Neuropsychiatric Complications and Treatment Approaches Following Traumatic Brain Injury

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Neuropsychiatric disorders regularly occur following traumatic brain injury (TBI) and are often diagnosed within the first year postinjury.^1,2 The most commonly diagnosed DSM Axis I disorders include mood, anxiety, and substance use disorders (SUDs).^2,3 While a preinjury diagnosis of psychiatric disorder is a strong predictor of postinjury disorders, a significant percentage of individuals with TBI are diagnosed with new onset of a neuropsychiatric disorder.^1-3

Psychosocial consequences of brain injury are also well documented and frequently include difficulties with coping and adaptation (ie, coping with emotional demands; adjustment to disabilities, etc), loss of relationships and social support (ie, difficulty maintaining relationships; limited opportunities to develop new relationships), and inability to participate in or fulfill meaningful roles due to physical and cognitive consequences of injury (ie, student, breadwinner, volunteer, spouse, parent, etc).⁴ These changes and losses negatively impact quality of life, and can result in symptoms such as agitation, thought disorders, anxiety, mood disorders, apathy, disinhibition, and sleep disorders.⁵ Important predictors of long-term outcome following TBI are neuropsychiatric symptoms that can lead to social isolation, and negatively influence community integration.^5-7 Psychosocial complications are implicated as a possible risk factor for the development of neuropsychiatric disorders following TBI.⁸

Neuropsychiatric and psychosocial consequences of brain injury involve a number of variables. Injury severity and lesion location disrupt neural circuitry responsible for emotional control, self-awareness, and impulse control. Psychological or psychodynamic variables include resources, personal values, personal attitudes toward disability, and personality characteristics. These influence how an individual perceives the impact of injury, as well as personal resources to adapt and recover. Finally, psychosocial variables impact an individual’s ability to engage in social and productive activities, and use networks of social support.^9,10 These variables can also create barriers to successful rehabilitation and community reintegration.

Dual Diagnosis

Dual diagnosis, also known as comorbidity or co-occurring disorder, refers to combinations of psychiatric disorders that co-occur in the same individual.¹¹ Symptoms of co-occurring disorders can overlap and may worsen the course of both disorders. In the case of TBI and co-occurring neuropsychiatric disorders, it is sometimes difficult to determine if presenting symptoms are the direct result of injury to the brain, or an appropriate situational reaction to the injury.¹² Many of the symptoms frequently reported following TBI, such as irritability, fatigue, sleep problems, decreased initiation, and attentional difficulties, may or may not be associated with a neuropsychiatric disorder such as depression.^13,14 Neuropsychiatric disorders exist in a significant percentage of individuals prior to TBI and brain injury can exacerbate the expression of symptoms.¹⁵ Finally, neuropsychiatric disorders are known to co-occur following TBI, particularly anxiety and depressive disorders.³ A thorough assessment is necessary to differentiate whether symptoms are due to the brain injury, a preexisting condition, psychosocial consequences stemming from injury, or a combination of factors.^14,16

Frequency and Course of Neuropsychiatric Disorders Following TBI

The frequency of neuropsychiatric disorders reported following TBI varies greatly due to methodological differences in studies, including study design, subject recruitment, diagnostic and assessment techniques employed, heterogeneous etiologies of injury and injury severity, and length of time postinjury when diagnoses are made.^3,17-19 Prospective studies, systematic reviews of the literature, and studies using the gold standard Structured Clinical Interview for DSM (SCID) to diagnose neuropsychiatric disorders following TBI can be summarized as follows:

• A significant percentage of individuals with TBI had a preinjury diagnosis of a psychiatric disorder. Gould and colleagues¹⁷ assessed adults with predominately moderate-to-severe TBI for a preinjury psychiatric disorder and followed the cohort (N=102) for 12 months postinjury. Neuropsychiatric disorder was diagnosed using the SCID. Over half of the participants had a preinjury SUD, mood disorder, or anxiety disorder. In a retrospective study of 100 participants with mild to severe TBI using the SCID to diagnose psychiatric disorder pre- and postinjury, Wehlan-Goodinson and colleagues¹⁸ found that 52% of the sample received a psychiatric diagnosis preinjury.
• Neuropsychiatric disorders are common after TBI, with the majority developing within the first year of injury. Gould reported that 60.8% of the study sample received a neuropsychiatric diagnosis, predominately mood and anxiety disorders within the first year postinjury.¹⁹ Alway and colleagues followed a cohort of adults with moderate-to-severe TBI for 5 years.¹ Psychiatric disorders were diagnosed using the SCID, and 75.2% of their sample received a neuropsychiatric diagnosis during the follow-up period, with the majority of disorders emerging in the first year of injury.
• While significant numbers of individuals with TBI had a preexisting psychiatric disorder, many new or novel neuropsychiatric disorders are diagnosed postinjury. Alway found that 45.8% of the study cohort developed new or novel neuropsychiatric disorder¹; Gould reported 56.5% of subjects in the cohort developed a new disorder not present prior to injury.¹⁹
• The timing of the emergence of neuropsychiatric disorders differs depending upon the presence or absence of a preexisting psychiatric disorder. Individuals with a preexisting psychiatric disorder often have a post-TBI neuropsychiatric disorder diagnosed upon initial assessment, or within the first 6 months of injury. However, individuals with no prior psychiatric history often develop a novel neuropsychiatric disorder later in the first year following injury.^3,19
• Some neuropsychiatric disorders may decline over time, while others remain stable. Alway found that anxiety disorders declined significantly over time, while mood and SUDs remained stable.¹ Whelan-Goodinson also reported a decline in SUD with few novel cases.¹⁸
• Neuropsychiatric disorders following TBI tend to co-occur. Alway found that anxiety and SUD co-occur.¹ Anxiety and depressive disorders also tend to co-occur following TBI.^3,18,19 Injury severity may be a factor as rates of neuropsychiatric disorder tend to decline over time for moderate-to-severe brain injuries, but may increase over time for mild TBI.

Diagnosis and Treatment Considerations

There are a number of interacting factors, such as preinjury psychiatric history, lesion location, injury severity, substance misuse, and psychosocial complications, that make it difficult to categorize patients for the purposes of neuropsychiatric diagnosis and treatment. For this reason, a highly individualized approach to diagnosis and treatment planning is recommended.^14,16 Arciniegas and colleagues¹⁴ recommend that assessment should include a thorough developmental, psychiatric and medication history, along with a current mental status and neurological examination. Neuropsychiatric symptoms should be quantified using standardized scales and inventories, and should be evaluated in the context of the patient’s premorbid history and current circumstances. Given that a large number of patients present with a mood disorder postinjury, mood stabilization should be a treatment priority.¹⁶ When medications are prescribed, Arciniegas¹⁴ recommends a conservative approach to because patients with TBI may be particularly sensitive and susceptible to medication adverse effects. Frequent monitoring is recommended for effectiveness, adverse effects, and drug interactions. Avoid medications with sedative properties. When possible, psychotherapy should accompany a medication regimen when treating neuropsychiatric disorders postinjury.¹⁴ Behavioral therapies based on the principles of classical and operant conditioning have been used to successfully manage behavioral dysregulation following traumatic brain injury. Cognitive behavior therapy (CBT) has been shown to reduce psychosocial distress by helping patients modify underlying thinking patterns and maladaptive automatic thoughts.²⁰ Cognitive impairments frequently accompany TBI and modifications to traditional CBT interventions, such as providing written materials, summarizing information, and repeating key learning points, have proven beneficial.²¹ Pilot projects with small samples and single case studies using Acceptance and Commitment therapy have shown promise in reducing symptoms of depression and anxiety following TBI.²² Therapeutic interventions that address trauma, such as EMDR, have been shown to reduce symptoms of anxiety and posttraumatic stress disorder following TBI.²³

Dr Seale is the regional director of clinical services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a chemical dependency counselor and psychological associate with independent practice. He also holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.

References

1. Alway Y, Gould KR, Johnston, L, et al. A prospective examination of axis I psychiatric disorders in the first 5 years following moderate to severe traumatic brain injury. Psychol Med. 2016;46(6):1331-1341.

2. van Reekum R, Cohen T, Wong J. Can traumatic brain injury cause psychiatric disorders? J Neuropsychiatry Clin Neurosci. 2000;12(3):316-327.

3. Ponsford J, Always Y, Gould KR. Epidemiology and natural history of psychiatric disorders after TBI. J Neuropsychiatry Clin Neurosci. 2018;30(4):262-270.

4. Oddy M. Psychosocial consequences of brain injury. In: Greenwood RJ, McMillan TM, Barnesx MP, Ward CD, eds. Handbook of Neurological Rehabilitation. Psychology Press; 2005:469-478.

5. Mundluru J, Subhan A, Lo TWB, et al. Neuropsychiatric presentations due to traumatic brain injury in cognitively normal older adults. J Neurotrauma. 2021;38(5):566-572.

6. Ciurli P, Formisano R, Bivona U, et al. Neuropsychiatric disorders in persons with severe traumatic brain injury: prevalence, phenomenology, and relationship with demographic, clinical, and functional features. J Head Trauma Rehabil. 2011;26(2):116-126.

7. Humphreys I, Wood RL, Phillips CJ, Macey S. The costs of traumatic brain injury: a literature review.  Clinicoecon Outcomes Res. 2013;5:281-287.

8. Scholten AC, Haagsma JA, Cnossen MC, et al. Prevalence and risk factors for anxiety and depressive disorders after traumatic brain injury: a systematic review. J Neurotrauma. 2016;33(22):1969-1994.

9. Pepping M, Roueche JR. Psychosocial consequences of significant brain injury. In: Tupper DE, Cicerone KD, eds. The Neuropsychology of Everyday Life: Issues in Development and Rehabilitation. Kluwer Academic Publishers; 1991.

10. Gainotti G. Emotional and psychosocial problems after brain injury. Neuropsychological Rehabilitation. 1993;3:259-277.

11. Bennett ME, Gjonbalaj-Morovics. The problem of dual diagnosis. In: Beidel DC, Frueh C Adult Psychopathology and Diagnosis, Eighth Edition. Wiley; 2018.

12. Kim E, Lauterbach EC, Reeve A, et al. Neuropsychiatric complications of traumatic brain injury: a critical review of the literature (a report by the ANPA Committee on Research). J Neuropsychiatry Clin Neurosci. 2007;19(2):106-127.

13. Morton MV, Wehman P. Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations. Brain Inj. 1995;9(1):81-92

14. Arciniegas DB, Topkoff J, Silver JM. Neuropsychiatric aspects of traumatic brain injury. Curr Treat Options Neurol. 2000;2(2):169-186.

15. Albrecht JS, Abariga SA, Rao V, Wickwire EM. Incidence of new neuropsychiatric disorder diagnoses following traumatic brain injury. J Head Trauma Rehabil. 2020;35(4):E352-E360.

16. Lauterbach MD, Notarangelo PL, Nichols SJ, et al. Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: insights into psychiatric practice. Neuropsychiatr Dis Treat. 2015;11:1601-1607.

17. Diaz AP, Schwarzbold ML, Thais ME, et al. Psychiatric disorders and health-related quality of life after severe traumatic brain injury: a prospective study. J Neurotrauma. 2012;29:1029-1037.

18. Whelan-Goodinson R, Ponsford J, Johnston L, Grant F. Psychiatric disorders following traumatic brain injury: their nature and frequency. J Head Trauma Rehabil. 2009;24:324-332.

19. Gould KR, Ponsford J, Johnston L, Schönberger M. The nature, frequency and course of psychiatric disorders in the first year after traumatic brain injury: a prospective study. Psychol Med. 2011;41(10):2099-2109.

20. Little A, Byrne C, Coetzer R. The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: a meta-analysis and systematic review. NeuroRehabilitation. 2021;48(1):67-82.

21. Anson K, Ponsford J. Evaluation of a coping skills group following traumatic brain injury. Brain Inj. 2006;20(2):167-178.

22. Kangas M, McDonald S. Is it time to act? The potential of acceptance and commitment therapy for psychological problems following acquired brain injury. Neuropsychol Rehabil. 2011;21(2):250-276.

23. Janssen EPJ, Spauwen PJJ, Rijnen SJM, Ponds RWHm. Exploration of eye movement desensitization and reprocessing in treating posttraumatic stress-disorder in patients with acquired brain injury: a retrospective case series. Eur J Psychotraumatol. 2023;14(2):2264117.