Jonathan M. Silver, MD

Editor's note: For letters to the editor regarding piece, 

, “Traumatic Brain Injury: Its Psychiatric Manifestations and Management. ”

 A quarter of a century ago, few clinicians, and certainly the public, had little concern or understanding of the consequences of traumatic brain injury (TBI). That article provided the perspective that psychiatrists have an important role in the treatment of patients who have had a TBI. Since that time, it is now recognized that disorders such as anxiety, depression, and posttraumatic stress disorder are significant contributors to increased symptoms and disability. This Special Report addresses several specific areas of concern that are of importance to psychiatrists: Can depression be prevented after TBI? What are the risks of suicide? Are there special issues in the elderly (the most rapidly growing population who experiences TBI)? What are the guidelines for the use of medications? What do we do about the post-TBI psychosis in patients?

With the increased interest in mild TBI (of which concussion is the mildest severity), practitioners are seeing many more individuals who have experienced an episode. To determine the natural history and consequences of TBI we need long-term prospective studies. 

of these are currently underway and comprise athletes, individuals who present to emergency departments, and the military.

 Findings from these studies will be invaluable in understanding selection bias that all studies (and individual practices) have.

The most important development in the treatment of individuals with TBI is the recognition that symptoms that persist are non-specific, and patients require a targeted and focused physical examination to determine etiology and treatment. We cannot adequately assess and treat our patients by relying solely on the use of rating scales and cognitive tests. This includes evaluation of visual problems (including symptom exacerbation with eye movements and assessment of convergence insufficiency); balance problems; careful assessment of neck issues, including manual examination for trigger points; and 

 with tests such as the Buffalo Concussion Treadmill Test (BCTT).

 It is also apparent that exercise may be an 

, and rest (except for decreasing the risk of another TBI) is detrimental.

Many patients may have depression or anxiety because no one has ever conducted a proper physical examination. Having persistent symptoms that have been “unexplained” has emotional consequences.

So, I invite you to explore the topics discussed in this Special Report, and the others mentioned in this introduction. For those interested, these topics (and many others) are discussed in detail in the 

I was surprised that in the Special Report on the Neuropsychiatry of Traumatic Brain Injury in the April issue that there was no mention of temporal lobe epilepsy (TLE).

The most common cause of TLE appears to be head trauma and it can present with many psychiatric symptoms including hallucinations, aggressive behavior, and depression. 

Sadly, it appears most cases of TLE are never diagnosed as most doctors including many neurologists and psychiatrists don't even consider it as a diagnostic possibility.  We still don't even know how many cases of TLE there are.

There are no tests to rule it out so in most cases the diagnosis must be made based on the symptoms. Although a positive EEG can make the diagnosis, a negative one does not rule it out. Even special EEGs performed with sleep deprivation and nasopharyngeal leads are reported to have a yield of less than 25% of cases. I strongly believe that many of the cases of athletes reported to be suffering from TBI may have TLE.

The reason it is so important to at least consider the diagnosis of TLE is that it is treatable with anticonvulsants. Certainly any doctor who sees a patient with behavioral changes following head trauma should carefully consider the possibility of this diagnosis and a medication trial. There is nothing to lose and much to gain.

Finally, Dr Silver states that "A quarter of a century ago, few clinicians, and certainly the public, had little concern or understanding of the consequences of traumatic brain injury."

There is some truth to this statement, but long before that, there were researchers such as John Lion and Dennis Madden at the University of Maryland, where I did my psychiatry residency, who were both studying this and teaching trainees the importance of considering the diagnosis of TLE. Unfortunately it seems most clinicians and certainly the public are still ignorant about TLE. 

Dr Silver is Clinical Professor of Psychiatry, New York University School of Medicine, New York, NY. Dr Silver reports that as senior editor he receives royalties for the 3rd edition of 

 Silver JM. Traumatic brain injury: its psychiatric manifestations and management. 

 NCAA-DOD Grand Alliance Care Consortium. 

 University of California, San Francisco. TRACK-TBI. Transforming Research and Clinical Knowledge in TBI. 

https://tracktbi.ucsf.edu/transforming-research-and-clinical-knowledge-tbi

 Chronic Effects of Neurotrauma Consortium (CENC). 

Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial

Determining if rest is best after concussion

 Silver JM, McAllister TW, Arciniegas DB, Eds. 

. Washington, DC: American Psychiatric Association Press; 2019.

Articles

This Special Report addresses several specific areas of concern that are of importance to psychiatrists: Can depression be prevented after traumatic brain injury? What are the risks? Are there special issues involved in treatment?

Neuropsychiatry of TBI

[[{"type":"media","view_mode":"media_crop","fid":"23947","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4666532534707","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2005","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 224px; height: 109px; float: right; margin: 2px 4px;","title":" ","typeof":"foaf:Image"}}]]Behavioral Neurology & Neuropsychiatry (BN & NP) is a medical specialty “committed to better understanding links between neuroscience and behavior and to the care of individuals with neurologically based behavioral disturbances.”

 Neuropsychiatrists specialize in the assessment and treatment of the cognitive, emotional, and behavioral symptoms from disorders such as traumatic brain injury, epilepsy, Parkinson disease, and Alzheimer disease. The CME article in this issue and 4 articles in this Special Report are devoted to several important topics in this field.

 John J. Campbell III, MD, and Annya Tisher, MD

, describe subtypes of deficits in executive functioning. They suggest a practical guide to its assessment, including pertinent history, and easy to perform office evaluations.

, offers a balanced perspective on a “hot topic” that we are frequently asked about-chronic traumatic encephalopathy (CTE)-and urges caution before prematurely concluding that we know more than what we do about the prevalence and risk factors for this disorder. The most accurate perspectives about CTE may not be gleaned from reports in the media.

, reviews the evaluation and treatment of patients with epilepsy. His article highlights that patients with epilepsy not only have seizures, but they also experience depression, affective instability, and psychosis that significantly impair quality of life.

In patients with Parkinson disease, neuropsychiatric problems often develop in addition to the “movement” disorder. Psychosis is the most difficult to treat, since medications used to improve movements may produce psychosis, and antipsychotic medications can exacerbate parkinsonian symptoms. 

, focus on psychosis in Parkinson disease and Parkinson-related disorders (eg, dementia with Lewy bodies, Parkinson disease dementia). They provide a review of the pros and cons of treatment and discuss what makes a patient with these disorders susceptible to psychosis.

There are several ways to assess a patient’s cognitive status, ranging from brief screening tests to comprehensive neuropsychological evaluations. 

, provides his perspective on the potential value of computerized cognitive testing.

Although excellent, these articles offer only a brief exposure to the issues that we confront. The American Neuropsychiatric Association

 is an exciting multidisciplinary organization devoted to this specialty. In 2004, the United Council for Neurologic Subspecialties,

 an organization composed of all of the major neurology organizations, recognized the subspecialty status of BN & NP.

 Since 2006, 23 accredited fellowship training programs have emerged, and we now have 321 diplomates who have passed the certification examination. After May 2014, you will be required to complete a fellowship training program in order to take the examination. Thus, if you wish to be certified, and are not currently a fellow, you must apply now to take the next examination offered in October 2014.

Journal of Neuropsychiatry and Clinical Neurosciences and Journal of Neurosurgery, Neurology, and Psychiatry

 Management of Adults With Traumatic Brain Injury,

 and Textbook of Neuropsychiatry and Clinical Neurosciences

) that provide clinically relevant information to help you treat your patients with these disorders. I hope that these Special Report articles are practical and informative and stimulate your interest in our field.

Dr Silver is Clinical Professor in the department of dsychiatry at the NYU Medical Center in New York, Past President and Fellow of the American Neuropsychiatric Association, and Diplomate in Behavioral Neurology & Neuropsychiatry. He reports no conflicts of interest concerning the subject matter of this Special Report.

 American Neuropsychiatric Association. http://www.anpaonline.org. Accessed March 5, 2014.

 United Council for Neurologic Subspecialties. http://www.ucns.org. Accessed March 5, 2014.

 Silver JM. Behavioral neurology and neuropsychiatry is a subspecialty. 

 Arciniegas DB, Anderson CA, Filley CM, eds. 

. Cambridge, UK: Cambridge University Press; 2013.

 Arciniegas DB, Zasler ND, Vanderploeg RD, Jaffee MS. 

Management of Adults With Traumatic Brain Injury

. Washington, DC: American Psychiatric Publishing; 2013.

 Silver JM, McAllister TW, Yudofsky SC, eds. 

. 2nd ed. Washington, DC: American Psychiatric Publishing; 2011.

Textbook of Neuropsychiatry and Clinical Neurosciences

. 5th ed. Washington, DC: American Psychiatric Publishing; 2008.

An overview of Behavioral Neurology and Neuropsychiatry, a medical specialty committed to better understanding links between neuroscience and behavior and to the care of individuals with neurologically based behavioral disturbances.

Jonathan M. Silver, MD

Articles

Neuropsychiatry of TBI

Introduction: Understanding the Links Between Neuroscience and Behavior