Clinical Case Conference

Psychiatric Sequelae of Traumatic Brain Injury: A Case Report

Beatrice Robbins, R.N., Ph.D.

four perspectives thus provide a roadmap for diagnosis

and treatment.
This approach has been particularly useful in the effective clinical management of this patient. Our success with
this patient emerges from the use of several distinct but
complementary perspectives to understand his problems.
We describe our patients history and treatment and then
describe how using the four perspectives approach led to
his arrival at an optimal level of functioning.

Jennifer Spiro, M.S.

Case Presentation

Julianna Ward, Ph.D.

Chief Complaint

Vani Rao, M.D.

Sharon Handel, M.D.
Sandeep Vaishnavi, M.D., Ph.D.
Shari Keach, L.C.P.C.

Fred Berlin, M.D., Ph.D.

Mr. C was a 42-year-old man who was referred for

immediate admission to the inpatient neuropsychiatry
unit at Johns Hopkins Hospital for evaluation and management of behavior problems associated with traumatic brain injury after initial treatment and rehabilitation at an outside hospital.

Present Illness

raumatic brain injury is a significant cause of disMr. C was doing well until he sustained a severe trauability in the United States, with both neurological and
matic brain injury and right orbital wall fracture after fallpsychiatric consequences (1). Although neurological seing from a 40-foot-high ladder. The duration of posttrauquelae usually stabilize with time, psychiatric disorders
matic amnesia and the 24-hour Glasgow Coma Scale (6)
persist because of their propensity to produce chronic
score at the time of injury are unknown. Other than sursymptoms and to follow a relapsing course. Mood and
gical repair of the orbital fracture, no other known medbehavioral problems after traumatic brain injury interical or surgical postfall complications were diagnosed or
treated at the outside hospital. He
fere with rehabilitation efforts and
was not under the influence of illicit
cause adverse outcomes such as undrugs or alcohol at the time of the
employment, repeated hospitalizaPatients with
fall. He was hospitalized for 3 weeks,
tions, legal problems, and alienation
traumatic
brain
injury
during which time he was in a coma
from family and friends (2, 3). In addifor approximately 2 weeks.
may also indulge in
tion, these effects are amplified by high
Upon discharge, he underwent 5
rates of psychiatric comorbidity (4)
weeks
of inpatient rehabilitation folabnormal goal-directed
(e.g., DSM axis I diagnoses) in patients
lowed by several weeks of outpatient
behaviors, which can rehabilitative care. At this time, he atwith traumatic brain injury.
tempted to return to work several
The case presented here of a 42-yearfurther increase their
times. However, he was unable to hold
old man with a history of two traumatic
a job because of socially inappropriate
emotional
distress
and
brain injuries exemplifies the clinical
behavior, such as arguing with male
and social complexities of traumatic
cause social,
coworkers and inappropriately touchbrain injury. The formulation of multiand groping female coworkers on
occupational, or legal ing
ple diagnoses and the design of a commultiple occasions. He was arrested
prehensive treatment plan for this patwice and incarcerated once for 3
problems.
tient were challenging. As described by
months because of these acts. Other
behavior problems since the trauMcHugh and Slavney in their book, The
matic brain injury included frequent outbursts of anger
Perspectives of Psychiatry (5), the use of an organized apand physically aggressive behavior, leading to separation
proach and conceptual framework is important in psychifrom his wife and alienation from several family members.
atric diagnosis and treatment. The four perspectives of
Mr. C received several trials of medication that were not efpsychiatry provide a framework for organizing a patients
fective (risperidone, 1 mg at bedtime; divalproex sodium,
psychiatric history in a structured manner, independent
750 mg b.i.d.; quetiapine, dose unknown; and methof the etiology. The essence of each perspective defines
ylphenidate, dose unknown) according to his family. There
how to approach a problem and design a solution. The
was no history of seizure after traumatic brain injury.
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CLINICAL CASE CONFERENCE

Mr. Cs behavior gradually became more disinhibited

and physically aggressive, and he was referred to Johns
Hopkins for evaluation and treatment recommendations. At the time of admission, he was most concerned
about intermittent episodes of depression that had been
occurring spontaneously for several years since the traumatic brain injury. He described a typical episode of depression as lasting for 2 to 4 weeks and characterized by
persistent sadness, loss of interest in life, loneliness, feelings of worthlessness, anxiety about the future, fatigue,
problems with inattention and memory, and passive suicidal thoughts. In addition, he also reported brief transient episodes of sadness that would last for a few hours
and would occur after a stressful event, such as a confrontation with a family member.

Family, Personal, and Social History

The patients family history was negative for known
neuropsychiatric disorders. His birth and early development were reportedly normal. He graduated from high
school and served in the Navy for 4 years, receiving an
honorable discharge. Before sustaining his traumatic
brain injury, he worked successfully as a subcontractor
for homebuilders. He was married for only 6 months before his injury, and he separated from his wife. He had
two young children who lived with his wife. He was receiving disability income. Mr. C drank socially and
smoked tobacco and marijuana briefly before his traumatic brain injury. He converted his religion from Catholicism to born-again Christian after discharge from the
military. However, he was ostracized by his church in
2003 secondary to sexually inappropriate behavior. He
had had no legal problems before the second traumatic
brain injury.

Past Medical and Psychiatric History

Mr. Cs medical history was significant for a prior traumatic brain injury that occurred while he was playing
baseball. He experienced a loss of consciousness of unknown duration after colliding with one of the other
players. He suffered fractures of several facial bones on
the right side and was hospitalized for approximately 4
days. His recovery was otherwise good, and he did not
suffer any medical or psychiatric consequences after this
injury. Since his second traumatic brain injury, he had
undergone several corrective eye surgeries. Before this
traumatic brain injury, Mr. C had no history of psychiatric
symptoms or treatment, and his personality was described by his father as happy-go-lucky but conscientious. He had no history of inappropriate social or sexual
behavior. He was now noted as having a short fuse. Additional medical comorbidities included a diagnosis of
ankylosing spondylitis and arthritis.
His medications at the time of admission to the neuropsychiatry unit included divalproex sodium, 750 mg
b.i.d.; sertraline, 75 mg/day; risperidone, 1 mg at bedtime; and indomethacin, 75 mg b.i.d. (for arthritis).

Mental Status Examination

Mr. C was found to have adequate hygiene and grooming. He was cooperative during the evaluation and made
good eye contact. He did not display psychomotor abnormalities or adventitious movements but was disinhibited
and jocular. His speech was mildly dysarthric but fluent

Am J Psychiatry 164:5, May 2007

and grammatically correct with no paraphrasic errors.

His thought processes were somewhat circumstantial,
but there was no loosening of associations or evidence of
a formal thought disorder. He described his mood as
anxious for having caused trouble to family. His affect
was labile and incongruent with his mood. He endorsed
transient passive death wishes but denied active suicidal
thoughts, intent, or plans. No other violent thoughts
were elicited. His self-attitude and vital sense were normal. He had no delusions, hallucinations, obsessions,
compulsions, or phobias. His insight into emotional difficulties was limited, and his judgment was poor, as evidenced by the socially inappropriate behavior. He scored
30 of 30 on the Mini-Mental State Examination.

Physical Examination and Diagnostic Findings

Abnormalities upon neurological examination included the following:

1. A mild upper motor neuron-type dysarthria

2. Diplopia with disconjugate extraocular movements
in all directions
3. Diminished pinprick sensation on the right side of
his face in areas innervated by all three branches of
the trigeminal nerve
4. Hyperreflexia (3+) in the lower extremities (of note,
there was no clonus, and plantar reflexes were flexor
bilaterally)
Testing performed during admission included brain
magnetic resonance imaging, which showed diffuse cerebral volume loss and right frontal and left temporal areas of encephalomalacia and gliosis, a normal EEG, and
normal blood tests (including a metabolic panel, a testosterone level, a thyroid-stimulating hormone level,
and tests for HIV and syphilis).
A neuropsychological assessment revealed frontal-subcortical system dysfunctions with impairments in processing speed (i.e., the Symbol Digit Modalities Test [7],
written and oral trials) and visual sequencing/set-shifting
(i.e., the Trail Making Test, Part B [8]). Relative weaknesses were found in divided auditory attention (i.e., the
Brief Test of Attention [9]), sustained visual attention
(i.e., the Continuous Performance Test [10]), social judgment (i.e., the Dartmouth-Rabin Judgment Questionnaire [11]), verbal and visual learning and memory (i.e.,
the Hopkins Verbal Learning TestRevised [12] and the
Brief Visuospatial Memory TestRevised [13]), and nondominant (left) hand fine motor coordination (i.e., the
Grooved Pegboard test [14]). Visual memory improved to
within the average range with provision of yes/no recognition testing, indicating a primary retrieval deficit. However, no such improvement was seen for verbal memory.
Baseline verbal intellect was estimated to be in the average range. Quantitative assessment of psychiatric symptoms was also performed. The Geriatric Depression Scale
(15) revealed mild to moderate symptoms of depression
(score=18 of 30). On the Lawton Activities of Daily Living
and Instrumental Activities of Daily Living Questionnaire
(16), the patient rated himself as needing some help
getting places that were not within walking distance,
preparing meals, doing handyman work, and managing
his medications and finances.

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program and weekly sexual behaviors group), and family

therapy (every 3 months).

FIGURE 1. The Four Perspectives of Psychiatry

Perspective

Triad

Treatment

Diagnostic Challenges

Etiology
Disease

Cure
Pathology

Syndrome
Potential

Dimensional

Guidance
and Strength
Provocation

Response

Physiological Drive
Behavior

Interpretation
and Conversion
Learning

Choice
Setting

Life Story

Rescript
Sequence

Outcome

Hospital Course
Mr. C was given a behavior plan detailing inappropriate behavior to minimize conflict with other patients
and staff. With the structured activities and predictable
routine that was provided on the inpatient unit, he remained compliant and had no behavior problems. Occasionally, there was evidence of inappropriate behavior,
such as being overly familiar with visitors on the floor,
but he was easily redirected in these instances. Because
of prior lack of benefit, he was tapered from divalproex
sodium and risperidone. Sertraline was titrated to 150
oral mg/day for symptoms of major depression. Considering his frontal lobe symptoms (i.e., impulsivity, poor
social judgment, low frustration tolerance, and behavioral disinhibition), amantadine was started and gradually increased to a dose of 100 mg/day. Mr. C was discharged to the Johns Hopkins Bayview Brain Injury
Clinic; the National Institute for the Study, Prevention,
and Treatment of Sexual Trauma (formerly called the
Johns Hopkins Sexual Disorders Clinic); and a psychosocial rehabilitation program.

Outpatient Treatment
Even though Mr. C did very well in the structured inpatient setting, he found returning to the community difficult. Establishing realistic expectations was critical to his
care, and the primary goals of therapy were to minimize
existing disability and maximize productivity. The strategies employed to achieve these outcomes included pharmacotherapy (continuation of sertraline and amantadine), individual cognitive behavior therapy (once a
week), group therapies (daily psychosocial rehabilitation

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Discussion

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In summary, Mr. C was an unfortunate middle-aged

man with a history of two traumatic brain injuries. He had
been suffering from mood and behavior problems since
the second incident. In addition, he had encountered several psychosocial stressors, including legal problems, separation from family and religious connections, unemployment, and increasing dependence on family members for
assistance. Clearly, the patients case was complicated,
and many would conclude that his prognosis was poor. Although the formulation of this patients case was challenging, successful treatment would emerge from disentangling his symptoms and their respective causes. Hence, we
attempted to use an organized approach with four perspectives to define and treat all of the patients problems
(5) (See Figure 1).
Each perspective has a unique logic and set of principles
that direct treatment in a very specific way. The perspective of disease is based on categories and asks, What does
the patient have? This perspective explains mental disturbances as secondary to a broken part in the brain.
The perspective of dimensions is based on the logic of gradation and quantification and asks, What is the patient?
The dimensional perspective explains problems of mental
life as arising out of the interaction between a persons vulnerability (e.g., personality characteristics) and the demands of an environment to which that trait is mismatched or poorly suited. The perspective of behavior is
based on the logic of goals and asks, What is the patient
doing? The behavior perspective emphasizes the goal-directed aspects of behavior and how problem behaviors are
gradually shaped by other factors (e.g., internal drives, environmental consequences). The perspective of the life
story is based on the logic of narrative and asks, What has
the patient encountered? The life story perspective highlights how a distressed state of mind could be the understandable result of disturbing life experiences.
Thus, the treatment for each type of problem is also different (see Figure 1): curative in the disease perspective by
fixing the broken part, guiding and supportive in the dimensional perspective by strengthening the vulnerability
and/or reducing the mismatch between patient traits and
environmental demands, interpreting and converting in
the behavior perspective by changing goals and reinforcements, and rescripting the patients narrative in the life
story perspective by offering more encouraging interpretations of unfortunate events.

The Disease Perspective

Several of Mr. Cs symptoms and problems could be explained by the damage caused to his brain. Mood disorders in patients with traumatic brain injury are associated
with the disruption of brain circuits involving regions such
as the prefrontal cortex, amygdala, hippocampus, basal
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ganglia, and thalamus (17). Studies in depression without

traumatic brain injury have also found involvement of the
frontal cortical regions and amygdala, suggesting that dysfunction of limbic prefrontal cortical structures impairs
the modulation of the amygdala, leading to abnormal processing of emotional stimuli (18). Several studies have revealed frontal lobe damage in patients with impulse control problems similar to Mr. Cs, such as improper social
etiquette and disinhibition (1921).
The treatment approach in the disease perspective focused on curing the disease (5). In this case, the injury is irreversible, and it is not possible to cure the disease; however, symptoms of the pathology can be minimized. A
literature review revealed that there is a limited evidence
base to guide treatment of neuropsychiatric symptoms after traumatic brain injury; however, guidelines and reviews based on randomized controlled trials have been
published. In particular, the Neurobehavioral Guidelines
Working Group has recently done a comprehensive review
of the evidence base for these disorders (22). Based on this
analysis, tricyclic antidepressants and selective serotonin
reuptake inhibitors (SSRIs) are recommended for depression after traumatic brain injury. There is insufficient evidence to support or refute use of any particular agent for
mania or anxiety disorders after traumatic brain injury.
For general cognitive functions, there is insufficient evidence to support any agent, but phenytoin in particular
may make cognition worse. Agents found to enhance specific types of cognitive functioning include methylphenidate for attention and speed of cognitive processing,
donepezil to enhance attention and memory, and bromocriptine for improving executive function. Beta blockers are recommended for aggression. Other treatment options for aggression include methylphenidate, cranial
electrical stimulation, SSRIs, valproic acid, lithium, tricyclic antidepressants, and/or buspirone (22).
Mr. Cs major depression responded well to sertraline,
an SSRI. Other researchers have recommended the use of
sertraline for the treatment of major depression after traumatic brain injury (2325). Symptoms of dysexecutive
function, such as impulsivity and disinhibition, are being
controlled by amantadine. There are several anecdotal reports on the use of amantadine, a dopaminergic agonist
and an N-methyl-D-aspartate (NMDA) receptor antagonist, in patients with dysexecutive function after traumatic
brain injury (2628).
Thus, many of Mr. Cs problems (major depression, cognitive deficits) could be explained by the disease perspective. However, to formulate all of his problems as purely
biological was to preserve the disease at the expense of the
person. Also, relying solely on biological treatments to
treat the symptoms was insufficient and not holistic.
Other researchers also agree that psychiatric disturbances
after traumatic brain injury have multiple causes: social,
environmental, developmental, and behavioral (17, 29,
30). However, an approach for how to deal with these
causes is usually not provided. We have attempted to adAm J Psychiatry 164:5, May 2007

dress the emotional and cognitive problems in this patient

by applying the four perspectives approach.

The Dimensional Perspective

The central theme of the dimensional perspective is
that emotional distress can be secondary to an individuals cognitive or affective trait vulnerabilities (5). Studies
have shown that patients with traumatic brain injury often have cognitive deficits and alterations in personality
and emotional regulations that can have adverse outcomes (31). Common changes include disinhibition, irritability, apathy, agitation, aggression, indifference to surroundings, and problems with executive functioning
(32). Disinhibition may be a particular problem in this
patient population. In a study comparing patients with
traumatic brain injury to normal comparison subjects on
the Revised Diagnostic Interview for Borderlines (33),
which is a measure of borderline traits, the patients with
traumatic brain injury had more borderline-like traits
than the comparison subjects on tasks of inhibition and
object relations. The subjects with traumatic brain injury
had a poorer performance on the go/no go task, indicating difficulty inhibiting their responses. The dimensional perspective includes assessing potential, provocation, and response. For example, Mr. Cs cognitive
inefficiencies, such as inattention and poor memory,
coupled with his personality traits after traumatic brain
injury of low frustration tolerance and quickness to anger
(potential) placed him at risk when stressed or challenged (provocation) to react aggressively or inappropriately (response). Although these cognitive and affective
trait vulnerabilities were clearly a sequelae of traumatic
brain injury, they were now the patients new persona or
new baseline. Trauma to the brain often causes injury to
the frontal-temporal regions with resultant cognitive, behavioral, and emotional impairments that can persist for
decades after traumatic brain injury (34). These impairments can be further exaggerated by other factors, such
as comorbid psychiatric disorders, substance abuse, and
environmental factors, such as excessive stimulation
and/or limited psychosocial support (34). Because there
is no cure for traumatic brain injury, treatment for a dimensional problem should focus on factors precipitating
the emotional distress and strategies used to reduce the
emotional response. The dimensional approach helps
recognize the patients vulnerabilities and provides guidance and strength to help the patient function to the fullest potential.
In accordance with the dimensional perspective, Mr. C
received guidance through instruction, practice, and support during individual and group therapy sessions. During
these sessions, Mr. C was educated about brain injury and
its consequences. Guidance included encouraging Mr. C
to acknowledge his deficits and to recognize a new baseline. During therapy sessions, his strengths (e.g., motivation to get better, desire to be self-sufficient, absence of
substance abuse) and weaknesses (cognitive deficits and
specific personality traits) were discussed. Modeling and
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role playing were used to demonstrate how his vulnerabilities could lead to trouble. Discussing his strengths improved his self-esteem and helped him stay motivated.
Guidance also included training to improve his interpersonal relationships, with an emphasis on learning to listen, exercising self-control when angry, and making conversation in a polite and responsible manner. Group
counseling was useful in providing actual interactions
with peers and opportunities for socialization to offset the
loneliness that often provoked Mr. Cs distress. This supportive and structured setting gave Mr. C an opportunity
to obtain safe feedback from peers. In addition, regular
family meetings were held to provide additional instruction and support.

Behavior Perspective
Even though the disease and the dimensional perspectives could explain many of Mr. Cs behavioral problems,
some of them, such as the sexually inappropriate behavior, were better explained using the behavior perspective.
Sexually inappropriate behavior can be particularly troublesome in this patient population. Simpson et al. (35) related patients with traumatic brain injury with sexually inappropriate behavior to comparison subjects with
traumatic brain injury without the behavior to identify social, cognitive, and medical correlates. They found a
higher incidence of psychosocial impairment and failure
to return to work after traumatic brain injury in subjects
with traumatic brain injury with sexually inappropriate
behavior. Premorbid temperament or postinjury medical
or cognitive variables were not significantly more common in the traumatic brain injury group with sexually inappropriate behavior. The researchers warn against having a simplistic explanation, such as frontal lobe damage
or psychosocial disturbance before traumatic brain injury,
as the cause for sexually inappropriate behavior that
emerges after injury.
The behavior perspective identifies conditions that represent problems of choice and control and is governed by
a triad of physiological drive, conditioned learning, and
choice. Motivated behaviors, such as eating, drinking,
sleeping, and sexuality, all depend on learning and maturation. However, these normal behaviors can become a
disorder when carried to excess in form or frequency.
These abnormal motivated behaviors are often sustained
by rewarding consequences. Mr. Cs inappropriate sexual
behavior is a typical example of an abnormal goal-directed behavior. Even though injury to the frontal lobes
may have resulted in impulsivity and disinhibition, making him vulnerable to hypersexual acts, this behavior is
probably shaped and maintained by positive reinforcements that Mr. C receives when he indulges in touching
others. The rewards, such as joy and/or attention, that he
receives may also be a distorted form of sexual outlet.
Treatment involves stopping or converting the problematic behavior. This approach involves confronting behavior, challenging the patients reluctance to change, and
adopting the new goal of striving to end it. The behavioral

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approach has been shown to help in this patient population. Fyffe et al. (30) described a case of a 9-year-old boy
diagnosed with traumatic brain injury who continued to
maintain inappropriate sexual behavior secondary to positive reinforcement in the form of social attention. A behavioral intervention in the form of functional communication training and extinction led to a reduction of the
inappropriate behavior. Zencius et al. (36) described the
effectiveness of simple strategies such as feedback and
scheduled massage to decrease hypersexual behavior in
brain-injured subjects. Bezeau et al. (37) reviewed the various types of sexually intrusive behavior following traumatic brain injury and discussed methods for assessment
and management.
Evaluation and treatment of inappropriate sexual behavior is often frustrating and challenging for the therapist
and awkward, embarrassing, and sometimes even shameful for the patient and/or his family. In the behavioral approach, these behaviors should be addressed respectfully
and in a professional manner, and the therapist should be
sensitive to the feelings of the person/family (38). The person should be told in a clear, straightforward manner that
the behavior is unacceptable. Family members should be
educated about the frequency of socially and sexually inappropriate behaviors after traumatic brain injury.
Management of Mr. Cs hypersexual behavior included a
combination of pharmacotherapy and psychotherapy.
The increased sexual drive was reduced pharmacologically with leuprolide. There is a significant literature on
the use of medroxyprogesterone and leuprolide acetate
for the treatment of paraphilias and hypersexual behavior
in patients with and without traumatic brain injury (39
42). Psychotherapy included group therapy and individual
therapy focused on providing clear recommendations
about acceptable and unacceptable behavior. Examples
include avoiding people and places where he was likely to
be vulnerable to hypersexuality, encouraging him to have
a responsible person supervise him when he was meeting
with friends, role-playing his actions before his dates,
modeling and providing feedback, and encouraging repetition of appropriate behavior. Regular discussion in simple language about the feelings and rights of the person
being touched and the legal consequences he had to suffer
because of his actions also helped. Mr. Cs strong religious
beliefs helped to reduce and keep this behavior in check.
The behavior perspective may also help patients with
traumatic brain injury with various other inappropriate
behaviors. Hegel and Ferguson (43) demonstrated a significant reduction in aggressive behavior using the technique
of differential reinforcement of other behaviors in a
brain-injured man. Tiersky et al. (44) compared the effectiveness of individual cognitive behavior psychotherapy
and individual cognitive remediation therapy to regular
follow-up treatment in patients with mild to moderate
traumatic brain injury. A total of 20 subjects were followed
for 11 weeks. They found that the group that received cognitive behavior therapy/cognitive remediation therapy
had reduced emotional distress and improved attention at
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1 and 3 months posttreatment. Bell et al. (45) used a novel

but simple method of scheduled telephone intervention
with counseling and education. In this study, 85 patients
with traumatic brain injury were selected at random for
telephone intervention, and 86 patients with traumatic
brain injury, for usual outpatient care. The telephone interventions consisted of motivational counseling and education and counseling regarding follow-up appointments and medications. At the end of 1 year, those who
received telephone intervention fared significantly better
on several behavioral outcomes and overall quality of life.
Cox et al. (46) also demonstrated the effectiveness of systematic motivation counseling to treat substance abuse in
patients with traumatic brain injury. Those who received
systematic motivation counseling had a significant reduction in negative affect and substance abuse compared to
patients with traumatic brain injury without systematic
motivation counseling. Other types of behavioral interventions found to be helpful for patients with traumatic
brain injury include natural setting behavior management, in which the focus is on education and individualized behavior modification in the natural community setting (47), and multidisciplinary treatment (48). The latter
study revealed that targeting patients with traumatic brain
injury with pre-injury psychiatric problems is effective in
reducing depressive symptoms postinjury.

The Life Story Perspective

The transient episodes of sadness and hopelessness
that Mr. C experienced are less satisfactorily explained by
any of the previous perspectives and are best explained by
the life story perspective. This perspective takes into account events that have taken place in a persons life and
tries to explain their distress as an outcome of this narrative (5). In other words, the life story perspective attempts
to make sense of emotional problems as meaningful responses to life encounters. McHugh and Slavney (5) defined the life story perspective as the triad of setting, sequence, and outcome. In the case presented, the setting is
the brain injury; sequences include the loss of his job, separation from his wife, family conflicts, and legal problems;
and outcomes are the demoralized states of sadness, loneliness, helplessness, and rage.
The goal of therapy in the life story perspective is to rescript events and the negative meanings adopted by the
patient. Individual and group therapy often help the person to reinterpret his or her life by providing an understanding of the setting and sequence and coping skills
and compensatory strategies to modify the outcome. Ultimately, the patient is encouraged to continue his or her
life with an acceptance of past events and renewed optimism about the potential for future successes that will
lead to a satisfying and fulfilling life.
Studies indicate that patients with traumatic brain injury face numerous psychosocial problems, such as those
experienced by Mr. C, that contribute to emotional distress, anger, and aggression (29, 49). When compared to
those with other chronic medical illnesses, people with
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traumatic brain injury have a unique set of problems that

increases the risk for emotional distress. First, traumatic
brain injury strikes suddenly, causing a dramatic change
in functional, social, and occupational life. Second, because of this acute onset, family members have not made
any preparations to take care of the handicapped braininjured person. This often results in family relationships
faltering. Third, because the physical sequelae of traumatic brain injury often resolve or stabilize, the psychiatric disturbances continue to persist or relapse, which
many families of patients with traumatic brain injury have
difficulty understanding. Fourth, many patients with traumatic brain injury are unable to obtain rehabilitation services that they need because of poor finances, lack of insurance, or difficulty finding an appropriate place. Finally,
impaired self-awareness is a common problem in traumatic brain injury (50). Patients with traumatic brain injury with impaired self-awareness when compared to
those without impaired self-awareness show more psychopathological symptoms, worse neuropsychological
function, and decreased functional independence (51).
Sherer et al. (52) noted that decreased self-awareness after
traumatic brain injury is secondary to multiple disruptions of the integrated, broadly distributed neural network
associated with awareness rather than lesions in particular brain regions. Others, however, have noted specific abnormalities in the right anterior prefrontal region in patients with traumatic brain injury with impaired selfawareness in relation to normal comparison subjects (53).
Lack of insight can be particularly challenging in the treatment of neuropsychiatric symptoms after traumatic brain
injury. Hurt (54) has proposed three specific strategies to
improve self-awareness. They include identification of the
strengths and limitations of people with traumatic brain
injury by formal vocational testing, confrontation of behavior problems through group therapy, and involvement
in a work setting to learn compensatory strategies and rebuild self-esteem. Other methods to improve awareness
include education in brain-behavior relations, goal and
journal group therapy, and video feedback therapy (55).
Mr. C had limited self-awareness, perhaps because of
the right frontal injury. Regular education, individual and
group therapy, and gentle confrontation of inappropriate
behavior all played a role in improving Mr. Cs awareness
of his deficits and improvement in behavior.

Conclusion
Traumatic brain injury is a complex condition associated with several psychiatric problems, some of which
could be direct manifestations of brain damage, and others, associated with the persons inherent cognitive or personality traits. In addition, patients with traumatic brain
injury may also indulge in abnormal goal-directed behaviors, which can further increase their emotional distress
and cause social, occupational, or legal problems. Finally,
their negative reactions and sense of pessimism may be
understood by their changing life circumstances and the
associated new challenges.
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We used four distinct but complementary perspectives

in formulating and treating Mr. Cs psychiatric problems
after traumatic brain injury. This organized approach
helped to identify and differentiate the independent aspects of his illness and provide the necessary pharmacological and nonpharmacological treatments. Mr. C has
made significant improvement since he began treatment
in our clinic. Although Mr. C is by no means cured, his
treatment was individually designed to help him attain the
goal of improving his overall quality of life.
We presented this case report to highlight the importance of using a structured formulation to diagnose and
treat the psychiatric sequelae of traumatic brain injury. To
clearly demonstrate the effectiveness of this organized approach, future studies should include larger numbers of
subjects and well-validated research instruments to assess
mood and cognitive and behavioral outcomes.
Received July 13, 2006; revision received Jan. 25, 2007; accepted
Feb. 7, 2007. From the Divisions of Geriatric Psychiatry and Neuropsychiatry and Medical Psychology and the Department of Psychiatry,
Johns Hopkins School of Medicine, Baltimore; and the Community
Psychiatry Program, Johns Hopkins Bayview Medical Center, Baltimore. Address correspondence and reprint requests to Dr. Rao, Suite
308, 550 N. Broadway, Baltimore, MD 21205; vrao@jhmi.edu (e-mail).
Ms. Spiro is a consultant for Respironics, Inc. Dr. Rao has received
NIH grants and grants from Pfizer and Forest. The remaining authors
report no competing interests.

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