ࡱ> yx@=WkTp/z_6XeY¤>%xcd``a@P[30d00(1002D0082Xh!(qM*@‚h(  d 1 36VɁj'46p`5+:Xl@ľA Ξ P1I("P6/ AL@@Pԏ0SlåVnH:l=ʼn@3ViGXD@3;)'4]HI)P7b h {A# = Ä@a$e @ <'(    Chart MSGraph.Chart.80*Microsoft Graph Chart/ 0DArialngsx:{( 0( 0 DTimes New Roman( 0( 0  DWingdingsRoman( 0( 0 @0.  @n?" dd@  @@`` @8HH"   #($).0789:;<>?@F?$$"$kTp/z_6_ 0AA@8ʚ;ʚ;g4MdMd@ 0ppp@ <4ddddlqt 0P:{ <4BdBdlp 00___PPT10 ppZ___PPT9<41##Psychiatric aspects of Brain InjurySeptember 2006+Psychiatric problems following brain injury"The injury The person The reaction  The injury/ Closed Penetrating Global Focal Other injuries/0 The personEPremorbid condition Alcohol or substance misuse Premorbid personality$ '   The reaction5Post concussion Trauma Social consequences Adjustment"++Psychiatric problems following brain injury,,#9The injury Closed Penetrating Global Focal Other injuries& / /#* Brain InjurypHead injury admissions 330/100,000/yr 10% to Neurosurgical unit 150/100,000 suffering disability after 1 yr 100/100,000 prevalence of  considerable disability Scottish figures (SNAP)BU4UL$) Brain InjuryModerate and severe physical and psychological disability 42/100,000/yr Persistent behavioural problems 3/100,000/yr McClelland 1993u%(Mild Brain Injuryo<30 mins loc PTA in hours Attention deficits Verbal retrieval Emotional distress Headache Dizziness PhotophobiapZp&'Moderate Brain InjuryGCS 9  12 PTA < 24 hours Headaches Memory problems 2/3 will not return to work'&Severe Head Injury@Attention Memory Emotional Psychosis Depression Social isolation8Psychiatric conditions following traumatic brain injury 99# Risk Relative Risk Major depression 44.3 7.9 Bipolar 4.2 5.3 GAD 9.1 2.3 OCD 6.4 2.6 Panic Disorder 9.2 5.8 PTSD 14.1 1.8 Schizophrenia 0.7 0.5 Substance Abuse 22 1.3 (Van Reekum et al 2000).P   PTSDTraumatic event Re-experienced Avoidance Increased arousal Symptoms for more than 1 month Clinically significant distress or arousal.Psychosis Due to TBIuSchizophrenia Seizures Delirium Confabulation Substance abuse Other pathology Latency Temporal lobe abnormalities $tZZv  Psychosis Due to TBIDelusions More common than hallucinations Persecutory Hallucinations Auditory Visual more in early onset Negative symptoms uncommon Neuroleptics (Fujii and Ahmed 2002)  Z-ZZ$Z(ZZ -$( , Psychosis Due to TBIjAbnormal EEG 70% L temporal MRI abnormalities Frontal Temporal Enlarged ventricles (Fujii and Ahmed 2002)2.&.=U  Personality changePhineas Gage Vermont, 13th September 1848 Capable railway construction crew foreman Accident with a tamping iron Most of L frontal lobe destroyed  Not Gage Irreverent, impatient, obstinate,capricious Feb 1860 developed seizures Died May 1860, $+ Frontal lobe syndromesDorsolateral prefrontal Executive dysfunction Impaired planning, organisation and set shifting Environmental dependency Impaired semantic memory and verbal fluency (L) Orbitofrontal Disinhibition Medial frontal/anterior cingulate Apathy (Cummings and Trimble)""  H      Consequences*Personal Economic Social Marital ParentalAntipsychotics_Dopamine receptors Parkinsonism Akathisia Sedation Dyskinesias Sedation Lower seizure threshold,  "AntidepressantsASSRIs Tricyclics Lower seizure threshold Anti-cholinergic effects$ 2Benzodiazepines4Sedative Hangover Tolerance Addictive AnticonvulsantAnticonvulsants%Antiepileptic Toxicity Teratogenicity&Management of aggression and agitationPoor evidence for effectiveness of medication Think why when and where it is occurring Think of what you are treating Think why you are using a specific drug Think side effects Think of interactions Vulnerability of the injured brain When to withdraw3Agitation and aggression pharmacological managementzWide variety used No strong evidence Adverse effects Beta blockers Research needed (Cochrane Review, Fleminger et al 2003)S({e  81GoalsBehavioural Cognitive, communication Functional, self care, leisure Emotional e.g. anxiety management Social e.g. family, placement . 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