Mental disorders during traumatic brain injury. Mental disorders in traumatic brain injuries
Brain injuries and their consequences remain one of the most difficult and unresolved problems of modern medicine and are of great importance due to their prevalence and severe medical conditions. social consequences. As a rule, a significant increase in the number of people who have suffered head injuries is observed during periods of war and the years immediately following them. However, even in conditions of peaceful life, due to the growth of the technical level of development of society, a fairly high incidence of injuries is observed. According to data carried out in the early 90s. epidemiological study of traumatic brain injury, in Russia, more than 1 million 200 thousand people receive brain damage annually (L.B. Likhterman, 1994). In the structure of disability and causes of death, traumatic brain injuries and their consequences are already long time take second place after cardiovascular pathology(A.N. Konovalov et al., 1994). These patients make up a significant proportion of people registered in psychoneurological dispensaries. Among the forensic psychiatric population, a significant proportion are people with organic brain lesions and their consequences of traumatic etiology.
Brain injury refers to mechanical damage to the brain and skull bones of varying types and severity. Traumatic brain injuries are divided into open and closed. With closed head injuries, the integrity of the skull bones is not compromised; with open ones, they are damaged. Open head injuries can be penetrating or non-penetrating. With penetrating injuries, there is damage to the substance of the brain and meninges; with non-penetrating injuries, the brain and meninges are not damaged.
With a closed head injury, concussion (commotion), bruises (concussion) and barotrauma are distinguished. Concussion occurs in 70–80% of victims and is characterized by changes only at the cellular and subcellular levels (tigrolysis, swelling, watering of brain cells). Brain contusion is characterized by focal macrostructural damage to the brain substance of varying degrees (hemorrhage, destruction), as well as subarachnoid hemorrhages, fractures of the bones of the vault and base of the skull, the severity of which depends on the severity of the contusion. Edema and swelling of the brain are usually observed, which can be local or generalized.
Traumatic brain disease. Pathological process that develops as a result mechanical damage brain and characterized by all its diversity clinical forms unity of etiology, pathogenetic and sanogenetic mechanisms of development and outcomes is called traumatic brain disease. As a result of a head injury, two oppositely directed processes are simultaneously launched, degenerative and regenerative, which occur with a constant or variable predominance of one of them. This determines the presence or absence of certain clinical manifestations, especially in long term head injuries. Plastic restructuring of the brain after a head injury may last for a long time(months, years and even decades).
During traumatic illness There are 4 main periods of the brain: initial, acute, subacute and long-term.
Initial period is observed immediately after receiving a head injury and is characterized by a loss of consciousness lasting from several seconds to several hours, days and even weeks, depending on the severity of the injury. However, in approximately 10% of victims, despite severe skull damage, loss of consciousness is not observed. The depth of switching off consciousness can be different: stupor, stupor, coma. When deafened, there is a depression of consciousness with the preservation of limited verbal contact against the background of an increase in the threshold of perception of external stimuli and a decrease in one’s own mental activity. With stupor, deep depression of consciousness occurs with preservation of coordinated defensive reactions and opening of the eyes in response to painful, sound and other stimuli. The patient is usually drowsy, lies with eyes closed, motionless, but with the movement of his hand he localizes the place of pain. Coma is a complete shutdown of consciousness without signs of mental life. There may be memory loss for a narrow period of events during, before and after the injury. Retrograde amnesia may reverse over time when the period of memory of events narrows or fragmentary memories appear. Upon restoration of consciousness, cerebrasthenic complaints, nausea, vomiting, sometimes repeated or repeated, are typical. Depending on the severity of the head injury, there are various neurological disorders, disorders of vital functions.
In the acute period of a traumatic illness, consciousness is restored and the cerebral symptoms. In case of severe head injuries, after the return of consciousness, a period of prolonged mental adynamia is observed (from 2–3 weeks to several months). In persons who have suffered a closed mild or moderate head injury, “minor contusion syndrome” is observed within 1–2 weeks in the form of asthenia, dizziness, and autonomic disorders (A.V. Snezhnevsky, 1945, 1947).
Asthenia is manifested by a feeling of internal tension, a feeling of lethargy, weakness, and apathy. These disorders usually worsen in evening time. When changing body position, while walking, when going up and down stairs, dizziness, darkening of the eyes, and nausea occur. Sometimes psychosensory disorders develop when patients feel as if a wall is falling on them, the corner of the room is beveled, and the shape of surrounding objects is distorted. Memory impairment, deterioration of reproduction, irritable weakness, and general cerebral disorders (headaches, dizziness, vestibular disorders) are noted. The ability to work is noticeably reduced, attention is disrupted, and exhaustion increases. Characterized by a change in the meaning-forming function and a decrease in the motivating function, a weakening of socially significant motives.
The depth and severity of asthenic disorders vary significantly. Some anxiety, irritability, restlessness, even with minor intellectual and physical stress, are replaced by lethargy, weakness, a feeling of fatigue, difficulty concentrating, and autonomic disorders. Typically these disorders are transitory nature, but they are also more persistent and pronounced and significantly aggravate insufficient performance.
The main symptom of minor contusion syndrome is headache. It occurs periodically with mental and physical stress, bending of the torso and head. Less often, the headache lasts constantly. All patients have disturbed sleep, which becomes restless, unrefreshing, with vivid dreams and is characterized by awakening with a feeling of fear. Persistent insomnia may occur.
Autonomic-vascular disorders are manifested by hyperhidrosis, hyperemia skin, cyanosis of the hands, sudden redness and blanching of the face and neck, trophic disorders of the skin, palpitations. Depending on the severity of the head injury, various neurological disorders are possible - from paresis, paralysis and intracranial hypertension to diffuse neurological microsymptoms.
The course of a traumatic disease in the acute period is wavy, periods of improvement are replaced by deterioration of the condition. Deterioration of the condition is observed when mental stress, under the influence of psychogenic factors, during atmospheric fluctuations. At the same time, asthenic manifestations intensify, the development of convulsive seizures, disturbances of consciousness such as twilight or delirious, acute short-term psychotic episodes of hallucinatory and delusional structure is possible.
The duration of the acute period is from 3 to 8 weeks, depending on the severity of the head injury.
The subacute period of a traumatic illness is characterized by either a complete recovery of the victim or a partial improvement in his condition. Its duration is up to 6 months.
The long-term period of a traumatic illness lasts several years, and sometimes the entire life of the patient. First of all, it is characterized by cerebrasthenic disorders with irritability, sensitivity, vulnerability, tearfulness, increased exhaustion due to physical and especially mental stress, and decreased performance. Patients complain of sleep disturbances, intolerance to heat and stuffiness, a feeling of lightheadedness when driving in public transport, and a slight decrease in memory. Hysteriform reactions may occur with demonstrative sobbing, wringing of hands, exaggerated complaints about poor health, and demands for special privileges. At objective research minor scattered neurological symptoms and vasovegetative disorders are detected. Typically, cerebrasthenic disorders have favorable dynamics and after a few years are completely leveled out.
Affective pathology is characteristic of the late stage of a traumatic illness. It may appear shallow depressive disorders in combination with more or less pronounced affective lability, when mood swings in the downward direction easily occur for a minor reason. Clinically more pronounced affective disorders are possible in the form of depressive states with a feeling of loss of interest in previous everyday worries, an unreasonable interpretation of the attitude of others towards oneself in a negative way, an experience of inability to active actions. Depressive affect can acquire a tinge of dysphoria, which is expressed in angry-negative reactions and a feeling of internal tension.
Depressive disorders are usually accompanied by increased excitability, irritability, anger, or gloominess, gloominess, dissatisfaction with others, sleep disorders, and impaired ability to work. In this case, mood disorders can reach the level of severe dysthymia or even dysphoria. The duration of such dysthymic and dysphoric states is no more than one to one and a half days, and their appearance is usually associated with situational factors.
In the structure of depressive states, an apathetic component can be detected when patients complain of boredom, indifference, lack of interest in the environment, lethargy, and decreased physical tone.
Most of these individuals are characterized by a decrease in the threshold of psychogenic sensitivity. This leads to an increase in situationally determined hysterical reactions and other primitive forms of expression of protest (auto- and hetero-aggression, reactions of the opposition), an increase in the rudeness and brutality of the affective reaction. The forms of behavior of patients in such cases are determined by short-term affective-explosive reactions with increased irritability, excitability, touchiness, sensitivity, and inadequacy of response to external influences. Affective outbursts with violent motor discharge usually occur for an insignificant reason, do not correspond in strength of affect to the genetic cause, and are accompanied by a pronounced vaso-vegetative reaction. To minor, sometimes harmless, remarks (someone laughs loudly, talks) they give violent affective discharges with a reaction of indignation, indignation, and anger. Affect is usually unstable and easily exhausted. Its long-term cumulation with a tendency to long-term processing of experiences is not typical.
Many patients develop psychopathic-like disorders in the late period of traumatic illness. However, it is often difficult to talk about a clinically defined psychopath-like syndrome. Emotional-volitional disorders in these cases, with all their typological uniformity, are not constant, arise under the influence of additional exogenous influences and are more reminiscent of psychopathic reactions of the explosive, hysterical or asthenic types.
Behind the façade of cerebrasthenic and emotional-volitional disorders, most patients exhibit more or less pronounced intellectual-mnestic changes. Mental and physical exhaustion, increased distractibility, weakened ability to concentrate lead to decreased performance, narrowed interests, and decreased academic performance. Intellectual weakness is accompanied by slowness of associative processes, difficulties in memorization and reproduction. It is usually not possible to unambiguously interpret these disorders due to a psychoorganic defect, as well as to assess its depth and quality due to the severity of asthenic manifestations, which, on the one hand, potentiate these disorders, and on the other, are one of the factors in their development.
A distinctive feature of all patients in the long-term period of head injury is the tendency to periodic exacerbations of the condition with aggravation of all components of the psychoorganic syndrome - cerebrasthenic, affective-volitional, intellectual-mnestic - and the appearance of new optional symptoms. Such exacerbations of psychopathological symptoms are always associated with external influences (intercurrent diseases, psychogenic disorders). Patients experience increased headaches, psychophysical fatigue, general hyperesthesia, sleep disturbances, and a sharp increase in vaso-vegetative disorders. At the same time it is increasing emotional stress, irritability and short temper sharply increase. Poorly corrected affective explosiveness takes on an extremely rude, brutal character and finds outlet in aggressive acts and destructive actions. Hysterical manifestations lose situational mobility and expressiveness, become sharp, monotonous with a pronounced component of excitability and a tendency to self-inflation. Personal disharmony is intensified due to the appearance of senesto-hypochondriacal and hysteroform (feeling of a lump in the throat, feeling of lack of air, interruptions in the heart) disorders, unstable ideas of self-deprecation, low value, attitude.
In the forensic investigative situation, the reactive lability characteristic of these individuals with the slight occurrence of psychogenic layers is also revealed. This manifests itself in a decrease in mood, increased affective excitability and lability, and in some cases in the appearance of hysteroform and puerile-pseudodementia disorders.
IN in rare cases After severe head injuries, traumatic dementia develops. The psychopathological structure of personality in these cases is determined by a gross psychoorganic syndrome with a pronounced decrease in all indicators of attention, thinking, memory, ability to predict, and the collapse of mechanisms for regulating cognitive activity. As a result, it is disrupted holistic structure intellectual processes, the combined functioning of the acts of perception, processing and fixation of new information, comparing it with previous experience, is disrupted. Intellectual activity loses the property of a purposeful adaptive process, and a mismatch occurs in the relationship between the results of cognitive activity and emotional-volitional activity. Against the background of the collapse of the integrity of intellectual processes, a sharp depletion of the stock of knowledge, a narrowing of the range of interests and their limitation to the satisfaction of basic biological needs, a disorder of complex stereotypes of motor activity and labor skills are revealed. There is a more or less pronounced impairment of critical abilities.
The formation of a psychoorganic syndrome in these cases follows the path of becoming an apathetic version of a psychoorganic personality defect and consists of paired symptoms such as torpidity of thinking and at the same time increased distractibility, decreased vital tone, apathy and adynamia in combination with affective lability, dysmnestic disorders with increased exhaustion . Pathopsychological research reveals in these cases increased exhaustion, fluctuations in performance, decreased intellectual productivity, impaired memory both direct and through indirect connections, weakened focus and inconsistency of judgments, and a tendency to perseveration.
During a traumatic illness, paroxysmal disorders and states of altered consciousness (traumatic epilepsy) may appear. Paroxysmal disorders occur both during the first year after the injury and in its long-term period after 10–20 or more years. Paroxysmal disorders of the acute and subacute period of a traumatic illness have a more favorable course and over time remain only in the anamnesis of the disease. Epileptiform disorders in the late period of traumatic brain injury have a less favorable prognosis. They are characterized by high polymorphism. These can be grand mal seizures, minor and abortive seizures, absence seizures, convulsive states without impairment of consciousness, non-convulsive seizures with a minimal convulsive component, vegetative seizures, attacks of psychosensory disorders.
Sometimes episodes of twilight stupefaction are observed. They manifest themselves as an acute and sudden onset without warning, a relatively short duration of the course, an affect of fear, rage with disorientation in the environment, the presence of vivid hallucinatory images of a frightening nature, and acute delirium. Patients in this state are motorically excited, aggressive, and at the end of the psychosis they experience terminal sleep and amnesia.
Illegal acts in such states are always directed against the life and health of others, do not have adequate motivation, are characterized by cruelty, failure to take measures to conceal the crime, and the experience of the alienness of the act. In forensic psychiatric practice they are often assessed as short-term painful disorders mental activity in the form of a twilight state.
In the long-term period of a traumatic illness, traumatic psychoses may occur. They usually occur 10–15 years after a head injury. Their development is projected by repeated head injuries, infectious diseases, psychogenic influences. They occur in the form of affective or hallucinatory-delusional disorders.
Affective psychoses are manifested by periodic states of depression or mania. Depressive syndrome characterized by decreased mood, melancholy affect, and hypochondriacal experiences. With mania, the background mood is elevated, anger and irritability predominate. At the height of affective psychoses, twilight stupefaction may develop. The psychotic state occurs in combination with a psychoorganic syndrome of varying severity. The course of psychosis is 3–4 months with subsequent reverse development of affective and psychotic symptoms.
Hallucinatory-delusional psychoses also occur without warning. On initial stage their development may lead to clouding of consciousness like twilight or delirium with the inclusion of hallucinatory phenomena. Subsequently, the clinical picture is dominated by polymorphic hallucinatory-delusional disorders with the inclusion of elements of the Kandinsky-Clerambault syndrome. With more easy version During the course of psychosis, the experiences of patients are in the nature of overvalued ideas of hypochondriacal or litigious content. Late traumatic psychoses differ from schizophrenia in the presence of a pronounced psychoorganic syndrome, the appearance at the height of their development of a state of impaired consciousness, and upon recovery from psychosis - signs of asthenia and intellectual-mnestic disorders.
Forensic psychiatric assessment of persons who have suffered head injuries is ambiguous and depends on the stage of the disease and the clinical manifestations of the disease. The most difficult expert assessment is the acute period of a traumatic illness, since experts do not observe it personally. To assess mental status retrospectively, they use medical documentation surgical hospitals, where the patient is usually admitted immediately after receiving a head injury, with materials from criminal cases and a description of the patient’s condition relative to that period. Taking into account retro- and anterograde amnesia, the information provided by patients is usually extremely scarce. At the same time, practice shows that in the acute period of a traumatic illness, serious illegal actions directed against the individual and transport offenses are often committed. Special meaning acquires an expert assessment of the victims.
In relation to persons who have committed unlawful acts, mild and moderate traumatic brain injuries are of greatest importance, since consciousness in these cases is not deeply clouded and is of a undulating nature. In persons in this condition, gait is not impaired and individual purposeful actions are possible. Nevertheless, a confused facial expression, lack of adequate speech contact, disorientation in the environment, further retro- and anterograde amnesia indicate a violation of consciousness in the form of deafness. These conditions fall under the concept of temporary mental disorder and indicate the insanity of these persons in relation to the act charged with them.
Medical measures that can be recommended for such patients are determined by the severity of the residual effects of the head injury. With complete reverse development of mental disorders, patients require treatment in general psychiatric hospitals.
If the examination reveals pronounced post-traumatic disorders in the subject (epileptiform seizures, periodic psychoses, pronounced intellectual and mental decline), compulsory medical measures may be applied to the patients in specialized psychiatric hospitals.
When experts commit transport offenses, the mental state of the driver is assessed from two positions. First, the driver may have had a history of traumatic brain injury, and at the time of the accident it is important to assess whether he or she had an abortive epileptiform disorder such as petit mal seizure, absence seizure, or full-blown seizure. The second position is that at the time of the accident the driver often receives a second traumatic brain injury. The presence of the latter masks the previous post-traumatic state. If the subject has previously suffered from a traumatic illness, this must be confirmed by appropriate medical documentation.
The most important thing for an expert opinion is the analysis of the traffic pattern, the testimony of those in the car with the driver at the time of the accident, the statement or denial alcohol intoxication, the person responsible for the accident’s description of his mental state. If at the time of the offense the expert’s consciousness is impaired, the person is declared insane. In cases where a traumatic brain injury was received at the time of the accident, regardless of its severity, the person is considered sane. The driver's further condition is assessed according to the severity of the traumatic brain injury. With complete reverse development of the post-traumatic state or with mild residual effects the person is sent for investigation and trial. If the expert commission ascertains the presence of pronounced post-traumatic disorders, then the person should be sent for treatment to a psychiatric hospital with routine observation as general principles, and for compulsory treatment. The further fate of the patient is determined by the characteristics of the course of the traumatic disease.
Forensic psychiatric examination of victims who received a head injury in a criminal situation has its own characteristics. At the same time, a complex of issues is resolved, such as the ability of a person to correctly perceive the circumstances of the case and testify about them, the ability to correctly understand the nature of the unlawful acts committed against him, as well as his ability, due to his mental state, to participate in judicial investigative actions and exercise his right to protection (procedural capacity). In relation to such persons, a comprehensive commission with a representative of the forensic medical examination resolves the issue of the severity of bodily injuries as a result of a head injury received in a criminal situation. If a person has received a slight injury as a result of unlawful acts committed against him, he can correctly perceive the circumstances of the incident and testify about them, as well as understand the nature and significance of what happened and exercise his right to defense.
When a person is diagnosed with signs of retro- and anterograde amnesia, he cannot correctly perceive the circumstances of the case and give information about them correct readings. It should be taken into account that such persons often replace memory disorders related to the period of the offense with fictions and fantasies (confabulation). This indicates the victim’s inability to correctly perceive the circumstances of the case. In this case, the examination is obliged to establish the time boundaries of memory disorders, taking into account the reverse dynamics of retrograde amnesia at the time of the examination. If post-traumatic disorders are not severe, then such a person can subsequently independently exercise his right to defense and participate in a court hearing. In case of severe head injuries and severe post-traumatic disorders, the person cannot perceive the circumstances of the case and give correct testimony about them.
When determining the severity of bodily injuries received by a victim in a criminal situation, a comprehensive forensic and forensic psychiatric examination is based on the severity of the traumatic brain injury, the duration of the initial and acute periods and the severity of mental disorders in the late period of the traumatic illness.
Forensic psychiatric examination of the long-term consequences of head trauma mainly concerns resolving the issue of the sanity of these individuals. By the time the crime is committed and the examination is carried out, they usually have minor post-traumatic disorders in the form of psychopathic-like, neurosis-like, affective and asthenic disorders, which does not exclude their sanity. In the presence of pronounced intellectual-mnestic disorders, up to traumatic dementia, patients should be declared insane.
Brain injuries are one of the most common forms of pathology and can be observed in everyday life, at work, in transport, in sports, and in wartime. The nature of mental disorders in traumatic injury brain, their severity is determined by the mechanism of injury, the presence of complicating factors, individual characteristics the victim, the stage of the traumatic disease. There are closed and open skull injuries.
Closed injuries are divided into concussions (concussions) and contusions (bruises). When the former prevail general phenomena, Related diffuse damage brain matter, in the second - local, depending on damage to a specific area of the brain. During the course of a traumatic disease, initial, acute, late and long-term periods are distinguished. Depending on the severity of the injury, in the initial period, degrees of loss of consciousness varying in depth and duration can be observed - from mild stupor to coma. Usually there are general cerebral symptoms (dizziness, nausea, vomiting), various vegetative, somatic disorders (respiratory disorders, cardiac activity, collapsed states, etc.). The initial period is the most difficult. Fatal outcomes are usually observed at this stage.
In the acute period, the consciousness of patients gradually clears up, but for a long time they remain inhibited, lethargic, and drowsy. Sometimes phenomena of retrograde and anterograde amnesia may be observed. States of switching off consciousness can be replaced by other disorders, and then at this stage delirium, twilight stupefaction, and, less commonly, amentia and oneiroid are observed. It should be taken into account that such patients require special observation and care, since inappropriate behavior them during this period may pose a danger to themselves and others.
IN late period against the background of cerebral asthenia under the influence external influences Hysteriform and epileptiform seizures may occur, twilight disturbances consciousness, hysterical and depressive states. Neurological symptoms gradually regress or are organized according to the lesion.
In the period of long-term consequences, patients experience neurosis-like symptoms. They show increased irritability, get tired quickly, and cannot tolerate strong smells and sounds. Performance, concentration, and memory decrease. Sleep disorders, constant headaches, dizziness, tinnitus, tremor of the tongue and limbs are often observed. In the future, some patients against this background may experience convulsive seizures, psychotic states with hallucinations, delusions, and severe affective disorders. In case of bruises accompanied by significant damage to brain tissue, in the period of long-term consequences, a sharp decline intellectual abilities, memory. In these cases they talk about traumatic dementia.
With open skull trauma, a generally similar dynamics of pathological disorders is observed. If an open injury is accompanied by penetrating (with disruption of the integrity of the dura mater) damage to the brain substance, the course of the disease may be complicated by intracerebral infection. Complications in the form of meningitis, meningoencephalitis, and brain abscesses usually do not occur immediately, but in an acute or even late period. In this case, psychosis with a picture of delirium or amentia is observed.
Mental disorders In case of traumatic brain injuries, it is customary to correlate the corresponding stages of development of the traumatic disease:
- 1) mental disorders of the initial period, manifested mainly by disorders of consciousness (stunning, stupor, coma) and subsequent asthenia;
- 2) subacute or prolonged psychoses that occur immediately after a head injury in the initial and acute periods;
- 3) subacute or prolonged traumatic psychoses, which are a continuation of acute psychoses or first appear several months after the injury;
- 4) mental disorders long-term period of traumatic brain injury (long-term or residual consequences), appearing for the first time several years later or arising from earlier mental disorders.
Symptoms and course.
Mental disorders that occur during or immediately after an injury are usually manifested by varying degrees of loss of consciousness (stunning, stupor, coma), which corresponds to the severity of the traumatic brain injury. Loss of consciousness is usually observed with concussion and contusion of the brain. When consciousness returns, the patient experiences a loss from memory of a certain period of time - the one following the injury, and often the one preceding the injury. The duration of this period varies - from several minutes to several months. Memories of events are not restored immediately or completely, and in some cases only as a result of treatment. After each injury with impaired consciousness, post-traumatic asthenia is noted with a predominance of either irritability or exhaustion. In the first option, patients become easily excitable, sensitive to various stimuli, with complaints of shallow sleep with nightmares. The second option is characterized by a decrease in desires, activity, performance, and lethargy. There are often complaints about headache, nausea, vomiting, dizziness, unsteadiness of gait, as well as fluctuations in blood pressure, palpitations, sweating, salivation, focal neurological disorders.
Acute traumatic psychoses develop in the first days after a closed craniocerebral injury, more often with bruises than with concussions. By clinical picture these psychoses are similar to those in somatic diseases (see) and are manifested mainly by clouding syndromes, as well as memory disorders and vestibular disorders. The most common form of traumatic psychosis is twilight stupefaction, the duration of which can be from several hours to several days and even weeks. Occurs, as a rule, after a short period of clarity of consciousness and the action of additional hazards (alcohol intake, premature transportation, etc.). The clinical picture of twilight stupefaction is different. In some cases, the patient is completely disoriented, agitated, rushing somewhere, rushing about, and does not answer questions. Speech is fragmentary, inconsistent, consists of individual words and shouts. With hallucinations and delusions, the patient becomes angry, aggressive, and can attack others. Some childishness and deliberateness may be noted in behavior. The condition can occur with disorientation, but without arousal. It manifests itself in the form of a special persistent drowsiness, from which the patient can be brought out for a while, but as soon as the stimulus stops acting, the patient again falls asleep. Twilight states with outwardly ordered behavior of patients who committed escapes, committed crimes and subsequently had absolutely no memory of their actions were described.
The second most common form of clouding of consciousness is delirium, which develops several days after the restoration of consciousness when exposed to additional hazards (there is an opinion that delirium usually occurs in persons who abuse alcohol). The condition usually worsens in the evening and at night, and during the day there appears orientation in place and time and even a critical attitude towards one’s condition (light intervals). The duration of psychosis ranges from several days to 2 weeks. The leading ones in the clinical picture are visual hallucinations - looming crowds of people, large animals, cars. The patient is anxious, afraid, tries to run, save himself, or takes defensive actions, attacks. Memories of the experience are fragmentary. Psychosis either ends with recovery after a long sleep, or passes into another state with severe memory impairment - Korsakoff syndrome.
The oneiric state is relatively rare. Oneiroid usually develops in the first days of the acute period against a background of drowsiness and immobility. Patients observe hallucinatory scenes in which fantastic events alternate with mundane ones. The facial expression is either frozen, absent, or enthusiastic, reflecting an overflow of happiness. Disorders of sensations such as sudden acceleration or, conversely, slowdown in the flow of time are quite often observed. Memories of the experienced state are retained to a greater extent than in delirium. Upon recovery from psychosis, patients talk about the content of their experiences.
Korsakov's syndrome is a protracted form of acute traumatic psychosis, usually arising as a result of severe traumatic brain injury, either after a period of deafness, or after delirious or twilight stupefaction. The duration of Korsakov's syndrome ranges from several days to several months. It occurs more severely and for a longer period of time in people who abuse alcohol (see Korsakov's psychosis). The main content of this syndrome is memory impairment, in particular, impairment of memorization and recording of current events. Therefore, the patient cannot name the date, month, year, or day of the week. He doesn’t know where he is or who his doctor is. Gaps in memory are replaced by fictitious events or those that took place previously. Consciousness is not impaired. The patient is accessible to contact, but criticism of his condition is sharply reduced.
Affective psychoses are less common than stupefaction and usually last for 1-2 weeks after the injury. The mood is often elevated, euphoric with talkativeness, carelessness, and unproductive excitement. Elevated mood may also be accompanied by lethargy and inactivity. During such periods, consciousness may be somewhat altered, which is why patients do not fully recall the events of these days in their memory.
Depressive states are observed less frequently than agitation. Low mood usually has a connotation of dissatisfaction, irritability, gloominess, or is combined with anxiety, fear and fixation on one’s health.
Paroxysmal disorders (attacks) often develop with brain contusions and open craniocerebral injuries. Seizures with loss of consciousness and convulsions of varying severity and duration (from a few seconds to 3 minutes) predominate. There are also symptoms of “already seen” (when you find yourself in an unfamiliar place, it seems that you have already been here, everything is familiar) and vice versa, “never seen” (in a well-known place the patient feels as if he is in a completely unfamiliar, unseen before). The clinical picture of paroxysms depends on the location of the focus of brain damage and its size.
Long-term consequences of traumatic brain injuries occur when, after the injury, there is no full recovery. This depends on many factors: the severity of the injury, the age of the patient at that moment, his state of health, character traits, the effectiveness of the treatment and the impact additional factors, for example, alcoholism.
Traumatic encephalopathy is the most common form of mental disorder during the long-term consequences of brain injury. There are several options.
Traumatic asthenia (cerebral asthenia) is expressed mainly in irritability and exhaustion. Patients become unrestrained, hot-tempered, impatient, unyielding, and grumpy. They easily enter into conflict and then repent of their actions. Along with this, patients are characterized by rapid fatigue, indecision, and lack of faith in own strength and opportunities. Patients complain of absent-mindedness, forgetfulness, inability to concentrate, sleep disturbances, as well as headaches and dizziness, aggravated by “bad” weather and changes in atmospheric pressure.
Traumatic apathy manifests itself in a combination of increased exhaustion with lethargy, lethargy, and decreased activity. Interests are limited to a narrow circle of concerns about one’s own health and the necessary conditions of existence. Memory is usually impaired.
Traumatic encephalopathy with psychopathization is more often formed by people with pathological character traits in the premorbid (before the illness) and is expressed in hysterical forms of behavior and explosive (explosive) reactions. A patient with hysterical personality traits exhibits demonstrative behavior, selfishness and egocentrism: he believes that all the forces of his loved ones should be directed to treating and caring for him, insists that all his desires and whims be fulfilled, since he is seriously ill. In individuals with predominantly excitable character traits, rudeness, conflict, anger, aggressiveness, and drive disorders are noted. Such patients are prone to alcohol and drug abuse. In a state of intoxication, they start fights and pogroms, and then they cannot remember what they did.
Cyclothyme-like disorders are combined either with asthenia or with psychopathic-like disorders and are characterized by mood swings in the form of unexpressed depression and mania (subdepression and hypomania). Low mood is usually accompanied by tearfulness, self-pity, fears for one’s own health and a persistent desire to be treated. Elevated mood is characterized by enthusiasm, tenderness with a tendency to faint-heartedness. Sometimes there are overvalued ideas of re-evaluating one’s own personality and a tendency to write complaints to various authorities.
Traumatic epilepsy usually occurs several years after the injury. There are major and minor seizures, absence seizures, twilight stupefaction, and mood disorders in the form of dysphoria. At long term diseases form epileptic personality changes (see Epilepsy).
Traumatic psychoses during the period of long-term consequences of traumatic brain injury are often a continuation of acute traumatic psychoses.
Affective psychoses manifest themselves in the form of periodically occurring depressions and manias (lasting 1-3 months). Manic episodes are more common than depressive episodes and occur predominantly in women. Depression is accompanied by tearfulness or a gloomy-angry mood, vegetative-vascular paroxysms and a hypochondriacal fixation on one’s health. Depression with anxiety and fear is often combined with clouded consciousness (mild stupor, delirious phenomena). If depression is often preceded by mental trauma, That manic state provoked by alcohol intake. An elevated mood sometimes takes the form of euphoria and complacency, sometimes excitement with anger, sometimes foolishness with feigned dementia and childish behavior. At severe course psychosis, clouding of consciousness such as twilight or amentive occurs (see Somatogenic psychoses), which is prognostically less favorable. Attacks of psychosis are usually similar to one another in their clinical picture, like other paroxysmal disorders, and are prone to repetition.
Hallucinatory-delusional psychosis is more common in men after 40 years of age, many years after the injury. Its onset is usually provoked by surgery or taking large doses of alcohol. It develops acutely, begins with clouding of consciousness, and then deceptions of hearing (“voices”) and delusional ideas become the leading ones. Acute psychosis usually becomes chronic.
Paranoid psychosis, unlike the previous one, is formed gradually over many years and is expressed in a delusional interpretation of the circumstances of the injury and subsequent events. Ideas of poisoning and persecution may develop. A number of people, especially those who abuse alcohol, develop delusions of jealousy. The course is chronic (continuous or with frequent exacerbations).
Traumatic dementia occurs in approximately 5% of people who have suffered a traumatic brain injury. More often observed as a consequence of severe open craniocerebral injuries with damage to the frontal and temporal lobes. Trauma in childhood and later life causes more pronounced intellectual defects. Repeated injuries, frequent psychoses, additional vascular lesions of the brain, and alcohol abuse contribute to the development of dementia. The main signs of dementia are memory impairment, decreased interests and activity, disinhibition of drives, lack of critical assessment own condition, importunity and misunderstanding of the situation, overestimation of one’s own capabilities.
Treatment.
In the acute period, traumatic disorders are treated by neurosurgeons, neurologists, otolaryngologists, ophthalmologists, depending on the nature and severity of the injury (see the relevant sections). Psychiatrists, in turn, intervene in the treatment process in the event of mental disorders, both in the acute period and at the stage of long-term consequences. Therapy is prescribed comprehensively, taking into account the condition and possible complications. In the acute period of injury, bed rest is necessary, good nutrition and compassionate care. In order to reduce intracranial pressure diuretics are prescribed (Lasix, urea, mannitol), administered intravenously magnesium sulfate(course treatment), if necessary, carry out lumbar puncture(in the lumbar region) and remove cerebrospinal fluid. It is recommended to alternately use metabolic drugs (Cerebrolysin, nootropics), as well as drugs that improve blood circulation (Trental, Stugeron, Cavinton). For severe vegetative-vascular disorders, tranquilizers (seduxen, phenazepam), pyrroxan, and small doses of neuroleptics (etaperazine) are used. For severe agitation, antipsychotics are used in the form of intramuscular injections(aminazine, tizercin). For hallucinations and delirium, haloperidol, triftazine, etc. are used. In the presence of seizures and other epileptic disorders, the use of anticonvulsants (phenobarbital, finlepsin, benzonal, etc.) is necessary. In parallel with medicinal methods of influence, physiotherapy, acupuncture, various methods psychotherapy. In cases of severe injuries and a long recovery period, painstaking work is required to restore working capacity and carry out professional rehabilitation.
Prevention
mental disorders in traumatic brain injuries lies in early and correct diagnosis of injury, timely and adequate treatment of both acute phenomena and possible consequences and complications.
See also:
Mental disorders with damage to cerebral vessels
This group includes mental disorders that arise from various forms of vascular pathology (atherosclerosis, hypertension and their consequences - stroke, heart attack, etc.). These diseases can occur without pronounced mental disorders, with a predominance of general somatic and neurological disorders...
Psychoendocrine disorders
Psychoendocrine disorders - a type psychosomatic diseases. On the one hand, the emergence endocrine diseases often provoked by the influence of psychogenic factors (diabetes, thyrotoxicosis). On the other hand, any endocrine pathology accompanied by deviations in the mental sphere, which constitute psychoendocrine syndrome or endocrine psychosyndrome...
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Brain injuries and their consequences remain one of the most difficult and unresolved problems of modern medicine and are of great importance due to their prevalence and severe medical and social consequences. According to data carried out in the early 90s. XX century An epidemiological study of traumatic brain injury shows that more than 1.2 million people suffer brain injuries annually in Russia. In the structure of disability and causes of death, traumatic brain injuries and their consequences have long occupied second place after cardiovascular pathology. Patients who have suffered traumatic brain injuries make up a significant number of people registered in psychoneurological dispensaries. Among the forensic psychiatric contingent, a considerable proportion are people with organic brain lesions and their consequences that have a traumatic etiology.
Under brain injuries understand mechanical injuries of the brain and skull bones of various types and severity.
Traumatic brain injuries are divided into open and closed. In contrast to open head trauma, closed head trauma includes concussion (commotion), bruises (concussion) and barotrauma. Brain contusion is characterized by focal macrostructural damage to the brain matter of varying degrees (hemorrhage, destruction), as well as hemorrhages, fractures of the bones of the vault and base of the skull, the severity of which depends on the severity of the contusion. Edema and swelling of the brain are usually observed; they can be local or generalized.
A pathological process that develops as a result of mechanical damage to the brain and is characterized, despite the diversity of its clinical forms, by the unity of its etiology, pathogenetic mechanisms development and outcomes is called traumatic brain disease. As a result of a head injury, two oppositely directed processes are simultaneously launched - degenerative And regenerative, which come with a constant or variable predominance of one of them. This determines the presence or absence of certain clinical manifestations, especially in the long-term period of head injury. Plastic restructuring of the brain after a head injury can last a long time (months, years and even decades).
In traumatic brain disease there are four main periods: initial, acute, subacute and long-term.
Of greatest interest is long-term period of traumatic illness, which lasts several years, and sometimes the entire life of the patient. It is characteristic of him affective pathology, which can manifest itself as mild depressive disorders in combination with more or less pronounced affective lability, when, for a minor reason, mood swings easily occur in the direction of its downward trend. Depressive disorders are usually accompanied by increased excitability, irritability, anger or gloominess, gloominess, dissatisfaction with others, sleep disturbances, and impaired ability to work. Most sick people are characterized by a decrease in the threshold of psychogenic sensitivity. This leads to an increase in situationally determined hysterical reactions and other primitive forms of expression of protest (auto- and hetero-aggression, opposition reactions), an increase in rudeness and affective reactions. The forms of their behavior in such cases are determined by short-term affective-explosive reactions with increased irritability, excitability, touchiness, sensitivity, and inadequate response to external influences.
In rare cases, after severe head injuries, it develops traumatic dementia. The behavior of patients with traumatic dementia is determined by emotional hardening, the disappearance of family attachments, a decrease in the moral and ethical threshold, and cynicism. Against this background, usually for minor reasons, explosive and hysterical reactions easily arise, often giving way to depressive disorders with decreased interests, lethargy, passivity, and adynamia. There is a severe decline in social adaptation.
During the course of a traumatic illness, the appearance of paroxysmal disorders And states of altered consciousness(traumatic epilepsy). Paroxysmal disorders occur both during the first year after the injury and in its long-term period after 10-20 or more years. Sometimes episodes of twilight stupefaction are observed. Patients in this state are motorically excited, aggressive, and at the end of the psychosis they experience terminal sleep and amnesia.
Illegal acts in such states are always directed against the life and health of others, do not have adequate motivation, are characterized by cruelty, failure to take measures to conceal the crime, and the experience of the alienness of the act. In forensic psychiatric practice, they are often assessed as short-term painful mental disorders in the form of a twilight state.
In the long-term period of a traumatic illness, traumatic psychoses, which usually occur 10-15 years after a head injury. Their development is projected by repeated head injuries, infectious diseases, and psychogenic influences. They occur in the form of affective or hallucinatory-delusional disorders.
Forensic psychiatric assessment treatment of people who have suffered head injuries is ambiguous and depends on the stage of the disease and the clinical manifestations of the disease. The most difficult expert assessment is the acute period of a traumatic illness, since experts do not observe it personally. The expert assessment of victims is of particular importance.
In relation to a person who has committed an unlawful act, the greatest importance is light and average degree the severity of the traumatic brain injury, since consciousness in these cases is not deeply clouded. These conditions fall under the concept of temporary mental disorder and indicate insanity person in relation to the act accused of him.
Forensic psychiatric examination of the long-term consequences of head trauma mainly concerns resolving the issue of the sanity of these individuals. By the time the crime is committed and the examination is carried out, they usually have minor post-traumatic disorders in the form of psychopathic-like, neurosis-like, affective and asthenic disorders, which does not exclude them sanity. In the presence of pronounced intellectual-mnestic disorders, up to traumatic dementia, patients should admit insane.
MINISTRY OF JUSTICE OF THE RUSSIAN FEDERATION
STATE EDUCATIONAL INSTITUTION
HIGHER PROFESSIONAL EDUCATION
"RUSSIAN LEGAL ACADEMY
MINISTRY OF JUSTICE OF THE RUSSIAN FEDERATION"
Kaluga (Kaluga) branch
ON THE TOPIC: Mental disorders in brain injuries
Performed:
INTRODUCTION………………………………………………………………………………2
CLINICAL PICTURE……………………………………………………………..3
SYNDROMES OF CONSCIOUSNESS DURING traumatic brain injury………………………………………………………………………………………………..6
MEMORY DISORDER IN traumatic brain injury…….9
TRAUMATIC EPILEPSY AND MENTAL DISORDERS WITH IT …………………………………………………………………………………..12
FEATURES OF CLOSED CRANIO BRAIN INJURY IN CHILDREN………………………………………………………………………………………14
FORENSIC PSYCHIATRIC EXAMINATION………………………..15
CONCLUSION………………………………………………………………………………….17
REFERENCES……………………………………………………...18
INTRODUCTION
Any head injury carries the risk of future complications. Currently, craniocerebral disease occupies one of the leading places in brain damage and is most widespread in young working age, and severe forms often lead to fatal outcome or disability.
Due to the accelerating pace of life, the problem of traumatic brain injuries in general and mental disorders associated with them in particular is becoming increasingly relevant. Most common reason This group of disorders involves morphological structural damage to the brain as a result of traumatic brain injury.
Changes due to brain damage physicochemical characteristics brain and metabolic processes are generally upset normal functioning the whole body. Among all exogenous-organic diseases, traumatic brain injury ranks first, with buried traumatic brain injuries accounting for about 90%. Mental disorders caused by trauma are determined by the nature of the injury, the conditions under which it was received, and the premorbid background. Traumatic brain injuries are divided into closed and open. With closed skull injuries, the integrity of the soft tissues is not compromised and the closedness of the cranial skull is preserved. Skull injuries are divided into penetrating and non-penetrating: violation of the integrity of only the soft tissues and bones of the skull, and accompanying damage to the dura mater and brain matter. Closed craniocerebral injuries usually remain aseptic; open craniocerebral injuries can be complicated by infection.
The classification of closed craniocerebral injuries identifies:
ü Commotions - concussion
ü contusions - brain contusions and blast injuries
Mental disorders directly caused by traumatic brain injury develop in stages and are characterized by a polymorphism of mental syndromes and, as a rule, their regressive development.
Four stages of development of mental disorders after traumatic brain injury are identified: initial, acute, convalescence and long-term consequences.
CLINICAL PICTURE
Pathological manifestations in case of traumatic brain injury depend on the nature of the injury, concomitant pathology, age and premorbid background. There are three degrees of severity of traumatic brain injury - mild, moderate, severe; and four periods of development of the traumatic process.
1. Initial period, period acute manifestations. The acute period occurs immediately after the injury, lasting 7–10 days. In most cases, it is accompanied by loss of consciousness, of varying depth and duration. The duration of unconsciousness indicates the severity of the condition. However, loss of consciousness is not a necessary symptom. Various degrees of fixation amnesia are observed, covering a short period before the injury and the fact of the injury itself, and there is a deterioration in visual memory. The severity and nature of mnestic disorders are an indicator of the severity of the injury. Persistent symptom acute period – asthenia, with a pronounced adynamic component. Low mood, touchiness, moodiness, weakness and somatic complaints indicate less severe asthenia. The phenomenon of hypersthesia. Difficulty falling asleep, superficial sleep. Vestibular disorders are constant, sharply increasing with changes in body position - dizziness. May be accompanied by nausea and vomiting. With space on convergence and movement eyeballs the patient becomes dizzy and falls - an oculostatic phenomenon. Transient anisocorria and mild pyramidal insufficiency in the form of asymmetry of deep reflexes may be observed. Constant vasomotor - autonomic disorders: pulse lability with a predominance of bradycardia, fluctuations in blood pressure, sweating and acrocyanosis, thermoregulation disorders with increased chilliness, dermographism - persistent and diffuse, redness of the face, aggravated by minor physical exertion. Increased salivation or, conversely, dry mouth. Local possible neurological symptoms, movement disorders in the form of paresis and paralysis, selective sensitivity disorders occur. With fractures of the bones of the base of the skull, signs of damage to the cranial nerves are revealed - paralysis of half the facial muscles, disturbances in eye movements - diplopia, strabismus. Meningeal symptoms may occur - stiff neck, Kernig's sign. The restoration of consciousness occurs gradually. During the period of restoration of consciousness, drowsiness, severe general lethargy, slurred speech, lack of orientation in place, time, weakening of memory, amnesia are observed - this is explained by the dynamics of extreme inhibition, after injury it undergoes a slow reverse development, the recovery of the second signaling system takes the longest.
2. Acute, secondary period from several days to 1 month. It begins as consciousness is eliminated. It is difficult to comprehend what is happening, mnestic disturbances are noted against the background of cerebrosthenic manifestations, mood instability, hyperesthesia and hyperpathy (increased susceptibility to psychogenic influences). Along with mental disorders, neurological, vegetative-vascular, and vestibular disorders are detected; epileptiform seizures and the development of acute psychoses are possible. Irritability, emotional instability, and fatigue are persistent symptoms that accompany brain injury. In the process of reverse development of psychopathological disorders traumatic origin a period arises when the cortex has not yet completely freed itself from protective inhibition, and therefore subcortical functions begin to prevail over cortical ones. The first signaling system prevails over the second signaling system, which creates a state characteristic of hysteria - hysteria-like post-traumatic states. There is a connection between the development of traumatic asthenia and premorbid personality characteristics, constitutional characteristics of the higher nervous activity of the victim. Neurasthenic syndrome occurs more easily in unbalanced individuals - irritable weakness, lability, rapid exhaustion. Protective inhibition promotes regenerative metabolic processes of the brain, restoring its performance. The appearance of post-traumatic depression is based on the phenomenon of exhaustion and diffuse protective inhibition on the cortex and subcortical structures. The occurrence of hypochondria during asthenia is explained by the formation of foci of stagnant excitation in the weakened cerebral cortex - fear of illness, may be associated with the predominance of subcortical influences and influences from the first signaling system (fears, fears, discomfort- sensual pad). The clinical basis of neurasthenia is weakness, exhaustion of cortical cells, deficiency of internal inhibition - the result is intolerance of weak stimuli, sleep disturbance, predominance of lower structures over higher ones, weakening of the second signaling system. The clinical course and duration of the acute and subacute period allow one to assume the possible consequences of a traumatic brain injury: the more severe the injury, the more severe the consequences and the longer the period of limited ability to work.
3. Revalescence period, duration up to 1 year. There is a gradual complete or partial restoration of impaired functions. The mildest consequences will be moderate distractibility, instability of voluntary attention, asthenization, touchiness, tearfulness, and vegetative-vascular insufficiency. The predominance in the clinical picture of cerebral, somato-vegetative and vestibular disorders, gastrointestinal dyskinesia, fluctuations in blood pressure, weather sensitivity, increased sweating. The structure of cerebro-asthenic manifestations includes individual intellectual-mnestic disorders.
4. Long-term consequences of traumatic brain injury occur after 1 year, manifest themselves in the form of a psychoorganic syndrome, characterized by increased exhaustion and low productivity of all mental processes, phenomena of underthinking, decreased memory and intelligence, and incontinence of affects. It is possible to form pathological personality traits of the asthenic, hippochondriacal, paranoid-querulant, hysterical, epileptoid type. Persistent manifestations include cerebral manifestations: headaches, dizziness, noise and heaviness in the head, hot flashes or a feeling of coldness in the head. These symptoms are based on circulatory disorders that remain a long period. Post-traumatic asthenia is expressed in persistent headaches, intolerance to noise, optical perception disorders and vestibular functions. Trauma can lead to persistent traumatic dementia, in this case a stable defective state occurs immediately after the disappearance of acute phenomena, in combination with a violation affective sphere. Serious traumatic brain injuries leave an imprint on the entire appearance of the patient, his activity, making him unable to work and to compensate for his defect. The affective-volitional sphere is extremely labile, the prevailing mood is hypochondriacal. The most severe manifestation of apatico-akinetic-abulic syndrome that is not amenable to active therapy methods. Accompanied by a sharp disorder of the emotional sphere, phenomena of asthenia and disturbance of vital functions. Prolonged reactive states with symptoms of surdomutism are characteristic.
SYNDROMES OF CONSCIOUS BLACKNESS DURING traumatic brain injury.
Impaired consciousness depends on the extent of the damage cerebral vessels. With any type of impairment of consciousness, there is a pathology of cortical activity with a violation of cortical-subcortical relationships, which primarily affects the processes of the second signaling system. The irradiation of transcendental inhibition and its distribution to subcortical and stem formations underlie the vital - dangerous forms unconscious states. Consciousness is a function of the brain and is directly dependent on blood flow to the brain. A sudden cessation of blood flow leads to loss of consciousness. Impaired consciousness is a symptom of oxygen and energy starvation of the brain. The loss of the activating influence of the reticular formation of the brain stem on the cerebral cortex also leads to loss of consciousness. The ascending effect of the reticular formation on the cerebral cortex is known, activating cellular systems provision and a certain level of activity state. Based on the teachings of Jaspers and Penfield about the centrencephalic system, which provides different levels consciousness. Brain paralysis is caused by damage to the hemispheric pathways, manifests itself in loss of consciousness, and on electroencephalography it is manifested by the effect of cortical silence. Under conditions of widespread unconditional inhibition in the cerebral cortex, the interaction of specific and nonspecific systems afferentation - that is, the functions of the reticular formation.
Occurring without impairment of consciousness (transitional, intermediate syndromes), which include hallucinosis, hallucinatory-paranoid state, apathetic stupor, confabulosis; 3) irreversible mental disorders with signs of organic damage to the central nervous system - Korsakovsky, psychoorganic syndromes. Transient psychoses. These psychoses are fleeting. Delirium is one of...
Primary and specialized psychiatric care for patients with memory and intellectual impairments. To achieve your goals you need to decide the following TASKS: 1) know the clinical features of memory and intellectual disorders; 2) know their nosological affiliation and clinical features in various organic brain lesions; 3) be able to identify this during communication with patients...
