Disclosures: Kathy Guo, MD: No financial relationships or conflicts of interest

Case Diagnosis: Psychosis following traumatic brain injury

Case Description or Program Description: A 19-year-old female with history of anxiety, PTSD, depression, and opioid use disorder was an unrestrained passenger involved in a motor vehicle accident. She initially responded to naloxone on the scene, but then required intubation. Imaging revealed intraparenchymal hemorrhage (IPH), intraventricular hemorrhage (IVH), and right occipital condyle fracture. On admission to the acute inpatient rehabilitation unit, she had ongoing psychotic symptoms including paranoia, agitation, and hallucinations.

Setting: Level 1 trauma center

Assessment/Results: MRI brain, 24 hour EEG, and lab workup including ammonia, B12, folate, MMA, TSH, varicella zoster, B1, lumbar puncture, and autoimmune encephalopathy panel were all normal. She was initially started on quetiapine and haloperidol, but was discontinued due to ongoing symptoms, and amantadine was thought to have worsened her hallucinations. She was then started on risperidone which ultimately improved the hallucinations. She also transitioned from oral buprenorphine/naloxone to injectable buprenorphine for management of opioid use disorder. At discharge, her symptoms improved with these medication adjustments and she ultimately did not require an inpatient psychiatric admission.

Discussion (relevance): Psychosis following brain injury (PFTBI) has several different presentations including schizophrenia, and isolated symptoms such as hallucinations or delusions. It is estimated that up to 10% of TBI patients experience symptoms of psychosis, which is three times higher than the general population, with latency of months to years, typically not observed in the acute phase. Risk factors include younger age, male gender, substance abuse, previous existing psychiatric diagnosis, or family history of schizophrenia/psychosis. Other differentials to consider are post-traumatic seizure disorder, mood disorders, past substance abuse, or a manifestation of a schizophrenia-like disorder.

Conclusions: PFTBI is a poorly understood condition with limitations in identification and treatment. It can be even more challenging to discern in a patient with a complicated psychiatric history. Appropriate management relies on treating the underlying cause.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/atypical-psychosis-following-traumatic-brain-injury-a-case-report/