Alwyn Lishman's contribution to the neuropsychiatry of head injury (traumatic brain injury); two key papers.

INTRODUCTION: Alwyn Lishman appreciated that if we are to understand the psychological consequences of cerebral disorder we must study the interaction between organic disease and psychological processes. METHODS: We have reviewed Lishman's two major publications on the neuropsychiatry of head injury, published in 1968 and 1988, and considered their conclusions in the light of current knowledge. RESULTS: In his 1968 paper on the psychiatric sequelae of open head injuries sustained in World War II Lishman demonstrated associations between the type of psychiatric sequelae and the location of the injury. He also found that those with "somatic complaints", such as fatigue or sensitivity to light, showed less evidence of organic injury. In his 1988 paper, he attempted to explain why a mild head injury may be followed by long-lasting symptoms. He suggested that in the absence of complications early, organic, symptoms (physiogenesis) should recover quickly. However, this healthy recovery could be jeopardised by psychological factors (psychogenesis), resulting in long-lasting symptoms. This model of physiogenesis and psychogenesis remains relevant today. CONCLUSIONS: The ideas Lishman developed in these two papers were the basis for his huge contribution to the field of neuropsychiatry, and remain relevant today.

Randomised, waiting list controlled trial of cognitive-behavioural therapy for persistent postconcussional symptoms after predominantly mild-moderate traumatic brain injury.

BACKGROUND: Persistent postconcussional symptoms (PCS) can be a source of distress and disability following traumatic brain injury (TBI). Such symptoms have been viewed as difficult to treat but may be amenable to psychological approaches such as cognitive-behavioural therapy (CBT). OBJECTIVES: To evaluate the effectiveness of a 12-session individualised, formulation-based CBT programme. METHOD: Two-centre randomised waiting list controlled trial with 46 adults with persistent PCS after predominantly mild-to-moderate TBI (52% with post-traumatic amnesia (PTA)≤24 hours), but including some with severe TBIs (20% with PTA>7 days). RESULTS: Improvements associated with CBT were found on the primary outcome measures relating to quality of life (using the Quality of Life Assessment Schedule and the Brain Injury Community Rehabilitation Outcome Scale). Treatment effects after covarying for treatment duration were also found for PCS and several secondary outcomes, including measures of anxiety and fatigue (but not depression or post-traumatic stress disorder (PTSD)). Improvements were more apparent for those completing CBT sessions over a shorter period of time, but were unrelated to medicolegal status, injury severity or length of time since injury. CONCLUSIONS: This study suggests that CBT can improve quality of life for adults with persistent PCS and potentially reduce symptoms for some, in the context of outpatient brain injury rehabilitation services. TRIAL REGISTRATION NUMBER: ISRCTN49540320.

Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study.

BACKGROUND: Gold standard protocols have yet to be established for the treatment of motor conversion disorder (MCD). There is limited evidence to support inpatient, multidisciplinary intervention in chronic, severe cases. AIMS: To evaluate the characteristics and outcomes of MCD patients admitted to a specialist neuropsychiatric inpatient unit. METHODS: All patients admitted to the Lishman Unit (years 2007-2011) with a diagnosis of MCD were included. Data relevant to characteristics and status with regard to mobility, activities of daily living (ADLs) and Modified Rankin Scale (MRS) score at admission and discharge were extracted. RESULTS: Thirty-three cases (78.8% female) were included; the median duration of illness was 48 months. In comparison with brain injury patients admitted to the same unit, more cases had histories of childhood sexual abuse (36.4%, n=12), premorbid non-dissociative mental illness (81.1%, n=27) and employment as a healthcare/social-care worker (45.5%, n=15). Cases showed significant improvements in MRS scores (p<0.001), mobility (p<0.001) and ADL (p=0.002) following inpatient treatment. CONCLUSIONS: Patients with severe, long-standing MCD can achieve significant improvements in functioning after admission to a neuropsychiatry unit.

Adult onset leukodystrophy with neuroaxonal spheroids and demyelinating plaque-like lesions.

Adult onset leukodystrophy with neuroaxonal spheroids is an uncommon cause of dementia. Both hereditary (autosomal dominant) and sporadic cases have been described. A 41-year-old African woman presented with inappropriate behavior and personality change consistent with frontal lobe dysfunction. MRI demonstrated diffuse frontoparietal white matter signal abnormality and volume loss, as well as focal enhancing white matter lesions, while CT scan showed white matter calcifications. She had been gradually deteriorating over the last 5 years, diagnosed as having progressive demyelinating illness. She died of recurrent chest infections. There was no familial history. The brain showed prominent symmetrical white matter changes with greyish discolorization mainly affecting the frontal and parietal lobes, with less involvement of the temporal lobe and only mildly affecting the occipital white matter. Histology revealed deep white matter atrophy with many neuroaxonal spheroids labelled by neurofilament and ß-amyloid precursor protein. In addition, scattered inactive demyelinating plaque-like lesions were found in the periventricular areas, brainstem and the cervical spinal cord. This case had typical features of an adult onset leukodystrophy with neuroaxonal spheroids. However, we also demonstrated demyelinating plaque-like lesions, which has not been previously described. The possibility of a demyelinating origin contributing to the changes may be considered in the pathogenesis of this condition.

Confabulations are emotionally charged, but not always for the best.

There is disagreement regarding the underlying basis of confabulation and, in particular, whether emotional mechanisms influence the presence or the content of confabulations. In this study, we have examined the emotional content of confabulations and "true" memories given by 24 memory-disordered patients on two autobiographical memory tasks. Two judges made pleasant/neutral/unpleasant ratings. Although many of the "memories" were evaluated as "neutral", there was an enhanced level of statements rated as having affective content (either pleasant or unpleasant) amongst these patients' confabulations, compared with their "true" memories. This affective bias was present irrespective of whether patients had suffered focal pathology extending to the ventro-medial frontal cortex (VMFC) or other pathology. There was also a correlation between participants' self-evaluated mood-states and both true and false memories' affective content, suggestive of a mood congruency effect in both types of memory. In summary, there was an enhanced tendency to produce memories with affective content (pleasant and unpleasant) amongst confabulations (whether or not there was VMFC pathology). The affective content of both confabulations and true memories produced may relate, in part, to an individual's current mood-state.

Confabulation: What is associated with its rise and fall? A study in brain injury.

The aim of this study was to investigate cognitive and emotional factors associated with the presence and clinical course of confabulation. 24 confabulating participants were compared with 11 brain injured and 6 healthy controls on measures of temporal context confusions (TCC), mood state (elation, depression) and lack of insight. Measures of autobiographical memory and executive function were also available. Changes in confabulation and these other measures were monitored over 9 months in the confabulating group. We found that TCC were more common in confabulating patients than in healthy controls, and that the decline in these errors paralleled the recovery from confabulation. However, TCC were not specific to the presence of confabulation in brain injury; and their decline was not correlated with change in confabulation scores over 9 months. We found that elated mood and lack of insight discriminated between confabulating and non-confabulating patients, but these measures did not correlate with either the severity of confabulation or change in confabulation scores through time. What seems to have been most strongly associated with the severity of confabulation scores at 'baseline' and changes through time (over 9 months) were the severity of memory impairment (especially on autobiographical memory) and errors on executive tests (particularly in making cognitive estimates). Greater autobiographical memory and executive impairment were associated with more severe confabulation. The findings were consistent with the view that confabulation results from executive dysfunction where autobiographical memory is also impaired; and that it resolves as these impairments subside.

The Rivermead Post Concussion Symptoms Questionnaire: a confirmatory factor analysis.

OBJECTIVE: To investigate the factor structure of the Rivermead Post Concussion Symptoms Questionnaire (RPQ) among individuals seen as part of routine follow-up following traumatic brain injury. METHODS: RPQ data from 168 participants was examined (mean age 35.2, SD 14.3; 89% with post traumatic amnesia duration<24 hours) six months after admission to an Accident & Emergency Department following TBI. Structural equation modelling was carried out to evaluate proposed models of the underlying structure of post-concussion symptoms (PCS). RESULTS: The results support the existence of separate cognitive, emotional and somatic factors, although there was a high degree of covariation between the three factors. A two-factor model that collapsed the emotional and somatic factors together showed a similar goodness-of-fit to the data, whilst a one-factor model proved a poor fit. CONCLUSION: The results support the notion of post-concussion symptoms as a collection of associated but at least partially separable cognitive, emotional and somatic symptoms, although questions persist regarding symptom specificity. The use of the RPQ is discussed, and classification bands for use in clinical practice are suggested.

Allocentric spatial memory in humans with hippocampal lesions.

An immersive virtual reality (IVR) system was used to investigate allocentric spatial memory in a patient (PR) who had selective hippocampal damage, and also in patients who had undergone unilateral temporal lobectomies (17 right TL and 19 left TL), their performance compared against normal control groups. A human analogue of the Olton [Olton (1979). Hippocampus, space, and memory. Behavioural Brain Science, 2, 315] spatial maze was developed, consisting of a virtual room, a central virtual circular table and an array of radially arranged up-turned 'shells.' The participant had to search these shells in turn in order to find a blue 'cube' that would then 'move' to another location and so on, until all the shells had been target locations. Within-search errors could be made when the participants returned to a previously visited location during a search, and between-search errors when they revisited previously successful, but now incorrect locations. PR made significantly more between-search errors than his control group, but showed no increase in within-search errors. The right TL group showed a similar pattern of impairment, but the left TL group showed no impairment. This finding implicates the right hippocampal formation in spatial memory functioning in a scenario in which the visual environment was controlled so as to eliminate extraneous visual cues.

Allocentric spatial memory activation of the hippocampal formation measured with fMRI.

Hippocampal activation was investigated, comparing allocentric and egocentric spatial memory. Healthy participants were immersed in a virtual reality circular arena, with pattern-rendered walls. In a viewpoint-independent task, they moved toward a pole, which was then removed. They were relocated to another position and had to move to the prior location of the pole. For viewpoint-dependent memory, the participants were not moved to a new starting point, but the patterns were rotated to prevent them from indicating the final position. Hippocampal and parahippocampal activation were found in the viewpoint-independent memory encoding phase. Viewpoint-dependent memory did not result in such activation. These results suggest differential activation of the hippocampal formation during allocentric encoding, in partial support of the spatial mapping hypothesis as applied to humans.

A longitudinal, multicentre, cohort study of community rehabilitation service delivery in long-term neurological conditions.

OBJECTIVES: Part A: To pilot the use of a register to identify and monitor patients with complex needs arising from long-term neurological conditions. Part B: To determine the extent to which patients' needs for health and social services are met following discharge to the community after inpatient rehabilitation; to identify which factors predict unmet needs and to explore the relationship between service provision and outcomes at 12 months. DESIGN: A multicentre, prospective, cohort study surveying participants at 1, 6 and 12 months using postal/online questionnaires and telephone interview. SETTING: Consecutive discharges to the community from all nine tertiary, specialist, inpatient neurorehabilitation services in London over 18 months in 2010-2011. PARTICIPANTS: Of 576 admissions 428 patients were recruited at discharge: 256 responded at 4 weeks, 212 at 6 months and 190 at 12 months. MEASURES: Neurological Impairment Scale, The Needs and Provision Complexity Scale, The Northwick Park Dependency Scale, Community Integration Questionnaire, Zarit Burden Inventory. RESULTS: n=322 (75%) expressed willingness to be registered, but in practice less than half responded to questionnaires at 6 and 12 months (49% and 44%, respectively), despite extensive efforts to contact them, with no significant differences between responders and non-responders. Significant unmet needs were identified within the first year following discharge, particularly in rehabilitation, social work support and provision of specialist equipment. Dependency for basic care and motor and cognitive impairment predicted services received, together accounting for 40% of the variance. Contra to expectation, patients whose rehabilitation needs were met were more dependent and less well integrated at 12 months post discharge than those with unmet needs. CONCLUSIONS: Registration is acceptable to most patients, but questionnaires/telephone interviews may not be the most efficient way to reach them. When community resources are limited, service provision tends to be focused on the most dependent patients. REGISTRATION: The study was registered with the NIHR Comprehensive Local Research Network: ID number 7503.

The size of demand for specialized neuropsychiatry services: rates of referrals to neuropsychiatric services in the South thames region of the United kingdom.

The authors assessed the number of referrals to neuropsychiatry services covering South London, Kent, Surrey, and Sussex (population 6,887,000) over a 2-year period. The average referral rate was 11.2 per 100,000 per population for each year. Geographical distance from the specialist provider strongly affected referral rates, with clinicians in South London making more referrals than those from outside London. Assessment of appropriateness of referrals indicated that more than 86% of referrals were highly appropriate, and thus the higher level of referrals from close proximity cannot be attributed to inappropriate referrals. A survey of clinicians reported lower awareness of services and how to access these services among those clinicians working at a greater distance from the service provider, which likely results in unmet needs. Greater attempts should be made to improve access to neuropsychiatric services for clinicians who do not practice within close proximity of a specialist neuropsychiatry service.

Brain injury rehabilitation: what works for whom and when?

PRIMARY OBJECTIVE: This paper reviewed the available evidence that patient characteristics may determine the type of intervention that works best in brain injury rehabilitation. REASONING BEHIND LITERATURE SELECTION: A broad search strategy was used to identify papers which enabled conclusions to be drawn about patient characteristics which determined rehabilitation effectiveness. Six main areas were considered: severity of the brain injury, presenting problem, complicating factors, rehabilitation readiness, demographic, and socio-geographic variables. CRITICAL ANALYSIS OF LITERATURE: A levels of evidence analysis was used to evaluate the studies. MAIN OUTCOMES AND RESULTS: Very few studies on rehabilitation effectiveness were found which attempted to define the patient characteristics which predict a good response to rehabilitation. The best evidence relates to injury severity; more intense programmes may be unnecessary for those with less severe injuries. There is some evidence that dysexecutive problems, i.e. difficulties with organization and control of behaviour and emotion, interfere with rehabilitation. CONCLUSIONS: Patient characteristics may well determine individual benefits from particular rehabilitation programmes. However, few studies have attempted to provide evidence about this. As health provision focuses on needs-led services, it becomes paramount to investigate effectiveness from the client's perspective.

Experience and perspectives on the classification of organic mental disorders.

The official diagnostic classification systems have been increasingly employed in the last few years, and this is true of both ICD-10 and DSM-IV. We will propose a few principles which should be considered when revisions are attempted. Our existing classifications should be simplified, but new syndromes incorporated where they have pathological justification. Links to other specialist diagnostic classifications should be made (e.g. in epilepsy, sleep disorders, dementias) wherever possible. A broader range of 'Neuropsychiatric Disorders' should be incorporated, including alcohol-related organic disorders, head injury, sleep disorders, if possible including the 'psychogenic syndromes'. Progressive, degenerative disorders need to be clearly distinguished from non-progressive syndromes, and some gradation of severity needs to be built into the classificatory system. Finally, the definitions need to be concise and accurate.

The neuropsychiatry of depression after brain injury.

Biological aspects of depression after brain injury, in particular traumatic brain injury (TBI) and stroke, are reviewed. Symptoms of depression after brain injury are found to be rather non-specific with no good evidence of a clear pattern distinguishing it from depression in those without brain injury. Nevertheless symptoms of disturbances of interest and concentration are particularly prevalent, and guilt is less evident. Variabilitiy of mood is characteristic. The prevalence of depression is similar after both stroke and TBI with the order of 20-40% affected at any point in time in the first year, and about 50% of people experience depression at some stage. There is no good evidence for areas of specific vulnerability in terms of lesion location, and early suggestions of a specific association with injury to the left hemisphere have not been confirmed. Insight appears to be related to depressed mood with studies of TBI indicating that greater insight over time post-injury may be associated with greater depression. We consider that this relationship may be due to depression appearing as people gain more awareness of their disability, but also suggest that changes in mood may result in altered awareness. The risk of suicide after TBI is reviewed. There appears to be about a three to fourfold increased risk of suicide after TBI, although much of this increased risk may be due to pre-injury factors in terms of the characteristics of people who suffer TBI. About 1% of people who have suffered TBI will commit suicide over a 15-year follow-up. Drug management of depression is reviewed. There is little specific evidence to guide the choice of antidepressant medication and most psychiatrists would start with a selective serotonin reuptake inhibitor (SSRI). It is important that the drug management of depression after brain injury is part of a full package of care that can address biological as well as psychosocial factors in management.