Widening the lens

Sarah Ashworth on psychiatric comorbidity in neuropsychiatric services.

I believe our experiences shape and colour the ‘lens’ through which we view our clients. This can at times be a challenge for those move to a specialist field, from a more general background. However, it can also be considered as an opportunity to widen the lenses of existing specialist services, acknowledging potential alternative, or comorbid, explanations for presenting difficulties.

From experience, psychiatric comorbidity for individuals with Acquired Brain Injury (ABI; brain damage caused by events after birth) is; relatively common, can increase associated difficulties (e.g. self-harm/suicide attempts, substance misuse), can impact negatively upon rehabilitation efforts, and often remains clinically overlooked. However, there appears to be a complex relationship between ABI and psychiatric comorbidities, one which is not uni-directional. Such difficulties may exist prior to the injury, co-occur at the time of the injury, or may manifest post-injury.

Psychological themes which appear to occur frequently within my formulations of individuals who have an ABI include pre-existing issues relating to impulsively, risk taking, substance misuse, social vulnerability, and often post-injury symptoms of depression and anxiety. Case examples include; an individual suffering with depression attempts suicide resulting in hypoxia and diffuse neurological damage; an individual diagnosed with psychosis is assaulted due to bizarre behaviour resulting in a TBI; a chronic alcoholic develops Korsakoffs syndrome (Alcohol Related Brain Damage; ARBD); an individual suffers with depression and anxiety following the loss of his job, partner and family; an impulsive individual experiences anxiety and flashbacks following a drink driving RTA resulting in an ABI. 

Reflection and awareness of the possible impact psychological factors involved with an ABI is key to rehabilitation efforts. However, refection upon neuro-services highlight factors which may challenge attempts to such psychological thinking.  

Diagnostic overshadowing is the attribution of an individual’s symptoms to one overarching condition, when such symptoms actually suggest a comorbid condition. From clinical reflection, this issue appears relevant within (often heavily medicalised) neuropsychiatric settings. Furthermore, the presence of specialist, often medical, clinicians trained and experienced in identifying and treating organic disorders may increase the likelihood that presenting symptoms are attributed to a neurobiological source. Such clinicians may view the individual with a ‘neurological lens’, discounting factors which may suggest psychological/emotional causes. Subsequently, the main focus of rehabilitation efforts tend to focus upon physical/cognitive rehabilitation, with a lack of focus upon clients’ psychological/emotional wellbeing.

It can be argued the traditional biomedical model dictates clinical areas addressed first are those considered most severe. ABI services (heavily influenced by the biomedical model), tend to prioritise physical, cognitive, psychiatric, and psychological/emotional difficulties in this hierarchical order. This can lead to psychosocial impacts of ABI remaining unaddressed due to pressures to reintegrate individuals back into the community once the physical/cognitive impairment has been addressed.

Ensuring a client receives comprehensive rehabilitation is the central aim of neuropsychiatric services. More attention should be paid to common psychiatric comorbidities within ABI populations. Specialist services should endeavour to recruit a combination of specialist and general professionals to ensure a rich multidisciplinary team rather than strive for the ideal of a ‘team of specialists’. This way the constellation of factors involved with ABI can be considered to form a holistic rehabilitation treatment pathway addressing physical/cognitive deficits, in addition to psychological/emotional issues. 

Relating to psychology as a profession, perhaps we shouldn’t discount more general mental health experience as a disadvantage when moving to a more specialist service, but rather see it as an opportunity to ‘widen the lens’

Dr Sarah Ashworth

Chartered Psychologist
Nottingham

References

Neurotrauma Law Nexus http://www.neurolaw.com/neuroglossary/ accessed on 03/02/2020

Rogers, J. M. & Read, C. A. (2007) Psychiatric comorbidity following traumatic brain injury, Brain Injury, 21:13-14, 1321-1333, DOI: 10.1080/02699050701765700

Wilson, B. A., Winegardner, J., Van Heugten, C. M. & Ownsworth, T. (2017). Neuropsychological Rehabilitation; the International Handbook. Routledge Publishers.

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