Psychiatric aspects of Brain Injury September 2006

Psychiatric problems following brain injury The injury The person The reaction

The injury Closed Penetrating Global Focal Other injuries

The person Premorbid condition Alcohol or substance misuse Premorbid personality

The reaction Post concussion Trauma Social consequences Adjustment

Psychiatric problems following brain injury The injury Closed Penetrating Global Focal Other injuries

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)

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

Mild Brain Injury <30 mins loc PTA in hours Attention deficits Verbal retrieval Emotional distress Headache Dizziness Photophobia

Moderate Brain Injury GCS 9 – 12 PTA < 24 hours Headaches Memory problems 2/3 will not return to work

Severe Head Injury Attention Memory Emotional Psychosis Depression Social isolation

Psychiatric conditions following traumatic brain injury Risk Relative Risk Major depression Bipolar GAD OCD Panic Disorder PTSD Schizophrenia Substance Abuse221.3 (Van Reekum et al 2000)

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

Psychosis Due to TBI Schizophrenia Seizures Delirium Confabulation Substance abuse Other pathology Latency Temporal lobe abnormalities

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)

Psychosis Due to TBI Abnormal EEG 70% L temporal MRI abnormalities Frontal Temporal Enlarged ventricles (Fujii and Ahmed 2002)

Personality change Phineas Gage Vermont, 13 th 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

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)

Consequences Personal Economic Social Marital Parental

Antipsychotics Dopamine receptors Parkinsonism Akathisia Sedation Dyskinesias Sedation Lower seizure threshold

Antidepressants SSRIs Tricyclics Lower seizure threshold Anti-cholinergic effects

Benzodiazepines Sedative Hangover Tolerance Addictive Anticonvulsant

Anticonvulsants Antiepileptic Toxicity Teratogenicity

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

Agitation and aggression pharmacological management Wide variety used No strong evidence Adverse effects Beta blockers Research needed (Cochrane Review, Fleminger et al 2003)

Goals 1. Behavioural 2. Cognitive, communication 3. Functional, self care, leisure 4. Emotional e.g. anxiety management 5. Social e.g. family, placement

Rehabilitation Eating own dinner Safer smoking Getting across Not getting cross

Attribution theory

Community Brain injury Teams 4 in Eastern Board area Southern Northern Western

The Team Consultant Specialist Registrar Neuropsychology

Service Development Neuropsychiatry inpatient assessment Rehabilitation Transitional living Supported accommodation

Team Development Specialist nursing skills SLT OT SW Physiotherapy CBT Medical staff