Neuropsychiatry of TBI

April 24, 2019
Jonathan M. Silver, MD
Volume 36, Issue 4

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?

AN UPDATE: TRAUMATIC BRAIN INJURY

Editor's note: For letters to the editor regarding piece, please click here.

In 1994 I wrote an article for Psychiatric Times, “Traumatic Brain Injury: Its Psychiatric Manifestations and Management. ”1 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. Several of these are currently underway and comprise athletes, individuals who present to emergency departments, and the military.2-4 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 assessment of exercise tolerance with tests such as the Buffalo Concussion Treadmill Test (BCTT).5 It is also apparent that exercise may be an effective treatment, and rest (except for decreasing the risk of another TBI) is detrimental.6

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 Textbook of Traumatic Brain Injury.7

Letter to the Editor

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. 

Steven A. King, MD, MS
April 30, 2019

Disclosures:

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 Textbook of Traumatic Brain Injury.

References:

1. Silver JM. Traumatic brain injury: its psychiatric manifestations and management. Psychiatric Times. 1994;9(8):12-14.

2. NCAA-DOD Grand Alliance Care Consortium. http://www.careconsortium.net/. Accessed March 10, 2019.

3. University of California, San Francisco. TRACK-TBI. Transforming Research and Clinical Knowledge in TBI. https://tracktbi.ucsf.edu/transforming-research-and-clinical-knowledge-tbi. Accessed March 10, 2019.

4. Chronic Effects of Neurotrauma Consortium (CENC). https://cenc.rti.org/. Accessed March 10, 2019.

5. Leddy JJ, Haider MN, Ellis MJ, et al. Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA Pediatr. February 2019; Epub ahead of print.

6. Giza CC, Choe MC, Barlow KM. Determining if rest is best after concussion. JAMA Neurol. 2018;75:399-400.

7. Silver JM, McAllister TW, Arciniegas DB, Eds. Textbook of Traumatic Brain Injury, 3rd ed. Washington, DC: American Psychiatric Association Press; 2019.

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