Post-TBI Behavioral Disturbances

Yet another neuropsychiatric complication of TBI is a set of behavioral disturbances including impulsivity, irritability, disinhibition, and/or aggression. These symptoms appear to be more likely to arise when the brain injury involves the temporal or orbitofrontal brain regions. Treatment options for these disruptive behavioral syndromes include antidepressants, buspirone, anticonvulsants, antipsychotics, beta blockers, and stimulants (see Table 12.1). 

Antidepressants. In our experience, clinicians who are trying to manage the behavior of impulsive or aggressive patients too often overlook antidepressants. Antidepressants are often just as effective as anticonvulsants, antipsychotics, or benzodiazepines, especially when managing mild-to-moderate behavioral disturbances. Furthermore, antidepressants are generally easier to use and easier to tolerate than these alternatives. Once again, the SSRIs are best studied and so represent the favored first-line treatment for managing mild-to-moderate behavioral lability 

One particular variant of the post-TBl behavioral disturbances, nighttime agitation, can be managed successfully with low bedtime doses of sedating antidepressants such as trazodone (25-50mg) or nortriptyline (10mg). These antidepressants may calm the patient and help him/her to sleep while avoiding the potential for confusion or disinhibition posed by other commonly used sleep medicines. 

The so-called atypical antipsychotics represent one of the newest options for managing disruptive behavioral syndromes. Because they have yet to be studied in patients who have suffered a TBI, we certainly cannot recommend the atypical antipsychotics for routine first-line use. Nevertheless, an atypical antipsychotic might prove helpful when other medicines aren t providing satisfactory results in the management of severe behavioral disturbances. Ziprasidone (Geodon) is available in an injectable form that we have found to be particularly helpful in TBI patients. 

Beta Blockers. The beta blockers, which act by interfering with noradrenergic transmission, have been used to manage aggression and other behavioral disturbances in patients who have suffered brain injury due to trauma and stroke for over 25 years. Several beta blockers have been tested including propranolol (Inderal), pindolol (Visken), nadolol (Corgard), and metoprolol (Lopressor). Fat-soluble beta blockers such as propranolol and pindolol more readily cross the blood-brain barrier and are thus better suited to managing psychiatric symptoms such as behavioral lability. 

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