ROLE OF THE PSYCHIATRIST IN NEUROREHABILITATION
The patient with a brain injury presents syndromes that combine cognitive disorders (memory, language, reasoning, attention, etc.) with emotional and behavioural disorders. In fact, it is very rare that they only suffer from motor impairment (inability to walk, paralysis, etc.). Our obligation is to describe in detail these changes in the assessment of patients. That is why the information provided by their families and people who know them well is essential since on occasions certain changes could go unnoticed in a medical interview. On the other hand, in order to understand the cognitive situation we have with the invaluable help of the assessment of the neuropsychologist. And for the diagnosis and treatment of these disorders we have the presence of the psychiatrist. But not a consultant psychiatrist that examines the patient on only one occasion and where if considered appropriate, a treatment treatment is indicated, what we have is a “bedside” psychiatrist. This person is with the patient day-to-day, which is essential to understanding the patient and their progress. Another function of the psychiatrist can be the modular, the interaction of the interdisciplinary team with families. People can feel support and harmony from simple active, empathetic listening.
People with brain damage may have changes in mood and emotional lability, with a tendency to cry or laugh for no apparent reason. Quite often depression can occur, which should be treated pharmacologically, because otherwise it may stall the overall progression of the patient. In fact, if there is no improvement in a patient, without the justification of organic cause or elapsed time, the presence of depression should be suspected. Disinhibition, lack of self-control or “slow-down” is also frequent, which can lead patients to say anything that they think, without considering whether it is appropriate or not, or to an action, without anticipating the consequences of what they are doing, with impulse prevailing over respect for social standards. Anger, irritability, or even aggressiveness may occur. But also the opposite is the case, with the occurrence of apathy. On other occasions, a degree of impatience, immaturity, puerility or egocentric behaviours may dominate, with the patient, in general, lacking empathy. They want something and they want it immediately, with no capacity to wait. The way of being of the person concerned, their personality, can change after brain damage. This may result in exacerbation and exaggeration from the previous characteristics of the patient, in their way of being, even to the point of radical or extreme change that makes the familiar say things such as “I have a stranger at home”, “I don’t recognize him”.
In many cases, psychopharmacology can be useful to treat certain impairments that may arise. For example, it may be helpful in insomnia, emotional lability or depression. In fact, a high percentage of patients benefit from the psychopharmacological treatments. The specialist psychiatrist in brain damage will know the medications that can cause iatrogenic complications in patients suffering from brain damage and which, therefore, should not be used. The specialist psychiatrist will also indicate, if considered appropriate, and once the family and patient have been informed, whether to use certain techniques such as Transcranial Magnetic Stimulation.
Psychiatry tries to understand the psychological suffering of the individual, and how it spreads to the family, therefore the interrelationship between them and the brain damage is necessary and unavoidable.
Therefore, upon admission the psychiatrist will perform a psychopathological examination on the patient and will undertake a psychopathological interview with the family. Hence, extract enough data to be able to relay the situation and mode of action to the team. On occasions, an indication of physical containment will be necessary (due to not being aware of disease and the existence of risk to one’s person or third parties, aggressiveness, etc.). To have a real understanding of the cognitive and affective-behavioural situation, it is essential, in addition to the data provided by neuropsychology, to observe the patient outside of the office, the way they act and interact with different people in everyday situations and in different spaces. Their condition is transferred to the team during clinical sessions, and depending on these sessions, and in accordance with the therapists, the objectives are planned and treatment is indicated, where considered appropriate.
Throughout the time that the patient is undergoing neurorehabilitation therapy they will be reviewed daily. A sketch is made of their mental state and behaviour, their oscillations or changes, and in line with this the appropriate action is taken. According to their progress, the objectives to be achieved are jointly re-established with the rest of the interdisciplinary team. The family is essential in this process and they continue to provide information on these matters.
When it gets close to hospital discharge, a report will be drafted in which the cognitive-behavioural and emotional situation will be outlined, as well as the improvements achieved and current status, along with drug treatment, if required, all of which will be reported to the family.