Non-motor impairments after ABI, behavior, emotion, motivation

After stroke… have neuropsychiatric disorders

33-50%

40% of pts after TBI have

two neuropsychiatric disorders

neuropsychiatric disorder after stroke/TBI treatment evidence

is limited, no clear consensus on the approach to take

Neuropsychiatric disorders are associated with

primary and secondary etiologies

Behavioral dyscontrol

tendency toward impulsive reactions toward internal/external stimuli

aspects of behavioral dyscontrol

agitation, disinhibition, aggression

agitation

state of restlessness and increased psychomotor activity reflecting underlying emotions

aspects impacting agitation

adverse environment, medical illness, aggression as direct effect of brain injury, depression, sundowning, insomnia, anxiety, psychosis

Disinhibition

inappropriate, nonaggressive responses reflecting an inability to appreciate behavioral norms

categories of disinhibition

physical and verbal

physical disinhibition

sexual advances, impulsivity

Verbal disinihibition

poorly considered utterances, breaking rules of discourse, egocentric perspective

Aggression

verbal outburst or physical violence directed at objects or people

risk factors for aggression

emotional dyscontrol, major depression, frontal lobe damage, pre-injury aggression

treatment for aggression

valproate, beta blockers, psychostimulants, SSRIs

reactive aggression

triggered by modest or trivial stimuli, out or proportion

nonreflective aggression

usually does not involve premeditation or planning, automatic response

nonpurposeful aggression

aggression serves no obvious long-term aims or goals

explosive aggression

buildup is NOT gradual

periodic aggression

brief outbursts of rage and aggression punctuated by long periods of relative calm

ego-dystonic aggression

after outbursts, patients are upset, concerned, and/or embarrassed, as opposed to blaming others or justifying behavior

Mood disorder

sustained, pervasive shift in emotion and/or feeling

examples of mood disorder

depression, anxiety, apathy

Depression

depressed mood, decreased capacity for pleasure

most common neuropsychiatric diagnosis after stroke and TBI

depression

risk factors for depression

frontal pole or left injury lateralization or serotonergic dysfunction (TBI), older, female, less education, prior psych disorder, stroke severity

Depression treatment

SSRI, tricyclic antidepressants (older medication), neuromodulation (stroke)

Anxiety

excessive worry, nervousness or unease about an anticipated event or situation

Anxiety can be

generalized or associated with post traumatic stress disorder

predictors of anxiety in stroke

increased severity, premorbid depression, early anxiety after injury, cognitive impairment

risk factors for anxiety in TBI

older, female, prior psych disorder, longer LOC, shorter PTA (more likely to remember getting injured)

Treatment of anxiety

SSRI, benzodiazepines (Xanax, Ativan)

SNRI can increase anxiety in

depressed patients

apathy

decrease in motivation

apathy is associated with

dysfunctional reward network and/or comorbid depression

apathy can be related to

cognition, behavior, emotion, or social interactions

treatment of apathy

dopamine-agonists, psychostimulants, acetylcholinesterase inhibitors

aspects of reward network

nucleus accumbent (ventral striatum, anterior cingulate gyrus, MOFC