Neuropsychiatric Assessment
Table1. Sample Questions for Traumatic Brain
Injury (TBI) assessment
Questions
Have you ever hit your head ?
Have you ever been in an accident ?
Have you ever been in or near an explosion
(If so) Did you black out, pass out , or lose consciousness ?
What is the last thing you remember before the injury
What is the first thing you recall after the injury?
(If no known LOC) at the time of the injury, did you experience any
change in your thinking or feel “dazed "or “confused”
Did you suffer any other injuries during the incident?
Rationale
Probe for car/motorcycle/bicycle/other major vehicles accidents,
falls, assaults, sports or recreational injuries, blast injuries.
Establish LOC ( verify LOC with witness, if possible)
Establish extent of retrograde amnesia
Estimate duration of LOC and/or PTA (Must ask when contiguous
memory function returned to define PTA interval)
Establish change in mentation or level of consciousness
Delineate post- TBI symptoms (see Table 4-5)
Has anyone told you that you’re different since the injury? If so how
have you changed?
Did anyone witness or observe your injury ?
Many people who have injured their head had been drinking or using
drugs: how about you?
Have you had any other injuries to your head or brain
Detect problems outside survivors awareness or those he or she may
be minimizing
Identify source of collateral history
Offer survivor greater “permission "to admit substance use and
determine if substances contributed to the altered mental status at the
time of injury
Identify previous TBIs that may increase morbidity from current
injury
Table 2. Classification of Traumatic Brain
Injury (TBI)

Type of TBI Glagsgow Coma Loss of Posttraumatic

Scale Consciousness Amnesia
Mild 13-15 30 minutes of less(or none) < 1 hour

Moderate 9-12 30 Minutes to 24 hours 1-24 hours

Severe ≤8 > 24 hours > 24 hours

 Mayo Traumatic Brain Injury (TBI) Severity
Classification System

 A Classify as moderate-severe (definite) TBI if one or more of the following criteria apply:
1. Death due to this TBI
2. Loss of Consciousness of 30 minutes or more
3. Posttraumatic anterograde amnesia of 24 hours or more

4. Worst Glagsgow Coma Scale full score in first 24 hours <13 (unless invalidated upon review e.g., attributable to intoxication, sedation, systemic shock)

5. One or more of the following present :

• Intracerebral hematoma
• Subdural hematoma
• Epidural Hematoma
• Cerebral Contusion
• Haemorrhagic contusion
• Penetration TBI (Dura penetrated)
• Subarachnoid haemorrhage
• Brainstem injury
 B. If none of Criteria A apply, classify as mild (probable) TBI if one or more of the following criteria apply:
1. Loss of consciousness of momentary to less than 30 minutes
2. Posttraumatic anterograde amnesia of momentary to less than 30 minutes
3. Depressed, basilar, or linear skull fracture (dura intact)
 C. If none of Criteria A or B apply, classify as symptomatic(possible) TBI if one or more of the following symptoms are present:
• Blurred vision
• Confusion (mental state changes)
• Dazed
• Dizziness
• Focal Neurological symptoms
• Headache
• Nausea
Table 3. Traumatic brain injury symptom
checklist

Cognitive Emotional Behavioral Physical

Level of consciousness Mood swings/liability Impulsivity Fatigue

Sensorium Depression Disinhibition Weight Change

Attention/Concentration Hypomania/mania Anger decontrol Sleep disturbance

Short-term memory Anxiety Inappropriate sexual behavior Headache

Processing speed Anger/irritability Lack of initiative Visual Problems

Executive function (planning, Apathy Change in personality Balance difficulties

abstract reasoning, problem Dizziness
solving, information processing, Coldness
ability to attend to multiple Change in hair/skin
stimuli, insight, judgement, etc.) Seizures
Spasticity
Loss of urinary control
Arthritic complaints
Table 4. Sources of Collateral History

People Documents
Family Police reports

Friends Emergency Medical

Coworkers Service reports

Witnesses to Injury Medical Records

Medical Staff Education history

Allied health professionals (occupational, physical, and Driving record

speech therapists, etc.)
Rancho Los Amigos Cognitive Scale

i. No response: Unresponsive to any stimulus

ii. Generalized response: Limited, Inconsistent, and no purposeful responses, often to pain only

iii. Localized response: Purposeful responses; may follow simple commands; may focus on presented object.

iv. Confused, agitated: Heightened state of activity; unable to perform self care; unaware of present events; agitation appears related to internal
confusion

v. Confused, inappropriate: Nonagitated: appears alert; responds to commands; distractible; does not concentrate on task; agitated responses to external
stimuli; verbally inappropriate does not learn new information

vi. Confused, appropriate: Goal directed behavior , needs cuing; can relearn old skills such as activities of daily living; severe memory problems, such
awareness of self and others

vii. Automatic, appropriate: Appears appropriately orientated; frequently robotlike in daily routine; minimal or absent confusion; shallow recall;
increased awareness of self and interaction in environment; lacks insight into condition; decreased judgement and problem solving; lacks realistic
planning for future

viii. Purposeful, appropriate: alert and orientated; recalls and integrates past events; learns new activities and continue without supervision; independent
in home and living skills; capable of driving; defects in stress tolerance, judgement, and abstract reasoning persist; may function at reduced levels in
society
 Table 5. Traumatic Brain Injury (TBI) –
Related DSM-IV-TR disorders
TBI Sequelae DSM-IV-TR disorders

Posttraumatic amnesia Delirium due to TBI (293.0)

Persistent global cognitive impairments in context of intact sensorium(after resolution Dementia due to TBI, with or without behavioral disturbance (294.11 and 294.10,
of posttraumatic amnesia) respectively)
“postconcussive” syndrome Cognitive disorder not otherwise specified (294.9)( research criteria specific for
“postconcussional disorder "in appendix B
Isolated impairment of memory Amnestic disorder due to head trauma (294.0)

Changes in personality Personality change ( apathetic, disinhibited, labile, aggressive, paranoid, other,
combined unspecified ) due to TBI (310.1)
Persistent hallucinations, delusions Psychotic disorder ( with delusions or hallucinations) due to TBI (293.81 and 293.82,
respectively)
Persistent anxiety symptoms Anxiety disorder (with generalized anxiety, panic attacks, or obsessive

Impaired Libido, arousal, erectile dysfunction, anorgasmia, etc.
Insomnia, reversal of sleep-wake cycle, daytime fatigue, etc
Sexual dysfunction due to TBI: female or male hypoactive sexual desire (625.8 and
608.89, respectively); male erectile disorder (607.84); other female or male sexual
dysfunction (625.8 and 608.89, respectively)
Sleep disorder due to TBI (780.xx): insomnia type (.52); Hypersomnia type (.54);
parasomnia type (.59); mixed type (.59)
Table 6. Neurological examination after traumatic brain injury : Key areas of
Assessment

Sensory Motor Other

Vision (look for fields cuts)
Smell (rule out anosmia)
Recognition (rule out
agnosia)
Strength, tone, gait(rule out Aphasia, Confabulation
ataxia)
Fine Motor movements, Seizures
speed, coordination
Coordination (observe for Frontal release signs
tremor)
Motor imitation (rule out
apraxia)
Reflexes
Table 7. Common endocrine disturbances after
traumatic brain injury
 Hypo/hyperthyroidism
 Impaired growth hormone release
 Impaired adrenal cortical function
 Hypopituitarism
 Hypothalamic hypogonadism
 Precocious puberty
 Hyperphagia
 Temperature dysregulation
 Syndrome of inappropriate antidiuretic hormone
 Diabetes insipidus
 Menstrual irregularities
 Changes in sexual function
 Table 8. Symptoms reported by family members of patients with severe brain
injury

% Reporting

Reported Symptom Mother Wife

Frustration 100 84
Irritability 55 74
Annoyance 55 68
Depression 45 79
Decreased social contact 27 77
Anger 45 63
Financial Insecurity 18 58
Guilt 18 47
Feeling trapped 45 42
 Table 9. “Bedside "evaluation of frontal lobe
function
Test Description
Clock Drawing test Instruct the patient to draw a clock,
including all the numbers, setting the
time at 10 past 11 (Provide all
instructions first, and then allow the
patient to begin)
Verbal Fluency Ask the patient to list number of words
that begin with the same letter or
number of animals named in 1 minute
Set shifts and sequencing (Verbal and Verbal: ask the patient to continue the
Written) pattern 1A-2B-3C written: ask the
patient to connect numbers in a
sequential and alternating manner (1A-
2B-3C, etc.)
Frequent findings
Poor planning( numbers inappropriately
positioned; numbers do not fit inside
clock; excess space inside clock,
perseveration, etc.)
Unable to name 10 or more words
perseveration
Perseveration
Inability to consistently shift sets (e.g.
1A-2B-3C-4C-5C-6C. Etc., or 1A-2B-
3C-3D-3E-3F,etc)
“Fist-palm-side” Ask the patient to place his or her right Perseveration of movement
fist into left palm, the right palm into
left palm, and then right side of hand
into left palm in a sequential manner
“Go-No Go "test Ask the patient to say “two "when one Inability to inhibit the visual stimulus
finger is held up; “one "when two (says “one "when one finger is
fingers are displayed displayed)
 Table 10. Mayo Portland Adaptability Inventory – 4 (MPAI-4) indexes and
item content

Ability Index Adjustment Index Participation Index

Mobility Anxiety Initiation
Use of hands Depression Social contact
Vision Irritability, Anger , Aggression Leisure and recreational activities
Audition Pain and Headache Self-care
Dizziness Fatigue Residence(i.e., homemaking
Motor speech Sensitivity to mild symptoms Transportation
Verbal communication Inappropriate social interaction Paid employment
Nonverbal communication Impaired self-awareness Other employment
Attention/concentration Family/ significant relationships Managing money and finances
Memory
Fund of information
Novel problem solving
Table 11. Items in the Sydney Psychosocial
Reintegration Scale

 Occupational Activities
1. Current work: Have the hours of work (or study) or the type of work (or study) your
relative does changed because of the injury
2. Work skills: has your relative’s ability to do his or her job(or studies) changed because of
the injury
3. Leisure: Has there been and decrease in the number of leisure activities or a change in the
types of leisure activities that your relative does now because of the injury?
4. Organizing activities: has there been any changes in relative’s ability to organize work
and leisure activities because of the injury
 Interpersonal Relationships
5. Spouse/partner: has your relative’s relationship with his or her partner changed because of
the injury? (if your relative does not have a partner at present. Has there been any changes
in him or her that would affect such a relationship?)
6. Family: Has your relative’s relationships with any other family members (except partner)
changed because of the injury?
7. Friends and other people: Has your relative’s relationships with other people outside
family (such as close friends, workmates, neighbours) changed because of the injury?
8. Communication: has your relative’s ability to communicate with other people (i.e. , Talk
with other people and understand what others say) changed because of the injury ?
 Independent Living Skills
9. Social skills: have your relative’s social skills and behavior in public changed because of
the injury
10. Personal Habits: Have your relative’s personal habits (e.g. his or her care in cleanliness,
dressing, and tidiness) changed because of the injury?
11. Transport: Has your relative’s ability to get about in the community and use transport
changed due to the injury ?
12. Accomodation: Has your relative’s abilities to live independently changed due to your
injury?
Table 12. Comprehensive assessment of
traumatic brain injury

 History
 Physical examination
 Mental status examination
 Mini-Mental state examination
 “Bedside” cognitive testing
 Neuropsychological testing
 Computed tomography of head (acute)
 Magnetic resonance imaging
 Functional brain imaging (single-photon emission computed tomography, positron emission tomography, functional magnetic
resonance imaging
 Electroencephalogram
 Evoked potentials
 Key Clinical Points

 A biopsychosocial approach is a useful framework in the neuropsychiatric assessment of traumatic brain injury (TBI) given the direct effects of injury on
the brain as well as the psychosocial impact of the injury
 Because most TBIs are invisible, with no external signs of injury, it is important to routinely screen patients for TBI by assessing for any history of head
injury resulting in an alteration in mental status and a subsequent change in functioning
 The most common parameters used in categorizing the severity of TBI are the Glagsgow Coma Scale, duration of loss of consciousness and length of
posttraumatic amnesia
 When assessing symptoms and signs of TBI, it is helpful to categorize them into cognitive, emotional, behavioural, and physical domains, with particular
attention to the temporal sequence of symptoms
 Although a thorough history is key to TBI diagnosis, “bedside "frontal lobe testing and specific rating scales are effective screening and assessment tools
 Because of the alteration of mental status and poor insight associated with TBI, it is imperative to obtain collateral information regarding the injury and
current functioning whenever possible.
 A risk factor for numerous psychiatric disorders are often comorbid with substance abuse, TBI is associated with a greater lifetime prevalence of suicide.
 Consideration of preinjury factors, such as the positive effect of higher education and negative effect of a history of psychiatric illness, is important in
estimating prognosis.
 A comprehensive assessment of TBI includes neuropsychological testing, electroencephalogram, and neuroimaging, with promising functional imaging
techniques and genetic testing for risk and resilience factors on the horizon
 The goal of a detailed neuropsychiatric evaluaton in TBI is to create a comprehensive treatment plan that will minimize the impact of disability and
maximize independence, well-being, social participation, and productivity