HOW TO TREAT PERSONALITY AND BEHAVIORAL DISORDERS DUE TO BRAIN DISEASE, INJURY, AND DYSFUNCTION 2025

HOW TO TREAT PERSONALITY AND BEHAVIORAL DISORDERS DUE TO BRAIN DISEASE, INJURY, AND DYSFUNCTION 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 6

PERSONALITY AND BEHAVIORAL DISORDERS DUE TO BRAIN DISEASE, INJURY, AND DYSFUNCTION

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

Doctor Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 6

PERSONALITY AND BEHAVIORAL DISORDERS DUE TO BRAIN DISEASE, INJURY, AND DYSFUNCTION

I. DEFINITION  

Changes in personality and behavior may occur as residual or concurrent disorders associated with brain disease, injury, or dysfunction. A personality change implies a fundamental alteration in a patient’s habitual activities and responses. When such a change manifests in adulthood, brain pathology should be suspected.

II. ETIOLOGY  

– Conditions specifically affecting the frontal lobes or subcortical structures often present with prominent personality changes.  

– Traumatic brain injury is a common cause, as are tumors (e.g., frontal lobe meningiomas or gliomas).  

– Progressive dementias, particularly those with degenerative features, such as vascular dementia, AIDS-related dementia, Huntington’s disease, and leukodystrophies.  

– Exposure to toxins, including radiation, can also induce significant personality alterations.

III. DIAGNOSIS  

1. Clinical Features  

Significant deviations from a patient’s pre-illness behavioral patterns are observed, with particular impairment in the expression of emotions, needs, and impulses. Cognitive functions may be broadly deficient or specifically impaired in planning and anticipating personal or social consequences, as seen in the so-called “frontal lobe syndrome.” However, it is now recognized that this syndrome can arise from damage beyond the frontal lobes to other discrete brain regions.  

Behaviorally, key symptoms include depression, increased impulsivity, and heightened aggression, potentially leading to substance abuse, noncompliance with rules, or criminal behavior.

2. Ancillary Testing  

Laboratory tests, imaging, and psychological assessments aid in identifying etiology, differentiating conditions, monitoring treatment, and predicting prognosis.  

– Basic Laboratory Tests:  

+ Blood tests: Hematology, liver and kidney function, electrolytes, creatine phosphokinase (CPK).  

+ Urinalysis.  

+ Drug screening.  

+ Syphilis serology, HIV testing.  

+ Cerebrospinal fluid (CSF) analysis.  

– Imaging and Functional Studies:  

+ Chest X-ray, abdominal ultrasound.  

+ Electroencephalogram (EEG), electrocardiogram (ECG), cerebral blood flow studies, transcranial Doppler ultrasound.  

+ Brain CT, MRI.  

– Psychological Assessments:  

+ Personality tests: Eysenck Personality Inventory (EPI), Minnesota Multiphasic Personality Inventory (MMPI).  

+ Emotional assessments: Anxiety (Zung, HAM-A), depression (Beck, HAM-D).  

Diagnostic Criteria for F07 Disorders (ICD-10):  

– G1. Objective evidence (from neurological exam or testing) and/or history of brain disease, injury, or dysfunction.  

– G2. No clouding of consciousness or severe memory impairment.  

– G3. Insufficient evidence of an alternative etiology for the behavioral or personality disorder warranting classification under F60-F69.  

1) Organic Personality Disorder (F07.0)  

Characterized by significant changes in pre-illness behavioral patterns, with notable impairment in emotional expression, needs, and impulses.  

– Definitive Diagnosis: Requires two or more of the following:  

+ Markedly reduced ability to sustain goal-directed activities.  

+ Emotional instability: Shallow, inappropriate cheerfulness (euphoria, inappropriate jocularity), easily shifting to irritability, short bursts of anger, or aggression; apathy may predominate in some cases.  

+ Expression of needs and impulses without regard for consequences or social norms (e.g., antisocial acts like theft, inappropriate sexual advances, overeating, or neglect of personal hygiene).  

+ Cognitive disturbances: Suspiciousness, paranoid ideation, or excessive preoccupation with abstract themes (e.g., religion, morality).  

+ Impaired speech: Slowed tempo, circumstantiality, over-inclusiveness, perseveration, or verbosity.  

+ Sexual dysfunction or altered sexual preferences.  

– Subtypes: Frontal lobe syndrome, limbic epilepsy personality syndrome, post-lobotomy syndrome, organic pseudopsychopathy, organic pseudoretardation, post-leukotomy syndrome.  

2) Post-Encephalitic Syndrome (F07.1)  

A residual behavioral change following recovery from viral or bacterial encephalitis. Symptoms are non-specific, varying by individual, pathogen, and age at infection.  

– Differs from organic personality disorder by its potential reversibility.  

– Features may include malaise, apathy or irritability, mild cognitive decline (learning difficulties), poor sleep, reduced appetite, altered sexual behavior, and impaired social judgment. Residual neurological deficits (e.g., paralysis, deafness, aphasia, apraxia, acalculia) may coexist.

3) Post-Concussion Syndrome (F07.2)  

Follows head trauma severe enough to cause loss of consciousness, presenting with diffuse symptoms:  

– Headache, dizziness (often without true vertigo).  

– Fatigue, irritability, difficulty concentrating or performing mental tasks, memory impairment, insomnia.  

– Reduced alcohol tolerance.  

– Decreased stress or emotional tolerance.  

– Secondary depression or anxiety due to loss of confidence and fear of permanent brain damage.  

– Definitive Diagnosis: Requires at least three of the above features.  

– Emotional distress exacerbates primary symptoms, creating a vicious cycle. Some patients become hypochondriacal, seeking diagnoses and adopting a chronic sick role, irrespective of compensation claims.  

– Subtypes: Post-contusional syndrome (encephalopathy), non-psychotic post-traumatic syndrome.  

– Objective tests (EEG, brainstem evoked potentials, brain imaging, nystagmography) may provide evidence, but results are often negative.

4) Other Organic Personality and Behavioral Disorders Due to Brain Disease, Injury, or Dysfunction (F07.8)  

Brain pathology may cause diverse cognitive, emotional, personality, and behavioral disorders not fully classifiable under F07.0-F07.2. Due to uncertain nosology, these are coded as “other.”  

– Includes distinct syndromes presumed to result from brain pathology but differing from F07.0-F07.2, and mild cognitive deficits not yet meeting dementia criteria in progressive disorders (e.g., Alzheimer’s, Parkinson’s), reclassified if dementia criteria are later met.

5) Unspecified Organic Personality and Behavioral Disorder Due to Brain Disease, Injury, or Dysfunction (F07.9)  

– Includes organic psychiatric syndromes not otherwise specified.

IV. TREATMENT  

1. Treatment Principles  

– Address the underlying brain-related cause as the primary focus.  

– Some disorders (e.g., post-encephalitic, post-concussion) may be reversible, making supportive care and monitoring critical.  

– Personality and behavioral changes often persist as organic sequelae, requiring patient management and education alongside treatment.

2. Treatment Framework  

Target secondary personality syndromes by addressing the underlying etiology first.

3. Specific Treatments  

3.1. Pharmacotherapy  

3.1.1. Cognitive Symptom Management  

Options:  

– Donepezil: 5-23 mg/day;  

– Rivastigmine: 1.5-12 mg/day (oral or transdermal);  

– Galantamine: 8-24 mg/day.  

Cognitive enhancers:  

– Cerebrolysin: 10-20 mL/day;  

– Ginkgo biloba: 80-120 mg/day;  

– Piracetam: 400-1200 mg/day;  

– Citicoline: 100-1000 mg/day;  

– Choline alfoscerate: 200-800 mg/day;  

– Vinpocetine: 5-100 mg/day.  

3.1.2. Antipsychotics  

For delusions, hallucinations, agitation: Options (1-3 agents):  

– Risperidone: 1-10 mg/day;  

– Quetiapine: 50-800 mg/day;  

– Olanzapine: 5-30 mg/day;  

– Clozapine: 25-300 mg/day;  

– Aripiprazole: 10-30 mg/day;  

– Haloperidol: 0.5-20 mg/day.  

3.1.3. Antidepressants  

For depression: Options (1-3 agents):  

– Amitriptyline: 25-150 mg/day;  

– Sertraline: 50-200 mg/day;  

– Citalopram: 10-40 mg/day;  

– Escitalopram: 10-20 mg/day;  

– Fluvoxamine: 100-200 mg/day;  

– Paroxetine: 20-50 mg/day;  

– Fluoxetine: 10-60 mg/day;  

– Venlafaxine: 75-375 mg/day;  

– Mirtazapine: 15-60 mg/day.  

3.1.4. Mood Stabilizers  

Options:  

– Valproate: 200-2500 mg/day;  

– Divalproex: 750 mg/day to 60 mg/kg/day;  

– Carbamazepine: 100-1600 mg/day;  

– Oxcarbazepine: 300-2400 mg/day;  

– Lamotrigine: 100-300 mg/day;  

– Levetiracetam: 500-1500 mg/day.  

3.1.5. Anxiolytics  

For anxiety, as needed:  

– Diazepam: 5-20 mg/day;  

– Bromazepam: 2-6 mg/day;  

– Zopiclone, zolpidem, zaleplon.  

– Beta-adrenergic antagonists (e.g., propranolol: 10-80 mg/day) may also be effective.  

– Supportive Medications: Hepatic support (aminoleban, silymarin, boganic, branched-chain amino acids); nutritional supplements (vitamins, minerals, balanced diet, IV nutrition).

3.2. Psychotherapy  

– Direct: Family therapy, individual psychotherapy.  

– Indirect:  

+ Ensure a safe environment for the patient and others;  

+ Maintain a quiet setting, minimizing stimuli;  

+ Promote sleep hygiene;  

+ Educate families on caregiving and nutrition.  

3.3. Physical and Occupational Therapy  

– Collaborate with rehabilitation specialists.  

– Goals: Restore motor function, provide speech therapy for language recovery.  

3.4. Management of Comorbid Conditions  

– Support daily activities (e.g., bathing, hygiene) to prevent complications from prolonged immobility and enhance quality of life.

V. PROGNOSIS AND COMPLICATIONS  

1. Prognosis  

Personality and behavioral disorders are often chronic sequelae of organic causes, making treatment challenging and prolonged. Prognosis worsens with multiple comorbidities or severe brain/systemic disease, particularly regarding care needs.

2. Complications  

– Related to the underlying condition (e.g., infections, trauma), requiring monitoring and control.  

– Behavioral impulsivity, aggression, or destructiveness may lead to severe consequences, necessitating careful management.

VI. PREVENTION  

As these disorders primarily stem from brain or systemic pathology, prevention involves improving overall health through exercise, nutrition, and balanced lifestyle habits. Early intervention for brain disorders and timely recognition of personality/behavioral changes are critical for effective management.

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