Psychiatric Sequelae in Head Injury patients – A Case Control Study.

Poorna Chandrika, P (2007) Psychiatric Sequelae in Head Injury patients – A Case Control Study. Masters thesis, Stanley Medical College, Chennai.


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INTRODUCTION: Classification of head injuries The head injuries are classified according to severity of head Injures. The severity of head injures is best gauged by the depth and the Duration of the impairment of consciousness following the head injury. In gauging the head injury. Glasgow coma scale (gcs) is most Commonly used (teasedale & jennet). Head injury classification Head injury glasgow coma scale Mild 13-15 Moderate 9-12 Severe 3 -8 Head injuries can also be classified as : 1) penetrating 2) non penetrating According to nature of damage as : concussion contusion laceration According to site of injury right left bilateral frontal parietal temporal occipital frontoparietal parieto occipital temporoparietal According to site of bleed extradural epidural subdural subarachnoid intracerebral Head injury is 2nd most important causes of mortality after Cancer. Early mortality has considerably improved as a result of Advances in the management of the early acute stages. Chronic sequale remain, a challenge to medical care and Communal resources, mental sequale outstrip the physical as a cause of Difficulty with rehabilitation, hardship at work, and social incapacity Generally. Clinical features Acute behavioral consequences. Most patients admitted to hospital have a mild injury. Minority Of these patients develop acute complications . Brain swelling, delayed Haematoma and intracranial infection) or prolonged postconcussional Symptoms. Most common consequence of head injury is impairment of Consciousness, ranging from transient confusion to protracted coma. The glasgow coma score (gcs) is commonly used to grade the severity Of traumatic brain injury. Scale gives a quantitative assessment of level Of consciousness and neuro-logical status based on patterns of eye Opening, as well as best verbal and motor responses. Gcs scores between 13 and 15 define mild brain injury, 9-12 Define moderate brain injury and scores between 3 and 8 define severe Brain injury. Early phase of recovery from traumatic brain injury is Characterized by disorientation, confusion and impaired memory Function. Post traumatic amnesia occurs during the period when the Patient is disoriented and confused. Duration of post traumatic amnesia Used as a measure of traumatic brain injury. Duration of post traumatic amnesia has proved to be a good Predictor of the degree of disability, vocational outcome and severity of Personality change after traumatic brain injury. Delirium in brain injury Patients may be due to structural brain damage, cerebral edema, brain Hypoxia, seizures, electrolyte imbalance, infections, medications or Alcohol withdrawal. Chronic behavioral consequences Cognitive disorders – cognitive disturbances are one of the most Important long term sequale of severe traumatic brain injury. Study on 127 patients after 1 year follow up showed slower information Processing and greater impairment in memory than control group. Memory functions are also impaired in traumatic brain injury patients. Dsm iv t.r diagnosis of amnesia disorder due to traumatic brain injury And chronic subtype may be made for those non demented patients. Several neuro psychological tasks are present to quantify these Deficits. Dementia Dementia is a syndrome defined by dsm – iv tr by impairment Of memory and at least one other cognitive domain in the absence of Alteration of consciousness. Apart from memory disturbances, these patients may be severely Apathetic and withdrawn. Traumatic brain injury is associated with expression of amyloid Precursor protein, oxidative stress and an increased deposition of Amyloid – b peptides that leads to onset of dementia. Personality changes Traumatic brain injury patients may experience significant Personality changes. These patients may be irritable, childish, anxious Or aggressive. Disinhibition is frequent and striking clinical feature that May lead to antisocial behavior, at the other end they may become Apathetic, abulic and withdrawn. Some investigators divide these changes in to 2 syndromes a Pseudo-depressed personality syndrome characterized by apathy and Blunted affect, and a pseudopsychopathic personality syndrome which is Characterized by disinhibition, egocentricity and sexual ina Propriateness. Dsm – iv tr defines personality change due to Traumatic brain injury as a persistent personality disturbance that Represents a change from individual’s previous personality. Roberts (1976, 79) survey of long term outcome of severe head Injuries found the commonest pattern of personality change had a Distinctly frontal character, termed it as “fronto – limbic dementia”. Temporal lobe injury associated with aggression and poor Impulse control. Mood disorders Depressive disorders Depressive disorders appear to be frequent complication among Patients with traumatic brain injury patients. According to dsm – iv tr diagnostic criteria, depressive Disorder due to brain injury is divided in to (1) with major depressive like episode. (2) with depressive features. Frequency varies from 6 to 77 percent, in another study major Depression frequency was 61 percent. In another study 2 years after Injury depression was found to be 42 percent. In another study 91 patients followed up for 2 years. 47 patients Developed mood disorder in the first year of follow up. Major depressive Disorder was occurred in 30 patients, nine patients had minor depression And remaining had manic or mixed episodes. Concluded that Approximately one half of traumatic brain injury patients develop mood Disorder in the first year of injury. Patients who were vulnerable developing mood disorders were Not significantly different with regard to demographic variables, severity Of brain injury or degree of functional disability. Depressed patients were more likely to have a personal history of Mood and anxiety disorders than the nondepressed group. Analysis of the oxford collection of head injury records Suggested that depressive symptoms were more common among patients With right hemisphere lesions. Symptoms of depression also more Among patients frontal and parietal lesions than among patients with Other lesion locations. (jorge, robinson) study of depressive disorder in patients after Traumatic brain injury was associated with left dorsolateral frontal or Left basal ganglia lesions. Most consistent clinical correlate of depressive disorder is poor Psychosocial adjustment. Secondary mania – have been reported in a number of organic Disorders such as thyroid disease, uremia and vitamin b12 deficiency or After open heart sugery. Recent study reported 6 of 66 patients had secondary mania one Year after injury. Secondary mania was not related to type or severity of Brain injury but a association was found with lesions in the ventral and Anterior aspects of temporal lobe. Differential diagnosis of mania after traumatic brain injury Include substance induced mood disorder, psychotic syndrome Associated with epilepsy. Anxiety disorders Anxiety disorders after traumatic brain injury may manifest Themselves as pathological worrying, anxious foreboding and autonomic Symptoms. Prevalence of obsessive-compulsive disorder occurring after Traumatic brain injury has been estimated to be 2 to 4 percent. Post traumatic stress disorder following tbi is characterized by Recurrent intrusive recollections, distressing dreams, and flash backs of Traumatic event. There has been controversy regarding whether ptsd can develop After traumatic brain injury, it has been thought that loss of Consciousness is inversely proportional to development of ptsd Prevalence of ptsd to be 27 to 38 percent after traumatic brain Injury. Vulnerability to anxiety disorders after traumatic brain injury has Been studied extensively but no specific characteristic has been noted in Terms of severity of brain injury, or social, physical or cognitive Impairment but one study noted the symptoms present with right orbito Frontal cortex lesions. In patients with anxious depression focal right hemispheric Lesions was found. Psychotic disorders Frequency of psychotic disorders in traumatic brain injury was 7%, these symptoms were observed within 2 years after head injury Positive symptoms were more frequent. Pathology of brain injury neuropathological classification of traumatic brain injury Lesions. Focal lesions intra cranial – extra cerebral haemorrhage (epidural and subdural Hemotomas and subarachnoid hemorrhage). intra cerebral hemorrhage. focal ischaemic lesions. Diffuse lesions diffuse axonal injury. diffuse ischaemic damage. Pathology Types of primary and secondary brain injuries. First level of categorization of head injury divides them into Closed or penetrating injuries depending on the integrity of meningeal Coverings. Missile wounds are the most frequent cause of penetrating Brain injuries. Motor vehicle accidents are the most frequent cause of closed Trauma, which represents the majority of tbi. Primary brain damage is produced by contact and inertial forces That occur at the time of injury. Contact forces may result in laceration To the scalp, skull fractures, intracranial hemorrhages, contusion and Intracerebral hemorrhages. Inertial loading consists of acceleration, deceleration and Rotational forces that result in diffuse axonal injury and eventually acute Subdural hematoma from the tearing of subdural bridging veins. Secondary brain damage is produced by pathological processes That are initiated at the moment of injury but spans a variable period After the traumatic episode. These include brain damage secondary to ischaemia (that Resulting from hypertension or hypoxia or both), brain swelling, raised Intracranial pressure and infection. Focal lesions consists of contusions and lacerations that usually Occur at the surface of brain. More prominent at the crest of cerebral Gyri and have a predilection for the frontal and temporal poles. Lacerations are usually accompanied by extracerebral hemorrhages (burst lobe). Intracranial extracerebral hemorrhages occur in the epidural Space. (ie between the skull and dura), the subdural space (ie between Dura and arachnodi) or the subarachnoid space. Intracerebral hemorrhages are often multiple involving frontal And temporal lobes and basal ganglia and may have a delayed onset (ie Hours or days after trauma). Diffuse lesions include diffuse axonal injury which occur within Corpus callosum, thalamus and dorsolateral quadrants of the upper Brainstem. Pathologic processes include fragmentation of the Axolemma, axonal transport disruption axonal bulb formation, Astrogliosis and microglial activation. Ischaemic damage is highly prevalent among patients with head Injuries. The influence of these different patterns of injury on the Psychiatric disorders after traumatic brain injury has not been Extensively studied. Focal and diffuse lesions usually coexist in traumatic brain Injured patients. . Cognitive impairment after head injury Cognitive impairment is, of course, the direct result of the Damage to brain tissue which has occurred. Minor injuries are Compatible with full intellectual recovery, even when indubitable loss of Consciousness has occurred, in the sense that the patient feels himself to Be unimpaired and psychometric tests Treatment of head injury : The treatment of acute stages of head injury and neurosurgical Interventions and early complications have not been covered up as they Are rarely dealt by the psychiatrists. Once the patient starts recovering and is out of neurosurgical care Psychological management has great importance in determining the Prognosis of the patient. Early management : Initial convalescent period is usually undertaken in hospital and Ideally in an atmosphere as free from stress as possible. Mental exertion Should be avoided at the same time physical activity should be Encouraged. Gradual exercises should be started with would also boost Up patients morale. Time should be devoted to exploration of patient’s anxieties. Fears should be brushed aside. Explanations should be given regarding The initial symptoms. More detailed and specialized care is required by Patients who have more severe brain damage with neurological sequelae And intellectual impairment. Also special attention should be given Towards patients with minor injures but with persistent psychiatric Disability. Neurological sequelae These are treated mainly with the help of neurologist, Physiotherapist and occupation therapist. Rehabilitation of cognitive functions is a very challenging task. Full psychometric assessment is very essential. There may be Impairments of memory, verbal ability, comprehension, visuospatial Ability, attention and manual dexterity. A optimistic approach is required in order to install enthusiasm With ready allowance for fatigue and tolerance for short comings. The Programme should be graded with goals at any stage which should Rational, realistic and achievable. Xangwill has stressed that the emphasis should be placed on Reeducation, compensation and substitution in rehabilitation. Reeducation involves retraining of the patients in skills and Accomplishments which have been impaired. Compensatory functions Must be trained, if attempts at reeducation fail. Compensatory functions Like using props for memory or methods of expression in severe motor Dysphasia can be used. Substitution is required when damage to a Particular function is irreparable. Newcombe had reviewed various Strategies to assist rehabilitation with cognitive retraining. Personality changes following head injury are difficult to modify. Psychotherapy is relatively superficial and should be aimed to help the Patient to achieve some insight into what he is lacking. A behavioural Modification should be tried to reduce disruptive behaviour and Encourage constructive behaviour. Psychotherapy and hebavioural Therapies may be of use in patients with depression, phobias or Headaches and postconcussional syndrome. Tranquillizing drugs such as benzodiazepaines may help to Relieve tension and anxiety. Antidepressants will help in depression. Chlorpromazine will be of help in patients with frontal lobe injures. Antipsychotic will help in acute delirium, psychosis and outburst of Violence. Anticonvulsants like carbamazapine may be of help in Preventing outburst of aggression.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Psychiatric Sequelae ; Head Injury Patients ; Case Control Study.
Subjects: MEDICAL > Psychiatry
Depositing User: Subramani R
Date Deposited: 19 Aug 2017 03:06
Last Modified: 19 Aug 2017 03:06

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