Simon Fleminger

Head injury as a risk factor for Alzheimer’s disease: the evidence 10 years on; a partial replication

Objective: To determine, using a systematic review of case-control studies, whether head injury is a significant risk factor for Alzheimer’s disease. We sought to replicate the findings of the meta-analysis of Mortimer et al (1991). Methods: A predefined inclusion criterion specified case-control studies eligible for inclusion. A comprehensive and systematic search of various electronic databases, up to August 2001, was undertaken. Two independent reviewers screened studies for eligibility. Fifteen case-control studies were identified that met the inclusion criteria, of which seven postdated the study of Mortimer et al. Results: We partially replicated the results of Mortimer et al. The meta-analysis of the seven studies conducted since 1991 did not reach significance. However, analysis of all 15 case-control studies was significant (OR 1.58, 95% CI 1.21 to 2.06), indicating an excess history of head injury in those with Alzheimer’s disease. The finding of Mortimer et al that head injury is a risk factor for Alzheimer’s disease only in males was replicated. The excess risk of head injury in those with Alzheimer’s disease is only found in males (males: OR 2.29, 95% CI 1.47 to 2.06; females: OR 0.91, 95% CI 0.56 to 1.47). Conclusions: This study provides support for an association between a history of previous head injury and the risk of developing Alzheimer’s disease.

The neuropsychiatry of depression after brain injury

Biological aspects of depression after brain injury, in particular traumatic brain injury (TBI) and stroke, are reviewed. Symptoms of depression after brain injury are found to be rather non-specific with no good evidence of a clear pattern distinguishing it from depression in those without brain injury. Nevertheless symptoms of disturbances of interest and concentration are particularly prevalent, and guilt is less evident. Variabilitiy of mood is characteristic. The prevalence of depression is similar after both stroke and TBI with the order of 20–40% affected at any point in time in the first year, and about 50% of people experience depression at some stage. There is no good evidence for areas of specific vulnerability in terms of lesion location, and early suggestions of a specific association with injury to the left hemisphere have not been confirmed. Insight appears to be related to depressed mood with studies of TBI indicating that greater insight over time post-injury may be associated with greater depression. We consider that this relationship may be due to depression appearing as people gain more awareness of their disability, but also suggest that changes in mood may result in altered awareness. The risk of suicide after TBI is reviewed. There appears to be about a three to fourfold increased risk of suicide after TBI, although much of this increased risk may be due to pre-injury factors in terms of the characteristics of people who suffer TBI. About 1% of people who have suffered TBI will commit suicide over a 15-year follow-up. Drug management of depression is reviewed. There is little specific evidence to guide the choice of antidepressant medication and most psychiatrists would start with a selective serotonin reuptake inhibitor (SSRI). It is important that the drug management of depression after brain injury is part of a full package of care that can address biological as well as psychosocial factors in management.

Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: An overview and a case illustration of obsessive-compulsive disorder

Survivors of acquired and traumatic brain injuries may often experience anxiety states. Psychological reactions to neurological trauma may be caused by a complex interaction of a host of factors. We explore how anxiety states may be understood in terms of a biopsychosocial formulation of such factors. We also review the current evidence for the presence of specific anxiety disorders after brain injury. We then describe how cognitive-behaviour therapy (CBT), a treatment of choice for many anxiety disorders, may be integrated with cognitive rehabilitation (CR), for the management of anxiety disorders in brain injury. We illustrate how CBT and CR may be delivered with a case of a survivor of traumatic brain injury (TBI) who had developed obsessive compulsive disorder and health anxiety. We show how CBT plus CR allows a biopsychosocial formulation to be developed of the survivors concerns for guiding a goal-based intervention. The survivor made significant gains from intervention in terms of goals achieved and changes on clinical measures. We argue that large-scale research is needed for developing an evidence base for managing emotional disorders in brain injury.

Brain injury rehabilitation: what works for whom and when?

Primary objective : This paper reviewed the available evidence that patient characteristics may determine the type of intervention that works best in brain injury rehabilitation. Reasoning behind literature selection : A broad search strategy was used to identify papers which enabled conclusions to be drawn about patient characteristics which determined rehabilitation effectiveness. Six main areas were considered: severity of the brain injury, presenting problem, complicating factors, rehabilitation readiness, demographic, and socio-geographic variables. Critical analysis of literature : A levels of evidence analysis was used to evaluate the studies. Main outcomes and results : Very few studies on rehabilitation effectiveness were found which attempted to define the patient characteristics which predict a good response to rehabilitation. The best evidence relates to injury severity; more intense programmes may be unnecessary for those with less severe injuries. There is some evidence that dysexecutive problems, i.e. difficulties with organization and control of behaviour and emotion, interfere with rehabilitation. Conclusions : Patient characteristics may well determine individual benefits from particular rehabilitation programmes. However, few studies have attempted to provide evidence about this. As health provision focuses on needs-led services, it becomes paramount to investigate effectiveness from the clients perspective.

Lishman's Organic Psychiatry

LISHMANS ORGANIC PSYCHIATRY , LISHMANS ORGANIC PSYCHIATRY , کتابخانه مرکزی دانشگاه علوم پزشکی ایران

Delusional Misidentification: An Exemplary Symptom Illustrating an Interaction between Organic Brain Disease and Psychological Processes

Delusional misidentification provides us with an excellent example of how it is necessary to take both organic brain disease and psychological processes into account when describing the development of mental symptoms. A model of delusional misidentification is proposed which was developed in an attempt to explain this interaction. The model is based on the events that occur during preconscious processing of perceptions. It predicts an inverse relationship between the presence of organic brain disease and the presence of paranoid delusions. This was tested using a retrospective analysis of case reports. A graded and inverse relationship between the degree of organic disturbance and the presence of paranoid delusions preceding the delusional misidentification was found. A satisfactory model of delusional misidentification syndromes must be able to acknowledge the way these two forces are able to interact.

Randomised, waiting list controlled trial of cognitive–behavioural therapy for persistent postconcussional symptoms after predominantly mild–moderate traumatic brain injury

Background Persistent postconcussional symptoms (PCS) can be a source of distress and disability following traumatic brain injury (TBI). Such symptoms have been viewed as difficult to treat but may be amenable to psychological approaches such as cognitive–behavioural therapy (CBT). Objectives To evaluate the effectiveness of a 12-session individualised, formulation-based CBT programme. Method Two-centre randomised waiting list controlled trial with 46 adults with persistent PCS after predominantly mild-to-moderate TBI (52% with post-traumatic amnesia (PTA)≤24 hours), but including some with severe TBIs (20% with PTA>7 days). Results Improvements associated with CBT were found on the primary outcome measures relating to quality of life (using the Quality of Life Assessment Schedule and the Brain Injury Community Rehabilitation Outcome Scale). Treatment effects after covarying for treatment duration were also found for PCS and several secondary outcomes, including measures of anxiety and fatigue (but not depression or post-traumatic stress disorder (PTSD)). Improvements were more apparent for those completing CBT sessions over a shorter period of time, but were unrelated to medicolegal status, injury severity or length of time since injury. Conclusions This study suggests that CBT can improve quality of life for adults with persistent PCS and potentially reduce symptoms for some, in the context of outpatient brain injury rehabilitation services. Trial registration number ISRCTN49540320.

Why do some patients after head injury deteriorate over the long term

When asked to see a patient who is deteriorating rather than getting better over time since a head injury, the clinician will need to rule out complications of the head injury, such as a subdural haematoma. The neuropsychiatrist will assess whether, for example, a depressive illness, anxiety disorder, psychosis or substance abuse explains the deterioration. But oftentimes there is no obvious explanation for the deterioration. This finding tallies with studies that find increasing cognitive impairment over time since injury in a proportion of patients.1 Explanations for this include accelerated cerebral atrophy2 and/or chronic inflammation3 or depleted cerebral reserve bringing forward age-related cognitive decline.4 Two papers with very different methodologies, one strong and one rather weaker, address the question of the long-term outcome after a head injury. Wang et al ,5 interrogated a clinical database containing …

Rehabilitation on a Cognitive Behavioural Unit Is Associated with Changes in FAM, not FIM

Functional Independence Measure + Functional Assessment Measure (FIM+ FAM) measures were taken for 38 clients on admission to and at discharge from an inpatient rehabilitation unit for people with cognitive and behavioural problems following acquired, single incident, brain injury. Over the course of the admission there was a significant improvement in FAM scores and cognitive and social items of the FIM+FAM. These improvements were not related to the amount of time elapsed between injury and admission to the rehabilitation unit. There was no significant change in FIM scores and neurophysical items of the FIM+FAM. Ceiling effects appear to have limited the scope for some of the FIM scales to detect change.

Experience and Perspectives on the Classification of Organic Mental Disorders

The official diagnostic classification systems have been increasingly employed in the last few years, and this is true of both ICD-10 and DSM-IV. We will propose a few principles which should be considered when revisions are attempted. Our existing classifications should be simplified, but new syndromes incorporated where they have pathological justification. Links to other specialist diagnostic classifications should be made (e.g. in epilepsy, sleep disorders, dementias) wherever possible. A broader range of ‘Neuropsychiatric Disorders’ should be incorporated, including alcohol-related organic disorders, head injury, sleep disorders, if possible including the ‘psychogenic syndromes’. Progressive, degenerative disorders need to be clearly distinguished from non-progressive syndromes, and some gradation of severity needs to be built into the classificatory system. Finally, the definitions need to be concise and accurate.