11.7a Person with TBI

i) Memory

What are some of the diagnostic challenges that Sam demonstrates? There are a number of problems, in particular, he had a memory problem.

He frequently said "I cannot remember" or "I do not know". This is a very common problem when assessing someone for a psychiatric illness after a brain injury.

They can have a significant impairment, particularly of short term memory. They can give you their past history quite clearly but they cannot tell what they have done for the past month. They often have experiences in the days or weeks before you see them that are relevant to the psychiatric assessment, but they cannot recall these symptoms.

The memory impairment provides us with a major impediment to obtaining a cross sectional history and a longitudinal history in the short term in terms of what the person has been like.

For a psychiatric assessment it is paramount to get a good idea of what the person is like over the days and weeks preceding the assessment. The memory impairment causes a significant obstruction in relation to assessing a person from the perspective of their psychiatric illness.



ii) Language

One of the impairments a person can have following a brain injury is an impairment of language.

They can have difficulties with regard to:

a) the generativity of speech and/or b) the comprehensibility of speech.

They can also have the difficulties as English is their second language.

They may have damage to their brain stem and have a particular quality to their speech which makes it very difficult to understand. For the more acutely injured patients, they may have very severe problems with respect to language and therefore this could prove a significant barrier to assessment.

Typically psychiatrists rely on what the person tells them to make an assessment or a diagnosis. So if you have a patient who has a language impairment because of a dysfunction of the brain it can be very difficult to elicit the necessary history.

Sam's language impairment was more related to the fact that English was a second language and he appeared to have less English now, after the brain injury, than he did prior to the time of the injury. He did not appear to have, in an assessment with a Lebanese speaking person, any difficulties with his capacity to communicate, although he generated little speech spontaneously.


iii) Attention

Impairments of attention are very common after a brain injury.

The relevance of this is that most psychiatric assessments will take the psychologist between half an hour to an hour. When any new patient is assessed normally the psychiatrist will spend an hour with that person.

Following brain injury a person's attention span may only be a few minutes to maybe 15 to 20 minutes at most.

Frequently what happens is that you cannot interview the patient long enough to be able to elicit the necessary history and to establish the rapport you need to be able to elicit that history. Patients become tired, fatigued, irritable and give the examiner even less information. Someone who is very distractible may be very difficult to contain in a normal office setting to obtain an adequate assessment.


iv) Awareness

One of the key problems related to a brain injury is that the brain injury can cause damage to the area of the brain that is involved in awareness.

While we do not have a specific area of the brain that we know manages or regulates awareness, the right frontal region is implicated in a person's awareness of injury as is the right parietal area.

Impairments of awareness are very common after brain injury. The brain injured person does not think there is anything wrong with them, they do not think they are doing anything wrong. They often act in an outraged manner when their impairments are relayed to them.

In a patient who has an impaired awareness the person does not recognise the behaviour or the thoughts they have as being abnormal or wrong.


Disturbances of self awareness of deficit after traumatic brain injury.  GP Prigatano.  Chapter 7 in:  Awareness of Deficit after Brain Injury.  Ed.  GP Pirgatano, DL Schacter.  Oxford University Press.  New York 1991.


v) Recognition of emotional expression

Another problem arises when the person has difficulties with the recognition of emotional expression - which can be caused by right frontal and right hemisphere injuries. They do not recognise or cannot communicate they are feeling depressed or anxious.

In the case of Sam, he really lacked any kind of awareness that his symptoms, his behaviour was abnormal. Sam was so disturbed in his behaviour that it became easy to elicit what symptoms he had with regard to his mental illness.

The patient can have a number of pre-determined factors that can be a real challenge when making an assessment because you have to try to work out what are the pre-injury factors that are being influenced by the brain injury.

What further complicates matters is that if a patient has a brain injury where litigation might be involved they may be very reluctant to disclose any kind of pre-injury factors, in particular pre-injury psychiatric illness.

vI) Psychological mindedness

Whether or not a person has psychological mindedness is a particular challenge.

Psychological mindedness refers to the person's ability to see that they can have emotions and that their behaviour can be influenced by their emotions.

It also is a determinant of whether or not a person can see things might be stressful and that would cause them to change how they feel or behave.


Somatisation is where the person does not express distressed emotions but rather develops physical symptomatology.

That is a real challenge when someone has a brain injury because they may come with a lot of physical symptoms that cause the rehabilitation team to do lots of investigations trying to work out what the cause is when it is an expression or a communication of psychological distress and psychiatric illness.

In some cultures there is less recognition and acceptance of mental illness.  As physical illness is more readily accepted it is common for mental illness to manifest itself as somatisation.


Answer these question:
What are examples of common diagnostic challenges for a person with mental health problems and TBI?

Check your answers here

Some examples are:

The person with TBI can give you their past history quite clearly but they can't tell what they have done for the past month.

The person with TBI can have difficulties with regard to

a) the generativity of speech and/or
b) the comprehensibility of speech.

Often following brain injury a person's attention span may only be a few minutes to maybe 15 to 20 minutes at most.

The person with TBI's lack of ability to see that they can have emotions and that their behaviour can be influenced by their emotions.

The person with TBI not expressing distressed emotions but rather developing physical symptoms.