Psychiatric Disorder or Behavior Secondary to Brain Injury?

The scene of the accident was horrific. A semi-truck travelling at a high rate of speed had slammed into the side of a highway patrol car. It took the 45 minutes to extricate the highway patrolman from his car. He was then airlifted to a hospital for the treatment of his severe injuries, which included a brain injury. A.V. had an alteration of consciousness at the scene and his Glasgow Coma Scale score was 3, indicating a severe brain injury. Other injuries included blunt chest and abdominal trauma, a right T2 transverse process spine fracture, a fracture to the right clavicle and fractures to the right first rib. An MRI of the brain revealed a subdural hematoma, cerebral contusions in the left temporal and bilateral frontal and parietal lobes, a right temporoparietal head laceration, a left temporoparietal skull fracture, and diffuse axonal injury to the white matter tracts in the brain.

Once A.V. had been medically stabilized, he was transferred to an acute rehabilitation facility for rehabilitation for his severe brain injury. Poor safety awareness, inability to consistently follow simple commands, decreased short-term memory, and impaired bilateral motor control were some of the deficits A.V. experienced upon admission to the acute rehabilitation facility. A.V. was not oriented to time, month, day, year or place and had started to express agitated behaviors. These problem behaviors had taken the form of angry language, being obnoxious and belligerent, threatening staff and attempting to exit the facility. These behaviors escalated to the point where staff called security and police officers to manage A.V.'s behaviors. Staff felt A.V. was not able to reason with staff and it was felt that he was incapable of making safe decisions. A.V. was taken to the emergency department even though there were no new neurological changes reported. A.V.'s behaviors persisted and he was sedated with intramuscular injections of Haldol, Ativan and Benadryl. He was then admitted into a locked psychiatric facility.

A psychiatric evaluation was conducted with A.V. There were no immediate reports of suicidal or homicidal ideation. The treatment plan was to keep A.V. in the locked psychiatric unit, continue with the medications he had received and add Seroquel, a mood stabilizer. Once A.V. realized staff had been mixing his medications in his food to increase medication compliance, he stopped eating.

Approximately, one month after his injury, A.V. was admitted to Centre for Neuro Skills®, a post-acute residential brain injury facility. A.V. was admitted into the inpatient program and received up to five hours of treatment Monday through Friday in the areas of physical and occupational therapies, cognitive rehabilitation, education therapy and counseling. Residential treatment programs focusing on activities of daily living and community re-integration occurred in the evenings and on weekends. At the time of admission to Centre for Neuro Skills®, A.V. was able to ambulate without the use of an assistive device but he had higher level balance impairments impacting his ability to cross streets safely. He also experienced problems with word finding, tangential and perseverative speech, decreased short-term memory and attention, delayed speed of information processing, confabulation, impaired problem solving ability, decreased physical endurance, decreased visual response times and impaired insight into his disability.

Initially, A.V. displayed problem behaviors including decreased cooperation, refusals and socially inappropriate behaviors. A.V.'s behavior was monitored every 15 minutes in the clinic setting and within one month of admission, he was fully cooperating in therapy sessions and his socially inappropriate behavior had decreased to the point where 15-minute monitoring was no longer necessary. A.V. was admitted to Centre for Neuro Skills® on Celebrex, Zyprexa, Zantac, Restoril, Ativan and a multi-vitamin. All medications were discharged within the first month of treatment, except the multi-vitamin and a blood pressure medication used to control his pre-existing hypertension.

A.V. spent approximately 3 months in treatment at Centre for Neuro Skills®. At the time of discharge, A.V. had increased his word finding skills, improved memory and attention, had passed a height evaluation and power tool assessment, had completed an adaptive driving evaluation and had been cleared to drive, and had participated in physical training required for return to his work as a highway patrolman. A.V. was being discharged home to his wife and children with no attendant care. He will also be able to return to work as a highway patrol officer once he completes the Fitness for Duty test.

It should be noted that A.V. did not have nor show any signs of a psychiatric disorder since his admission to CNS. In fact, court ordered psychiatric treatment was dismissed due to improvement noted in all areas of functioning. Often times, individuals who have suffered a brain injury will develop socially inappropriate behaviors as a result of their injury. Medications often used to treat challenging behaviors may elicit more agitation from the person with brain injury and or confuse the person at a time when attention and arousal are already problematic. The keys to successful treatment of problem behaviors involve the appropriate diagnosis, structured treatment and the use of applied behavioral analysis techniques. These techniques proved to be successful in A.V.'s case.