The incidence of head injury requiring hospitalization in the US is approximately 200 per 100,000 people but increases to more than 600 per 100,000 in young males.1 Patients sustaining severe closed head injury (CHI) (ie, nonmissile injury in which sudden acceleration or deceleration is the primary traumatic force) receive primary care from neurosurgeons and may be referred for rehabilitation, depending on their residual neurologic functioning and resources. However, recent research indicates that behavioral disturbance is a major component of disability after CHI and contributes to the eventual outcome in these predominantly young patients to an equal or greater extent than motor or cognitive impairment.24
There is growing recognition that severely head injured patients are likely to have psychiatric difficulties which may require outpatient psychiatric treatment or psychiatric hospitalization. A variety of behavioral problems may be manifested, depending on the severity of the patient's injury, the stage of recovery, the patient's premorbid psychosocial adjustment and the postinjury environment-1,5 In response to these findings, rehabilitation has shifted to emphasize emotional and social factors in the quality of the patient's life after head trauma. Therefore, psychiatrists are increasingly being consulted to assist in the management of these patients.57
The degree of behavioral disturbance varies as a function of the severity of the head injury. Severity has traditionally been assessed in several ways: initial level of consciousness, duration of coma, and duration of post-traumatic amnesia (PTA). Level of consciousness is measured most often by the Glasgow Coma Scale (GCS) of Teasdale and Jennett which assesses three components of impaired consciousness; the stimulus required to elicit eye opening, the best motor response, and the best verbal response.8 The duration of coma has been measured by various methods, including the time during which the patient fails to obey verbal commands. The period following the injury for which the patient is unable to consistently remember ongoing events defines the duration of PTA.9
In this article, we will review behavioral manifestations of the transitional and long-term stages of recovery following moderate and severe head injury. The transitional period will be defined as recovery of full consciousness and resolution of PTA. The duration of this stage may range from a few days to several months. The long-term phase will denote up to several years after hospitalization. Finally, a classification of behaviors following mild head injury, ie, the "postconcussional syndrome," will be presented.
TRANSITIONAL RECOVERY AFTER MODERATE OR SEVERE HEAD INJURY
As the patient emerges from coma, a variety of characteristic behaviors are frequently exhibited. These features include restlessness, agitation, combativeness, labile emotional reactions (eg, fear, grief, anger), emotional withdrawal or excessive dependency, confusion, distractibility. disorientation and amnesia. '·10·? In contrast to agitation, the transitional period is characterized by lethargy in some CHI patients. Hallucinations are infrequent but have been well -documented during this stage.1 Ruesch and Moore found that slow performance, impairment of judgment, and inability to sustain effort were also associated with early stages of recovery in head-injury.'2 According to DSM-III nomenclature, the patient's behavior during this stage of recovery can be diagnosed as Delirium (293.00) for which the essential elements are clouding of consciousness and disorientation, along with an inability to attend to the environment. Speech and language disorders, including anomia and generally diminished word-finding ability, are often present during this period.'3 Frequently, patients may perseverate on an idea, word or person, resulting in a disjointed flow of conversation. Receptive language may also be impaired, particularly for complex instructions.
Agitation (eg, kicking, dislodging intravenous lines, screaming, picking at body) following head injury was investigated by Levin and Grossman'4 who found that observer's ratings of agitation on the Brief Psychiatric Rating Scale15 were directly related to the severity of head injury. Patients who exhibited marked agitation had more behavioral problems as recovery progressed than did patients who were less agitated or lethargic. Agitation was particularly common among younger head-injured patients and among patients who were aphasie following CHI.
Disorientation and Post-traumatic Amnesia
Russell and Smith established that PTA duration is predictive of neurological sequelae and persistent disability in head injured servicemen.9 In addition, Lishman found that the longer the duration of PTA, the greater the likelihood of psychiatric disability as defined by impaired cognitive capacities, affective and behavioral disorders, somatic complaints and "formal psychiatric illness."16
Benton, Van Allen and Fogel showed that a brief bedside test frequently disclosed temporal disorientation in brain damaged patients who did not appear to be disoriented by clinical observation.17 Trie authors noted that disorientation was related to impaired memory for new information. To serially measure day-to-day changes in orientation and memory during the early stages of recovery after head injury. Levin and colleagues developed the Galveston Orientation and Amnesia Test (GOAT).18 The scale is easily administered and scored (75 to 100 defines the normal range) in several minutes, and measures orientation to person, place and time as well as memory for the events preceding and following the injury (retrograde and anterograde amnesia, respectively). Levin et al found that a PTA duration (defined by the persistence of defective GOAT scores) which exceeded two weeks was strongly related to the severity of initial impairment of consciousness as reflected by the GCS score at the time of hospital admission and to computed tomographic (CT) scan evidence of diffuse or bilateral brain injury.18 Recent studies have shown that other cognitive and somatic signs in addition to orientation and memory are useful in monitoring improvements in consciousness.19 The authors found that speech patterns (eg, audibility and intelligibility), attention, counting from I to 20, and explaining simple concepts were among the 12 behaviors which were useful in monitoring the patient's cognitive improvement.
Memory abilities during PTA can best be described as "islands of memory" in which the patient fails to remember a chronological sequence of events, but might recall fragments followed by periods of amnesia.20 In addition, the patient may tend to confabulate information about the nature of his/her injuries and the circumstances of the hospital admission or even deny any head trauma.2' Questions concerning geographic orientation and the patient's interpretation of his injury are useful in discerning confabulation and delusions which may also be present but are rarely well-organized.
The end of PTA is marked by the restoration of continuous memory. The duration of PTA has been traditionally estimated by the patient's retrospective report about the return of his memory, or by examination of medical records. These methods, however, are of questionable reliability and of no assistance to clinicians during the transitional period. Consequently, direct assessment of orientation during PTA is more informative.
Psychiatric diagnosis of affective disturbance following head injury is difficult due to the composite of affective symptoms, thinking disturbance and other behavioral problems. 5,13,14 Levin and Grossman reported depression and hypomania among the disturbances after head injury.14 They also found constricted emotional expression to be accompanied by blunted affect, cognitive impairment, and social withdrawal. Research has suggested that post-traumatic emotional responses may be related to the altered levels of brain catecholamines and cholinergic metabolism.1
LONG-TERM RECOVERY AFTER MODERATE OR SEVERE HEAD INJURY
The neurosurgeon's judgment of recovery frequently reflects the 30% to 50% mortality of severe head injury rather than the presence of behavioral sequelae which may be more apparent to a psychiatrist or psychologist. Jennett and Bond developed the Glasgow Outcome Scale to characterize the outcome of head injury.3 Briefly, the four levels of survival include: a) persistent vegetative state (ie, patients who remain speechless and unable to meaningfully interact with their environment but recover a sleep-waking cycle), b) severe disability, in which the patient is dependent on others for supportive care because of mental and/or physical disability, c) moderate disability, which designates those individuals who can use public transportation and work in a reduced capacity or within sheltered settings, and d) good recovery, or independent daily functioning which closely approximates premorbid functioning, but is not defined solely by employment status because extrinsic factors can affect return to work.
Outcome research has employed questionnaires and interviews with the patients and their families to determine the major complaints and areas of behavioral and social dysfunction. Frequent residual complaints by patients and families include memory problems, fatiguability, irritability, unrealistic self-appraisal and poor planning, inappropriate interpersonal behavior, reduced social contacts, impatience, verbal and physical aggression, depression and anxiety, and increased family tension.14,22-24 Older head injured patients tend to have more of these symptoms than do younger patients.25
According to DSM-HI, head trauma is among the most common etiologic factors in the Organic Personality Syndrome (310.10) which is characterized by emotional lability, poor impulse control, apathy or suspiciousness in the absence of marked intellectual deficits. While long-term recovery in some head-injured patients may be described adequately using this diagnosis, many of these patients exhibit concomitant cognitive impairment. The diagnosis of Dementia (294.10), which recognizes the presence of cognitive deficits, implies impressive loss of intellectual abilities and memory impairment without clouding of consciousness. Personality changes such as irritability, apathy, and/or social withdrawal are "almost invariably present" (p. 109). An additional DSM-H! classification applicable to the long-term outcome of head injury is the Amnestic Syndrome (294.00) to describe memory disturbance in the context of relatively intact intellectual capacities.
Bond determined through neurological examination and structured interviews that recovery could be delineated by three major areas - neurophysical, mental and social.26 Mental aspects were defined as memory, intellect and personality. Social aspects included work, leisure, family and friends, and criminal behavior. Bond found that neurophysical outcome (eg, hemiparesis) and mental (or cognitive) outcome were not related, while social outcome was significantly correlated with intellectual and neurophysical outcome. Social disability was related to the verbal skills on the Wechsler Adult Intelligence Scale, but overall personality symptoms were unrelated to intellectual capacity.
Thomsen found that the families of CHI patients reported that their personality changes were more of a burden than their physical disability.24 Specifically, the families reported the patients to be irritable, "hot-tempered," restless, lacking spontaneity, emotionally regressed, labile, and stubborn. The family members and the patients agreed that reduced social contact was a problem during recovery.
The early studies by Thomsen and Bond have been supported by later research. In a comparison öf head-injured patients and patients who had extracranial (limb) injuries, Oddy and colleagues found no differences in their complaints of depression, reduced social activities and dissatisfaction with their work.22 The head-injured patients complained of boredom more often than did the limbinjured group. On a symptom checklist, the subjective complaints of the head-injured patients were predominantly related to cognitive and personality changes, while limb-injured patients complained more about depression and anxiety. The greatest differences in complaints were found between the severe (PTA more than 7 days) and "less severe" (PTA less than 7 days) head-injured patients. The more severe patients returned to work later, had fewer close friends and were more dependent on family support.
The behavior of head-injured patients during the first year of recovery has been elaborated by Brooks and McKinlay through interview and rating scales administered 3, 6, and 12 months following injury.27 At 12 months post-injury, the patients who were reported to have personality changes were described as more irritable, excitable, unreasonable, to have increased temper, reduced energy, and to "dislike company." Even those patients who were not described as exhibiting personality changes were reported to be less energetic, more temperamental and less enthusiastic than before their injury.
In 1980 Oddy and Humphrey examined the reports of head-injured patients two years after injury and found that although about 80% of the patients had returned to work, they were employed in a somewhat reduced or altered capacity (eg, a policeman on office duty).28 Physical disability rather than cognitive deficits seemed to be related to job duties. Individuals with premorbid behavior patterns such as "nervousness" or "suspiciousness" tended to delay returning to work. Leisure activities were reduced for 50% of the patients, but this was not related to physical disability. The investigators hypothesized that, since the patients did not report increased boredom, infrequent activities may have been due to diminished motivation to seek leisure opportunities. Contrary to findings during the early recovery stages, patients did not report having fewer friends. Rather, they reported less social outings with their friends. Interestingly, this finding was associated with memory impairment instead of personality changes or physical deficits. At 12 months postinjury, family relationships were reported to be strained, but one year later, families and patients reported getting along as well as before the injury.
Less encouraging results were obtained in a study of more severely head-injured patients (average coma duration of four weeks) who had been in a rehabilitation setting. Weddell, Oddy and Ienkins interviewed the families and patients two years following the injury and found that 28 of 50 cases had not returned to work and were reported to complain of reduced leisure activities, boredom, increased dependency on family members, more severe memory deficits and personality disturbances.29 These individuals were also more impaired on Bond's neurophysical exam than were the patients who had returned to work. Both workers and non-workers complained of fewer friends, but the number of social contacts ("acquaintances") had not changed since the injury.
Oddy found that the family's perceived stress was related to the extent and number of complaints about the patient's behavior.22 The families in the study by Weddell, Oddy and Jenkins reported the patients to be much more irritable (a source of family tension), while a number of patients were reported to be more affectionate and disinhibited than before the injury.29 Brooks and McKinlay reported that families perceived the patients as more of a burden as time passed, even though the nature of the behavior problems did not change.27 The authors suggested that, as time passes, the family becomes less able to cope with the patient, especially as financial and social resources diminish. Consistent with these findings, Jellinek and colleagues found that patients reported less emotional distress when they were independent in selfcare skills and mobility, even though work and leisure activities had been disrupted.30
It would appear that family complaints about head-injured patients center around personality and behavior changes rather than physical disability, and that family tensions increase during and up to two years following injury. Further study is necessary to determine if family distress might be reduced were the patient to achieve greater selfreliance and less dependency.
In addition to interviews and questionnaires, personality assessment with the Minnesota Multiphasic Personality Inventory (MMPI) has also been used to determine the long-term psychological effects of head injury. Dikmen and Reitan found that CHI patients endorsed more MMPI items relating to depression, anxiety, somatic concern, and "strange experiences" than other patient groups.25·31 Those patients with impaired performance on neuropsychological tests also continued to show more emotional problems 18 months after injury. As recovery progressed, all patients were found to improve both on the personality profile and on tests of cognitive abilities.
Such an improvement in emotional status over time was unsubstantiated in a cross-sectional study by Fordyce, Roueche and Prigatano.2 Patients tested at least six months (mean = 25 months) after their injury exhibited more severe emotional distress on the MMPI than patients tested earlier (mean = 3.7 months). Based on both the MMPI and the Katz Adjustment Scale (completed by the patient's relatives), depression, anger, anxiety, thinking disturbance and social withdrawal were significantly more severe in patients who were tested more than six months after injury. Unlike previous research, the patient's emotional status was independent of coma duration and of improvement in neuropsychological capacities. The authors postulated that acutely injured patients are unaware of their neuropsychological deficits and social maladjustment until later in the course of recovery. Interpretation of these results is complicated by possible differences between the "early" and "late" groups with respect to the initial severity of injury and possibly by differences in premorbid psychological adjustment.
In addition to interviews and questionnaires, observer rating scales such as the Brief Psychiatric Rating Scale (BPRS) of Overall and Gorham have been used to determine the long-term behavioral effects of head injury.14 Levin and Grossman studied 50 adult CHI patients who had sustained nonmissile head injuries and who were younger than 50 years old.14 Patients were included in the investigation if they had no antecedent history of alcoholism or other neuropsychiatrie disorder. Ratings were based on observations, semi-structured interviews and behavior during neuropsychological testing after the patient's confusion and disorientation had subsided. Severity of injury in this study was defined as follows: Grade I patients were conscious on hospital admission and had no neurological deficits; Grade II patients were unconscious for less than 24 hours and may have exhibited neurologic deficits; Grade III patients were comatose for 24 hours or longer and may have manifested focal neurologic deficits.
The profile of mean scores on each BPRS scale and the grand mean for all 18 scales appear for each grade of injury in the Figure. The statistical level of significance obtained by analysis of covariance for the main effect of grade (severity) of injury is shown in the upper row of values. Results of pairwise contrasts between the three grades of injury are shown above the corresponding scales. As shown in the Figure, the greatest differences among the grades of injury were found on scales measuring emotional withdrawal (reduced social interaction), conceptual disorganization (eg, disconnected thought processes), motor retardation, unusual thought content, blunted affect, excitement (including agitation) and disorientation. Mild (Grade I) injuries exhibited primarily anxiety and somatic concern, whereas the Grade III group demonstrated significantly greater conceptual disorganization than either Grade I or II patients.
In summary, evidence obtained from interviews and ratings by relatives and trained observers shows that the emotional and behavioral disturbances after head injury greatly affect the patient's overall functioning in the family and in society. Recent studies of psychosocial outcome of CHl demonstrate the importance of assessing the social and familial spheres of the patient's functioning. The family members who take care of a headinjured patient frequently need assistance in adapting to the patient's personality changes.
Minor head injuries (ie, brief or no loss of consciousness; no neurologic or CT evidence of a brain lesion) far outnumber severe head injuries.32 Previous research has shown that microscopic lesions in the cerebral white matter can occur secondary to shear strain in mild head injuries.' While such lesions are compatible with complete recovery, this evidence suggests that a minor head injury is not as inconsequential as once thought.
The postconcussional syndrome, which is most often described after a mild head injury, refers to a constellation of somatic and psychological symptoms including headache, dizziness, fatigue, reduced concentration, memory deficit, irritability, anxiety, insomnia, hypochondriacal concern, hypersensitivity to noise and photophobia.1 The DSM-IH classification of this syndrome is Atypical or Mixed Organic Brain Syndrome (294.80), most likely because the symptoms are not as severe or as extensive as those described in Dementia and the Organic Personality Syndrome.
Gronwall and Wrightson examined patients with uncomplicated minor head injury who exhibited PTA for less than 24 hours and who were without cerebral hematoma or contusion.33 In this study, postconcussional symptoms co-existed with reduced information processing skills, and, as the cognitive ability improved over the first month after injury, the somatic complaints diminished. These complaints did not reflect a neurotic predisposition, but, rather, a stage of recovery from head injury. However, the persistence of symptoms past the "normal period of recovery" (defined as less than 35 days) was postulated as the perpetuation of "fixed neurotic reactions" (p. 608).
Rimel and colleagues studied 424 patients with minor head injury, defined by unconsciousness of 20 minutes or less, a GCS score on admission indicative of disorientation and confusion with otherwise preserved consciousness, and hospitalization not exceeding 48 hours.32 There was no CT scan evidence of cerebral damage and no other medical complications. Three months after the injury the patients were interviewed and neuropsychological tests were administered. Approximately 78% of the patients complained of headaches, and 59% complained of memory problems. Half of the patient group reported a reduction in financial status, and a fourth were unemployed (with the exception of nearly all professionals and executives who were working). Those individuals who had not returned to work reported greater life stress than did the patients who were employed. Neuropsychological testing revealed deficits in attention, concentration, memory, and/or judgment. Surprisingly, only 6 of the 424 patients were involved in litigation concerning the accidents. Insurance claims were not found to affect significantly the patient's return to work or general social recovery. A major shortcoming of this study, however, was the failure of the investigators to assess separately those 31% of patients with previous head injuries.
Figure. Mean score by each grade of injury on individual scales of Brief Psychiatric Rating Scale (BPRS), with grand mean and results of analysis of covariante. Scale scores were adjusted for effects of variation in the injury-rating interval, Order of scales corresponds to that of published BPRS. Open circles connected by solid line indicate grade I; open squares connected by dashed line, grade II; solid triangles connected by solid line, grade III. (From Levin HS, Grossman RG: Behavioral sequelae of closed head injury. Arch Neurol 1978; 35:720-727. Reproduced with permission of authors and publisher. Copyright, American Medical Association).
Levin, Benton and Grossman cited evidence fora neurologic basis for early postconcussional complaints, concluding that these symptoms can begin early after minor head injury and persist up to two months.' If, however, the symptoms persist longer, and particularly if they first appear after the patient is discharged from hospital care, the syndrome may be attributed in part to personality characteristics exacerbated by the emotional trauma of head injury or extrinsic factors. Management of patients with minor head injuries should focus on providing information and support in order to ameliorate the psychological trauma of the acute injury and the sequelae which persist for about a month. To prevent the patient and family from reacting to postconcussional symptoms with undue alarm which can cause secondary problems, Gronwall and Wrightson suggest follow-up clinical evaluations and support as the patient resumes daily routines.33
Recent studies of the neurobehavioral outcome of head injury have implicated behavioral disturbance and social maladjustment as major contributors to long-term disability. Since advanced emergency evacuation, CT scanning and improved neurosurgical management have increased survival after severe brain injury, the role of psychiatrists in the long-term care of these patients will become increasingly prominent. In view of the growing population of young patients with acquired brain injury, treatment of this group may represent a new frontier for psychiatry.
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