TBI: TBH I don’t know much

[Alemo]

Hi all,

Saw a patient this weekend with “bipolar disorder” and in taking history found that he had sustained several TBI’s starting at age 15. Between these and PTSD, he manifested the whole gamut of psychiatric symptoms. I’ve also noticed there have been some adjacent discussions about TBI on other posts.

I’ve realized I haven’t had any training in TBI theory/management besides “if they’re manic give them the antimanics” and “propranolol helps impulsivity.”

Given that I don’t want to do a brain injury fellowship, do you guys have any good resources on learning more about TBI?

What pearls do you incorporate into practice?

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[WisNeuro]

Depends on the TBI severity. Mild, wouldn't worry much. Start getting into complicated mild through severe, then there may be some issues. Really need to characterize it well first. Way too many providers see TBI and make it an etiology for everything, even if it's of no consequence.

 

[deleted1100659]

. Way too many providers see TBI and make it an etiology for everything, even if it's of no consequence.

100% agree here. Depends on the extent of the TBI, and when the symptoms emerged, what those symptoms are, what was going on at the time, etc.

try to lock down what you're treating exactly, I see people treat symptoms rather than disorders and in the long term, things often dont improve that way

 

[Alemo]

Exactly this is what I’m talking about. It seems like it’s disregarded completely as an etiology, or everyone uses it as the origin of all symptoms. How exactly would one go about distinguishing say, mania, from mood disorder related vs brain injury related? Irregular cycling? Rapid onset? And does it have implications for treatment (“we were gonna give him Depakote anyway”)?

 

[WisNeuro]

First step, thorough clinical interview, hopefully bolstered by objective medical records. That would give you a good idea of the severity and chronology of the TBI. If it's mild, I wouldn't put much stock in it. And, you'll likely get a lot of "good old days" bias from self-report, which can be countered if there are good med records.

 

[smalltownpsych]

First step, thorough clinical interview, hopefully bolstered by objective medical records. That would give you a good idea of the severity and chronology of the TBI. If it's mild, I wouldn't put much stock in it. And, you'll likely get a lot of "good old days" bias from self-report, which can be countered if there are good med records.

After this clinical inteview and review of records, if it does sound as though there could be some lasting neurological effects, I would probably refer for a neuropsychological evaluation so the patient and I can understand more specifically where the deficits are and how that can impact the functioning. That also helps to eliminate some of the tendency to attribute everything to the TBI.

 

[jbomba]

So I've got a middle aged guy right now who had multiple, verified TBI and is completely disinhibited. Labile, abrupt anger, yelling at staff and other patients, very difficult to redirect in conversation because hell talk for hours if you let him. Using vpa, clonidine...any other thoughts in a case like this?

 

[clausewitz2]

So I've got a middle aged guy right now who had multiple, verified TBI and is completely disinhibited. Labile, abrupt anger, yelling at staff and other patients, very difficult to redirect in conversation because hell talk for hours if you let him. Using vpa, clonidine...any other thoughts in a case like this?

I know some of our brain injury people might think about methylphenidate in a situation like this. Certainly the impulsivity, emotional lability, and total inability to shut up would all fit into ADHD absent the TBI. This is assuming you can actually interrupt him even if he tends to drag the conversation back to whatever he feels like talking about and he's more rambling than frankly tangential. Does he sleep?

 

[PsyDr]

Let me sum up Silver's position: amantadine.

 

[jbomba]

I know some of our brain injury people might think about methylphenidate in a situation like this. Certainly the impulsivity, emotional lability, and total inability to shut up would all fit into ADHD absent the TBI. This is assuming you can actually interrupt him even if he tends to drag the conversation back to whatever he feels like talking about and he's more rambling than frankly tangential. Does he sleep?

Yeah that's an interesting thought. He definitely sleeps fine.

 

[hallowmann]

Yeah that's an interesting thought. He definitely sleeps fine.

I would second the long-acting stimulant recommendations. I've seen good results with both Concerta and Vyvanse.

I've got a guy, multiple moderate to severe TBIs documented with one recently resulting in disinhibition, impulsivity, outbursts, and worsening depression with suicidal ideation. Was being cautious and starting on 1 med at a time (almost no prior psychotropic trials as most mood symptoms were since the most recent TBI), then was hospitalized for a few days. Dude came out literally with 7 new meds (2 antipsychotics, low-dose once-daily Cogentin, Keppra - oddly dosed daily, a different SRI, trazodone, and hydroxyzine) feeling slightly less suicidal, more tired, more confused, and otherwise the same. I have yet to get any information from facility that hospitalized him and family is not health literate so history was rough, but started peeling the ones that didn't make sense, decreased trazodone, and he's not as tired and confused with no worsening. Still debating a stimulant, but want to actually see how things shake out on only 2-3 psychotropics first. Why does it feel like ASD and TBI patients always end up with problematic polypharmacy?

 

[clausewitz2]

Why does it feel like ASD and TBI patients always end up with problematic polypharmacy?

Person can't act right and are scary, make them not be scary.

 

[calvnandhobbs68]

I would second the long-acting stimulant recommendations. I've seen good results with both Concerta and Vyvanse.

I've got a guy, multiple moderate to severe TBIs documented with one recently resulting in disinhibition, impulsivity, outbursts, and worsening depression with suicidal ideation. Was being cautious and starting on 1 med at a time (almost no prior psychotropic trials as most mood symptoms were since the most recent TBI), then was hospitalized for a few days. Dude came out literally with 7 new meds (2 antipsychotics, low-dose once-daily Cogentin, Keppra - oddly dosed daily, a different SRI, trazodone, and hydroxyzine) feeling slightly less suicidal, more tired, more confused, and otherwise the same. I have yet to get any information from facility that hospitalized him and family is not health literate so history was rough, but started peeling the ones that didn't make sense, decreased trazodone, and he's not as tired and confused with no worsening. Still debating a stimulant, but want to actually see how things shake out on only 2-3 psychotropics first. Why does it feel like ASD and TBI patients always end up with problematic polypharmacy?

I always love the reflex prescribe antipsychotic with cogentin.

Moderate/severe ASD (and ID) patients are often because the caretakers are trying to sedate them out of any aggression without implementing any behavioral interventions. Also because they frequently can't communicate and gets some "prescriber" that just keeps cranking up the risperidone/depakote/haldol/thorazine/whatever until they're sedated or have some bad side effects, then adds another one. That's why I did not like the "phone call telemedicine" stuff in 2020 because you're just getting caretaker/group home reports and often these are biased towards "keep this person as compliant as possible at all time". TBI can be the same thing.
I have had/do have ID patients who get high quality behavioral therapy though in their group homes though and are on polypharmacy that keeps aggression down to the point they can be managed in the community. After a long period of time, ASD/ID patients can end up on odd but seemingly effective regimens that keep them from breaking down doors or punching their roommates or eloping impulsively.
Ex. I have one on long term Klonopin + Risperidone + Depakote + Trazodone I inherited who I know gets great quality care through her group home and does pretty well, another one on Focalin + Latuda + Lexapro + Depakote (that I was able to swap out for Intuniv at least) that definitely decompensated as soon as I started to try to decrease her Latuda).

 

[clozareal]

Given that I don’t want to do a brain injury fellowship, do you guys have any good resources on learning more about TBI?

You can start with the David Arciniegas Textbook of Neuropsychiatry and Clinical Neurosciences or his other book Behavioral Neurology and Neuropsychiatry. You can also consider the Manual of Traumatic Brain Injury which has a section on mood disorders.

 

[splik]

You can start with the David Arciniegas Textbook of Neuropsychiatry and Clinical Neurosciences or his other book Behavioral Neurology and Neuropsychiatry. You can also consider the Manual of Traumatic Brain Injury which has a section on mood disorders.

The APA neuropsychiatry textbook has never been good (read: worst neuropsych textbook out there), and the most recent edition is unusuable (which is true for many of their recent editions because they have strict page limits for cost cutting reasons). The recommend neuropsychiatry texts are either Lishman's Organic Psychiatry or Moore's Textbook of Clinical Neuropsychiatry and Behavioral Neuroscience. Both are excellent neuropsychiatry texts.

The Textbook of TBI from APA isn't bad though. The Management of Adults with TBI is also a reasonable text (with editors from psychiatry, neurology, PM&R and neuropsychology backgrounds).

 

[hallowmann]

I always love the reflex prescribe antipsychotic with cogentin.

Moderate/severe ASD (and ID) patients are often because the caretakers are trying to sedate them out of any aggression without implementing any behavioral interventions. Also because they frequently can't communicate and gets some "prescriber" that just keeps cranking up the risperidone/depakote/haldol/thorazine/whatever until they're sedated or have some bad side effects, then adds another one. That's why I did not like the "phone call telemedicine" stuff in 2020 because you're just getting caretaker/group home reports and often these are biased towards "keep this person as compliant as possible at all time". TBI can be the same thing.
I have had/do have ID patients who get high quality behavioral therapy though in their group homes though and are on polypharmacy that keeps aggression down to the point they can be managed in the community. After a long period of time, ASD/ID patients can end up on odd but seemingly effective regimens that keep them from breaking down doors or punching their roommates or eloping impulsively.
Ex. I have one on long term Klonopin + Risperidone + Depakote + Trazodone I inherited who I know gets great quality care through her group home and does pretty well, another one on Focalin + Latuda + Lexapro + Depakote (that I was able to swap out for Intuniv at least) that definitely decompensated as soon as I started to try to decrease her Latuda).

Don't get me wrong, there are definitely patients who need complicated regimens, and I don't really consider that polypharmacy if there is clear benefit/need for each med. It's just the reflex, "this person's brain doesn't work, let me give them a bunch of meds all at once" that I don't understand.

 

[Alemo]

Thanks guys, a lot of good information here.

 

[smalltownpsych]

One thing to add to TBI discussion spurred by @whopper from other thread.
Sleep is huge and the brain is so much more easily fatigued after an injury and most patients don’t understand or realize that. It is important for us to emphasize the importance of getting lots and lots of extra rest and limiting cognitive and emotional workload during early phase of recovery. I have had a lot of success with just helping TBI patients monitor this and stay in the optimal range of CNS arousal to promote neuronal development as its part of what I do for all my patients. I never want my patients understressed/stimulated/activated or over-stressed/stimulated/activated and for TBI the problem is usually the latter.

 

[WisNeuro]

Just to advocate for proper care and feeding of mild TBI. Best thing in that population is to be accurate about their expected recovery and not feed into the iatrogenesis that some other specialties are guilty of (Speech, OT, optho). You get a lot of somatic type people, and expectancy effects are a beast in those individuals. Start treating their concussion like it was a 2 week coma with major bleeds, and guess how well that patient is going to do going forward?

 

[calvnandhobbs68]

Just to advocate for proper care and feeding of mild TBI. Best thing in that population is to be accurate about their expected recovery and not feed into the iatrogenesis that some other specialties are guilty of (Speech, OT, optho). You get a lot of somatic type people, and expectancy effects are a beast in those individuals. Start treating their concussion like it was a 2 week coma with major bleeds, and guess how well that patient is going to do going forward?

Yeah this is an issue with one of my patients that I'm not sure I'm ever going to fix....had a couple mild concussions in a high school sport like a year ago now and still complaining of various somatic/cognitive/psychiatric complaints but functioning just fine. Keep trying to set realistic expectations around the fact that nobody feels "perfect" day to day but parents are totally feeding into this too and keep taking him to all these OT/PT places, concussion places and most recently neurology.

 

[WisNeuro]

Yeah this is an issue with one of my patients that I'm not sure I'm ever going to fix....had a couple mild concussions in a high school sport like a year ago now and still complaining of various somatic/cognitive/psychiatric complaints but functioning just fine. Keep trying to set realistic expectations around the fact that nobody feels "perfect" day to day but parents are totally feeding into this too and keep taking him to all these OT/PT places, concussion places and most recently neurology.

OT/PT/Chiros need those billing dollars. Why not get someone in for weekly sessions over a year or two? Who cares if they have no real norms for the tests they use, or checks on validity? So what if their interventions make people worse in the long run? They got to practice outside of their scope and increase their billables.

 

[PsyDr]

It is important for us to emphasize the importance of getting lots and lots of extra rest and limiting cognitive and emotional workload during early phase of recovery.

RCT evidence says that this practice causes MORE symptoms, not less.

 

[WisNeuro]

RCT evidence says that this practice causes MORE symptoms, not less.

Oh, how I wish other providers knew this info. I still see this recommendation like 6 months to a year out from concussion.

 

[smalltownpsych]

RCT evidence says that this practice causes MORE symptoms, not less.

I'm not talking about mild or even moderate concussions who probably have no measurable deficits. I was referring more to my patients who have had serious TBIs with lasting deficits. Is that still a mistake from that stance?

 

[jbomba]

Oh, how I wish other providers knew this info. I still see this recommendation like 6 months to a year out from concussion.

What are your recommendations for the first 4-8 weeks after TBI?

 

[WisNeuro]

What are your recommendations for the first 4-8 weeks after TBI?

Uncomplicated mild? Probably a good idea to take some time away from contact sports for a week or two more to lessen rare chance of second impact syndrome. Maybe a day or two off school. But after that, business as usual. Best recommendation is to tell them that they may feel off for a few days, but that they will be back to normal pretty quickly.