A.D. Macleod

Impaired eye movements in post-concussion syndrome indicate suboptimal brain function beyond the influence of depression, malingering or intellectual ability

Post-concussion syndrome (PCS) can affect up to 20%-30% of patients with mild closed head injury (mCHI), comprising incomplete recovery and debilitating persistence of post-concussional symptoms. Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired post-acutely in mCHI. Here, we examined whether PCS patients continue to show disparities in eye movement function at 3-5 months following mCHI compared with patients with good recovery. We hypothesized that eye movements might provide sensitive and objective functional markers of ongoing cerebral impairment in PCS. We compared 36 PCS participants (adapted World Health Organization guidelines) and 36 individually matched controls (i.e. mCHI patients of similar injury severity but good recovery) on reflexive, anti- and self-paced saccades, memory-guided sequences and smooth pursuit. All completed neuropsychological testing and health status questionnaires. Mean time post-injury was 140 days in the PCS group and 163 days in the control group. The PCS group performed worse on anti-saccades, self-paced saccades, memory-guided sequences and smooth pursuit, suggesting problems in response inhibition, short-term spatial memory, motor-sequence programming, visuospatial processing and visual attention. This poorer oculomotor performance included several measures beyond conscious control, indicating that subcortical functionality in the PCS group was poorer than expected after mCHI. The PCS group had poorer neuropsychological function (memory, complex attention and executive function). Analysis of covariance showed oculomotor differences to be practically unaffected by group disparities in depression and estimated intellectual ability. Compared with neuropsychological tests, eye movements were more likely to be markedly impaired in PCS cases with high symptom load. Poorer eye movement function, and particularly poorer subcortical oculomotor function, correlated more with post-concussive symptom load and problems on activities of daily living whilst poorer neuropsychological function exhibited slightly better correlations with measures of mental health. Our findings that eye movement function in PCS does not follow the normal recovery path of eye movements after mCHI are indicative of ongoing cerebral impairment. Whilst oculomotor and neuropsychological tests partially overlapped in identifying impairment, eye movements showed additional dysfunction in motor/visuospatial areas, response inhibition, visual attention and subcortical function. Poorer subconscious oculomotor function in the PCS group supports the notion that PCS is not merely a psychological entity, but also has a biological substrate. Measurement of oculomotor function may be of value in PCS cases with a high symptom load but an otherwise unremarkable assessment profile. Routine oculomotor testing should be feasible in centres with existing access to this technology.

Concussion and mild head injury

A concussion is a physical injury to the head resulting in altered mental function, with expectation of recovery within 2–3 weeks. In a significant minority of cases the symptoms persist longer, thereby comprising a symptom complex commonly referred to as the “post concussion syndrome”, that is, one or more somatic (for example, headaches, dizziness), cognitive (for example, poor concentration, memory), or behavioural/affective (for example, irritability, mood swings) symptoms. Unfortunately, the referral of a patient with the possibility of post concussion syndrome to a busy neurology outpatient clinic can precipitate an inward sigh of reluctant resignation in even the most diligent neurologist or neurosurgeon. We know we are in for a potentially lengthy consultation—long on symptoms and short on signs. Moreover, the process can be convoluted and meandering, as unrewarding for the patient as it is unsatisfying for the clinician. It is important to acknowledge at the outset that there is a dearth of evidence-based knowledge of the underlying pathogenesis, and even less of the best management of post concussive symptoms. Thus, much of the information and advice in this article is empirical and based on expert and personal experience. The terminology surrounding trauma to the head confuses patients, doctors, and lay commentators alike. Terms such as concussion, mild head injury, mild TBI (traumatic brain injury), cerebral concussion, and post concussion syndrome are often used interchangeably to describe the physical injury itself as well as its immediate and later symptomatic consequences. There is in fact no commonly agreed definition of concussion, or whether it even differs from the term mild TBI. Our own working definition is that concussion is an acute trauma-induced change of mental function which generally lasts less than 24 hours (with or without preceding loss of consciousness) and associated with other symptoms (such as headaches and dizziness) which …

The Reactivation of Post-Traumatic Stress Disorder in Later Life

The natural history of chronic PTSD was observed by reviewing the veterans medical records, which had been commenced at enlistment, prior to active service. The masking of intrusive symptoms in mid-life was usual. A terminal phase of symptomatic reactivation in older age may occur. The indelibility of the memory of fear is demonstrated by these veterans. The reticence to retell the trauma story remains a major obstacle in the study of the mental health sequelae of warfare. War-related psychiatric disorder in the elderly male is easily missed. Direct questioning regarding military service is advisable. The ineffectiveness of the management strategies offered to World War II PTSD sufferers is clearly apparent. Forty-five World War II veterans reporting recent reactivation of chronic posttraumatic stress disorder (PTSD) symptoms were clinically assessed in order to determine war pension disability. In the course of these examinations, factors implicated in the exacerbation of their re-experiencing and arousal symptoms were recorded. The most prominent of these factors was that of physical ill health. Retirement, loneliness, comorbid psychiatric illness, anniversaries, service reunions, and alcohol and psychotropic medication usage were other factors.

Demoralisation--a useful conceptualisation of non-specific psychological distress among refugees attending mental health services.

Background: While it is recognised that many refugee and migrant clients present at mental health services with non-specific psychological distress little is known about successful intervention strategies. Aims: The aim of this study was to systematically review clinical files to determine the degree of ‘demoralisation’ symptoms among a sample of refugee and migrant clients attending a community-based mental health service. Method: Sixty-four closed cases were reviewed using a specifically designed case review sheet as a checklist which included diagnostic criteria for a Demoralisation Syndrome. Results: The findings indicated that while many of the refugee and migrant clients had attracted a diagnosis of major depressive disorder, in the main they did not benefit from a normal course of treatment. Further analysis suggested that demoralisation may be a preferable concept for many of these clients rather than affective disorder. This finding suggests that demoralisation may be a different construct than low mood or depression. Conclusions: The findings add support to the concept that demoralisation could be a distinct diagnostic entity in its own right that may be useful to clinicians attending refugee and migrant clients.

Posttraumatic stress disorder: do electrical startle responses and thyroid function usefully supplement self‐report? A study of Vietnam War veterans

Objective: To investigate the usefulness of electrical startle responses and thyroid function as supplements to self-report measures of posttraumatic stress disorder (PTSD). Method: Invitations were sent to all New Zealand Vietnam War veterans known to be living in North Canterbury; 50 responded and the 35 living in or near Christchurch were included. Self-report measures of PTSD (the Davidson Trauma Scale (DTS) and the Symptom Check List (SCL-90-R)), an eye blink electrical startle response and thyroid function were measured. The DTS was re-administered one to two weeks later to assess short-term test–retest reliability. Six months later the DTS and the electrical startle response were measured again. Results: The veterans reported a wide range of PTSD severity, with 15/35 reporting prior diagnosis of PTSD. The DTS showed high short-term test–retest reliability (r = 0.93) and a moderate correlation after 6 months (r = 0.73). It also showed sensitivity to change; in one to two weeks the scores increased by nearly half a standard deviation, possibly because of an imminent ‘homecoming’ march. The DTS and a PTSD scale from the SCL-90-R were highly correlated (r = 0.89). The total triiodothyronine (T3) to free thyroxine (T4) ratio measure of thyroid function correlated poorly with self-report (r ≤ 0.27). The electrical startle response also correlated poorly with self-report (r ≤ 0.26), showed low internal consistency between left and right sides (r = 0.43), and correlated 0.39 over six months. It was disliked by the veterans and had increased slightly at 6 month follow-up, perhaps because of sensitization. Conclusions: The DTS was reliable and correlated highly with the SCL-90-R PTSD scale. Neither thyroid function nor eye blink electrical startle correlated with each other or with selfreport, and reliability was not good for electrical startle. These two measures do not appear to add anything useful to the assessment of PTSD.

Untangling chronic pain and post-concussion symptoms: the significance of depression

ABSTRACT Objectives: Post-concussion-like symptoms (PCS) are common in patients without a history of brain injury, such as those with chronic pain (CP). This exploratory study examined neuro-cognitive and psychological functioning in patients with PCS following mild traumatic brain injury (mTBI) or CP, to assess unique and overlapping phenomenology. Methods: In this case-control study, participants (n = 102) with chronic symptoms after mTBI (n = 45) were matched with mTBI recovered (n = 31) and CP groups (n = 26), on age, gender, ethnicity and education. Psychological status, cognitive functioning, health symptoms, beliefs and behaviours were examined. Results: Participants who had not recovered from an mTBI and participants with CP did not differ in terms of PCS symptoms, quality of life, distress or illness behaviours, however, the CP group endorsed fewer subjective cognitive problems, more negative expectations about recovery and more distress (p < 0.05). On cognitive testing participants who had not recovered from an mTBI demonstrated greater difficulties with attention (p < 0.01) although differences disappeared when depression was controlled in the analyses. Conclusions: Unique patterns associated with each condition were evident though caution is required in attributing PCS and cognitive symptoms to a brain injury in people with mTBI presenting with chronic pain and/or depression. Psychological constructs such as illness and recovery beliefs appear to be important to consider in the development of treatment interventions.

The (Palliative) care of Huntington’s disease

Palliative care services are increasingly becoming involved in the care of neurodegenerative disorders. Huntington’s disease is a rare, familial disorder. Care from diagnosis is palliative. Though other specialist disciplines need to be involved in the care, palliative expertise and oversight is valuable and appreciated. Based upon a review of literature and three decades of clinical experience with over a hundred patients and their families this article provides an overview of the palliative care issues confronted when attending these patients and their families.

Fear in palliative care

Fear and anxiety are similar, but different, clinical states. Fear is an unpleasant emotional response caused by the anticipation or awareness of danger and encourages avoidance from the threat. The cancer journey, for most, involves episodes of fear. Anxiety is prompted by generalized, non-specific threats to the ‘self’ motivating hypervigilance and the retention of proximity to the perceived threat. Anxiety is a common emotion experienced in the approach to the end of life. Whilst management of anxiety states is well appreciated, the management of fear states, with the exception of phobias, is not. This article considers the limited literature on the management of fear.