Neuropsychiatric consequences of traumatic brain injury. Causes of head injury. Physical symptoms. Outcome (Thornhill et al, 2001)
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1 Neuropsychiatric consequences of traumatic brain injury Professor Shoumitro Deb, MD. University of Birmingham & Warwick Medical School, UK. Causes of head injury Fall Assault RTA Deb et al (1999) 42% 27% 22% Thornhill et al (2001) 46% 28% 11% Outcome (Thornhill et al, 2001) GCS N Good outcome % % % Outcome (Thornhill et al, 2001) Mild Moderate Severe Physical 58% 66% 82% Cognitive 43% 49% 76% Mood 47% 48% 78% Disability (home) 22% 28% 42% (outside) 34% 35% 67% Physical symptoms Paralysis Ataxia Co-ordination problem Speech problem Epilepsy Sensory problems Headache, dizziness etc. 1
2 Neuropsychiatric Sequelae Cognitive Psychiatric Behavioural Social Daily Living Skills Carer Burden Neuropsychiatric sequelae of Head Injury Behavioural problems Cognitive deficits Psychiatric Illness Psychiatric illness Psychiatric syndromes Psychological symptoms Depression Anxiety Irritability Sleep problems Controversial concepts Personality change Aggressive Apathetic Child like Post Concussional Syndrome Postconcussional syndrome Physical Headache, dizziness Cognitive Impaired memory, difficulty in concentration and performing mental tasks Psychological Fatigue, irritability, insomnia, reduced tolerance to stress, emotional excitement and alcohol PI one year after TBI (Deb et al,1999) 196 hospitalised patients 164 (120 age yrs) interviewed GHQ-28 CIS-R & PSQ SCAN-1CD-10 diagnosis 2
3 PI in TBI (Deb et al, 1999, AJP) (Deb & Burns, 2007, Brain Injury) PI diagnosis Overall rate Schizophrenia TBI group 32% vs. 16% 0.8% Gen. Pop. 16.4% 0.4% Gender Male (110) 21.6% Female (54) 11.3% Depression* GAD Panic Disorder* Phobia OCD 14% 2.5% 9% 0.8% 1.6% 2% 3% 0.8% 1.1% 1.2% Age* yrs (120) 21.7% Over 64 yrs (44) 9% GCS (134) 17.2% <13 (30) 23.3% History of PI* Present (28) 42.9% Absent (136) 13.2% GOS* Unfavourable (59) 36.8% Favourable (105) 8.6% History of TBI* Present (42) 28.6% Absent (122) 14.8% MMSE* (121) 16.5% <23 (40) 25% Alcohol* Present (122) 21.3% Absent (42) 9.5% Conclusion The rate of PI is similar (age dependent). Depression and Panic significantly more prevalent. Younger age, poor outcome, lower MMSE, history of PI, alcohol consumption and TBI are risk factors. 3
4 The rate of neurobehavioural symptoms (n=146) (Deb et al, BJP 1999; JNNP, 1998) One or more 62% Three or more 40% One or two 22% Three to six 21% More than six 19% The rate of neurobehavioural symptoms (n=146) Disinhibition 3% Planning difficulty 12% Verbal outbursts 15% Lack of initiative 15% Slowness in thinking 18% Mood swings 18% Diminished socialisation 27% The rate of neurobehavioural Deb Gouvier Wales Low mood 19% 12% Tiredness 24% 28-35% 30% Impatience 30% 42-49% Sleep problem 32% 26% Irritability 35% 31-43% 22% Socio-demographic Age Gender Risk factors Pre-morbid Education* Social class* Alcohol Previous head injury Previous psychiatric illness IQ (NART) Severity of head injury Risk factors Outcome factors Clustering of neurobehavioural Factor1 GCS score* PTA length ERSS score* MMSE score CIS-R score* Compensation Difficulty in planning Slowness in thinking Lack of initiative Dependence on others 4
5 Clustering of neurobehavioural Factor 2 Tiredness Low mood Sleep problems Clustering of neurobehavioural Factor 3 Irritability Impatience Mood swings Verbal outbursts Pattern of neurobehavioral Elderly group Younger group Dependence Disinhibition Planning difficulty Poor memory Safety hazard Slowness in thinking Tiredness Sleep problems Higher rate of neurobehavioural symptoms in severe head injury Dependence Depressed mood Planning difficulty Poor memory Mood swings Irritability Conclusion Neurobehavioural symptoms are common one year post TBI. Causal relationship is not established. Lower social class, lower educational achievement, low GCS, poor outcome, psychiatric caseness are the risk factors. The pattern of neurobehavioural symptoms varied between age groups and according to the severity of the TBI. 5
6 P-HIPS (48-items) (Deb et al 2007a) C-HIPS (53-items) (Deb et al 2007b) Patient Head Injury Neurobehavioural Assessment Scale (P-HINAS) Temper/ irritable Lack of motivation Social behaviour Patient version - example Patient Head Injury Community Living Scale (P-HICLS) Mobility Sports activity Leisure activity Patient Head Injury Cognitive Assessment Scale (P-HICAS) Difficulty with group conversation Difficulty with planning/ organisation Patient Head Injury Physical Assessment Scale (P-HIPAS) Pain other than headache Sensitivity to light/ noise References (s.deb@bham.ac.uk) Deb S., Bryant E., Morris P. G., Prior L., Lewis G. & Haque S. (2007) Development and psychometric properties of the Patient-Head Injury Participation Scale (P-HIPS) and the Patient-Head Injury Neurobehavioral Assessment Scale (P-HINAS): patient and family determined outcome scales. Neuropsychiatric Disease and Treatment, 3, 3, Deb S., Bryant E., Morris P. G., Prior L., Lewis G. & Haque S. (2007) Development and psychometric properties of the Carer-Head Injury Neurobehavioral Assessment Scale (C-HINAS) and the Carer-Head Injury Participation Scale (C-HIPS): patient and family determined scales. Neuropsychiatric Disease and Treatment, 3, 3, Deb S. & Burns J. (2007) Neuropsychiatric consequences of traumatic brain injury: a comparison between two age groups. Brain Injury, 21, 3, Deb S., Lyons I, Koutzoukis C., Ali I. & McCarthy G. (1999) Rate of psychiatric illness one year after traumatic brain injury. American Journal of Psychiatry, 156, Deb S., Lyons I. & Koutzoukis C. (1999) Neurobehavioural symptoms one year after a head injury. British Journal of Psychiatry, 174, Deb S., Lyons I. & Koutzoukis C. (1998) Neuropsychiatric sequelae one year after a minor head injury. Journal of Neurology Neurosurgery and Psychiatry, 65,
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