Psychiatric aspects of Brain Injury by bjdpkx

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									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          44.3     7.9
Bipolar                   4.2      5.3
GAD                       9.1      2.3
OCD                       6.4      2.6
Panic Disorder            9.2      5.8
PTSD                      14.1     1.8
Schizophrenia             0.7      0.5
Substance Abuse           22       1.3
(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, 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
   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

								
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