Post TBI Psychiatric Sequelae***



Arch Gen Psychiatry. 2004 Jan;61(1):53-61.

Psychiatric illness following traumatic brain injury in an adult health maintenance organization population.

Fann JR, Burington B, Leonetti A, Jaffe K, Katon WJ, Thompson RS.

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98105-6560, USA.

    BACKGROUND: Psychiatric illness after traumatic brain injury (TBI) has been shown to be prevalent in hospitalized and tertiary care patient populations. OBJECTIVE: To determine the risk of psychiatric illness after TBI in an adult health maintenance organization population. DESIGN: Prospective cohort study. SETTING: Large staff-model health maintenance organization. PARTICIPANTS: Nine hundred thirty-nine health plan members diagnosed as having TBI in 1993 and enrolled in the prior year, during which no TBI was ascertained. Three health plan members per TBI-exposed subject were randomly selected as unexposed comparisons, matched for age, sex, and reference date. MAIN OUTCOME MEASURE: Psychiatric illness in the 3 years after the TBI reference date, determined using computerized records of psychiatric diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification, prescriptions, and service utilization. RESULTS: Prevalence of any psychiatric illness in the first year was 49% following moderate to severe TBI, 34% following mild TBI, and 18% in the comparison group. Among subjects without psychiatric illness in the prior year, the adjusted relative risk for any psychiatric illness in the 6 months following moderate to severe TBI was 4.0 (95% confidence interval [CI], 2.4-6.8) and following mild TBI was 2.8 (95% CI, 2.1-3.7; P<.001) compared with those without TBI. Among subjects with prior psychiatric illness, the adjusted relative risk for any psychiatric illness in the 6 months following moderate to severe TBI was 2.1 (95% CI, 1.3-3.3) and following mild TBI was 1.6 (95% CI, 1.2-2.0; P =.005). Prior psychiatric illness significantly modified the relationship between TBI and subsequent psychiatric illness (P =.04) and was a significant predictor (P<.001). Persons with mild TBI and prior psychiatric illness had evidence of persisting psychiatric illness. CONCLUSIONS: Both moderate to severe and mild TBI are associated with an increased risk of subsequent psychiatric illness. Whereas moderate to severe TBI is associated with a higher initial risk, mild TBI may be associated with persistent psychiatric illness.



Arch Gen Psychiatry. 2004 Jan;61(1):42-50. Related Articles, Links          

Major depression following traumatic brain injury.

Jorge RE, Robinson RG, Moser D, Tateno A, Crespo-Facorro B, Arndt S.

Department of Psychiatry, University of Iowa, 500 Newton Road, Iowa City, IA 52242, USA.

            BACKGROUND: Major depression is a frequent psychiatric complication among patients with traumatic brain injury (TBI). To our knowledge, however, the clinical correlates of major depression have not been extensively studied. OBJECTIVE: To determine the clinical, neuropsychological, and structural neuroimaging correlates of major depression occurring after TBI. DESIGN: Prospective, case-controlled, surveillance study conducted during the first year after the traumatic episode occurred.Settings University hospital level I trauma center and a specialized rehabilitation unit. METHODS: The study group consisted of 91 patients with TBI. In addition, 27 patients with multiple traumas but without evidence of central nervous system injury constituted the control group. The patients' conditions were evaluated at baseline and at 3, 6, and 12 months after the traumatic episode. Psychiatric diagnosis was made using a structured clinical interview and DSM-IV criteria. Neuropsychological testing and quantitative magnetic resonance imaging were performed at the 3-month follow-up visit. RESULTS: Major depressive disorder was observed in 30 (33%) of 91 patients during the first year after sustaining a TBI. Major depressive disorder was significantly more frequent among patients with TBI than among the controls. Patients with TBI who had major depression were more likely to have a personal history of mood and anxiety disorders than patients who did not have major depression. Patients with major depression exhibited comorbid anxiety (76.7%) and aggressive behavior (56.7%). Patients with major depression had significantly greater impairment in executive functions than their nondepressed counterparts. Major depression was also associated with poorer social functioning at the 6-and 12-month follow-up, as well as significantly reduced left prefrontal gray matter volumes, particularly in the ventrolateral and dorsolateral regions. CONCLUSIONS: Major depression is a frequent complication of TBI that hinders a patient's recovery. It is associated with executive dysfunction, negative affect, and prominent anxiety symptoms. The neuropathological changes produced by TBI may lead to deactivation of lateral and dorsal prefrontal cortices and increased activation of ventral limbic and paralimbic structures including the amygdala.



J Neuropsychiatry Clin Neurosci 16:306-314, August 2004
A Neuropsychological Comparison of Psychotic Disorder Following Traumatic Brain Injury, Traumatic Brain Injury Without Psychotic Disorder, and Schizophrenia

Daryl Fujii, Ph.D., Iqbal Ahmed, M.D. and Earl Hishinuma, Ph.D.;

            Neuropsychological functioning in individuals with psychotic disorder following traumatic brain injury (PDFTBI), traumatic brain injury without psychosis (TBIWP), and schizophrenia were compared against each other and to the means of normal subjects. It was predicted that the PDFTBI group would be similar to the schizophrenic group in patterns of deficits, but milder in severity. Compared to scores from a normal sample, the PDFTBI group scored significantly lower in intelligence, vocabulary, verbal memory, and executive functioning, while the schizophrenic group scored significantly lower in intelligence, working memory, verbal memory, visual spatial abilities, and executive functioning. No differences were found between normal subjects and the TBIWP group. Implications of our findings for the conceptualization of psychotic disorders are discussed.



Archives of Clinical Neuropsychology

Article in Press, Corrected Proof

The construct of problem solving in higher level neuropsychological assessment and rehabilitation

Joseph F. Rath, Donna M. Langenbahn, Dvorah Simon, Rose Lynn Sherr, Jason Fletcher and Leonard Diller

            Three inter-related studies examine the construct of problem solving as it relates to the assessment of deficits in higher level outpatients with traumatic brain injury (TBI). Sixty-one persons with TBI and 58 uninjured participants completed measures of problem solving and conceptually related constructs, which included neuropsychological tests, self-report inventories, and roleplayed scenarios. In Study I, TBI and control groups performed with no significant differences on measures of memory, reasoning, and executive function, but medium to large between-group differences were found on timed attention tasks. The largest between-group differences were found on psychosocial and problem-solving self-report inventories. In Study II, significant-other (SO) ratings of patient functioning were consistent with patient self-report, and for both self-report and SO ratings of patient problem solving, there was a theoretically meaningful pattern of correlations with timed attention tasks. In Study III, a combination of self-report inventories that accurately distinguished between participants with and without TBI, even when cognitive tests scores were in the normal range, was determined. The findings reflect intrinsic differences in measurement approaches to the construct of problem solving and suggest the importance of using a multidimensional approach to assessment.



Ashman, T.A., Spielman, L.A., Hibbard, M.R., Silver, J.M., Chandna, T., & Gordon, W.A. (in press). Psychiatric challenges in the first 6 years after traumatic brain injury: Cross-sequential analyses of axis I disorders. Archives of Physical Medicine and Rehabilitation.

Hibbard, M.R., Ashman, T.A., Spielman, L., Chun, D., Charatz, H., & Melvin, S. (in press). Predictors of depression post-TBI. Archives of Physical Medicine and Rehabilitation.


Curr Psychiatry Rep. 2003 Jul;5(3):197-201.    
Psychotic disorder and traumatic brain injury.
Zhang Q, Sachdev PS.
The Neuropsychiatric Institute, Prince of Wales Hospital, Barker Street, Randwick NSW 2031, Australia.
    Traumatic brain injury (TBI) can result in serious and disabling neuropsychiatric disorders, such as cognitive deficits and personality change, as well as severe and chronic psychosis. This review focuses on the relationship between TBI and schizophrenia-like psychosis (SLP) including its epidemiology, diagnostic criteria, clinical presentation, psychopathology, risk factors, and pathophysiology. The relationships between post-traumatic epilepsy and SLP, and brain trauma and schizophrenia, are also discussed. The risk of SLP does increase after TBI. The clinical presentation has considerable overlap with primary schizophrenic disorder, with a prominence of persecutory and other delusions and auditory hallucinations, as well as a lack of negative symptoms. The onset is often gradual, with a subacute or chronic course. More severe and diffuse brain injury, especially of the temporal and frontal lobes, is the most prominent risk factor. Genetic load may also play a role, but presence of epilepsy could be a protective factor. Further large and systematic longitudinal studies are needed.

Int Rev Psychiatry. 2003 Nov;15(4):328-40.

Psychosis following traumatic brain injury.

    Arciniegas DB, Harris SN, Brousseau KM.

    Neuropsychiatry Service, Department of Psychiatry, University of Colorado Health Sciences Center, Denver, CO 80262, USA.

    Psychosis is a relatively infrequent but potentially serious and debilitating consequence of traumatic brain injury (TBI), and one about which there is considerable scientific uncertainty and disagreement. There are several substantial clinical, epidemiological, and neurobiological differences between the post-traumatic psychoses and the primary psychotic disorders. The recognition of these differences may facilitate identification and treatment of patients whose psychosis is most appropriately regarded as post-traumatic. In the service of assisting psychiatrists and other mental health clinicians in the diagnosis and treatment of persons with post-traumatic psychoses, this article will review post-traumatic psychosis, including definitions relevant to describing the clinical syndrome, as well as epidemiologic, neurobiological, and neurogenetic factors attendant to it. An approach to evaluation and treatment will then be offered, emphasizing identification of the syndrome of post-traumatic psychosis, consideration of the differential diagnosis of this condition, and careful selection and administration of treatment interventions.



Actas Esp Psiquiatr. 2003 Nov-Dec;31(6):353-60.    Related Articles, Links          

[Psychiatric and neuropsychological legal assessment of traumatic brain damage and Law]

[Article in Spanish]

Quemada Ubis JI, Hormaechea Beldarrain JA, Munoz Cespedes JM.

Servicio de Dano Cerebral, Hospital Aita Menni, Bilbao, Spain.

            Medico-legal assessment of people who have suffered injuries in road traffic accidents must use Law 30/95 as a reference frame. Psychiatric and neuropsychological syndromes secondary to traumatic brain injury (TBI) are no exception and pose demanding challenges to physicians and psychologists. This paper analyzes descriptive and nosological difficulties face by psychiatrists and psychologists; their expert contribution includes translation of official diagnostic entities into categories published in the annex of Law 30/95. Our psychopathological repertoire was created in the 19th century and has hardly been revised since. The wide and varied types of neuropsychological impairments encountered in TBI have to be diagnosed within a very narrow range of DSM-IV and ICD-10 categories. The most common conflicts encountered in the medicolegal arena are revised: the differential diagnosis between dementia and combinations of organic personality disorder with cognitive impairment; differential diagnosis between spontaneous psychiatric illness (bipolar disorder, schizophrenia) and psychiatric syndromes secondary to brain injury (posttraumatic psychosis, organic bipolar disorder); differential diagnosis between concussional syndrome and organic personality disorder, cognitive impairment or organic affective disorder. Specific diagnostic guidelines are suggested for each of these clinical situations. Actas Esp Psiquiatr 2003;31(6):353-360



Arch Phys Med Rehabil. 2003 Nov;84(11):1621-8.   Related Articles, Links          

Depression assessment after traumatic brain injury: an empirically based classification method.

Seel RT, Kreutzer JS.

Defense and Veterans Brain Injury Center, McGuire Veterans Administration Medical Center and Department of Physical Medicine and Rehabilitation, Medical College of Virginia, Richmond, 23249, USA.

            OBJECTIVES: To describe the patterns of depression in patients with traumatic brain injury (TBI), to evaluate the psychometric properties of the Neurobehavioral Functioning Inventory (NFI) Depression Scale, and to classify empirically NFI Depression Scale scores. DESIGN: Depressive symptoms were characterized by using the NFI Depression Scale, the Beck Depression Inventory (BDI), and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Depression Scale. SETTING: An outpatient clinic within a Traumatic Brain Injury Model Systems center. PARTICIPANTS: A demographically diverse sample of 172 outpatients with TBI, evaluated between 1996 and 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The NFI, BDI, and MMPI-2 Depression Scale. The Cronbach alpha, analysis of variance, Pearson correlations, and canonical discriminant function analysis were used to examine the psychometric properties of the NFI Depression Scale. RESULTS: Patients with TBI most frequently reported problems with frustration (81%), restlessness (73%), rumination (69%), boredom (66%), and sadness (66%) with the NFI Depression Scale. The percentages of patients classified as depressed with the BDI and the NFI Depression Scale were 37% and 30%, respectively. The Cronbach alpha for the NFI Depression Scale was.93, indicating a high degree of internal consistency. As hypothesized, NFI Depression Scale scores correlated highly with BDI (r=.765) and MMPI-2 Depression Scale T scores (r=.752). The NFI Depression Scale did not correlate significantly with the MMPI-2 Hypomania Scale, thus showing discriminant validity. Normal and clinically depressed BDI scores were most likely to be accurately predicted by the NFI Depression Scale, with 81% and 87% of grouped cases, respectively, correctly classified. Normal and depressed MMPI-2 Depression Scale scores were accurately predicted by the NFI Depression Scale, with 75% and 83% of grouped cases correctly classified, respectively. Patients' NFI Depression Scale scores were mapped to the corresponding BDI categories, and 3 NFI score classifications emerged: minimally depressed (13-28), borderline depressed (29-42), and clinically depressed (43-65). CONCLUSIONS: Our study provided further evidence that screening for depression should be a standard component of TBI assessment protocols. Between 30% and 38% of patients with TBI were classified as depressed with the NFI Depression Scale and the BDI, respectively. Our findings also provided empirical evidence that the NFI Depression Scale is a useful tool for classifying postinjury depression. (Note: depression screening measures all have very low ppp versus the traditional criterion variable of depression)



Am J Psychiatry 2002 Aug;159(8):1315-21

Comment in:

Am J Psychiatry. 2002 Aug;159(8):1261-4.

Axis I and II psychiatric disorders after traumatic brain injury: a 30- year follow-up study.

Koponen S, Taiminen T, Portin R, Himanen L, Isoniemi H, Heinonen H, Hinkka S, Tenovuo O.

Department of Psychiatry, Turku University Central Hospital, Finland.

            OBJECTIVE: Patients who had suffered traumatic brain injury were evaluated to determine the occurrence of psychiatric disorders during a 30-year follow-up. METHOD: Sixty patients were assessed on average 30 years after traumatic brain injury. DSM-IV axis I disorders were diagnosed on a clinical basis with the aid of the Schedules for Clinical Assessment in Neuropsychiatry (version 2.1), and axis II disorders were diagnosed with the Structured Clinical Interview for DSM-III-R Personality Disorders. Cognitive impairment was measured with a neuropsychological test battery and the Mini- Mental State Examination. RESULTS: Of the 60 patients, 29 (48.3%) had had an axis I disorder that began after traumatic brain injury, and 37 (61.7%) had had an axis I disorder during their lifetimes. The most common novel disorders after traumatic brain injury were major depression (26.7%), alcohol abuse or dependence (11.7%), panic disorder (8.3%), specific phobia (8.3%), and psychotic disorders (6.7%). Fourteen patients (23.3%) had at least one personality disorder. The most prevalent individual disorders were avoidant (15.0%), paranoid (8.3%), and schizoid (6.7%) personality disorders. Nine patients (15.0%) had DSM-III-R organic personality syndrome. CONCLUSIONS: The results suggest that traumatic brain injury may cause decades- lasting vulnerability to psychiatric illness in some individuals. Traumatic brain injury seems to make patients particularly susceptible to depressive episodes, delusional disorder, and personality disturbances. The high rate of psychiatric disorders found in this study emphasizes the importance of psychiatric follow-up after traumatic brain injury.



J Neurol Neurosurg Psychiatry. 2002 May;72(5):615-20.
Psychiatric illness and subsequent traumatic brain injury: a case control study.
Fann JR, Leonetti A, Jaffe K, Katon WJ, Cummings P, Thompson RS.
Department of Psychiatry, University of Washington, Seattle, Washington,
OBJECTIVE: To determine whether psychiatric illness is a risk factor for subsequent traumatic brain injury (TBI). METHODS: Case control study in a large staff model health maintenance organisation in western Washington State. Patients with TBI, determined by International classification of diseases, 9th revision, clinical modification (ICD-9-CM) diagnoses, were 1440 health plan members who had TBI diagnosed in 1993 and who had been enrolled in the previous year, during which no TBI was ascertained. Three health plan members were randomly selected as control subjects, matched by age, sex, and reference date. Psychiatric illness in the year before the TBI reference date was determined by using computerised records of ICD-9-CM diagnoses, psychiatric medication prescriptions, and utilisation of a psychiatric service. RESULTS: For those with a psychiatric diagnosis in the year before the reference date, the adjusted relative risk for TBI was 1.7 (95% confidence interval (CI) 1.4 to 2.0) compared with those without a psychiatric diagnosis. Patients who had filled a psychiatric medication prescription had an adjusted relative risk for TBI of 1.6 (95% CI 1.2 to 2.1) compared with those who had not filled a psychiatric medication prescription. Patients who had utilised psychiatric services had an adjusted relative risk for TBI of 1.3 (95% CI 1.0 to 1.6) compared with those who had not utilised psychiatric services. The adjusted relative risk for TBI for patients with psychiatric illness determined by any of the three psychiatric indicators was 1.6 (95% CI 1.4 to 1.9) compared with those without any psych iatric indicator. CONCLUSION: Psychiatric illness appears to be associated with an increased risk for TBI.

NeuroRehabilitation. 2002;17(4):357-68.    
Evaluation and treatment of psychosis after traumatic brain injury.
McAllister TW, Ferrell RB.
    Dartmouth Medical School, Department of Psychiatry, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
    A review of research studies to date suggests that psychosis is a relatively rare, but serious, complication of traumatic brain injury (TBI). Psychotic syndromes occur more frequently in individuals who have had a TBI than in the general population. Onset of symptoms can be early or late. Psychosis can occur during the period of post-traumatic amnesia, in association with post-traumatic epilepsy, in association with TBI-related mood disorders, and as a chronic, schizophrenia-like syndrome. TBI can interact with genetic vulnerability to increase the risk of developing illnesses such as schizophrenia. Thorough diagnostic assessment is the foundation of rational and effective pharmacotherapy for psychosis after TBI. Atypical antipsychotic drugs have emerged as first line drugs for treatment of psychotic disorders from all causes, including TBI. Anticonvulsant, antidepressant or other drugs may also be needed in some cases. Medication approaches must be adjusted for the particular characteristics and vulnerabilities of the patient with a TBI.

Curr Psychiatry Rep. 2002 Oct;4(5):354-62.    
Traumatic brain injury in older adults.
Ferrell RB, Tanev KS.
Section of Neuropsychiatry, Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.   

  Traumatic brain injury (TBI) is a serious health risk for older adults, and the consequences of TBI range from full recovery to death. For many who survive, there is a legacy of cognitive, physical, and emotional disability. Falls are the major cause of head injury in older adults. There are many risk factors including pre-existing brain disease, other diseases, and, sometimes, iatrogenic factors. Efforts directed at prevention are of great importance. Outcome studies indicate that outcome is generally worse for older people than for younger people with similar injuries, but older individuals also deserve aggressive rehabilitation directed at the best possible recovery. This review will discuss the symptoms and syndromes that commonly result from TBI with comments about treatment.

NeuroRehabilitation 2002;17(2):105-13

The phenomenology of depression after brain injury.

Starkstein SE, Lischinsky A.

Department of Neuropsychiatry and Neuropsychology, Raul Carrea Institute of Neurological Research-FLENI, and CENEBA, Buenos Aires, Argentina.

            One important challenge in neuropsychiatry is how to diagnose depression in patients with acute brain lesions, since there may be an overlap between symptoms of depression and signs associated with the neurologic disease. The best approach is to assess the presence of depressive symptoms using semi-structured or structured psychiatric interviews such as the Present State Exam, the Structured Clinical Interview for DSM- IV, or the Schedules for Clinical Assessment in Neuropsychiatry. The diagnosis of a depressive syndrome should be made using standardized diagnostic criteria for mood disorders due to neurological disease such as in the DSM-IV or the ICD-10. Depression rating scales, such as the Hamilton Depression Scale and the Center for Epidemiologic Scales for Depression may be used to rate the severity of depression and monitor the progression of antidepressant treatment. Most studies in acute and chronic neurologic disorders demonstrated the specificity of both autonomic and psychological symptoms for the syndrome of depression. The present review article examines important considerations before a diagnosis of depression in neurologic disease, discusses a variety of psychiatric instruments that are used to examine the presence and severity of depression in neurologic disease, examines relevant phenomenological issues, and proposes different diagnostic strategies.


Curr Treat Options Neurol. 2002 Jan;4(1):59-75.    
Emotional Disturbances Following Traumatic Brain Injury.
Hurley RA, Taber KH.
    *Departments of Psychiatry and Behavioral Sciences and Radiology, The Herbert J. Frensley Center for Imaging Research, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
    Mood disturbances are common sequelae of traumatic brain injury (TBI), but the scientific database for such disorders is very limited in descriptive, prognostic, and treatment data. Post-TBI symptoms often cross diagnostic boundaries and include cognitive loss, amotivation, psychosis, mood, changes, or other domains. The treating physician must be mindful that clear diagnostic boundaries may not exist. Premorbid level of functioning commonly affects post-TBI level of functioning. When setting treatment goals, this must be considered. Patients who had lower levels of psychosocial functioning before the injury may not fare as well afterwards. Treatment of post-TBI mood symptoms should proceed after a full diagnostic work-up including imaging and electroencephalographic (EEG) studies, neuropsychologic testing, and physical and laboratory examinations. Once the diagnostic picture is established, treatment should then proceed with a multidisciplinary team (physician, social worker, neuropsychologist, and others). For the medications, consider both target symptoms and side effects; start medications with low doses and raise slowly, give full therapeutic trials before switching or adding second agents, avoid benzodiazepines if possible, limit anticholinergic or antidopaminergic agents, and avoid providing large quantities of lethal medications. When starting medications for the treatment of mood disorders following TBI, several general principles of treatment in this population should be considered, including: balancing treatment of target symptoms with the potential for adverse effects; making use of side effects to treat comorbid problems when present (ie, relatively antidepressant for depression and marked insomnia); using a "start low, go slow" approach; continuing dose escalation to full therapeutic levels (ie, completing therapeutic trials) before switching or adding augmenting agents; avoiding agents with predictable and functionally important adverse effects (ie, benzodiazepines, strongly anticholinergic or antidopaminergic agents); and avoiding prescription of large and potentially lethal quantities of medications.


J Cogn Neurosci 2002 Jul 1;14(5):709-20

Is the human amygdala critical for the subjective experience of emotion? Evidence of intact dispositional affect in patients with amygdala lesions.

Anderson AK, Phelps EA.

Stanford University, Stanford, CA, USA.

            It is thought that the human amygdala is a critical component of the neural substrates of emotional experience, involved particularly in the generation of fear, anxiety, and general negative affectivity. Although many neuroimaging studies demonstrate findings consistent this notion, little evidence of altered emotional experience following amygdala damage has been gathered in humans. In a preliminary test of the amygdala's role in phenomenal affective states, we assessed the extent of experienced positive and negative affective states in patients with amygdala damage and age-, sex-, and education-matched controls. To assess chronic changes in experienced affect, all groups were administered the Positive and Negative Affect Schedules (PANAS, Watson, Clark, & Tellegen, 1988). In the first study, we examined the effects of amygdala lesions on affective traits in 10 left and 10 right amygdala-damaged patients, 1 patient with bilateral amygdala damage (SP), and 20 control subjects. Subjects were asked to indicate the typicality of different experiential states of positive (e.g., inspired, excited) and negative (e.g., afraid, nervous) valence. In a second study, we examined more closely the effects of bilateral amygdala damage on the day-to-day generation of affective states by administering the PANAS daily for a 30-day period to patient SP and age-, sex-, and education-matched controls. In both experiments, no differences in the magnitude and frequency of self-reported positive or negative affect were found between control subjects and patients with amygdala damage. Moreover, principal components analyses of the covariation among different affects (across individuals in Study 1 and within individuals across days in Study 2) confirmed a two-factor (positive vs. negative) description of experienced affect in controls. A highly similar two-factor description of experienced affect was found in patients with amygdala lesions. This suggests that the underlying structure of affective states was intact following amygdala damage. It is concluded that the human amygdala may be recruited during phenomenal affective states in the intact brain, but is not necessary for the production of these states.


Brain Inj. 2001 Mar;15(3):189-209.

Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.

Hoofien D, Gilboa A, Vakil E, Donovick PJ.

The National Institute for the Rehabilitation of the Brain Injured, Israel.

            The goal of this study was to measure the very long-term mental and psychosocial outcomes of severe traumatic brain injury (TBI). Seventy-six persons with severe TBI were evaluated extensively by means of standardized scales, neuropsychological tests and evaluations by family members, at an average of 14.1 (SD = 5.5) years post-injury. Six mental and functional domains were examined: psychiatric symptomatology, cognitive abilities, vocational status, family integration, social functioning, and independence in daily routines. The findings indicate a long-term differential effect of severe TBI, with seriously affected psychiatric symptomatology, family and social domains, as compared to moderately influenced cognitive, vocational and independent functioning. Relatively high rates of depression, psychomotor slowness, loneliness and family members' sense of burden were found. In addition to their epidemiological importance, the results indicate that persons with TBI and their families may need professional assistance to maintain a reasonable psychosocial quality of life, even more than a decade post-injury.


J Neuropsychiatry Clin Neurosci. 2001 Winter;13(1):61-9.

Comment in:
* J Neuropsychiatry Clin Neurosci. 2001 Fall;13(4):533-4.
Risk factors in psychosis secondary to traumatic brain injury.
Fujii DE, Ahmed I.
Department of Neuropsychology, Hawaii State Hospital, Kaneohe, 96744, USA.
    Psychosis is a rare but devastating sequela of traumatic brain injury (TBI). This study examined risk factors for developing a psychosis secondary to TBI (PSTBI). Demographics of 25 inpatients with PSTBI were statistically analyzed for risk factors. Data from the PSTBI group were also compared with data from a control group of TBI patients without psychosis. Results indicate the PSTBI group was more likely to have had a previous congenital neurological disorder or to have sustained a head injury prior to adolescence. The PSTBI also had a higher proportion of males. Discussion focuses on potential models for developing PSTBI.


J Am Acad Child Adolesc Psychiatry. 2001 May;40(5):572-9.

Lifetime and novel psychiatric disorders after pediatric traumatic brain injury.

Bloom DR, Levin HS, Ewing-Cobbs L, Saunders AE, Song J, Fletcher JM, Kowatch RA.

Department of Pediatrics, University of Texas-Houston Health Sciences Center, USA.

            OBJECTIVE: To assess lifetime and current psychiatric disorders at least 1 year after traumatic brain injury (TBI) in children and adolescents. METHOD: Forty-six youths who sustained a TBI between the ages of 6 through 15 years were evaluated at least 1 year post-TBI to identify the presence of lifetime and/or novel psychiatric disorders. Semistructured interviews of the parent and child and standardized parent self-report rating instruments were used. RESULTS: Attention-deficit/hyperactivity disorder and depressive disorders were the most common lifetime and novel diagnoses. A wide variety and high rate of novel psychiatric disorders were identified; 74% of these disorders persisted in 48% of the injured children. Internalizing disorders were more likely to resolve than externalizing disorders. Both interviews and parent ratings were sensitive to current externalizing behaviors; interviews more often detected internalizing disorders, whereas parent ratings also identified cognitive difficulties. CONCLUSIONS: Findings were generally consistent with previous research demonstrating the high rate of novel psychiatric disorders following pediatric TBI. Psychiatric interviews were sensitive in identifying both lifetime and novel disorders.



Brain Inj. 2000 Jan;14(1):45-61.

Axis II psychopathology in individuals with traumatic brain injury.

Hibbard MR, Bogdany J, Uysal S, Kepler K, Silver JM, Gordon WA, Haddad L.

Department of Rehabilitation Medicine, The Mount Sinai School of Medicine, New York, NY 10029, USA.

            PRIMARY OBJECTIVES: To determine the frequency and nature of post-TBI personality disorders (PDs) in a community-based sample of individuals with TBI. RESEARCH DESIGN: One hundred individuals with TBI were administered a structural clinical interview to determine Axis II psychopathology. METHODS OF PROCEDURES: The Structured Clinical Interview for DSM-IV Personality Disorders, Clinician Version (SCID II) was used to determine 12 Axis II personality disorders. SCID II questions were modified so that symptom onset could be rated as occurring pre-injury vs. post-TBI. Data were analysed using student T-tests, chi-square analysis and one way analyses of variance. OUTCOMES AND RESULTS: Pre-TBI PDs were diagnosed in 24% of the sample; antisocial PD and obsessive-compulsive PD were the most common diagnoses. Post-TBI, 66% of the sample met criteria for at least one PD, with PDs independent of TBI severity, age at injury, and time since injury. The most common post-TBI PDs were: borderline, avoidant, paranoid, obsessive-compulsive and narcissistic. Men were more likely to be diagnosed with antisocial PD and narcissistic PD. Individuals with pre-TBI PDs were at greater risk of acquiring additional psychopathology post-TBI. Personality traits endorsed by more than 30% of the sample post-TBI reflected loss of self-confidence, attempts to cope with cognitive and interpersonal failures and negative affect. CONCLUSION: These findings argue against a specific TBI personality syndrome, but rather a diversity of personality disorders reflective of the persistent challenges and compensatory coping strategies developed by individuals post-TBI. Prospective need for clinical assessment, pro-active education and focused treatment approaches are discussed.


Curr Treat Options Neurol. 2000 Mar;2(2):169-186.     Related Articles, Links
Neuropsychiatric Aspects of Traumatic Brain Injury.

Arciniegas DB, Topkoff J, Silver JM.
Departments of Psychiatry and Neurology, University of Colorado Health Sciences Center, Campus Box C268-68, 4200 East 9th Avenue, Denver, CO 80262, USA.
    Traumatic brain injury (TBI) may produce a variety of neuropsychiatric problems, including impaired cognition, depression, mania, affective lability, irritability, anxiety, and psychosis. Despite the common occurrence of these symptoms following TBI, there are relatively few studies that provide clear guidance regarding management. Many symptoms (eg, irritability, affective lability, fatigue, sleep disturbance, and impaired cognition) are primarily consequences of brain injury rather than symptoms of a comorbid psychiatric disorder such as major depression. Although it is difficult to study the complicated treatments needed for such symptom complexes, we are able to recommend an approach to the evaluation and treatment of neuropsychiatric problems following traumatic brain injury. A thorough assessment of the patient is a prerequisite to the prescription of any treatment. This assessment should include a thorough developmental, psychiatric, and medication history; a detailed mental status examination; a complete neurologic examination; and quantification of neuropsychiatric symptoms using standardized and accepted inventories (eg, Neurobehavioral Rating Scale, Neuropsychiatric Inventory ). All symptoms must be evaluated in the context of the patient's premorbid history and current treatment because neuropsychiatric symptoms may be influenced by either factor or by both factors. Psychotherapy is an important component of the treatment of neuropsychiatric problems following TBI. Additionally, patients should be encouraged to become involved with local TBI support groups. When medications are prescribed, it is essential to use cautious dosing (low and slow) and empiric trials with continuous reassessment of symptoms using standardized scales and monitoring for drug-drug interactions. In general, medications with significant sedative, antidopaminergic, and anticholinergic properties should be avoided, and benzodiazepines should be used sparingly, if at all. Although patients with TBI may be particularly susceptible to adverse effects of psychopharmacologic medications, at times dosages similar to those used for the non-brain-injured psychiatric patient may be needed. When a single medication does not provide adequate relief of symptoms or cannot be tolerated at therapeutic doses, an alternative strategy is to augment the effect of one medication by using a second low-dose agent with a different mechanism of action.

Brain Inj 2000 Jun;14(6):513-33

Psychiatric treatment outcome following traumatic brain injury.

Burg JS, Williams R, Burright RG, Donovick PJ.

Binghamton University, NY, USA.

            The relationship between self-reported history of traumatic brain injury (TBI) and psychiatric treatment outcome was investigated. TBI was hypothesized to be frequent, associated with cognitive deficits on neuropsychological testing, and less amenable to standard psychiatric treatment. Subjects were 42 psychiatric patients with a self-reported history of TBI and 25 psychiatric patients with no TBI history. Subjects received approximately 2 weeks of inpatient psychiatric treatment. Subjects received neuropsychological testing and completed the Brief Symptom Inventory weekly. TBI was frequent (66% of subjects); multiple injuries were common. Neuropsychological performance was generally average in both groups with few group differences. Subjects, on average, reported significantly decreased psychiatric symptoms on discharge. However, the TBI group appeared to improve less than the control group; group status was a significant predictor of treatment outcome. Implications of results for assessment and treatment of psychiatric disorders in patients with a history of TBI are discussed.



J Neuropsychiatry Clin Neurosci 2000 Summer;12(3):316-27

Can traumatic brain injury cause psychiatric disorders?

van Reekum R, Cohen T, Wong J.

Department of Psychiatry and Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, University of Toronto, Ontario.

            Traumatic brain injury (TBI) may cause psychiatric illness. This article reviews the evidence on the basis of an established set of causation criteria. The evidence is convincing for a strong association between TBI and mood and anxiety disorders. Substance abuse and schizophrenia are not strongly associated with TBI, and there is little research into the rates of personality disorders after TBI. Evidence for a biologic gradient is lacking, but such a gradient may not be relevant to TBI. Evidence for the correct temporal sequence is present. Preliminary evidence suggests a biologic rationale for TBI causing psychiatric illness. Further and methodologically improved research is supported and required.


Am J Psychiatry 1999 Mar;156(3):374-8

Rate of psychiatric illness 1 year after traumatic brain injury.

Deb S, Lyons I, Koutzoukis C, Ali I, McCarthy G.

Division of Psychological Medicine, University of Wales College of Medicine, Heath Park, Cardiff, United Kingdom.

            OBJECTIVE: Neuro/behavioral symptoms are not uncommon after a traumatic brain injury. However, psychiatric syndromes per se have rarely been studied in patients with such an injury. The purpose of this study was to evaluate the type and extent of psychiatric syndromes in patients with traumatic brain injury. METHOD: One hundred ninety-six hospitalized adults were studied 1 year after a traumatic brain injury with the use of a two-stage psychiatric diagnostic procedure. Psychiatric diagnoses were made according to ICD-10 criteria on the basis of data from the Schedules for Clinical Assessment in Neuropsychiatry interview. RESULTS: Of 164 patients interviewed, 30 (18.3%) had an ICD-10 diagnosis of a psychiatric illness. Among the 120 patients who were 18-64 years old, 21.7% had a psychiatric illness, compared with 16.4% in a study of the general population. A depressive illness was present in 13.9% of the traumatic brain injury patients, compared with 2.1% of the general population, and panic disorder was present in 9.0%, compared with 0.8% of the general population. CONCLUSIONS: In comparison with the general population, a higher proportion of adult patients had developed psychiatric illnesses 1 year after a traumatic brain injury; the rates of depressive episode and panic disorder were significantly higher in the study group. A history of psychiatric illness, an unfavorable global outcome according to the Glasgow Outcome Scale, a lower score on the Mini-Mental State examination, and fewer years of formal education seemed to be important risk factors in the development of a psychiatric illness. Compensation claims, however, were not associated with the rate of psychiatric illness.



Arch Phys Med Rehabil. 1998 Jan;79(1):90-103.

Depression following traumatic brain injury.

Rosenthal M, Christensen BK, Ross TP.

Department of Physical Medicine and Rehabilitation, Wayne State University, Detroit, MI, USA.

            OBJECTIVE: Review the existing literature on the incidence, neurobiological and psychosocial correlates, and methods of assessment and treatment of depression following traumatic brain injury (TBI). DATA SOURCES: Computerized database searches of the English-language literature from Index Medicus, Psychological Abstracts, Excerpta Medica, and Cumulative Index of Nursing and Allied Health Literature. STUDY SELECTION: Given the relatively small number of publications specifically related to TBI and depression, all studies appearing in the peer-reviewed literature were included in the review. In addition, studies examining depression and other neurologic diseases (eg, stroke) were also reviewed as to the potential applicability of the theoretical model or methodology used. CONCLUSIONS: Depression occurs with sufficient frequency to be considered a significant consequence after TBI. Depression can impede the achievement of optimal functional outcome, whether in the acute or chronic stages of recovery. It appears that a combination of neuroanatomic, neurochemical, and psychosocial factors is responsible for the onset and maintenance of depression. Its treatment is typically psychopharmacologic, with best results obtained from nontricyclic antidepressants. These results have not been confirmed in double-blind clinical trials, however. Future research should use comprehensive, integrative models of depression that include demographic, biologic, and psychosocial factors; enhanced functional neuroimaging techniques; controlled studies of psychopharmacologic and other interventions; and prospective designs with long-term follow-up.


 Semin Clin Neuropsychiatry. 1998 Jul;3(3):211-223.     Related Articles, Links
Traumatic Brain Injury and Psychosis: What Is the Connection?
McAllister TW.
Dartmouth Hitchcock Medical Center, Lebanon, NH
    Psychotic syndromes occur more frequently in individuals who have had a traumatic brain injury (TBI) than in the general population. Psychotic syndromes following a TBI can present in the period of post-traumatic anmesia, in association with post-traumatic epilepsy, in association with TBI-related mood disorders, and as a chronic, schizophrenia-like syndrome. Individuals with schizophrenia (a chronic psychotic disorder) have a higher frequency of prior TBI than individuals with other psychiatric disorders. These observations suggest an intriguing link between psychosis and TBI. The study of the neuroanatomical and neuropathological substrate of schizophrenia, and of the core symptoms of the disorder ("negative" symptoms, hallucinations, delusions), suggests that abnormalities in the structure and function of certain brain regions play a role in the genesis and maintenance of these core symptoms. The key brain regions include the dorsolateral prefrontal cortex, temporal lobe structures, basal ganglia, thalamus, and cingulate gyrus. These brain regions are commonly injured in many patients with TBI, suggesting a possible mechanism underlying the observed link between TBI and psychosis. This article reviews the literature on TBI and psychosis, and suggests an approach to the evaluation and treatment of individuals with TBI and psychosis.

Axis I psychopathology in individuals with TBI.

Hibbard MR, Uysal S, Kepler K, Bogdany J, Silver J.

Journal of Head Trauma Rehabilitation, 1998, 13(4), 24-39.
Department of Rehabilitation Medicine, The Mount Sinai Medical Center, New York, New York 10029, USA.

            OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TBI onset. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview. MAIN OUTCOME MEASURES: SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders. RESULTS: Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis I diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit. CONCLUSION: TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.


J Am Acad Child Adolesc Psychiatry. 1997 Sep;36(9):1278-85.    
Traumatic brain injury in children and adolescents: psychiatric disorders at two years.
Max JE, Robin DA, Lindgren SD, Smith WL Jr, Sato Y, Mattheis PJ, Stierwalt JA, Castillo CS.
Department of Psychiatry, University of Iowa, Iowa City 52242, USA.
    OBJECTIVE: To extend findings regarding predictive factors of psychiatric outcome from the first to the second year after traumatic brain injury (TBI) in children and adolescents. METHOD: Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the presence of a psychiatric disorder, not present before the injury ("novel"), during the second year after TBI. RESULTS: Fifty subjects enrolled, and the analyses focused on 42 subjects followed at 24 months. Severity of injury, preinjury family function, and preinjury lifetime psychiatric history predicted the development of a "novel" psychiatric disorder present in the second year. CONCLUSION: These data suggest that there are children, identifiable through clinical assessment, at increased risk for "novel" psychiatric disorders in the second year after TBI.


Brain Inj 1996 May;10(5):319-27

Psychiatric disorders after traumatic brain injury.

van Reekum R, Bolago I, Finlayson MA, Garner S, Links PS.

Department of Psychiatry, University of Toronto, Canada

            Substantial psychological and neurobehavioural evidence is available to support the hypothesis that traumatic brain injury (TBI) is a risk factor for subsequent psychiatric disorders. However, studies utilizing established psychiatric diagnostic schemes to study these outcomes after TBI are scarce, and no studies have included an assessment of personality disorders in addition to the major psychiatric disorders. This study utilizes structured psychiatric interviews to measure the prevalence of DSM-III(R) disorders in a sample of 18 subjects derived from a TBI rehabilitation programme. Results revealed high rates for major depression, bipolar affective disorder, generalized anxiety disorder, borderline and avoidant personality disorders. Co-morbidity was also high. A preliminary study of postulated predictive factors revealed possible roles for sex and for initial severity of injury. The study supports the association between TBI and psychiatric disorder, and suggests the need for monitoring, for prevention, and for treatment of psychiatric disorders after TBI.


Am J Psychiatry 1995 Oct;152(10):1493-9

Psychiatric disorders and functional disability in outpatients with traumatic brain injuries.

Fann JR, Katon WJ, Uomoto JM, Esselman PC.

Department of Psychiatry and Behavioral Sciences, University of Washington Medical Center, Seattle, USA.

            OBJECTIVE: This study examined psychiatric sequelae of traumatic brain injuries in outpatients and their relation to functional disability. METHOD: Fifty consecutive outpatients with traumatic brain injuries who came to a brain injury rehabilitation clinic for initial evaluation were examined for DSM-III-R diagnoses with the use of the National Institute of Mental Health Diagnostic Interview Schedule. The patients completed the Medical Outcomes Study Health Survey to assess functional disability and a questionnaire to assess postconcussion symptoms and self-perceptions of the severity of their brain injuries and cognitive functioning. RESULTS: Thirteen (26%) of the patients had current major depression, and an additional 14 (28%) reported a first-onset major depressive episode after the injury that had resolved. Twelve (24%) had current generalized anxiety disorder, and four (8%) reported current substance abuse. The group with depression and/or anxiety was significantly more impaired than the nondepressed/ nonanxious patients according to the Medical Outcomes Study Health Survey measures of emotional role functioning, mental health, and general health perceptions. The depressed/anxious group also rated their injuries as significantly more severe and their cognitive functioning as significantly worse, despite the lack of significant differences in objective measures of severity of injury and Mini-Mental State examination scores. The depressed patients reported significantly more postconcussion symptoms that were increasing in severity over time. CONCLUSIONS: Depression and anxiety are common in outpatients with traumatic brain injuries. Patients with depression or anxiety are more functionally disabled and perceive their injury and cognitive impairment as more severe. Depressed patients report more increasingly severe postconcussion symptoms.


Am J Psychiatry 1993 Jun;150(6):916-21

Secondary mania following traumatic brain injury.

Jorge RE, Robinson RG, Starkstein SE, Arndt SV, Forrester AW, Geisler FH.

Department of Psychiatry, College of Medicine, University of Iowa.

OBJECTIVE: In this study patients were examined during the first year after traumatic brain injury to determine the presence of secondary mania. METHOD: A consecutive series of 66 patients with closed-head injury were evaluated in the hospital and at 3-, 6-, and 12-month follow-ups. The patients were examined with a semistructured psychiatric interview and scales for measurement of impairment in activities of daily living, intellectual function, and social functioning. Patients fulfilling the DSM-III-R criteria for mania were compared to patients with major depression and to patients without affective disturbances in regard to their background characteristics, impairment variables, and lesion locations. RESULTS: Six patients (9%) met the criteria for mania at some point during follow-up. The presence of temporal basal polar lesions was significantly associated with secondary mania even when the effect of other lesion locations was taken into account. Secondary mania was not found to be associated with the severity of brain injury, degree of physical or cognitive impairment, level of social functioning, or previous family or personal history of psychiatric disorder. The duration of mania, however, appeared to be brief, lasting approximately 2 months. CONCLUSIONS: The 9% frequency of secondary mania in these patients with traumatic brain injury is significantly greater than that seen in other brain-injured populations (e.g., patients with stroke). The major correlate was the presence of a temporal basal polar lesion.




Re: preinjury variables, see the review paper, Preinjury Factors Affecting Disability Following TBI, on the villa,  under the Masquerades of Brain Injury Series

direct link:


…and also see the  Recent TBI Abstracts, under the Neuroscience Abstracts section on for

recent papers relating to preinjury and post-injury factors...