Neuropsychiatric aspects of Traumatic Brain Injury , mainly based on Lishmans Textbook of Organic Psychiatry

1. Neuropsychiatric aspects of
Traumatic Brain Injury
Dr.Cijo Alex
Chair : Dr.R.Kumar Proffesor and HOD
28 – 10 – 2014

2. 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”

3. 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

4. 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

5. Generally the risk factors of TBI include
Male sex,
Younger age,
Alcohol use disorders,
Lower SES,
ASPD traits and
Psychiatric illness

6. 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.

7. 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

8. Clinical Features
Clinical Features of Neuropsychiatric aspects
of TBI can be divided into
1) Acute and
2) Chronic

9. #Acute effects –
Three conditions
1) Loss of Consciousness ,
2) Post Traumatic Delirium / Confusion
and
3) Post Traumatic Amnesia

10. #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

11. 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

12. 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.

13. 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

14. 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

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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.

21. 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

22. The outstanding features of Frontal
lobe syndrome includes Irritability,
Apathy, Euphoria, Disinhibition,
Inappropriate Jocularity and Altered
sexual behavior.

23. 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

24. 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 .

25. 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.

26. 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.

27. 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.

28. 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.

29. 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

30. 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.

31. 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.

32. 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

33. 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.

34. Fear of permanent brain damage is common
and can result in hypochondriasis.
Patient may take permanent sick role
occasionally

35. 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.

36. 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.

37. 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.

38. 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.

39. 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

40. Thank You