1. Psychiatric aspects of Brain Injury September 2006

2. Psychiatric problems following brain injury The injury The person The reaction

3. The injury Closed Penetrating Global Focal Other injuries

4. The person Premorbid condition Alcohol or substance misuse Premorbid personality

5. The reaction Post concussion Trauma Social consequences Adjustment

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

7. 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)

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

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

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

11. Severe Head Injury Attention Memory Emotional Psychosis Depression Social isolation

12. Psychiatric conditions following traumatic brain injury Risk Relative Risk Major depression 44.37.9 Bipolar4.25.3 GAD9.12.3 OCD6.42.6 Panic Disorder9.25.8 PTSD14.11.8 Schizophrenia0.70.5 Substance Abuse221.3 (Van Reekum et al 2000)

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

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

15. 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)

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

17. 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

18. 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)

19. Consequences Personal Economic Social Marital Parental

20. Antipsychotics Dopamine receptors Parkinsonism Akathisia Sedation Dyskinesias Sedation Lower seizure threshold

21. Antidepressants SSRIs Tricyclics Lower seizure threshold Anti-cholinergic effects

22. Benzodiazepines Sedative Hangover Tolerance Addictive Anticonvulsant

23. Anticonvulsants Antiepileptic Toxicity Teratogenicity

24. 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

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

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

27. Rehabilitation Eating own dinner Safer smoking Getting across Not getting cross

28. Attribution theory

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

30. The Team Consultant Specialist Registrar Neuropsychology

31. Service Development Neuropsychiatry inpatient assessment Rehabilitation Transitional living Supported accommodation

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