Psychological sequelae of head injury

To understand the mental symptoms that follow head injury it is necessary to know about the person who was injured, what brain injuries they sustained, and the consequences. However, the interaction between these three antecedents is complex and poorly understood.

Antecedents Pretraumatic factors

People who take risks or get into fights are more likely to sustain a head injury; therefore these personality traits, present before injury, are over-represented in head injury survivors. Young men are at high risk, as are those who have already had a head injury or have cognitive dysfunction. (20>

The poor social adjustment of many patients before the head injury partly explains why so many run into behavioural problems afterwards. But premorbid characteristics do not strongly predict who will develop emotional and behavioural problems. Nevertheless, traumatic brain injury probably has the potential to turn preinjury personality traits into postinjury personality disorders.

The trauma

The extent of brain injury probably explains less than 10 per cent of the variance in the amount of psychiatric morbidity that follows brain injury. (21> In general, early psychiatric symptoms, within weeks and months of the injury, correlate better with the extent and location of brain injury than do late psychiatric symptoms. Left hemisphere damage seems to be associated with greater psychiatric morbidity. Specific relationships between the location of brain injury and the psychiatric symptoms are discussed below.

But the head injury is also a psychological trauma. Amnesia for the event, as a result of the head injury, protects against post-traumatic stress disorder (see Chapter. 5,3.8). However, it is a mistake to believe that amnesia for the event prevents a psychological stress reaction to the event itself.

• The meaning of the event may be distressing to the patient. (22> In the case of assaults, the head injury may act as a marker of the potential for further assaults. An accident may have been life threatening and a shocking reminder to the patient that they are mortal. They may feel aggrieved by an employer's negligent action that caused the accident.

• The patient may be amnesic for the event, lacking explicit memories of what happened, but retain implicit memory of what happened. The consequences of these implicit memories may be akin to those observed in one of Claperede's amnesic patients. (23> The doctor shook the patient's hand, pricking it while doing so with a concealed drawing pin. The next day the patient could not remember having met the doctor, but flinched from shaking his hand when it was offered.

• They may have islets of intact memories that may be extremely frightening/24'

Post-traumatic factors

Post-traumatic factors deserve special attention because they are most likely to be amenable to intervention. The psychiatrist needs to consider the patient's reaction to any disability, as well as the consequences of the disability on the role of the patient in the family and society. There may be reinforcing cycles of maladaptive behaviour, and compensation claims may complicate the picture.

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