Psychiatric Times.
No. 4
Neuropsychiatric Aspects of Traumatic Brain Injury
By Edward Kim, MD, MBA |
April 1, 2006
In uncontrolled studies, the cholinesterase
inhibitor donepezil(Drug information on donepezil) (Aricept)
has demonstrated some beneficial
effects on TBI-related memory deficit.9 The psychostimulants have demonstrated
efficacy in improving attention,
concentration, and vigilance, but
patients should be monitored for increased
irritability.10 Clinicians must
also take into consideration these
acquired cognitive deficits when providing
instructions and education to
patients, who may be easily overwhelmed
by the information exchange.
Aggression and impulsivity
Patients who sustain multiple head
injuries over time appear to demonstrate
increased irritability with each subsequent
injury, particularly when the injuries are associated with loss of
consciousness.11 Premorbid risk factors
for aggression include a history of
impulsive aggression,12 arrest, and
substance abuse.13 Aggression is also
frequently encountered in post-TBI
mania, which occurs in 7% to 9% of
patients independent of severity of
injury, cognitive impairment, or physical
disability.14 While post-TBI manic
syndromes may resemble the classic
manic syndrome of euphoria, elation,
increased energy, and grandiosity, a
more common presentation is a
dysphoric mixed bipolar syndrome.15
Treatment of post-TBI aggression
aims to reduce disruptive behaviors
without negatively impacting other
areas of functioning. Anticonvulsants
appear to be effective and well-tolerated
in treating these disorders, although
cognitive impairment may occur at
higher doses.16 Traditional antipsychotics
have been associated with
cognitive impairment in TBI patients,
but second-generation antipsychotics
appear to be better tolerated.17
Depression
The prevalence of major depression
following TBI ranges from 15% to
61%.18,19 Estimates are limited by the
wide variety of methodologies and diagnostic
criteria. Some investigators noted
that fatigue, frustration, poor concentration,
boredom, and distractibility
were common in depressed TBI
patients, but feeling sad or blue was not
as common.20 On the other hand, Jorge
and associates21 found that feelings of
depression and sadness did, in fact,
discriminate between depressed and
nondepressed patients and suggested
that cognitive impairment and fatigue
were not useful diagnostic symptoms
in this population.
Treatment of post-TBI depression
with antidepressants appears to be effective,
as is psychotherapy and, when
necessary, electroconvulsive therapy.
Effective treatment is considered crucial
to maximizing cognitive and psychosocial
functioning, which are often
compromised by depressive symptoms.22
Summary
TBI is frequently complicated by
neuropsychiatric symptoms that are
multiply determined. The complex
interaction between neurobiologic
changes and the external social environment
may lead to devastating
psychosocial morbidity, even in the
absence of profound neurologic or
cognitive impairment. Increased vigilance
for previously undiagnosed or
incidental TBIs in general mental health
populations may lead to more effective
clinical management.
Dr Kim is associate director of medical strategy,
neuroscience at Bristol-Myers Squibb and
clinical associate professor of psychiatry,
Robert Wood Johnson Medical School,
Piscataway, NJ. He reports that he has no
conflicts of interest regarding the subject matter
of this article.
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