Christopher M. Davidson, MD Assistant Professor Sanford School of Medicine Department of Psychiatry.
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Christopher M. Davidson, MD Assistant Professor Sanford School of Medicine Department of Psychiatry Disclosure No relevant financial or nonfinancial relationships to disclose. Goals of Presentation Familiarization with neuropsychiatric theory, terminology and corresponding neuroanatomy Increase understanding of the sometimes difficult to describe neuropsychiatric signs and symptoms following TBI Describe DSM-5 Diagnosis of neuropsychiatric syndromes related to TBI Calling “it” something…making a diagnosis Everything needs a name and a number for identifying treatment, predicting prognosis, exchanging information, furthering research, driving reimbursement Diagnosis of a disorder often means a specific set of symptoms among many Many different ways to diagnose in studies, people with different expertise using different parameters for making the diagnosis at variable times post injury “It” may not have a name or many names According to Santiago Ramón y Cajal: "The brain is a world consisting of a number of unexplored continents and great stretches of unknown territory.“ The Nobel Prize in Physiology or Medicine 1906 was awarded jointly to Camillo Golgi and Santiago Ramón y Cajal "in recognition of their work on the structure of the nervous system" Prize The Map 1930s Signaling Debate Sparkers versus Soupers Electrical Signaling: Action Potentials Chemical Signaling: Neurotransmitters Wait… what about Background Homeostasis? Complex feedback drives change in biological structures and function. How Important is Everything? What we don’t know about, can’t measure and aren’t interested in…might be important…for awhile. Immune System Endocrine System Toxicology The Brain is… Composed of circuits, that are hard to see. Using complex electrical and chemical signaling. Soft and fragile, easy to tear and bruise. Able to reinnervate, but limited in regeneration. Able to be conceptualized by altered structure and function, leading to cognitive and behavior changes. The Brain is…Circuits in a Soup + Sparkers and UNITE! Soupers Diffusion Tensor Imaging What are the long-term consequences of TBI? Short or long-term problems, requiring help in performing activities of daily living. Altered thinking, sensation, learning, language, behavior, or emotions. Depression, anxiety, difficulty controlling anger or substance abuse. What are the long-term consequences of TBI? Epilepsy and increased the risk for both Alzheimer’s and Parkinson’s diseases and other brain disorders associated with increasing age. CTE: Chronic Traumatic Encephalopathy: Sports, Military, Prisoners. When to worry about consequences? More severe injury, greater number of injuries, less time between injuries. The Outward Appearance of Brain Change is often Personality Change Family and caregivers describe changes in personality Most changes in personality after TBI described as impaired executive function or ‘‘dysexecutive syndromes’’ General Categorization of Executive Functions and Responsible Brain Regions Social Comportment (Lateral Orbitofrontal) Context specific awareness of one’s behavior relative to past individual and societal norms, self-monitoring and self-correction. Higher Order Cognitive Function (Dorsolateral Prefrontal) Mental flexibility, problem solving, setshifting. Motivated or Reward-Related Behavior (Anterior Cingulate) Initiation, sequencing, achieving, finishing. Social Comportment Impulsivity Irritability Affective Instability Awareness Deficits: Limited or total lack of understanding, more likely to recognize motor skill deficits Paroxysmal onset, brief duration, exaggerated intensity of response out of proportion to the precipitating stimulus If unaware of issue, then unlikely to address it Major Frontal-Subcortical Circuits Arciniegas DB, Beresford T. Principles of Neuropsychiatry: An Introductory Approach. Cambridge, United Kingdom: Cambridge University Press; 2001. Brain Areas Vulnerable to TBI Zasler, N. et. al. Brain Injury Medicine 2nd Ed. 2012. Cingulate Cortex Preinjury Psychiatric Disorders Preinjury rates consistently exceed community rates Most Common Preinjury Psychiatric Disorders SUD 32% Depression 20% Postinjury Psychiatric Disorders Any postinjury psychiatric disorders 65-80% Higher in those with preinjury disorders Depression, anxiety most common Novel postinjury psychiatric disorders 40-48% Depression, SUD, anxiety most common Novel Postinjury Psychiatric Disorders Versus Community Lifetime Prevalence Adults Depression 27–61% Anxiety 35-48% Substance Use 21-28% PTSD 14-19% Mania 9% Psychosis 3-7% v 5-17% MDD v 25% Any v 13-21%* v 8% v BPD 1 %/Any 2-5% v ScZ 1%/ Any 2-3% *alcohol and other drugs, except nicotine with is about 24% Brain Injury and the Criminal Justice System Alcohol may be greatest risk factor for suicide, brain injury and homicide. Brain Injury and Substance Use Disorders increase risk for each other. Before, during, after incarceration prisoners tend to have more brain injury and substance use than the general population. What is the DSM ? Diagnostic and Statistical Manual of Mental Disorders…now Version 5 A common language for describing psychopathology Not a psychiatric 'Bible‘ Similar to a dictionary with labels and definitions Clinical training and experience is needed for proper and intended use Non-axial Diagnosis DSM-5 replaces the DSM-IV multiaxial systems (5 axes) with non-axial documentation of diagnosis DSM-5 combines the former axes I (Psychiatric Illness), II (Personality Disorders and Mental Retardation) , and III (General Medical Illness) Separate notations for psychosocial and contextual factors (formerly axis IV) and disability (formerly axis V) Dimensional Approach A new dimensional approach (added to categorical diagnoses) allows clinicians to rate disorders along a continuum of severity May lessen need for "not otherwise specified (NOS)" conditions, which are now termed "not elsewhere defined" (NED)" conditions. A dimensional diagnostic system may help with risk stratification and treatment planning Neurocognitive Disorder Replaces Dementia and Amnestic Disorders Subgroups: Mild or Major Subspecifier "with" or "without behavioral disturbances" Degrees of cognitive impairment on basis of cognitive decline, especially the inability to perform ADLs independently. Mild Neurocognitive Disorder Cognitive decline is "modest“, does not interfere with "capacity for independence in everyday activities" paying bills taking medications correctly Major Neurocognitive Disorder Cognitive decline is "significant“, impairment does interfere with a patient's independence to the point that assistance is required. Diagnostic distinction relies heavily on observable behaviors. DSM-5 Cognitive Domains for Neurocognitive Disorders Major or Mild Impairment in Complex Attention Executive Function Learning and Memory Language Perceptual-Motor Social Cognition More of the DSM-5 Neurocognitive Disorder Due to Multiple Etiologies Delirium Personality Change Due to Traumatic Brain Injury or Another Medical Condition Personality Change Due to Traumatic Brain Injury Persistent personality disturbance that represents a change from previous characteristic personality pattern that is a direct pathophysiological consequence of brain injury. Specifiers: Labile Disinhibited Aggressive Apathetic Paranoid Other Combined Unspecified Incidence of Severe Psychiatric Disorders Following Hospital Contact for Head Injury Orlovska et. al., Am J Psychiatry 2013. 113,906 persons Danish nationwide population-based registry. Adjusted for gender, age, calendar year, presence of a psychiatric family history, epilepsy, infections, autoimmune diseases, and fractures not involving the skull or spine. Incidence of Severe Psychiatric Disorders Following Hospital Contact for Head Injury Head injury at any age was associated with a increase in risk for schizophrenia 65%, depression 59%, bipolar disorder 28%. No significance for injury proneness (fractures besides skull or spine) or family history of mental illness. Head injury between ages 11 and 15 years was the strongest predictor for subsequent development of schizophrenia, depression, and bipolar disorder. 86% increased risk for schizophrenia if head injury sustained between ages 10 to 15 years. Conclusion Neuropsychiatric Consequences of Brain Injury are: Complex in many ways Difficult to describe Challenging to treat Burdensome to society in many ways, especially the injured, their families and support network…it is time to help them! Helmets Can Be Cool!