of a

WORLDHEALTHORGANIZATION(1978) Mental Disorders: Glossary

district servicewithout psychiatrictrainees.Bulletin of theRoyal College of Psychiatrists, 10, 338-340.

andGuideto theirClassificationin AccordancewiththeNinth Revision of the International Classification of Diseases(lCD 9). Geneva: WHO.

KINGDON, D. G. & SzuLEcic&, T. K. (1986) Establishment

& BAKEWELL, E. (1988)Aggressivebehaviour:evaluation of adistrict'snon-seclusion policy.BritishJournalof Psychiatry, 153,631—634. KRAWIECKA, M.,



ZANITON,M. & HELLMAN,S. (1981) The complicated

business of

settingup residentialalternatives.Hospitaland Community Psychiatry, 32, 335—339.


standardised psychiatricassessmentscale for rating chronic

*David 0. Kingdon, MRCPsych, Consultant Psychi atrist; Douglas Turkington, MRCPsych, Senior

patients. ActaPsychiatrica Scandinavica, 55,299—308. NoRm EAST THAMESREGIONALHEALTH AUThORITY(1990) Report of the Fourth Annual Conference of Team for the Assessmentof Psychiatric Services.London: NETRHA. P@anY-JoNES, W. L. (1988)Asylum for the mentallyill in historical perspective.



Registrar, Katy Malcolm, MRCPsych, Senior Registrar, Krystyna Szulecka, MRCPsych,Consultant Psychi

12, 407—410.

WING, J. K. & MoRRIs, B. (eds) (1981) Handbook of Psy chiatric RehabilitationPractice. Oxford: Oxford University Press. & FURLONG, R. (1987) A haven for the severelydisabled within the context of a comprehensive psychiatric community service.British Journal of Psychiatry, 149, 449-457.

Bipolar Affective Disorder J. S. BAMRAH




Head Injury


A patient developed distinct episodes of major depressive illness, schizophreniformpsychoses and mania as well as focal epilepsyfollowing head injury. Head injury may be directly causative in the development of affective psychoses, in this case secondary bipolar (mixed) disorder. British Journal of Psychiatry (1991), 158, 117—119

Head injuries resulting from road traffic accidents are a major causeof cerebral damage, particularly in young adults. One estimate suggestsan annual attendancerate for head injuries of about 2000per

atrist, BassetlawDistrict GeneralHospital, Worksop, Nottinghamshire; Emmett Larkin, MRCPsych, Consultant Psychiatrist, Rampton Hospital,

not straightforward and has fuelled several debates, particularly

in the development

of psychosis.


(e.g. Davison & Bagley, 1969) favour a direct aetiological role, while others prefer a constitutional predisposition as the main contributing factor (e.g.

Lishman, 1973). Depressive psychoses occur most frequently, although schizophrenia, and less com

monly mania, are also reported (Achte et al, 1969). An unusual casewith no psychotic vulnerability is reported here.

100000 referrals to casualty departments, with about

250 requiring admission to general surgical wards (Jennett & MacMillan, 1981). The most common presentation is of closedheadinjuries; in open head injuries the intradural contents communicate with the outside through skull and scalp wounds usually as a result of a sharp and circumscribed impact. In the closedheadinjury, the effectsof externaltrauma are enhanced

by the undulating

internal surface of

the cranium, damaged protective coverings of the brain, cutting action of blood vessels, and shearing and rotation of the brain, thus producing widespread neuronal injury and multiple areas of focal damage (Crockard, 1983). Not surprisingly perhaps, a number of psychiatric conditions have been reported following closed head injury, with or without any demonstrable neurological sequelae. The relationship is, however,

Case report The patient was involved in a car accident at the age of 27 years and sustained multiple fractures, including closed head injury involving fractures of the right skull bones. He

wasunconsciousfor over 12hours, and had retrogradeand anterogradeamnesiasupon recovery.Beforethe accident, he had worked as a busy salesmanand was describedby his wife as being a ‘¿very able' man. He had no previous history of psychiatric illness, alcoholism or any illness suggestiveof cerebraldisorder, and no psychiatric illness

or epilepsyarereportedin the family. Following the accident, he developed an amnestic syndrome,headaches,anxiety, tearfulness,and wasunable

to work. In fact, he neverregainedemployment,and although according to his wife he remained fairly well betweenrelapseswhile on medication, helived a restricted life, in the extremelycaring atmosphereof his family. His symptomsgraduallyworsened,and two yearsafter the head


118 injury

he had his first


of severe depression,


insomnia,hypochondriasis, and suicidalideation,which responded to a course of electroconvulsive therapy (ECT). At age 31, he developed focal epilepsy, associated with

Jacksonian fits spreading fromtheleft handto theleftarm, and



tonic—clonic seizures


incontinence, andunconsciousness lasting10minutes.The fits were controlled

with phenobarbitone



whichwerediscontinued 20 yearslaterwithno recurrence. Between

the ages of 32 and 35, he had three further


of depressive illness associated with three suicidal attempts;

on each occasion he improved with ECT and anti depressants. At 40, he developed




subsidedspontaneously;a year later he took a further overdose

of drugs in response

to commanding


hallucinations. He was convinced the voices were trans mitted



via a broadcasting




thoughtswerebeingremovedfrom and insertedinto his mind. He had thought disorder, persecutory

delusions, and

believed that his body had been programmedby a computer. In addition, his affect was depressed. His IQ (Wechsler Adult Intelligence Scale) was 99, and on the Wechsler Memory Scale and Williams Memory Tests, results were in line with the IQ estimate, delayed recall was

well preserved, and there was impairment of the verbal learning

of new material.

Bender Gestalt drawings


accurately reproduced. On the Eysenck Personality Fig. 1 Scandemonstratesevidenceof generalisedcerebralatrophy, Inventory,

his neuroticism

score was high, his extraversion

scorelow, compatiblewitha ‘¿dysthymic personalitytype'. Physical examination, routine blood tests, lumbar puncture and electroencephalography


were all normal.

with particular prominence of the cerebrospinal-fluid spaces over the frontal lobes. The ventricular systemis normal in position.



courseof chlorpromazine relievedhispsychoticsymptoms. At the age of 48, he presented with similar symptoms associated with a depressive state which responded to trifluoperazine and amitriptyline. At 57 years, he again developed delusions of being controlled by a computer and

of thoughts being removed from his mind by beams emitted by the computer, persecutory delusions, and third-person a@uditoryhallucinations. Although routine investigations and EEG were again normal, a computerised tomography (CT) brain scan showed a generalised in the frontal region (Fig. 1).



Depot flupenthixol decanoate failed to control his symptoms but he responded to trifluoperazine which he continued until he was 58, when he presented with a manic psychosis. On admission, he was elated, sexually dis inhibited, insomniac, and had loud, pressured speech. He believed he was exceptionally gifted, and described grandiose plans on space travel. He showed a copy of a poem he had sent to President Reagan about the space race, and thought his exploits would make his whole family rich. No schizophrenic first-rank symptoms were elicited. Flupenthixol decanoate (40 mg every three weeks) and chlorpromazine (100mg per day) resolved his psychosis, allowing his discharge three weeks later. He was readmitted two weeks later in a hypomanic state. He was overfamiliar, elated, grandiose, had pressure of speech and, quite uncharacteristically, he had been drinking heavily. Lithium carbonate and thioridazine induced complete remission, with no recurrence of symptoms two years later.

The case illustrates the heterogeneity of psychiatric symptoms resulting from brain injury in a patient

who developed distinct episodes of major depressive illness, schizophreniform psychoses and mania. Although these syndromes may occur after head injury


et a!, 1969), there have been no reports

of cases with such a variety of psychotic disorders occurring sequentially in the same patient following head injury. The association of schizophrenic symptoms with focal epilepsy is well documented. However, affective psychosis preceded the onset of epilepsy in this patient and seems to have resulted directly from the head injury and ensuing brain insult. In a review of manic states occurring secondary to organic brain syndromes, Krauthammer & Klerman (1978) did not consider head injury as a causative factor despite previous reports supporting such an association. They have described four factors important in distinguishing secondary from primary mania: close temporal relationship between physical and mental illnesses, later age at onset of mania, absent pre-morbid characteristics, and lack of family history. Since their publication, a number of cases have been described which fulfil their criteria for


AFFECTIVE DISORDER AFTER HEAD INJURY secondary mania (e.g. Clark & Davison, 1987; Bracken, 1987; Shukla et al, 1987; Yatham et a!, 1988). This patient developed a secondary bipolar (mixed) disorder with recurrent episodes of major depression and mania. We suggestthat the caseadds to the growing evidence that head injury may be directly causative in affective psychoses. In keeping with the observation by Cohn et a! (1977), we observed a good response to lithium at two-year follow-up. Clark & Davison (1987) advocate the use of ECT in secondary mania, and this casesupports the use of ECT in depressiveillness secondary to head injury. The effectiveness of ECT on its own has not previously been described in such cases, but reaffirms the findings of Merskey & Woodforde (1972) that ECT might modify the course of secondary depressive illness. On present evidence we cannot speculate on the neuroanatomical substrates involved in the diverse manifestations of psychotic syndromes. New imaging techniques and post-mortem studies are required to understand the neuropathological basis for these phenomena. Acknowledgements @

We are grateful to Mrs S. Pickstone for performing psychological tests, and to the Radiology Department, Withington Hospital, for permission to report the CT scan.

BRACKEN,P. (1987) Mania following head injury. British Journal

ofPsychiatry, 150, 690-692. CLARK,A. F. & DAVISON,K. (1987) Mania following head injury.

A report of two cases and a reviewof the literature. British Journal ofPsychiatry,

630—63 1. CROCKARD,H. A. (1983) Head Injuries. Contemporary Neurology.

London: Butterworths. DAVISON,K. & BAGLEY,C. R. (1969) Schizophrenia-like psychoses associated with organic disorders of the central nervous system:

a review of the literature. In Current Problems in Neuro psychiatry (ed. R. N. Herrington), pp. 113-184.British Journal

of PsychiatrySpecialPublicationNo.4. London:RoyalCollege of Psychiatrists. JENNETr, B. & MACMILLAN, R. (1981) Epidemiology

ACHTE, K. A., HILLBOM, E. & AALBERG, V. (1969) Psychoses

following war brain injuries. Acta PsychiatricaScandinavica,45, 1—18.

of head

injury. British Medical Journal, 282, 101-104. KRAUTHAMMER,C. & KLERMAN,G. L. (1978) Secondary


Manic syndromes associated with antecedent physical illness or drugs. Archives of General Psychiatry, 35, 1333—1339. LISHMAN,W. A. (1973) The psychiatric

sequelae of head injury:

a review. PsychologicalMedicine, 3, 304—318. MERSKEY,H. & WOODFORDE,J. M. (1972) Psychiatric

sequelae of

minor head injury. Brain, 95, 521—528. SHUKLA, S., COOK, B. L., MUKHERJEE, S., et al (1987) Mania following head trauma. American Journal of Psychiatry, 14,

93—96. YATHAM, L. N., BENBOW,J. C. & JEFFERS, A. M. (1988) Mania following head injury. Acta Psychiatrica Scandinavica, 77,

359—360. S. Bamrah,

Withington FRCPsych,


150, 81—84.

COHN, C. K., WRIGHT, J. R. & DE VAUL, R. A. (1977) Post head trauma syndrome in an adolescent treated with lithium carbonate: a case report. Diseases of the Nervous System, 38,

MB, BS, MRCPsych, Senior Registrar,


J. Johnson, MD, FRCP(Ed),



Wit hington

Hospital, Didsbury, Manchester M20 8LR *Correspondence: Bridgewater Hospital, Green Lane, Eccles, Manchester M30 ORL

Organic Manic Syndrome Associated with Advanced Uraemia due to Polycystic Kidney Disease CHRISTOPHER S. THOMAS and 1. JAMES NEALE

Mania secondary to advanced uraemia caused by polycystic disease of the kidneys in a 62-year-old woman involved a complex interplay of physical, psychologicaland social factors. Psychotherapyand thioridazineled to full recovery. British Journal of Psychiatry (1991), 158, 119—121 Mania in associationwith uraemia was first reported at the end of the 19th century, but only one casehas been documented this century (El-Mallakh et a!, 1987). These cases are examples of organic manic


or secondary




ranging from extracranial to intracranial, may be implicated in the pathogenesis

of secondary manias

(Krauthammer & Klerman, 1978;Stasiekand Zetin, 1985;


et a!,


In two



had been receiving haemodialysis, one developed hypomania following a septic focus (Cooper, 1967) and in the other mania was the presenting feature of a progressivedialysisencephalopathy (Jack eta!, 1983).

Bipolar affective disorder following head injury. J S Bamrah and J Johnson BJP 1991, 158:117-119. Access the most recent version at DOI: 10.1192/bjp.158.1.117

References Reprints/ permissions You can respond to this article at Downloaded from

This article cites 0 articles, 0 of which you can access for free at: To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;158/1/117 on October 13, 2016 Published by The Royal College of Psychiatrists

To subscribe to The British Journal of Psychiatry go to:

Bipolar affective disorder following head injury.

A patient developed distinct episodes of major depressive illness, schizophreniform psychoses and mania as well as focal epilepsy following head injur...
679KB Sizes 0 Downloads 0 Views