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Emotional disturbances following traumatic brain injury

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Opinion statement

  • Mood disturbances are common sequelae of traumatic brain injury (TBI), but the scientific database for such disorders is very limited in descriptive, prognostic, and treatment data. Post-TBI symptoms often cross diagnostic boundaries and include cognitive loss, amotivation, psychosis, mood, changes, or other domains. The treating physician must be mindful that clear diagnostic boundaries may not exist.

  • Premorbid level of functioning commonly affects post-TBI level of functioning. When setting treatment goals, this must be considered. Patients who had lower levels of psychosocial functioning before the injury may not fare as well afterwards.

  • Treatment of post-TBI mood symptoms should proceed after a full diagnostic work-up including imaging and electroencephalographic (EEG) studies, neuropsychologic testing, and physical and laboratory examinations. Once the diagnostic picture is established, treatment should then proceed with a multidisciplinary team (physician, social worker, neuropsychologist, and others). For the medications, consider both target symptoms and side effects; start medications with low doses and raise slowly, give full therapeutic trials before switching or adding second agents, avoid benzodiazepines if possible, limit anticholinergic or antidopaminergic agents, and avoid providing large quantities of lethal medications.

  • When starting medications for the treatment of mood disorders following TBI, several general principles of treatment in this population should be considered, including: balancing treatment of target symptoms with the potential for adverse effects; making use of side effects to treat comorbid problems when present (ie, relatively antidepressant for depression and marked insomnia); using a “start low, go slow” approach; continuing dose escalation to full therapeutic levels (ie, completing therapeutic trials) before switching or adding augmenting agents; avoiding agents with predictable and functionally important adverse effects (ie, benzodiazepines, strongly anticholinergic or antidopaminergic agents); and avoiding prescription of large and potentially lethal quantities of medications.

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References and Recommended Reading

  1. Busch CR, Alpern HP: Depression after mild traumatic brain injury: a review of the current literature. Neuropsychol Rev 1998, 8:95–108.

    Article  PubMed  CAS  Google Scholar 

  2. Hibbard MR, Uysal S, Kepler K, et al.: Axis I psychopathology in individuals with traumatic brain injury. J Head Trauma Rehab 1998, 13:24–39.

    CAS  Google Scholar 

  3. Satz P, Forney DL, Zaucha K, et al.: Depression, cognition, and functional correlates of recovery outcome after traumatic brain injury. Brain Inj 1998, 12:537–553.

    Article  PubMed  CAS  Google Scholar 

  4. Bowen A, Chamberlain MA, Tennant A, et al.: The persistence of mood disorders following traumatic brain injury: a 1 year follow-up. Brain Inj 1999, 13:547–553.

    Article  PubMed  CAS  Google Scholar 

  5. Douglas JM, Spellacy FJ: Correlates of depression in adults with severe traumatic brain injury and their careers. Brain Inj 2000, 14:71–88.

    Article  PubMed  CAS  Google Scholar 

  6. Curran CA, Ponsford JL, Crowe S: Coping strategies and emotional outcome following traumatic brain injury: a comparison with orthopedic patients. J Head Trauma Rehab 2000, 15:1256–1274.

    CAS  Google Scholar 

  7. Ownsworth TL, Oei TPS: Depression after traumatic brain injury: conceptualization and treatment considerations. Brain Inj 1998, 12:735–751.

    Article  PubMed  CAS  Google Scholar 

  8. Bowen A, Neumann V, Conner M, et al.: Mood disorders following traumatic brain injury: identifying the extent of the problem and the people at risk. Brain Inj 1998, 12:177–190.

    Article  PubMed  CAS  Google Scholar 

  9. Rosenthal M, Christensen BK, Ross TP: Depression following traumatic brain injury. Arch Phys Med Rehab 1998, 79:90–103.

    Article  CAS  Google Scholar 

  10. Paradiso S, Chemerinski E, Yazici KM, et al.: Frontal lobe syndrome reassessed: comparison of patients with lateral or medial frontal brain damage. J Neurol Neurosurg Psychiatry 1999, 67:664–667.

    PubMed  CAS  Google Scholar 

  11. Jorge RE, Robinson RG, Starkstein SE, et al.: Secondary mania following traumatic brain injury. Am J Psychiatry 1993, 150:916–921.

    PubMed  CAS  Google Scholar 

  12. Shukla S, Cook BL, Mukherjee S, et al.: Mania following head trauma. Am J Psychiatry 1987, 144:93–96.

    PubMed  CAS  Google Scholar 

  13. Yablon SA: Posttraumatic seizures. Arch Phys Med Rehab 1993, 74:983–1001.

    CAS  Google Scholar 

  14. Starkstein SE, Pearlson GD, Boston J, Robinson RG: Mania after brain injury: a controlled study of causative factors. Arch Neurology 1987, 44:1069–1073.

    CAS  Google Scholar 

  15. Starkstein SE, Boston JD, Robinson RG: Mechanisms of mania after brain injury: 12 case reports and review of the literature. J Nerv Ment Dis 1988, 176:87–100.

    Article  PubMed  CAS  Google Scholar 

  16. Robinson RG, Boston JD, Starkstein SE, Price TR: Comparison of mania and depression after brain injury: causal factors. Am J Psychiatry 1988, 145:172–178.

    PubMed  CAS  Google Scholar 

  17. Starkstein SE, Mayberg HS, Berthier ML, et al.: Mania after brain injury: neuroradiological and metabolic findings. Ann Neurol 1990, 27:652–659.

    Article  PubMed  CAS  Google Scholar 

  18. House A, Dennis M, Molyneux A, et al.: Emotionalism after stroke. BMJ 1989, 298:991–994.

    PubMed  CAS  Google Scholar 

  19. Zeilig G, Drubach DA, Katz-Zeilig M, Karatinos J: Pathological laughter and crying in patients with closed traumatic brain injury. Brain Inj 1996, 10:591–597.

    Article  PubMed  CAS  Google Scholar 

  20. Ross ED, Stewart RS: Pathological display of affect in patients with depression and right frontal brain damage: an alternative mechanism. J Nerv Ment Dis 1987, 175:165–172.

    Article  PubMed  CAS  Google Scholar 

  21. Dark FL, McGrath JJ, Ron MA: Pathological laughing and crying. Aust N Z J Psychiatry 1996, 30:472–479.

    PubMed  CAS  Google Scholar 

  22. Wong AH, Smith M, Boon MS: Herbal remedies in psychiatric practice. Arch Gen Psychiatry 1998, 55:1033–1044.

    Article  PubMed  CAS  Google Scholar 

  23. Vogel G: Pharmacology. How the body’s “garbage disposal” may inactivate drugs. Science 2001, 291:35–37.

    Article  PubMed  CAS  Google Scholar 

  24. Bracken P: Mania following head injury. Br J Psychiatry 1987, 150:690–692.

    Article  PubMed  CAS  Google Scholar 

  25. Clark AF, Davison K: Mania following head injury: a report of two cases and a review of the literature. Brit J Psychiat 1987, 150:841–844.

    PubMed  CAS  Google Scholar 

  26. Riess H, Schwartz CE, Klerman GL: Mania syndrome following head injury: another form of secondary mania. J Clin Psychiatry 1987, 48:29–30.

    PubMed  CAS  Google Scholar 

  27. Nizamie SH, Nizamie A, Borde M, Sharma S: Mania following head injury: case reports and neuropychological findings. Acta Psychiatr Scand 1988, 77:637–639.

    PubMed  CAS  Google Scholar 

  28. Goldstein LB: Basic and clinical studies of pharmacologic effects on recovery from brain injury. J Neural Transplant Plast 1993, 4:175–192.

    Article  PubMed  CAS  Google Scholar 

  29. Arciniegas DB, Topkoff J, Silver JM: Neuropsychiatric aspects of traumatic brain injury. Curr Treat Options Neurol 2000, 2:169–186.

    PubMed  Google Scholar 

  30. Fann JR, Uomoto JM, Katon WJ: Sertraline in the treatment of major depression following mild traumatic brain injury. J Neuropsychiatry Clin Neurosci 2000, 12:226–232. A well designed single blinded study demonstrating success of sertraline in this population.

    PubMed  CAS  Google Scholar 

  31. Fann JR, Uomoto JM, Katon WJ: Cognitive improvement with treatment of depression following mild traumatic brain injury. Psychosomatics 2001, 42:48–54. An interesting further analysis of the previous data demonstrating cognitive improvement with sertraline treatment.

    Article  PubMed  CAS  Google Scholar 

  32. Cassidy JW: Fluoxetine: a new serotonergically active antidepressant. J Head Trauma Rehab 1989, 4:67–69.

    Google Scholar 

  33. Bessette RF, Peterson LG: Fluoxetine and organic mood syndrome. Psychosomatics 1992, 33:224–226.

    PubMed  CAS  Google Scholar 

  34. Wroblewski BA, Guidos A, Leary J, Joseph AB: Control of depression with fluoxetine and antiseizure medication in a brain-injured patient. Am J Psychiatry 1992, 149:273–273.

    PubMed  CAS  Google Scholar 

  35. Breen R, Goldman CR: Response to “Evaluation of brain injury related behavioral disturbances in community mental health centers.” Comm Mental Health J 1997, 33:359–364.

    Article  Google Scholar 

  36. Sloan RL, Brown KW, Pentland B: Fluoxetine as a treatment for emotional lability after brain injury. Brain Inj 1992, 6:315–319.

    PubMed  CAS  Google Scholar 

  37. Nahas Z, Arlinghaus KA, Kotrla KJ, et al.: Rapid response of emotional incontinence to selective serotonin reuptake inhibitors. J Neuropsychiatry Clin Neurosci 1998, 10:453–455.

    PubMed  CAS  Google Scholar 

  38. Muller U, Murai T, Bauer-Wittmund T, von Cramon DY: Paroxetine versus citalopram treatment of pathological crying after brain injury. Brain Inj 1999, 13:805–811. An interesting open trial demonstrating effective treatment of pathological crying.

    Article  PubMed  CAS  Google Scholar 

  39. Andersen G, Stylsvig M, Sunde N: Citalopram treatment of traumatic brain damage in a 6-year-old boy. J Neurotrauma 1999, 16:341–344.

    PubMed  CAS  Google Scholar 

  40. Lipper S, Tuchman MM: Treatment of chronic post-traumatic organic brain syndrome with dextroamphetamine: first reported case. J Nerv Ment Dis 1976, 162:366–371.

    Article  PubMed  CAS  Google Scholar 

  41. Evans RW, Gualtieri CT, Patterson D: Treatment of chronic closed head injury with psychostimulant drugs: a controlled case study and an appropriate evaluation procedure. J Nerv Ment Dis 1987, 175:106–110.

    Article  PubMed  CAS  Google Scholar 

  42. Gualtieri CT, Evans RW: Stimulant treatment for the neurobehavioral sequelae of traumatic brain injury. Brain Inj 1988, 2:273–290. A well designed double blind study that demonstrates the success of methylphenidate in this population.

    PubMed  CAS  Google Scholar 

  43. Udaka F, Yamao S, Nagata H, et al.: Pathologic laughing and crying treated with levodopa. Arch Neurol 1984, 41:1095–1096.

    PubMed  CAS  Google Scholar 

  44. Saran AS: Depression after mild closed head injury: role of dexamethasone suppression test and antidepressants. J Clin Psychiatry 1985, 46:335–338.

    PubMed  CAS  Google Scholar 

  45. Dinan TG, Mobayed M: Treatment resistance of depression after head injury: a preliminary study of amitriptyline response. Acta Psychiatr Scand 1992, 85:292–294.

    PubMed  CAS  Google Scholar 

  46. Wroblewski BA, Joseph AB, Cornblatt RR: Antidepressant pharmacotherapy and the treatment of depression in patients with severe traumatic brain injury: a controlled, prospective study. J Clin Psychiatry 1996, 57:582–587.

    PubMed  CAS  Google Scholar 

  47. Wroblewski B, Glenn MB, Cornblatt R, et al.: Protriptyline as an alternative stimulant medication in patients with brain injury: a series of case reports. Brain Inj 1993, 7:353–362.

    PubMed  CAS  Google Scholar 

  48. Allman P: Drug treatment of emotionalism following brain damage. J Royal Soc Med 1992, 85:423–424.

    CAS  Google Scholar 

  49. Wroblewski BA, McColgan K, Smith K, et al.: The incidence of seizures during tricyclic antidepressant drug treatment in a brain-injured population. J Clin Psychopharmacol 1990, 10:124–128.

    PubMed  CAS  Google Scholar 

  50. Newburn G, Edwards R, Thomas H, et al.: Moclobemide in the treatment of major depressive disorder (DSM-3) following traumatic brain injury. Brain Inj 1999, 13:637–642.

    Article  PubMed  CAS  Google Scholar 

  51. Joshi P, Capozzoli JA, Coyle JT: Effective management with lithium of a persistent, post-traumatic hypomania in a 10-year-old child. J Dev Behav Pediatr 1985, 6:352–354.

    Article  PubMed  CAS  Google Scholar 

  52. Pope HG, McElroy SL, Satlin A, et al.: Head injury, bipolar disorder, and response to valproate. Compr Psychiatry 1988, 29:34–38.

    Article  PubMed  Google Scholar 

  53. Stewart JT, Hemsath RH: Bipolar illness following traumatic brain injury: treatment with lithium and carbmazepine. J Clin Psychiatry 1988, 49:74–75.

    PubMed  CAS  Google Scholar 

  54. Yatham LN, Benbow JC, Jeffers AM: Mania following head injury. Acta Psychiatr Scand 1988, 77:359–360.

    PubMed  CAS  Google Scholar 

  55. Bamrah JS, Johnson J: Bipolar affective disorder following head injury. Br J Psychiatry 1991, 158:117–119.

    Article  PubMed  CAS  Google Scholar 

  56. Zwil AS, McAllister TW, Cohen I, Halpern LR: Ultra-rapid cycling bipolar affective disorder following a closed-head injury. Brain Inj 1993, 7:147–152.

    PubMed  CAS  Google Scholar 

  57. Parmelee DX, O’Shanick GJ: Carbamazepine-lithium toxicity in brain-damaged adolescents. Brain Inj 1988, 2:305–308.

    PubMed  CAS  Google Scholar 

  58. Glenn MB, Wroblewski B, Parziale J, et al.: Lithium carbonate for aggressive behavior or affective instability in ten brain-injured patients. Am J Phys Med Rehab 1989, 68:221–226.

    CAS  Google Scholar 

  59. Kraus MF: Neuropsychiatric sequelae: assessment and pharmacologic intervention. In Traumatic Brain Injury. Edited by Marion DW. New York: Thieme Medicine; 1999:173–185.

    Google Scholar 

  60. Sayal K, Ford T, Pipe R: Case study: bipolar disorder after head injury. J Am Acad Child Adolesc Psychiatry 2000, 39:525–528.

    Article  PubMed  CAS  Google Scholar 

  61. Massagli TL: Neurobehavioral effects of phenytoin, carbamazepine, and valproic acid: implications for use in traumatic brain injury. Arch Phys Med Rehab 1991, 72:219–226.

    CAS  Google Scholar 

  62. Monji A, Yoshida A, Koga H, et al.: Brain injury-induced rapid-cycling affective disorder successfully treated with valproate. Psychosomatics 1999, 40:448–449.

    PubMed  CAS  Google Scholar 

  63. Groswasser Z, Stern MJ: A psychodynamic model of behavior after acute central nervous system damage. J Head Trauma Rehab 1998, 13:69–79.

    CAS  Google Scholar 

  64. Miller LJ, Mittenberg W: Brief cognitive behavioral interventions in mild traumatic brain injury. Appl Neuropsychol 1998, 5:172–183.

    Article  PubMed  CAS  Google Scholar 

  65. Mittenberg W, Zielinski RE, Fichera S: Recovery from mild head injury: a treatment manual for patients. Psychother Private Pract 1993, 12:37–52.

    Google Scholar 

  66. Paniak C, Toller-Lobe G, Durand A, Nagy J: A randomized trial of two treatments for mild traumatic brain injury. Brain Inj 1998, 12:1011–1023. Of interest, randomized trial of early education versus more intensive interventions after TBI.

    Article  PubMed  CAS  Google Scholar 

  67. Paniak C, Toller-Lobe G, Reynolds S, et al.: A randomized trial of two treatments for mild traumatic brain injury: 1 year follow-up. Brain Inj 2000, 14:219–226. Of interest, a follow-up at one year of early education versus more intensive interventions after TBI.

    Article  PubMed  CAS  Google Scholar 

  68. Delmonico RL, Hanley-Peterson P, Englander J: Group psychotherapy for persons with traumatic brain injury: management of frustration and substance abuse. J Head Trauma Rehab 1998, 13:10–22. Of interest, teaches how to structure therapy groups for different stages of recovery.

    CAS  Google Scholar 

  69. Ruedrich SL, Chu CC, Moore SL: ECT for major depression in a patient with acute brain trauma. Am J Psychiatry 1983, 140:928–929.

    PubMed  CAS  Google Scholar 

  70. Hartmann SJ, Saldivia A: ECT in an elderly patient with skull defects and shrapnel. Convuls Ther 1990, 6:165–171.

    PubMed  Google Scholar 

  71. Crow S, Meller W, Christenson G, MacKenzie T: Use of ECT after brain injury. Convuls Ther 1996, 12:113–116.

    PubMed  CAS  Google Scholar 

  72. Kant R, Bogyi AM, Carosella NW, et al.: ECT as a therapeutic option in severe brain injury. Convuls Ther 1995, 11:45–50.

    PubMed  CAS  Google Scholar 

  73. Childs A, Crismon ML: The use of cranial electrotherapy stimulation in post-traumatic amnesia: a report of two cases. Brain Inj 1988, 2:243–247.

    PubMed  CAS  Google Scholar 

  74. Smith RB, Tiberi A, Marshall J: The use of cranial electrotherapy stimulation in the treatment of closed-head-injured patients. Brain Inj 1994, 8:357–361.

    PubMed  CAS  Google Scholar 

  75. Baker-Price LA, Persinger MA: Weak, but complex pulsed magnetic fields may reduce depression following traumatic brain injury. Percept Mot Skills 1996, 83:491–498.

    PubMed  CAS  Google Scholar 

  76. Satz P, Zaucha K, McCleary C, et al.: Mild head injury in children and adolescents: a review of studies 1970–1995. Psychol Bull 1997, 122:107–131. An excellent critical review of 25 years of studies on head injured children.

    Article  PubMed  CAS  Google Scholar 

  77. Light R, Asarnow R, Satz P, et al.: Mild closed-head injury in children and adolescents: behavior problems and academic outcomes. J Consult Clin Psychol 1998, 66:1023–1029.

    Article  PubMed  CAS  Google Scholar 

  78. Warschausky S, Kewman D, Kay J: Empirically supported psychological and behavioral therapies in pediatric rehabilitation of TBI. J Head Trauma Rehab 1999, 14:373–383.

    CAS  Google Scholar 

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Authors and Affiliations

  1. Departments of Psychiatry and Behavioral Sciences and Radiology, The Herbert J. Frensley Center for Imaging Research, Baylor College of Medicine, One Baylor Plaza, 77030, Houston, TX, USA

    Robin A. Hurley MD

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  1. Robin A. Hurley MD
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  2. Katherine H. Taber PhD
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Hurley, R.A., Taber, K.H. Emotional disturbances following traumatic brain injury. Curr Treat Options Neurol 4, 59–75 (2002). https://doi.org/10.1007/s11940-002-0005-5

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