0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letters   |    
Does Memory Impairment Exclude a Diagnosis of OCD After Traumatic Brain Injury?
Rudi Coetzer, Ph.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2011;23:E12-E12.

To the Editor: In addition to physical and cognitive impairment, neuropsychiatric disturbances after traumatic brain injury (TBI) are relatively common.1 Although depression and anxiety are most common,1,2 obsessive-compulsive disorder (OCD) has also been reported,13 albeit less frequently, and possibly representing a more transient neuropsychiatric complication of TBI.3 Diagnosing OCD in the context of TBI is complex because of overlapping symptomatology.4 Cognitive impairment, for example, of memory, can be difficult to distinguish from compulsions. Similarly, impairment of executive function, in particular, perseveration, can be mistaken for obsessions. Structured cognitive assessment may disentangle these symptoms and help clarify diagnoses in individual cases.

The first case has been reported in greater depth elsewhere2 and is presented for comparison only. A 27-year-old man presented with OCD with severe TBI, after a road-traffic collision 51/2 years earlier. He presented with clear obsessions and compulsions. His Florida Obsessive Compulsive Inventory (FOCI)5 provided further evidence of obsessions and compulsion. There was no premorbid history of psychiatric illness. A CT of the brain showed a fracture of the left parietal bone extending into the floor of the anterior fossa, a left frontal contusion, and a basal skull fracture. The remainder of the brain was reported as normal. Cognitive assessment revealed superior general intellectual ability, normal memory, but subtle impairment of executive function, in particular, set-shifting (Trails). Indeed, the patient reported often remaining overly focused on one aspect of a situation to avoid possible distraction (poor set-shifting). Uncertainty when recalling information resulted in repetitions, when objectively memory performance was robust.

The second case is a 56-year-old man with severe TBI after a fall, seen 7 years post-TBI for repeat neuropsychological testing. He had no premorbid psychiatric illnesses. He presented with disinhibited behavior, severe memory impairment, and being very rooted in behavioral patterns. He hoarded numerous objects in his pockets, becoming anxious when having to empty his pockets—behavior that appears to resemble obsessions and compulsions. Whereas the FOCI5 showed moderately elevated scores, the performance was clearly a reflection of poor memory. Cognitive assessment revealed average-to-high average general intellectual ability. There were subtle indications of executive dysfunction in the area of set-shifting (Trails). Very significant impairment of memory was present. Neuro-imaging showed contusions to the orbito-frontal cortex bilaterally, large hematomas and contusions of the left occipital and temporal lobes and lateral and ventral-temporal lobe of the left hemisphere.

The cases reported here unsurprisingly both had executive dysfunction, very common in TBI. Memory may be a more useful function to consider, as it appears to function as a conduit between obsessions and compulsions in OCD. TBI patients with memory impairment may present with repetitive behaviors mirroring compulsions, which may actually often represent their strategy for preventing memory failure, as opposed to a response to obsessions. Where this is the case in patients with TBI, a diagnosis of OCD should be questioned.

Van Reekum  R;  Cohen  T;  Wong  J:  Can traumatic brain injury cause psychiatric disorders? J Neuropsychiatry Clin Neurosci 2000; 12:316–327
[PubMed]
[CrossRef]
 
Coetzer  R:  Anxiety and Mood Disorders Following Traumatic Brain Injury: Clinical Assessment and Psychotherapy.  London, UK,  Karnac Books, 2010
 
Childers  MK;  Holland  D;  Ryan  MG  et al:  Obsessional disorders during recovery from severe head injury: report of four cases.  Brain Inj 1998; 12:613–616
[PubMed]
[CrossRef]
 
Williams  WH;  Evans  J;  Fleminger  S:  Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: an overview and case illustration of obsessive-compulsive disorder.  Neuropsychol Rehabil 2003; 13:133–148
[PubMed]
[CrossRef]
 
Storch  EA;  Kaufman  DA;  Bagner  D  et al:  The Florida Obsessive-Compulsive Inventory: development, reliability, and validity.  J Clin Psychol 2007; 63:851–859
[PubMed]
[CrossRef]
 
References Container
+

References

Van Reekum  R;  Cohen  T;  Wong  J:  Can traumatic brain injury cause psychiatric disorders? J Neuropsychiatry Clin Neurosci 2000; 12:316–327
[PubMed]
[CrossRef]
 
Coetzer  R:  Anxiety and Mood Disorders Following Traumatic Brain Injury: Clinical Assessment and Psychotherapy.  London, UK,  Karnac Books, 2010
 
Childers  MK;  Holland  D;  Ryan  MG  et al:  Obsessional disorders during recovery from severe head injury: report of four cases.  Brain Inj 1998; 12:613–616
[PubMed]
[CrossRef]
 
Williams  WH;  Evans  J;  Fleminger  S:  Neurorehabilitation and cognitive-behaviour therapy of anxiety disorders after brain injury: an overview and case illustration of obsessive-compulsive disorder.  Neuropsychol Rehabil 2003; 13:133–148
[PubMed]
[CrossRef]
 
Storch  EA;  Kaufman  DA;  Bagner  D  et al:  The Florida Obsessive-Compulsive Inventory: development, reliability, and validity.  J Clin Psychol 2007; 63:851–859
[PubMed]
[CrossRef]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Books
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 8.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 35.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 8.  >
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 44.  >
Textbook of Traumatic Brain Injury, 2nd Edition > Chapter 39.  >
Topic Collections
Psychiatric News
Read more at Psychiatric News >>
APA Guidelines
PubMed Articles
Novel applications of deep brain stimulation. Surg Neurol Int 2012;3(Suppl 1):S26-33.