Mental disorders associated with traumatic brain injury
Introduction
Introduction to mental disorders associated with traumatic brain injury Because the brain suffers from various traumas directly or indirectly, and the mental disorders and subsequent syndromes that appear on this basis are mental disorders associated with craniocerebral injury. The diagnosis should indicate the type of craniocerebral injury and the type of syndrome that is left behind, such as concussion syndrome, psychotic symptoms caused by brain contusion, personality changes caused by brain contusion, dementia, amnesia syndrome, etc. Mental disorders are divided into acute mental disorders and chronic mental disorders. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: post-traumatic syndrome
Cause
Causes of mental disorders associated with traumatic brain injury
(1) Causes of the disease
Whether there are mental disorders and manifestations of mental disorders in craniocerebral injury are related to the degree and location of craniocerebral injury. The more serious the injury, the more extensive the site, the more likely it is to cause mental disorder. The time of psychiatric symptoms is directly related to the severity of trauma. In addition, it has a certain relationship with the neurological type, environmental factors, individual quality, and the psychological state before and after the injury and the psychological state during the injury. The mechanism may be a transient cerebral circulation disorder, and the nerve conduction pathway is blocked by the brain cell disorder. Central nervous cell membrane discharge causes neuronal excitability changes, brain neuron damage causes disturbance of consciousness, brain stem network structure is damaged, and the negative evaluation of brain injury may be the main cause of psychogenic disorder.
(two) pathogenesis
Primary brain injury
(1) Concussion: Concussion refers to the temporary disorder that occurs when the brain functions in the head. It is the lightest type of craniocerebral injury. Most of them have no evidence of organic damage, but there are also very few deaths. By.
The main problem of psychiatry is the post-concussion syndrome. There are many theories about the mechanism of post-concussion syndrome, but it is not only organic factors, psychosocial factors, the mixed mechanism of the two and some corrected insights. The immediate factor of shock is obviously the effect of violence on the skull, and the post-concussion syndrome often lasts for a long time, obviously not only the impact of trauma.
1 etiology study:
A. Psychogenesis: Lidvall et al (1974) found that women and non-technical workers are prone to post-concussion syndrome. These people have psychological stress in the early stages of craniocerebral trauma, and the symptoms are reflected in their accidents. Anxiety, fear of disease and possible damage to brain structures.
B. Physiological mechanism: Rutherford holds an organic view. He observed 145 patients with mild head injury. Afterwards, 74 (51%) found one or more symptoms of concussion syndrome. He found that within 24 days after the injury, these patients had headache, diplopia, loss of odor and other symptoms, and these symptoms were higher in the 6 weeks after sputum, Montgomery et al (1991) on 26 cases of mild trauma (after traumatic forgetting) No more than 12 days) follow-up observations revealed that half of the patients still had symptoms at 6 and 6 months after the injury. The wave in the EEG was changed, the brain stem conduction was delayed, and the response time was prolonged.
C. Both organic and non-organic factors work together: Keshavan et al. (1981) observed 60 patients with mild head injury in the emergency department and found that the occurrence of post-concussion syndrome and post-traumatic amnesia (posttraumatic amnesia , PTA) is associated with intellectual impairment and is also associated with pre-patient neuroticism.
D. Psychosocial factors have an impact, but organic factors are also involved: Kay et al (1971) studied 474 patients with craniocerebral injury, including 94 cases of post-concussion syndrome, followed by 3 to 6 months, found that psychosocial factors An important role suggests that if the syndrome persists after a concussion, the symptoms of neurosis may be secondary and the course of the disease may be delayed.
E. Irrespective of organicity: Lishman (1968) observed 670 brain injury soldiers in World War II, and found that 71 people still have post-concussion syndrome after 1 to 5 years. These patients have no intellectual damage, and they believe that The organic factor has nothing to do with it.
F. Quality factors are more obvious than organic factors: Denker (1958, 1960) studied 63 pairs of single-oval twins and 81 pairs of twin-oval twins, and found that tracking was 3 to 25 years (average 10 years), and the injured side was concussed. In the occurrence of post-syndrosis, the role of quality factors is more obvious than the instrumental factors.
2 The occurrence of post-concussion syndrome is related to the following factors, in addition to the above factors:
A. Pre-injury factors: age, cerebral arteriosclerosis, alcoholism, mental quality (genetic vulnerability, past mental illness, personality traits), pre-existing psychosocial difficulties (family, economic, professional), recent life Events and other factors play a role in post-concussion syndrome after injury (Lishman, 1988).
B. Peritraumatic factor: loss of consciousness during injury, forgetfulness after trauma, other physical injuries (skull, scalp, vestibular device), emotional influence and meaning (fear of serious consequences), injury environment (traffic accident, Factors such as industrial trauma, sports accidents, home events, etc. should also be considered in the study of the occurrence of post-concussion syndrome. The iatrogenic effects may also be brought about in emergency rescue during injury.
C. Post-traumatic factors: including mental damage, physical disability, malformation, scar formation, seizures, etc. If there is an emotional response to an accident (referring to trauma) after an injury, persistent psychosocial difficulties, compensation and litigation issues , will inevitably affect the course of post-concussion syndrome.
3 Mechanism of disturbance of consciousness during concussion: disturbance of consciousness can occur from a few seconds to 30 minutes during concussion. There are many hypotheses about the mechanism of coma, but it has not been fully clarified so far:
A. Cerebrovascular theory advocates that concussion is a barrier to transient cerebral circulation.
B. Cellular Molecular Disorders The authors believe that concussion is a molecular disorder of brain cells that causes nerve conduction pathways to block.
C. Cell membrane discharge theory speculates that the central nervous cell membrane discharges during concussion, causing changes in the excitability of nerve tissue, resulting in physiological and metabolic disorders.
D. Cerebrospinal fluid shock theory is a theory formed after the Second World War. When a concussion occurs, cerebrospinal fluid rapidly moves in the ventricular system or the formed fluid waves impact the ventricular wall, causing damage to the third ventricle, the aqueduct and the brain tissue around the fourth ventricle. .
E. Neuronal injury theorists believe that damage to the interneurons of the brain causes disturbance of consciousness.
F. Recently, the mechanism accepted by most scholars is that the brain stem network structure is damaged. In addition, the sharp changes in intracranial pressure and cerebrovascular dysfunction during injury also play a role in promoting growth.
(2) Brain contusion and laceration:
1 General change: When the skull is damaged by brain tissue caused by external force, it is called brain contusion and laceration. This type of trauma is characterized by more serious and persistent disturbance of consciousness (more than half an hour). In addition to the whole brain symptoms, clinical manifestations There may be focal symptoms, and traumatic subarachnoid hemorrhage is often associated with cerebrovascular injury.
A. Mental disorders directly caused by brain damage: The main pathological changes of brain contusion and laceration are hemorrhage, edema and necrosis. These changes cause increased intracranial pressure and thus produce a series of biochemical, circulatory and electrophysiological changes. It may explain the occurrence of coma after trauma and some intermediate states from coma to waking, such as ambiguity and confusion.
Local brain injury can cause corresponding focal symptoms. The more prominent syndromes are frontal lobe, temporal lobe and brain base. These parts are vulnerable to traumatic brain injury.
Once the brain injury occurs, it immediately causes brain dysfunction. This is different from other brain organic diseases and lacks the process of disease development. Therefore, the patient lacks psychological preparation beforehand, and inevitably compensates in the face of functional defects. Most of the studies on the compensatory behavior of patients with organic diseases are from cases of traumatic brain injury (Goldstein, 1942).
According to some scholars (Hillbom, 1960, Achte, 1969, Levin, 1979), the study of mental illness in large brain injury, the prevalence of schizophrenia-like psychosis is 2.1% to 2.6%, far more than schizophrenia in general The prevalence of the population, these patients generally have a short-term onset after trauma, family history of mental history is low, half with mental retardation, 1/2 to 1/3 have brain atrophy, often accompanied by brain weakness and autonomic symptoms, suggesting the spirit Schizophrenia-like psychosis is directly caused by brain damage, and the injury site is in the frontotemporal lobe and limbic system.
Juvenile craniocerebral trauma, such as the spread of the brain, leads to structural defects in the brain (brain atrophy, enlargement of the ventricles) and lack of function. Because the brain is in an immature and undulating stage, there is no behavioral change, and the puberty, internal environment When the violent activity began, the brain function could not adapt to these changes, and the onset of the disease began. The clinical manifestation was a cyclical course (TECyxapeba, 1958). These cases belonged to early damage and later developed.
The incidence of epilepsy caused by craniocerebral injury is higher, and some manifest as psychotic seizures. Among the 3552 cases of craniocerebral injury analyzed by Achte (1969), epilepsy psychosis accounts for 1.3%.
Craniocerebral injury can also cause other forms of mental disorders. In Achte (1969), affective disorders accounted for 1%, paranoid psychosis was 2%, hallucinations were 0.1%, suspected psychosis and "prolonged concussion." Mental illness can also occur.
B. Psychogenic mental disorders caused by attitudes toward craniocerebral injury: In the occurrence of such psychogenic disorders, trauma, individual quality and environmental factors are combined, Achte (1969) reported craniocerebral injury The incidence of psychogenic disorders is 0.2%. In addition, after concussion or brain contusion, compensation and litigation problems have not been resolved over time, and nerves can occur under the interaction of quality and situational factors. Symptoms, such as snoring, obsessive-compulsive disorder, suspected illness, neurasthenia, anxiety and so on.
2. Secondary brain injury - intracranial hemorrhage Intracranial hemorrhage, such as intracranial hemorrhage, occurs when it accumulates in a certain part of the cranial cavity and reaches a considerable volume, which causes compression of the brain tissue and causes corresponding clinical symptoms. "The intracranial hematoma encountered in the psychiatric clinic is mostly subdural. Patients often forget the process of head trauma. The hematoma develops unconsciously. It is said that the incidence of subdural hematoma after craniocerebral trauma is 10%. In a group of 3100 patients with psychosis, 8% of subdural hematomas were found (Kolb, 1973). Subdural hematoma can be associated with various psychotic conditions, especially in the elderly, epilepsy, alcoholism and paralysis. Patients with dementia, because these people are prone to head trauma.
After craniocerebral injury, subdural hematoma can occur sharply or later, headache is inevitable, but more important is the change of consciousness state, the patient can recover from acute brain trauma coma, when the patient is irritating Or confusion, mental state varies from day to day, and even from time to time. The most common signs are hemiplegia or central facial paralysis. The symptoms of chronic subdural hematoma are similar, but mild to severe intellectual impairment can occur, and the patient is initially Damage can not be remembered.
Prevention
Prevention of mental disorders associated with traumatic brain injury
After the accident, doctors and relatives should not show fear and avoid traumatic post-traumatic mental disorder. Patients with mild traumatic brain injury should not stay in the hospital for too long and do too much examination, because it is easy for the patient to feel seriously injured. To promote the occurrence of post-traumatic syndrome, encourage early return to work, conscious disturbance in the brain injury should rest in bed for 1 to 2 weeks, to prevent the occurrence of post-concussion syndrome, to do a good job of social intervention before discharge, for The patient creates conditions to provide a supportive social environment, which is conducive to rehabilitation, and therefore does not cause family disputes and attention to compensation problems, which can make the symptoms worse or persistent, and learn to pay attention to safety and avoid head trauma in daily life.
Complication
Complications of mental disorders associated with traumatic brain injury Complications post-traumatic syndrome
If the patient with mild traumatic brain injury stays in the hospital for too long and does too much examination, it will easily cause the patient to feel the serious injury and promote the occurrence of post-traumatic syndrome. Post-concussion syndrome may occur in craniocerebral injury.
Symptom
Symptoms of mental disorders associated with traumatic brain injury Common symptoms Dementia, dullness, dullness, stagnation, irritability, spotted hemorrhage
1. Acute mental disorders associated with craniocerebral injury Acute mental disorders including craniocerebral injury including concussion, coma, paralysis and amnesia syndrome, mainly with disturbance of consciousness, are more common within 24 hours, and are often confused. For more than 72 hours, amnesia syndrome occurs, and the duration of early mental disorders may be positively correlated with the duration of disturbance of consciousness.
(1) Concussion syndrome: The concussion syndrome is first described by Strallss and Savitsky (1934). It refers to the transient disorder of brain function after the brain is subjected to violence. It has a transient loss of consciousness and can be recovered. Generally, you can't recall the scene at the time of injury and the moment before the injury. It can be accompanied by headache, vomiting, dizziness, irritability, emotional instability, lack of self-confidence, difficulty in concentration and autonomic symptoms (pale skin, cold sweat, blood pressure drop) , the pulse is slow and slight, the breathing is slow, etc.).
(2) Traumatic coma: severe concussion and brain contusion can completely lose the response to stimuli, enter a more persistent coma, after a coma, there may be a period of sleepiness, restlessness, turbidity, etc. There are two kinds of outcomes: that is, consciousness is completely restored or transferred to traumatic paralysis.
(3) Traumatic sputum: sputum usually evolves from coma or lethargy. The internal brain damage can be concussion or contusion or bleeding. In most cases, sputum is mild, showing confusion and irritability. The state of dreams is exaggerated, uneasy, disorientation, confusion, fear, fear, etc. Some behaviors in the sputum reflect the pre-treatment occupational characteristics, while others show resistance, noisy, uncooperative, insulting, and others are aggressive. , boring and offensive, if there is an illusion, often a rich visual illusion image, serious cases can be in a state of chaotic excitement, attempting to go out, strong impulsive violence is dangerous to yourself and the surrounding, With the improvement of noisy convulsions, some patients still maintain a lot of words and endowed with persistent stereotypes. After the irritating stage, the patients showed childish excitement and pleasure, sometimes being replaced by shackles or dreams.
The duration of sputum helps to determine the severity of brain damage. For example, more than one month means severe tissue damage.
(4) Traumatic amnesia - fictional syndrome: Most patients with traumatic brain injury have different levels of disturbance of consciousness, so there will be forgetting of a period of experience before and after injury, such as antegrade and/or retrograde forgetting, forgetting in acute mental disorders Generally speaking, it is short-lived. Here, it mainly refers to the organic disorder characterized by memory impairment after the acute phase of traumatic brain injury. This disorder is due to the memory of the inner side or middle part of the temporal lobe. Areas such as the papillary body, hippocampus complex, Qianlong, and dorsal medial nucleus of the thalamus are damaged; clinically, because of their forgetting often accompanied by fiction, it can also be called amnesia-fiction syndrome. This syndrome is most significant. The performance is fictitious. At the same time, there are memory disorders, near memory, and far memory. There are defects in the near memory, especially in the near memory. The consciousness is clear, other cognitive activities are not damaged, and forgetting and fiction are mostly present at the same time. Fiction can be true and invented. Mixing, but also a complete fiction, and often instead of forgotten facts, accompanied by corresponding emotional reactions, inspiring questions can cause phase Contradictory statements, from the appearance of the patient seems to be alert, such as careful examination will find that their perception is disturbing, many patients show quiet and mild euphoria or even funny, but often become irritating when asking questions Traumatic amnesia - the duration of fictional syndrome is shorter than in alcoholic cases.
(5) Subdural hematoma: This disease can be rushed or delayed, so it is included in the acute phase. It can cause headache and lethargy after injury, but it can also occur in weeks or months. The headache is fluctuating. Mild and heavy, symptoms of dementia may occur. The symptoms of late onset are drowsiness, dullness, memory loss and confusion. Subdural hematoma may present all symptoms of dementia, occasionally showing acute paralysis with exercise excitement, headache often Very serious, but also volatility, when the time is light and heavy, patients can lack the signs of the nervous system, only mild headaches and fluctuating mental disorders, about half of the patients detected optic disc edema, cerebrospinal fluid pressure slightly increased, The protein is quantitatively increased and the appearance is yellow, but the cerebrospinal fluid pressure can also be normal or below normal.
2. Chronic mental disorders associated with craniocerebral injury Chronic mental disorders associated with craniocerebral injury are mainly memory impairment, thinking disorder, personality disorder, and the damaged parts of the mental disorder are temporal lobe, frontal lobe and parietal lobe.
(1) Symptoms arising from the establishment of new adaptation needs for the consequences of craniocerebral injury: catastrophic response can be manifested in the face of injury, followed by occupational paralysis, avoidance, etc., the patient's brain function defects are characterized by excitatory reduction, attention Dissipation, the sensitivity to external stimuli is enhanced, patients are difficult to understand and accept ordinary things, resulting in doubts and anxiety, the ability to solve problems is impaired, there is no difference in the type of dysfunction caused by craniocerebral injury, and the patient responds to a certain stimulus. Excitement is easy to spread and lasting. These symptoms are divided into 3 types:
1 Behavioral manifestations of craniocerebral injury: Patients with brain function defects associated with craniocerebral injury often show disaster response. Due to lack of psychological preparation in advance, when they face unsolvable problems, patients with craniocerebral injury become Sudden anxiety, excitement and stunnedness, some anger, depression and emotional instability, when the pulse and breathing increase, performance of restlessness and timidity, and even sudden tears, the disaster response may not be that the patient realizes that he is not competent for work. Response, because this reaction occurs when the patient attempts to perform a task, rather than after the task cannot be performed (Mayer-Gross et al., 1963), and the patient cannot tell why he is still anxious and depressed. Moderate people, at this time become elusive, angry, easy to get angry and even aggressive, the consequences of the disaster response is that the patient becomes lonely and retreating, in order to avoid contact with the environment that makes him feel fear, sometimes the patient takes I dont know how to follow the instructions, in order to prevent or aggravate anxiety, the patients keep moving, making people feel that they are busy. It is impossible and impossible to take a deliberate attitude towards the work, so that he does not give him the task, and let him be an isolated bystander. This phenomenon of undesired excessive activities to seek attention is seen in dementia cases, usually It is called occupational paralysis. In essence, patients avoiding homework is that they worry that if they contact the homework, they will trigger an unpleasant disaster response. Patients often maintain a rigid and cautious attitude. This is excessive order, and patients pass this pathway. To adapt to themselves.
2 to establish alternative behaviors to adapt to the needs of the environment: in order to avoid the disaster response, patients with brain injury are specifically reflected in the reduction of excitability, that is, only a stronger stimulus can produce a response, in addition, because their attention is diminished, They seem to have unusually high susceptibility to a variety of external stimuli, while at the same time, because they have difficulty distinguishing the context or occasions in which they face things, the common causes of brain injury patients in ordinary environments It is difficult to understand and feel, resulting in doubts and anxiety, because their ability to perceive is insufficient, so the ability to solve problems is impaired.
Craniocerebral injury often inhibits their understanding of disability, which seems to occur more easily when some of the patient's functions are partially destroyed than when it is completely destroyed. This condition is also seen in cases of sensory defects and paralysis, because of partial impairment In the case, it is quite difficult to find a new balance in order to adapt to the environment.
Lesion damage not only causes loss of individual abilities, but despite the different types of dysfunction, there are some common symptoms, which are based on pathological inertia. Once the patient responds to a certain stimulus, the excitement is very easy to spread and lasts for a long time. If such patients are asked to point out the difference between the image and the background in perception, they are often difficult to perform, so when the patient attempts to solve the problem, even in a normal environment, the patient's experience is like a normal person facing a blurred picture. The same, feeling vague is not certain.
3 abstract attitudes and specific attitudes: Goldstein (1942) has described two attitudes of such patients to the world, namely abstract attitudes and specific attitudes.
A. Abstract Attitude: An abstract attitude is expressed by the ability of the patient to adopt a mental attitude at will; to transfer one aspect of the situation to the other; to grasp several aspects of a situation; to grasp the main part of the matter and to the whole thing Isolation and decomposition into its components; abstracting common features, starting before the concept is formed; symbolizing behavior and thinking; separating themselves from external things, they are separated from the real experience, their thinking And behavior is governed by the general concept of the same attribute in the general situation.
Goldstein pointed out that the characteristics of abstract attitudes are not as good as the average person can use abstract and specific attitudes according to the needs of the objective environment, but they are immutable. Patients with parietal lobe injury can use scissors and keys, but require patients to imitate the actions to complete these operations. When it fails, it will completely fail.
B. Specific attitude: It is a form of fixed thinking, and can not be carried out later than the immediate experience or the stimulation of current things. The ability of abstraction of craniocerebral injury cases is impaired, and it is difficult to change from abstraction to concrete.
(2) Post-concussion syndrome: a neurosis-like mental disorder caused by concussion, and some books are called brain injury (brain contusion) syndrome, but it can also occur because of mild brain injury. It is often referred to as post-concussion syndrome, which is a common complication after craniocerebral injury. About 55% of patients with craniocerebral injury appear during concussion recovery, headache, fatigue, anxiety, insomnia, hyperalgesia Attention deficit, irritability, depression and other symptoms, including headache, dizziness, anxiety, fatigue, and 20% to 30% of patients can be chronic, Aubrey Lewis (1942) pointed out that concussion The post-syndrome is a "psychiatric pathological state that makes doctors and lawyers feel headaches." He questions the taxonomic location and pathogenesis of this syndrome. The nature of this syndrome is still inconclusive.
According to the frequency order of occurrence, patients may have headache, dizziness, fatigue, anxiety, insomnia, sensitivity to sound and light, difficulty in concentration, irritability, subjective feelings, depression, etc. The first four symptoms are most common, but Subjectively felt, not the observer can directly measure, Mittenberg et al (1992) used a list of 30 symptoms for patients 1 to 7 years after mild head trauma, including emotions, body and memory. Classes, the most common symptoms are irritability, fatigue, concentration difficulties, anxiety, depression, headache and difficulty in thinking, headaches are pulsating, supine, physical and mental work, nervous, excited and increased after drinking, After rest and quiet, it can be relieved. Dizziness is not really dizzy, there is no subjective sense of rotation, just dizziness and instability, and it is aggravated when changing position and head position, sometimes accompanied by blackening of the eyes, short-sighted vision Ambiguity and uncertainty, fatigue of the limbs is prone to fatigue, can not adhere to longer-term labor, thus affecting work, emotional anxiety, depression, and fluctuations, small tension will make heart Poor, sleep disorders can be manifested as difficulty falling asleep, often wake up early, dream more, sensitive to sound, light, can not tolerate strong sound and light, feel physical discomfort based on organic, difficult to focus, memory loss, Irritability, irritability, irritability, bickering, etc. There is a lot of evidence that patients with post-concussion syndrome have obvious neurotic quality tendencies, and psychosocial factors play an important role in the course of disease progression (Lishmen, 1988), concussion The latter syndrome is easier to heal than the post-traumatic amnesia.
Lewis (1942) compared post-concussion syndrome with general neuroticism and found that the clinical manifestations of the two were very similar. Some patients had some difficult situations before the injury, which caused their load to adapt to the environment to increase, and the brain injury weakened their adaptation. Function, which makes the symptoms of neurosis more obvious. In addition, some patients are affected by the so-called "head consciousness". They think that the head is crucial in life. Once injured, it will bring serious consequences and cause fear. And in the later psychiatric and neurotic reactions, this fear is expressed, so in the treatment of such patients, to avoid the concept that they have been seriously injured, and it is not recommended to take long breaks and excessive examinations, so as not to add patients Some iatrogenic symptoms.
(3) Personality change after trauma: After the traumatic brain injury, the patient's behavior pattern and interpersonal relationship have significant and lasting changes. This personality change is not only a cause of trauma, but also the personality characteristics and psychological factors before trauma. There are also influences, which are related factors that have an important role. Personality change refers to the change of habits and habits of patients' behaviors. Therefore, the response to objective things and people is different from the past. The degree of personality change is very different, or very significant. Slightly until only someone familiar with him can discover that his or her personal changes may or may not be realized.
Usually the clinical manifestations are: solitude, stubbornness, self-centered, paranoid, suspicious, careless, irritating, easy to quarrel with people and misconduct; cognitive deficits, often forgotten, concentration difficulties and random thinking If you are diminished and lose your mind, you will not be able to work and study. The childish exaggerated speech will increase, but it will be difficult to control. Sometimes it will show dullness, apathy and lethargy, indifference to the surrounding things, and sometimes episodes of anger, impulsivity and aggression. Self-control is weakened, children's patients, destructive and anti-social behaviors and confrontational aggression are more prominent. The age-related changes in personality manifestations, the lighter personality changes are not the cause of organic damage, but the psychological after injury. Caused by the reaction, this change is the uncontrolled strengthening of the personality characteristics before the injury, resulting in family and interpersonal tension, and some can have cognitive impairment at the same time, often manifested as forgetting, paying attention to difficulties, slow thinking, do not know what to read, I don't know what to do, etc., where the frontal lobe damage can show a special personality change, that is, the problem cannot be treated objectively. Lack of anticipation and flexibility, can not foresee the consequences of self-behavior and unfounded euphoria, increased speech, naive and exaggerated, sluggish, indifferent, sleepy, irritating, and irritating patients can behave illegally Disciplinary behavior, aggressive.
Lishman (1978) distinguishes post-traumatic personality changes into brain damage with personality changes and personality changes unrelated to brain damage.
1 brain damage associated with personality changes: this type of personality change is a side of the whole dementia after brain injury, some patients also have cognitive deficits, so this personality change can be understood as the emotional response to brain defects after trauma In addition, the personality changes of some patients are the result of local brain damage caused by the corresponding brain part, and the age factor also influences the manifestation of personality changes after trauma.
The most common personality changes are forgotten, attention concentration difficulties and random thinking decline, which is inevitably reflected in the behavior of the lost, do not know what books to read, do not know why go out, do not know what to buy in the store, in the previous paragraph involving patients Behavioral changes caused by the establishment of new adaptation needs for the consequences of craniocerebral injury are also personality changes.
Frontal lobe damage can cause special personality changes. These patients are characterized by the inability to look at the problem objectively, lack of predictability and flexibility, cannot predict the consequences of their actions and the lack of basis, their words are more difficult to control, and they are more naive and Exaggerated, when they are alone, they are slow, indifferent and lethargic, they are indifferent to the surrounding things, and their feelings are dull.
Another type of personality change in craniocerebral injury is irritability, impaired self-control, and can manifest attacks and violent episodes, violations of social law, and are more prominent in children, destruction, antisocial behavior, and confrontational aggressive behavior.
Example: Male, 27 years old, junior high school literacy level, unmarried, due to misconduct, participated in fights and burglary, was sent to labor camp, was destroyed in labor camp farm, defecate indoors, eat toothpaste, was released on bail home, daze after arriving home No words, in a sub-hard state, after the start of activities, suspected of being tracked, attacking impulsive behavior, first hospitalization in December 1980, EEG showed mild abnormalities, progressed after treatment with chlorpromazine and other treatment, completed after work , undisciplined, fighting, stealing, frivolous, decreased labor capacity, the second hospitalization in May 1982, progressed after treatment with chlorpromazine, but still consistently showed behavioral disorder, the third hospitalization in November 1990, There are speech disorders, auditory hallucinations, illusions, and behavioral disorders.
In June 1980, the left occipital trauma (brick head bruise), when the ear snoring, but did not fall to the ground, complained of severe headache, after the occurrence of misbehavior, CT is normal, EEG shows a wide range of abnormalities (both slow Wave, a small amount of sharp waves), brain topography shows double-increased slow wave power.
During the third hospitalization, there were many automatic symptoms in the evening. When I suddenly got up and went to the ground, my eyes were dull. I could still have a simple conversation with people. I couldnt recall them afterwards. I was diagnosed with personality changes after brain trauma, schizophrenia-like episodes. Automated symptoms showed that mental symptoms disappeared after treatment, but personality changes did not improve.
2 Personality disorders unrelated to brain injury: often manifested as the appearance of the previous personality characteristics under the influence of craniocerebral injury, mostly manifested as volatility of depression, morbid anxiety, compulsive personality and persistent irritability.
(4) Traumatic dementia: more common brain injury, leading to severe dementia is rare, brain trauma can cause cognitive impairment in a single field, can also cause a wide range of intelligent decline like dementia, but severe dementia is rare, single Cognitive impairment in the field, mostly due to focal brain injury, such as forehead, forelock of temporal lobe injury, memory impairment, difficulty in concentration and random thinking; superior hemisphere injury causes speech, understanding obstacles, etc.; trauma Sexual dementia is caused by a relatively high degree of brain damage.
Frazier and Ingnam (1920) reported that 200 patients with craniocerebral gunshot wounds, 4 (2%) experienced a severe decline, and Hillbom (1960) found that 15% of 1505 patients with penetrating trauma had cognitive impairment, Ota (1969). 1168 cases of closed craniocerebral injury were observed, of which 3% had cognitive impairment. These patients showed cognitive impairment, mental retardation, mental retardation, unresponsiveness, dull emotion, memory loss, and decreased attention.
The lesions are more limited or mild, showing only functional defects and relatively singular symptoms in a single field, such as speech, decreased computing power, mild mental decline, decreased work, life, and learning ability.
If the injury is extensive or severe, there will be multiple barriers or multiple symptoms, such as apathy, sluggish expression, lack of initiative, slow thinking, poor understanding or loss of judgment, memory impairment, emotional instability, etc. Some also showed euphoria, lack of self-control ability and led to rash or unruly behavior; significant decline in intelligence, and even lost work, study, and social skills.
A small number of patients have comprehensive intelligence defects, life needs people to care, lack of language expression, etc., close to the degree of severe dementia.
(5) Traumatic encephalopathy: usually refers to the traumatic encephalopathy of pugilists, also known as "punch drunk", which occurs when the boxer's head is repeatedly hit by repeated attacks. The onset is a continuous and accumulated punctate hemorrhage and necrosis in the brain. It is mainly manifested as cerebellar symptoms, extrapyramidal symptoms and mental decline. The disease develops to a certain extent (1 year later). The degree of mental decline depends on the traumatic brain injury. The scope and extent of the patient's fine techniques are impaired, the muscles are slow, the balance is poor, the confusion is mild, the attention is declining, the concentration and memory are reduced, the speech is heavy and ambiguous, similar to drunkenness, most patients are multilingual And euphoric, after the chaos and memory defects become more serious, intelligent damage can reach the degree of functional disability, the disease develops to a certain degree, about one year later, the degree of mental decline depends on the extent and severity of craniocerebral injury. .
(6) Traumatic epilepsy: more occurs in brain damage caused by meningeal puncture, due to adhesions of meninges and brain parenchyma left after trauma, scar involvement and localized atrophy, the incidence of closed brain trauma is 5% The incidence of traumatic epilepsy is affected by the degree of injury and the length of the follow-up period. The incidence of epileptic seizures in the open brain injury of the dural is as high as 30% to 50%, which is secondary to 20 to 35 years old. One of the most common causes of epilepsy patients, brain traumatic epilepsy can be divided into early and late, the former occurred within 1 month after the injury, accounting for 10% to 15%, of which more occurred 48 hours after the accident; Late-onset occurs in 2 years after injury, accounting for 85%. The temporal lobe lesion can cause mental seizures, and the patient sometimes shows a state of dreams, staged forgetting, deja vu, sudden emotional outbursts and illusion.
(7) Schizophrenia-like psychosis: Schizophrenia-like disorders suggest that the pathological lesions in the temporal lobe may have intelligent defects, positive pathological signs of the nervous system, often accompanied by brain weakness and autonomic symptoms and personality changes, and similar spirits may occur. Achte (1969) reported 3552 cases of brain traumatic demobilized soldiers, and tracked 22 to 26 years, found that schizophrenic psychosis accounted for 2.6%, while procedural (progressive) schizophrenia was 0.84. %, the pathological damage of such cases may be in the temporal lobe (Lishman, 1978).
(8) Paranoid psychosis: often occurs after a long time after brain trauma, regardless of the degree of brain damage, can develop into traumatic paranoid dementia, the incidence of paranoid psychosis (not schizophrenia) after craniocerebral injury 2.1%, due to the influence of delusion, is one of the many unfortunate reasons after craniocerebral injury. This kind of situation is not uncommon in patients with post-traumatic dementia. The content of delusion is mostly the concept of victimization and paralysis. Paranoid psychosis is often more in trauma. After a long time onset, its occurrence seems to have nothing to do with the severity of craniocerebral injury, it is more difficult to blame a local brain injury, there are 1/4 impotence in the paranoid, suggesting that pre-existing personality instability and situational factors are delusional The occurrence of the occurrence, the occurrence of paranoid symptoms based on intelligent defects, called traumatic paranoid dementia (Lewin, 1979).
(9) Affective psychosis: Obviously, craniocerebral injury may induce or promote the disease, but there is no evidence that there is an organic basis for cases after trauma. Achte (1969) data in patients with craniocerebral injury The incidence of depression was 1.3%, and mania was 0.1%. Montgomery et al. (1991) pointed out that 2/3 mild post-traumatic cases had depressive symptoms or were associated with or without post-concussion syndrome.
(10) Long-term mental disorders caused by early childhood craniocerebral injury: These long-term mental disorders are not unique to craniocerebral injury. They are also seen in early childhood brain infections, poisoning and other diseases, usually with insufficient brain structure and function between traumatic residues. Children can have mental decline, positive neurological signs, but no obvious behavioral changes, puberty arrives, gonads begin to vigorously move, and the internal environment also changes accordingly. The defective interbrain can not adapt and withstand the body. The onset of steady-state requirements, mental disorders often take a cyclical course, the onset is sharp, the patient's consciousness is blurred, the orientation is poor, there may be auditory hallucinations and fragmentary delusions, no purpose of excitement, lasting 1 to 2 weeks of relief, the patient's performance is quiet Before, the interval is 1 to 2 weeks, and the cycle is repeated several times. The cerebral ventricle is enlarged by gas cerebral angiography or CT. Especially in the third ventricle, the extraction of cerebrospinal fluid can alleviate the condition. Injecting air often induces seizures. This disease is a self-limiting disease. The internal environment is balanced and the episode can be suspended.
Acute craniocerebral injury mental disorder is easy to identify, mental disorder caused by brain injury must have the premise of head trauma, mental symptoms or directly from brain trauma, or definitely related to it, general mental disorder symptoms immediately after trauma, after a certain period of time The process is gradually improved, and the diagnosis is generally not difficult, but attention should be paid to the evidence of the degree of trauma, the extent of the injury and the relationship between the extent of the injury and the mental symptoms. Because of the occurrence and development of the mental disorder, the course of the disease is closely related to the traumatic brain injury, and the more serious the traumatic brain injury, The more extensive the injury site, the more likely it is to cause mental disorders. The extensive injury is likely to cause a total disorder of mental function. The most common cause of mental disorders is temporal lobe damage, followed by the prefrontal and frontal lobe, and the opportunity of mental disorders in the parietal and occipital lobe. At least, temporal lobe injury often causes personality disorder, manifested as emotional instability and control disorder; personality disorder caused by prefrontal lobe, manifested as apathy, immature, will decline, mental retardation, parietal lobe injury easily cause cognitive dysfunction ; 243
Examine
CT
Diagnosis
Diagnostic criteria
1.
(1)
(2)6
(3)CT
(4)
2.
(1)
(2)
(3)
(4)
(5)
(6)
(7)1
3.
(1)
(2)
(3)2
(4)18(18)
4.
(1)
(2);;
(3)
(4)
(5)4
5.
(1)
(2)
(3)
(4)1
Differential diagnosis
1.
(1)
(2)
(3)
(4)
(5)(CTMRIPETBEAMSPECT)()(Lishman1988)(PTSD)()PTSD
2.2
