Neuropsychiatric aspects of

Traumatic Brain InjuryDr.Cijo Alex

Chair : Dr.R.Kumar Proffesor and HOD

28 – 10 – 2014

Introduction

TBI refers to any external mechanical

force acting on the brain which may

cause temporary or permanent

dysfunction

TBI can be Open / Closed ; Focal / Diffuse

As noted by Headway , the UK national

head injury association ,

“ A head injury is for Life”

Concussion – A loosely defined term .

The general consensus is that

concussion refers to mild TBI and may

result in post concussion syndrome

Contusion – Refers to cerebral

laceration

Epidemiology

Generally, 2 per 1000 population suffers head injury

per year and majority are mild injuries

The incidence of TBI is generally coming down in

developed countries but not in developing

countries.

However TBI in developed countries are usually of

high severity.

Increased rates of TBI in developing parts of the

world are partly due to high two wheeler usage and

poor road safety conditions

Generally the risk factors of TBI include

Male sex,

Younger age,

Alcohol use disorders,

Lower SES,

ASPD traits and

Psychiatric illness

TBI has been named the

“silent epidemic”

because of the limited knowledge about

the issue and of its symptoms, such

as memory and cognitive problems,

which may not be immediately

evident.

Psychiatric disorders and traumatic brain injury , Neuropsychiatr Dis Treat. Aug 2008; 4(4): 797–816.

The Etiology and path physiology of

Neuropsychiatric aspects of TBI

Focal or diffuse head injuries , either open or

closed can cause neuropsychiatric sequale

in many ways

Direct neuronal damage

Cerebral Anoxia , Edema or Necrosis

Sudden Ca++ influx , ↑Ach , ↑Glutamate

Biopsychosocial model

Clinical Features

Clinical Features of Neuropsychiatric aspects

of TBI can be divided into

1) Acute and

2) Chronic

#Acute effects –

Three conditions

1) Loss of Consciousness ,

2) Post Traumatic Delirium / Confusion

and

3) Post Traumatic Amnesia

#Chronic sequel –

Ten conditions

1) Cognitive Impairment ,

2) Personality Changes ,

3) Psychosis ,

4) Affective Disorders,

5) PTSD and anxiety,

6) Aggression,

7) Post Concussion Syndrome,

8) Post TBI Headache,

9) TBI as a risk factor for Epilepsy and

10) TBI as a risk factor for Dementia

LOC, followed by Confusion/Delirium

and later Amnesia forms the cardinal

symptoms of acute phase of TBI.

Severity and extent of these features

often give an idea about the severity

and prognosis of TBI

Loss of Consciousness

Impairment of consciousness can range from

momentary dazing to prolonged coma.

Sometimes there may not be obvious LOC,

but merely a “ding” with muddled thinking

or dizziness .

But typically, the LOC is complete and person

may fall down.

Level of consciousness (GCS Score) and

duration of LOC varies with the severity

of TBI.

Generally longer and severe the LOC,

severe the TBI and chances of

permanent brain damage are high.

LOC is generally followed by confusion or

PTD

Post Traumatic Delirium

As the LOC resolves , Confusion and

Disorientation may be obvious , termed

PTD.

May include restlessness, confusion and

disorientation to TPP. Severity of PTD

depends on the severity of TBI and in

severe cases delusions and hallucinations

are common.

Once the PTD resolves, underlying PTA may

become evident

Post Traumatic Amnesia

This includes the period of LOC and

PTD , but becomes evident once PTD

resolves.

It can be retrograde or anterograde.

Confabulations may be evident.

PTA may be seen even without LOC, like

the school boy who continues to play

football after having a TBI, but having

amnesia of the events including TBI.

This is usually seen in boxers also.

Duration and severity of PTA is dependent on the

severity of TBI and is considered a prognostic

indicator.

Generally, if PTA < 24 hrs, prognosis is better and

chances of permanent brain damage

considered less

Old age and injury to dominant hemisphere can

worsen PTA

Chronic Sequel to TBI include

1) Cognitive Impairment ,

2) Personality Changes ,

3) Psychosis

4) Affective Disorders,

5) PTSD and anxiety,

6) Aggression,

7) Post Concussion Syndrome,

8) Post TBI Headache,

9) TBI as a risk factor for Epilepsy,

10) TBI as a risk factor for Dementia

Cognitive Impairment

Post TBI cognitive impairment is

particularly common and pronounced in

cases with PTA> 24 hrs.

However, in focal and penetrative TBI, PTA

may be even absent and yet cognitive

impairments may be seen.

Generalized psychomotor slowing,

impaired attention and concentration,

impaired memory and impaired

executive functioning are hallmarks of

post TBI cognitive impairment

As a general rule, post TBI patients show

impaired frontal lobe / executive

functioning.

Memory problems are also common and

word finding difficulties may occur.

Severe cases may lead to post TBI

Dementia or Persistent Vegetative State.

Focal and Penetrating injuries may cause

focal deficits than global effects.

Personality Changes

Post TBI personality changes are among the

most distressing chronic sequel. Post TBI

personality changes can vary from mild ones

with coarsening of premorbid personality

traits to more severe ones in which a

dramatic change of personality can occur.

Post TBI personality changes are dependent on

the location of the injury and frontal lobe

syndromes remains the classic example for

post TBI personality change

The outstanding features of Frontal

lobe syndrome includes Irritability,

Apathy, Euphoria, Disinhibition,

Inappropriate Jocularity and Altered

sexual behavior.

The Case report of Phineas Gage , the

American rail road worker who sustained

transcranial injury following workplace

accident is a prototype of post TBI

personality change

His doctor, John Harlow, described his

personality changes: from being a

responsible and socially well-adapted

man, Gage became negligent, irreverent

and profane, unable to take

responsibilites

And based on the exact location in Frontal

lobe, various syndromes are described

including

- DLPFC Syndrome with Executive dysfunction

and impaired Attention & Concentration aka

Dysexecutive syndrome ,

- OFC Syndrome characterized by disinhibition

and Personality changes aka

Psuedopsychopathic and

- VMPFC Syndrome characterized by Akinesis

and impaired motivation aka

Psudeodepressive .

Temporal lobe lesions typically causes

features of epileptic personality change

including circumstantiality and over

involvement in abstract themes like

religion.

Basal syndrome results from injury to basal

structures of brain like midbrain and

hypothalamus and is characterized by

apathy and labile mood.

Post TBI Psychosis

Onset can be of varying duration and the

causal effect of TBI may be difficult to

ascertain. Reverse causation is also a

chance, especially in the prodrome of

psychosis or even simple chance

coincidence.

Childhood TBI and birth insults may act as a

predisposing factor for development of

Schizophrenia.

Auditory hallucinations and persecutory

delusions are usually seen in post TBI

psychosis.

Also, TBI is more common among people with

long standing psychosis than the general

population.

Affective Disorders

Includes Depression and Mania

General consensus is that R sided lesions

cause Mania and L sided lesions cause

Depression.

Up to 30% of post TBI patients develop

MDD with in first year, with

hopelessness and anhedonia.

More common if associated with

dysfunction or loss of job , thus

making biopsychosocial model

applicable.

Increased prevalence of BPAD and

Mania has also been reported among

people with h/o TBI. Irritability was

found more than Euphoria

PTSD and Anxiety disorders

After TBI, many patients experience

flashbacks, nightmares and avoidance of

the accident situations and increased

startle responses.

GAD, Specific phobias like those related to

the TBI environment are also common.

Aggression

Post TBI aggression, both verbal and

physical is found in at least a quarter

of people with TBI.

Sexual aggression is also seen in many

cases.

Post Concussion syndrome

ICD 10 codes it under F07.2 .

The syndrome usually occurs following head

trauma with LOC and is characterized by

Headache, Dizziness, Irritability, Fatigue,

Insomnia and Memory difficulties.

At least two symptoms are needed for a

diagnosis

Though TBI of any severity can cause post

concussion syndrome, mild TBI is more

prone.

Many features of Somatization are seen and

psychogenic origin of PCS has been

proposed.

Fear of permanent brain damage is common

and can result in hypochondriasis.

Patient may take permanent sick role

occasionally

Post TBI Headache

Headache is very common in the acute

phase of TBI and usually resolves in a

few days.

However some pts report prolonged

headache after TBI and may persist

for many years which may show poor

response to analgesics.

Severe post TBI headache should raise

suspicion of chronic SDH.

TBI as a risk factor for Epilepsy

Post TBI epilepsy develops in around

5% of closed injuries and around 30%

in penetrating injuries.

Also TBI can be secondary to Epilepsy.

Closed head injury is generally

associated with Temporal Lobe

Epilepsy.

Severity of TBI also plays a role.

Contusions are more prone to cause

epilepsy. Cortical scarring due to

contusions are highly epileptogenic.

TBI as a risk factor for Dementia

TBI may be a risk factor for AD, chronic SDH

or Dementia pugilistica though the causal

strength with AD is not very clear.

However multiple mild TBIs are a definite risk

factor for Dementia due to chronic SDH and

Dementia Pugilistica.

Conclusion

TBI can result in a wide range of psychiatric

illnesses including personality disorders

These long term effects can vary from mild

symptoms to severe and trouble some

changes like personality disorders

Thank You