When new psychological symptoms emerge after a head injury

If a patient with a complicated psychiatric history suffers a traumatic brain injury and then develops new psychological problems, how do you know whether the new problems are related to the head injury or the prior psychiatric diagnoses? This dilemma forms the latest 'complex case' to appear in the journal Personality and Mental Health where it is accompanied by five expert commentaries.

The complex case is described by psychiatrist Kathleen Diehl at the University of Michigan. She undertook several sessions of therapy with a woman referred to as 'Ms C' after the lady, a 50-year-old divorcee, had suffered a head injury as a result of a fall at work. Prior to the accident, Ms C had a long history of depression, suicidality, self-harm and had received a diagnosis of borderline personality disorder - a condition associated with relationship problems and emotional lability. Ms C had been physically abused as a child and had suffered extreme physical brutality at the hands of her ex-husband. She had two children, one of whom had cerebral palsy and had been moved to foster care.

After her fall, Ms C reported chronic dizziness, double-vision and head aches, but three brain scans, two taken immediately after her injury, have failed to uncover any signs of brain injury. Other symptoms to emerge after her fall include apparently unprovoked episodes of dissociation, in which Ms C would regress to a child-like manner and speak in a girl's voice. She experienced temporal dislocation, believing that she was living through a time eleven years prior to the present, such that she claimed not to recognise her pets or the medical staff attending to her. Despite these claims she seemed able to use modern technologies, such as her mobile phone. As plans for her return to work approached she developed panic symptoms. She was mostly oppositional in therapy and declined to participate in 'dialectical behavioural therapy' exercises which are designed to help increase emotional tolerance and help reduce distress.

Traumatic brain injury is known to lead to psychological problems in many cases, but given the negative brain scan results and Ms C's prior history, the psychiatrist Diehl concluded that it is 'difficult to distinguish organically based symptoms from emotional problems'. She asks: Just 'how do Ms C's medical and psychiatric symptoms overlap?' The expert replies, unfortunately behind a pay wall, are available here.
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Diehl, K. (2009). Head trauma, dissociation and possible development of multiple personalities. Personality and Mental Health, 3 (4), 295-301 DOI: 10.1002/pmh.95