ii) Posttraumatic stress disorder (PTSD)

The severity of the trigger event is part of the diagnostic criteria for posttraumatic stress disorder. For a person to have a posttraumatic stress disorder after being involved in a brain injury, the event that caused the brain injury has to be one where the event comprised a threat to the life or physical integrity of the person or others and the person’s response involved fear, helplessness or horror.

Since most of our traumatic brain injuries are from motor vehicle accidents it means it has to be a motor vehicle accident where there was significant injury, for example, entrapment or other parties were significantly injured. The minor bump rear end accident does not reach the severity criteria to allow a person to make a diagnosis of posttraumatic stress disorder. This diagnostic criteria is important when you make a diagnosis of a posttraumatic stress disorder. If a person has not met the severity criteria then the diagnosis of an adjustment disorder with anxious and depressed mood would be appropriate.

The severity of the brain injury does not influence whether or not a person develops a posttraumatic stress disorder. There has always been the thought that if a person has a brain injury that results in unconsciousness that this should stop the person from getting a posttraumatic stress disorder because after the severity criteria the next most important criteria has to do with the re-experiencing of the event either by dreams or traumatic recollections, flashbacks. People who are rendered unconscious by the brain injury often do not remember the event and it was therefore thought that if they were truly rendered unconscious they would not be able to develop a posttraumatic stress disorder. This is a fallacy. Being rendered unconscious does not protect you from having a posttraumatic stress disorder. It is possible to be traumatised by the realisation of having been in a life-threatening accident. Often patients develop traumatic recollections about their time in posttraumatic amnesia, or from the seconds before impact, or because they are shown photos of their car/themselves post injury.

 

iii) Panic disorder

Panic disorder is anxiety disorder with very discrete episodes of severe anxiety associated with a number of physical symptoms where they fear that something is going to go wrong or they may die.

Patients with brain injury may not be good at reporting panic attacks because of their other brain injury symptoms.

Over many years of clinical experience of treating patients with brain injury the number of patients Dr Jungfer has seen that have reported panic attacks is quite low. There are probably a variety of reasons for this. Embarrassment is an issue. Also the person is not able to say what situation triggered their panic attack and so they feel reluctant to discuss it or disclose it. The other factor is that they may not recognise that they are having a panic attack because they have a general increased amount of anxiety associated with all the cognitive problems they have from a brain injury. 

Research suggests that panic attacks do not occur more frequently in head injured patients because the incidence of panic attacks is high in our community generally.

It is described that a person who has not previously had panic attacks developing panic attacks post-brain injury.

Why people get panic attacks is not well understood. We know people can have their first panic attack when they are faced with a task that is too cognitively challenging for them or for patients who have over learned a task and then when they go to practice that task in the real world find that something else has happened, something unpredictable. If they have an anxious predisposition that this can precipitate them having a panic attack.

The patients Dr Jungfer has treated over the years who have presented with panic disorders or significant anxiety symptoms like a panic disorder were patients whose diagnosis of traumatic brain injury was missed in the early stages.  These are patients who had significant orthopaedic injury as well as brain injury. They were managed in orthopaedic wards and fell through the system in relation to the diagnosis of the brain injury. They then spent some time off work because of their orthopaedic injuries and it is when they returned to work and they started doing things that are cognitively challenging that they find they cannot cope with that situation.  Because they do not know what is going on, and if they are fairly highly stressed individuals, they can experience their first panic attack.

Unfortunately, by the time they often present for treatment the panic symptoms are well entrenched, reinforced and also the person finds it very difficult to accept and understand that they have had a brain injury. It can be very difficult to convince a person that their impairments are related to a brain injury, particularly when it was not diagnosed in the first instance.

Overall we do not have a lot of information about panic attacks and this might be surprising considering it can happen in up to 9.2% of brain injured patients (Ref. Silver JM, Kramer R, Greenwald S, Weissman M: The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiological Catchment Area Study. Brain Injury. 15:  935-945. 2001). It is very similar to what we see in non-brain injured people but often the patients with brain injury are not going to be able to tell us what the precipitant is.

 

 

iv) Obsessive compulsive disorder (OCD)

OCD is an anxiety disorder which can occur following brain injury.

It has been the study of people with obsessive compulsive disorder that have arisen due to organic brain lesions that has helped psychiatry understand obsessive compulsive disorder in the general population.

People who have OCD and who have not had a brain injury have mild abnormalities at neuropsychometric assessment and they have also been shown to have abnormalities on functional and structural MRI. Obsessive compulsive disorder is a disorder that has a biological basis.  Studying people who have had brain injuries and then developed obsessive compulsive disorder is going to increase our understanding about obsessive compulsive disorder in general, but also to increase our understanding about the function of the brain.

The incidence of OCD is high in brain injured patients compared to the incidence in the general population.

People with OCD can have obsessions, which are the recurrent ruminative thoughts and accompanying compulsions which are the repetitive stereotypical behaviours, in many ways represent a perseveration of a motor activity.

The obsessive compulsive symptoms can also have a sub-syndromal presentation where people have what is called organic obsessiveness where they are particularly focused on things being ordered.  This organic obsessiveness often arises in people who have obsessional traits prior to the injury, they like things to be in a specific way.  After their brain injury, they develop the habit of having things in exactly a certain way to try to compensate for their cognitive impairments. Distinguishing between organic obsessiveness and an obsessive compulsive disorder following a brain injury can be difficult. 

 

v) Phobic disorders

In the Diagnostic and Statistical Manual Interview Schedule which is used in epidemiological studies there is a diagnostic grouping called phobic disorders or specific phobic disorders. It is a diagnosis that puts together everything else that people can be anxious about. It includes social phobia and specific phobias.

The phobic disorders occur following traumatic brain injury. Phobic disorders are common, about 11.2% in some studies had phobic disorders which is a significant increased risk. They are common because the diagnostic criteria can be fairly specific. In the case of people with a traumatic brain injury, they may have a car phobia rather than a full blown posttraumatic stress disorder. The reason that they get this diagnosis is that they do not have a lot of the traumatic recollections and they may not have a lot of the hyperarousal symptoms, they simply have the phobic avoidance symptoms,  they avoid being in motor vehicles.

Anxiety disorder may occur comorbidly. For example, people may have panic disorder and major depression. They might have a panic disorder, a specific phobia and a major depression, or a posttraumatic stress disorder and major depression. There are many comorbidities that occur.