Differences

This shows you the differences between two versions of the page.

Link to this comparison view

cl:tbi [on April 25, 2020]
cl:tbi [on July 18, 2023] (current)
psychdb
Line 1: Line 1:
-====== Traumatic Brain Injury ======+====== Traumatic Brain Injury ​(TBI) ======
 {{INLINETOC}} {{INLINETOC}}
 ===== Primer ===== ===== Primer =====
Line 5: Line 5:
  
 == Epidemiology == == Epidemiology ==
-About 2% of the population lives with TBI-associated disability. Males account for the majority of TBI cases. The leading causes of TBI are due to falls, motor vehicle accidents, contact sports, and assaults.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4494623/​|Lauterbach,​ M. D., Notarangelo,​ P. L., Nichols, S. J., Lane, K. S., & Koliatsos, V. E. (2015). Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: Insights into psychiatric practice. Neuropsychiatric disease and treatment, 11, 1601.]])] There are three peak mean ages of highest TBI incidence, including 0–4 years, 15–19 years, and over 65 years.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4494623/​|Lauterbach,​ M. D., Notarangelo,​ P. L., Nichols, S. J., Lane, K. S., & Koliatsos, V. E. (2015). Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: Insights into psychiatric practice. Neuropsychiatric disease and treatment, 11, 1601.]])]+  * About 2% of the population lives with TBI-associated disability. ​ 
 +  * Males account for the majority of TBI cases. The leading causes of TBI are due to falls, motor vehicle accidents, contact sports, and assaults.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4494623/​|Lauterbach,​ M. D., Notarangelo,​ P. L., Nichols, S. J., Lane, K. S., & Koliatsos, V. E. (2015). Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: Insights into psychiatric practice. Neuropsychiatric disease and treatment, 11, 1601.]])] ​ 
 +  * There are three peak mean ages of highest TBI incidence, including 0–4 years, 15–19 years, and over 65 years.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4494623/​|Lauterbach,​ M. D., Notarangelo,​ P. L., Nichols, S. J., Lane, K. S., & Koliatsos, V. E. (2015). Diagnostic and treatment challenges in traumatic brain injury patients with severe neuropsychiatric symptoms: Insights into psychiatric practice. Neuropsychiatric disease and treatment, 11, 1601.]])] 
 + 
 +== Prognosis == 
 +  * Neuropsychiatric symptoms tend to be most severe in the first few months following a TBI.  
 +    * In mild-moderate TBI, the typical course is complete or substantial improvement of neuropsychiatric symptoms.  
 +      * Approximately 80% of all TBIs are of mild severity.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26269903|Laskowski RA, Creed JA, Raghupathi R. Pathophysiology of Mild TBI: Implications for Altered Signaling Pathways]])] 
 +      * The symptoms associated with mild TBI resolve within days to weeks after the injury, with complete resolution typical by 3 months.  
 +      * Neuropsychiatric symptoms such as depression, irritability,​ fatigue, headache, photosensitivity,​ sleep disturbance also tend to resolve in the weeks following mild TBI.  
 +  * In moderate-to-severe TBI, seizures (particularly in the first year), photosensitivity,​ and hyperacusis can remain.  
 +    * Neuropsychiatric symptoms such as irritability,​ aggression, depression, sleep disturbance,​ fatigue, and apathy can occur.  
 +    * These changes can lead to significant psychosocial impairment compared to the pre-injury level, and deterioration in interpersonal relationships.  
 +    * Moderate and severe TBI are associated with increased risk of depression, PTSD, aggression, and possibly neurodegenerative diseases such as [[geri:​dementia:​alzheimers|Alzheimer'​s disease]]. 
 + 
 +== Older Adults == 
 +  * Those aged >75 years have the highest incidence of TBI of any group.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17038079|Thompson,​ H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic brain injury in older adults: epidemiology,​ outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590-1595.]])] 
 +  * The most common mechanism of injuries are falls from standing height and motor vehicle accidents. In this older cohort, women are affected more than men. There is an increased risk of intracranial bleeding (even in those with mild TBIs).  
 +  * Older adults generally also have higher morbidity and mortality, slower recovery, and worse functional outcomes.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17038079|Thompson,​ H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic brain injury in older adults: epidemiology,​ outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590-1595.]])] 
 +  * The impairment in cognitive domains post-TBI may improve within the first 6 to 12 months, but keeping an age-related [[geri:​dementia:​|dementia]] on the differential diagnosis is important. 
 +  * Additionally,​ the increased frequency of pre-existing and co-morbid medical conditions make TBI outcome assessments challenging,​ and it can be hard to isolate the effect of the TBI alone.  
 +  * Though age is an important prognostic factor for recovery in TBI, it is not the sole determining factor. Older adults with TBI can have similar outcomes as their younger cohorts.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10969893|Rapoport,​ M. J., & Feinstein, A. (2000). Outcome following traumatic brain injury in the elderly: a critical review. Brain injury, 14(8), 749-761.]])]
  
 == Comorbidity == == Comorbidity ==
-Individuals post-TBI have a higher chance of developing [[mood:​1-depression:​|depression]] and [[trauma-and-stressors:​ptsd|posttraumatic stress disorder (PTSD)]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12724117|Rapoport,​ M. J., McCullagh, S., Streiner, D., & Feinstein, A. (2003). Age and major depression after mild traumatic brain injury. The American Journal of Geriatric Psychiatry, 11(3), 365-369.]])] Although substance use is high before the onset of a TBI, it in fact declines after injury.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29939106|Ponsford,​ J., Alway, Y., & Gould, K. R. (2018). Epidemiology and natural history of psychiatric disorders after TBI. The Journal of neuropsychiatry and clinical neurosciences,​ 30(4), 262-270.]])] PTSD can have symptoms such as anxiety, irritability,​ insomnia, personality changes, and memory problems, and this overlap can sometimes complicate the diagnostic picture.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​24568300|Tanev,​ K. S., Pentel, K. Z., Kredlow, M. A., & Charney, M. E. (2014). PTSD and TBI co-morbidity:​ scope, clinical presentation and treatment options. Brain injury, 28(3), 261-270.]])]+  * Individuals post-TBI have a higher chance of developing [[mood:​1-depression:​|depression]] and [[trauma-and-stressors:​ptsd|posttraumatic stress disorder (PTSD)]].[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​12724117|Rapoport,​ M. J., McCullagh, S., Streiner, D., & Feinstein, A. (2003). Age and major depression after mild traumatic brain injury. The American Journal of Geriatric Psychiatry, 11(3), 365-369.]])] 
 +  * Although substance use disorders can high before the onset of a TBI, it in fact declines after injury.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​29939106|Ponsford,​ J., Alway, Y., & Gould, K. R. (2018). Epidemiology and natural history of psychiatric disorders after TBI. The Journal of neuropsychiatry and clinical neurosciences,​ 30(4), 262-270.]])] 
 +  * In those with a trauma history related to the TBI, subsequent ​PTSD can have symptoms such as anxiety, irritability,​ insomnia, personality changes, and memory problems, and this overlap can sometimes complicate the diagnostic picture.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​24568300|Tanev,​ K. S., Pentel, K. Z., Kredlow, M. A., & Charney, M. E. (2014). PTSD and TBI co-morbidity:​ scope, clinical presentation and treatment options. Brain injury, 28(3), 261-270.]])]
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
- +===== DSM-5 Diagnostic Criteria =====
-===== Diagnostic Criteria =====+
 == Criterion A == == Criterion A ==
 The criteria are met for [[cl:​2-major-neurocog-disorder|major]] or [[cl:​3-mild-neurocog-disorder|mild neurocognitive disorder]] The criteria are met for [[cl:​2-major-neurocog-disorder|major]] or [[cl:​3-mild-neurocog-disorder|mild neurocognitive disorder]]
Line 21: Line 43:
   - Posttraumatic amnesia.   - Posttraumatic amnesia.
   - Disorientation and confusion.   - Disorientation and confusion.
-  - Neurological signs (e.g.neuroimaging demonstrating injury; a new onset of seizures; a marked worsening of a preexisting seizure disorder; visual field cuts; anosmia; hemiparesis).+  - Neurological signs (e.g. neuroimaging demonstrating injury; a new onset of seizures; a marked worsening of a preexisting seizure disorder; visual field cuts; anosmia ​(loss of smell); hemiparesis).
  
 == Criterion C == == Criterion C ==
Line 34: Line 56:
  
 ==== Chronic Traumatic Encephalopathy (CTE) ==== ==== Chronic Traumatic Encephalopathy (CTE) ====
-**Chronic traumatic encephalopathy (CTE)** is a term used to describe brain degeneration likely caused by repeated head trauma. A diagnosis of CTE can only be made during autopsy. CTE is a rare condition and usually found in individuals who play contact sports.+**Chronic traumatic encephalopathy (CTE)** is a term used to describe brain degeneration likely caused by repeated head trauma. CTE is thought to significantly increase the risk for dementia.[([[https://​pubmed.ncbi.nlm.nih.gov/​31380933/​|Schneider,​ JA. (2019). Multiple pathologic pathways to dementia in football players with chronic traumatic encephalopathy. JAMA neurology, 76(11), 1283-1284.]])] ​A diagnosis of CTE can only be made during autopsy. CTE is a rare condition and usually found in individuals who play contact sports.
  
 </​WRAP>​ </​WRAP>​
Line 44: Line 66:
 == Symptoms == == Symptoms ==
 The cognitive presentation and symptoms after a TBI can be variable. Difficulties in the domains of complex attention, executive ability, learning, and memory are common as well as slowing in speed of information processing and disturbances in social cognition. In more severe TBIs that involve brain contusion, hemorrhage, or a penetrating injury, there can be more neurocognitive deficits, such as aphasia, neglect, and constructional dyspraxia. TBIs are also associated with: The cognitive presentation and symptoms after a TBI can be variable. Difficulties in the domains of complex attention, executive ability, learning, and memory are common as well as slowing in speed of information processing and disturbances in social cognition. In more severe TBIs that involve brain contusion, hemorrhage, or a penetrating injury, there can be more neurocognitive deficits, such as aphasia, neglect, and constructional dyspraxia. TBIs are also associated with:
-  - Disturbances in emotional function ​(irritability,​ easy frustration,​ tension and anxiety, affective lability)+  - Affective changes ​(irritability,​ easy frustration,​ tension and anxiety, affective lability)
   - Personality changes (disinhibition,​ apathy, suspiciousness,​ aggression)   - Personality changes (disinhibition,​ apathy, suspiciousness,​ aggression)
-  - Physical ​disturbances ​(headache, fatigue, sleep disorders, vertigo or dizziness, tinnitus, hyperacusis,​ photosensitivity,​ anosmia, reduced tolerance to psychotropic medications) ​+  - Physical ​changes ​(headache, fatigue, sleep disorders, vertigo or dizziness, tinnitus, hyperacusis,​ photosensitivity,​ anosmia, reduced tolerance to psychotropic medications) 
 +  - Loss of smell can often occur due to sinonasal tract disruption, direct shearing or stretching of olfactory nerve fibers at the cribiform plate, or local contusion or bleeding within the olfactory bulb and cortex.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC6051255/​|Howell,​ J., Costanzo, R. M., & Reiter, E. R. (2018). Head trauma and olfactory function. World journal of otorhinolaryngology-head and neck surgery, 4(1), 39-45.]])]
   - Seizures, hemiparesis,​ visual disturbances,​ cranial nerve deficits (particularly in more severe TBI, neurological symptoms and signs)   - Seizures, hemiparesis,​ visual disturbances,​ cranial nerve deficits (particularly in more severe TBI, neurological symptoms and signs)
 </​WRAP>​ </​WRAP>​
Line 110: Line 133:
 </​WRAP>​ </​WRAP>​
  
-===== Prognosis ===== 
-Neuropsychiatric symptoms tend to be most severe in the first few months following a TBI. In mild-moderate TBI, the typical course is complete or substantial improvement of neuropsychiatric symptoms. Approximately 80% of all TBIs are of mild severity.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​26269903|Laskowski RA, Creed JA, Raghupathi R. Pathophysiology of Mild TBI: Implications for Altered Signaling Pathways]])] The symptoms associated with mild TBI resolve within days to weeks after the injury, with complete resolution typical by 3 months. Neuropsychiatric symptoms such as depression, irritability,​ fatigue, headache, photosensitivity,​ sleep disturbance also tend to resolve in the weeks following mild TBI.  
  
-In moderate to severe TBI, seizures (particularly in the first year), photosensitivity,​ and hyperacusis can remain. Neuropsychiatric symptoms such as irritability,​ aggression, depression, sleep disturbance,​ fatigue, and apathy can occur. These changes can lead to significant psychosocial impairment compared to the pre-injury level, and deterioration in interpersonal relationships. Moderate and severe TBI are associated with increased risk of depression, PTSD, aggression, and possibly neurodegenerative diseases such as Alzheimer'​s disease.+===== Guidelines ===== 
 +<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​See also: **[[teaching:​clinical-practice-guidelines-cpg|]]**</​alert>​
  
-==== Older Adults ==== +{{page>teaching:clinical-practice-guidelines-cpg#​traumatic-brain-injury-tbi&​nouser&​noheader&​nodate&​nofooter}}
-Those aged >75 years have the highest incidence of TBI of any group.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17038079|Thompson,​ H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic ​brain injury ​in older adults: epidemiology,​ outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590-1595.]])] The most common mechanism of injuries are falls from standing height and motor vehicle accidents. In this older cohort, women are affected more than men. There is an increased risk of intracranial bleeding (even in those with mild TBIs). ​+
  
-Older adults generally also have higher morbidity and mortality, slower recovery, and worse functional outcomes.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17038079|Thompson,​ H. J., McCormick, W. C., & Kagan, S. H. (2006). Traumatic brain injury in older adults: epidemiology,​ outcomes, and future implications. Journal of the American Geriatrics Society, 54(10), 1590-1595.]])] The impairment in cognitive domains post-TBI may improve within the first 6 to 12 months, but keeping an age-related [[geri:​dementia:​|dementia]] on the differential diagnosis is important. Additionally,​ the increased frequency of pre-existing and co-morbid medical conditions make TBI outcome assessments challenging,​ and it can be hard to isolate the effect of the TBI alone. Though age is an important prognostic factor for recovery in TBI, it is not the sole determining factor. Older adults with TBI can have similar outcomes as their younger cohorts.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​10969893|Rapoport,​ M. J., & Feinstein, A. (2000). Outcome following traumatic brain injury in the elderly: a critical review. Brain injury, 14(8), 749-761.]])] 
 ===== Resources ===== ===== Resources =====
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
 == For Providers == == For Providers ==
 +  * **[[https://​www.nature.com/​articles/​nrdp201684|Blennow,​ K. et al. (2016). Traumatic brain injuries. Nature reviews Disease primers, 2(1), 1-19.]]**
 +  * [[https://​pubmed.ncbi.nlm.nih.gov/​31206780/​|Brody,​ D. L., Chan, L., & Cizza, G. (2019). How do you treat traumatic brain injury? One symptom at a time. Annals of neurology, 86(3), 329.]]
   * [[https://​www.psychiatrictimes.com/​special-reports/​pharmacological-management-psychiatric-aspects-traumatic-brain-injury|PsychiatricTimes:​ Pharmacological Management of the Psychiatric Aspects of Traumatic Brain Injury]]   * [[https://​www.psychiatrictimes.com/​special-reports/​pharmacological-management-psychiatric-aspects-traumatic-brain-injury|PsychiatricTimes:​ Pharmacological Management of the Psychiatric Aspects of Traumatic Brain Injury]]
   * [[https://​www.bcmj.org/​articles/​pharmacological-interventions-traumatic-brain-injury|Talsky,​ A., Pacione, L. R., Shaw, T., Wasserman, L., Lenny, A., Verma, A., ... & Bhalerao, S. (2010). Pharmacological interventions for traumatic brain injury. BC Med J, 53(1), 26-31.]]   * [[https://​www.bcmj.org/​articles/​pharmacological-interventions-traumatic-brain-injury|Talsky,​ A., Pacione, L. R., Shaw, T., Wasserman, L., Lenny, A., Verma, A., ... & Bhalerao, S. (2010). Pharmacological interventions for traumatic brain injury. BC Med J, 53(1), 26-31.]]
Line 133: Line 155:
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
- 
-