Psychiatric aspects of Brain Injury

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Psychiatric aspects of Brain Injury

• September 2006

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Psychiatric problems following brain injury

• The injury
• The person
• The reaction

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The injury

• Closed
• Penetrating
• Global
• Focal
• Other injuries

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The person

• Premorbid condition
• Alcohol or substance misuse
• Premorbid personality

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The reaction

• Post concussion
• Trauma
• Social consequences
• Adjustment

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Psychiatric problems following brain injury

• The injury
• Closed
• Penetrating
• Global
• Focal
• Other injuries

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Brain Injury

• Head injury admissions
• 330/100,000/yr
• 10 to Neurosurgical unit
• 150/100,000 suffering disability after 1 yr
• 100/100,000 prevalence of considerable
  disability
• Scottish figures (SNAP)

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Brain Injury

• Moderate and severe physical and psychological
  disability 42/100,000/yr
• Persistent behavioural problems 3/100,000/yr
• McClelland 1993

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Mild Brain Injury

• lt30 mins loc
• PTA in hours
• Attention deficits
• Verbal retrieval
• Emotional distress
• Headache
• Dizziness
• Photophobia

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Moderate Brain Injury

• GCS 9 12
• PTA lt 24 hours
• Headaches
• Memory problems
• 2/3 will not return to work

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Severe Head Injury

• Attention
• Memory
• Emotional
• Psychosis
• Depression
• Social isolation

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Psychiatric conditions following traumatic brain
injury

• Risk Relative Risk
• Major depression 44.3 7.9
• Bipolar 4.2 5.3
• GAD 9.1 2.3
• OCD 6.4 2.6
• Panic Disorder 9.2 5.8
• PTSD 14.1 1.8
• Schizophrenia 0.7 0.5
• Substance Abuse 22 1.3
• (Van Reekum et al 2000)

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PTSD

• Traumatic event
• Re-experienced
• Avoidance
• Increased arousal
• Symptoms for more than 1 month
• Clinically significant distress or arousal

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Psychosis Due to TBI

• Schizophrenia
• Seizures
• Delirium
• Confabulation
• Substance abuse
• Other pathology
• Latency
• Temporal lobe abnormalities

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Psychosis Due to TBI

• Delusions
• More common than hallucinations
• Persecutory
• Hallucinations
• Auditory
• Visual more in early onset
• Negative symptoms uncommon
• Neuroleptics
• (Fujii and Ahmed 2002)

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Psychosis Due to TBI

• Abnormal EEG 70
• L temporal
• MRI abnormalities
• Frontal
• Temporal
• Enlarged ventricles
• (Fujii and Ahmed 2002)

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Personality change

• Phineas Gage
• Vermont, 13th September 1848
• Capable railway construction crew foreman
• Accident with a tamping iron
• Most of L frontal lobe destroyed
• Not Gage
• Irreverent, impatient, obstinate,capricious
• Feb 1860 developed seizures
• Died May 1860

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Frontal lobe syndromes

• Dorsolateral prefrontal
• Executive dysfunction
• Impaired planning, organisation and set shifting
• Environmental dependency
• Impaired semantic memory and verbal fluency (L)
• Orbitofrontal
• Disinhibition
• Medial frontal/anterior cingulate
• Apathy
• (Cummings and Trimble)

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Consequences

• Personal
• Economic
• Social
• Marital
• Parental

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Antipsychotics

• Dopamine receptors
• Parkinsonism
• Akathisia
• Sedation
• Dyskinesias
• Sedation
• Lower seizure threshold

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Antidepressants

• SSRIs
• Tricyclics
• Lower seizure threshold
• Anti-cholinergic effects

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Benzodiazepines

• Sedative
• Hangover
• Tolerance
• Addictive
• Anticonvulsant

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Anticonvulsants

• Antiepileptic
• Toxicity
• Teratogenicity

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Management of aggression and agitation

• Poor evidence for effectiveness of medication
• Think why when and where it is occurring
• Think of what you are treating
• Think why you are using a specific drug
• Think side effects
• Think of interactions
• Vulnerability of the injured brain
• When to withdraw

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Agitation and aggressionpharmacological
management

• Wide variety used
• No strong evidence
• Adverse effects
• Beta blockers
• Research needed
• (Cochrane Review, Fleminger et al 2003)

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Goals

• Behavioural
• Cognitive, communication
• Functional, self care, leisure
• Emotional e.g. anxiety management
• Social e.g. family, placement

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Rehabilitation

• Eating own dinner
• Safer smoking
• Getting across
• Not getting cross

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Attribution theory
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Community Brain injury Teams

• 4 in Eastern Board area
• Southern
• Northern
• Western

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The Team

• Consultant
• Specialist Registrar
• Neuropsychology

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Service Development

• Neuropsychiatry inpatient assessment
• Rehabilitation
• Transitional living
• Supported accommodation

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Team Development

• Specialist nursing skills
• SLT
• OT
• SW
• Physiotherapy
• CBT
• Medical staff