PSYCHOLOGICAL SEQUELAE: POSTCONCUSSION, FRONTAL LOBE, AND TEMPORAL LOBE SYNDROMES

  1. Postconcussion Syndrome
    • A cluster of symptoms which can appear immediately following or after several days or weeks after mild TBI. Up to 50% of patients discharged from the emergency department with minor head injury will develop postconcussive syndrome within 1 month of injury (Bazarian, et al 2000). Manifestations can range from transient, mild symptoms to ongoing disabling problems (Kushner, 1998).
    • Risk factors include female gender, poor social support, elevated self-reported depressive symptoms at 1-month postinjury, and injuries caused by motor vehicle accidents or assaults. Comorbidities include concurrent diagnosis of major depressive disorder and/or posttraumatic stress disorder (McCauley, et al 2001)
    • Repeated mild brain injuries that occur over an extended period of time, such as months or years, can result in cumulative neurologic and cognitive deficits. Repeated mild brain injuries that occur within a short period of time, such as hours, days, or weeks -- while an individual is still symptomatic from an earlier injury -- are termed "second impact syndrome", result in loss of cerebrovascular autoregulation and progressive cerebral edema, and can be catastrophic or fatal (Anon., 1997; Kushner, 1998).
    • Symptoms include:
      • Posttraumatic headaches, the most common symptom, which usually resolve with time, but may take up to one year to resolve
      • Dizziness/light headedness
      • Sensitivity to noise and light
      • Anxiety/irritability
      • Depression
      • Fatigue, insomnia, drowsiness; fatigue may be due to sleep disturbances, which are relatively common following TBI and include difficulty sleeping, waking up too early, sleeping more than usual, and problems falling asleep (Clinchot, et al 1998). The Pittsburgh Sleep Quality Index is a valid and useful screening tool for assessing insomnia among postacute TBI patients (Fictenberg, et al 2001)
      • Nausea/vomiting
      • Confusion, signs of which include a vacant stare, disorientation, delayed verbal or motor responses, and concentration/attention problems (Kushner, 1998)
      • Memory problems
      • Slurred speech (Kushner, 1998)
      • Blurred vision
      • Imbalance and incoordination (Kushner, 1998)
      • Tonic posturing and clonic movements (McCrory & Berkovic, 2000)
      • Somatic complaints
      • Alcoholic beverage intolerance
    • Treatment of symptoms is much as for other conditions and includes graded resumption of activity, antidepressant medication, and cognitive restructuring (Mittenberg & Burton, 1994). Early single session therapy can prevent post-concussion syndrome following mild head injury as effectively as traditional outpatient thereapy (Mittenberg, et al 2001)

  2. Frontal Lobe Syndromes - Include symptoms of behavioral dyscontrol, such as:
    • Impulsivity and disinhibition, particularly in orbitofrontal injury
    • Blunted affect, emotional and/or social withdrawal, passivity, and lack of spontaneity, particularly in dorsalateral cortex injury
    • Aggression, outbursts of rage, and violent behavior, particularly in damage to the inferior orbital surface of the frontal lobe
    • Amotivation and apathy, particularly in mesial frontal lobe damage
    • Disorganization
    • Attentional and memory deficits. A meta-analytic review found large and significant deficits in specific measures of information processing speed, attention span, focused/selective attention, sustained attention, and supervisory attentional control following severe TBI. Age, education, and postinjury interval were not significantly related to these deficits in attention (Mathias & Wheaton, 2007).
    • Executive dysfunction, particularly in damage to the dorsal convexity of the frontal lobes
    • Mood dysregulation
    • Impaired social judgement
    • Uncharacteristic lewdness
    • Inability to appreciate the effects of one's own behavior or remarks on others
    • Impaired communication skills, such as an impaired capacity to understand conversational inference (Pearce, et al 1998)
    • Loss of social graces
    • Diminution of attention to personal appearance and hygiene
    • Boisterousness
    • Stronger imitative response tendencies (Brass, et al 2003)

  3. Temporal Lobe Syndromes - Include disturbances of language, memory, learning, and behavior
    • Behavior changes include episodic hyperirritability, angry or aggressive outbursts, and sudden onset of dysphoric mood states
    • Dominant temporal lobe injury causes language disturbances (aphasias) and disorders of sensation or sensory integration

Based on information in The American Psychiatric Textbook of Neuropsychiatry, 3d ed, SC Yudofsky and RE Hale, eds. Washington, DC, APA, 1997 and in Marion DW. Traumatic Brain Injury. New York, Thieme, 1999, except for information where other papers are cited.