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Psychiatric Issues in Traumatic Brain Injury
Establishing a Differential Diagnosis and Identifying Effective Treatment for Individuals
with TBI and Behavioral Health Problems
Rolf B. Gainer, PhD, Dip. ABDA
Neurologic Rehabilitation Institute, Brookhaven Hospital, Tulsa, OK (800) 927-3974 www.brookhavenhospital.com
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ObjectivesExplain the scope of problems experienced by traumatic brain injury (TBI) patients, including behavioral health issues Discuss effective strategies for diagnosing neurological impairment, psychiatric illness, and co-morbidityReview conditions created by TBI that can exacerbate underlying psychiatric conditions
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ObjectivesExamine clinical presentation of persons with a dual diagnosis, which includes TBIExamine treatment/rehabilitation implications for individuals with dual diagnosis
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Psychiatric Issues in Individuals with TBI
Behavioral components of TBI which resemble psychiatric illnessEffects of brain injury on individuals with pre-existing conditionsIssues of co-morbidityDiagnostic skills
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Facts About Brain InjuryEvery day nearly 6,000 Americans sustain a brain injury (www.biausa.org)400,000 individuals with moderate and severe brain injuries in the USA are hospitalized each year
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Causes of Brain InjuryMotor Vehicle Accidents 50%Falls 21%Assaults 12%Sports/Recreation 10%Other 7%
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Physical Effects of Brain Trauma in Closed Head Injuries
Direct ImpactCoup and Contra Coup InjuriesRotation and ShearingSwellingBleedingNeurochemical ChangesSecondary Effects
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TBI Severity Distribution InjuryMild 85%Moderate 10%Severe 5%Mortality Rate 11%
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Assumptions about TBIPhysiological impairmentDisruption of sensoriumDisinhibitionArousal and attention problemsUnstable mood statesProblems in learning and organization
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Behaviors in Early RecoveryDisorientationParanoid IdeationDepressionHypomaniaConfabulation
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Behaviors in Early Recovery RestlessnessAgitationCombativenessEmotional LabilityConfusionHallucinations
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In the early phase of TBI recovery, some behaviors can resemble a psychiatric illness.
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Biological Aspects of Injury Further Psychological Problems
Seizure disorder may include irritability and behavior dyscontrolCognitive problems, especially memory, affect, emotional responseDenial of deficits may affect capacity to receive helpPreviously effective medications may not work or may exacerbate injury-related problemsDepression may prevent participation
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The Basic Person Doesn’t ChangeThe injury alters specific aspects of the person’s psychological, cognitive and emotional functionSpecific personality traits or style remain
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TBI Affects All Aspects of LifePreviously competent individuals may show symptoms of psychiatric diseaseCoping skills are stressedBehavioral controls are lost
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TBI Affects All Aspects of LifeSocial skills and roles are affectedInsight into TBI-related changes may be limitedPreviously self-managed symptoms may become out of controlRelationships/support systems are stressed
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Positive Predictors of Recovery Outcome
Focal vs. Globalized injuryAggressive early intervention and trauma careWork history
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Positive Pre-Injury Predictors
Medical/behavioral complicationsPre-injury achievement levelLearning, school and work historyExtroverted personalityPositive social history
Level of severity, coma durationNatural recovery and return of functions
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Positive Pre-Injury Predictors
“Good character” and self controlStrong-willed, determined personality
Perseverance and motivationStrong social and family network and supportAbsence of pre-injury psychiatric symptomsAbsence of substance abuse
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Negative PredictorsPoor response to psychiatric medicationsPoor response to “talking” therapiesFailure in behavioral programs requiring memory and problem-solvingSocial network failure: divorce, separation
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Negative PredictorsFailure at workInvolvement in the criminal justice systemPersistence of chronic pain and headache symptomsLack of support system
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Lateralization Issues of Behavior Deficits
Left Hemisphere: depression, agitation, anxietyDiffuse: attention, concentration, arousal, response
Right Hemisphere: unable to respond, flat affect
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TBI and Psychiatric DiseaseTraumatic Brain Injury can mimic
psychiatric symptoms Examples: memory problems, behavioral
and emotional control problems, mood disorders
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Biological Brain Changes can Mimic Psychiatric Disease
Biological changes can exacerbate a pre-existing psychiatric diseaseExecutive Syndrome can resemble a thought disorderBehavioral features can resemble other conditions
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TBI and Psychiatric DiseaseTBI can mask psychiatric
symptomsExample: Frontal system
damage can produce expressive aposody/blunting, which may reduce the person’s ability to express sadness
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Risk Factors Associated with Psychiatric Diagnosis (Lishman, 1988)
Organic factors Psychosocial factors (socio-economics, pre-morbid personality)Past history of psychiatric illnessFamily history of psychiatric illnessMaleEmergence of problems one year post-injury
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Research HighlightsLocalization of injury (Fann, 1995)Noradrenergic and serotonergic projections are sites of contusion (Rosenthal, 1998)Individuals with depression and anxiety perceive themselves as more ill (Fann, 1995)
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Research HighlightsReaction to failure (Alexander, 1975, 1992)Right hemisphere damage (Silver, 1992)Pre-morbid factors and social adjustment (Robinson & Jorge, 1993)Biochemical response (Robinson & Jorge, 1993)
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Brain Injured Patients with Psychiatric Disorders (Van Reekum, 2003)
The level of severity of the person’s brain injury relates to the potential for the emergence of psychiatric disorders in the first 24 months post-injury
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Personality Disturbances After Brain Injury
Anxiety or “catastrophic reaction”Emotional lability/disinhibitionParanoia and psychomotor agitationDenialDepressionSocial withdrawalAmotivation/abulia
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Distinguishing Brain Injury from Psychiatric Problems
Physical injury to the brainCognitive and behavioral deficitsEmotional and personality changeAttention, concentration, arousal, filteringMemory problemsSeizure problemsSelf regulation
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Psychological Syndromes can Co-occur or Predate Injury
When did the symptoms emerge, before or after the TBI?What were persons like before injury?What were their coping styles?How have they adjusted to disability?What new symptoms/behaviors have developed?
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Problems in Diagnosing Psychiatric Illness in TBI
Timing between injury and emergence of symptomsIn mild cases lack of documentation of extent/severity of injuryPre-morbid personality traitsPre-injury issues
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Rate of Psychiatric Illness One Year Post Brain Injury
Past studies focused on individuals with TBI who were seen in psychiatric hospitals
21.7% of individuals with TBI had ICD-9 diagnosis vs 16.4% of general population (1998)
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Psychiatric Diagnosis Distribution Following TBI
Male - 21.6%Female – 11.3%Mild brain injury –17.2%Moderate and severe brain injury – 23.3%
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Psychiatric Diagnosis FeaturesRelationship of psychiatric diagnosis to:
Younger ageGlasgow outcome scale scoreHistory of pre-injury ETOH use/abuseHistory of psychiatric illnessLower Mini Mental State scoreFewer years of education (Deb, 1999)Not working before injury (Bowen, 1998)
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Psychiatric Issues in TBI CasesMale/female 70%/30% more likely to develop psychiatric symptomsElevated risk for bi-polar affective disorderSeizures noted in 50% of cases with mania (Shukla, 1987)Limbic system lesions in 75% of manic cases (Starkstein, 1987)Family history of mood disorders
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Diagnostic Issues in BI GroupDepressive episode 13.9% vs. 2.1%Panic Disorder 9.0% vs. 0.8%Generalized anxiety 2.5% vs. 3.1% Phobic disorder 0.8% vs. 1.1%Obsessive compulsive 1.6% vs. 1.2%Schizophrenia 0.8% vs. 0.4%ETOH dependence 4.9% vs. 4.7%
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Brain Injury and DepressionDepression following brain injury occurs at a rate of 44.3% vs. 5.9% in non-brain injured population
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Differential Diagnosis IssuesHow can the clinician determine the role of injury and pre/post injury psychiatric factors that contribute to behavioral dysfunction?
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Pre-existing Psychiatric Disorders Related to TBI
Dementia due to head injuryCognitive disorderBipolar disorder (manic or depressive typesMood disorders (depression, mania)Sleep disorderAnxiety disordersIntermittent explosive disorder
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Pre-existing Conditions can Affect Recovery from TBI
Limited coping skillsImpaired ability to manage symptomsCognitive problems limit capacity to manage disability and pre-existing conditionAdvent of new behaviorsPrior medications may increase cognitive problems
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Effect of TBI on Underlying Psychiatric Disease
Reduced capacity to self-manage symptomsDiminished impulse control leads to enhanced interpersonal problemsPsychological defenses and coping skills fail to functionDenial of deficits prevents person from responding to injury-related deficits
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Effect of TBI on Underlying Psychiatric Disease
Interpersonal relationships changeSocial role is alteredSeizures and dyscontrol event are misinterpretedEnhanced dependent needs affect psychological status
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Adjustment Difficulty due to Emotional & Behavioral Issues
Emotional changeImpaired perception of social interactionImpaired self controlIncrease dependencyBehavioral rigidity
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Most Frequent Problems Cited by Family Members
SlownessIrritabilityImpatienceDepressionMemory
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Co-Morbidity: PTSD & TBI (Arnon, 1998)
32% of motor vehicle accident victims meet diagnostic criteria for PTSD one year post-injuryThose with PTSD have higher rates of pre-morbid/co-morbid psychopathology (anxiety and affective disorders)Immediacy of PTSD symptoms is a better predictor of later PTSD than injury severity
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Role of Prior Learning or Attentional Problems in Occurrence of Psychiatric Diagnosis
Prior learning and attentionalproblems are enhanced Diminished filtering and stimuli selectionAltered coping skills produce dysfunctional responses
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Psychiatric Issue or Brain Injury?
Mania vs. Arousal problems AnxietyDenial ConfusionDepressionCognitive problemsPersonality changesIntellectual changesThought disorder vs. Thinking problem
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Psychiatric Features of TBI Mania - AgitationAnxiety - Catastrophic Reaction(Goldstein)Denial - Inability to accept deficitsConfusion - Disorientation and memory problemsDepression – Withdrawal, abulia
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Neurologic and Neuropsychiatric Features
Atypical seizure disordersIntermittent explosive disorder (Yudofsky)Neurologic rage or limbic-psychotic aggressive syndrome (Dorothy Lewis)
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Neurologic Rage IdentifiersSudden loss of behavioral control, “out of the blue”Inability to stop the behaviorSeizure-like quality, unawareness of the individual to the eventDeficient memory of the event (Dorothy Lewis)
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Factors Leading to Behavioral Problems in TBI
Primary and secondary aspects of the physical injuryDevelopment of emotional problemsDevelopment of cognitive problems
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Two Type of Behavioral Problems
Behavioral excess –too muchBehavioral deficit –too little
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Neurobehavioral IssuesHyper/hypo arousalLevel of response to external events/filteringStimulus control vs. stimulus boundDenialJudgmentImpulsivity vs. self-regulationIrritability and seizure-like events
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Neurobehavioral Features
Aggressivity and assaultivenessApathy, abulia, lack of motivationIrritability, impatience
Impulsivity (lack of self-regulation)Level of motor agitation/restlessness
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Interpersonal/Psycho-Social Factors of Behavioral Problems
Impaired self-perceptionEmotional changesEgocentric thinkingImpaired perception of social issuesIncreased dependencyBehavioral rigidity
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Interpersonal/Psycho-Social Factors of Behavioral Problems
IrritabilityAnger control problemsMood instabilityHypo/hyper sexualityDiminished drive/ motivationCognitive deficits
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Factors of Cognitive Problems in TBI
Level of arousalSensorium disruptionConcentration and focusFiltering, stimuli control
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Factors of Cognitive Problems
Problem-solving and decision-makingLanguage and communication
Orientation and confusionMemory, information retrieval
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Cognitive Problems Can Look Like Behavioral Problems
Attention and filtering problemsOver/under arousalConcentrationMemoryTask learningNovel learning (old to new)
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The first step in making a diagnosis is to think of it.
-- Thibault, 1992
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Evaluate and Separate Post-Injury from Pre-Injury Problems
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Diagnostic Approaches
Developmental and school historyNeurological evaluationNeuropsychological assessmentMedical file review
Interview with individualComprehensive medical and psychiatric history
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Pre-Morbid Issues Presence of known psychiatric conditionLevel of adjustment, degree of attainment (school, work, family)History of learning, behavior and conduct problemsHistory of substance problemsMedical historySchool and vocational history
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Post-Injury Effect on Coping Skills and Personality
Response to disabling condition(s)Cognitive deficitsNeurobehavioral deficitsExternal support systemMotivation/initiativeSubstance use/abuseEngagement in meaningful activities
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Persistent Problems of Recovery and Rehabilitation
Irritability ImpulsivityEgocentricityLabilityJudgment deficitsImpatienceTension/AnxietyDepression
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Implications for Rehabilitation:
Why Patients “Fail”
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Persistent Problems of Recovery and Rehabilitation
HypersexualityHyposexualityDependencySilliness/EuphoriaAggressivityApathyChildishnessDisinhibition
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Why Patients “Fail”
Strategy:Individual and Group Psychotherapy
Why?Can’t identify problems as shared by othersDifficulty maintaining behavioral alternatives
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Why Patients “Fail”Strategy:
Insight-Oriented Approaches
Why?Can’t identify problem with selfProblems with generalization
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Why Patients “Fail”Strategy:
Didactic Approaches
Why?Memory problems prevent use of previous learning
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Why Patients “Fail”Strategy:
Milieu Treatment
Why?Social deficits inhibit positive peer group membership
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Why Patients “Fail”Strategy:
Cognitive-Behavioral Therapy
Why?Memory problems and difficulty with generalizations
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Why Patients “Fail”Strategy:
Behavior Modification
Why?Problems with impulse controlMemory problems prevent reinforcement strategy from being effective
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Why Patients “Fail”Strategy:
Medication Management
Why?Some medications further cognitive problems or cause disinhibited behavior
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Why Patients “Fail”Strategy:
Addictive Treatment/Self-Help Groups
Why?Cognitive problems prevent identification with the speaker/group processIndividual cannot apply information to self
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Why Patients “Fail”Person cannot process “talking therapies”Limited insightNew behaviors (e.g. impulsivity) are related to the brain injuryIncreased dependenceUnable to relate to previously effective support groups (e.g. AA, NA)
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Support System Stresses Increase Psychological Issues
High incidence of divorce or loss of primary relationship (50% in first two years post-injury)Adult children return to aging parents for physical assistanceLoss of friends and workHigh potential for substance use/abuseLoss of social role with family, friends and communityCultural factors influence recovery
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Social Network Issues Complicate Rehabilitation
Social network failure seen 24-months post injury (Burke and Weslowski. 1989)Psychological effect of withdrawal or loss of supports
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Social Network Issues Complicate Rehabilitation
Changing social role post-injury affects self-image and self-worthIndividual response to loss of functions and social changesRecidivism and emergence of psychiatric symptoms commonly seen 12-24 months post-injury
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Increasing Success in Rehabilitation and
Treatment:
What Works!
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What Works?Early identification of problemsHighly structured, social learning environmentRepetitive “teaching” of behavioral alternativesExternal controls managed by staff, gradually transferred to the individualNeurological approach to medication managementIntegrated rehab program, including psychiatric and substance abuse treatment
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What Works?Emphasis on learning and relearning of social roleTeaching “scripts” for social interactionGuided/supported attendance at AA/NA/self-help groupsUse of “failures” within treatment to address denial and limited insight
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What Works?Focus on social role re-entry and response of family, friends, co-workers, peers, and others to the personStaff understanding of TBI-related behavioral, cognitive, emotional and psychological issuesUnderstanding of adjustment to disabilityTeaching individual about consequences of TBIPromoting return to work, avocational and recreational activities
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What Works?Consistent response from staff throughout the environment Use of behavioral analysis to understand brain/behavior issuesAvoidance of negative consequences for behavior problemsFocus on discharge engineering to assure that the individual moves to a supportive placement with the solid transfer of information and management techniques
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Neurological Rehabilitation Institute (NRI)
atBROOKHAVEN
Tulsa’s Specialty Hospital
800-927-3974www.brookhavenhospital.com