Forensic Updates

Update on Psychiatric Disorders After Traumatic Brain Injury

Dr. Sam Goldstein

Complimentary Service of the Neurology, Learning and Behavior Center

The Neurology, Learning and Behavior Center provides multi-disciplinary, clinical and forensic assessment, case management, trial consultation and treatment services for children and adults with brain injury and dysfunction, Attention-Deficit Hyperactivity Disorder, language disorders, learning disability, developmental delay, emotional disorders, Autism and adjustment problems. The Center is dedicated to the provision of treatment services.

Update on Psychiatric Disorders After Traumatic Brain Injury

It is the rule rather than the exception that individuals recovering from Traumatic Brain Injury experience psychiatric problems. These problems often result from two causes. The first, direct trauma to the brain that adversely impacts emotional regulation and behavior. The second, often more difficult to understand and treat, results from the consequences of living with an injury that often significantly disrupts personal, professional and family life. Further, many clinicians recognize that rate of recovery, level of daily functioning and ultimately long-term prognosis and outcome appears critically tied to an individual’s ability to achieve stability of emotional functioning and affect regulation as well as the capacity to return to a near normal lifestyle.

The measurement of emotional, behavioral and self-regulatory problems following brain injury follows a scientific protocol similar to the measurement of other neuropsychological skills and abilities. An understanding of pre-trauma functioning is essential. History obtained from the affected individual, friends and family members is also important. Finally, standardized, self-report measures evaluating level of emotional disturbance, symptoms and impairment, leads the evaluator to a symptom count system and diagnoses utilizing the text revision of the Fourth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.

The nature and incidence of psychiatric and emotional problems in adults suffering Traumatic Brain Injury was recently illuminated in a study reporting a thirty year follow-up of brain injured individuals. DSM-IV Axis I symptoms were diagnosed using a structured clinical interview. Axis II or personality problems were diagnosed with a second interview. Cognitive impairments were measured with a neuropsychological test battery. As has been reported in short term studies of emotional dysfunction following Traumatic Brain Injury, this study demonstrates that a significant number of individuals struggle long term with psychiatric disorders following Traumatic Brain Injury. Forty-eight percent of these individuals experienced an Axis I disorder that began after the Traumatic Brain Injury. Sixty-two percent had an Axis I disorder anytime during their lives. The most common disorders after Traumatic Brain Injury were major depression (27%), alcohol abuse or dependence (12%), panic disorder (8%), specific phobia (8%) and psychosis (7%). Fourteen subjects or 23% had at least one personality disorder. The most prevalent individual personality disorders were avoidant (15%), paranoid (8%), and schizoid (7%). Nine subjects or 15% had DSM-III-R organic personality syndromes. Interested readers are referred directly to the article by Koponen and colleagues (American Journal of Psychiatry, August 2002, Volume 159, pages 1315-1321).

These statistics are significantly higher for the majority of these disorders than occurs in the general population. Keep in mind, these conditions, for the majority of these individuals, developed post brain injury. For some it was likely the direct effect of trauma. For others, the consequence of significant changes in their lives, and probably for some a combination.

It is reasonable to conclude that Traumatic Brain Injury causes decades lasting vulnerability to psychiatric illness in many individuals. In these individuals, appropriate care and treatment of emotional and behavioral problems may well speak to the difference between poor or adverse outcome. Clearly, additional research is needed to determine to what extent these adverse outcomes can be mitigated by early identification and appropriate diagnosis as well as psychosocial and medical intervention on a long-term, supportive basis. Further studies are also needed specifically of individuals with mild Traumatic Brain Injury. In clinical settings, it often appears that the long term adverse emotional and psychiatric problems these individuals experience may also be related to difficulty with chronic pain and stress.

These data highlight the importance of emotional, behavioral and psychiatric assessment as part of a comprehensive neuropsychological battery. It is my experience that for many individuals recovering from Traumatic Brain Injury, long-term prognosis and functioning is often better predicted by emotional regulation and psychiatric stability than eventual level of cognitive and neuropsychological function.