The relationship of neuropsychological status and productive outcomes following traumatic brain injury.

Neuropsychological assessment is a standard component of traumatic brain injury rehabilitation programmes; however, the relationship between neuropsychological test scores and functional abilities is not clear. The current study compared serial neuropsychological test data with functional outcomes for 152 subjects. Outcome was operationally defined for three activity settings (home, school, work) with six levels of productivity for each. Productivity was defined as one's ability to function at increasing levels of independence. Demographic and caseload variables were analysed utilizing correlation and stepwise multiple regression analyses. Significant relationships to outcome were found between certain neuropsychological test scores, and certain demographic variables. Positive outcomes were related in part to patient's speed of information processing, memory skills, and simultaneous processing abilities. Also related to positive outcomes were mechanism of injury, level of insurance funding, premorbid educational level, and negative history of substance abuse. The activity setting influenced outcome such that it appeared to be most difficult to return to work, suggesting the necessity of adequate vocational assistance. However, cognitive and demographic variables accounted for less than 30% of the total variance in outcome. Therefore, brain injury rehabilitation must be multifaceted.

Steroid withdrawal psychosis in a patient with closed head injury.

An 18-year-old student sustained a basilar skull fracture and seventh cranial nerve paralysis from a car-pedestrian accident. In the emergency room she scored 12 on the Glasgow Coma Scale. Dexamethasone 16 mg/day was administered in an attempt to reverse the facial palsy. After a 14-day course of therapy, the corticosteroid was abruptly withdrawn over a 24-hour period. On the day the dexamethasone was discontinued, the patient became severely depressed and developed an organic psychosis that persisted for ten weeks, necessitating psychiatric hospitalization. Psychopharmacologic therapy was required to control her mental symptoms. After discharge from the psychiatric hospitalization, she participated in a cognitive retraining program for closed head injury patients and soon thereafter returned to her studies. A possible explanation for this patient's organic psychosis was the abrupt withdrawal of steroid therapy. Alternate etiologies include the closed head injury and reactive psychosis. Comparison of this patient's symptoms with other cases of steroid psychosis showed similarities in time of onset, presentation of symptoms, and duration of psychosis. The use of steroids in closed head injury patients for the reduction of cerebral edema, is an important indication; however, adverse reactions such as psychoses can be prevented by slow withdrawal of the drug. Psychiatrists should be aware of the possibility of withdrawal psychoses as a result of steroid therapy in closed head injury patients.