When a depressive condition is present after TBI, it is important to assess for depressed mood and emotional response to daily events. Many patients with disordered motivation are not particularly bothered by the impaired motivation. Depressed mood and true anhedonia suggest a mood disorder rather than subcortical injury sequelae. If a subcortical motivation problem is present, cautious use of low-dose stimulant medications (as outlined below) may be appropriate.
CASE VIGNETTE
Sgt B, a 24-year-old Marine Corps veteran of Afghanistan, is admitted to inpatient psychiatry. He is convinced that his religious beliefs are permanently altered by the Buddhist statues he had seen in Bamiyan, Afghanistan. He also reports auditory hallucinations of derogatory comments about his appearance. There is no family history of psychotic illness, but he reports 1 blunt head injury with a loss of consciousness that lasted 10 to 60 minutes.
Certainly, the diagnosis of paranoid schizophrenia is a leading possibility in a young man with new-onset delusions and hallucinations. However, with reports of psychosis after TBI, the psychiatrist must elicit a careful longitudinal history of symptom onset and duration. A thorough review of systems for possible TBI-related physical or neurological conditions also is indicated.
Neurological signs can also support a TBI diagnosis. When vestibular and oculomotor testing is available, it can be a useful technique in diagnosing TBI.15 In one case, the TBI diagnosis was confirmed by the presence of an internuclear ophthalmoplegia that was not present before military service in Iraq, and in another case, a unique vestibular problem in a blast-exposed veteran was identified.16 Neurological localization can be suspected from psychiatric or cognitive symptoms. One veteran in our clinic experienced a blunt head injury that should have affected his inferior frontal lobes. On examination, this veteran lacked awareness of social cues and insight into his interpersonal deficits, none of which were present before his injury. The spouse of another veteran from our clinic reported unusual sexual behaviors in the veteran, and video electroencephalographic monitoring confirmed frontal lobe seizure activity that was temporally correlated with the sexual behavior.
Treatment recommendations
The typical treatment recommendation for mood, anxiety, psychotic, or cognitive disorders in the setting of TBI is to treat the psychiatric disorder as if the TBI was not present. It also is important to discuss carefully any proposed treatments with the patient and/or family members because there are no medications with FDA-approved indications for psychiatric sequelae of TBI.
Clinicians also must remember the possibility of comorbid medical and neurological disorders. Among combat veterans, the most common comorbid condition with TBI will be PTSD, but it also is important to assess for major depression, panic disorder, and substance use disorders. If an Axis I disorder is diagnosed, it should be appropriately treated with medication and/or psychotherapy. The treatment of comorbid PTSD and TBI can be difficult because of overlapping clinical symptoms. We recommend serial evaluation of the reexperiencing symptoms as an outcome measure because these symptoms should not be affected by comorbid TBI.
Persistent and prominent arousal or avoidance symptoms, such as irritability and an apathy syndrome, may be caused by TBI, perhaps due to medical or neurological sequelae. When identified, these conditions should be treated or referred to the appropriate specialty physician. For example, endocrine deficiencies after TBI are not common but should be considered when facing “treatment-resistant depression.”
TBI affects psychosocial treatments. The presence of cognitive problems may affect the type or delivery of psychotherapy. There are no useful data to guide psychotherapy selection for veterans with comorbid psychiatric disorders and TBI. Our group often reviews neuropsychological test results before starting psychotherapy in the patient with a known TBI.
Neuropsychological testing may show specific deficits and relative strength. This information can facilitate psychotherapy by engaging the patient’s strongest cognitive domains whenever possible. Interdisciplinary team meetings between the mental health and TBI teams can be extremely helpful in planning a coordinated biopsychosocial treatment response. There remains a definite need for research into the optimal psychotherapeutic approach for comorbid psychiatric conditions and TBI.
The comorbid medical and neurological conditions associated with TBI can adversely affect clinical outcome. Common comorbid conditions include chronic pain, insomnia, and substance use disorders. Chronic pain has been reported in 43% of veterans with TBI.17 Approximately 50% of patients with TBI reported one or more sleep problems, including sleep apnea, periodic limb movements of sleep, and narcolepsy. Substance abuse can further complicate any cognitive difficulties, either directly as substance effect (eg, alcohol(Drug information on alcohol) use) or indirectly by interfering with sleep. Mitigating these associated conditions will improve patient outcome.
