SIR: The major clusters of psychiatric symptoms related to traumatic brain injury (TBI) are those of behavioral sequelae and of cognitive impairment. Clinically, these psychiatric symptoms are a very difficult barrier to overcome in rehabilitation programs.
We report a case of a brain-injured patient with refusal to eat who responded to risperidone after failing to respond to other treatments.
>A 66-year-old man without any past psychiatric history suffered traumatic brain injury following a traffic accident and was thereafter admitted to a hospital. A left orbitofrontal lobe contusion and a traumatic subarachnoid hemorrhage were documented by a CT scan. Neurosurgical intervention was not indicated in this case.
After the head injury, the patient developed psychiatric symptoms. His behavioral symptoms included increased aggression, agitation with yelling, and depression. Cognitive problems involved decreased attention and problems with memory. Residual deficits also included moderate right hemiparesis. The neurobehavioral deficits continued to be a very difficult barrier to rehabilitative progress. Medication trials with conventional antipsychotics (haloperidol, chlorpromazine) at therapeutic dosages were not effective.
In addition, about a month after the traffic accident, he started to refuse eating and would not cooperate with any medical treatment. He actively resisted requests to participate in rehabilitation. He refused to allow either food or medicine to be placed in his mouth. He lost weight, and undernourishment made his rehabilitative progress even more difficult. Medication trials with sulpiride 150 mg/day, amantadine 300 mg/day, fluvoxamine 150 mg/day, and some benzodiazepines did not improve the situation.
He was referred to our hospital 2 months after the traffic accident. At that time, risperidone was initiated at a dose of 2 mg/day, and 3 weeks later it was increased to 3 mg/day. About a week after the initiation of risperidone, he began to calm down and showed a greatly reduced level of aggression. He also accepted food without resistance. He agreed to participate in physical therapy 2 weeks after starting the risperidone treatment. Cognitive function also improved. He was discharged home 2 months after starting risperidone treatment and has subsequently been maintained on 3 mg/day of risperidone while pursuing outpatient rehabilitation programs.
The patient's refusal to eat and active resistance to instructions were considered to be catatonic signs.1 Catatonia is a clinical syndrome that has multiple causes.2 There is a case report of organic catatonia following frontal lobe injury;3 the patient's catatonic signs included stereotypic movements, iterations, and verbigerations, and she responded well to clozapine. Gamma-aminobutyric acid (GABA) receptors have been suggested to play a crucial role in catatonia,1 but the precise mechanisms by which psychotropic drugs relieve catatonic symptoms have not yet been elucidated.4 There is one case report of catatonic stupor and mutism that were successfully treated with risperidone;5 a CT scan in that case revealed bilateral orbitofrontal atrophy. Whatever the central mechanism, risperidone appears to be an effective treatment for patients who refuse to eat.
Further studies are needed to confirm the effectiveness of risperidone for the treatment of refusal to eat after TBI.