Psychosis following traumatic brain injury

Psychiatric sequelae of traumatic brain injury - future directions in research

Despite growing appreciation that traumatic brain injury (TBI) is an important public health burden, our understanding of the psychiatric and behavioural consequences of TBI remains limited. These changes are particularly detrimental to a person's sense of self, their relationships and their participation in the wider community, and they continue to have devastating individual and cumulative effects long after TBI. This Review relates specifically to TBIs that confer objective clinical or biomarker evidence of structural brain injury; symptomatic head injuries without such evidence are outside the scope of this article. Common psychiatric, affective and behavioural sequelae of TBI and their proposed underlying mechanisms are outlined, along with a brief overview of current treatments. Suggestions for how scientists and clinicians can work together in the future to address the chasms in clinical care and knowledge are discussed in depth.

Current and Potential Pharmacologic Therapies for Traumatic Brain Injury

The present article reviewed the pharmacologic therapies of traumatic brain injury (TBI), including current and potential treatments. Pharmacologic therapies are an essential part of TBI care, and several agents have well-established effects in TBI care. In the acute phase, tranexamic acid, antiepileptics, hyperosmolar agents, and anesthetics are the mainstay of pharmacotherapy, which have proven efficacies. In the post-acute phase, SSRIs, SNRIs, antipsychotics, zolpidem and amantadine, as well as other drugs, have been used to manage neuropsychological problems, while muscle relaxants and botulinum toxin have been used to manage spasticity. In addition, increasing numbers of pre-clinical and clinical studies of pharmaceutical agents, including potential neuroprotective nutrients and natural therapies, are being carried out. In the present article, we classify the treatments into established and potential agents based on the level of clinical evidence and standard of practice. It is expected that many of the potential medicines under investigation will eventually be accepted as standard practice in the care of TBI patients.

Multifactorial Causes of Paranoid Schizophrenia With Auditory-Visual Hallucinations in a 31-Year-Old Male With History of Traumatic Brain Injury and Substance Abuse

Schizophrenia is a chronic psychiatric disorder that classically presents with distortions of thought, behavior, and perceptions that are often misdiagnosed. One difficulty in diagnosing schizophrenia is due to its phenotypically heterogeneous condition that can be precipitated by a combination of genetic, epigenetic, and environmental factors. The prevalence of schizophrenia is roughly 1%, but it is often misdiagnosed. Possible differential diagnoses include depression or bipolar disorder with psychosis, psychosis due to a medical condition, schizotypal and schizoid personality disorders, and neurocognitive disorders. 

In this case report, a 31-year-old male presents with thoughts of suicide following a recent exacerbation of his hallucinations. On presentation, the patient presented with a historical diagnosis of “paranoid schizophrenia” as well as a history of traumatic brain injury (TBI), poly-substance use disorder, and a family history of schizophrenia. This case serves to highlight the difficulties of making an accurate diagnosis and providing evidenced-based treatment.

Psychopharmacology of traumatic brain injury

The pathophysiology of traumatic brain injury (TBI) can be highly variable, involving functional and/or structural damage to multiple neuroanatomical networks and neurotransmitter systems. This wide-ranging potential for physiologic injury is reflected in the diversity of neurobehavioral and neurocognitive symptoms following TBI. Here, we aim to provide a succinct, clinically relevant, up-to-date review on psychopharmacology for the most common sequelae of TBI in the postacute to chronic period. Specifically, treatment for neurobehavioral symptoms (depression, mania, anxiety, agitation/irritability, psychosis, pseudobulbar affect, and apathy) and neurocognitive symptoms (processing speed, attention, memory, executive dysfunction) will be discussed. Treatment recommendations will reflect general clinical practice patterns and the research literature.

Clinical profile and comorbidity of traumatic brain injury among younger and older men and women: a brief research notes

OBJECTIVE

Comorbid disorders influence the course and outcomes of rehabilitation following traumatic brain injury (TBI), yet sex- and age-related disparities in the frequency distribution of these disorders remain poorly understood. We aimed to describe comorbid disorders by the International Classification of Diseases in patients with TBI undergoing inpatient rehabilitation in Ontario, Canada over a 3-year period, by sex and age, and discuss their potential impact on rehabilitation outcomes.

RESULTS

The percentage of TBI patients with one or more comorbid disorder is higher among older (≥65 years) men and women than among those who are younger or middle-aged (<65 years). Among younger and middle-aged patients, multiple injuries and trauma, mental health conditions, and nervous system disorders were the most prevalent comorbidities. In older patients, circulatory, endocrine, nutritional, metabolic, and immune disorders were the most prevalent comorbidities. Our results suggest that a multisystem view of rehabilitation of men and women with TBI across age categories is needed to reflect the complex clinical profile of TBI patients undergoing rehabilitation.

Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: insights into psychiatric practice

Traumatic brain injury (TBI) causes a variety of neuropsychiatric problems that pose diagnostic and treatment challenges for providers. In this report, we share our experience as a referral neuropsychiatry program to assist the general psychiatrist when adult TBI patients with psychiatric symptoms present for evaluation and treatment. We completed a retrospective study of patients with moderate-to-severe TBI and severe neuropsychiatric impairments. We collected information on demographics, nature of injury, symptomatology, diagnoses, and treatments. Data analysis indicates that mood stabilization was a key concern, often requiring aggressive pharmacological management. Cognitive dysfunction was a problem for the majority of patients, but was only medicated in a third, due to poor efficacy or behavioral side effects. The co-occurrence of multiple TBI-related symptoms and diagnoses in this patient cohort emphasizes the need for individualized psychopharmacological approaches and interventions.

Patient Characterization Protocols for Psychophysiological Studies of Traumatic Brain Injury and Post-TBI Psychiatric Disorders

Psychophysiological investigations of traumatic brain injury (TBI) are being conducted for several reasons, including the objective of learning more about the underlying physiological mechanisms of the pathological processes that can be initiated by a head injury. Additional goals include the development of objective physiologically based measures that can be used to monitor the response to treatment and to identify minimally symptomatic individuals who are at risk of delayed-onset neuropsychiatric disorders following injury. Research programs studying TBI search for relationships between psychophysiological measures, particularly ERP (event-related potential) component properties (e.g., timing, amplitude, scalp distribution), and a participant's clinical condition. Moreover, the complex relationships between brain injury and psychiatric disorders are receiving increased research attention, and ERP technologies are making contributions to this effort. This review has two objectives supporting such research efforts. The first is to review evidence indicating that TBI is a significant risk factor for post-injury neuropsychiatric disorders. The second objective is to introduce ERP researchers who are not familiar with neuropsychiatric assessment to the instruments that are available for characterizing TBI, post-concussion syndrome, and psychiatric disorders. Specific recommendations within this very large literature are made. We have proceeded on the assumption that, as is typically the case in an ERP laboratory, the investigators are not clinically qualified and that they will not have access to participant medical records.

Psychiatric disorders and traumatic brain injury

Psychiatric disorders after traumatic brain injury (TBI) are frequent. Researches in this area are important for the patients' care and they may provide hints for the comprehension of primary psychiatric disorders. Here we approach epidemiology, diagnosis, associated factors and treatment of the main psychiatric disorders after TBI. Finally, the present situation of the knowledge in this field is discussed.

Does traumatic brain injury predispose individuals to develop schizophrenia?

PURPOSE OF REVIEW

Psychosis following traumatic brain injury has been studied in both prospective and retrospective studies that have been frequently limited by unclear criteria for classifying psychiatric syndromes or case ascertainment bias regarding traumatic brain injury. Schizophrenia is a psychotic disorder commonly attributed to the interaction of genetic vulnerability and environmental events, yet its relationship with traumatic brain injury has not been systematically reviewed.

RECENT FINDINGS

The literature is not conclusive and highlights the challenges to observational research in conditions in which case ascertainment is difficult. The evidence supports a risk-modifying effect of traumatic brain injury in individuals who are genetically at risk for schizophrenia, but is less supportive of traumatic brain injury as an independent risk factor for schizophrenia in individuals without such risk.

SUMMARY

Research in psychotic disorders following traumatic brain injury must distinguish schizophrenia from other psychotic syndromes, and take familial risk factors into consideration.

Quetiapine for mania due to traumatic brain injury

Secondary mania develops in as many as 9% of persons with traumatic brain injuries. The treatment of posttraumatic mania is not well defined, and agents traditionally used for the treatment of idiopathic manic episodes may not be well suited for use among individuals with traumatic brain injuries. Atypical antipsychotics are indicated for the treatment of idiopathic bipolar disorder, and have been used for other purposes among individuals with posttraumatic neuropsychiatric disturbances. This article offers the first description of the treatment of posttraumatic mania using the atypical antipsychotic quetiapine. Beneficial effects of this agent on posttraumatic mania, cognitive impairments, and functional disability in the subacute post-injury period are described. Possible mechanisms of action are discussed and the need for additional investigation of quetiapine for posttraumatic mania is highlighted.

Use of methylphenidate in traumatic brain injury

OBJECTIVE

To review literature regarding the effectiveness of methylphenidate in the management of the cognitive and behavioral changes observed following traumatic brain injury (TBI).

DATA SOURCES

A literature search was conducted using the following databases: MEDLINE (1966-June 2004); Cochrane Central Register of Controlled Trials, fourth quarter 2004 (1988-June 2004); and International Pharmaceutical Abstracts (1970-June 2004). Methylphenidate and brain injury were the key search terms used. Limits were set to include clinical trial publications, human subjects, and English language.

DATA SYNTHESIS

Ten clinical trials evaluating the efficacy and safety of methylphenidate in pediatric and adult patients with TBI are reviewed. Improvements in different aspects of cognition and behavior were evaluated before, during, and after treatment with methylphenidate. The results demonstrated that methylphenidate is likely to improve memory, attention, concentration, and mental processing, but its effects on behavior have not been determined.

CONCLUSIONS

Larger, double-blind, placebo-controlled studies are needed to determine optimal doses, during which phase of recovery to begin treatment, length of treatment, and long-term effects for patients with mild, moderate, and severe TBI.

Neuropsychiatric consequences of traumatic brain injury: a review of recent findings

PURPOSE OF REVIEW

Behavioral and psychiatric disturbances are the more frequent consequences of traumatic brain injury and major determinants of the quality of life of patients. This review was designed to familiarize the reader with the more recent work published in this field.

RECENT FINDINGS

We have now a more consistent view of the epidemiology of post-traumatic brain injury psychiatric disorders both in adult and pediatric populations. Mood disorders, anxiety disorders and substance use disorders are the more prevalent psychiatric diagnoses among traumatic brain injury patients. The phenomenological characteristics and clinical correlates of major depression, post-traumatic stress disorder, alcohol use disorders, and post-traumatic brain injury attention deficit hyperactivity disorder have been studied in more detail. Newer structural, metabolic and functional neuroimaging techniques help to clarify the pathogenesis of these disorders. In turn, this knowledge may lead to the implementation of more efficient therapeutic interventions. Unfortunately, controlled treatment studies have been the exception in the field, and treatment decisions usually lack adequate empirical support.

SUMMARY

Recent advances in the basic neuroscience of traumatic brain injury as well as in behavioral genetics, social science and neuroimaging techniques should contribute to a better understanding of the pathophysiology of the psychiatric disorders occurring after the injury. There is a great need for randomized, double-blind, placebo-controlled trials to establish the most effective treatments for these disorders.

Cholinergic parameters and the retrieval of learned and re-learned spatial information: a study using a model of Wernicke-Korsakoff Syndrome

This is a factorial (2 x 2 x 2) spatial memory and cholinergic parameters study in which the factors are chronic ethanol, thiamine deficiency and naivety in Morris water maze task. Both learning and retention of the spatial version of the water maze were assessed. To assess retrograde retention of spatial information, half of the rats were pre-trained on the maze before the treatment manipulations of pyrithiamine (PT)-induced thiamine deficiency and post-tested after treatment (pre-trained group). The other half of the animals was only trained after treatment to assess anterograde amnesia (post-trained group). Thiamine deficiency, associated to chronic ethanol treatment, had a significant deleterious effect on spatial memory performance of post-trained animals. The biochemical data revealed that chronic ethanol treatment reduced acetylcholinesterase (AChE) activity in the hippocampus while leaving the neocortex unchanged, whereas thiamine deficiency reduced both cortical and hippocampal AChE activity. Regarding basal and stimulated cortical acetylcholine (ACh) release, both chronic ethanol and thiamine deficiency treatments had significant main effects. Significant correlations were found between both cortical and hippocampal AChE activity and behaviour parameters for pre-trained but not for post-trained animals. Also for ACh release, the correlation found was significant only for pre-trained animals. These biochemical parameters were decreased by thiamine deficiency and chronic ethanol treatment, both in pre-trained and post-trained animals. But the correlation with the behavioural parameters was observed only for pre-trained animals, that is, those that were retrained and assessed for retrograde retention.