Keywords
adolescent TBI - psychosis - Acceptance and Commitment Therapy - family therapy
Traumatic brain injury (TBI) is common among children and adolescents[1]
[2] with a peak in mid-adolescence, ages 15 to 17 years.[3] According to Center for Disease Control and Prevention data, in 2009, an estimated
2,48,418 children and adolescents (age 19 or younger) were treated for concussion
or TBI in emergency departments in the United States, and the diagnosis of concussion
or TBI in this age group rose 57% between 2001 and 2009.[4] Most adolescent TBIs are in males and are typically sports-related injuries.[1]
[3]
[5] Individuals who have endured a TBI, even mild TBI, otherwise called concussion,
often experience a wide-range of symptoms that negatively impact quality of life,
including physical, cognitive, and psychological symptoms.[6] Personality changes (e.g., increased aggression and disinhibition) are the most
common psychological changes following a TBI in children and adolescents.[7]
[8] Depression and anxiety can also develop following TBI.[9] In some individuals, such symptoms resolve within weeks, while in others, these
symptoms remain for years, and a history of multiple TBIs increases risk for developing
chronic depression and cognitive impairments later in life.[10]
Hallucinations are a less common form of psychological illness following TBI.[11]
[12]
[13]
[14]
[15] Estimates of psychotic symptoms (e.g., hallucinations and delusions) are calculated
to be present in as many as 20 to 25% of all TBI cases, and the presence of psychotic
symptoms does not seem to be related to severity of head injury.[13] TBIs also increase the risk of developing chronic psychosis symptoms (e.g., schizophrenia[16]
[17]).
In a recent case,[11] a male with a history of TBI in early adulthood reported experiencing ongoing auditory
hallucinations for 30 years, starting within a year of enduring a TBI. This patient
was treated pharmacologically (i.e., with an antipsychotics and an anticonvulsant)
and with group psychotherapy. Improvements in mood and cognitive functioning and reduction
in hallucinations were noted within 10 days of treatment, but no long-term data are
available to indicate the duration of these improvements. It is also unclear if pharmacological,
psychotherapeutic, or a combination of the two treatments was most effective for the
patient. Antipsychotic medication was also successful in treating psychosis following
a second TBI in a 51-year-old male.[18] Both cases relied on second-generation antipsychotics, which have been recommended
over the first-generation antipsychotics because of differences in interactions with
recovering neural processes;[19] the first-generation antipsychotics may decrease synaptic plasticity.[20]
Although there is little information on pharmacological treatment of psychosis following
TBI,[20]
[21] there is even less information on psychotherapeutic treatment. Psychotherapy as
an alternative or adjunct to pharmacological treatment has shown mixed effectiveness
in treating behavioral and/or mood disorders in cases of TBI (for reviews refer to[22]
[23]). Cognitive behavioral therapy (CBT) is one of the most commonly used psychotherapies
to treat mood and behavioral symptoms in TBI cases. CBT was effective in reducing
depressed and anxious mood, somatic complaints, and social problems in children and
adolescents (4–18 years of age) with TBI when compared with those in individuals who
did not receive psychotherapy.[24] However, more rigorous studies in adult populations do not find support for CBT
over other treatments.[22]
[25]
Acceptance and Commitment Therapy (ACT) may be an alternative psychotherapeutic treatment
for mental health problems following TBI.[26] ACT uses present moment awareness and acceptance of physical and mental symptoms
to fulfill goals and live a life that the patient values. The latter piece may be
a key component to recovery following TBI.[27] A brief ACT intervention resulted in fewer re-hospitalizations of patients with
psychosis compared with treatment as usual for up to a year,[28]
[29] but it is unclear how effective ACT is in treating psychosis following TBI. A recent
study of children with TBI and other brain injuries investigated the impact of a dual-intervention,
which included family therapy and ACT.[30] In this study, it was found that children in the dual-intervention group had greater
parent-reported improvements in both behavioral and emotional problems compared with
those in a treatment as usual group. Effects were largely maintained 6 months post-baseline,
but psychotic symptoms were not discussed and were likely not endorsed in these patients.
Brown et al's[30] approach, using multiple systems of therapy (e.g., individual and family therapy)
to address mental health problems, has also been employed as an evidence-supported
treatment for those with early psychosis.[31] Dynamic factors such as family functioning and social support have been found to
improve outcomes for children and adults following TBI.[32] Family therapy has also been claimed to be an important component in treatments
of adolescents with TBI.[33]
[34] Psychotherapeutic interventions to improve family communication[35] have shown benefits in treating mood and behavioral disturbance in adolescents who
have endured a TBI[33] (for review refer to[36]). In addition, such interventions may help reduce distress in parents who are facing
changes as their child recovers from TBI.[37] However, it is unclear if multisystem psychotherapy is effective in treating TBI-related
psychosis symptoms.
The following is a case of TBI-related visual and auditory hallucinations in a 14-year-old
male. The patient was involved in a multisystem approach that included Vestibular-Ocular
Physical Therapy, for balance and motor symptoms, as well as ACT-oriented individual
and family therapies.
Case Report
Patient
A 14-year-old, Hispanic male student was referred to the Behavioral Health Clinic
for the treatment of post-concussive syndrome, 4 weeks after the appearance of visual
and auditory hallucinations. The adolescent presented with his third concussion, a
mild TBI which he sustained during American Football practice. Prior to this, he had
sustained two concussions from a basketball and a football practice within the previous
2 years. No long-term symptoms were noted following the two previous concussions.
The third, most recent, concussion was the most severe for the patient. Hallucinations
appeared approximately 3 weeks after the third concussion in addition to other concussive
symptoms with an earlier onset (see below for more details). Parents refused pharmacological
treatment for the psychotic symptoms of their son and self-referred the adolescent
for psychotherapy. Written informed consent was obtained from the patient's parents
prior to participation in psychotherapy. After an extensive intake interview, individual
and family therapies were recommended for the patient, and his parents agreed to the
treatment. The patient and parents also provided consent for presenting the case to
the scientific community after the completion of the therapies.
Injury
The impact of the injury struck from below the chin, with the angle of force diagonal
from the chin to top rear of the head. Magnetic resonance imaging scans without contrast,
including T1-weighted and diffusion scans of the brain, were conducted 4 weeks after
the injury. No abnormalities were detected. However, it is possible that this type
of trauma could result in coup–contrecoup forces at the base of the brain near the
basal ganglia and at the back of the brain in the parieto-occipital region, possibly
causing undetected dopaminergic alteration.
Symptoms
Immediate Symptoms
The patient reported concussive symptoms in the morning following the concussion.
The initial concussive symptoms were nausea, dizziness, difficulty with speech, and
difficulty walking.
Delayed Symptoms
At the time of the therapy intake, 7 weeks after the injury, the patient described
experiencing fatigue and difficulty with attention and balance. Hallucinations began
3 weeks post-TBI with vivid visual and auditory components. The theme of the hallucinations
was generally negative and disparaging, though not persecutory. For example, the patient
often saw a horror movie-like figure who would say things such as “You will not get
better.” This was accompanied by the patient's own thought of “I am never going to
get better.” At the time of the initial individual therapy session (i.e., 7 weeks
post-TBI), hallucinations appeared multiple times daily. Anxiety and depression were
also present. He expressed thoughts that suggested fear of failure: “If I don't try
then I will not fail.” The patient expressed thoughts of self-harm. However, he denied
intent to harm himself because he would not want to hurt his family emotionally. The
patient took a 3-month medical leave from school ∼10 weeks after the injury due to
physical and cognitive symptoms and intrusive hallucinations.
Assessment
Cognitive Testing
Neuropsychological assessment was performed 11 weeks following the TBI. Testing identified
strengths in short-term and long-term memory, reasoning and problem solving, and fine
motor and perceptual skills, but weaknesses in task initiation, planning and flexibility,
visual processing speed, maintaining and shifting attention, and inhibition of visual
and auditory distractors.
Psychological Assessment
During the intake interview, the patient reported moderate depression (Beck Depression
Inventory = 27[38]) and endorsed symptoms of anxiety (i.e., sweaty palms, jitteriness, and racing heart;
Beck Anxiety Inventory = 23[39]). The patient reported a pre-injury history of worry and symptoms related to anxiety
that exacerbated post-injury. Some reported pre-injury worries were associated with
family communications and family expectations. Therefore, family therapy was offered
as another approach to managing the patient's anxiety. Family history of mental health
disorders, including schizophrenia, was denied. The patient qualified for the Diagnostic
and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis 293.82
[F06.0] psychotic disorder due to TBI with hallucinations.
Treatment
Vestibular-Ocular Physical Therapy
The patient began Vestibular-Ocular Physical Therapy 1 week after the TBI to promote
balance and to reduce dizziness. After completing the physical therapy course, he
continued to do physical therapy exercises daily at home for 6 months ([Fig. 1]).
Fig. 1 Timeline of events (in weeks) after the traumatic brain injury. Abbreviations: A/V
Ha, auditory/visual hallucinations; -E, end; Fam, family therapy; Indiv, individual
therapy; MRI, magnetic resonance imaging; Online Sc, online schooling; -S, start;
TBI, traumatic brain injury; VOT, vestibular-ocular physical therapy.
Individual Therapy
The patient underwent 11 sessions of Acceptance and Commitment Therapy, a third-wave
behavioral therapy that uses present moment awareness and acceptance of physical and
mental symptoms to fulfill goals meaningful to the patient. The patient was taught
a problem solving approach to be used during specified ‘worrying time’ and was encouraged
to notice hallucinations and see them simply as thoughts arising rather than symptoms
of psychosis that provoke anxiety.[28] A metaphor of “song stuck in the head” was used to interpret the hallucinations.
The patient also learned and practiced relaxation and mindfulness exercises.
Family Therapy
The patient and his family (mother, father, and two younger siblings) completed seven
sessions of family therapy. Family therapy, often added to therapies with adolescent
identified patients, aimed to improve communication among all family members, de-emphasizing
focus on the ‘identified patient’.[33] The family completed role-playing exercises in which direct and honest communication
skills were practiced to reduce stress. Each family member expressed their expectations
of the family unit. Then, behavioral goals were implemented to help meet each member's
expectations. Compliance of behavior with goals was monitored, and barriers to achieving
goals were addressed by all family members. The family also learned to notice individual
bodily sensations that correspond to one's emotions. The family chose a phrase that
was repeated throughout the week every time a member noticed her/himself feeling a
physical sensation typically associated with anger. The goal of the exercise was to
increase awareness of feelings (i.e., anger), before such feelings escalated, to make
it easier to communicate with each other in a respectful and honest manner.
Results
At the beginning of the individual therapy, the therapist created 10-point ‘self-rating’
scales to measure post-concussive symptoms that were used throughout the treatment
period ([Table 1]). At the end of treatment, the patient's self-rated anxiety reduced; he reported
better attention, less fatigue, no difficulty with balance or speech, and higher trust
in his physical and mental abilities. The patient reported reduced general distress,
anxious arousal, and anhedonic depression on the Mini-Mood and Anxiety Symptom Questionnaire
(Mini-MASQ[40]
[ 41]). Cognitive and psychological symptoms also improved to the point where the patient
was able to return to school following a 3-month medical leave of absence. In addition,
the patient's psychotic symptoms were reported to be in remission with no hallucinations
experienced for more than a year (at ∼18-month follow-up). Qualitative parent report
suggested that the patient returned to the baseline functioning by the end of the
treatment.
Table 1
Symptom changes across a four-month period
|
Initial
|
Final
|
|
Self-rating scales (up to10)
|
|
Anxiety
|
7
|
3
|
|
Attention difficulty
|
7
|
2
|
|
Fatigue
|
8
|
2
|
|
Balance difficulty
|
2.5
|
1
|
|
Speech difficulty
|
1
|
1
|
|
Trust in physical abilities
|
8
|
9
|
|
Trust in mental abilities
|
4
|
7
|
|
Mini-MASQ
|
|
Distress
|
14
|
8
|
|
Anxious arousal
|
14
|
10
|
|
Anhedonic depression
|
29
|
20
|
Abbreviation: Mini-MASQ, Mini-Mood and Anxiety Symptom Questionnaire.
However, it is not clear whether the patient will experience hallucinations in the
future. Psychoeducation regarding the possibility of experiencing hallucinations in
the future and/or developing schizophrenia were discussed. Behavioral health resources
were provided should psychotic symptoms return, and the patient and family were warned
of environmental factors (e.g., drug use) that may put the patient at even greater
risk for developing schizophrenia. Given that the patient had a prior history of sports-related
concussion, which likely contributed to his recent TBI presentation, the topic of
continuing contact sports was also discussed in individual and family therapy.
Discussion
Taken together, this case highlights the potential benefit of multisystem psychotherapeutic
approaches as alternatives or complements to pharmacological treatments for post-TBI
mental health complications. The patient's relatively quick remission of hallucinations,
significantly decreased anxiety, and return to school feeling competent and ready
after a 3-month medical leave of absence warrant further investigations into such
behavioral approaches. This case is unique in several ways. The patient experienced
the uncommon symptom of hallucinations following TBI, he had a previous history of
head injuries, he underwent psychotherapy and did not take medications, and his psychotic
symptoms were in remission after the psychotherapeutic treatment.
As in previous cases of TBI,[11]
[18] it was important for the treatment team to distinguish early-onset schizophrenia
from psychotic symptoms secondary to TBI. It is unknown whether or not the patient
will experience symptoms of psychosis later in life as was the reality for the previous
cases of psychosis following TBI.[11]
[18] Given that those who have suffered a TBI are at increased risk for developing schizophrenia,[16]
[17] it is important to provide psychoeducation to such individuals.[42] Those with a history of TBI and their families should be made aware of symptoms
surrounding schizophrenia-related disorders and be informed of community mental health
resources for treating schizophrenia.
Should the patient's hallucinations remain in remission, differences in long-term
presentation between this case and previous cases[11]
[18] could possibly reflect the underlying brain regions affected by the TBI. Dobry et
al's[11] case had extensive damage to the temporal lobes, while our patient's injury showed
neither magnetic resonance imaging (MRI) (at 4 weeks post-injury) nor neuropsychological
assessment (at 11 weeks post-injury) evidence suggesting any temporal lobe damage/dysfunction.
Fuji and Fuji's[13] review of post-TBI psychosis suggests that damage to the temporal lobes has the
highest association with psychotic symptoms, followed by damage to the frontal lobes.
Longitudinal studies are also needed to determine if multisystem psychotherapy for
psychosis following a TBI would result in lower risk of developing chronic psychosis
compared with those who do not participate in psychotherapy. Even if multisystem psychotherapy
does not result in lower rates of chronic psychosis compared with no psychotherapy,
multisystem psychotherapy may result in better ability to cope with the illness in
those who partake in the therapy compared with those who do not. However, research
is needed to confirm or disconfirm differences in longitudinal outcomes.
Hallucinations are difficult to treat without medications, but often medication is
used as the only treatment for hallucinations.[31]
[43] Multisystem psychotherapeutic approaches that include medication management and
psychotherapeutic approaches to address medication adherence and other behavioral
issues may be most effective in treating the first-episode psychosis.[31] It is not clear if the behavioral-only approaches used to treat our patient would
work for other patients experiencing psychosis symptoms as a result of TBI. Several
lines of research surrounding the topic are needed to better characterize treatment.
More single-case studies and randomized controlled trials are needed to determine
if multisystem psychotherapy alone (i.e., without medications) would be effective
in treating either psychosis following a TBI or first-episode psychosis in those who
refuse pharmacological treatment.
Dismantling studies should also be pursued to identify which specific components of
our multisystem treatment account for observed post-treatment changes.[36] Could any psychotherapy work as effectively? Is Vestibular-Ocular Physical Therapy
the key to recovery, or are all components of our treatment needed for the best outcomes?
With constant limitations on funding for mental health care, these are questions that
need answers. Psychotherapies that address family problems after TBI seem to show
consistent improvements across several outcomes,[33]
[44] and parental involvement in rehabilitation can improve outcomes.[34] Involving families and/or addressing family problems as part of treatment for children
and adolescents with TBI is likely beneficial because symptoms, family burden, and
recovery are often interrelated for children with TBI-related symptoms.[45]
Our observations suggest that ACT may potentially be a viable approach to psychotherapeutic
treatment for future cases of psychotic disorders following TBI, especially when combined
with family therapy. ACT combined with family therapy was also found to be better
than treatment as usual for reducing both behavioral and emotional problems in children
with TBI.[30] However, it is not clear if ACT would be better, worse, or equivalent to CBT treatment[46]
[47] for mood and/or psychosis following TBI. In Pastore et al's[24] study of CBT as treatment for behavioral and mood symptoms following TBI, those
receiving CBT, who were not medicated, showed the greatest improvements, suggesting
the possibility of interactions between psychotherapy and pharmacotherapy. Our patient
did not take medications while receiving psychotherapy and had clinically significant
reductions in anxiety-related symptoms. The current literature has mixed findings
regarding psychotherapeutic treatments for TBI,[22] which may be a product of methodological limitations, but also may be due to individual
differences in treatment effectiveness as is suggested by Pastore et al.[24]
Investigation into individual differences in treatment response should be pursued
to improve patient care and maximize resources. Several factors may contribute to
individual differences, including genetic[48] and psychosocial factors.[49]
[50] Although we do not have information as to our patient's genetic susceptibility for
developing psychosis, he does appear to have potential protective factors that may
have contributed to his recovery. The patient's growing religious faith has been linked
to better recovery compared with those without religious faith.[51]
[52]
[53] Hispanic ethnicity is a complex and multifaceted characteristic that may or may
not improve recovery post-TBI.[54] He does not have a family history of psychotic disorders, which have been associated
with increased risk for developing schizophrenia after a TBI.[55]
Conclusion
To our knowledge, this is the first non-pharmacological multisystem psychotherapeutic
intervention of psychotic symptoms post mild TBI. No controlled trials have explored
treatment for psychosis following TBI using longitudinal designs. Such investigations
are needed to gain a better understanding of psychosis following TBI over time to
develop interventions for better treating and coping with such symptoms. Dismantling
studies should be conducted to identify which components of psychotherapy and Vestibular-Ocular
Physical Therapy best work together and for whom. Investigations of this nature can
help identify other possible contributors to the patient's quick recovery (e.g., spirituality).
It is important to create multi-component approaches that fit the individual patient
and do not use excess resources so that we can meet the healthcare needs of more people.
