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Psychiatric aspects of Brain Injury

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.

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Psychiatric aspects of Brain Injury

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  1. Psychiatric aspects of Brain Injury September 2006

  2. Psychiatric problems following brain injury • The injury • The person • The reaction

  3. The injury • Closed • Penetrating • Global • Focal • Other injuries

  4. The person • Premorbid condition • Alcohol or substance misuse • Premorbid personality

  5. The reaction • Post concussion • Trauma • Social consequences • Adjustment

  6. Psychiatric problems following brain injury • The injury • Closed • Penetrating • Global • Focal • Other injuries

  7. 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)

  8. Brain Injury • Moderate and severe physical and psychological disability 42/100,000/yr • Persistent behavioural problems 3/100,000/yr McClelland 1993

  9. Mild Brain Injury • <30 mins loc • PTA in hours • Attention deficits • Verbal retrieval • Emotional distress • Headache • Dizziness • Photophobia

  10. Moderate Brain Injury • GCS 9 – 12 • PTA < 24 hours • Headaches • Memory problems • 2/3 will not return to work

  11. Severe Head Injury • Attention • Memory • Emotional • Psychosis • Depression • Social isolation

  12. 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)

  13. PTSD • Traumatic event • Re-experienced • Avoidance • Increased arousal • Symptoms for more than 1 month • Clinically significant distress or arousal

  14. Psychosis Due to TBI • Schizophrenia • Seizures • Delirium • Confabulation • Substance abuse • Other pathology • Latency • Temporal lobe abnormalities

  15. 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)

  16. Psychosis Due to TBI • Abnormal EEG 70% • L temporal • MRI abnormalities • Frontal • Temporal • Enlarged ventricles (Fujii and Ahmed 2002)

  17. 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

  18. 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)

  19. Consequences • Personal • Economic • Social • Marital • Parental

  20. Antipsychotics • Dopamine receptors • Parkinsonism • Akathisia • Sedation • Dyskinesias • Sedation • Lower seizure threshold

  21. Antidepressants • SSRIs • Tricyclics • Lower seizure threshold • Anti-cholinergic effects

  22. Benzodiazepines • Sedative • Hangover • Tolerance • Addictive • Anticonvulsant

  23. Anticonvulsants • Antiepileptic • Toxicity • Teratogenicity

  24. 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

  25. Agitation and aggressionpharmacological management • Wide variety used • No strong evidence • Adverse effects • Beta blockers • Research needed (Cochrane Review, Fleminger et al 2003)

  26. Goals • Behavioural • Cognitive, communication • Functional, self care, leisure • Emotional e.g. anxiety management • Social e.g. family, placement

  27. Rehabilitation • Eating own dinner • Safer smoking • Getting across • Not getting cross

  28. Attribution theory

  29. Community Brain injury Teams • 4 in Eastern Board area • Southern • Northern • Western

  30. The Team • Consultant • Specialist Registrar • Neuropsychology

  31. Service Development • Neuropsychiatry inpatient assessment • Rehabilitation • Transitional living • Supported accommodation

  32. Team Development • Specialist nursing skills • SLT • OT • SW • Physiotherapy • CBT • Medical staff

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