If gold and diamonds are metaphors for sinew and muscle, Mrs. Helen Harcourt could have been an Olympic weight lifter. Bejeweled and attired in an opulence more appropriate for the coronation of English royalty than a visit to a commoner doctor, she nonetheless appeared anxious and vulnerable. “I must apologize for my husband’s not coming,” she lamented. “He changed his mind at the last minute.” Mrs. Harcourt acknowledged that her husband neither trusted nor liked psychiatrists. (Names and details of the case have been changed to protect the patient’s privacy.)

“Has he ever ‘seen’ a psychiatrist?” I inquired.

“No. But for many years before his skiing accident, I had asked him to go with me for couples counseling, but he always refused,” she replied.

Eighteen months prior to his scheduled meeting with me, Mr. Harcourt, the president and CEO of an international energy company, was seriously injured while helicopter skiing in British Columbia. Not wearing a helmet, he suffered severe brain injury when he careened at high velocity into an ice-hardened snow bank. After three weeks he emerged from coma with manifestations of prefrontal and left-brain injury including right hemiparesis, a severe expressive aphasia, and neuropsychiatric symptoms including impulsivity, impaired social judgment, affective lability, and depression. His intellect and cognition were spared. Over the next year and a half, he worked diligently with his team of rehabilitation professionals and made excellent progress with articulated speech and ambulation. Nonetheless, Mr. Harcourt spent most of his time at home where he would have temper tantrums elicited by seemingly minor frustrations in which he would scream expletives and throw and break objects. He reacted especially vehemently to Mrs. Harcourt’s efforts to assist him when he lost his balance and fell.

Mr. Harcourt met criteria for the following DSM-IV-TR diagnoses:

• Axis I: (293.83) Mood disorder due to traumatic brain injury with a major depressive-like episode; and (301.1) personality change due to traumatic brain injury, aggressive type

• Axis II: (301.81) Narcissistic personality disorder

His major depression responded to antidepressant treatment, as did his irritability and episodic dyscontrol to a combination of a lipid soluble beta-blocker and an anticonvulsant. To Mrs. Harcourt’s surprise, her husband became engaged in intensive, psychodyamically oriented psychotherapy. He gained insight into how his emotional responses to his critical, detached father and enveloping mother were directly related to his low self-esteem, constrained capacity for intimacy, poor quality of relationships, and impaired psychological adjustment to the physical limitations associated with traumatic brain injury (TBI).

As highlighted in bold below, the case of Mr. Harcourt illuminates five principles about the care of patients (and their families) in which TBI is complicated by a personality disorder.

• For a multiplicity of reasons, the comorbidity of personality disorders and TBI is common.  First, both conditions are highly prevalent. According to the Centers for Disease Control and Prevention, each year approximately 1.7 million people sustain traumatic brain injuries that result in 52,000 deaths, 275,000 hospitalizations, and 1,365,000 hospital visits. For many of the millions of survivors of TBI, there are chronic sequelae. The median prevalence of published studies of all personality disorders ranges from 11.55 percent to 12.26 percent, with narcissistic personality disorder comprising only about 0.61 percent of the population.

  Second, personality disorders can increase the risk for sustaining TBI, with examples including impulsivity, recklessness, irritability, and aggressiveness leading to physical altercations for people with antisocial personality disorder.

• TBI often intensifies the symptoms related to personality disorders and the associated reluctance to accept help and support from family members and mental health professionals. 

• The suddenness and multifarious deleterious consequences of TBI and many other neuropsychiatric disorders almost invariably place enormous stress on family members and caregivers of the patient.  When TBI occurs in the context of personality disorder, the familial and caregiver relationships with the patient are exceedingly complex. Interventions must be understood and effected in the context of the nature of the pre- and post-TBI relationships, which will be significantly influenced by the patient’s personality disorder.

• Given the complexities involved in the neuropsychiatric manifestations of brain injury complicated by personality disorder, it is essential that the psychiatrist be eclectic and flexible in treatments provided.  In the case of Mr. Harcourt, I provided psychopharmacology; individual, supportive, and insight-oriented psychotherapy for both him and his wife; neuropsychiatric counseling/education (related to brain-based aspects and implications of TBI) for him and his family; couples counseling; and family counseling.

• Psychiatric treatment of patients with both TBI and a personality disorder is effective.  Prior to his psychiatric care, Mr. Harcourt was severely impaired by the concomitants of TBI and narcissistic personality disorder, which also adversely affected his wife and children. The patient and the family unit were failing. The symptoms and signs of his mood disorder and organic dyscontrol responded within two months to psychopharmacological treatment. Couples counseling with Mr. and Mrs. Harcourt helped to reduce power struggles, identify and agree on strategies to reduce his risk-taking behavior, and avoid the unwieldy consequences of his maternal transference to his wife. Finally, individual psychotherapy of Mrs. Harcourt enabled her to understand the reasons for her vulnerabilities to entering and remaining in an exploitative demeaning relationship and how to change in ways that enabled independent growth and actualization of her potential and goals. At this time Mrs. Harcourt reports feeling “happy and successful as a wife, mother, and graduate student in neuroscience.” Interestingly, she tells me that she almost never wears jewelry these days.

Stuart C. Yudofsky, M.D., is the D.C. and Irene Ellwood Professor and Chair of the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He also holds the Drs. Beth K. and Stuart C. Yudofsky Presidential Chair in Neuropsychiatry, serves as the chair of the Department of Psychiatry at Methodist Hospital, and is editor of the Journal of Neuropsychiatry and Clinical Neurosciences. He is the author of Fatal Flaws: Navigating Destructive Relationships With People With Disorders of Personality and Character and, with Robert E. Hales, M.D., is coeditor of the Clinical Manual of Neuropsychiatry. APA members may purchase these books at a discount at www.appi.org.