Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study

OBJECTIVE: Patients who had suffered traumatic brain injury were evaluated to determine the occurrence of psychiatric disorders during a 30-year follow-up. METHOD: Sixty patients were assessed on average 30 years after traumatic brain injury. DSM-IV axis I disorders were diagnosed on a clinical basis with the aid of the Schedules for Clinical Assessment in Neuropsychiatry (version 2.1), and axis II disorders were diagnosed with the Structured Clinical Interview for DSM-III-R Personality Disorders. Cognitive impairment was measured with a neuropsychological test battery and the Mini-Mental State Examination. RESULTS: Of the 60 patients, 29 (48.3%) had had an axis I disorder that began after traumatic brain injury, and 37 (61.7%) had had an axis I disorder during their lifetimes. The most common novel disorders after traumatic brain injury were major depression (26.7%), alcohol abuse or dependence (11.7%), panic disorder (8.3%), specific phobia (8.3%), and psychotic disorders (6.7%). Fourteen patients (23.3%) had at least one personality disorder. The most prevalent individual disorders were avoidant (15.0%), paranoid (8.3%), and schizoid (6.7%) personality disorders. Nine patients (15.0%) had DSM-III-R organic personality syndrome. CONCLUSIONS: The results suggest that traumatic brain injury may cause decades-lasting vulnerability to psychiatric illness in some individuals. Traumatic brain injury seems to make patients particularly susceptible to depressive episodes, delusional disorder, and personality disturbances. The high rate of psychiatric disorders found in this study emphasizes the importance of psychiatric follow-up after traumatic brain injury.     

Axis I and Axis II diagnoses in patients with chronic idiopathic urticaria

OBJECTIVE: This study presents the current prevalence of Axis I and Axis II psychiatric diagnoses and factors associated with the existence of Axis I psychiatric disorders in patients with chronic idiopathic urticaria (CIU). METHOD: The study sample was composed of 89 patients with CIU and 64 control subjects. Axis I and Axis II psychiatric disorders were ascertained by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders, respectively. RESULTS: Of patients with CIU, 44 (49.4%) had at least one Axis I diagnosis, and 40 (44.9%) had at least one personality disorder. The most common Axis I disorder was obsessive-compulsive disorder (25.8%), and the most common Axis II disorder was obsessive-compulsive (30.3%) personality disorder in patients with CIU. Obsessive-compulsive disorder, major depression, obsessive-compulsive and avoidant personality disorders were more prevalent in patient group compared to control group. Obsessive-compulsive and avoidant personality disorders were related to the existence of Axis I disorders in patients with CIU. CONCLUSION: Psychiatric morbidity seems to be a frequent healthy problem in patients with CIU.     

Predictors of personality change due to traumatic brain injury in children and adolescents in the first six months after injury

OBJECTIVE: To assess the phenomenology and predictive factors of personality change due to traumatic brain injury. METHOD: Children (N = 177), aged 5 to 14 years with traumatic brain injury from consecutive admissions to five trauma centers, were followed prospectively at baseline and 6 months with semistructured psychiatric interviews. Injury severity, lesion characteristics, and preinjury variables including psychiatric disorder, family psychiatric history, family function, socioeconomic status, psychosocial adversity, and adaptive function were assessed with standardized instruments. RESULTS: Personality change occurred in 22% of participants in the first 6 months after injury. Severity of injury predicted personality change, whereas none of the psychosocial variables predicted personality change. Lesions of the dorsal prefrontal cortex, specifically the superior frontal gyrus, were associated with personality change after controlling for severity of injury or the presence of other lesions. CONCLUSIONS: These findings are consistent with models of affective dysregulation that implicate a dorsal prefrontal cortex system important for effortful regulation of affective states.     

Personality dimensions measured by the Temperament and Character Inventory (TCI) in subjects with social phobia

The present study investigated personality dimensions by means of the Temperament and Character Inventory (TCI) in subjects with social phobia with or without a co-existing avoidant personality disorder. Thirty-one individuals with social phobia were recruited through advertisement and diagnosed with the Structured Clinical Interview for DSM-IV I and II psychiatric disorders. Comorbid Axis I psychiatric disorders were diagnosed in 29% of the cases. Co-occurring personality disorders were present in 55.8% of the cases, and avoidant personality disorder in 48.4%. The social phobia subjects, as compared to healthy controls of the same age, scored significantly higher in the TCI dimension measuring Harm avoidance but significantly lower in Persistence, Self-directedness, Cooperativeness and Self-transcendence. Presence of avoidant personality disorders in the social phobia subjects was associated with significantly higher Harm avoidance, particularly on the subscale Shyness with strangers. In conclusion, individuals with social phobia were characterized by high comorbidity of avoidant personality disorder and deviations in TCI personality dimensions. Enhanced Harm avoidance was the most prominent personality trait. The observed deviations in TCI dimensions were primarily related to the social phobia itself and not to the presence of concurrent personality disorders.     

重型颅脑损伤患者精神障碍的临床分析

目的 探讨重型颅脑损伤后精神障碍的发生率、表现形式及影响因素。方法 以深圳市1999年10月1日至2000年9月30日因交通事故所致重型颅脑损伤的183例幸存者为研究对象,在颅脑损伤治疗后（平均6个月）,由2名精神科副主任医师根据中国精神疾病分类方案与诊断标准第2版修订本对这些伤者的精神状态进行评估。结果 （1）在183例中,罹患各类精神障碍者共165例,发生率为90．2％,其中智能障碍者为142例（77．6％）。（2）在183例,中度及其以上智力损伤者为29例（15．8％）。（3）有智力损伤组的脑干损伤、颅内血肿及≥3个脑叶损伤的比例高于无智力损伤组（P＜0．01）;伴有精神障碍组的平均年龄（P＜0．05）、脑干损伤（P＜0．05）及≥3个脑中损伤（P＜0．01）的比例高于无精神病性障碍组;有人格改变组额叶损伤、开颅清除血肿并减压治疗的比例高于无人格改变组（P＜0．01）。结论 重型颅脑损伤后精神障碍的发生率较高,应引起有关临床学科的重视。     

APOE-epsilon4 predicts dementia but not other psychiatric disorders after traumatic brain injury

The authors studied the association between APOE-epsilon4 genotype and axis I and II psychiatric disorders an average of 30 years after traumatic brain injury. Sixty patients were dichotomized into subjects with and without APOE-epsilon4 allele. Dementia and subclinical dementia were significantly more common with the presence of APOE-epsilon4. The occurrence of other psychiatric disorders did not differ between patients with and without APOE-epsilon4 allele.     

Quality of life in patients with chronic idiopathic urticaria: the impact of Axis I and Axis II psychiatric disorders

OBJECTIVE: Chronic idiopathic urticaria (CIU) associated with lower quality of life (QoL) levels. Psychiatric disturbances are frequently present in patients with CIU. This study examined the impact of Axis I and Axis II psychiatric disorders on the QoL of patients with CIU. METHOD: The study sample consisted of 100 subjects including CIU patients with only Axis I psychiatric diagnoses (n=25), CIU patients with only Axis II diagnoses (n=25), CIU patients with both Axis I and Axis II diagnoses (n=25), CIU patients without any Axis I and Axis II diagnosis (n=25), and healthy control subjects with respect to urticaria and psychiatric disorders (n=25). The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (SCID-1) and the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders (SCID-II) was used to determine Axis I and Axis II psychiatric disorders, respectively. QoL levels were assessed by means of the World Health Organization QoL Assessment-Brief (WHOWOL-BREF). RESULTS: There were significant differences among the groups with respect to all WHOQOL-BREF subscale scores. The QoL levels were similar among CIU patients with only Axis I psychiatric diagnoses, CIU patients with only Axis II diagnoses and CIU patients with both Axis I and Axis II diagnoses, and between CIU patients without any Axis I and Axis II diagnosis, and healthy control subjects. When compared with those of CIU patients without any Axis I and Axis II diagnosis, CIU patients without concurrent psychiatric diagnoses had significantly lower scores in most domains of the QoL scale. CONCLUSIONS: Axis I and Axis II psychiatric disorders seem to be considerable factors influencing the QoL in CIU patients.     

Restless legs syndrome as a possible predictor for psychiatric disorders in parents of children with ADHD

Attention-deficit hyperactivity disorder (ADHD) is a common disorder with estimated prevalence of 5% in children and 3.4% in adults. Psychiatric disorders are a frequent concomitant feature. Restless legs syndrome (RLS) may mimic the symptoms of ADHD. The aim of the study is to evaluate whether the presence of RLS predicts occurrence of psychiatric disorders in parents of children with ADHD. Thirty-seven parents of 26 children with ADHD were examined for RLS and for lifetime prevalence rates of psychiatric disorders and personality disorders based on the Structured Clinical Interview for DSM-IV Diagnoses (SCID). Prevalence rates in parents were 29.7% for RLS, 67.6% for Axis I and 40.5% for Axis II disorders. Mothers revealed higher rates for depression, anxiety disorders and ADHD than fathers, whereas personality disorders occurred at higher rates in fathers. The presence of RLS predicted a diagnosis of ADHD (odds ratio (OR) 21.9), agoraphobia (OR = 20.4) and any anxiety disorder (OR = 8.5). Although limited by the small sample size, we found evidence for increased rates of cluster B personality disorders (OR = 59.3) in parents with RLS. All parents of the latter group (100%) reported a positive family history of psychiatric disorders which was not the case in parents without RLS (69.2%) excluding the index children with ADHD. RLS seems to indicate increased vulnerability for psychiatric disorders, i.e., ADHD and anxiety disorders, in a subgroup of parents from ADHD children. Synaptic dysfunction affecting dopaminergic transmission among other transmitter systems may be a common final pathway related to the phenotypic spectrum of ADHD.     

Axis I and Axis II diagnoses in women with PCOS

Objective

The objective was to determine the current prevalence of Axis I and Axis II psychiatric diagnoses in patients with polycystic ovary syndrome (PCOS).

Method

The study sample included 73 patients with PCOS and 73 control subjects. Psychiatric disorders were determined by structured clinical interviews.

Results

The rate of any Axis I psychiatric disorder (28.8% vs. 15.1%), social phobia (13.7% vs. 2.7%), generalized anxiety disorder (11.0% vs. 1.4%), any Axis II psychiatric disorder (23.3% vs. 9.6%) and avoidant personality disorder (12.3% vs. 1.4%) was significantly more common in the patient group compared to the control group.Of women with PCOS, 21 (28.8%) had at least one Axis I and 17 (23.3%) had at least one Axis II diagnosis. The most common Axis I disorder was social phobia (13.7%) and the most common Axis II disorder was avoidant personality disorder (12.3%) in women with PCOS. Social phobia, generalized anxiety disorder, and avoidant personality disorder were significantly more common in the patient group compared to the control group.

Conclusion

Our results suggest that a considerable proportion of women with PCOS also present with anxiety and personality disorders.     

Boomerang Sign on MRI

Introduction

Altered mental status and more subtle cognitive and personality changes after traumatic brain injury (TBI) are pervasive problems in patients who survive initial injury. MRI is not necessarily part of the diagnostic evaluation of these patients.

Methods

Case report with relevant image and review of the literature.

Results

Injury to the corpus callosum is commonly described in traumatic brain injury; however, extensive lesions in the splenium are not well described. This image shows an important pattern of brain injury and demonstrates a common clinical syndrome seen in patients with corpus callosum pathology.

Conclusion

Injury to the splenium of the corpus callosum due to trauma may be extensive and can cause significant neurologic deficits. MRI is important in the diagnostic evaluation of patients with cognitive changes after TBI.     

The reliability of evidence about psychiatric diagnosis after serious crime: part II. Agreement between experts and treating practitioners

In this second part of our study, we examined the extent of agreement between treating practitioners and expert witnesses on psychiatric diagnoses in evidence presented in criminal proceedings. We found good agreement on diagnoses of acquired brain injury, schizophrenia-spectrum psychoses, depressive disorders, intellectual disability, substance abuse, and personality disorders; fair agreement on substance-induced psychotic disorder; and poor agreement on the presence of anxiety disorders. A proportion of defendants with diagnosis by experts of substance-induced psychotic disorder also had a diagnosis of schizophrenia-spectrum psychosis by treating practitioners. Treating practitioners and experts engaged by the prosecution rarely made the diagnosis of post-traumatic stress disorder. Overall, there was moderate agreement between experts and treating practitioners on the principal Axis I disorder, and the evidence for psychiatric diagnoses presented by treating practitioners in criminal cases was found to be generally reliable.     

Small orbitofrontal traumatic lesions detected by high resolution MRI in a patient with major behavioural changes

We report a case of a male patient who showed personality changes and marked social problems after a traumatic brain injury. Although suspected to have lesions in the orbitofrontal cortex because of the typical characteristics of his behavioural change, lesions were not apparent using conventional imaging techniques. However, investigation using high-resolution MRI revealed lesions in the orbitofrontal cortex. Our case suggests that standard MRI scanning techniques may have only limited power. Hence, we stress the important role played by qualitative assessments of emotion, personality, and social behaviour in evaluating sequelae of traumatic orbitofrontal injuries.     

Psychiatric comorbidity as a predictor of clinical response to nortriptyline in treatment-resistant major depressive disorder

BACKGROUND: A number of studies of major depressive disorder suggest that psychiatric co-morbidity may contribute to treatment resistance. The purpose of this study was to test whether the presence of comorbid Axis I and Axis II disorders predicts clinical response to an open trial of nor-triptyline among patients with treatment-resistant depression. METHOD: Ninety-two outpatients with treatment-resistant DSM-III-R major depressive disorder were enrolled in a 6-week open trial of nor-triptyline (Nov. 1992-Jan. 1999). The presence of comorbid Axis I and Axis II disorders was established at baseline with the use of the Structured Clinical Interview for DSM-III-R. Chi-square analyses were used to test Axis I or Axis II co-morbid conditions as a predictor of clinical response to nortriptyline. RESULTS: Thirty-nine patients (42.4%) responded to nortriptyline. The presence of avoidant personality disorder (p <.01) predicted poorer response to nortriptyline. The response rate was 16.7% for patients with and 48.6% for patients without comorbid avoidant personality disorder. No other comorbid diagnoses were found to predict clinical response in a statistically significant manner. CONCLUSION: The presence of avoidant personality disorder conferred a poorer prognosis in treatment-resistant depression patients treated with nortriptyline.     

Psychiatric symptoms and cerebellar pathology

The authors describe three patients hospitalized for psychiatric disorders, all of whom had cerebellar lesions. Referring to recent research on nonmotor cerebellar functions, the authors suggest that patients with cerebellar lesions may develop an organic brain syndrome that closely resembles the organic brain syndrome associated with cerebral cortical lesions.     

Mood and behavioral symptoms in individuals with chronic solvent exposure

Psychiatric symptoms have been reported for individuals who experience chronic exposure to low levels of organic solvents. However, it is not known what proportion of such individuals experience psychiatric disorder; which specific disorders may be characteristic of this population; or whether bioaccumulation of lead contributes to the relationship between solvent exposure and psychiatric symptoms. Twenty-nine male journeymen painters and 32 male non-painter control subjects were administered semi-structured diagnostic interviews for DSM-III-R Axis I and Axis II disorders. Career solvent exposure and blood lead levels were also measured. Painters and control subjects did not differ significantly with respect to age, intelligence, or demographic characteristics. Results showed that the probability of being diagnosed with a mood disorder differed significantly in painters (41%) and control subjects (16%). Painters (66%) and control subjects (50%) did not differ for substance use diagnoses. Groups also did not differ for personality disorders involving an onset before 25 years of age. In contrast, painters exhibited a sub-clinical pattern of personality dysfunction involving symptomatology that was measured allowing for late onset (after age 25). Finally, a significant dose–response relationship was observed between career solvent exposure, blood lead level, and personality symptoms. In summary, these data showed an increased rate of psychological disturbance in a significant and substantial number of painters. However, not all painters were so characterized. This overall pattern raises a question regarding a potential role for differential vulnerability, which requires empirical validation.     

Comparison of MRI and electrophysiological studies for detecting brainstem lesions in traumatic brain injury

The yield of magnetic resonance imaging (MRI) and electrophysiological studies in detecting brainstem lesions was assessed in 35 patients suffering from traumatic brain injury (Glasgow Coma Scale, 3-10). As an inclusion criterion, all patients had brainstem trauma as revealed by early MRI or electrophysiological studies. Of the 35 cases, 7 (20%) had brainstem lesions detected by MRI only, whereas in 10 patients (29%), electrophysiological examination disclosed impairment of brainstem function with normal MRI. In 18 (51%) subjects, both diagnostic techniques revealed brainstem lesions. The midbrain was the most common location of lesions. Masseter reflex recording had the highest yield (93%) of abnormal findings. No mismatch with respect to site and side of abnormality occurred between MRI and electrophysiological studies. Outcome analysis indicated an unfavorable course for the vast majority (83%) of patients, regardless of the diagnostic means disclosing traumatic brainstem injury. Therefore, both techniques are effective in disclosing traumatic brainstem injury, with diagnostic overlap in about 50% of cases. In contrast to MRI, electrophysiological investigation is easily performed and repeated at low cost in the setting of an intensive care unit, where such patients are typically hospitalized after trauma. In addition to electrophysiological assessment of brainstem function, MRI is recommended in each case having normal electrophysiological findings when brainstem injury is suspected.     

MR-based in vivo hippocampal volumetrics: 2. Findings in neuropsychiatric disorders

Magnetic resonance imaging (MRI) has opened a new window to the brain. Measuring hippocampal volume with MRI has provided important information about several neuropsychiatric disorders. We reviewed the literature and selected all English-language, human subject, data-driven papers on hippocampal volumetry, yielding a database of 423 records. Smaller hippocampal volumes have been reported in epilepsy, Alzheimer's disease, dementia, mild cognitive impairment, the aged, traumatic brain injury, cardiac arrest, Parkinson's disease, Huntington's disease, Cushing's disease, herpes simplex encephalitis, Turner's syndrome, Down's syndrome, survivors of low birth weight, schizophrenia, major depression, posttraumatic stress disorder, chronic alcoholism, borderline personality disorder, obsessive-compulsive disorder, and antisocial personality disorder. Significantly larger hippocampal volumes have been correlated with autism and children with fragile X syndrome. Preservation of hippocampal volume has been reported in congenital hyperplasia, children with fetal alcohol syndrome, anorexia nervosa, attention-deficit and hyperactivity disorder, bipolar disorder, and panic disorder. Possible mechanisms of hippocampal volume loss in neuropsychiatric disorders are discussed.     

Depression in patients with acute traumatic brain injury.

OBJECTIVE: This study was undertaken to examine patients with closed head injuries for the presence of depressive disorders. METHOD: A consecutive series of 66 patients with closed head injuries but no significant spinal cord or other organ system injury were examined by means of a semistructured psychiatric interview. The Hamilton Rating Scale for Depression as well as scales measuring impairment in activities of daily living, intellectual functioning, and social functioning were administered. The patients' CT scans were also examined. RESULTS: Seventeen patients had major depression and two had minor depression. The presence of left dorsolateral frontal lesions and/or left basal ganglia lesions and, to a lesser extent, parietal-occipital and right hemisphere lesions was associated with an increased probability of developing major depression. Compared to the nondepressed group, the group with major depression had a higher frequency of previous psychiatric disorder and showed evidence of poorer social functioning. CONCLUSIONS: Major depression occurs in about one-quarter of patients after traumatic brain injury. This is the same frequency as in other major disorders such as stroke. Major depression appears to be provoked by one or more factors that include poor premorbid social functioning and previous psychiatric disorder or injury to certain critical brain locations.     

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.     

180例颅脑外伤后精神障碍的鉴定结果分析

目的探讨颅脑外伤后精神障碍的临床类型及相关因素。方法收集180例颅脑外伤后司法鉴定案例资料,并对精神障碍的临床类型及相关因素进行分析。结果精神障碍的鉴定诊断类型为:器质性遗忘综合征、器质性人格改变、器质性智能损害、器质性神经症样症状和器质性精神症状。以颞叶、额叶、弥漫性损伤多见,共163例,且CT显示多有颞叶、额叶软化灶等异常,共123例。影响智能损害的因素为颞叶或额叶损伤、外伤程度严重,CT及EEG异常。器质性神经症样症状多见于女性,外伤程度轻,多无弥漫性损伤,CT未见明显异常。结论颅脑外伤后精神障碍多见于颞叶、额叶、弥漫性损伤;智能损害者外伤程度严重,EEG异常率高;器质性神经症样症状与轻度脑损伤有关。