Head Injury and Mental Handicap

A clinical and pathological study of head injury and the implications in mental handicap are outlined. Non-accidental injury as a form of child abuse is suspected as contributing considerably to the cause of mental handicap in populations resident in long-stay hospital, but this is unlikely to be the best environment for such patients. A number of mentally handicapped epileptic patients who injure their heads during fits and patients who repeatedly bang their heads as a feature of self-injurious behaviour are exposed to progressive neurological deficits associated with lesions in the brain which could further impair the efficiency of brain function.

A review of mild head trauma. Part II: Clinical implications

In Binder et al. (1997) a metal-analytic review revealed a small effect size attributable to a history of mild head trauma (MHT). The results suggested a weak association between MHT and persistent neuropsychological deficits. In this paper, additional outcome data are summarized and the results are discussed. On a chronic basis, 7-8% of MHT patients remain symptomatic and 14% are disabled from work. Magnetic resonance studies of acutely injured persons may show lesions that are not detected in usual clinical practice. It is likely that the effects of these lesions dissipate with time, consistent with the neuropsychological data. The association between MHT and cognitive deficits, symptoms, and disability may not be casual; data suggest that MHT patients have more psychosocial problems prior to injury than do non-injured persons. The examiner of the MHT patient with chronic complaints must consider alternative medical and psychiatric explanations and perform a differential diagnosis. The possibility of a neurological basis for sustained neuropsychological problems cannot be completely dismissed. Presently, however, there is little evidence for neurological causation of most persisting complaints.

Cognitive sequelae of repeated head injury in a population of intravenous drug users

The relationship between closed head injury and performance on neuropsychological (NP) tests was investigated in a group of intravenous drug users (IVDUs). Subjects with repeated head traumas involving loss of consciousness (LOC) performed worse than both a control group without LOC and reference group with only a single episode of LOC. There were no significant differences between the last two groups. Performance on tests of memory, attention, and motor performance was significantly worse in the group with repeated head injury. The average time since the last episode of LOC was more than 11 years. We conclude from these findings that a single episode of LOC does not result in significant cognitive impairment in this population. Two or more episodes, however, are more likely to produce chronic cognitive impairment.

Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations

The psychosocial problems of decreased social contact, depression, and loneliness that occur for many with traumatic brain injury (TBI) create a major challenge for enhancing efforts at community re-entry. Despite dramatic physical progress within the first six months after injury, these psychosocial problems remain a persistent long-term problem for the majority of individuals with severe TBI. Researchers have consistently suggested that the psychosocial problems associated with TBI may actually be the major challenge facing rehabilitation. The majority of individuals who sustain TBI are young males between the ages of 19 and 25, who are in the early stages of establishing their independence in areas including friendships, leisure activities, intimate relationships, residence, and employment. The problem of social isolation and decreased leisure activities create a renewed dependence of the survivor on his/her family to meet these needs. In this article we review a large number of papers which examine the psychosocial and emotional sequelae for TBI patients. The results of those studies demonstrate four primary themes. The first theme depicts that individuals who experience severe TBI are at high risk for a significant decrease in their friendships and social support. The second theme relates to the lack of opportunity for establishing new social contacts and friends. The third theme relates to the decrease in leisure activities for individuals with severe TBI. Finally, anxiety and depression are found at high levels for prolonged periods of time following severe TBI. Several clinical recommendations are drawn from this literature review. They are: (1) Clinicians such as psychiatric social workers, psychologists, or psychiatrists may need to be called upon more quickly for intervention. The treating physiatrist cannot be expected to provide the insight and frequency of psychological services that may be necessary for many of these patients. (2) Since the literature seems to suggest that the presence of one psychosocial deficit, e.g., anxiety, will often be followed by other similar types of problems, e.g. depression, the treatment team needs to be sensitive to how rapidly these problems can cascade into a very dangerous situation. (3) Perhaps the most compelling recommendation we can make is for community rehabilitation specialists to focus significantly more energies and resources upon the psychological health of clients with TBI. Staff need to be trained to detect these signals that clients with TBI are often sending. It is apparent that psychosocial factors contribute to a rising obstacle level to community adjustment.

Psychiatric disorders following closed head injury: an overview of biopsychosocial factors in their etiology and management

Head trauma in our society is a common occurrence, resulting in significant expenditure of societal resources. Psychiatric consequences following the injury may be the cause of significant disability during the recovery process. While nearly any psychiatric symptom or disorder may occur following head injury, there are a few common complications which are reviewed in this article. Biopsychosocial factors reported to play a role in the etiology of post-traumatic psychiatric dysfunction are reviewed, diagnostic issues are discussed, and new findings regarding treatment are reviewed.

A controlled study of neuropsychological deficits in acute spinal cord injury patients

According to a number of studies, between 40% and 60% of acute traumatic spinal cord injury (SCI) patients demonstrate cognitive dysfunction resulting from various forms of cerebral damage, including concurrent or premorbid closed head injury, chronic alcohol or substance abuse, and other causes. However, applicability of findings from these reports has been limited due to the use of inadequate neuropsychological testing techniques and the lack of control data. In a collaborative investigation, 81 acute SCI patients and 61 non-injured control subjects between 18 and 55 years of age completed a comprehensive motor-free neuropsychological test battery, including: Halstead Category Test (HCT), Vocabulary Subtest (VOCAB) of the Wechsler Adult Intelligence Scale - Revised; Mental Control (MC) Subtest, and Initial and Recall trials of Logical Memory (LM) and Paired Associates (PA) Subtests of the Wechsler Memory Scale; and the 8 trials of the Rey Auditory Verbal Learning Test (RAVLT). Percentages of retained information on the LM and PA were also calculated. Impairment levels for each test were defined as values which exceeded two standard deviations (one-tailed) from the control mean. Based on this definition, the prevalence of neuropsychological abnormality on each test ranged between 10% and 40%. Mean performance levels of patients were significantly more impaired than those of control subjects for all tests except for the Interference trial of the RAVLT and for the percentages of retained information on the LM and PA subtests. Comparison of test results of SCI patients with those of control subjects demonstrates that poor attention span and limited initial learning ability are frequent problems among SCI patients. Other common neuropsychological deficits among these patients include poor concentration ability, impaired memory function, and altered problem solving ability. These deficits may interfere with rehabilitation following SCI.

Physiogenesis and psychogenesis in the 'post-concussional syndrome'

The aetiological factors relevant to the development of post-concussional symptoms are reviewed. From the numerous studies carried out to date, it would appear that both physiogenic and psychogenic influences are important in their genesis. However, where mild-to-moderate injuries are concerned, organic factors are chiefly relevant in the earlier stages, whereas long-continued symptoms are perpetuated by secondary neurotic developments, often of a complex nature.

Persisting symptoms after mild head injury: a review of the postconcussive syndrome

Seemingly mild head injuries frequently result in persisting postconcussive syndromes. The etiology of these symptoms is often controversial. Neuropsychological, neurophysiological, and neuropathological evidence that brain damage can occur in the absence of gross neurological deficits after mild injuries is reviewed. Direct impact to the head is not required to cause brain injury. Understandably, psychological factors also play a role in post-head-injury disability, but the effect of compensation claims and preinjury psychopathology is often secondary to organic factors. Persons over age 40 or with a history of previous head injury are more vulnerable to protracted symptomatology.

Assessment of closed head injury in trauma-related spinal cord injury

The complete medical records of 122 patients who sustained traumatic spinal cord injuries were reviewed to determine the frequency and results of emergency room assessments for loss of consciousness (LOC) and post-traumatic amnesia (PTA). Eighty-eight percent of the patients were assessed for LOC and 19% were assessed for PTA. Fifty patients (41% of the total population) admitted to LOC, PTA or both. Fourteen of these 50 patients underwent subsequent radiographic examinations of the skull, all of which were negative. Because of the association of intracranial complications and long-term cognitive sequelae with even brief LOC or PTA, early recognition of craniocerebral trauma is an important component of the acute management of spinal cord injured patients.

Planning for better standards in the care of the neurological sequelae of trauma

Injuries of the nervous system are common, and cause many deaths and much permanent disability. They inflict an enormous financial burden on the national economy; in Australia, adequate data are at present lacking, but a simple extrapolation from Canadian statistic suggests an estimate of more than $500,000,000 annually for the injuries resulting from road traffic accidents alone; if other causes of injury are included, the figure may reach one billion dollars. The neurosurgeon is specifically trained to undertake the management of all forms of neurological trauma; however, in Australia, and in many other countries, only a small minority of such injuries receive neurosurgical care. This is chiefly because the number of neurosurgeons at present available is small in relation to the tasks. Many cases must therefore be in the care of general or orthopaedic surgeons, especially in country centres, and it is important that these surgeons should have some basic neurosurgical training. The Neurosurgical Society of Australasia wishes to formulate a programme to ensure that opportunities for such training are available throughout Australia. This programme should also embody a national plan for research into the treatment and prevention of neurological trauma.

Subjective impairment and social recovery after closed head injury

The level of social recovery achieved by a representative series of 50 young adults was assessed six months after a severe closed head injury (post-traumatic amnesia greater than 24 hours). Work, leisure activities, and contact with friends were the areas of life most affected, whereas family life and marital relationships appeared to withstand changes at this stage in the recovery process. Many patients were still suffering from subjective symptoms, but these appeared to have relatively minor effects on ability to resume normal activities. Physical disability was a much more important factor at this stage. A control group of patients with limb injuries suffered similar disruption of their lives, but reported few subjective complaints.

Psychiatric sequelae of head injury

The psychiatric problems which may arise following head injury are common, occurring in from 10-77% of cases. The behaviours manifest often impede the progress of treatment causing frustration to the staff, and continuing distress to the patient. To assist in their understanding, I will present the sorts of problems which may arise, with reference to the course of the symptoms and behaviour and to their management.

Late recovery from head injury: case report and review

Some problems of prognosis in patients with head injury are reviewed, and a case of late and unexpected recovery from post-traumatic dementia presented. The possible mechanism of recovery is discussed with particular reference to normal pressure hydrocephalus.

The psychiatric sequelae of head injury: a review

The review deals mainly with the more chronic psychiatric sequelae of head injury. The constellation of factors—psychological, social, and organic—which may contribute to enduring disability are discussed. Principal areas of disability are then considered in detail—namely, intellectual impairments, change of personality, psychotic illness, and neurotic disorders.