Head Injury History: Recognizing Traumatic Brain Injury in Psychiatric Evaluation
This is Part 3 in our series on the Medical History.
Read Part 2: Female Reproductive History: How It Shapes Psychiatric Diagnosis and Treatment Safety
In Part 2 we reviewed the importance of the female reproductive history. This part focuses specifically on traumatic brain injury (TBI) as a significant risk factor for psychiatric disorders. Head injury can directly cause psychiatric symptoms, increase lifetime risk for psychiatric illness, and fundamentally alter treatment approach and prognosis.
Understanding head injury history is essential for distinguishing TBI-related psychiatric presentations from primary psychiatric disorders, recognizing when psychiatric symptoms may reflect evolving neurological complications requiring urgent medical intervention, and adjusting medication choices to account for increased seizure risk and cognitive vulnerability. Failure to obtain comprehensive head injury history can result in misdiagnosis, inappropriate treatment, and missed opportunities for neurosurgical or neurological referral.
Learning Objectives
After reading this section, you should be able to:
- Obtain a structured traumatic brain injury history including mechanism, severity indicators, timing, and subsequent symptoms
- Distinguish psychiatric symptoms directly related to traumatic brain injury from independent primary psychiatric disorders based on temporal relationships and clinical features
- Recognize posttraumatic complications (subdural hematoma, posttraumatic epilepsy, progressive neurodegeneration) that may present with psychiatric symptoms and require urgent medical evaluation
- Adjust psychiatric medication selection based on traumatic brain injury history, particularly regarding seizure risk and cognitive side effects
- Identify when neuroimaging, neurology consultation, or neurosurgical evaluation is indicated in patients with psychiatric symptoms and head injury history
- Understand the dose-dependent relationship between TBI severity and psychiatric disorder risk
Start With Chart Review
Before interviewing the patient, review the medical record for documentation of head trauma and its sequelae.
Key elements to review:
- Emergency department records: Look for any ED visits for head trauma, even remote. Note mechanism of injury, Glasgow Coma Scale score, loss of consciousness duration, and disposition.
- Neuroimaging: Review any CT or MRI brain imaging. Look for skull fractures, intracranial hemorrhage, contusions, diffuse axonal injury, encephalomalacia (old injury sites), or other structural changes.
- Neurology or neurosurgery notes: Check for documentation of posttraumatic complications, seizures, cognitive deficits, or recommendations for psychiatric evaluation.
- Rehabilitation records: Look for documentation from inpatient rehab, cognitive therapy, occupational therapy, or speech therapy following TBI.
- Neuropsychological testing: Review any formal cognitive testing, which may document specific deficits (executive function, memory, processing speed) related to injury.
- Problem list: Look for documented TBI, postconcussive syndrome, posttraumatic headaches, or cognitive disorder due to TBI.
- Medication list: Note antiseizure medications, which may indicate posttraumatic epilepsy or prophylaxis.
- Timeline: Map when injuries occurred relative to psychiatric symptom onset.
💡 Clinical Pearl: If you find old neuroimaging showing encephalomalacia, skull fractures, or hemorrhage that the patient didn’t mention, ask specifically about head injuries. Patients often don’t recognize the significance of “minor” injuries or may have amnesia for the event itself. Similarly, if the chart shows psychiatric symptoms emerged within months of documented head trauma, this temporal relationship should be prominently featured in your formulation.
Why this matters: Many patients do not spontaneously report head injuries, particularly if they occurred years ago or if they did not result in hospitalization. Remote head injury may still be relevant to current psychiatric presentation, as TBI confers increased lifetime risk for psychiatric disorders even when symptoms emerge years after injury.
Interview the Patient
Screening for Head Injury
Opening questions:
- “Have you ever had a significant head injury, concussion, or blow to the head?”
- “Have you ever been in an accident where you hit your head, for example, a car accident, fall, sports injury, or assault?”
- “Have you ever been knocked unconscious or ‘had your bell rung’?”
Follow-up and context questions:
- “Tell me more about what happened. How did you injure your head?”
- “Was this a single injury, or have you had multiple head injuries?”
- “How old were you when this happened?” (If multiple injuries: “Let’s start with the most serious one, and then you can tell me about the others.”)
💡 Clinical Pearl: Many patients, particularly athletes and veterans, have experienced multiple concussions. Don’t stop after documenting one injury, ask: “Have you had any other head injuries, even ones you might think were minor?” Cumulative effect of multiple injuries may be more significant than any single injury.
Characterizing Injury Severity
Follow-up questions for each reported injury:
- “Did you lose consciousness? If so, for how long?”
- “Do you remember what happened right before the injury and right after, or is there a gap in your memory?”
- “Were you dazed, confused, or ‘seeing stars’ after the injury?”
- “Did you go to the hospital or see a doctor? What did they tell you?”
- “Did you have any imaging done, like a CT scan or MRI? What did it show?”
Why This Information Matters
Severity indicators: Several factors help estimate TBI severity:
- Loss of consciousness (LOC): Duration of LOC correlates with injury severity. LOC >30 minutes suggests moderate-severe TBI.
- Posttraumatic amnesia (PTA): The duration of amnesia (both retrograde for events before injury and anterograde for events after injury) is a strong predictor of outcome. PTA >24 hours suggests severe TBI.
- Glasgow Coma Scale (GCS): If documented in ED records. GCS 13-15 = mild TBI, 9-12 = moderate TBI, 3-8 = severe TBI.
- Neuroimaging findings: Any intracranial hemorrhage, contusion, or skull fracture indicates more severe injury.
🚩 Red Flag: Loss of consciousness >30 minutes, posttraumatic amnesia >24 hours, or any intracranial bleeding on imaging indicates moderate-to-severe TBI and confers substantially elevated risk for chronic psychiatric and cognitive sequelae.
Psychiatric risk is dose-dependent: More severe injuries confer greater psychiatric risk. However, even “mild” TBI (concussion) is associated with increased risk for depression, anxiety, and PTSD, particularly with repeated injuries.
Timing and Subsequent Symptoms
Follow-up questions:
- “After the injury, did you notice any changes in your thinking, memory, concentration, or ability to learn new things?”
- “Did you notice changes in your mood, personality, or behavior after the injury?”
- “Did you develop headaches, dizziness, sensitivity to light or noise, or sleep problems?”
- “Did you develop any seizures after the head injury?”
- “When did you first notice the symptoms that brought you here today? How soon after the injury was that?”
Why This Information Matters
Temporal relationship is key: The timing of psychiatric symptom onset relative to TBI helps distinguish organic symptoms from independent psychiatric illness:
- Days to months after injury: Symptoms emerging soon after TBI are more likely organically related (direct brain injury effects, posttraumatic epilepsy, or psychological reaction to injury and functional impairment).
- Years after injury: Symptoms emerging years later may represent independent psychiatric illness, though the TBI still confers increased lifetime risk.
💡 Clinical Pearl: When a patient reports head injury history, always ask about the timing of psychiatric symptom onset relative to the injury. Symptoms appearing within days to months after injury are more likely to be organically related, while symptoms emerging years later may represent independent psychiatric illness, though the injury still confers increased lifetime risk.
Postconcussive syndrome: A constellation of cognitive (memory problems, difficulty concentrating), physical (headaches, dizziness, fatigue), and emotional (irritability, anxiety, depression) symptoms following mild TBI. Symptoms typically peak in first weeks to months and gradually improve, though 10-15% of patients have persistent symptoms beyond 3 months.
Chronic traumatic encephalopathy (CTE): Progressive neurodegenerative disease associated with repetitive head trauma (contact sports, military blast exposure). Presents with mood changes, behavioral dyscontrol, cognitive decline, and sometimes motor symptoms. Can only be definitively diagnosed postmortem, but should be considered in patients with repetitive TBI and progressive symptoms.
Treatment and Complications
Follow-up questions:
- “Did you require any surgery or long-term treatment for the head injury?”
- “Did you do any rehabilitation, such as physical therapy, occupational therapy, or cognitive therapy?”
- “Do you still have any symptoms from that injury, such as headaches, memory problems, or mood changes?”
- “Have you seen a neurologist or had any follow-up imaging?”
Why This Information Matters
Neurosurgical intervention: History of craniotomy, burr holes for subdural evacuation, or intracranial pressure monitoring indicates severe TBI with likely structural brain damage and elevated psychiatric risk.
Rehabilitation involvement: Participation in neurorehabilitation suggests significant functional impairment from injury and provides documentation of specific deficits that may persist.
Persistent symptoms: Ongoing cognitive, emotional, or physical symptoms from TBI affect quality of life and treatment approach. Residual executive dysfunction, memory impairment, or emotional lability may be misattributed to psychiatric illness rather than recognized as TBI sequelae.
🚩 Red Flag: New or worsening psychiatric symptoms in someone with remote TBI history should prompt consideration of delayed complications: late subdural hematoma (can occur weeks to months after injury, especially in elderly or on anticoagulants), posttraumatic epilepsy (can emerge years after injury), or progressive neurodegenerative changes.
Head Injury as Psychiatric Risk Factor
Epidemiological relationship: TBI increases risk for multiple psychiatric disorders:
- Depression: 2-3 fold increased risk, with higher rates following moderate-severe TBI
- Bipolar disorder: 2-3 fold increased risk
- Schizophrenia and psychotic disorders: 1.5-2 fold increased risk
- Anxiety disorders: 2-3 fold increased risk, including PTSD (particularly after assault-related TBI)
- Substance use disorders: 2 fold increased risk
- Suicide: 3-4 fold increased risk, particularly in first year after TBI
Risk factors for psychiatric sequelae:
- Injury severity (more severe = higher risk)
- Age at injury (adolescent injuries confer particularly high risk)
- Multiple injuries (cumulative effect)
- Frontal and temporal lobe injuries
- Premorbid psychiatric history
- Inadequate social support and rehabilitation access
Mechanisms: TBI affects psychiatric function through multiple pathways: structural brain damage (particularly frontal-temporal circuits involved in emotion regulation), neurotransmitter disruption (serotonergic, dopaminergic systems), neuroinflammation, neuroendocrine changes, and psychosocial impact of disability and changed self-identity.
Distinguishing TBI-Related Presentations from Primary Psychiatric Illness
Features suggesting TBI-related psychiatric symptoms:
- Temporal proximity (symptoms within months of injury)
- No prior psychiatric history before injury
- Associated cognitive impairment (attention, memory, executive function)
- Prominent irritability, emotional lability, and impulsivity (more than typical in mood disorders)
- Coexisting headaches, fatigue, dizziness, sleep disturbance
- Incomplete response to standard psychiatric treatments
Features suggesting independent psychiatric illness:
- Psychiatric symptoms preceded TBI
- Strong family history of psychiatric illness
- Symptoms emerged years after injury without clear trigger
- Symptom profile matches primary psychiatric disorder without prominent cognitive features
- Good response to standard psychiatric treatment
💡 Clinical Pearl: TBI and primary psychiatric illness are not mutually exclusive. A patient may have had major depressive disorder before a car accident and then develop additional post-TBI depression, irritability, and executive dysfunction. Careful history clarifies which symptoms were present before and which emerged after injury.
Treatment Implications
Medication considerations:
- Increased seizure risk: TBI increases risk for posttraumatic epilepsy (2-10% for mild TBI, 10-20% for moderate TBI, 20-50% for severe TBI with penetrating injury). Avoid or use caution with pro-convulsant medications:
- Bupropion (contraindicated in moderate-severe TBI with seizure history)
- Clozapine (lower seizure threshold)
- High-dose tricyclic antidepressants
- Rapid benzodiazepine withdrawal
- Tramadol
- Cognitive side effects: Patients with TBI often have baseline cognitive vulnerabilities that make them more sensitive to medication side effects affecting cognition:
- Benzodiazepines (sedation, memory impairment)
- Anticholinergics (confusion, memory problems)
- Topiramate (cognitive dulling)
- Some antipsychotics (sedation, executive dysfunction)
- Preferred agents: SSRIs generally well-tolerated, though watch for apathy with chronic use. Stimulants (methylphenidate, modafinil) may be helpful for post-TBI cognitive symptoms and fatigue. Lamotrigine has mood-stabilizing effects without cognitive impairment.
Psychotherapy considerations: Cognitive impairment from TBI may affect ability to participate in insight-oriented therapies. Consider cognitive-behavioral therapy with concrete, structured approach, and accommodate memory deficits (written session summaries, homework reminders). Address grief and adjustment to changed identity and functioning.
Coordination with neurology: Patients with moderate-severe TBI, posttraumatic epilepsy, or progressive symptoms require ongoing neurology involvement. Coordinate medication choices to avoid interactions and ensure epilepsy control is optimized.
When to Pursue Further Medical Evaluation
Indications for urgent neuroimaging:
- New psychiatric symptoms with recent TBI (within weeks)
- Worsening symptoms despite treatment
- New focal neurological findings
- Change in level of consciousness
- Severe headaches, particularly if increasing
- Any concern for subdural hematoma or hemorrhage
Indications for neurology referral:
- Posttraumatic seizures
- Progressive cognitive decline
- Treatment-resistant psychiatric symptoms following TBI
- Need for neuropsychological testing to document deficits
Indications for neuropsychological testing:
- Clarifying cognitive profile for treatment planning
- Documenting deficits for disability determination
- Distinguishing cognitive symptoms of TBI from depression or psychosis
- Establishing baseline before medication trials
What to Document
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Basic TBI screening: history of head injury, approximate timing, no details of severity | “Patient denies history of significant head injury or loss of consciousness.” | No TBI history, or remote minor injury with no apparent relationship to current symptoms |
| Standard | Above + details of injury mechanism, loss of consciousness duration, emergency treatment, imaging results, relationship to psychiatric symptom onset | “Patient reports single TBI at age 22 (now age 35) in motor vehicle accident. Lost consciousness approximately 5 minutes, ED evaluation with negative head CT, diagnosed with concussion, full recovery per patient report. Current depressive symptoms began 6 months ago, 13 years after injury, no clear temporal relationship. No ongoing TBI-related symptoms. No seizure history.” | Any TBI history, even if remote or unrelated to current presentation |
| Detailed | Above + comprehensive injury characterization, severity indicators, complications, treatment history, temporal analysis of symptom onset, formulation of TBI contribution, medication adjustments for TBI history | “Patient is a 28-year-old man presenting with depression, irritability, impulsivity, and executive dysfunction that began 3 months ago. History of moderate TBI 4 months ago: fell from ladder at work, struck occipital region, LOC approximately 20 minutes, ED evaluation with CT showing right frontal contusion and small subdural hematoma (conservatively managed). Hospitalized 3 days, then 2 weeks outpatient PT/OT. Reports persistent headaches, difficulty concentrating, memory problems, and emotional lability since injury. Prior to injury, no psychiatric history. On MSE, patient has difficulty with sustained attention, slowed processing speed, and concrete thinking. Given temporal proximity of symptom onset to moderate TBI, prominent cognitive and emotional dysregulation, and location of injury (frontal), psychiatric symptoms likely represent TBI sequelae rather than primary mood disorder.” | Moderate-severe TBI, temporal relationship between TBI and psychiatric symptoms, treatment planning requires consideration of TBI effects |
Why This Information Matters
Diagnostic accuracy and avoiding misdiagnosis: TBI-related psychiatric symptoms are frequently misdiagnosed as primary psychiatric disorders when head injury history is not obtained or its significance is not recognized. A patient with post-TBI irritability, impulsivity, and mood lability may be misdiagnosed with borderline personality disorder or bipolar disorder. A patient with post-TBI apathy and executive dysfunction may be misdiagnosed with depression or negative symptoms of schizophrenia. Accurate recognition of TBI as the underlying cause fundamentally changes treatment approach, prognosis communication, and rehabilitation planning.
Safety and recognition of complications: Psychiatric symptoms may be the presenting feature of evolving neurological complications requiring urgent intervention. A patient with worsening confusion and personality changes weeks after “minor” head trauma may have a delayed subdural hematoma. A patient with episodic rage attacks following TBI may have posttraumatic epilepsy. Failure to recognize these patterns delays neurosurgical or neurological treatment and places patients at risk for serious morbidity or mortality.
Medication safety: TBI history significantly affects psychiatric medication selection. Using bupropion in a patient with moderate TBI and unrecognized seizure risk may precipitate seizures. Prescribing multiple sedating medications to a patient with pre-existing TBI-related cognitive impairment may worsen function and safety (fall risk, impaired judgment). Knowledge of TBI history allows for safer medication choices and closer monitoring.
Prognosis and expectations: TBI-related psychiatric symptoms may have different trajectory and treatment response compared to primary psychiatric disorders. Post-TBI depression may be more resistant to standard antidepressant treatment and require multimodal rehabilitation approach. Post-TBI personality changes may be permanent, requiring adjustment and compensatory strategies rather than expectation of full symptom resolution. Accurate prognostication helps patients and families understand what to expect and plan appropriately.
Rehabilitation and functional recovery: Recognition of TBI allows for referral to appropriate rehabilitation services (cognitive therapy, vocational rehabilitation, support groups) that may not be offered to patients diagnosed with primary psychiatric disorders. TBI rehabilitation focuses on compensatory strategies, environmental modifications, and functional restoration in ways distinct from psychiatric treatment.
Legal and disability considerations: TBI documentation may be relevant for disability determination, workers’ compensation claims, personal injury litigation, or veteran’s benefits. Thorough documentation of TBI history and its relationship to psychiatric symptoms provides important medico-legal support for patients pursuing these avenues.
The assessment of traumatic brain injury history is not an optional “extra” in psychiatric evaluation, it is a fundamental component that directly informs diagnosis, treatment, safety, and prognosis. The brain is the organ of psychiatric illness, and any history of structural injury to that organ must be carefully evaluated and integrated into the psychiatric formulation.
Next in this series: Part 4 – Seizure Disorders in Psychiatric Patients: Mimics, Comorbidity, and Medication Risks
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