“Making Headway”: Multidisciplinary Advances and Controversies in Neuropsychiatric Diagnosis and Treatment of Traumatic Brain Injury

Abstract:

Background: Traumatic brain injury (TBI) is a major public health problem and is responsible for over 2.5 million people seeking medical care with 69,000 deaths worldwide annually. It is the signature injury of recent military conflicts, as well as a growing burden of illness for civilians and athletes. While large epidemiologic studies have uncovered factors associated with better outcomes, diagnostic and treatment approaches to neuropsychiatric symptoms after TBI still remain elusive with little standardization of care. Multidisciplinary and multimodal interventions are now becoming the forefront of managing the complexities that emerge from neuropsychiatric sequelae after injury.



Approach: This symposium will explore key unresolved dilemmas of evaluation and management in TBI care with a focus on multidisciplinary treatment and recent, cutting-edge alternatives to pharmacologic interventions in four phases of TBI: acute, subacute, chronic and progressive. Case examples, differential diagnosis, workup algorithms, and treatment guidelines will be presented, along with strength of supporting evidence.

Dr. Jeffrey Zabinski will review assessment of acute TBI, including factors indicating emergency room evaluation, neuroimaging, and admission for observation. He will present management of neuropsychiatric sequelae that may emerge within the first hours to days after injury, including encephalopathy, agitation, intoxication/withdrawal, posttraumatic amnesia, and decisional capacity to refuse treatment. He will review both behavioral and pharmacological agents used in the management of agitation after acute TBI in addition to the role of ketamine for TBI in the ICU setting.



Dr. Durga Roy will present the diagnostic challenges and treatment approaches in subacute injury that address depression, anxiety, disinhibition, executive dysfunction, and apathy after TBI. She will present her current research on prognostic markers and will discuss recent evidence on pharmacologic and neuromodulatory interventions in TBI neuropsychiatry. She will introduce her comprehensive multidisciplinary brain injury outpatient day program and will focus on the importance of occupational therapy, mindfulness, anger management, and psychoeducation for caregivers in the management of neuropsychiatric problems after TBI.



Dr. Daniel Krasna will discuss comprehensive risk factor assessment and multimodal approaches to treatment and rehabilitation in subacute TBI by discussing cognitive biases, past psychiatric history and symptom amplification in the context of the neurorehabilitation of brain injury. From the perspective of Physical Medicine and Rehabilitation (PMR), he will discuss how neuropsychiatric sequelae are often undiagnosed and first noticed in rehab settings whether in therapies or through PMR evaluation. He will present behavioral interventions and common referrals needed to diagnose and treat sequelae for success in PMR therapies to improve outcomes in the rehabilitation after TBI. He will focus on how team-based approaches between physiatry, and rehabilitation therapy services teams are essential to improving outcomes.

Dr. John Dougherty will present recent advances in Sports Psychiatry with current evidence on the assessment and management of sports-related concussion. Mild TBI constitutes a heterogeneous population for a variety of reasons, including a great variance in persistence and severity of symptoms. Dr. Dougherty will highlight diagnostic challenges in the treatment of athletes and discuss the evidence of alternative interventions such as ketamine in chronic and progressive post-concussive syndrome.