Psychiatric care of traumatic brain injury

謝光煬台灣大學醫學士暨理學博士台灣大學醫學士暨理學博士奇美醫學中心精神科主治醫師奇美醫學中心精神科主治醫師南台科技大學生科所助理教授南台科技大學生科所助理教授

Epidemiology of Epidemiology of traumatic brain injury (TBI)

Leading causes: motor Leading causes: motor vehicle crashes, falls, vehicle crashes, falls, struck by/against events, violencestruck by/against events, violence..

High risk groups: adolescents and young adults, High risk groups: adolescents and young adults, people older than 75 years of age. people older than 75 years of age.

Male-to-female ratio = 2:1Male-to-female ratio = 2:1 Mortality rate: 5-6 %Mortality rate: 5-6 % Prevalence of TBI-related long-term disabilityPrevalence of TBI-related long-term disability in in

general population: general population: 1-2 %1-2 %

Pathology of TBIPathology of TBI

Penetrating or closed injury Penetrating or closed injury Epidural hemorrhageEpidural hemorrhage Subdural hemorrhageSubdural hemorrhage Subarachnoid hemorrhageSubarachnoid hemorrhage Intracerebral hemorrhageIntracerebral hemorrhage ContusionContusion Diffuse axonal injury Diffuse axonal injury

Sequelae of TBISequelae of TBI

Individual and variableIndividual and variable Neurological symptoms:Neurological symptoms:SeizureSeizureBlurred or double vision (diplopia)Blurred or double vision (diplopia)Motor disorders: Motor disorders: weakness in limbs or facial muscles, muscle spasm, weakness in limbs or facial muscles, muscle spasm,

incoordination of movements, unsteady gait. incoordination of movements, unsteady gait. Sensory disorders: tingling, numbness, pain. Sensory disorders: tingling, numbness, pain. Aphasia, slurred speech, dysphagia.Aphasia, slurred speech, dysphagia.Dizziness, headache, vertigo.Dizziness, headache, vertigo. Psychiatric symptomsPsychiatric symptoms

Psychiatric symptoms of TBIPsychiatric symptoms of TBI

Cognitive symptoms:Cognitive symptoms: decreased attention, decreased attention, decreased speed in information processing, decreased speed in information processing, impaired executive function, problems with impaired executive function, problems with memory and learning new information. memory and learning new information.

Mood symptoms:Mood symptoms: depression, anxiety, depression, anxiety, irritability, impulsivity, disinhibition, irritability, impulsivity, disinhibition, emotional lability, inappropriate affect.emotional lability, inappropriate affect.

Psychotic symptoms:Psychotic symptoms: delusion, hallucination, delusion, hallucination, catatonia.catatonia.

Personality change, behavior problemPersonality change, behavior problem (agitation, aggression, disturbing). (agitation, aggression, disturbing).

Pathogenesis of posttraumatic Pathogenesis of posttraumatic psychiatric disturbance psychiatric disturbance Preinjury factors: Preinjury factors: age, gender, neurogenetics, age, gender, neurogenetics,

baseline cognitive function, psychiatric baseline cognitive function, psychiatric conditions, substance abuse, socioeconomic conditions, substance abuse, socioeconomic environment, and risk-taking behaviors.environment, and risk-taking behaviors.

Injury characteristics: Injury characteristics: location, type, and location, type, and severity of neural damage.severity of neural damage.

Postinjury factors: Postinjury factors: social support, timely social support, timely medical and rehabilitative treatments, medical and rehabilitative treatments, socioeconomic status, and medicolegal issues.socioeconomic status, and medicolegal issues.

(Am J Psychiatry(Am J Psychiatry.. 2009; 166:653–661) 2009; 166:653–661)

Natural course of TBI (1)Natural course of TBI (1)

Stages of recovery:Stages of recovery: Acute stage: Acute stage: to stabilize the patient to stabilize the patient

immediately after the injury. immediately after the injury. Subacute stage: Subacute stage: to rehabilitate and return to rehabilitate and return

the patient to the community. the patient to the community. Chronic stage: Chronic stage: to continue rehabilitation to continue rehabilitation

and treat the long-termand treat the long-term impairments. impairments.

Natural course of TBI (2)Natural course of TBI (2)

There is There is a period ofa period of posttraumatic amnesia or posttraumatic amnesia or confusion,confusion, defined as occurring defined as occurring between the between the time of injury and the return of continuous time of injury and the return of continuous memory. memory.

A 6- to 12-month period of spontaneous A 6- to 12-month period of spontaneous recovery follows.recovery follows. After this period, remaining After this period, remaining symptoms are likely to be permanent.symptoms are likely to be permanent.

Long-term outcome: Long-term outcome: 22.2% improved, 15.2% 22.2% improved, 15.2% declined, and 62.6% unchangeddeclined, and 62.6% unchanged from 1 year from 1 year after injury to 5 years. after injury to 5 years.

(J Head Trauma Rehabil. 2001; 16:343-55.)(J Head Trauma Rehabil. 2001; 16:343-55.)

Indicators of prognosisIndicators of prognosis

Duration of coma:Duration of coma: the shorter the coma, the shorter the coma, the better the prognosis. the better the prognosis.

Posttraumatic amnesia/confusion:Posttraumatic amnesia/confusion: the the shorter this period, the better the shorter this period, the better the prognosis. prognosis.

Age:Age: patients over 60 or under 2 years old patients over 60 or under 2 years old have the worst prognosis.have the worst prognosis.

Pharmacological strategies Pharmacological strategies for neuroprotection in TBIfor neuroprotection in TBI

Strategies targeting inflammation, Strategies targeting inflammation, oxidative damage, glutamate oxidative damage, glutamate excitotoxicity, cell death and excitotoxicity, cell death and regeneration have been proposed and regeneration have been proposed and under investigation.under investigation.

Psychiatric pharmacotherapy Psychiatric pharmacotherapy at acute/subacute stage of TBIat acute/subacute stage of TBI

Posttraumatic amnesia/confusion or delirium is the Posttraumatic amnesia/confusion or delirium is the major psychiatric problem at major psychiatric problem at acute/subacute stage of acute/subacute stage of TBI. However,TBI. However, using using antipsychoticsantipsychotics at this period at this period has has a negative impact on cognitive recovery.a negative impact on cognitive recovery. It results in 7 It results in 7 more days required to clear posttraumatic amnesia. more days required to clear posttraumatic amnesia.

(Brain Inj. 2006; 20:905-11.)(Brain Inj. 2006; 20:905-11.) Avoid giving antipsychotics at this stage unless there Avoid giving antipsychotics at this stage unless there

is confusion or delirium with significant behavior is confusion or delirium with significant behavior problem.problem.

Use 2Use 2ndnd-generation antipsychotics since they have less -generation antipsychotics since they have less negative effects on cognitive recovery. negative effects on cognitive recovery.

Psychiatric pharmacotherapy at Psychiatric pharmacotherapy at subacute/chronic stages of TBIsubacute/chronic stages of TBI

Psychiatric symptoms at subacute/chronic stage of Psychiatric symptoms at subacute/chronic stage of TBI need appropriate intervention since they TBI need appropriate intervention since they impede the recovery process and rehabilitation.impede the recovery process and rehabilitation.

Patients with moderate to severe TBI who Patients with moderate to severe TBI who developed mood disorders had significantly developed mood disorders had significantly smaller hippocampal volumes and worse smaller hippocampal volumes and worse vocational outcomes at 1-year follow-up than vocational outcomes at 1-year follow-up than patients with equivalent severe TBI who did not patients with equivalent severe TBI who did not develop mood disturbance. develop mood disturbance.

(Biol Psychiatry. 2007; 62:332-8. )(Biol Psychiatry. 2007; 62:332-8. ) Current practice is a Current practice is a symptom-based approachsymptom-based approach..

Points for attention about Points for attention about psychiatric pharmacotherapy of TBIpsychiatric pharmacotherapy of TBI

Be aware that patients with TBI are especially sensitive to extrapyramidal symptomsextrapyramidal symptoms.

Sedative and anticholinergic effects of medications may impede cognitive functions.cognitive functions.

Start low and go slow.Start low and go slow. Be careful of the motor and cognitive effects Be careful of the motor and cognitive effects

of medications.of medications. Assess risk and benefit.Assess risk and benefit.

Treating cognitive symptomsTreating cognitive symptoms

Stimulants:Stimulants: methylphenidate 20-40 mg/d methylphenidate 20-40 mg/d recommended for increasing attention and recommended for increasing attention and speeding up information processing. Also speeding up information processing. Also effective for depression.effective for depression.

Cholinergic agentsCholinergic agents:: donepezil 5-10 mg/d donepezil 5-10 mg/d recommended for improving attention and recommended for improving attention and memory.memory.

Dopaminergic agents:Dopaminergic agents: amantadine, amantadine, bromocriptine.bromocriptine.

Treating behavioral symptomsTreating behavioral symptoms

Beta-blockers: propranolol 20-160 mg/d Beta-blockers: propranolol 20-160 mg/d recommended for aggression or recommended for aggression or agitation. agitation.

Underlying mood or psychotic symptoms Underlying mood or psychotic symptoms should be treated.should be treated.

Treating mood symptomsTreating mood symptoms

Antidepressants:Antidepressants: sertraline and other sertraline and other selective serotonin reuptake inhibitors selective serotonin reuptake inhibitors (SSRIs)(SSRIs) for depression and anxiety. for depression and anxiety.

Anticonvulsants:Anticonvulsants: valproate valproate for irritability, for irritability, impulsivity and posttraumatic epilepsy.impulsivity and posttraumatic epilepsy.

Be careful of sedative and muscle-relaxing Be careful of sedative and muscle-relaxing effects of benzodiazepines. Avoid using effects of benzodiazepines. Avoid using them in patients with TBI.them in patients with TBI.

Treating psychotic symptomsTreating psychotic symptoms

It has been proposed that 2nd-generation antipsychotics should be the primary agents for psychosis and significant agitation after TBI.

There are some case reports and case series using risperidone, ziprasidone, quetiapine, olanzapine, or clozapine in TBI, mostly for the management of agitation.

There is a lack of literature about zotepine, aripiprazole and amisulpride in TBI.

Neuropsychological and Neuropsychological and occupational assessmentoccupational assessment To evaluate the degree of damage and To evaluate the degree of damage and

recoveryrecovery To help application for disability To help application for disability

certificate and welfarecertificate and welfare To provide evidence for lawsuit or To provide evidence for lawsuit or

litigationlitigation

Holistic care of TBIHolistic care of TBI

Neuropsychiatric pharmacotherapyNeuropsychiatric pharmacotherapy Neuropsychological rehabilitationNeuropsychological rehabilitation Psychotherapy, cognitive behavioral Psychotherapy, cognitive behavioral

therapytherapy Social welfare and supportSocial welfare and support

Thanks for attentionThanks for attention