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PARTVSocial Issues30 The Family System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533Marie M. Cavallo, Ph.D.Thomas Kay, Ph.D.31 Systems of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559D. Nathan Cope, M.D.William E. Reynolds, D.D.S., M.P.H.32 Social Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571Andrew Hornstein, M.D.33 Ethical and Clinical Legal Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583Robert I. Simon, M.D.PARTVITreatment34 Psychopharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609Jonathan M. Silver, M.D.David B. Arciniegas, M.D.Stuart C. Yudofsky, M.D.35 Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641Irwin W. Pollack, M.D., M.A.36 Cognitive Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655Wayne A. Gordon, Ph.D.Mary R. Hibbard, Ph.D.37 Behavioral Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661Patrick W. Corrigan, Psy.D.Patricia A. Bach, Ph.D.38 Alternative Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679Richard P. Brown, M.D.Patricia L. Gerbarg, M.D.

PARTVIIPrevention39 Pharmacotherapy of Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 699Saori Shimizu M.D., Ph.D.Carl T. Fulp, M.S.Nicolas C. Royo, Ph.D.Tracy K. McIntosh, Ph.D.40 Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727Elie Elovic, M.D.Ross Zafonte, D.O.Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 749

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ContributorsJennifer Adams, B.S.Michigan State University, East Lansing, MichiganXavier Amador, Ph.D.Adjunct Professor, Columbia University College of Physicians and Surgeons, New York, New YorkC. Alan Anderson, M.D.Associate Professor of Neurology, Psychiatry, and Emergency Medicine, University of Colorado Health SciencesCenter; Staff Physician, Denver Veterans Affairs MedicalCenter, Denver, ColoradoKaren E. Anderson, M.D.Assistant Professor, Departments of Psychiatry and Neurology, University of Maryland School of Medicine, Baltimore, MarylandDavid B. Arciniegas, M.D.Assistant Professor of Psychiatry and Neurology and Director, Neuropsychiatry Service, University of ColoradoHealth Sciences Center, Denver, ColoradoKimberly A. Arlinghaus, M.D.Associate Professor of Psychiatry and Physical Medicineand Rehabilitation, Baylor College of Medicine; SeniorConsultant for Psychiatry and Director, Psychiatry Consultation/Liaison Program, Michael E. DeBakey VAMedical Center, Houston, TexasPatricia A. Bach, Ph.D.Assistant Professor of Psychology, Illinois Institute ofTechnology, Institute of Psychology, Chicago, IllinoisJeffrey T. Barth, Ph.D.Director, Brain Injury and Sports Concussion Institute,University of Virginia School of Medicine, Charlottesville, VirginiaRichard P. Brown, M.D.Associate Professor of Clinical Psychiatry, ColumbiaUniversity College of Physicians and Surgeons, NewYork, New YorkMarie M. Cavallo, Ph.D.Assistant Director, Adult Day Services Department, andDirector, TBI Services, Association for the Help of Retarded Children, New York, New YorkSudeep Chakravorty, M.D.Assistant Professor of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PennsylvaniaLawrence D. Chu, M.S., M.P.H., Ph.D.Assistant Professor in Biostatistics and Epidemiology,Department of Health Sciences, California State University–Northridge, Northridge, CaliforniaKenneth J. Ciuffreda, O.D., Ph.D.Distinguished Teaching Professor, Chair, Department ofVision Sciences, SUNY State College of Optometry,New York, New YorkD. Nathan Cope, M.D.Chief Medical Officer, Paradigm Health Corporation,Concord, CaliforniaCheryl Corcoran, M.D.Assistant Professor of Clinical Psychiatry, New York StatePsychiatric Institute, New York, New YorkPatrick W. Corrigan, Psy.D.Professor of Psychiatry and Psychology, NorthwesternUniversity, Center for Psychiatric Rehabilitation at Evanston Northwestern Healthcare, Evanston, IllinoisErin D. Bigler, Ph.D.Professor, Departments of Psychology and Neuroscience,Brigham Young University, Provo, Utah; Adjunct Professor, Departments of Psychiatry and Radiology, Universityof Utah School of Medicine, Salt Lake City, UtahElie Elovic, M.D.Associate Professor, Department of Physical Medicineand Rehabilitation, University of Medicine and Dentistryof New Jersey–New Jersey Medical School, Newark,New Jersey; Director, Traumatic Brain Injury Laboratory, Kessler Medical Rehabilitation Research and Education Corporation, West Orange, New JerseyDonna K. Broshek, Ph.D.Assistant Professor and Associate Director, Brain Injuryand Sports Concussion Institute, University of VirginiaSchool of Medicine, Charlottesville, VirginiaAnthony Feinstein, M.D., Ph.D.Professor, Neuropsychiatry Program, University of Toronto, Sunnybrook and Women’s College Hospital, Toronto, Ontario, Canadaxiii

xi vLaura A. Flashman, Ph.D.Associate Professor of Psychiatry, Department of Psychiatry, Division of Neuropsychiatry, Dartmouth MedicalSchool, Lebanon, New Hampshire; New HampshireHospital, Concord, New HampshireJason R. Freeman, Ph.D.Associate Director, Brain Injury and Sports ConcussionInstitute, University of Virginia School of Medicine,Charlottesville, VirginiaCarl T. Fulp, M.S.Predoctoral Fellow, Traumatic Brain Injury Laboratory,Department of Neurosurgery, University of PennsylvaniaSchool of Medicine, Philadelphia, PennsylvaniaThomas A. Gennarelli, M.D.Professor and Chair, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WisconsinPatricia L. Gerbarg, M.D.Assistant Professor of Clinical Psychiatry, New YorkMedical College, Valhalla, New YorkJamshid Ghajar, M.D., Ph.D.President, Brain Trauma Foundation, New York, New YorkWayne A. Gordon, Ph.D.Jack Nash Professor, Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, New YorkDavid I. Graham, M.B.B.Ch., Ph.D.Professor and Head of Neuropathology, Institute of Neurological Sciences, Southern General Hospital, Glasgow,ScotlandRoger Hartl, M.D.Assistant Professor of Neurosurgery, Department ofNeurological Surgery, Joan and Sanford I. Weill CornellMedical College, Cornell University, New York, NewYorkMary R. Hibbard, Ph.D.Professor, Department of Rehabilitation Medicine,Mount Sinai School of Medicine, New York, New YorkAndrew Hornstein, M.D.Assistant Clinical Professor of Psychiatry, ColumbiaUniversity College of Physicians and Surgeons, NewYork, New York; Attending Psychiatrist, Head InjuryServices, Helen Hayes Hospital, West Haverstraw, NewYorkRobin A. Hurley, M.D.Associate Professor, Departments of Psychiatry andRadiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Clinical Associate Professor, Department of Psychiatry, BaylorCollege of Medicine, Houston, Texas; Associate Chiefof Staff/Mental Health, Hefner VAMC, Salisbury,North CarolinaContributorsRicardo E. Jorge, M.D.Assistant Professor of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IowaNeera Kapoor, O.D., M.S.Associate Clinical Professor, Department of Clinical Sciences and Director, Raymond J. Greenwald RehabilitationCenter, SUNY State College of Optometry, New York,New YorkThomas Kay, Ph.D.Assistant Clinical Professor, Department of RehabilitationMedicine, New York University School of Medicine; RuskInstitute of Rehabilitation Medicine, New York, New YorkRichard E. Kennedy, M.D.Assistant Professor, Departments of Psychiatry and Physical Medicine & Rehabilitation, Virginia CommonwealthUniversity School of Medicine, Richmond, VirginiaEdward Kim, M.D.Associate Professor of Psychiatry, University of Medicineand Dentistry of New Jersey–Robert Wood JohnsonMedical School, Piscataway, New JerseyJess F. Kraus, M.P.H., Ph.D.Professor of Epidemiology, University of California, LosAngeles, School of Public Health; Director, Southern California Injury Prevention Research Center, Los Angeles,CaliforniaLawrence A. Labbate, M.D.Professor of Psychiatry and Behavioral Sciences, MedicalUniversity of South Carolina, Charleston, South CarolinaMorris Levin, M.D.Associate Professor of Medicine (Neurology) and Associate Professor of Psychiatry, Dartmouth Medical School,Lebanon, New HampshireMark R. Lovell, Ph.D.Director, Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, PennsylvaniaDolores Malaspina, M.D.Professor of Clinical Psychiatry, New York State Psychiatric Institute, New York, New YorkRobert S. Marin, M.D.Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Instituteand Clinic, Pittsburgh, PennsylvaniaMichael F. Martelli, Ph.D.Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, Virginia; Clinical Assistant Professor, Departments ofPsychology and Psychiatry, Virginia Commonwealth University Health System, Richmond, Virginia; ConcussionCare Centre of Virginia, Ltd., Tree of Life, L.L.C., GlenAllen, Virginia

ContributorsxvJeffrey E. Max, M.B.B.Ch.Professor, In-Residence, Department of Psychiatry, University of California, San Diego, School of Medicine; Director of Neuropsychiatric Research, Children's Hospitaland Health Center, San Diego, CaliforniaVani Rao, M.D.Assistant Professor, Division of Geriatric Psychiatry andNeuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MarylandThomas W. McAllister, M.D.Professor of Psychiatry, Department of Psychiatry, Section of Neuropsychiatry, Dartmouth Medical School,Lebanon, New HampshireWilliam E. Reynolds, D.D.S., M.P.H.Public Service Professor, School of Social Welfare, andClinical Associate Professor, School of Public Health,State University at Albany, Albany, New YorkScott McCullagh, M.D.Assistant Professor, Neuropsychiatry Program, University of Toronto, Sunnybrook and Women’s College Hospital, Toronto, Ontario, CanadaEdwin F. Richter III, M.D.Associate Clinical Director, Rusk Institute of Rehabilitation Medicine, New York, New YorkTracy K. McIntosh, Ph.D.Professor of Neurosurgery and Director, TraumaticBrain Injury Laboratory, Department of Neurosurgery,University of Pennsylvania School of Medicine, Philadelphia, PennsylvaniaNorman S. Miller, M.D.Professor of Psychiatry and Medicine, Department ofPsychiatry, Michigan State University College of HumanMedicine, East Lansing, MichiganKeith Nicholson, Ph.D.Comprehensive Pain Program, Toronto Western Hospital, Toronto, Ontario, CanadaAlison Moon O'Shanick, M.S., C.C.C.-S.L.P.Center for Neurorehabilitation Services, Midlothian,VirginiaGregory J. O’Shanick, M.D.Medical Director, Center for Neurorehabilitation Services, Midlothian, Virginia; National Medical Director, BrainInjury Association of America, McLean, VirginiaMary F. Pelham, Psy.D.Neuropsychologist, Moss Rehab, Elkins Park Hospital,Elkins Park, PennsylvaniaKirsten Plehn, Ph.D.Fellow in Clinical Neuropsychology, Department of Psychiatric Medicine, University of Virginia School of Medicine, Charlottesville, VirginiaIrwin W. Pollack, M.D., M.A.Emeritus Professor of Psychiatry, University of Medicineand Dentistry of New Jersey–Robert Wood JohnsonMedical School, Piscataway, New JerseyTrevor R. P. Price, M.D.Private Practice of General Adult Psychiatry, Geriatric Psychiatry, and Neuropsychiatry, Bryn Mawr, PennsylvaniaRobert G. Robinson, M.D.Paul W. Penningroth Professor and Head of Psychiatry,Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IowaDonald C. Rojas, Ph.D.Associate Professor of Psychiatry, University of ColoradoHealth Sciences Center, Denver, ColoradoPamela Rollings, M.D.Adult Psychiatry, Wellspan Behavioral Health, Divisionof Neurosciences, Behavioral Health Services, WellspanHealth–Delphic Office, York, PennsylvaniaNicolas C. Royo, Ph.D.Postdoctoral Fellow, Traumatic Brain Injury Laboratory,Department of Neurosurgery, University of PennsylvaniaSchool of Medicine, Philadelphia, PennsylvaniaSaori Shimizu, M.D., Ph.D.Postdoctoral Fellow, Traumatic Brain Injury Laboratory,Department of Neurosurgery, University of PennsylvaniaSchool of Medicine, Philadelphia, PennsylvaniaArif M. Shoaib, M.D.Clinical Assistant Professor, Department of Psychiatry,University of Texas Health Science Center at Houston,Houston, TexasJonathan M. Silver, M.D.Clinical Professor of Psychiatry, New York UniversitySchool of Medicine, New York, New YorkRobert I. Simon, M.D.Clinical Professor of Psychiatry and Director, Program inPsychiatry and Law, Georgetown University School ofMedicine, Washington, D.C.Jennifer Spiro, M.S.Research Coordinator, Division of Geriatric Psychiatryand Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School ofMedicine, Baltimore, Maryland

xv iContributorsKatherine H. Taber, Ph.D.Research Health Scientist, Research and Education Service Line, Hefner VAMC, Salisbury, North Carolina; Research Fellow, School of Health Information Sciences,University of Texas Health Science Center at Houston,Houston, TexasDeborah L. Warden, M.D.Associate Professor of Neurology and Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland; National Director, Defense andVeterans Brain Injury Center, Walter Reed Army MedicalCenter, Washington, D.C.Paula T. Trzepacz, M.D.Clinical Professor of Psychiatry, University of Mississippi School of Medicine, Jackson, Mississippi; AdjunctProfessor of Psychiatry, Tufts University School ofMedicine, Boston, Massachusetts; Medical Director,U.S. Neurosciences, Lilly Research Laboratories, Indianapolis, IndianaStuart C. Yudofsky, M.D.D.C. and Irene Ellwood Professor and Chairman, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Chief, Psychiatry Service,The Methodist Hospital, Houston, TexasGary J. Tucker, M.D.Emeritus Professor, Department of Psychiatry, University of Washington School of Medicine, Seattle,WashingtonThomas N. Ward, M.D.Associate Professor of Medicine, Section of Neurology,Dartmouth-Hitchcock Medical Center, Lebanon, NewHampshireRoss Zafonte, D.O.Professor and Chair, Department of Physical Medicineand Rehabilitation, University of Pittsburgh School ofMedicine, Pittsburgh, PennsylvaniaNathan D. Zasler, M.D.Clinical Associate Professor, Department of PhysicalMedicine and Rehabilitation, University of Virginia,Charlottesville, Virginia; Concussion Care Centre of Virginia, Ltd., Pinnacle Rehabilitation, Inc., Tree of Life,L.L.C., Glen Allen, Virginia

ForewordTRAUMATIC BRAIN INJURY (TBI) is a major publichealth problem in the United States, yet it is hardly recognized and receives little support or attention from the media and policy makers. As a family, we have lived with theconsequences of TBI for many years. We know from firsthand experience the suffering and pain, the frustration anddisappointment, and the anger and grief families gothrough after TBI.Information is the key to understanding TBI andbringing about the support that people with TBI need.The cost in terms of dollars is staggering, more than 48billion per year; the costs to families and individuals withTBI are overwhelming.We decided to write this foreword for the new Textbook of Traumatic Brain Injury because it is comprehensiveand addresses the key problems of psychosocial and psychological deficits, which are the major sources of disability after TBI. We believe that a major part of the reasonTBI is not recognized as a major health problem is thelack of scientific, understandable information on the neuropsychological sequelae of TBI. There has been a lack ofappropriate education in this area for psychiatrists, forother mental health professionals, and for those involvedin the rehabilitation of persons with TBI. This text goesa long way in fulfilling this educational need.This text will help in the understanding of the complex nature of TBI and in the education of professionals,who often are not trained in treating TBI. The authorsare all well known in the field, and the topics coveredprovide a rich source of information and material all inone text.There are 40 chapters divided into seven sections covering everything from epidemiology, aggressive disorders, cognitive changes, fatigue and sleep problems,chronic pain, mood disorders, family systems, and pharmacological therapy to prevention. In other words, thistext is so full of data-based information and useful material that it is a must read for everyone involved in the careand treatment of TBI, as well as for those concernedabout training and prevention.We are grateful to Professor Jonathan M. Silver,M.D., Professor Thomas W. McAllister, M.D., and Professor Stuart C. Yudofsky, M.D., for editing and organizing this text.xviiSarah and James Brady

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PrefaceEACH YEAR IN the United States, more than three million people sustain a traumatic brain injury (TBI). In thispopulation, the psychosocial and psychological deficits arethe major source of disability to the patient and of stress tothe family. Patients may have difficulties in many vital areasof functioning, including family, interpersonal, work, school,and recreational activities. Many have extreme personalitychanges. Unfortunately, the psychiatric impairments causedby TBI often are unrecognized because of the deficiency ofappropriate education in this area for psychiatrists and othermental health professionals. Most clinicians lack experiencein treating and evaluating patients with TBI and are, therefore, unaware of the many subtle but disabling symptoms.In 1994, we edited the book Neuropsychiatry of Traumatic Brain Injury as a comprehensive data-based text toserve as a clinically relevant and practical guide to theneuropsychiatric assessment and treatment of patientswith TBI. Since that time, there has been an explosion of information in this area. We have greatly expanded our previous book and decided to change the title to Textbook ofTraumatic Brain Injury. The emphasis remains on the neuropsychiatric aspects of traumatic brain injury, and we recognize that this edition does not address all aspects of acutemanagement, neurosurgical interventions, and rehabilitation interventions. Whereas in the initial volume there wasone chapter on neuropsychiatric assessment, that chapterhas been divided into separate chapters that cover structuralimaging, functional imaging, and electrophysiologic techniques. The first volume also included a chapter on neuropsychological assessment. We realized that readers can findmany chapters and texts on this issue. Therefore, we havedecided to include a chapter that specifically addresses issuesrelevant to TBI that arise during neuropsychological assessment. All chapters covering neuropsychiatric disorders havebeen revised. To address the multiple neuropsychiatric sequelae experienced by our patients, but not encompassed bythe usual psychiatric syndromes, we included chapters reviewing apathy, awareness of deficits, fatigue, pain, headaches, balance problems, visual difficulties, and sports injuries. New chapters on social issues and systems of care areincluded. The full range of treatment modalities is discussed,including a chapter on alternative therapies.xixAs before, we have endeavored to assemble a group ofauthors who are authoritative and renowned in their areas. We hope that this book will be used by psychiatrists,neuropsychologists, clinical psychologists, physiatrists,neurologists, and other professionals, including residentsand trainees, involved in brain injury rehabilitation.We have learned from readers’ comments in our otherbooks, such as The American Psychiatric Press Textbook ofNeuropsychiatry, that few people read a textbook from coverto cover. Most read only one or several chapters during anyparticular period. Consequently, we tried to ensure th

Editorial Board Keith D. Cicerone, Ph.D. Director of Neuropsychology, JFK-Johnson Rehabilitation Institute,