Professional Documents
Culture Documents
Case Presentation
Chief Complaint
Present Illness
raumatic brain injury is a significant cause of disMr. C was doing well until he sustained a severe trauability in the United States, with both neurological and
matic brain injury and right orbital wall fracture after fallpsychiatric consequences (1). Although neurological seing from a 40-foot-high ladder. The duration of posttrauquelae usually stabilize with time, psychiatric disorders
matic amnesia and the 24-hour Glasgow Coma Scale (6)
persist because of their propensity to produce chronic
score at the time of injury are unknown. Other than sursymptoms and to follow a relapsing course. Mood and
gical repair of the orbital fracture, no other known medbehavioral problems after traumatic brain injury interical or surgical postfall complications were diagnosed or
treated at the outside hospital. He
fere with rehabilitation efforts and
was not under the influence of illicit
cause adverse outcomes such as undrugs or alcohol at the time of the
employment, repeated hospitalizaPatients with
fall. He was hospitalized for 3 weeks,
tions, legal problems, and alienation
traumatic
brain
injury
during which time he was in a coma
from family and friends (2, 3). In addifor approximately 2 weeks.
may also indulge in
tion, these effects are amplified by high
Upon discharge, he underwent 5
rates of psychiatric comorbidity (4)
weeks
of inpatient rehabilitation folabnormal goal-directed
(e.g., DSM axis I diagnoses) in patients
lowed by several weeks of outpatient
behaviors, which can rehabilitative care. At this time, he atwith traumatic brain injury.
tempted to return to work several
The case presented here of a 42-yearfurther increase their
times. However, he was unable to hold
old man with a history of two traumatic
a job because of socially inappropriate
emotional
distress
and
brain injuries exemplifies the clinical
behavior, such as arguing with male
and social complexities of traumatic
cause social,
coworkers and inappropriately touchbrain injury. The formulation of multiand groping female coworkers on
occupational, or legal ing
ple diagnoses and the design of a commultiple occasions. He was arrested
prehensive treatment plan for this patwice and incarcerated once for 3
problems.
tient were challenging. As described by
months because of these acts. Other
behavior problems since the trauMcHugh and Slavney in their book, The
matic brain injury included frequent outbursts of anger
Perspectives of Psychiatry (5), the use of an organized apand physically aggressive behavior, leading to separation
proach and conceptual framework is important in psychifrom his wife and alienation from several family members.
atric diagnosis and treatment. The four perspectives of
Mr. C received several trials of medication that were not efpsychiatry provide a framework for organizing a patients
fective (risperidone, 1 mg at bedtime; divalproex sodium,
psychiatric history in a structured manner, independent
750 mg b.i.d.; quetiapine, dose unknown; and methof the etiology. The essence of each perspective defines
ylphenidate, dose unknown) according to his family. There
how to approach a problem and design a solution. The
was no history of seizure after traumatic brain injury.
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Perspective
Triad
Treatment
Diagnostic Challenges
Etiology
Disease
Cure
Pathology
Syndrome
Potential
Dimensional
Guidance
and Strength
Provocation
Response
Physiological Drive
Behavior
Interpretation
and Conversion
Learning
Choice
Setting
Life Story
Rescript
Sequence
Outcome
Hospital Course
Mr. C was given a behavior plan detailing inappropriate behavior to minimize conflict with other patients
and staff. With the structured activities and predictable
routine that was provided on the inpatient unit, he remained compliant and had no behavior problems. Occasionally, there was evidence of inappropriate behavior,
such as being overly familiar with visitors on the floor,
but he was easily redirected in these instances. Because
of prior lack of benefit, he was tapered from divalproex
sodium and risperidone. Sertraline was titrated to 150
oral mg/day for symptoms of major depression. Considering his frontal lobe symptoms (i.e., impulsivity, poor
social judgment, low frustration tolerance, and behavioral disinhibition), amantadine was started and gradually increased to a dose of 100 mg/day. Mr. C was discharged to the Johns Hopkins Bayview Brain Injury
Clinic; the National Institute for the Study, Prevention,
and Treatment of Sexual Trauma (formerly called the
Johns Hopkins Sexual Disorders Clinic); and a psychosocial rehabilitation program.
Outpatient Treatment
Even though Mr. C did very well in the structured inpatient setting, he found returning to the community difficult. Establishing realistic expectations was critical to his
care, and the primary goals of therapy were to minimize
existing disability and maximize productivity. The strategies employed to achieve these outcomes included pharmacotherapy (continuation of sertraline and amantadine), individual cognitive behavior therapy (once a
week), group therapies (daily psychosocial rehabilitation
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Discussion
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role playing were used to demonstrate how his vulnerabilities could lead to trouble. Discussing his strengths improved his self-esteem and helped him stay motivated.
Guidance also included training to improve his interpersonal relationships, with an emphasis on learning to listen, exercising self-control when angry, and making conversation in a polite and responsible manner. Group
counseling was useful in providing actual interactions
with peers and opportunities for socialization to offset the
loneliness that often provoked Mr. Cs distress. This supportive and structured setting gave Mr. C an opportunity
to obtain safe feedback from peers. In addition, regular
family meetings were held to provide additional instruction and support.
Behavior Perspective
Even though the disease and the dimensional perspectives could explain many of Mr. Cs behavioral problems,
some of them, such as the sexually inappropriate behavior, were better explained using the behavior perspective.
Sexually inappropriate behavior can be particularly troublesome in this patient population. Simpson et al. (35) related patients with traumatic brain injury with sexually inappropriate behavior to comparison subjects with
traumatic brain injury without the behavior to identify social, cognitive, and medical correlates. They found a
higher incidence of psychosocial impairment and failure
to return to work after traumatic brain injury in subjects
with traumatic brain injury with sexually inappropriate
behavior. Premorbid temperament or postinjury medical
or cognitive variables were not significantly more common in the traumatic brain injury group with sexually inappropriate behavior. The researchers warn against having a simplistic explanation, such as frontal lobe damage
or psychosocial disturbance before traumatic brain injury,
as the cause for sexually inappropriate behavior that
emerges after injury.
The behavior perspective identifies conditions that represent problems of choice and control and is governed by
a triad of physiological drive, conditioned learning, and
choice. Motivated behaviors, such as eating, drinking,
sleeping, and sexuality, all depend on learning and maturation. However, these normal behaviors can become a
disorder when carried to excess in form or frequency.
These abnormal motivated behaviors are often sustained
by rewarding consequences. Mr. Cs inappropriate sexual
behavior is a typical example of an abnormal goal-directed behavior. Even though injury to the frontal lobes
may have resulted in impulsivity and disinhibition, making him vulnerable to hypersexual acts, this behavior is
probably shaped and maintained by positive reinforcements that Mr. C receives when he indulges in touching
others. The rewards, such as joy and/or attention, that he
receives may also be a distorted form of sexual outlet.
Treatment involves stopping or converting the problematic behavior. This approach involves confronting behavior, challenging the patients reluctance to change, and
adopting the new goal of striving to end it. The behavioral
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approach has been shown to help in this patient population. Fyffe et al. (30) described a case of a 9-year-old boy
diagnosed with traumatic brain injury who continued to
maintain inappropriate sexual behavior secondary to positive reinforcement in the form of social attention. A behavioral intervention in the form of functional communication training and extinction led to a reduction of the
inappropriate behavior. Zencius et al. (36) described the
effectiveness of simple strategies such as feedback and
scheduled massage to decrease hypersexual behavior in
brain-injured subjects. Bezeau et al. (37) reviewed the various types of sexually intrusive behavior following traumatic brain injury and discussed methods for assessment
and management.
Evaluation and treatment of inappropriate sexual behavior is often frustrating and challenging for the therapist
and awkward, embarrassing, and sometimes even shameful for the patient and/or his family. In the behavioral approach, these behaviors should be addressed respectfully
and in a professional manner, and the therapist should be
sensitive to the feelings of the person/family (38). The person should be told in a clear, straightforward manner that
the behavior is unacceptable. Family members should be
educated about the frequency of socially and sexually inappropriate behaviors after traumatic brain injury.
Management of Mr. Cs hypersexual behavior included a
combination of pharmacotherapy and psychotherapy.
The increased sexual drive was reduced pharmacologically with leuprolide. There is a significant literature on
the use of medroxyprogesterone and leuprolide acetate
for the treatment of paraphilias and hypersexual behavior
in patients with and without traumatic brain injury (39
42). Psychotherapy included group therapy and individual
therapy focused on providing clear recommendations
about acceptable and unacceptable behavior. Examples
include avoiding people and places where he was likely to
be vulnerable to hypersexuality, encouraging him to have
a responsible person supervise him when he was meeting
with friends, role-playing his actions before his dates,
modeling and providing feedback, and encouraging repetition of appropriate behavior. Regular discussion in simple language about the feelings and rights of the person
being touched and the legal consequences he had to suffer
because of his actions also helped. Mr. Cs strong religious
beliefs helped to reduce and keep this behavior in check.
The behavior perspective may also help patients with
traumatic brain injury with various other inappropriate
behaviors. Hegel and Ferguson (43) demonstrated a significant reduction in aggressive behavior using the technique
of differential reinforcement of other behaviors in a
brain-injured man. Tiersky et al. (44) compared the effectiveness of individual cognitive behavior psychotherapy
and individual cognitive remediation therapy to regular
follow-up treatment in patients with mild to moderate
traumatic brain injury. A total of 20 subjects were followed
for 11 weeks. They found that the group that received cognitive behavior therapy/cognitive remediation therapy
had reduced emotional distress and improved attention at
Am J Psychiatry 164:5, May 2007
Conclusion
Traumatic brain injury is a complex condition associated with several psychiatric problems, some of which
could be direct manifestations of brain damage, and others, associated with the persons inherent cognitive or personality traits. In addition, patients with traumatic brain
injury may also indulge in abnormal goal-directed behaviors, which can further increase their emotional distress
and cause social, occupational, or legal problems. Finally,
their negative reactions and sense of pessimism may be
understood by their changing life circumstances and the
associated new challenges.
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