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Emotional sequelae of head injury.

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Emotional Sequelae of Head Injury
Sureyya Dikmen, PhD, and Ralph M. Reitan, PhD
The emotional after-effects of head injury in relation to acuteness versus chronicity of the injury and neuropsychological deficits were studied. The results indicate that there is a decline in emotional distress over time after the injury
and show that patients with significant initial and residual neuropsychological deficits experience greater emotional distress than those with negligible difficulties.
Dikmen S, Reitan RM: Emotional sequelae of head injury. Ann Neurol 23492-494, 1977
Estimates of the incidence of head in jury in the United
States alone vary from 750,000 to 3 million per year,
with 60,000 persons permanently disabled. Of the
multiple consequences of head injury, many would
agree that mental symptoms are the more persistent
and constitute the major cause of disability [ 2 , 71.
The literature on this important clinical problem
reflects the variability that exists among head-injured
patients with respect to occurrence of emotional difficulties and the nature and time course of these
disorders. Although many etiological factors-such as
severity of head injury [13], amount and location of
brain damage [S, 91, premorbid personality [ l , 131,
related compensation and litigation [ 10, 111, and psychogenic mechanisms [9, 131-have been introduced
to account for psychiatric sequelae, the degree of their
contribution to the emotional outcome does not seem
major, nor d o they appear to be strongly predictive of
patients at risk. The information available in this area,
however, has been based largely on observation of
patients and on retrospective and cross-sectional
study designs and has utilized clinical observations and
clinical methods of evaluation. The subjects studied
have been select groups of head-injured patients,
comprising persons with severe head in juries, wartime veterans, o r patients evaluated for specific medical, legal, or emotional problems. Longitudinal studies
of emotional difficulties in fairly representative civiiian adult head-in jured patients, utilizing standard
methods of evaluation, have been relatively few. Furthermore, adequate study has not yet been given to
the relationship between impairment of adaptive
abilities and emotional functions over time following
head injury.
The present study was done to evaluate the longterm natural history of emotional reactions in headinjured patients and to study the relationship between
impairment of cognitive-intellectual abilities and resulting emotional problems of adjustment.
Subjects and Methods
From the Department of Neurological Surgery, University of
Washington School of Medicine, Seattle, WA.
Address reprint requests to Dr Dikmen, Epilepsy Center (ZA-50),
Harborview Medical Center, Seattle, WA 98104.
Accepted for publication July 15, 1977.
492
The subjects were 27 adult patients consecutively admitted
to neurosurgical wards due to head injuries. The group
consisted of 25 men and 2 women with a mean age of 31.07
years (range, 18 to 68) and education of 12.37 years (range,
7 to 18). Diagnoses included concussion in 15, contusions in
6, and both concussion and contusion in 6. Skull fractures
were present in 10, absent in 15, and undetermined in 2.
Clinical neurological examination at discharge was normal
for 17, mildly abnormal for 7 , abnormal for 2 , and not reported for 1.
As a measure of emotional functions, the Minnesota Multiphasic Personality Inventory (MMPI) was administered
[ 3 ] . In addition to the MMPI, which is the focus of the
present study, the subjects were evaluated by an extensive
battery of neuropsychological measures including the
Wechsler-Bellevue Intelligence Scale, Halstead’s Nruropsychological Test Battery, and various measures of memory and of sensory-perceptual and motor functions [12].
Each subject was tested individually on all measurements
soon after the injury, and the same tests were repeated 12
and 18 months later.
I n analyzing the data, the question of changes in emotional reactions following the injury was examined first.
MMPI validity and clinical scale values for the total group
over the three evaluations were subjected to trend analysis
of variance [51. Second, the relationships between
cognitive-intellectual and various adaptive ability impairments and emotional reactionswere examined.The subjects
were divided into two subgroups based on extensive initial
neuropsychological results available for each patient. The
group designated impaired consisted of patients with
moderate or marked neuropsychological deficits; the
normallmild group comprised patients with normal function
o r only mild deficits. The same procedure was applied for
the 12- and 18-month evaluations. The performance of the
impaired versus normaVmild groups on MMPI testing was
compared utilizing Student’s t-test [ 5 ] .
Results and Discussion
Table 1 presents the MMPI results in terms of trend
analyses for the total sample over the three evalua-
tions. Significant reductions were obtained for the
Hypochondriasis, Depression, Hysteria, Psychasthenia, and Schizophrenia scales. These results suggest
that although individual variations may occur, headinjured patients in general complain of more depression, anxiety, somatic problems, and strange experiences soon after the injury. This subsides with time,
possibly as a consequence of recovery from the other
impairing effects of the injury or as an adjustment to
o r acceptance of residual deficits. Evidence for recovery of cognitive and other adaptive abilities in the
patients included in this study has been reported
elsewhere [4].
The MMPI results based on comparisons of headinjured patients with impaired versus normal/mild
neuropsychological deficits for the three evaluation
periods are given in Table 2. On all three examinations, but especially on the initial testing, patients
with significant neuropsychological deficits also
showed greater emotional difficulties than those who
were only mildly impaired or normal. It is important
to point out that patients who were neuropsychologically impaired at 12 and 18 months were
older than those with milder neuropsychological difficulties, suggesting that older patients do not recover
neuropsychological functions as rapidly as younger
head-injured patients and that they also complain of
more emotional difficulties.
If neuropsychological functions are used as an index
of severity, patients who continue to show neuroticlike complaints have more serious injuries. This result
is contrary to certain previous reports in the literature
[9, 131 but is consistent with the reports of Bond [2]
and Goldstein [6]. “Psychogenic mechanisms” are
probably overused in explaining the difficulties experienced by head-injured patients. This tendency is
fostered by focusing o n neurological deficits that are
likely to be absent in most cases of civilian head
Table 1. Means and F Values for Trend Analyses of M M P l Variables in 27 Patients following Head Injury
Variable
Initial
Examination
12-Month
L
E
K
Hypochondriasis
Depression
Hysteria
Psychopathic dev.
Paranoia
Psychasthenia
Schizophrenia
Mania
ap < 0.01.
bp < 0.02.
58.48
56.18
58.70
58.57
64.37
61.00
64.22
55.56
59.70
62.85
55.44
52.56
54.37
58.93
52.74
57.76
57.74
63.37
56.48
57.73
59.04
56.87
18-Month
F Value
51.52
56.33
57.11
52.18
57.37
56.33
57.30
54.4 1
52.96
56.52
54.96
1.3
0.8
1.0
4.7”
4.0b
4.7 ”
2.5
0.6
6.0”
4.6”
0.7
Table 2. Mean Valtres and t Ratios for M M P l Variables in Patientj
with Impaired versus NormaliMild Neuropsychological Pevformances
Initial Examination
Variables
L
F
K
Hypochondriasis
Depression
Hysteria
Psychopathic dev.
Paranoia
Psychasthenia
Schizophrenia
Mania
“p < 0.01.
’p < 0.05.
Mean Values in
Imp aired
Croup
Mean Values in
Normal/Mild
Group
t-Test
(df = 25)
60.87
57.55
64.11
67.78
70.00
67.44
67.87
59.00
64.33
69.11
51.11
49.78
55.50
56.00
53.00
61.55
57.78
62.39
53.83
57.37
59.72
57.61
3.33”
0.64
2.44b
3.17“
1.64
2.1?~~
1.14
1.44
1.42
1.27
2.08b
t-Test at
12 Months
t-Test at
18 Months
(df = 25)
(df = 25)
0.52
0.30
0.43
3.14”
2.86“
1.05
0.09
1.47
0.82
0.2 1
3.05 ”
0.76
0.42
1.63
3.06“
3.68“
0.88
0.20
0.19
1.GO
0.46
2.34b
Dikmen and Reitan: Sequelae of Head Injury
493
injuries, by overlooking posttraumatic cognitiveintellectual difficulties that are not easily detectable
without neuropsychological examination, and by relying on background information that is largely based on
select and biased samples of persons who have continuing medical, legal, and emotional difficulties.
Clinical observation and insight are invaluable
guides to important areas of investigation. In order to
develop a better understanding of posttraumatic emotional sequelae, these clinical insights need to be operationally defined, quantified, and subjected to systematic investigation. Through such efforts it may be
possible to identify the factors that account for the
currently unexplained variability in emotional adjustment in head-injured patients.
Supported by National Institutes of Health Contracts NOl-NS-22326 and N01-NS-6-2341.
References
1. Aita JA, Reitan RM: Psychotic reactions in the late recovery
period following brain injury. Am J Psychiatry 105:161- 169,
1948
2. Bond MR: Assessment of psychosocial outcome after severe
head injury, in Outcome of Severe Damage to the Central
Nervous System (Ciba Foundation Symposium No. 34). New
York, American Elsevier, 1975
3. Dahistrom WG, Welsh GS, Dahlstrom LE: An MMPI Handbook. Vol 1, Clinical Interpretation. Minneapolis, University
of Minnesota Press, 1972
4. Dikmen S, Reitan RM: Psychological deficits and recovery of
functions after head injury. Trans Am Neurol Assoc 101:7277, 1976
5. Edwards AL: Experimental Design in Psychological Research.
New York, Holt, Rmehart and Winston, I968
6. Goldstein K: After Effects of Brain Injuries in War. New York,
Grune & Stratton, 1942
7. Jennect B, Bond MR: Assessments of outcome after severe
brain damage-a practical scale. Lancet 1:480-484, 1975
8. Lishman WA: Brain damage in relation to psychiatric disability
after head injury. Br J Psychiatry 114:373-410, 1968
9. Lishinari WA: The psychiatric sequelae of head injury: a review. Psycho1 Med 3:304-318, 1975
10. Miller H: Accident neurosis. Br Med J 1:919-925,992-998,
1061
11. Miller €3: Mental after-effects of head injury. Proc K Soc Med
59:257-261, 1966
12. Reitan MR, Davison LA (eds): Clinical Neuropsychology: Current Status and Applications.Washington DC, V H Winston and
Sons, 1974
13. Ruesch J, Rowinan K: Prolonged post-traumatic syndromes
following head injury. Am J Psychiatry 102:145 -163, 1945
494 Annals of Neurology Vol 2 No 6 December 1977
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