Transcript Psychiatric aspects of Brain Injury

Psychiatric aspects of
Brain Injury
September 2006
Psychiatric problems following
brain injury
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The injury
The person
The reaction
The injury
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Closed
Penetrating
Global
Focal
Other injuries
The person
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Premorbid condition
Alcohol or substance misuse
Premorbid personality
The reaction
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Post concussion
Trauma
Social consequences
Adjustment
Psychiatric problems following
brain injury
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The injury
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Closed
Penetrating
Global
Focal
Other injuries
Brain Injury
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Head injury admissions
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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)
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Brain Injury
Moderate and severe physical and
psychological disability 42/100,000/yr
 Persistent behavioural problems 3/100,000/yr
McClelland 1993
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Mild Brain Injury
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<30 mins loc
PTA in hours
Attention deficits
Verbal retrieval
Emotional distress
Headache
Dizziness
Photophobia
Moderate Brain Injury
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GCS 9 – 12
PTA < 24 hours
Headaches
Memory problems
2/3 will not return to work
Severe Head Injury
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Attention
Memory
Emotional
Psychosis
Depression
Social isolation
Psychiatric conditions following
traumatic brain injury
Risk
Major depression
Bipolar
GAD
OCD
Panic Disorder
PTSD
Schizophrenia
Substance Abuse
(Van Reekum et al 2000)
44.3
4.2
9.1
6.4
9.2
14.1
0.7
22
Relative
Risk
7.9
5.3
2.3
2.6
5.8
1.8
0.5
1.3
PTSD
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Traumatic event
Re-experienced
Avoidance
Increased arousal
Symptoms for more than 1 month
Clinically significant distress or arousal
Psychosis Due to TBI
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Schizophrenia
Seizures
Delirium
Confabulation
Substance abuse
Other pathology
Latency
Temporal lobe abnormalities
Psychosis Due to TBI
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Delusions
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Hallucinations
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More common than hallucinations
Persecutory
Auditory
Visual more in early onset
Negative symptoms uncommon
Neuroleptics
(Fujii and Ahmed 2002)
Psychosis Due to TBI
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Abnormal EEG 70%
L temporal
MRI abnormalities
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Frontal
Temporal
Enlarged ventricles
(Fujii and Ahmed 2002)
Personality change
Phineas Gage
Vermont, 13th 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
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Dorsolateral prefrontal
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Orbitofrontal
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Executive dysfunction
Impaired planning, organisation and set shifting
Environmental dependency
Impaired semantic memory and verbal fluency (L)
Disinhibition
Medial frontal/anterior cingulate
Apathy
(Cummings and Trimble)
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Consequences
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Personal
Economic
Social
Marital
Parental
Antipsychotics
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Dopamine receptors
Parkinsonism
Akathisia
Sedation
Dyskinesias
Sedation
Lower seizure threshold
Antidepressants
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SSRIs
Tricyclics
Lower seizure threshold
Anti-cholinergic effects
Benzodiazepines
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Sedative
Hangover
Tolerance
Addictive
Anticonvulsant
Anticonvulsants
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Antiepileptic
Toxicity
Teratogenicity
Management of aggression
and agitation
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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)
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Goals
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Behavioural
Cognitive, communication
Functional, self care, leisure
Emotional e.g. anxiety management
Social e.g. family, placement
Rehabilitation
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Eating own dinner
Safer smoking
Getting across
Not getting cross
Attribution theory
Community Brain injury Teams
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4 in Eastern Board area
Southern
Northern
Western
The Team
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Consultant
Specialist Registrar
Neuropsychology
Service Development
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Neuropsychiatry inpatient assessment
Rehabilitation
Transitional living
Supported accommodation
Team Development
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Specialist nursing skills
SLT
OT
SW
Physiotherapy
CBT
Medical staff