Physiogenesis and psychogenesis in the 'post-concussional syndrome'

Quality of life and neuropsychological changes in mild head trauma. Late analysis and correlation with S100B protein and cranial CT scan performed at hospital admission

INTRODUCTION

mild head trauma (MHT) is defined as a transient neurological deficit after trauma with a history of impairment or loss of consciousness lasting less than 15 min and/or posttraumatic amnesia, and a Glasgow Coma Scale between 13 and 15 on hospital admission. We evaluated 50 MHT patients 18 months after the trauma, addressing signs and symptoms of post-concussion syndrome, quality of life and the presence of anxiety and depression. We correlate those findings with the S100B protein levels and cranial CT scan performed at hospital admission after the trauma.

METHOD

patients were asked to fill out questionnaires to assess quality of life (SF36), anxiety and depression (HADS), and signs and symptoms of post-concussion syndrome. For the control group, we asked the patient's household members, who had no history of head trauma of any type, to answer the same questionnaires for comparison.

RESULTS

total quality of life index for patients with MHT was 58.16 (+/-5), lower than the 73.47 (+/-4) presented by the control group. Twenty patients (55.2%) and four (11.1%) controls were depressed. Seventeen patients (47.2%) presented anxiety, whereas only eight (22.2%) controls were considered anxious. Victims of MHT complained more frequently of loss of balance, dry mouth, pain in the arms, loss of memory and dizziness than their respective controls (p<0.05). We found no correlation between the presence of these signs and symptoms, quality of life, presence of anxiety and depression with S100B protein levels or with presence of injury in the cranial CT performed at hospital admission.

CONCLUSION

MHT is associated with a higher incidence of post-concussion syndrome symptoms, lower quality of life and anxiety than their respective controls even 18 months after the trauma.

Neuropsychological function 23 years after mild traumatic brain injury: a comparison of outcome after paediatric and adult head injuries

PRIMARY OBJECTIVE

To the authors' knowledge no study comparing very long-term neuropsychological outcome after mild paediatric and adult traumatic brain injury (TBI) has been published. The primary objective of this study was to compare neuropsychological outcome 23 years after mainly mild paediatric and adult TBI.

RESEARCH DESIGN

The study was a neuropsychological follow-up 23 years after a prospective head injury study conducted at a Norwegian public hospital.

METHODS AND PROCEDURES

One hundred and nineteen patients were assessed with a comprehensive neuropsychological test battery. Of these, 45 were paediatric TBI and 74 were adult TBI.

MAIN OUTCOMES AND RESULTS

Both the paediatric and adult groups obtained scores in the normal range. In the paediatric group significant relationships were found between head injury severity and current neuropsychological function. The most important predictors of poor outcome were length of post-traumatic amnesia (PTA) and a combination of PTA and EEG pathology within 24 hours of injury. No influence of pre- and post-injury risk factors on current neuropsychological function was evident.

CONCLUSIONS

The findings indicate that children sustaining complicated mild TBI may be more vulnerable to development of chronic mild neuropsychological dysfunction than adults sustaining similar head injuries.

Long-term morbidities following self-reported mild traumatic brain injury

The objective of this study was to examine the prevalence of long-term psychiatric, neurologic, and psychosocial morbidities of self-reported mild traumatic brain injury (MTBI). A cross-sectional cohort sample of three groups was examined: those who had not been injured in a motor vehicle accident nor had a MTBI (n = 3,214); those who had been injured in an accident but did not have a MTBI (n = 539); and those who had a MTBI with altered consciousness (n = 254). Logistic regression analyses were used to model odds ratios for the association between group and outcome variables while controlling demographic characteristics, comorbid medical conditions, and early-life psychiatric problems. Compared with uninjured controls, MTBI increased the likelihood of depression and postconcussion syndrome. MTBI also was associated with peripheral visual imperceptions and impaired tandem gait. Similarly, the MTBI group had poorer psychosocial outcomes including an increased likelihood of self-reported disability, underemployment, low income, and marital problems. Results suggest that MTBI can have adverse long-term psychiatric, neurologic, and psychosocial morbidities.

Non-pharmacological approaches to treatment

Chronic fatigue syndrome (CFS) as currently defined overlaps with other syndromes including chronic pain, fibromyalgia, anxiety and depression. It also resembles historical descriptions of neurasthenia. The role of psychological (cognitive) and behavioural therapies in CFS is examined. There are both pragmatic and theoretical arguments for their application to CFS. It is pragmatic to target obvious and treatable factors including inactivity and depression. A theoretical model in which psychological, physiological and social factors interact offers a plausible rationale for such treatment but is not yet empirically proven. While there is evidence for the efficacy of this type of therapy in related syndromes, the evidence in CFS is inconclusive. A randomized controlled trial of combined cognitive and behavioural therapy currently in progress is described. Initial results suggest that most patients receiving cognitive behaviour therapy improve, especially in terms of functional impairment. It remains to be seen whether this therapy will prove to be more effective than standard general practitioner care. In the meantime cognitive behaviour therapy offers a pragmatic and rational therapy for patients with CFS.

Illness perceptions and outcome in mild head injury: a longitudinal study

BACKGROUND

A range of neuropathological and psychosocial factors have been implicated in the aetiology and maintenance of post-concussional syndrome (PCS), with a growing consensus in the literature that this is a complex, multifactorial condition. The role of patients' perceptions in PCS has not been examined to date.

OBJECTIVE

This longitudinal study examines the role of illness perceptions in predicting outcome following mild head injury, controlling for severity of injury, post-traumatic stress symptoms, anxiety and depression, using a logistic regression analysis.

METHOD

73 patients were admitted to an accident and emergency department with mild head injury (Glasgow Coma Scale score 13-15; loss of consciousness <20 min; post-traumatic amnesia <24 h). Data on PCS symptomatology, illness perceptions, post-traumatic stress symptoms, anxiety and depression were collected after the injury and at the 3 month follow-up. Logistic regression analysis was used to evaluate predictors of outcome.

RESULTS

Following a mild head injury, symptomatic patients who believe that their symptoms have serious negative consequences on their lives and will continue to do so, are at heightened risk of experiencing significant enduring post-concussional symptoms (p<0.001). Adding measures of severity of injury, post-traumatic stress symptoms, anxiety and depression to the regression model did not improve prediction of outcome.

CONCLUSION

Whatever other physical or psychological factors may be involved, patients' perceptions of their illness early after head injury play a part in the persistence of PCS.

Relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status following mild traumatic brain injury: a follow-up study

OBJECTIVES

To explore the long-term relations among sociodemographic, neurologic, clinical, and neuropsychologic variables, and vocational status in persons with mild traumatic brain injury (MTBI), and to identify the symptoms that determine whether or not these individuals return to work.

DESIGN

Longitudinal quasi-experimental between-groups design.

PARTICIPANTS

Eighty-five MTBI subjects aged between 16 and 65 years.

SETTING

The emergency ward of the Trois-Rivieres Regional Hospital Centre in Quebec, Canada.

MAIN OUTCOME MEASURES

Age, gender, Glasgow Coma Scale score, duration of posttraumatic amnesia, duration of retrograde amnesia, total of symptoms at emergency, time elapsed since the trauma, Paced Auditory Serial Addition Task, Stroop Color Word Test, California Verbal Learning Test, and the number of symptoms at follow-up (12 to 36 months posttrauma).

RESULTS

Only the total number of symptoms reported at follow-up was related to vocational status. The majority of individuals had returned to work 1 year or more post-MTBI. Individuals who had not returned to work reported the greatest number of symptoms, which could be linked to their affective status. Six affective symptoms, 5 cognitive symptoms, 6 physical symptoms, and 8 symptoms relating to social and daily life activities differentiated the participants who had returned to work from those who had not.

CONCLUSIONS

Patient characteristics, injury severity indicators, and cognitive functions were not associated with vocational status. To better understand post-MTBI vocational status, it is important to focus on subjective complaints that arise following the injury.

One-year follow-up of patients with mild traumatic brain injury: occurrence of post-traumatic stress-related symptoms at follow-up and serum levels of cortisol, S-100B and neuron-specific enolase in acute phase

OBJECTIVE

To investigate serum levels of cortisol (a biochemical marker of stress), S-100B and neuron-specific enolase (two biochemical markers of brain tissue injury), in acute phase in mild traumatic brain injury patients and the occurrence of post-traumatic stress-related symptoms 1 year after the trauma.

METHODS

Blood samples were taken in patients (n = 88) on admission and approximately 7 hours later for analysis. Occurrence of post-traumatic stress-related symptoms was assessed for 69 patients using items from the Impact of Event Scale questionnaire (IES) at follow-up at 15 +/- 4 months after the injury.

RESULTS

Serum levels of cortisol were more increased in the first sample (cortisol/1, 628.9 +/- 308.9 nmol L-1) than in the second blood sample (cortisol/2, 398.2 +/- 219.4 nmol L-1). The difference between these samples was statistically significant (p < 0.001). Altogether 12 patients (17%) showed post-traumatic stress related symptoms at the time of the follow-up. Stepwise forward logistic regression analysis of symptoms and serum concentrations of markers revealed that only S-100B in the second sample was statistically significantly (p < 0.05) associated to symptoms (three symptoms of the avoidance sub-set of IES).

CONCLUSION

A major increase in serum concentrations of cortisol indicates that high stress levels were reached by the patients, in particular shortly ( approximately 3 hours) after the trauma. The association between the occurrence of post-traumatic stress related symptoms and serum levels of S-100B (generally considered as a biochemical marker of brain injury) seem to reflect the complexity of interactions between brain tissue injury and the ensemble of stress reactions.

The relationship of psychological and cognitive factors and opioids in the development of the postconcussion syndrome in general trauma patients with mild traumatic brain injury

The relationship of psychological and cognitive factors in the development of the postconcussion syndrome (PCS) following mild uncomplicated traumatic brain injury (mTBI) has received little study. This may be because of the widely held belief that neurological factors are the cause of early PCS symptoms, whereas psychological factors are responsible for enduring symptoms. To further understand these relationships, the association between PCS and neuropsychological and psychological outcome was investigated in 122 general trauma patients, many of whom had orthopedic injuries, around 5 days following mTBI. Apart from verbal fluency, participants with a PCS did not differ in their performances on neuropsychological measures compared to those without a PCS. Individuals with a PCS reported significantly more psychological symptoms. Large effect sizes present on the psychological measures showed that the difference between participants with a PCS and without was greater on psychological than on neuropsychological measures. Analyses also revealed a relationship between opioid analgesia and depression, anxiety and stress, and opioids and reduced learning. The results suggest that psychological factors are present much earlier than has previously been considered in the development of the PCS.

The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis

OBJECTIVE

To investigate the factor structure of the Rivermead Post Concussion Symptoms Questionnaire (RPQ) among individuals seen as part of routine follow-up following traumatic brain injury.

METHODS

RPQ data from 168 participants was examined (mean age 35.2, SD 14.3; 89% with post traumatic amnesia duration<24 hours) six months after admission to an Accident & Emergency Department following TBI. Structural equation modelling was carried out to evaluate proposed models of the underlying structure of post-concussion symptoms (PCS).

RESULTS

The results support the existence of separate cognitive, emotional and somatic factors, although there was a high degree of covariation between the three factors. A two-factor model that collapsed the emotional and somatic factors together showed a similar goodness-of-fit to the data, whilst a one-factor model proved a poor fit.

CONCLUSION

The results support the notion of post-concussion symptoms as a collection of associated but at least partially separable cognitive, emotional and somatic symptoms, although questions persist regarding symptom specificity. The use of the RPQ is discussed, and classification bands for use in clinical practice are suggested.

Randomized treatment trial in mild traumatic brain injury

OBJECTIVE

To determine whether multidisciplinary treatment of mild traumatic brain injury (MTBI) improves neurobehavioral outcome at 6 months postinjury.

METHODS

Subjects with MTBI were randomly assigned to treatment (n=97) or nontreatment (control, n=94) groups. Treated patients were assessed within 1 week of injury and thereafter managed by a multidisciplinary team according to clinical need for a further 6 months. Control subjects were not offered treatment. Six-month outcome measures included: severity of postconcussive symptoms (Rivermead Post-Concussion Disorder Questionnaire), psychosocial functioning (Rivermead Follow-up Questionnaire), psychological distress (General Health Questionnaire), and cognition (neurocognitive battery).

RESULTS

Treatment and control subjects were well-matched for demographic and MTBI severity data. In addition, the two groups did not differ on any outcome measure. However, in individuals with preinjury psychiatric difficulties (22.9% of the entire sample), subjects in the treatment group had significantly fewer depressive symptoms 6 months postinjury compared with untreated controls (P=.01).

CONCLUSIONS

These findings suggest that routine treatment of all MTBI patients offers little benefit; rather, targeting individuals with preinjury psychiatric problems may prove a more rational and cost-effective approach.

Ethical Controversies in Neuropsychological Test Selection, Administration, and Interpretation

Due to the lack of uniform agreement on certain aspects of neuropsychological assessment practice, ethical issues can arise. Ethical controversies related to some of the most basic assessment practices of the clinical neuropsychologist are addressed. Current controversies related to neuropsychological test selection, test administration, and test interpretation are discussed and illustrated by case vignettes. Brief analyses of the ethical ramifications of the controversies are offered, followed by suggestions and recommendations for dealing with these conflicts. By resolving these conflicts as a discipline, more consistent standards of neuropsychological practice could be established, which would be of ultimate benefit to both professional and consumer alike.

Explaining medically unexplained symptoms: toward a multidimensional, theory-based approach to somatization

In spite of the apparent clinical importance of somatization, the concept does not have a single meaning. The focus of the present article is therefore not on scrutinizing existing diagnostic categories but rather on the different dimensions that relate to somatization and on the relevance of psychological models such as social learning theory, stress coping, illness cognition, and self-regulation models for explaining more carefully the predisposing, precipitating, and perpetuating factors of (different types of) somatization. This combined approach could lead to the definition of more homogeneous and, therefore, clinically more meaningful subgroups of somatization.

Are mild head injuries as mild as we think? Neurobehavioral concomitants of chronic post-concussion syndrome

Background

Mild traumatic brain injury (MTBI) can sometimes lead to persistent postconcussion symptoms. One well accepted hypothesis claims that chronic PCS has a neural origin, and is related to neurobehavioral deficits. But the evidence is not conclusive. In the attempt to characterise chronic MTBI consequences, the present experiment used a group comparison design, which contrasted persons (a) with MTBI and PCS, (b) MTBI without PCS, and (c) matched controls. We predicted that participants who have experienced MTBI but show no signs of PCS would perform similar to controls. At the same time, a subgroup of MTBI participants would show PCS symptoms and only these volunteers would have poorer cognitive performance. Thereby, the performance deficits should be most noticeable in participants with highest PCS severity.

Method

38 patients with a single MTBI that had occurred at least 12 month prior to testing, and 38 matched controls, participated in the experiment. A combination of questionnaires and neuropsychological test batteries were used to assess the extent of PCS and related deficits in neurobehavioral performance.

Results

11 out of 38 MTBI participants (29%) were found to suffer from PCS. This subgroup of MTBI patients performed poorly on neuropsychological test batteries. Thereby, a correlation was found between PCS symptom severity and test performance suggesting that participants with more pronounced PCS symptoms performed worse in cognitive tasks. In contrast, MTBI patients with no PCS showed performed similar to matched control. We further found that loss of consciousness, a key criterion for PCS diagnosis, was not predictive of sustained PCS.

Conclusion

The results support the idea that MTBI can have sustained consequences, and that the subjectively experienced symptoms and difficulties in everyday situations are related to objectively measurable parameters in neurocognitive function.

Routine and quantitative EEG in mild traumatic brain injury

This article reviews the pathophysiology of mild traumatic brain injury, and the findings from EEG and quantitative EEG (QEEG) testing after such an injury. Research on the clinical presentation and pathophysiology of mild traumatic brain injury is reviewed with an emphasis on details that may pertain to EEG or QEEG and their interpretation. Research reports on EEG and QEEG in mild traumatic brain injury are reviewed in this setting, and conclusions are drawn about general diagnostic results that can be determined using these tests. QEEG strengths and weaknesses are reviewed in the context of factors used to determine the clinical usefulness of proposed diagnostic tests. Clinical signs, symptoms, and the pathophysiologic axonal injury and cytotoxicity tend to clear over weeks or months after a mild head injury. Loss of consciousness might be similar to a non-convulsive seizure and accompanied subsequently by postictal-like symptoms. EEG shows slowing of the posterior dominant rhythm and increased diffuse theta slowing, which may revert to normal within hours or may clear more slowly over many weeks. There are no clear EEG or QEEG features unique to mild traumatic brain injury. Late after head injury, the correspondence is poor between electrophysiologic findings and clinical symptoms. Complicating factors are reviewed for the proposed commercial uses of QEEG as a diagnostic test for brain injury after concussion or mild traumatic brain injury. The pathophysiology, clinical symptoms and electrophysiological features tend to clear over time after mild traumatic brain injury. There are no proven pathognomonic signatures useful for identifying head injury as the cause of signs and symptoms, especially late after the injury.

Impaired spatial learning in a novel rat model of mild cerebral concussion injury

The aim of the present study was to develop a model of mild traumatic brain injury in the rat that mimics human concussive brain injury suitable to study pathophysiology and potential treatments. 34 male Wistar rats received a closed head trauma (TBI) and 30 animals served as controls (CON). Immediately following trauma, animals lost their muscle tone and righting reflex response, recovering from the latter within 11.4 +/- 8.2 min. Corneal reflex and whisker responses returned within 4.5 +/- 3.0 min and 6.1 +/- 2.9 min, respectively. The impact resulted in a short transient decrease of pO2 (P < 0.001), increase in mean arterial blood pressure (P = 0.026), and a reduction of heart rate (P < 0.01). Serial MRI did not show any abnormalities across the entire cerebrum on diffusion, T1, T2, and T2*-weighted images at all investigated time points. TBI animals needed significantly longer to locate the hidden platform in a Morris water maze and spent less time in the training quadrant than controls. TBI led to a significant neuronal loss in frontal cortex (P < 0.001), as well as hippocampal CA3 (P = 0.017) and CA1 (P = 0.002) at 9 days after the trauma; however, cytoskeletal architecture was preserved as indicated by normal betaAPP- and MAP-2 staining. We present a unique, noninvasive rat model of mild closed head trauma with characteristics of human concussion injury, including brief loss of consciousness, cognitive impairment, and minor brain injury.

Early coping strategies do not influence the prognosis after whiplash injuries

This is a 1-year prospective study to investigate the prognostic value of coping strategies such as catastrophising for persistent pain after a whiplash injury. A consecutive series of 96 patients who were seen in the emergency room in the acute phase after the injury were followed prospectively for 1 year. Age, gender and whether or not pain in the neck preceded the accident was recorded. Cases involving fractures or dislocations of the cervical spine, head trauma or pre-existing neurological disorders were not included. The mean interval between the accident and the initial examination was 3+/-2(S.D.) days. Coping was measured using the Coping Strategies Questionnaire (CSQ). The outcome parameter was self-reported neck pain at 1 year after the motor vehicle accident. At 1 year, 34% of the patients had neck pain. Women developed chronic neck pain more often than men (71% versus 29%); they also had significantly higher coping activity, such as diverting attention, praying or hoping (p<0.05), catastrophising and increasing behavioural activities (p<0.0001). Women reported pain in the neck or shoulder more often before the accident and this was the only statistically significant predictor of chronic symptoms when analysed by logistic regression (odds ratio 4.5). To conclude, we found no evidence that the different coping patterns during the early phase after a whiplash injury influenced the prognosis.

Outcome from mild traumatic brain injury

PURPOSE OF REVIEW

The focus of this review is outcome from mild traumatic brain injury. Recent literature relating to pathophysiology, neuropsychological outcome, and the persistent postconcussion syndrome will be integrated into the existing literature.

RECENT FINDINGS

The MTBI literature is enormous, complex, methodologically flawed, and controversial. There have been dozens of studies relating to pathophysiology, neuropsychological outcome, and the postconcussion syndrome during the past year. Two major reviews have been published. Some of the most interesting prospective research has been done with athletes.

SUMMARY

The cognitive and neurobehavioral sequelae are self-limiting and reasonably predictable. Mild traumatic brain injuries are characterized by immediate physiological changes conceptualized as a multilayered neurometabolic cascade in which affected cells typically recover, although under certain circumstances a small number might degenerate and die. The primary pathophysiologies include ionic shifts, abnormal energy metabolism, diminished cerebral blood flow, and impaired neurotransmission. During the first week after injury the brain undergoes a dynamic restorative process. Athletes typically return to pre-injury functioning (assessed using symptom ratings or brief neuropsychological measures) within 2-14 days. Trauma patients usually take longer to return to their pre-injury functioning. In these patients recovery can be incomplete and can be complicated by preexisting psychiatric or substance abuse problems, poor general health, concurrent orthopedic injuries, or comorbid problems (e.g. chronic pain, depression, substance abuse, life stress, unemployment, and protracted litigation).

Neurobehavioural outcomes of mild head injury in children and adolescents

The vast majority of closed-head injuries (CHI) in children are of mild severity. Even if only a small proportion of children with mild CHI suffer persistent negative outcomes, then mild CHI is a serious public health problem. This paper summarizes the existing literature regarding the neurobehavioural outcomes associated with mild CHI in children and adolescents, focusing on the longstanding debate regarding post-concussive syndrome. The paper also discusses conceptual and methodological issues that arise in research on the outcomes of mild CHI, including the definition of mild CHI; selection of comparison groups; measurement of outcomes; assessment of risk factors; timing of outcome assessments; and prediction of outcomes for individual children. The paper describes an ongoing research project that may help to resolve some of the longstanding controversies and uncertainties regarding the outcomes of mild CHI in children and concludes with a review of likely future directions for research on the outcomes of mild CHI. The long-term goal of research in this area is to develop a comprehensive and integrated biopsychosocial model of outcomes that can help guide clinical management.

Aspectos da interconsulta psiquiátrica em hospital de trauma

Os autores se propõem a abordar os aspectos particulares da interconsulta psiquiátrica em um hospital de trauma. Para isso, revisam os aspectos gerais de uma interconsulta em um hospital geral, e, posteriormente, destacam as características que diferenciam a consultoria psiquiátrica em um hospital de trauma. Os eventos psiquiátricos mais relevantes no trauma são as tentativas de suicídio violentas, o abuso de substâncias e as reações psíquicas ao traumatismo. O ponto de destaque se refere à especificidade da relação entre trauma e doenças psiquiátricas: ambos podem ser causa ou conseqüência. A interconsulta psiquiátrica é um novo campo de atuação interdisciplinar e de produção científica para a psiquiatria.

Bipolar disorder after traumatic brain injury

Objective. We report the case of a 47-year-old man with no psychiatric antecedents who developed manic and depressive symptoms after traumatic brain injury (TBI). Methods and results. Findings on neurobehavioral examination, neuropsychological test battery, electrophysiological and imaging exams suggested the presence of a diffuse cerebral injury with a predominance of left fronto-temporal findings. Conclusions. This case demonstrates that TBI may cause vulnerability to psychiatric disorders, with long latency periods, and that its course may be independent of cognitive impairment and recovery.

Post-traumatic syndrome after minor head injury cannot be predicted by neurological investigations

The aim of this study is to investigate predictive factors of post-traumatic syndrome in children with minor head injury. Prospective neurological, electroencephalographic and psychological investigations were performed in 98 children aged 3-13 years within 24 h after the trauma and 4-6 weeks later. Inclusion criteria for mild head injury were unconsciousness <10 min or none at all, lack of overt neurological symptoms and other complications requiring intensive care. Twenty-six of the children had been unconscious for a short period. Ten had suffered a skull fracture. Within the first 24 h, nearly all children reported acute symptoms of concussion and 64 of 98 showed abnormal EEG findings. After 4-6 weeks, 23 of 98 still exhibited post-traumatic complaints with headache, fatigue, sleep disturbances, anxiety and affect instability. Such post-traumatic symptoms did not correlate with somatic, neurological or electroencephalographic findings observed immediately after the injury or at the follow-up investigation. As opposed to the situation in more severe head trauma, post-traumatic syndrome after minor head injury in children is apparently not due to central nervous injury detectable by neurological examination or electroencephalography. Irrespective of the necessity of neuroradiological investigations and repeated EEGs in more severe and complicated head trauma, we discourage the routine EEG examination in very slight head injury and instead rather recommend parent and patient counselling.

Neuropsychological and information processing deficits following mild traumatic brain injury

Neuroradiological and neuropathological investigations have found evidence of diffuse brain damage in the frontal and temporal lobes, corpus callosum, and fornices in patients who have sustained a mild traumatic brain injury (TBI). However, neuropsychological assessments of these patients do not typically target many of the subtle information processing deficits that may arise from diffuse damage involving the frontotemporal regions of the brain as well as white matter pathology, including the corpus callosum. Consequently, we have a limited understanding of the deficits that may be attributable to temporary or permanent disruptions to these functional pathways. This study assessed a group of mild TBI patients (N = 40) and a matched control group (N = 40) on a number of standard neuropsychological tests of selective and sustained attention, verbal and non-verbal fluency, and verbal memory. In addition, reaction time (RT) tasks, requiring both the inter- and intra-hemispheric processing of visual and tactile information, were used to assess the functional integrity of the tracts that are likely to be affected by diffuse damage. In the 1st month after sustaining their injury, the mild TBI group demonstrated deficits in attention, non-verbal fluency, and verbal memory. They also demonstrated slower visual and tactile RTs, with the visual RTs of mild TBI patients being more affected by increased task difficulty and the need to transfer information across the corpus callosum, than did their matched controls.

Contemporary issues in mild traumatic brain injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To determine (1) minimum criteria in adults for clinical diagnosis of mild traumatic brain injury (TBI) and (2) whether persistent postconcussive syndrome exists as a nosologic entity.

DATA SOURCES

PubMed search by MEDLINE of head injuries from January 1977 to July 2002.

STUDY SELECTION

All reviews and studies of mild TBI with special reference to those on persistent postconcussive syndrome having a general trauma cohort as a control comparison.

DATA EXTRACTION

Review of design and other methodologic issues. Studies dependent on superior strength of evidence (as defined by the American Academy of Neurology) concerning the biologic nature of persistent postconcussive syndrome.

DATA SYNTHESIS

A period of altered awareness with amnesia brought on by a direct craniofacial blow is the starting point in determining whether diffuse mild TBI has occurred. An amnestic scale is more helpful than Glasgow Coma Scale score in grading mild injury and in formulating minimum inclusion criteria for mild TBI. Neuropsychologic test results coupled with self-reported symptoms should not be taken as the primary source of evidence for mild TBI. Prolonged cognitive impairment after injury is not unique to brain trauma.

CONCLUSIONS

Persistent postconcussive syndrome after mild brain trauma, uncomplicated by focal injury, is biologically inseparable from other examples of the posttraumatic syndrome. To account for the persistent cognitive and behavioral sequelae of posttraumatic states, including persistent postconcussive syndrome, we need further studies on the emerging concept of limbic neuronal attrition occurring as a maladaptive response to pain and stress.

Examination of "postconcussion-like" symptoms in a healthy sample

The post-concussion syndrome (PCS) is relatively common following mild traumatic brain injury (MTBI). However, the factors that cause and maintain this syndrome continue to be debated. The purpose of this investigation was to examine the prevalence of postconcussion-like symptoms in a sample of healthy individuals. Participants (N = 104) completed the British Columbia Postconcussion Symptom Inventory-Short Form (BC-PSI-Sf), a test designed to measure both the frequency and intensity of ICD-10 criteria for PCS, and the Beck Depression Inventory (2nd ed.). Specific endorsement rates of postconcussion-like symptoms ranged from 35.9% to 75.7% for any experience of the symptoms in the past 2 weeks, and from 2.9% to 15.5% for the experience of more severe symptoms. Symptoms reported on the BC-PSI-Sf also showed a moderately high correlation with self-reported depressive symptoms [r (102) =.76, p <.01]. This study illustrates that the presence of postconcussion-like symptoms: (a). are not unique to mild head injury and are commonly found in healthy individuals, and (b). are highly correlated with depressive symptoms.

Outcome after mild traumatic brain injury: an examination of recruitment bias

OBJECTIVES

Research concerning the natural history after mild traumatic brain injury (TBI) faces a number of methodological challenges, including those related to subject recruitment. The aim of this study was to determine whether subjects who agree to participate in longitudinal research differ from those who do not. The presence of identifiable, selective factors operating during recruitment may be an important source of systematic bias. In Canada, given the presence of universal healthcare coverage, this issue can be examined using population based, administrative databases to obtain information about a cohort that was approached for study enrollment, regardless of whether they ultimately agreed to participate.

METHODS

A sample of 626 consecutive patients with mild TBI was invited to enroll in TBI outcome research. Those who agreed to participate (n=272) were compared with those who refused (n=354) on demographic, past health, and injury related variables. Thereafter, using encrypted health card data, the two groups were contrasted with respect to pre-injury and post-injury healthcare utilisation.

RESULTS

No premorbid differences between the groups emerged. However, all early indices of TBI severity were significantly worse for the participants group (p<0.001). Consistent with these findings, healthcare utilisation rates were no different before injury, but were significantly increased after injury for the participants (p<0.001), even beyond the period of study enrollment (p<0.001). Differences remained even after controlling for those with significant non-TBI injuries.

CONCLUSIONS

Premorbid factors did not predict whether patients comply with, or refuse study participation. However, the participants group was biased toward those with more significant injuries, which translated into higher rates of healthcare utilisation after injury. These results strike a cautionary note, given the apparent systematic bias influencing enrollment in longitudinal studies of mild TBI.

The neurophysiology of concussion

Cerebral concussion is both the most common and most puzzling type of traumatic brain injury (TBI). It is normally produced by acceleration (or deceleration) of the head and is characterized by a sudden brief impairment of consciousness, paralysis of reflex activity and loss of memory. It has long been acknowledged that one of the most worthwhile techniques for studying the acute pathophysiology of concussion is by the recording of neurophysiological activity such as the electroencephalogram (EEG) and sensory evoked potentials (EPs) from experimental animals. In the first parts of this review, the majority of such studies conducted during the past half century are critically reviewed. When potential methodological flaws and limitations such as anesthetic protocols, infliction of multiple blows and delay in onset of recordings were taken into account, two general principles could be adduced. First, the immediate post-concussive EEG was excitatory or epileptiform in nature. Second, the cortical EP waveform was totally lost during this period. In the second parts of this review, five theories of concussion which have been prominent during the past century are summarized and supportive evidence assessed. These are the vascular, reticular, centripetal, pontine cholinergic and convulsive hypotheses. It is concluded that only the convulsive theory is readily compatible with the neurophysiological data and can provide a totally viable explanation for concussion. The chief tenet of the convulsive theory is that since the symptoms of concussion bear a strong resemblance to those of a generalized epileptic seizure, then it is a reasonable assumption that similar pathobiological processes underlie them both. Further, it is demonstrated that EPs and EEGs recorded acutely following concussive trauma are indeed the same or similar to those obtained following the induction of a state of generalized seizure activity (GSA). According to the present incarnation of the convulsive theory, the energy imparted to the brain by the sudden mechanical loading of the head may generate turbulent rotatory and other movements of the cerebral hemispheres and so increase the chances of a tissue-deforming collision or impact between the cortex and the boney walls of the skull. In this conception, loss of consciousness is not orchestrated by disruption or interference with the function of the brainstem reticular activating system. Rather, it is due to functional deafferentation of the cortex as a consequence of diffuse mechanically-induced depolarization and synchronized discharge of cortical neurons. A convulsive theory can also explain traumatic amnesia, autonomic disturbances and the miscellaneous collection of symptoms of the post-concussion syndrome more adequately than any of its rivals. In addition, the symptoms of minor concussion (a.k.a. being stunned, dinged, or dazed) are often strikingly similar to minor epilepsy such as petit mal. The relevance of the convulsive theory to a number of associated problems is also discussed. These include the relationship between concussion and more serious types of closed head injury, the utility of animal models of severe brain trauma, the etiology of the cognitive deficits which may linger long after a concussive injury, the use of concussive (captive bolt) techniques to stun farm animals prior to slaughter and the question of why some animals (such as the woodpecker) can tolerate massive accelerative forces without being knocked out.

Psychiatric aspects of traumatic brain injury

TBI is a complex heterogenous disease that can produce a variety of psychiatric disturbances, ranging from subtle deficits in cognition, mood, and behavior to severe disturbances that cause impairment in social, occupational, and interpersonal functioning. With improvement and sophistication in acute trauma care, a number of individuals are able to survive the trauma but are left with several psychiatric sequelae. It is important for psychiatrists to be aware of this entity because an increasing number of psychiatrists will be involved in the care of these patients. Treatment should be interdisciplinary and multifaceted, with the psychiatrist working in collaboration with the patient, caregiver, family, other physicians, and therapists. The goal of treatment should be to stabilize symptoms; maximize potential; minimize disability; and increase productivity socially, occupationally, and interpersonally.

Neurophysiological and behavioral concomitants of mild brain injury in collegiate athletes

OBJECTIVES

There is still limited understanding regarding the effect of mild brain injury (MBI) on normal functioning of the human brain with respect to motor control and coordination. To our knowledge, no research exists on how both the accuracy of force production and underlying neurophysiological concomitants are interactively affected by MBI. The aim of this study is to provide empirical evidence that there are at least transient functional changes in the brain associated with motor control and coordination in collegiate athletes suffering from MBI as reflected in alterations of force trajectory patterns and electroencephalogram (EEG) potentials both in time and frequency domains.

METHODS

Comparisons of the performance and concomitant EEG waveforms both in time and frequency domains of 6 collegiate athletes with MBI and 6 normal subjects in a series of isometric force production tasks were made. The traditional averaging techniques to obtain the slow-wave movement-related potentials (MRP) and Morlet wavelet transform to obtain EEG time-frequency (TF) profiles associated with task performance were used. Subjects performed isometric force production tasks when the level of nominal force was experimentally manipulated. EEG recordings from the frontal-central areas were analyzed with respect to the accuracy of force production during the ramp phase.

RESULTS

Behaviorally, the accuracy of force trajectory performance was considerably impaired in MBI subjects even when the amount of task force was only increased from 25 to 50% maximum voluntary contraction (MVC) within a given subject. Electro-cortically, impaired performance in MBI subjects was associated with alterations in EEG waveforms, amplitude of MRP and TF profiles of EEG.

CONCLUSIONS

Both behavioral and electro-cortical data of control subjects generally were comparable with those from subjects with MBI when small amounts of force were regulated. However, differences become apparent as the amount of task force production was increased. Overall our findings identify the presence of transient functional changes in the brain associated with motor control and coordination in subjects suffering from MBI.

Somatization: a critical review of conceptual and methodological issues

Despite its apparent clinical importance and the extensive research that has been conducted in the past decades, somatization remains a complex concept. Two distinct ways of looking at somatization can be distinguished: somatization as a phenomenon that is secondary to psychological distress (presenting somatization) and somatization as a primary phenomenon characterized by medically unexplained symptoms (functional somatization). The literature was analyzed in terms of this distinction and a selective review was conducted, focusing on a critical analysis of conceptual and methodological issues related to presenting and functional somatization. A number of measurement issues related to somatization in general were also highlighted. On the basis of the available data, the strengths and weaknesses of different concepts are pointed out. Conclusions are formulated regarding which concepts or approaches might be useful both clinically and from a research perspective. Finally, a number of suggestions for future research are offered.

Cross-cultural study of symptom expectation following minor head injury in Canada and Greece

OBJECTIVES

The purpose of the present study is to compare the frequency and nature of expected symptoms in Greece (a country where the chronic post-concussive syndrome is largely unknown) with that in Canada.

METHODS

A symptom checklist was administered to two subject groups selected from local companies in Patras, Greece, and Edmonton, Canada, respectively. Subjects were asked to imagine having suffered head trauma with loss of consciousness in a motor vehicle accident and to check off symptoms, they expected might arise from the injury. For symptoms they anticipated, they were asked to select the period of time they expected those symptoms to persist.

RESULTS

In both the Greek and Edmontonian groups, the pattern of symptoms anticipated closely resembled the acute symptoms commonly reported by accident victims with minor head injury. Yet, while many Edmontonians also anticipated symptoms to last months or years, very few Greek subjects selected any symptoms as being likely to persist in a chronic manner.

CONCLUSIONS

In Greece, despite the frequent experience of minor head injury in motor vehicle accidents, there is a very low rate of expectation of any chronic sequelae from such an injury, contrasting greatly with the response shown in Canada, where the prevalence of the chronic post-concussive syndrome is higher. Symptom expectation in some countries may be an important factor in the development of the chronic post-concussive syndrome.

Symptom expectation after minor head injury. A comparative study between Canada and Lithuania

OBJECTIVES

The purpose of the present study is to compare the frequency and nature of expected symptoms in Lithuania (a country where the chronic post-concussive syndrome is largely unknown) with that in Canada.

METHODS

A symptom checklist was administered to two subject groups selected from local companies in Kaunas, Lithuania, and Edmonton, Canada, respectively. Subjects were asked to imagine having suffered head trauma with loss of consciousness in a motor vehicle accident, and to check off symptoms they expected might arise from the injury. For symptoms they anticipated, they were asked to select the period of time they expected those symptoms to persist.

RESULTS

In both the Lithuanian and Edmontonian groups, the pattern of symptoms anticipated closely resembled the acute symptoms commonly reported by accident victims with minor head injury. Yet, while many Edmontonians also anticipated symptoms to last months or years, very few Lithuanian subjects selected any symptoms as being likely to persist in a chronic manner.

CONCLUSIONS

In Lithuania, despite the frequent experience of minor head injury in motor vehicle accidents, there is a very low rate of expectation of any chronic sequelae from such an injury, contrasting greatly with the response shown in Canada, where the prevalence of the chronic post-concussive syndrome is higher. Symptom expectation in some countries may be an important factor in the development of the chronic post-concussive syndrome.

Posttraumatic stress disorder and traumatic brain injury: can they co-exist?

The possibility that posttraumatic stress disorder (PTSD) can develop following traumatic brain injury (TBI) has been the subject of considerable debate. The traditional view has held that impaired consciousness that occurs with TBI precludes encoding of the traumatic experience, and this prevents subsequent reexperiencing symptoms. This paper critically reviews available, empirical studies on PTSD in TBI populations and suggests that these two conditions can co-exist. The various mechanisms that may mediate PTSD following TBI are discussed, and special attention is given to issues that recognize the distinctive features of PTSD following TBI. These processes include implicit processing, biologically mediated fear conditioning, and reconstruction of trauma memories. Finally implications for assessment, treatment, and forensic investigation of PTSD in TBI populations are, addressed. This review concludes that TBI populations provide a useful means by which the role of traumatic memories (and impaired memories) in posttraumatic adjustment can be studied.

Evidence-Based review of sport-related concussion: clinical science

The clinical nature of sport-related concussion is discussed in this paper. Particularly highlighted are the difficulties with definition, injury severity grading, classification, and understanding of clinical symptoms. In addition, the well-recognized sequelae of concussion including the motor and convulsive manifestations are discussed in detail. Where possible, an evidence-based approach is adopted to assist the understanding of the literature in this complex area.

The effects of litigation on symptom expression: a prospective study following mild traumatic brain injury

OBJECTIVE

To prospectively assess the association between litigation and neurobehavioural symptoms following mild Traumatic Brain Injury (TBI).

DESIGN

a prospective study with the inception cohort assessed on average 42.2(17.2) days after injury.

SETTING

an outpatient clinic within a large general hospital.

PATIENTS

a consecutive sample of 100 clinic attenders with mild TBI.

OUTCOME MEASURES

A cognitive screen (Mini-Mental State Examination (MMSE), Galveston Orientation and Amnesia Test (GOAT), a measure of psychological distress (the 28 item General Health Questionnaire (GHQ)) and two head injury outcome measures, the Glasgow Outcome Scale (GOS) and the Rivermead Head Injury Follow-up Questionnaire (RHFUQ).

RESULTS

Demographic characteristics, TBI severity ratings and premorbid risk factors for poor outcome did not differ between litigants (27.8 per cent of the sample) and non-litigants. However, litigants were significantly more anxious (p<0.0001), depressed (p<0.01), had greater social dysfunction (p<0.0001) and had poorer outcome on the GOS (p<0.002) and RHFUQ (p<0.002). There were no cognitive differences between the groups.

CONCLUSIONS

the data demonstrate an association between litigation and increased psychological distress at the outset of the litigation process. While association is not synonymous with causality, the absence of demographic, premorbid and TBI related differences between litigants and non-litigants suggests that the pursuit of compensation may influence the subjective expression of symptoms following mild traumatic brain injury.

Fibromyalgia and other unexplained clinical conditions

Several unexplained clinical conditions frequently coexist with fibromyalgia; these include chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorder, tension and migraine headaches, and others. However, only recently have studies directly compared the physiological parameters of these conditions (eg, fibromyalgia vs irritable bowel syndrome) to elucidate underlying pathogenic mechanisms. This review summarizes data from comparative studies and discusses their implications for future research.

A psychological assessment of adolescent and young adult inpatients after traumatic brain injury

The purpose of this study was to evaluate the cognitive, behavioural, depressive and self-awareness disorders, and their relationships, after severe traumatic brain injury (TBI) in adolescent and young adult inpatients. Two groups of patients with (n = 83) and without (n = 103) TBI, aged 14-25 years, hospitalized after severe traumatic pathology, were compared using the clinician's report and self-report. A higher frequency of depressive tendencies in TBI patients than in controls was shown in the clinician's therapeutic attitude (i.e. prescription of antidepressant drugs), the clinician's report and the self-report. The same difference between the two groups was observed for behavioural and schooling problems in the clinician's report, but not in the self-report. Discrepancies between self- and clinician's evaluation were in favour of a lack of self-awareness of behavioural and cognitive disorders among TBI patients. Correlations of depressive mood with anxiety and cognitive complaints were stronger in TBI than in non-TBI patients. Depression in TBI patients seems compatible with some degree of lack of self-awareness of cognitive and behavioural difficulties.

The no-fault flavor of disability syndromes

There are many controversial disability syndromes, representing medicolegal and social dilemmas for a variety of medical disciplines. Health care professionals are at a loss to cure these patients, and judges and disability review boards struggle to be fair while at the same time trying to understand the basis and appropriateness of the ever-growing claims of disability. We review these disability syndromes, examining the basis for their existence, their mechanism, and how these patients can better be understood in a constructive and helpful manner. In doing so, we emphasize the sick role, illness behavior, secondary and tertiary gain, and somatization.

Disability pensions in relation to traumatic brain injury: a population study

From a Danish national register of hospitalizations, all patients were identified who had a discharge diagnosis of traumatic brain injury between the years 1979-1993 inclusive, at ages 18-66 years inclusive. These were classified as having suffered either a concussion (n = 74,398), a cranial fracture (n = 4,452) or a cerebral contusion (n = 8,141). Patients in each of these groups were then checked in annual registers of disability pension awards between 1979-1995. Disability pensions had been awarded to 16% of the concussion group, 18% of the fracture group, and 33% of the contusion group. Date of application, grounds for the application, and the pension level awarded were noted. Analysis of the date of application for the disability pension revealed that in all groups a high proportion of the pension applications had been made prior to the injury. Among the concussion group, the pension award appeared to be independent of the injury itself. Rather, being awarded a disability pension appeared to be related to conditions which themselves are risk factors for a traumatic brain injury, e.g. chronic skeletomuscular disease and psychiatric disorders including alcoholism. Comparison with population statistics revealed that the relative risk of being assigned a low or intermediate disability pension is markedly elevated among the concussion group, especially at younger ages and among males. For the fracture and contusion groups, a clear post-injury elevation in rate was detectable, especially for highest level pensions.

Neuropsychiatric sequelae of traumatic brain injury

The authors review the psychiatric disturbances associated with traumatic brain injury. They highlight the close link between traumatic brain injury and psychiatry and provide an overview of the epidemiology, risk factors, classification, and mechanisms of traumatic brain injury. They describe various neuropsychiatric sequelae, and the respective treatments are outlined with emphasis on a multidisciplinary approach.

Whiplash associated disorders: is there a place for psychiatrists and psychologists?

Between 25 and 30% of the victims of a whiplash injury have complaints after one year. This condition is referred to as late whiplash syndrome. This syndrome is characterized by pain of the neck, headache, forgetfulness, poor concentration, mental fatigue, and affective symptoms. The causes of the persistent symptoms are unknown. In all, the evidence that late-whiplash syndrome is a neurological disorder is flimsy. Current opinion holds that the acute basis is the painful injury of the neck. In the months following the accident, pain is the substrate on which psychological and social factors may act. Emotional symptoms such as lability of affect and disturbed mood, or posttraumatic stress disorders are common after whiplash. Although there is definitely a place for psychiatrists and psychologists in the treatment of late whiplash syndrome, these professionals are not involved in late whiplash disorder as much as they should be. Brief psychological treatment has proven to significantly reduce the severity and duration of symptoms. Optimal management must cover the treatment of pain, depression, anxiety, and fatigue; adequate psycho-education, stressing the good long-term outcome; and education of patients and relatives on possible cognitive symptoms.

Cognitive performance in multiple trauma patients 3 years after injury

OBJECTIVES

Patients with sequelae from multiple trauma commonly display cognitive disturbances, specifically in the areas of attention and memory. This study was designed to assess cognitive functioning 3 years after severe multiple trauma and to investigate how cognitive performance is related to head injury severity and psychological distress respectively.

METHODS

Sixty-eight multiple trauma patients were tested with a screening battery consisting of six neuropsychological tasks 3 years after injury. A measure of psychological distress (20-item General Health Questionnaire, or GHQ-20) was also administered.

RESULTS

Patients who neither showed signs of reduced consciousness on admission to the hospital nor reported significant psychological distress at follow-up tended to have normal test performance. In five of the six tasks, cognitive impairment was related to the severity of the traumatic brain injury as measured by the Glasgow Coma Scale (GCS). In both attention span tasks, patients designated as cases by the GHQ had significantly lower scores than noncase patients. These bivariate relationships were upheld in multiple regression analyses, in which age, sex, and GCS and GHQ scores were entered as independent variables. When patients with severe head injuries were excluded from the analyses, GCS scores still contributed to the variance in tests of verbal attention span and delayed recall, but performance on attentional tasks was more strongly related to psychological distress than to GCS scores.

CONCLUSIONS

Cognitive deficits in multiple trauma patients were related both to the severity of the traumatic brain injury and to the degree of psychological distress. The strength of the association between brain injury as indicated by GCS scores and cognitive performance differed between different tasks. Neuropsychological testing may assist in differentiating primary organic from secondary psychogenic impairments.

Postconcussive symptoms and posttraumatic stress disorder after mild traumatic brain injury

Postconcussive symptoms after mild traumatic brain injury (MTBI) may be exacerbated by anxiety associated with posttraumatic stress. The aim of this study was to investigate the relationship between postconcussive symptoms and posttraumatic stress disorder (PTSD) in an MTBI population. Survivors of motor vehicle accidents who either sustained an MTBI (N = 46) or no TBI (N = 59) were assessed 6 months posttrauma for PTSD and postconcussive symptoms. Postconcussive symptoms were more evident in MTBI patients with PTSD than those without PTSD, and in MTBI patients than non-TBI patients. Further, postconcussive symptoms were significantly correlated with PTSD symptoms. These findings indicate that postconcussive symptoms may be mediated by an interaction of neurological and psychological factors after MTBI.

Neurobehavioural symptoms one year after a head injury

BACKGROUND

Neurobehavioural symptoms are common immediately after a minor head injury but have not been studied one year after the injury.

AIMS

To estimate the rate and pattern of neurobehavioural symptoms one year after a head injury of varying severity.

METHOD

Adults who had been hospitalised after a head injury (n = 196, 164 of whom had a face-to-face interview) and showed indirect evidence of brain assault were assessed for the presence of neurobehavioural symptoms with the help of a behaviour rating scale.

RESULTS

About 40% had three or more symptoms. Individual symptoms varied among 3% (social disinhibition), 15% (lack of initiative) and 35% (irritability) of the cohort. Premorbid factors such as lower social class and lower educational achievement, head-injury-related factors such a low Glasgow coma score, and outcome-related factors such as the presence of a disability according to the Edinburgh Rehabilitation Status Scale and psychiatric caseness according to the Clinical Interview Schedule--Revised, significantly influenced the rate and the pattern of behavioural symptoms. The pattern of symptoms varied between age groups and according to the severity of the head injury.

CONCLUSIONS

A significant proportion of patients with varying degrees of severity of head injury showed behavioural symptoms after one year of head injury.

Rate of psychiatric illness 1 year after traumatic brain injury

OBJECTIVE

Neurobehavioral symptoms are not uncommon after a traumatic brain injury. However, psychiatric syndromes per se have rarely been studied in patients with such an injury. The purpose of this study was to evaluate the type and extent of psychiatric syndromes in patients with traumatic brain injury.

METHOD

One hundred ninety-six hospitalized adults were studied 1 year after a traumatic brain injury with the use of a two-stage psychiatric diagnostic procedure. Psychiatric diagnoses were made according to ICD-10 criteria on the basis of data from the Schedules for Clinical Assessment in Neuropsychiatry interview.

RESULTS

Of 164 patients interviewed, 30 (18.3%) had an ICD-10 diagnosis of a psychiatric illness. Among the 120 patients who were 18-64 years old, 21.7% had a psychiatric illness, compared with 16.4% in a study of the general population. A depressive illness was present in 13.9% of the traumatic brain injury patients, compared with 2.1% of the general population, and panic disorder was present in 9.0%, compared with 0.8% of the general population.

CONCLUSIONS

In comparison with the general population, a higher proportion of adult patients had developed psychiatric illnesses 1 year after a traumatic brain injury; the rates of depressive episode and panic disorder were significantly higher in the study group. A history of psychiatric illness, an unfavorable global outcome according to the Glasgow Outcome Scale, a lower score on the Mini-Mental State examination, and fewer years of formal education seemed to be important risk factors in the development of a psychiatric illness. Compensation claims, however, were not associated with the rate of psychiatric illness.