Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study
Koponen S, Taiminen T, Portin R, Himanen L, Isoniemi H, Hinkka S and Tenovuo O;
Commented by , 25 Sep 2002
Background
While psychiatric morbidity following traumatic brain injury (TBI) is common, short follow-up periods and lack of structured interviews in previous research limit our understanding of this problem.
Purpose
Evaluate the occurrence of axis I and II disorders following TBI over a 30-year period. (For information on the DSM-IV axis, see www.behavenet.com, ed. note)
Methods
Retrospective follow-up of 60 patients initially referred for neuropsychological evaluation, an average of 30 years post-TBI. Demographic data was obtained; including severity of TBI based on duration of amnesia.
Current and lifetime DSM-IV axis I disorders were diagnosed using the Schedules for Clinical Assessment in Neuropsychiatry. Personality disorders (PDs) were diagnosed with the Structured Clinical Interview for DSM-III-R Personality Disorders; organic personality syndrome was assessed as per DSM-III-R.
Collateral history was sought from relatives for unreliable interviews. The Mild Deterioration Battery evaluated cognitive functioning. Chi-square or Fisher’s exact tests measured differences in categorical variables, and one-way ANOVA for continuous variables. 95% confidence intervals for rates of psychiatric disorders.
Results
Novel axis I disorders developed in 48.3% post-TBI; lifetime and current axis I disorders were found in 61.7% and 40.0%, respectively. The most common novel axis I disorders were
- major depression (26.7%)
- alcohol abuse or dependence (11.7%)
- panic disorder (8.3%)
- specific phobia (8.3%)
- psychotic disorders (6.7%)
Definite PDs or organic personality syndrome (OPS) was found in 30%; additional subthreshold PDs and OPS were found in 18.3% and 8.3%, respectively. The most prevalent PDs were
- avoidant (15%)
- paranoid (8.3%)
- schizoid (6.7%)
Approximately one-third of patients with a lifetime axis I disorder had a comorbid PD or OPS, and almost two-thirds of patients with the latter had a lifetime axis I disorder. Total rates of novel axis I disorders, PDs and OPS did not significantly differ among the four severity levels of TBI. Nor were there any significant gender differences in the total rates of novel axis I disorders, PDs or OPS.
13.8%, all male, had very significant cognitive impairment, with no significant differences among the four TBI severity levels.
Discussion
The high rate of axis I and II disorders post-TBI is a striking finding. Compared to the population-based Epidemiological Catchment Area survey, the prevalence of current and lifetime axis I disorders was approximately double in this TBI sample.
Similarly, the prevalence rate of PDs was at least double compared with population studies, noteworthy based on observations of PDs declining with age.
The study illustrates psychiatric morbidity post-TBI is not merely a state phenomenon, rather an enduring disability throughout one’s life. As observed previously, psychiatric morbidity was not related to the severity of the injury.
This study highlights the interface between neurology and psychiatry, specifically the importance of monitoring for psychiatric illness in this population. Unfortunately, the extent to which this naturalistic sample received effective treatment was not addressed, a perennial problem with this disabled population too often narrowly conceptualized as either “psychiatric” or “neurological”.
Additional limitations, as noted by the authors, include the possible sampling bias of a group referred for neuropsychological evaluation, along with the reliability of retrospective diagnoses, particularly where collateral sources were not consistently available.