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185

Section 3

Organic syndromes of schizophrenia: other neurological disorders

brain injury

Perminder S. Sachdev

Facts box

of severe TBI on the victim is almost always devastat-r
ing, but even mild TBI can result in serious and dis-The many anecdotal reports of
abling neuropsychiatric disorders, ranging from cog-schizophrenia-like psychosis (SLP) following
nitive deficits and personality change to severe and
traumatic brain injury (TBI) do not provide

chronic psychosis.

strong evidence for a link between the two

The association between TBI and schizophrenia-because of the likelihood of chance
like psychosis (SLP) has generated research interest for
association and the subjective nature of the
more than a century
[4],
but systematic studies have
determination.

been relatively few. The most important question is
r
One large cross-sectional study did not

whether TBI predisposes an individual to schizophre-provide strong evidence for an association
nia or SLP. If this can be unequivocally established,
between head injury and schizophrenia.

a number of other questions become relevant: What
r
The case control studies provide strong

is the prevalence of SLP following TBI? Are the clin-evidence that TBI does not substantially
ical features of SLP related to TBI different from
increase the risk of schizophrenia in the

schizophrenia? What is its prognosis? What factors,
general population, although a small increase
related to the injury as well as to the individual, predis-cannot be ruled out.

pose the person with TBI to develop SLP? Is the devel-r
The association may be stronger in those with
opment of SLP particularly related to injury to spe-a genetic vulnerability to schizophrenia or
cific brain regions? Does the study of SLP advance our
the presence of preinjury psychopathology.

understanding of the etiopathogenesis of schizophrer
nia? We first examine the epidemiological evidence
Psychosis following TBI has considerable

and then attempt to answer some of these questions.

overlap with primary schizophrenic disorder,
with a prominence of persecutory and other

delusions, auditory hallucinations, and a

Epidemiology

dearth of negative symptoms.

The evidence for an association between SLP and TBI
r
More severe and diffuse brain injuries,

has come from a number of sources, and the various
especially those involving the temporal and

studies can be grouped according to their design. The
frontal lobes, are the most prominent risk

most definitive study would be a longitudinal cohort
factor, and EEG and neuroimaging

design, in which a large number of head-injured indi-abnormalities are often present.

viduals across a wide age range, and a matched not
head-injured control group, would be followed up
prospectively using standard instruments and well-Traumatic brain injury (TBI) is a common problem
defined diagnostic criteria. Because this ideal study
with major public health implications. A conservative
does not exist, the evidence must be pooled from a
estimate of the annual incidence of TBI in the United
variety of sources.

States is 200 per 100,000 per year
[1],
and estimates of
its prevalence range from 2.5 to 6.5 million individuals
[2].
Disorders arising from traumatic injuries to the
Case reports

brain are more common than any other neurological
Observations by clinicians have been a major fac-