Question: What types of psychiatric problems can a person with brain injury experience?
Answer: Brain Injury Source, Volume 2, Issue 1, Ask the Doctor
Anthony B. Joseph, MD
Introduction
Psychiatric issues of various kinds can be an important clinical complication in the recovery from and treatment of brain injury.
In this context, a psychiatric problem may be conceptualized broadly as a clinically significant dysfunction of human behavior. Besides including such traditional psychiatric topics as mood disorders, aggression, psychosis and substance abuse, this definition has the advantage of highlighting the value of recognizing the psychiatric or behavioral component in other problems frequently faced by individuals with brain injury, such as disorders of cognition, memory, attention, coordination and movement.
Brain injury is often a complex, diffuse process that results in widespread areas of cerebral dysfunction. As a consequence, multiple neurological systems responsible for behavioral homeostasis may misfunction simultaneously leading to a mixed presentation of coexistent psychiatric problems in multiple behavioral domains.
Frameworks for Considering Psychiatric Illness After Brain Injury
There are numerous different models for analyzing psychiatric illness in people with brain injury. Each emphasizes a different aspect of clinical presentation and can be predictive of treatment and prognosis.
Perhaps the most common and useful is the DSM-IV approach. This manual, a consensus document produced by the American Psychiatric Association, divides psychiatric illness into clusters of symptoms and behaviors that constitute diagnosable syndromes, for example, bipolar affective disorder or atypical disorder or atypical psychosis. Although the terminology is frequently inelegant and the manual appears both confused and confusing when dealing with the concept of psychiatric illness secondary to neurological injury, it does provide a consistent set of diagnostic terms, which are broadly useful in predicting future outcomes and suggesting treatment approaches with medication.
Another useful approach is to take a life history of the person. In this method, the focus is on long term behavioral patterns, which may or may not be diagnosable in DSM-IV terms, to understand how a brain injury has affected behavior and to try and predict how this will continue in the future.
An example of this approach would be a twenty-five year old male with a preinjury history of attention deficit disorder, mild depression, oppositionalism and alcohol abuse who suffered a traumatic brain injury at age nineteen.
Important to know is that his current problem of severe anger, ongoing depression and non-compliance with therapies while more intense now, have their origins prior to the brain injury. The clinical implication is that treatment of such behavior is going to take much more time and require a more carefully coordinated treatment team than if the same behavior had begun for the first time after the injury.
Another model is the neuropsychological one. This has the advantage of analyzing behavior at a more neurological and functional level than DSM-IV. However, it does so at the cost of losing the psychiatric focus.
Typically, a neuropsychological analysis will emphasize brain functions such as attention, memory, ability to switch set and visuospatial functioning. This information is used to support an understanding of the effects of brain injury that may underlie or drive any given psychiatric illness. Often a neuropsychologist will be able to advise on which areas of the brain are most damaged. A traditional example would be to link right-hemisphere damage with a left-sided hemi-neglect. Taking the example of the individual described previously, a more sophisticated analysis would be to relate the damage to his anterior right hemisphere with his depression, left neglect and denial of illness leading to treatment refusal. This approach has clear utility for understanding some aspects of psychiatric illness at a more fundamental level.
Switching focus, probably the most practically useful clinical model of behavior for the brain injury population is the neurotransmitter model. Although this is not quite the same as the more widely known psychopharmacological model, it does underlie it.
In this view, behavior and psychiatric illness are seen as being driven by too much or too little neurotransmitter activity. Modify the neurotransmitter activity level with psychopharmacological agents and the theory predicts that the behavior should resolve. Unfortunately, while broadly correct, this model has some critical and major flaws. Simply put, these amount to a lack of knowledge sufficient to allow clinically accurate individual predictions. One reason for this is that neurotransmitters seem to be broad modulators of whole classes of human brain function and behavior, and their effects overlap. Psychoactive medications thus usually change many things at once and their effects, in general, are not specifically predictable. The situation becomes even more complicated when multiple medication and dose changes are made simultaneously or close together.
Another complication is that individual responses, and probably brain chemistry, often appear to vary significantly. This implies that the generalized understanding of how a medication works can not always be applied to an individual. This is a concern that appears to be confirmed by the empirical results of clinical practice.
The net effect of these, and other complications, is that the use of medication to treat psychiatric illness after brain injury is neither precise nor completely predictable. While medications can be extremely beneficial for people, intense individualization is often required for their application.
Finally some other approaches that have been commonly used to try and understand psychiatric illness after brain injury have been to divide persons into acute and sub-acute versus chronic categories or to separate them by rehabilitation status such as coma-stimulation versus community re-entry. While useful in certain narrow circumstances, these schemes do not have the broad utility of those discussed above.
Categories of Psychiatric Disorder after Brain Injury
There are too many specific psychiatric disorders that can occur after brain injury to discuss individually here. However, there are a smaller number of broader categories of these disorders that may be usefully addressed.
In the following categories, different disorders are grouped by the hallmark behavioral features most commonly seen, and often shared, within the category.
Affective Disorders
Affective disorders may be thought of as disorder of mood and related conditions. These include bipolar disorder, depression, mania, obsessive compulsive disorders, panic and anxiety disorders, and even eating, attentional and substance abuse disorders.
The cardinal clinical elements that are seen in these disorder can include any of the following, and their intensity may vary: depression; mania; obsessions; compulsions; perseveration; panic attacks; anxiety; bulimia; anorexia; and inattention. Additionally, elements of motor disturbances such as bradykinesis or hyperkinesis are often present. Also seen are impulsivity, changes in motivational status, and under- or overarousal.
Psychotic Disorders
These disorders are much less common after brain injury than affective disorders, but when they occur they can be devastating to rehabilitation goals or to the maintenance of community residential status.
Psychosis refers to a process in which individuals do one of the following: experience events which are not really happening, such as auditory, visual or tactile hallucinations; have fixed unshakable beliefs called delusions, that are not reversible when correct information is provided, such as believing that they are the victim of a conspiracy; or have one of several specific disorders of information processing or language function leading to what is called a thought disorder.
Psychosis has many different causes and can occur as a secondary phenomenon due to mania, depression, epilepsy or brain injury.
Impulsivity
Individuals frequently present with complaints related to being too impulsive. Collectively, such problems are often referred to as impulse control disorders. They may be specific such as pyromania or compulsive shoplifting, or general such as explosive disorder or organic personality syndrome.
Impulsivity can occur independently, but is often secondary to, or at least exacerbated by, another coexistent psychiatric disorder, such as mania or agitated depression.
Aggression and Violence
For a minority of people with brain injury, significant aggression and even interpersonal violence are problems. For a large group of these individuals, such aggression is also secondary to or exacerbated by another coexistent psychiatric disorder. For a smaller group, it is idiopathic and may well reflect a general disinhibition of neurologic function in which aggressive impulses become more easily acted upon.
Arousal and Motivational Disorders
For a small group of individuals with brain injury significant disturbances of arousal and/or motivation are seen. Usually these syndromes are separate but they can occur together. Both seem to be common in persons with a coexistent affective disorder. Depression, poor motivation, decreased initiation and underarousal are a relatively common combination. Insufficient arousal and motivation can be very severe functional problems and often require intensive intervention when they occur.
Attentional-Cognitive-Amnestic Disorders
Disorders of attention are particularly common after brain injury. They may be present as a classic case of attention deficit hyperactivity disorder, or be more subtle. As the brain injury increases in severity, a major impairment of information processing or memory is more likely. Although these are not usually thought of as psychiatric disorders, they often lead to behavioral disturbance and may be accompanied by affective and impulsivity disorders. They may also complicate previous or coexisting psychiatric illness, an important focus to keep in mind when planning treatment.
Eating Disorders
Classic cases of eating disorder, such as bulimia or anorexia, are relatively rare after brain injury. More common are partial or atypical forms, involving binge eating, a lowered threshold for vomiting ad compulsive eating. Debatably, it might also be worth considering excessive water drinking within this category.
Personality Disorders
Strictly speaking, personality disorder really requires a lifelong pattern of specified behavioral disturbances to be diagnosable, and personality disturbances newly acquired after brain injury are not usually thought of as "secondary" personality disorders. However, personality issues occurring pre-morbidly are often intensified by a brain injury. This intensification is a legitimate focus of attention in treatment planning as it may require a more consistent and intense series of clinical interventions than would be needed in the non-personality disordered individual.
Substance Abuse
Substance abuse is an area of special concern in the general population. Often implicated in traumatic brain injuries and if not specifically addressed in treatment, substance abuse can essentially nullify progress made in other areas of rehabilitation, especially after reintegration into the community where substances are much more readily available.
Mild Brain Injury Syndrome
This syndrome, although probably no longer controversial in the field, is still not widely recognized among non-specialist clinicians. Its name is a misnomer in the sense that a so-called "mild" brain injury can devastate the functional and interpersonal life of an individual by causing significant dysfunction in the realms of attention, cognition and memory while leaving them with an unchanged external appearance. This deceptive and apparent physical "normality" can, in turn, lead a person’s symptoms to be dismissed or rejected as "not real." In some classes of psychiatric illness, individuals do complain of symptoms that they are inventing in various ways and for different reasons. These are known as factitious disorders and their diagnosis is as straightforward and non-mysterious as any other category of illness. The fact that a person "looks normal" should never be a sufficient reason for dismissing complaints. If the clinical facts in such a situation support it, a positively affirmed diagnosis of a factitious disorder is appropriate. If not, the individual’s concerns, no matter how difficult to understand, should prompt the search for another kind of explanatory diagnosis.
As a final point, mild brain injury syndrome is important to recognize as it can often respond to cognitive rehabilitation and effective psychopharmacological interventions.
Some Special Considerations
Whatever their clinical presentation, individuals with brain injury that exhibit psychiatric disorder share some common features.
Rehabilitation, not just behavior control, should almost always be a goal that should be aggressively pursued before being abandoned. Often, control of psychiatric symptoms is necessary before rehabiltiation can be fully effective and too many individuals lose opportunities for rehabilitation because their behavior is out of control.
Cognitive and behavioral rehabilitation should often be considered in addition to the more common rehabilitation modalities such as physical therapy, speech-language and vocational rehabilitation. People with severe brain injury may have a much slower learning curve than other individuals in rehabilitation and premature abandonment of their rehabilitation is a real concern.
Finally, individuals with brain injury are especially susceptible to the sedative and agitating side effects of psychoactive medications. This is not a reason to ignore or avoid these medications in this population but does necessitate their judicious and individualized use.