highly outspoken and outgoing. Regardless of the type of personality change, it can be challenging for the individual to accept or even acknowledge. Increased understanding and acceptance from loved ones and friends is imperative to adapting to changes in personality. Making negative comments or judgments about how different the individual’s personality is can be detrimental to their emotional and mental well-being.

Executive Functions & Memory Changes Impacting Behavior

In a blog post about the importance of routines and TBI, I described executive functions as higher-order cognitive tasks, which include planning, attention, problem-solving, working memory, emotional self-regulation, initiation and inhibition of behavior. Below I have outlined the ways in which impaired cognitive functions, in particular, the executive functions, may impact behavior.

  • Impulsivity: Reduced control over the initiation and inhibition of behaviors can lead to impulsivity. Brain injury survivors, particularly those who have experienced frontal lobe injuries, may engage in more risky activities without considering the consequences. Such activities may include impulsive spending or reckless driving to name some examples. The individual may also be more willing to speak out on things that others might choose to filter and make crude, hurtful, or inappropriate remarks. Inappropriate remarks or behaviors may even be sexual in nature. Angry outbursts can also be a hallmark of impulsivity, even if this was not at all part of the individual’s temperament prior to the injury. It is important to understand that brain injury survivors do not have control over these behaviors but can be provided with tools to manage them. These tools may include thoughtful feedback, practicing appropriate social skills, as well as implementing cues that indicate the individual should reflect on their actions in the moment.
  • Mental Flexibility: Mental flexibility can be compromised as a result of brain injury. TBI survivors may be more rigid in their thinking. In other words, they may have difficulty adapting to changes that arise from situations or their environment. Generally, people can modify their thoughts and/or actions to adapt to unforeseen changes; however, this can be particularly taxing on those dealing with TBI. Survivors may also have diminished ability to see more than one solution to a problem. It is crucial to acknowledge that these reactions to a lack of structure and predictability are not a desire to be “difficult” or “stubborn” on the part of the injured person. Sometimes perseveration, which can be described as the repetition of thoughts, behaviors, or statements, may also be prevalent. Although individuals with TBI may become aware of perseverative behaviors, they may not be able to cease them on demand. Patience, the use of cues, and encouraging task switching is essential when dealing with this particular symptom.
  • Memory and Concentration: It is common for TBI survivors to experience memory deficits. In some instances, they will not be able to remember periods of time, particularly those that occur post-injury. It is common for short-term memory to be adversely affected, making learning new concepts a major challenge. Compensatory strategies, such a writing things down, repetition, experiential learning, and maintaining routine/structure, can address memory deficits. Individuals who have suffered a brain injury may be more prone to distractibility, which may manifest as having difficulty focusing on more than one task or maintaining focus during a conversation. This may also impact ability to learn new concepts or remember details. Loved ones should be patient and understanding, creating an environment that seeks to reduce distractions, prevent overstimulation, and enhance memory cues.

This list is not exhaustive by any means. It is essential for those with TBI and their loved ones to be open to ongoing learning in order to maximize potential for rehabilitation and to manage adapting to changes. A lack of insight or self-awareness can be an effect of TBI and can very well cause impediments to addressing such behavioral changes. Clinicians at PNBC are equipped with the skills and training to promote insight, improve optimism and self-esteem, as well as provide a sense of control over what can feel like dramatic changes for patients and family members alike. We aim to foster growth and self-empowerment by educating patients and their families, while keeping in mind the barriers that require empathy and understanding.

Written by: Beverly Sharifian, MA, APCC

Ms. Sharifian is an associate professional clinical counselor at Pacific Neurobehavioral Clinic, PC.

Food and the Brain

You are what you eat. It’s a cliché phrase that most of us have heard but probably have not put much thought into. We know that certain types of diets can lead to health problems, such as obesity, diabetes, and high cholesterol, but did you know that what you eat can also have an impact on your brain? Which, in turn, can have affect your mood, energy level, and cognitive functioning?

Historically, nutritional science has not been emphasized in the study of psychiatric or neurologic conditions. It has only been within the last few years that we are beginning to have a better understanding of the relationship between nutrition and the brain. The following lists just a few tidbits of information to demonstrate the importance of food on our brain functioning.

Food and the Developing Brain

Nutritional deficiencies in childhood could have an impact on the developing brain. For example, iron deficiencies and lack of essential fatty acids have been associated with poor myelination of brain cells[1], which could lead to problems with processing speed and attention. Studies have also shown that children diagnosed with ADHD also have a very high rate of magnesium deficiency. In one study, 95% of the ADHD group tested had a magnesium deficiency! [2] Thus, ensuring proper nutrition in children exhibiting behavioral or cognitive problems is an essential first step before moving to more drastic measures such as prescribing controller prescription medications.

Food and the Adult Brain

A healthy diet still has its uses in the adult brain. Our brain is a very busy organ that is not only in charge of our thinking processes and feelings but sending signals to the rest of our body to control its functioning. The brain requires a lot of energy to run, and the source of that energy is largely in the food that we eat. Just as putting in high-grade gasoline can keep a car running efficiently in the long-term, the quality of the food that we eat will also maximize our brain health.

It is important to eat a wide variety of food that provides all the essential nutrients that our bodies need to function efficiently. A poor diet lacking in certain nutrients can lead to “brain fog” symptoms such as fatigue, difficulties concentrating, and slower processing. We have all experienced these symptoms to some degree (think to when you last tried to do something cognitive complex while on an empty stomach!)

Furthermore, nutritional deficiencies have been associated with a number of different neuropsychological symptoms. For example. vitamin D and vitamin B (particularly B12)[3] deficiencies are associated with depression as well as cognitive impairment.[4]  However, too much of a mineral can also lead to problems, as this often leads to development of free radicals that can damage cells. Iron toxicity has been associated with neurodegenerative diseases like Alzheimer’s disease or Parkinson’s disease.[5]

Preventing Risk Factors for Cerebrovascular Disease

Using the analogy of food as fuel, think of your blood vessels as the pumps that are feeding your brain. Diets that are high in unhealthy fats can lead to clogging of those pumps which can lead to reduced blood and oxygen flow to the brain over time. Likewise, too much protein or too much glucose in the bloodstream can also lead to oxidation and hardening of blood vessels over time, which narrows the pathways for blood flow. This is why hypertension is considered to be the biggest risk factor for strokes. Diabetes and high cholesterol are other conditions that can lead to cerebrovascular changes over time. A proper diet to reduce these risk factors is vital.

Special Diets to Prevent Neurological Symptoms

In general, a balanced diet with lots of vegetable varieties, complex carbohydrates, and healthy fats is best for our general physical and brain health. However, some people may require a different ratio of macronutrients (proteins, fats, carbohydrates) to help with specific health conditions. For example, several studies have shown that keto diets may be effective in preventing seizures in children with epilepsy.[6] More recent studies are also looking into ketones providing a neuroprotective effect against neurodegenerative conditions, such as Alzheimer’s disease, though this is still up for debate.[7] However, it is cautioned that a ketogenic diet can lead to deprivation of nutrients that would be found in a more balanced diet. Consideration of starting a keto diet should be discussed with one’s physician and ideally a dietitian to determine a healthy meal plan.

The Microbiome

Most recently, there has been an explosion of research investigating the microbiome, which is the universe of bacteria that lives within our bodies. These bacteria outnumber our human cells, and they play a role in digestion and the immune system. Gut bacteria imbalances have been associated with inflammatory conditions such as irritable bowel disease.[8]

Furthermore, we have learned that there is bidirectional communication between the gut and the brain through several different pathways. Studies have suggested that, at least in rats, certain bacteria found in the gut appears to influence the development of emotional behavior, stress- and pain-modulation systems, and brain neurotransmitter systems.[9] Further research is being conducted on how this translates to human beings.

In short, science is finally catching up to examine the interconnection between nutrition with neuropsychiatric conditions. There is still much to learn, but it is apparent that what we eat can have profound effects on our general health, which includes our brain!

Nutritional Counseling at PNBC

Nutrition is something that is often overlooked that we at PNBC feel is important to include as part of a comprehensive treatment plan for neuropsychological conditions. We are happy to announce that we will soon be offering nutritional counseling services with a registered dietitian (RD) who will work in tandem with our psychologists and therapists.


Written by Delia Silva, PsyD, ABPP-CN. Dr. Silva is a board-certified neuropsychologist and owner of Pacific Neurobehavioral Clinic.


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[1] Yehuda, S., Rabinovitz, S., & Mostofsky, D. I. (2006). Nutritional deficiencies in learning and cognition.

[2] Kozielec, T., & Starobrat-Hermelin, B. (1997). Assessment of magnesium levels in children with attention deficit hyperactivity disorder (ADHD). Magnesium Research10(2), 143-148.

[3] Oh, R., & Brown, D. L. (2003). Vitamin B12 deficiency. American family physician67(5), 979-986.

[4] Etgen, T., Sander, D., Bickel, H., Sander, K., & Förstl, H. (2012). Vitamin D deficiency, cognitive impairment and dementia: a systematic review and meta-analysis. Dementia and geriatric cognitive disorders33(5), 297-305.

[5] Altamura, S., & Muckenthaler, M. U. (2009). Iron toxicity in diseases of aging: Alzheimer’s disease, Parkinson’s disease and atherosclerosis. Journal of Alzheimer’s Disease16(4), 879-895.

[6] Levy, R. G., Cooper, P. N., Giri, P., & Weston, J. (2012). Ketogenic diet and other dietary treatments for epilepsy. Cochrane database of systematic reviews, (3).

[7] Włodarek, D. (2019). Role of ketogenic diets in neurodegenerative diseases (Alzheimer’s disease and Parkinson’s disease). Nutrients11(1), 169.

[8] Morgan, X. C., & Huttenhower, C. (2012). Human microbiome analysis. PLoS Comput Biol8(12), e1002808.

[9] Mayer, E. A., Tillisch, K., & Gupta, A. (2015). Gut/brain axis and the microbiota. The Journal of clinical investigation125(3), 926-938.

CBT-I for Troubled Sleep

Having trouble sleeping lately? Whether it involves difficulty falling asleep, staying asleep, and/or feeling restless the next day, it is no wonder that with the ongoing pandemic, there has been a surge of troubled sleepers worldwide. Some experts are even coining the term “coronasomnia” for the increased COVID-19-related sleep issues, creating a vicious “insomnia-causes-stress-causes-more-insomnia cycle” (UC Davis Health, 2020).


A recent report from the National Institutes of Health (NIH; Morin & Carrier, 2020) emphasized a study that revealed increased rates of clinically significant insomnia along with more acute stress, anxiety and depression in response to the pandemic (Lin et al., 2020). There is sufficient evidence demonstrating how a lack of sleep can have a range of negative health impacts, ranging from depression to an increased risk for heart conditions. Of concern, is that these sleep disturbances may become chronic and endure well after the pandemic. Thus, the individuals who develop sleep disturbances during COVID-19 may be at greater risk for long-term adverse health outcomes, exemplifying the “call for concerted public health interventions” (Morin & Carrier, 2020). Correspondingly, the European CBT-I Academy Task Force has compiled some practical recommendations available to the public to help individuals manage sleep disturbances during the pandemic (Altena et al., 2020), you may find that article here.


What is CBT for Insomnia (CBT-I)?

If you feel that your insomnia is getting out of control and you are having difficulty sleeping lasting for weeks, you may benefit from Cognitive Behavioral Treatment for Insomnia (CBT-I). CBT-I was developed and tested by Dr. Gregg Jacobs at Harvard Medical School and the University of Massachusetts Memorial Medical Center (Jacobs, 2020). This treatment is a structured, evidence-based program which aims to help individuals relearn how to sleep. The program is brief (i.e., six weeks), which includes an initial evaluation followed by five sessions with a CBT-I certified provider. Furthermore, CBT-I is covered by most insurance companies.


During the CBT-I sessions, individuals are taught:

  • how to change sleep thoughts and behaviors.
  • lifestyle habits that improve sleep
  • relaxation skills


Moreover, CBT-I has been endorsed by the NIH, New England Journal of Medicine, the Lancet, American Psychological Association (APA), Consumer Reports, and the American College of Physicians as an effective and preferred method for treating chronic insomnia (Jacobs, 2020).


How Effective is CBT-I?

Research on CBT-I (Jacobs, Benson, & Friedman, 1996; Jacobs, Pace-Schott, Stickgold, & Otto, 2004; Morin, 2004; Morin et al., 1999, 2004, 2006; Wu, Bao, Zhang, Deng, & Long, 2006; Wu, Appleman, Salazar, & Ong, 2015) shows that:

  • 75% of insomnia patients experience significantly improved sleep
  • 85- 90% reduce or eliminate sleeping pills
  • CBT is more effective than sleeping pills


Find a CBT-I Therapist

If you are interested in learning more about CBT-I, please feel free to contact PNBC for additional information.


Written by Angela J. Patino, Psy.D. Dr. Patino is a bilingual clinical and forensic psychologist and CBT-I certified provider at PNBC. She is currently offering CBT-I telehealth sessions with select clients.



Altena, E., et al. (2020). Dealing with sleep problems during home confinement due to the COVID-19 outbreak: Practical recommendations from a task force of the European CBT-I Academy. Journal of Sleep Research. doi: 10.1111/jsr.13052.

Jacobs, G. (2020). CBT-I Treatment. Retrieved from

Jacobs, G., Benson, H., & Friedman, R. (1996). Perceived benefits in a behavioral medicine insomnia program: A clinical report. American Journal of Medicine, 100, 212-216.

Jacobs, G., Pace-Schott, E., Stickgold, R., & Otto, M. (2004). Cognitive behavioral therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison. Archives of Internal Medicine, 164, 1888-1896.

Lin, L., et al. (2020). The immediate impact of the 2019 novel coronavirus (COVID-19) outbreak on subjective sleep status. Sleep Medicine, S1389-9457(20)30221-5. doi: 10.1016/j.sleep.2020.05.018

Morin, C. (2004). Cognitive-behavioral approaches to the treatment of insomnia. Journal of Clinical Psychiatry, 65(16), 33-40.

Morin, C., Bastien, C., Guay, B., Radouco-Thomas, M., Leblanc, J., & Vallieres, A. (2004). Randomized clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. American Journal of Psychiatry, 161, 332-342.

Morin, C., Bootzin, R., Buysse, D., Edinger, J., Espie, C., & Lichstein, K. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29(11), 1398-1414. doi: 10.1093/sleep/29.11.1398

Morin, C. & Carrier, J. (2020). The acute effects of the COVID-19 pandemic on insomnia and psychological symptoms. Sleep Medicine. doi: 10.1016/j.sleep.2020.06.005

Morin, C., Hauri, P., Espie, C., Spieldman, A., Buysse, D., & Bootzin, R. (1999). Nonpharmacologic treatment of chronic insomnia: An American Academy of Sleep Medicine review. Sleep, 22(8), 1134-1156. doi: 0.1093/sleep/22.8.1134

UC Davis Health. (2020). COVID-19 is wrecking our sleep with coronasomnia – tips to fight back. Retrieved from–tips-to-fight-back-/2020/09

Wu, J., Appleman, E., Salazar, R., & Ong, J. (2015). Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: A meta-analysis. JAMA Internal Medicine, 175(9), 1461-1472. doi: 10.1001/jamainternmed.2015.3006

Wu, R., Bao, J., Zhang, C., Deng, J., & Long, C. (2006). Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychotherapy and Psychosomatics, 75, 220-228.

Making Self-Care a Priority 

It is hard to believe 2021 is less than 90 days way. This year, with all of the many challenges, seems to be flying by. With the transition to working from home, many employees have found themselves even busier than when they were working in the office. Add to thatschool-aged and/or college-aged distance learnersand perhaps another adult or two also working from home, you can begin to feel like an afterthought in your own mind. The demands for your attention, your great ideas, your support, your space, your time…can feel endless. It is easy to get caught up in the next thing on your to do lists, help a colleague with the new account at work, volunteer for that special committee, or other ways you prioritize other people’s needs over your own.  

When you continue in these cycles of constant giving, without taking time to refuel or refill yourself back up, the quality of your giving can deteriorate without you realizing it. Your patience may run thin, your temper may shorten, and before long the “giving” that once gave you pleasure, now feels exhausting. Simple acts of self-care can keep you energized and strengthen to thrive even when it feels as though you are constantly giving. 

What is Self-Care?  

Self-care is intentionally being good to yourself; taking care of yourself in a way that is sustaining for youThis will look different from person to person, and that is okay. What I need can be different than what you need because we are different people. Self-care is not being selfish, particularly if there are many people around you that need you and rely on you. It does not have to be an expensive purchase or all-day adventure…although those could certainly qualify as self-careThink about the last time you boarded an airplane and found yourself waiting for the flight to take off. The flight attendants begin their safety presentation and give instructions on how to use the oxygen masks if they become available. The flight attendants instruct you to put on your own oxygen mask before helping anyone else with their oxygen mask. Why? Because to help others, you need to have already been helped yourself. Prioritizing your self-care is essential when there are demands on you to care for others around you. 

How do you do it?  

Start small. With the COVID-19 social distancing restrictions, there may not be very many options available outside of the home, so use what you have or what you can easily obtainIt may be easiest to incorporate self-care in activities you are already doing. Think about ways to enhance the things that you are already doing and be intentional about experiencing the pleasures in the moments. Perhaps use an aromatherapy body wash and inhale the relaxing or rejuvenating scent while showering. Or, take a few extra minutes and run a warm bath and add essential oils, bubble bath, or soothing bath salts. You need to bathe, so why not take a few moments to enhance the experience before going to bed or starting your day? When you have your morning coffee or afternoon tea, take a moment to walk outsidebreath in fresh air and enjoy the flavor of your warm (or iced) beverage. When you are out grocery shopping, pick up a new fresh herb to add to your pasta or saladgrab a new sauce for your protein, or grab that fruit or vegetable you have all ways wanted to try. These small actions can have lasting impact on you, your well-being, and the care your give to others. 


What are some ways you can begin to practice self-care? 


Written by Takisha Corbett, Ph.D. Dr. Corbett is a clinical psychologist at Pacific Neurobehavioral Clinic, PC.



Emotional Effects of Traumatic Brain Injury

Survivors of traumatic brain injury are often left to deal with unforeseen changes and symptoms. Impact to various regions of the brain, such as the area responsible for regulating emotions, can cause survivors of TBI to sense a lack of control over their feelings. Adjusting to life after brain injury may also trigger stress and lead to adverse emotional states. Below are some of the emotional symptoms that may manifest following traumatic brain injury:

  • Mood Fluctuations: Depending on the area of impact, TBI can cause sudden shifts in mood, such as fluctuating from content to irritable without any triggering event. In some instances, survivors of TBI may find themselves laughing for extended periods or experiencing sudden bursts of crying. This can be particularly challenging to manage because the emotional expression is often incongruent with the individual’s internal feelings. In other words, the individual is unable to control or cease laughter, when in actuality, they are feeling down or depressed. These exaggerated shifts in mood are referred to as emotional lability. This symptom can be concerning to both survivors and their loved ones due to its unpredictable nature and the individual’s lack of control over the expression of emotion.

  • Anger: Irritability is another common emotional change following TBI. Impact to brain regions that control emotional expression, in addition to difficulty adjusting to changes in recovery and experiencing intense pain, may all contribute to increased irritability and anger. Some survivors have diminished patience and find it difficult to control their temper. Regardless of the individual’s temperament prior to injury, angry outbursts may include yelling or screaming, using profanity, threatening others, and throwing or slamming things. These feelings can be unfamiliar to some survivors of TBI who had rarely experienced or expressed them in this manner prior to the onset of injury.

  • Depression: It can be particularly difficult to distinguish symptoms of depression from the symptoms of brain injury. Sudden onset of symptoms may be attributed to the injury, whereas gradual onset tends to point to depression. General feelings of sadness can be expected throughout the recovery process, given the experience of significant life changes. However, when feelings become overwhelming or impair functioning, they may be indicative of depression. Depressive symptoms may include low mood, loss of pleasure in activities, lack of motivation, changes in appetite, sleep disturbances, isolation, fatigue, hopelessness, and thoughts of dying. Feelings of guilt may complicate this experience, as survivors may feel that they are to blame for their injury or that they should have gratitude for surviving the event.

  • Anxiety: Survivors of brain injury may become more sensitive to stimuli and find that daily tasks, such as making decisions about what to wear, are stressful. The pressure of not being able to return to work or modifications in daily routines due to sensory overload can trigger anxiety. Feelings of anxiety may be physiological (increased heart rate, difficulty breathing) or cognitive (excessive worry, difficulty concentrating). Survivors of TBI may even suffer from panic attacks, which occur suddenly and unexpectedly without any particular trigger, causing behavioral changes (avoidance). Given the significant life adjustments following injury and throughout the recovery process, anxiety may be a temporary response. However, it is wise to consult with a professional in order to determine the cause of anxiety, as well as the appropriate interventions.

Managing Emotional Symptoms


Communicating feelings can seem unfeasible when individuals cannot quite understand what it is that they are feeling or experiencing. It is nevertheless important to express needs and feelings to loved ones/caregivers who may also observe these emotional changes but are uncertain about what they can do to help. Isolating from others can compound problems and make the symptoms feel increasingly unmanageable. It is crucial to ask for support when needed. Survivors of TBI may find peer support, either in the form of mentoring or TBI support groups, more effective than leaning on loved ones. Consulting with medical providers about symptoms can provide clarity regarding treatment options, which may include medication management or counseling services. It is important to note that each individual’s experience with TBI is unique, resulting in distinct needs that require tailored interventions.

Clinicians at PNBC use empirically-based interventions and psychoeducation to help TBI survivors distinguish the symptoms of injury from symptoms that may be indicative of a mood disorder. The clinicians’ diverse backgrounds and specializations enable clients to receive care attuned to their needs. Examples of interventions include cognitive behavioral therapy to address negative thought processes and manage pain, relaxation strategies such as grounding techniques or progressive muscle relaxation to reduce anxiety, and trauma-informed approaches that may relieve post-traumatic stress. Therapy can increase insight into symptoms, reducing the unknowns and making the recovery process feel more manageable.

Written by Beverly Sharifian, MA, APCC.

Pre-Surgical Psychological Clearance for a Spinal Cord Stimulator (SCS) Trial

Have you been recommended a spinal cord stimulator (SCS) trial implantation by your treating physician? Are you wondering what to expect from the required pre-surgical psychological evaluation? Are you asking yourself, why is a psychological evaluation even required? Well then, read this article, you shall.


What is a Spinal Cord Stimulator?

In brief, an SCS trial is usually recommended to patients by a medical provider after all other conservative forms of medical treatment have failed to provide an optimal level of pain relief. Conservative treatment may include medication(s), injection(s), physical therapy, or other non-surgical treatments. Essentially, spinal cord stimulation may help relieve pain and improve the quality of life in people with chronic pain, such as low back and leg pain. Spinal cord stimulation works by blocking pain signals in nerves from reaching the brain, where pain is processed (Highsmith, 2019). A spinal cord stimulator is a small device implanted under the skin, which then delivers a slight electrical impulse that masks or changes pain signals before they reach the brain (Highsmith, 2019). The SCS trial period, which usually lasts at least 5 to 7 days, determines whether the permanent version of the treatment will be beneficial to the patient.


Both the SCS trial and permanent procedures are considered to be minimally invasive. Permanent implantation is, well, permanent; thus, full commitment is required from the patient. As with any procedure, there are both benefits and risks with an SCS implantation, and not all patients with chronic pain are considered to be treatment candidates. Therefore, it is highly recommended that patients obtain an adequate understanding of the procedure, risks, and expectations from the referring physician.


What Should I Expect with A Pre-Surgical Psychological Evaluation?

Among the factors considered to determine whether a patient is an appropriate candidate for the SCS trial implantation, includes the patient’s mental health. An abundance of studies have shown that the presence of certain mental health symptoms and/or conditions may affect the outcomes of some surgical procedures, such as the SCS implantation (Bruns & Disorbio, 2009; Celestin, Edwards, & Jamison, 2009; den Boer et al., 2006). Thus, most insurance companies, and even some states, now require pre-surgical psychological clearance for SCS implantation.


Typically, the psychological evaluation consists of a clinical interview between the patient and a trained psychologist to discuss the patient’s medical, social, family, education, and mental health history. Questionnaires, and/or psychological tests, are provided to obtain more information about how the patient manages his or her pain, mood, and overall daily functioning. In general, chronic pain patients are more likely (i.e., four times more likely) than the general public to experience symptoms of depression, irritability, and anxiety (Kleiber, Jain, & Trivedi, 2005). The pre-surgical psychological evaluation can offer recommendations to help improve these symptoms. The appointment time for an evaluation usually takes up to three hours and is completed in one appointment. However, depending on the individual’s needs, the appointment may take longer. Ultimately, most people are cleared for the SCS trial. The small percentage of individuals who do not get cleared are recommended alternative ways of managing their pain.


If you are considering the SCS trial to help manage your pain, please consult with your pain management specialist and/or treating physician to explore if this treatment would be beneficial to you. If you are already scheduled for your pre-surgical psychological evaluation at PNBC, please feel free to ask your evaluating psychologist any remaining questions you may have.


Written by Angela Patino, PsyD. Dr. Patino is a psychologist at Pacific Neurobehavioral Clinic, PC.



Bruns, D., & Disorbio, J. M. (2009). Assessment of biopsychosocial risk factors for medical treatment: A collaborative approach. Journal of Clinical Psychology in Medical Settings, 16(2), 127-147.


Celestin, J., Edwards, R., & Jamison, R. (2009). Pretreatment psychosocial variables as

predictors of outcomes following lumbar surgery and spinal cord stimulation: A

systematic review and literature synthesis. Pain Medicine, 10(4), 639-653.


den Boer, J., Oostendorp, R., Beems, T., Munneke, M., Oerlemans, M., & Evers, A. (2006). A

systematic review of bio-psychosocial risk factors for an unfavourable outcome after

lumbar disc surgery. European Spine Journal, 15(5), 527-536.


Highsmith, J. (2019). What is spinal cord stimulation? How spinal cord stimulation can help reduce chronic back and extremity pain. Spine Universe. Retrieved from


Kleiber, B., Jain, S., & Trivedi, M. (2005). Depression and pain: Implications for symptomatic presentation and pharmacological treatments. Psychiatry. 2(5), 12-18.




Anxiety’s Impact on Cognitive Functioning

Anxiety is an emotion that we feel in response to a threat or a potential threat. Often, it helps us out. For example, anxiety can motivate us to practice an upcoming presentation for class, take a step back when standing at the edge of a tall building, or prepare for an important occasion like meeting in-laws for the first time.


However, anxiety can become unmanageable and unhelpful.


It can cause physiological symptoms such as shortness of breath, racing heart, and shakiness. Anxiety can also cause us to change our behavior. For example, we may frequently check that the front door is locked or avoid doing things we want or need to do (e.g., speak up in a work meeting). Finally, it can impact our thoughts such as worrying about things that could happen in the future like trouble paying bills or upcoming social events.


These anxiety-related symptoms can capture and maintain our attention, and make it harder to focus on the task at hand. When anxiety has reached the level that it feels unmanageable or difficult to control, it can make the very things we are anxious about more difficult. For example, when anxious during a presentation at school, we may begin to feel ourselves sweat and shake. Soon, all we can focus on are the physiological symptoms we are experiencing and the thought, “everyone must be noticing how anxious I am right now.” We may decide to cut the presentation short, which may temporarily relieve the anxiety but teach us that we couldn’t handle that experience, making it harder the next time around.


This situation is just one example of how anxiety can cause cognitive problems, such as difficulty focusing, remembering important details, and making decisions. Some experience anxiety in social situations and can have thinking difficulties when around new or influential people, such as coworkers or a boss, or when anticipating being in that situation. Others feel anxious in relation to a traumatic or stressful event that occurred in the past and may have difficulty focusing when thoughts of the event arise and/or in response to specific reminders of the event. For some, anxious thoughts are nearly constant, and may generalize to just about any stressful situation that could arise such as worry about losing loved ones or becoming ill.


If you have anxiety along with other conditions, such as: trouble sleeping, depression, attention deficit hyperactivity disorder (ADHD), chronic pain, traumatic brain injury (TBI), and/or alcohol and substance use, that can have a negatively compounding effect on cognitive functioning. Imagine that your ability to think (e.g., memory, attention, problem solving) is a pie, and each of these conditions represent a piece. If you have anxiety, it eats a piece of the pie. ADHD eats up another one. Poor sleep eats up another one. Pain eats up another one. Then you are left with only a couple pieces to get through the day—whether it be work, school, and/or caring for loved ones—it just doesn’t seem like enough!


Here is the good news. There are many great strategies to help manage anxiety including breathing techniques and mindfulness, physical activity, and engaging in self-care. That being said, sometimes anxiety and related conditions are too much to manage on our own. Seeing a clinician can be really helpful as a guide through these techniques and to provide treatments that have been shown to improve anxiety and cognitive abilities in large-scale studies. Clinicians at PNBC provide psychotherapy to individuals with anxiety and commonly co-occurring conditions who may be experiencing cognitive difficulties in their everyday life.


Written by Sarah Jurick, Ph.D. Dr. Jurick is a neuropsychologist at Pacific Neurobehavioral Clinic, PC. 

Advocating for Your Healthcare Needs

Speaking up to a medical provider for your healthcare needs can feel a bit intimidating. This can become even more uncomfortable if you feel as though your provider is not “hearing you” or appears to dismiss your concerns. This type of experience can lead to retreating and avoiding contact with a medical provider; however, this can be detrimental to your health.

Your health is important and advocating for your healthcare needs is a great way to demonstrate your concerns to your medical provider in a constructive manner. Advocacy can be done with a few simple actions and can increase your awareness regarding the nature of your presenting problem or symptoms. Here are a few suggestions to get you started:

      • Be specific regarding when you experience the symptoms. This includes when the symptoms began or how long you have been experiencing the problem. Sometimes it can be hard to pinpoint exactly when it started, so think back to major events or activities that have occurred (a birthday, work event, holiday, etc.) and determine if you were experiencing the symptoms or problem at that time. This also includes noting if the problem or the symptoms are worse at different times of the day, or after specific activities (i.e. after exercises versus after sitting for several hours).
      • Clarify how the problem impacts you and your overall functioning. For example, what difficulties, pain, or deficits are you experiencing as a result of these symptoms or problem? Does it interfere with your sleep, your appetite, your ability to concentrate, intimacy with your partner, spending time with your children or friends, productive at work, or simply enjoying down time? Sometimes we may not realize how broadly the symptoms or problem has impacted our lives until we take time to think about this question.
      • Describe what interventions you have tried to help alleviate the problem or the symptoms and whether they have been effective. Have you tried pain medication or physical therapy, exercising or stretching, changes in eating habits, or changes in sleeping patterns, etc.? Have you already had imaging, lab work, or an evaluation by a specialist completed? If so, are you able to get these results to your medical provider to incorporate this information into your current assessment? Do you have concerns about these assessments? It is okay to speak up and share your concerns.
      • Ask questions. This is your time with your medical provider, so ask clarifying questions to ensure you understand the recommendations or the next steps. If something doesn’t make sense to you, ask your provider to explain it again. Also, if you feel your provider may have misunderstood something you said, it is important to clarify with him or her so they accurately capture your perspective.
      • It’s okay to do some research. If you want to look up information related to your symptoms or problem, be sure to use reputable websites, such as the websites connected to your provider’s medical group or your insurance provider. If your research suggests a particular course of action, bring up this option with your medical provider. Ask about the pros and cons for this course of action, and what are some alternative options.

    Once you settle on a course of action with your provider, confirm what the next steps should be, including when you will need to follow up to see this provider again.

    Advocating for yourself can be an empowering experience. It also increases your awareness of your lived experience with a problem or symptoms, so you are better able to discuss them with your provider. Please note these suggestions can also be applied when for you advocate for someone else’s healthcare needs. You deserve great healthcare and it is okay to advocate for it.


    Written by Takisha Corbett, Ph.D. Dr. Corbett is a psychologist at Pacific Neurobehavioral Clinic, PC. 

The Importance of Routines for TBI Neurorehabilitation

Daily routines can be essential to maintaining physical and mental health, as they increase productivity, help manage stress, and enable us to make progress towards our short-term and long-term goals. Disruptions in daily routines and activities can be upsetting, particularly for those navigating the recovery process. It is natural to want to return to our baseline level of functioning after suffering injury; however, successful recovery is centered on a gradual return to previous activity levels. For survivors of traumatic brain injury (TBI), a flexible routine is an essential component of treatment, as it seeks to address impairments and promote normative functions.

Cognitive Processes and TBI

Cognitive symptoms and deficits are common following traumatic brain injury. The APA Dictionary of Psychology defines cognition as, “all forms of knowing and awareness, such as perceiving, conceiving, remembering, reasoning, judging, imagining, and problem-solving.” Executive functions, including planning, attention, problem-solving, working memory, emotional self-regulation, initiation and inhibition of behavior, decision-making, motivation, and flexible thinking are more complex cognitive tasks. These cognitive abilities are often compromised following traumatic brain injury, highlighting the importance of a consistent routine that seeks to re-establish these functions. It can be especially challenging when tasks that used to be second-nature feel strenuous or unmanageable. A predictable daily routine can help survivors of TBI regain their cognitive skills and enhance executive functions.

How Routines Can Improve Quality of Life

Sleep Hygiene

All individuals can benefit from a consistent bedtime routine in order to ensure that they are getting adequate, quality sleep and maintaining a healthy circadian rhythm. However, for individuals who have suffered a TBI, rest is even more crucial, as it promotes recovery and healing of the brain. Waking up and going to bed at the same time every day, in addition to establishing both a bedtime routine and morning ritual, can improve quality of sleep and reduce fatigue. Given that sleep disturbances and fatigue are common symptoms of TBI, treatment may involve psychoeducation on sleep hygiene and promoting the practice of activities that optimize energy levels, such as mild physical exercise.

Routines with ADLs

Activities of daily living (ADLs) are life skills that foster independence. They include hygiene practices, eating, getting dressed, mobility, and continence. Due to cognitive deficits, ability to perform ADLs may be significantly impacted following TBI. For instance, memory impairments and attention deficits may impede the ability to shower and get dressed in a reasonable time frame. Practicing these skills at a set time each day and in a specific order can create automatic habits, as well as increase awareness surrounding particular areas of need that should be addressed in treatment.

Instrumental activities of daily living (IADLs) involve higher-order cognitive abilities and include medication management, finances and budgeting, shopping and preparing meals, as well as housekeeping. An unfamiliar aspect of one’s daily routine following TBI may include remembering to take medications or engaging in rehabilitation exercises, such as those learned in physical, occupational, or speech therapy. Daily structure can increase the likelihood that these tasks will be completed and allows survivors to focus on one task at a time without distractions.

Self-Care Activities

Engaging in self-care via physical activity, relaxation techniques, engagement in hobbies or special interests, and social interaction is part of a well-rounded routine. Self-care practices can promote emotion regulation, stress management, a positive outlook, as well as improve overall well-being. Daily routines should involve some form of self-care based on the unique needs and preferences of the individual. For some, self-care may involve journaling or spending time alone while others might find that spending time with loved ones is what they need to recharge.


Focus of Treatment and Rehabilitation

A routine that is adapted to meet our current needs and abilities will promote the most growth in recovery. It is imperative that survivors of TBI understand and acknowledge limitations in order to prevent overexerting themselves early on in the recovery process. It is normal to feel disappointed about diminished independence and difficulty managing life skills. For instance, an individual who worked a full-time job, drove independently, and multi-tasked throughout the day may have trouble adjusting to a less strenuous routine.

Clinicians at PNBC can foster acceptance in regards to current impairments, encouraging and empowering clients to execute a rehabilitative routine that will eventually lead to a more familiar lifestyle. Psychotherapeutic treatment at PNBC can assist clients with improving insight into their symptoms and recovery, practicing compensatory strategies to manage deficits, and processing emotions related to impairments. TBI survivors require both predictability and flexibility in their routines, keeping in mind that sensory overload can have adverse impacts on their well-being. Taking a slow and steady approach while remaining motivated and committed to making gradual improvements day-to-day will create long-lasting improvements.


Written by Beverly Sharifian, MS, APCC. Ms. Sharifian is an associate professional clinical counselor working under the supervision of Dr. Delia Silva at PNBC.


Parenting While Coping With Chronic Pain

One of the concerns reported by my chronic pain clients who are also parenting is feeling like they are not as engaged with their children as they would like to be. In addition to generating feelings of guilt and shame around their parenting, this also frequently leads to stress and conflict with the other parent, or the household in general.

Individuals with chronic pain frequently experience symptoms like fear of re-injury, worry about the future and their health, low motivation, and fatigue, to name a few. These can lead to being less active and having no desire to participate in engaging with their children and family. Some of my clients also report that they frequently feel irritable and snap at their immediate family members, including their children, further straining relationships. When this is combined with chronically experiencing pain and coping with various limitations as a result, it can lead to feelings of sadness, hopelessness, low mood, isolation and more.

The biggest challenge for individuals experiencing chronic pain is learning to live in a “new normal.” Shifting their expectations and reframing their thoughts and ideas about what it means to live a fulfilling life, who they are, and how they matter and engage within their families and communities. In reference to parenting in particular, it is important to first have honest, developmentally appropriate conversations with children and family members, about what the person is experiencing in terms of pain and emotionally, as well as how other people in the family are feeling. This helps establish mutual understanding and can lead to having a positive support system for the person experiencing pain.

This is beneficial because it helps create empathy and space for everyone to be able to positively communicate their emotions and needs. If someone is having a particularly tough day with pain, for example, when there is already a foundation of knowledge and understanding, it may be easier to ask for down time, alone time and a break from activities, or whatever else helps the person cope best. It may also help make it easier for family members and children to hear, without internalizing this as a form of rejection.

It is also important to note that with flexibility and some creativity, people experiencing chronic pain can continue to share experiences with their family and play with their children. Many times, we get stuck in thinking that if we can’t do something how we always have, we cannot do it at all. This is what frequently leads to not wanting to engage with children and family. If we shift our focus to what we can do, versus what we can’t, we may discover new ways of doing things that will help us connect with our family and children.

This is not to say we are to ignore our emotions and feelings of grief or loss about what we cannot do, because they are very real and valid. These emotions deserve attention and space for individuals to process and feel them. What it does mean, is that we don’t get stuck there. We flow between giving tough emotions space, and then making room for some positives ones as well, leading to a more balanced state.

Some activities for parents and children to do, which with some adaptation can be done standing, sitting or even laying down, depending on individual needs include:

*Playing with Play-Doh
*Making art
*Making a puzzle
*Reading a book
*Taking the children to the park and watching them play
*Flying a kite
*Watching something together
*Cooking together
*Sharing mealtime conversations
*Having a picnic
*Listening to music
*Watering plants
*Going on a nature walk
*Go watch their extracurricular activities
*Take a picture taking walk
*Go swimming

Another consideration is a person’s ability to focus and be present, as well as being able to cope with irritability when in pain. Some ways to cope with this is being spontaneous and taking advantage of the times when they are feeling better or having a ‘good day’, to help balance the days when they need to make themselves a priority and need space for themselves; making these interactions short (quality versus quantity of time), but more frequent; choosing calming or relaxing activates; or having another adult participate so they don’t have to lead or be responsible for full engagement.

Many times, children mainly want a parent’s attention and presence. If parents can adapt to the necessary changes in interaction and find time to engage, while making sure to be as comfortable as possible, they will find that they can be more present with their children, and more active in parenting. This will lead to positive feelings for everyone involved, and a more balanced emotional state for the parent experiencing chronic pain.


Written by Taina Aceves, MA, LMFT. Ms. Aceves is a therapist at Pacific Neurobehavioral Clinic, PC.

The Impact of Sheltering in Place on Mental Health and Chronic Pain

Since shelter in place orders began to take effect in March, many of my own clients have seen increases in pain and mental health symptoms. While sheltering in place has placed many restrictions on people, as well as significantly changed how we all experience our day to day lives, there are two things that directly impact pain and mental health: social distancing and restricted, limited or no physical activity. Human connection and physical activity are important parts of managing chronic pain and mental health symptoms. Both are tools and behavioral changes I recommend to my clients in therapy.

First, it is worth noting that following shelter in place orders, including social distancing and mask wearing, is important to help slow the spread of COVID, until a solution can be found. The following are recommendations on how to try and compensate for these restrictions, not a call to avoid following the orders.

Having a support system, being able to have conversations, spending time with friends and loved ones, and connecting with co-workers are important to our overall well-being and help us cope with chronic pain and mental health symptoms, including anxiety, depression and stress. Being able to engage in social activities with others serves as a positive distraction from pain and difficult emotions, and it also helps create positive experiences that improve our mood and outlook, by helping to balance negative focus and thoughts. In addition, the benefits of being able to physically touch or be touched by others are many, and include stress reduction, increases in oxytocin and may even help improve the immune system.

The first question is: how do you cope with not being able to have as much human connection as before, particularly in-person contact?

If you have other members in your household whom you are sheltering in place with, you may have an easier time meeting this need than someone who lives alone. Make time to share quality time with your household members, that do not fall into the ordinary, daily routine. Backyard dates or picnics, movie nights, game nights, and cooking together are some ideas. When appropriate, engage in physical touch, like hugging.

If you live alone, make use of technology to try and stay connected to others. Engage in video or voice conversations, participate in virtual hangouts, game nights or dates, and maybe try virtually cooking new recipes with others. Massaging yourself may also be helpful for both emotional and physical well-being. Shelters across the United States reported a sharp increase in pet adoptions since the pandemic began, so if you have the desire, time and resources to care for a pet, this can also be a great option. Just keep in mind that caring for your pet will still be necessary once the shelter in place orders lift, and you should be willing and prepared to continue to love and care for your pet, even after this is all over.

The second question is: how do you balance sheltering in place and engaging in physical activity?

Many of us are unsure about what is and is not permitted under shelter in place, and this has led to a decrease in physical activity for many of us. The first tip is to work out inside your home, especially if you are having difficulty managing anxiety about leaving your home or are a high-risk individual for COVID. If you are having trouble getting motivated, think about virtually working out with someone. At this point, it is worth mentioning that getting some sun and fresh air does the mind and the body good. Which leads us to the second option: get outdoors. Though it is important to understand that as long as there is a pandemic, there will be risk associated with leaving our homes, it is also important to know that there are ways which decrease the risk of contracting COVID while engaging in outdoor physical activity. These include wearing a mask, avoiding crowded places, going out during ‘off hours’ (for example, avoiding the beach on the weekend) and staying physically distanced from other people. You can start with short walks around your neighborhood, during the times when there are less people out. Schedule these outings into your week to help you follow through. You can also engage in outdoor activity with others, as long as you practice social distancing and wear your masks.

The bottom line is- get creative and make the best of it. Try to find ways in which you can safely practice things that do you good, like socializing and activity. They may not be perfect, ideal, or exactly what you need, but something will be better than nothing, and keeping yourself and others safe during this pandemic is worth it. During shelter in place, it is beneficial to adopt an attitude of adaptation versus all or nothing. It is for your own good, and your mind and body will thank you!

Written by Taina Aceves, MA, LMFT. Taina is a therapist at Pacific Neurobehavioral Clinic, PC, in San Diego, CA.

Practicing Mindfulness

Many people have asked, “what is mindfulness, and can it really help me?” The answers to those questions are simple and developing a mindfulness practice can be relatively easy.  Many mindfulness resources are accessible for free on websites and mobile apps, while other resources are available on a subscription basis or by enrolling in a class or seminar. There are tons of options out there and they are just a few clicks away. As we explore practicing mindfulness, several links to resources are included below. These links are not endorsements of these apps or organizations; there are provided as references and convenience for those looking to access resources to start a mindfulness practice.

Over the past several years there has been a growing body of research on the benefits of mindfulness. The websites for many public and private organizations, such as National Institutes of Health, The Mayo Clinic, and Kaiser Permanente provide information on how to practice mindfulness. Many of these sites also share research outcomes which can help us to better understand the impact of a mindfulness practice across a variety of settings including home, work, sports, medical treatments, etc. In addition, there are many mobile apps, such as Headspace, which offer convenient guides to help establish or further develop a mindfulness practice, as well as information on the science behind mindfulness.

What is mindfulness?

Mindfulness is generally described as being fully present in the current moment. In any given moment, our attention can shift between several topics or tasks. Even when we are “paying attention” or focusing on one object, our attention frequently shifts, even for brief instances. When we practice mindfulness, we learn how to increase our ability to focus, to be fully present in the moment. In other instances, our attention can be divided because we may try to push some thoughts or memories out of our awareness because they may be unpleasant or distressing. Research has shown developing a mindfulness practice can help improve stress tolerance, which also strengthens our ability to be present in the current moment.

So, how do I learn to increase my ability to focus and improve my stress tolerance?

There are many mindfulness techniques to help you get started and learn the basics. Here is a common technique:

  • Mindful breathing—try spending 1 minute focusing on your breathing. Notice the rise and fall of your shoulders, rib cage, or abdomen. Notice if your breathing is shallow or deep, if the rate of your breathing is rapid or slow. If your mind wanders off to other topics, simply recognize it and return your attention back to your breathing. It is very natural for our minds to wander, so this may happen quite a bit; however, the more you practice mindful breathing, over time you are a likely to notice you are better able to catch your attention shifting and turn your attention, your focus back to your breathing.

Mindful breathing is a simple way to begin a mindfulness practice and improve your ability to focus your attention and increase distress tolerance. As you continue this practice, you can increase the length of time you focus on your breathing to 2 minutes, 3 minutes, or 5 minutes. Other mindfulness techniques that my help include another exercise call body scan, focusing your attention on different parts of your body. The University of California, San Diego Center for Mindfulnessoffers several guided audios and videos to help navigate through brief mindfulness sessions, including a 10-minute guide to body scan.

There are many options out there to help you get your mindfulness practice going. Simple chose one and start practicing.




NIH: ( )

Mayo: (,

Kaiser: ( )

Headspace: ( )

UCSD Center for Mindfulness ( )

Written by Takisha Corbett, Ph.D. Dr. Corbett is a licensed psychologist specializing in health psychology at Pacific Neurobehavioral Clinic, PC.

The Pursuit of Justice: Understanding the Cause and Committing to Action 

The energy in the air has been heightened with tension over the past few months. Initially, this was due to the global pandemic of COVID-19. Now, the United States has become the epicenter of a polarizing movement surrounding race and justice. Video of the gruesome death of George Floyd at the hands of Minneapolis Police officers is heart wrenching and disturbing to watch.

We have become inundated with a variety of charged images and messages from the media, on social media, and in our communities. With such a steady flow of information, it is easy to lose sight of the central message in the pursuit of justice and become distracted or overwhelmed.

The continuum of reactions to this movement is laden with intense emotions including anger, sadness, worry, confusion, ambivalence, and in some cases, indifference. The presence of these powerful emotions can lead one to feel paralyzed or powerless. It is important to know other people may feel the same way. To manage intense emotions, a common reaction may be to withdraw; however, redirecting your focus to the pursuit of justice can help alleviate some of the distressing experience. This pursuit of justice is to address routine police brutality that leads to the death of unarmed black men across this country. Together, we can make a change.  Many people may not know what to do to impact change in the pursuit of justice, or how to navigate difficult and uncomfortable conversations on race or justice. Here are a few tips to keep in mind.

  • Discussions about race can be uncomfortable, and that is okay. Knowing that the rights and freedoms of groups of people are violated daily is also discomforting; so, we can channel that discomfort into action.
  • We can achieve more together: the pursuit of justice for all takes all of us. Over the past several weeks retailers, websites, corporations, social media outlets, universities, and other establishments have posted anti-racism notices and actions plans. The next time you see one, click on it and read it to find out how others are committing to action.
  • Become aware of current opportunities to make change within your sphere of influence. This could be within your community, at your company, or in your city. Search the internet for upcoming events or activities sponsored by reputable local restaurants, businesses, non-profit organizations, universities, advocacy groups, etc. and try to join. Perhaps even invite a friend(s) to go along with you. There are also webinars you can watch, blogs and websites you can read, social media posts, or community activities, committees, or events you can attend or donate. Always practice due diligence and common sense safety practices.
  • Be open to self-reflection, personal growth, and change. We all have blind spots and carry biases. We can typically only see these aspects of ourselves when someone else points them out to us. Simply having blind spots or biases does not mean a person is bad or a racist. We can acknowledge these characteristics are present and be intentional to grow in those areas; to change.
  • Speak up when we witness an injustice. When we see something, we need to say something to bring attention to injustice. Silence creates a cloak for injustice to persist.
  • Remember, change takes time, and the pursuit of justice takes the community.

Written by Takisha Corbett, Ph.D. Dr. Corbett is a licensed psychologist currently open to new patients at Pacific Neurobehavioral Clinic, PC. 

Coping with Hospital Stays During the COVID-19 Pandemic

As the country begins the process of re-opening and lifting some restrictions, we find many activities are resuming. These include medical procedures that may have been postponed, as hospitals and medical facilities everywhere braced and prepared for treating individuals with COVID-19 back in March. If you are one of many patients who are being scheduled for procedures and treatments that require hospitalization, you and your family members are probably being confronted with the likelihood that no one will be allowed to enter the hospital with you, or stay with you during recovery. Medical care facilities around the country are implementing strict policies that ban visitors to try and limit the spread and risk of COVID-19 within their facilities, and there is no sign that these restrictions will be lifted in the near future.


Getting medical treatments that require hospital stays are generally anxiety producing for patients and their loved ones. If we add to this that they will likely need to go through this without a support person by their side, and the added concerns due to the COVID-19 pandemic, it is to be expected that patients and their loved ones will experience and increase in worry and anxiety.

Here are some tips that may help decrease some of those worries and anxiety:


  • You and your family can inquire as to what precautions are in place to protect patients from COVID, if this is something that you are feeling concerned about. Going into the situation as informed as possible will help you and your loved ones feel more in control and less anxious, setting you up for a better experience.
  • Ensure your family knows who and where to call for information if they are unable to reach you, to help decrease their concern and worry. If they feel more at ease, there is less opportunity that you will be impacted by their anxiety too.
  • Set up reliable communication. Make sure you have a phone, a charger, headphones (if allowed) and that you know how to use them all. If possible, make use of video calls to communicate with your loved ones- you may find they bring more emotional connection and comfort than voice calls or text messages alone.
  • Pack some activities that your doctor pre-approves, and you enjoy, to keep yourself entertained during your stay. Crossword puzzles, art, reading material, or a smart device with downloaded (in case streaming is not possible) shows, movies or games, are some examples. The more entertained you are, the less time you will have to focus on worries or being alone.
  • Be prepared to implement some relaxation techniques during your stay, to use when you feel the need. Some examples are listening to your favorite music, breathing exercises, progressive muscle relaxation, grounding techniques and visualization.
  • If permitted, pack some of your favorite, doctor-approved, non-perishable snacks to enjoy as you recover.
  • Remember that some anxiety around medical procedures and hospital stays is completely normal. Tell yourself this to prevent being critical of yourself or putting yourself down for having these emotions. Instead, focus on taking care of yourself, being kind to yourself and implementing positive coping tools to help you manage these feelings.
  • Sleep! Rest is an important part of recovery. If you find yourself having trouble sleeping, practice some of the relaxation techniques mentioned above. If allowed, come prepared with essential oils that may help you wind down, or request a permitted caffeine free tea to enjoy.

Before implementing any of the above suggestions, be sure to discuss these with your doctor, to ensure everything you want to implement is allowed by the medical facility and approved by your physician. During times of high stress or anxiety, you can help manage how you are feeling by focusing on what you are able to control, such as seeking helpful and necessary information, and implementing tools that help you feel more calm. Keep in mind that the treatment you are receiving is meant to help your body and improve your health outlook, and you will soon be reunited with your loved ones. As the saying goes, “this too shall pass”.

Written by Taina Aceves, LMFT. Ms. Aceves is currently accepting therapy patients via telehealth at Pacific Neurobehavioral Clinic, PC.


neuropsychology and psychology clinic

Tips on Managing COVID-19 Anxiety

The world is collectively living through an event unlike any other experienced during our lifetimes. The COVID-19 pandemic has changed how we are living our lives. We are living in daily uncertainty, facing something largely unknown to us still, in constant concern over our health and the health of our loved ones, and for some, grief as well as added stress and pressure over finances and meeting our basic needs. All of this while being stuck at home (in some states and countries) and having limited or no access to our support systems (friends, family and other loved ones) and the places and activities we enjoy; it is the perfect recipe for increased mental health symptoms and needs.   

Thankfully, many people can continue to access mental health services via telehealth* (see below for more information). In addition to mental health services, self-Care is something you can do at home to help relieve anxiety, stress and other mental health symptoms you may be experiencing as a result of the pandemic and social distancing regulations.   

Self-care can be defined as things we do that we enjoy and help us relax. These are unique to each individual, but here are some examples of self-care:   

  • Having a video call with your friends and family 
  • Watching a movie or show that brings you positive emotions 
  • Engaging in a creative outlet of your choice 
  • Taking a relaxing bath 
  • Aromatherapy 
  • Reading enjoyable books 
  • Having a virtual book-club 
  • Meditating 
  • Cooking 
  • Getting restful sleep 
  • Playing games 
  • Practicing yoga 
  • Exercising 
  • Getting outdoors, safely, while practicing social distancing and following your local regulations 
  • Skincare 
  • Listening to music 
  • Playing instruments 

It is easy to forget about practicing self-care, so it is important to schedule it into our days. A minimum of one self-care activity a day is recommendable, particularly during high stress or high anxiety times, such as the one we are currently living through.  

First, you can create a growing list of things or activities that are enjoyable and relaxing for you. Then, create a weekly schedule of self-care based on those activities, or, alternatively, pick one activity from that list every morning, to engage in on that day. Writing down or sharing your plan with someone can help you commit and follow through. Having a self-care buddy, even a virtual one, with whom to practice self-care, can also help you follow through and hold yourself accountable, in addition to potentially making the activity more enjoyable. You can face-mask with your friend via FaceTime, do online gaming with a loved one or work out with a buddy, for example. Get creative and make it fun! Practice self-care consistently, on a daily basis, and notice what difference this makes for your mental health. Taking care of ourselves is always important, and even more so when going through difficult times. Make the time to do this, as much as possible, to reap the benefits.    

*You can reach out to your health insurance, medical care provider or mental health care provider, to inquire about telehealth services. You can also search for mental health providers that offer telehealth via Psychology Today or Therapy Den. We are currently accepting new telehealth patients at PNBC.  


Additionally, here are some mental health resources available free of cost: 

Disaster Distress Helpline 1 (800) 985-5990 (también disponible en Español) 

Access & Crisis Line 1 (888) 724-7240 (también disponible en Español) 

2-1-1 San Diego Dial 2-1-1 from any phone (también disponible en Español) 

San Diego County Behavioral Health Resources 


Additional stress coping tips can be found on the CDC website.


Written by Taina Aceves, LMFT.  

neuropsychology and psychology clinic

COVID-19 Mental Health Survival Kit

One way or another, the recent coronavirus (COVID-19) outbreak has impacted our daily lifestyle. No more movie theater night outs, meeting up with a friend for coffee, or the usual morning rush to get to school and for some, work. The safety recommendations to stay home and “flatten the curve” is creating a new way of life. We have already seen the changes, particularly, with the increased use of technology serving different needs, including, but not limited to: continuing our socialization while keeping physical distancing, having meals and other necessities delivered to our homes, maintaining remote work, and staying distracted with entertainment. In addition to these changes, we have also experienced a shift in our perspective of the self, the world, and the future. This change in perspective, if not balanced, can bring upon a negative chainlike reaction to different aspects of our lives including our psychological, social, and occupational functioning.

How so, you ask? Well because how we think, affects how we feel and how we act. Fortunately, years of research and contributions from insightful individuals, have gifted us knowledge and tools to help us keep moving forward, especially when we find ourselves drifting away onto the dark side, be it due to fear, panic, overwhelming anxiety, depression, or  numbness. The following recommendations are considered crucial tools and knowledge to have in order to help us survive this COVID-19 crisis.

Tip #1: What are you doing for relaxation and self-care?

Stress management skills should be part of our “essentials package.” We all have an embedded “fight or flight response system” which when triggered, orchestrates a physical phenomenon in our bodies. In its basic form, the fight or flight response is our survival mechanism, allowing us to react quickly to life-threatening situations (Harvard Health Publishing, 2018). However, when this survival mechanism is frequently turned on (e.g., every time we see or hear a new article involving COVID-19), it becomes “chronic stress.” According to research, repeated stress activation can take a toll on our physical and psychological health, that is, chronic stress may contribute to serious medical and mental health problems such as high blood pressure, heart disease, diabetes, obesity, anxiety, depression, and addiction (National Institute of Mental Health, 2020). On the bright side, there are techniques to counter the stress response:

  • Relaxation: This is the time to try meditation, deep breathing exercises, and visualization of calming scenes. I usually recommend patients to visualize a scene of their “paradise vacation” while using their five senses, that is: see the details of the scenery, smell the scents of the scenery, feel the weather of the scenery, hear the sounds of the scenery, and if applicable, taste the scenery (e.g., salty ocean water). Especially during this time of limited access to destinations, the use of visualization exercises can serve as a mental vacation away from home.
  • Exercise: The California statewide stay-at-home order does not necessarily restrict us from exercising outdoors. According to the stay-at-home order invoked on 03/19/20 by Governor Newsom, “…so long as you are maintaining a safe social distance of six feet from people who aren’t part of your household, it is ok to go outside for exercise, a walk or fresh air.” It is recommended that you stay up to date on changes to the current stay-at-home order to avoid a fine or other penalty. In the meantime, while following recommended health precautions (i.e., using a face mask, staying 6 feet away from others outside of your household, etc.) if you can, take a walk outside at least once daily. Get your heart pumping and muscles activated to reduce muscle tension. Speaking of face masks, the Centers for Disease Control and Prevention (CDC) just released a DIY video on how to make your own mask to help fight spread of the virus, you can find it here. Other great ways to get exercise include instructional home-based exercise videos which are now widely available online. Just make sure to check in with your healthcare provider before embarking on any strenuous exercise to avoid injury.
  • Get proper sleep: Sleep deficiency is associated with many chronic health problems, including heart disease, kidney disease, high blood pressure, diabetes, stroke, obesity, and depression (National Institute of Health, 2020). And a deprived immune system is the last thing we want during this crisis. Getting a proper amount of sleep each night can help protect our mental health, physical health, quality of life, and safety. Of course, the amount of sleep needed changes over the course of our lives, but the American Academy of Sleep Medicine (AASM) recommends between 7 and 8 hours of sleep a day for adults. For more tips on how to establish better sleep habits, please visit our “Sleep Hygiene” blog here.
  • Social support: Again, the “social distancing” recommendations are intended towards physical distancing, not socialization per se. Social support can fulfill emotional, tangible, informational, and social needs. Now is the time to reach out to your network of friends, family, and acquaintances. Check in with them and see how they are handling this crisis. Offer support, be it emotional or maybe even just informational. Reminisce on good times and make plans for the future once the crisis becomes more stable. Don’t forget, technology allows us the opportunity to use video and audio as a way to connect with others.

Tip #2: Challenge irrational thoughts

This may be a more difficult task than the rest. The reason being that for most of us, our irrational thoughts have accompanied us for a longtime, settling in as habitual patterns in our minds, emerging automatically from time to time. It may be difficult to pinpoint the irrational thoughts at first. However, with practice, and if needed with support from a mental health professional, we gradually begin to notice these maladaptive thinking patterns that have been impacting our emotions and behaviors. This is the essence of Cognitive Behavioral Therapy (CBT): “how we think influences how we feel and how we behave.” Monitor your thoughts and identify which ones are interfering with your daily functioning during this crisis. Challenge them. Do you tend to think in terms of extremes? Is there a more balanced way to see the situation? Am I looking at all the evidence? Am I confusing my feelings with the facts?

With the increased use of technology, mental health apps have also emerged as a useful healthcare tool. You might find the following phone apps useful in managing your mental health:

Tip #3: If needed, seek professional help

If, after attempting to cope with this crisis using the coping mechanisms you have resorted to for years, or after attempting to incorporate the recommended tools above, you continue to find yourself struggling to cope through this crisis, then by all means, please seek professional support. You are not alone in this struggle, and ensuring your mental health is being managed properly is important. There are different types of mental health treatment available, I recommend you take the first step to learn more about which type would be a good fit for you. Given the COVID-19 outbreak and health recommendations, more mental health providers are providing video-based therapy appointments. At Pacific Neurobehavioral Clinic, we have a variety of providers willing to help and walk you through the process. You can reach us here. The following hotlines also provide free and confidential emotional support 24 hours a day, 7 days a week:

  • National Suicide Prevention Lifeline: English 1-800-273-8255; Spanish 1-888-628-9454
  • Access and Crisis Line: 1-888-724-7240


California Coronavirus (COVID-19) Response, 2020. Stay home except for essential needs. Retrieved from

Beck Cognitive Behavior Therapy, 2019. What is cognitive behavior therapy (CBT)? Retrieved from

Harvard Health Publishing, 2018. Understanding the stress response. Retrieved from:

National Institute of Health, 2020. Sleep deprivation and deficiency. Retrieved from

National Institute of Mental Health, 2020. 5 things you should know about stress. Retrieved from


Written by Angela Patino, Psy.D. @ Pacific Neurobehavioral Clinic.

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Tips for Managing Chronic Worrying – a Common Symptom of Anxiety

If you find yourself constantly worrying about all the things that could possibly go wrong and trying to find solutions to those hypothetical scenarios- you may find this post helpful.

Most things we do in our daily lives serve some sort of purpose, whether we are aware of it or not. Sometimes the purpose is positive, sometimes negative and sometimes it’s both. When working with clients who experience chronic worrying, I have heard it helps them “feel prepared”, “feel safe”, “feel secure”, “feel more comfortable,” among other things. While this may be true, many of us also experience negative effects from this type of worrying, mainly, increased negative thoughts, increased anxiety symptoms, and it takes a toll on our bodies (we may lose sleep, for example).

Worry can serve a positive purpose in our life; for example, it may serve as a motivator to study if you are worried about how you will do on a test. However, like many things, it can cross a line where it goes from being helpful, to being harmful (you are so worried, you cannot focus or study). For each of us, this threshold is different, and to identify it we must first be aware of the symptoms of anxiety we personally experience, and learn to notice them. When you notice these symptoms spiking, it may be a sign that this threshold was crossed for you.

I would like you to visualize that you are about to go on a run, hike or walk. It is a beautiful day outside- the air is crisp; the sun is out. You are energized and excited. Before you go, you grab one bottle of water, because it is reasonable to expect that you will get thirsty- so you prepare for this. Before you walk out, you go back to grab another one, because what if this one is not enough? Then another one, because what if you accidentally spill one of them? And on, and on, and on. Pretty soon, you are headed out with a backpack full of water bottles, weighing you down. You feel prepared. What else are you feeling? Are you comfortable? Are you feeling calm?

This begs the question- Is it worth being prepared for everything at, potentially, the expense of your mental and physical well-being? That is something only you can decide. Start by asking yourself:

How does worry affect me?
Is it negatively impacting different areas of my life? If so, how?
And most importantly- does it bother me?

If you answered yes to this last one, the following tips may help you manage chronic worry, thereby decreasing or preventing anxiety symptoms from getting worse.

Limit your exposure to things that make you worry (news, crime stories, etc.)- you decide what that limit is. To which point is it helpful, and when does it become harmful for you? This ties back in to knowing your symptoms and being aware of when your they spike.
Prepare yourself, if this helps you, but set limits for yourself. For example, allow yourself to have a plan A and B, but not plans A though Z.
Make it a rule for yourself that you will try to only worry about, and find solutions for, problems that are real, that are happening for you. Try to avoid hypotheticals.
Know that you are a capable human being, and that you can come up with solutions to problems, as they arise. Trust in yourself. Think back on times when you successfully solved difficulties that were unexpected.
Build a support system. Friends, family, and others that you can rely on when you encounter difficulties are a great resource and may provide some relief to worrying about what you will do if something goes wrong.
When you find it difficult to stop worrying thoughts, practice self-care and relaxation techniques. Calm breathing, watching a film you enjoy, socializing, meditating or exercising are a few examples. Crete a list of the self-care and relaxation tools that work for you.

Together, these tips can help you manage worry. As always, if you find that you are struggling to manage any of these symptoms on your own, consult with your primary care provider or mental health provider for additional support.

By Taina Aceves, LMFT


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Sleep Hygiene Techniques

7 to 9 Hours of Uninterrupted Sleep

Sounds easy, right? Unless you are part of the 1 in 3 American adults who don’t get enough sleep, according to the CDC.  Sleep deprivation can be caused by many things- sleep disorders, children, work or homework, to name a few.  But do you know the many negative side effects that result from not getting adequate sleep?  You likely know some of the obvious ones, like drowsiness or that extra cup of coffee you’re needing in the morning- but others may surprise you.

Some other common side effects of insufficient sleep include:

  • Learning and memory problems
  • Difficulty with attention and focus
  • Problems with perception and judgement
  • Increased chances of getting into car accidents
  • Mood Disorders (depression or anxiety)
  • Health problems

If you feel that you are not getting adequate sleep at night, talking with your primary care provider is a good idea, particularly if you are also experiencing or have experienced, any of the above.


In addition, here are some tips for Sleep Hygiene:

  • Establish a routine of sleep and awake time and stick to it as much as possible (try to go to bed and wake up at about the same time on most days).
  • Expose yourself to natural light and stay active during the day.
  • Do your best to avoid naps.
  • Avoid caffeinated drinks, nicotine or alcohol later in the day as well as large meals close to bedtime.
  • Try practicing relaxation techniques before bed, like meditation or listening to calming music, to help your body relax and calm your mind.
  • Reserve your bed or the spot where you sleep for sleep only (avoid watching television, reading or using technology there).
  • Create a calming and comfortable environment where you sleep (diffusing essential oils or a comfortable pillow may help).
  • Turn off lights and electronic devices, as these can disrupt your sleep.
  • If you are not asleep within 20 minutes, get out of bed to do something calming, like writing, drawing or reading.

Sure, implementing all of these changes at once may seem overwhelming.  If you are able to do it, great!  If not, start with one, and see if that helps.  Slowly incorporate more, as needed, and choose which ones work for you.  Remember that the goal is to establish sleep habits that will get you a better night’s sleep, so you can reap the benefits.


Author: Taina Aceves, LMFT

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About Neuropsychological Evaluations

What is a neuropsychologist?

A neuropsychologist is a clinical psychologist with specialized training in the applied science of brain-behavior relationships. Neuropsychologists use cognitive and psychological tests to assess, diagnose, and provide treatment recommendations for individuals with neurological, medical, and psychiatric conditions. These assessments provide a better understanding of each patient’s cognitive, behavioral, and emotional strengths and weaknesses. A thorough definition can be found here at the National Academy of Neuropsychology’s website.

Neuropsychologists hold licenses in clinical psychology. However, not every clinical psychologist has the training necessary to competently practice neuropsychology. Therefore, when looking at a neuropsychologist’s credentials, it is recommended to find one that is board-certified by the American Board of Professional Psychology in the specialty of clinical neuropsychology (ABPP-CN), or the American Board of Professional Neuropsychology (ABN). There are also neuropsychologists who are not board-certified, but may have met the Houston Conference training standards that is accepted within the field of neuropsychology.

How is a neuropsychological evaluation performed?

Typically, a neuropsychological assessment will involve: A comprehensive interview with the neuropsychologist to gather information pertaining to the questions at hand, review of relevant records (for example medical records or school reports), and neuropsychological (cognitive and psychological) testing. After the evaluation, the neuropsychologist writes a report that presents the results of the evaluation, a diagnosis and conceptualization of how the individual is functioning, and appropriate recommendations that will lead to the next steps of treatment planning. Feedback and education on the results of the evaluation are provided to patients whenever possible.

What does a neuropsychological evaluation test for?

The testing looks at several areas of cognition associated with brain functioning. These domains include:

  • General intellectual abilities
  • Academic achievement
  • Motor and sensory functioning
  • Attention and processing speed
  • Expressive and receptive language abilities
  • Visuospatial/perceptual abilities
  • Learning & memory
  • Executive functions (higher-order thinking abilities, i.e. problem-solving, abstract reasoning, etc.)
  • Personality and emotional functioning

How long does a neuropsychological evaluation take?

It depends on the nature of the referral question. It can typically take anywhere from two hours up to ten hours of face-to-face time with the patient. For longer evaluations, it is possible to break it up into different days.

What happens after the neuropsychological evaluation?

The neuropsychological report should help to clarify diagnostic questions and provide a treatment plan. For most clinical evaluations, the neuropsychologist should have a feedback session with the patient to discuss the results of the evaluation, the diagnosis, and the recommended course of treatment. Depending on the diagnosis, there may be recommendations for different specialists to provide treatment. The neuropsychological evaluation is a valuable tool to plan out a course of action to help treat conditions.

What are some reasons to get a neuropsychological evaluation?

A neuropsychlogical assessment with adults would be useful for a number of reasons that include:

  • Diagnostic clarification for treatment planning
  • Differentiate between psychiatric and neurologic conditions
  • Help determine the cause of cognitive or emotional symptoms
  • Identify cognitive strengths and weaknesses
  • Diagnose or rule out attention deficit/hyperactivity disorder (ADHD) and specific learning disabilities
  • Rule out and differentiate between different types of dementias (ex: Alzheimer’s disease vs. frontotemporal dementias vs. vascular dementia vs. Lewy body dementia, among others)
  • Measuring changes in cognitive functions after a traumatic brain injury or acquired neurologic conditions such as strokes (cerebrovascular accident), anoxic brain injuries, multiple sclerosis, toxic chemical exposure, encephalitis, brain tumors, or post-surgical changes.

How can I schedule a neuropsychological evaluation at PNBC?

Please click on this link to learn how to make a referral or make an appointment.

Author: Delia Silva, PsyD, ABPP-CN

Brain Overview

The brain is divided into two halves, called hemispheres. Clinically, they are described as the “dominant” and “non-dominant” hemispheres. The dominant hemisphere is generally the half in which language abilities are housed, which for most people is the left (about 99% of right-handed people and 85% of left-handed people). While all aspects of thinking use both the left and right halves of your brain, certain functions are thought to be lateralized, or more strongly associated, with specific hemispheres.

Each hemisphere can be divided into specific areas called lobes (frontal, parietal, temporal, and occipital), as well as lower brain structures, the cerebellum and the brain stem. Each of these areas are generally associated with specific brain functions.

•Higher-order thinking
•Abstract reasoning
•Emotional control
•Planning and organization
•Behavioral regulation
•Motor skills
•Speech production
•Memory retrieval
•Learning and memory
•Language comprehension
•Auditory perception
•Spatial perception
•Object recognition
• Vision
•May be associated with higher-order thinking abilities
•Orientation and arousal
•Regulation of bodily functions (i.e. breathing, sleep, blood pressure)
•Movement and sensation

Author: Delia Silva, PsyD, ABPP-CN