The Neuropsychiatry of Complex Brain Injury Care

Lindsey Gurin, MD, discusses how clinicians can approach patients whose symptoms fall at the intersection of psychiatry and neurology. Drawing on her work with traumatic brain injury, PTSD, and persistent post-concussive symptoms, she explains why attempts to separate psychological trauma from neurological injury often obscure what patients actually need.

The conversation explores identity disruption after brain injury, the unintended effects of rigid recovery timelines, and the importance of continuity in understanding symptoms over time. Dr. Gurin also discusses how neurodevelopmental traits such as ADHD shape vulnerability and treatment response, when stimulant medications can be appropriate after concussion, and why breaking complex presentations into treatable components often matters more than assigning a single diagnosis.

Lindsey Gurin, MD, is Assistant Professor in the Departments of Neurology, Psychiatry, and Rehabilitation Medicine at NYU Langone Health, and Director of the Neurology/Psychiatry Residency Program.

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00:00 Brain Injury and Identity
01:27 What Is the Psychiatry–Neurology Double Board?
02:41 Why PTSD and TBI Overlap
03:28 What “Shell Shock” Really Means
06:00 When Concussion Symptoms Don’t Go Away
07:25 Life Before vs After Brain Injury
08:46 ADHD as a Hidden Risk Factor
10:28 Using Stimulants After Brain Injury
12:40 Rethinking “Post-Concussion Syndrome”
13:27 The Future of Neuropsychiatric Care

This episode is intended for psychiatrists and other clinicians caring for patients with complex neuropsychiatric presentations at the intersection of psychiatry and neurology.

This discussion is for educational purposes and does not substitute for individual clinical judgment or patient care.

Senior Producer: Jon Earle

Transcript

[00:00:00] LINDSEY GURIN, MD : The psychological trauma of a brain injury—there's a neurological impact, but then there's this idea of this thing that happened to me, and your identity changes, and how you make sense of the problems you're having now as opposed to before. And is there continuity of you as a person from before and after? These dynamic situations, dynamic factors, are very important and often are overlooked in people with neurological injury.

[00:00:27] CHARLES MARMAR, MD: Welcome, I'm Dr. Charlie Marmar, Chair of the Department of Psychiatry at NYU Grossman School of Medicine. I am delighted today to be in conversation with Dr. Lindsey Gurin. Dr. Gurin is an Assistant Professor in the departments of psychiatry, neurology, and rehab medicine, and a deep expert in both neurological aspects of psychiatric illness and psychiatric aspects of neurological illness. And we're very proud to say she is our director of one of America's few combined residency programs, the Double Board Psychiatry-Neurology Program, which aims to train psychiatrists and neurologists to be able to work at the interface of those disciplines with the most complex patients. Welcome, Lindsey, it's great to speak with you.

[00:01:25] LINDSEY GURIN, MD : Thank you so much. It's a pleasure to be here.

[00:01:27] CHARLES MARMAR, MD: What is the Double Board Psychiatry-Neurology Program?

[00:01:31] LINDSEY GURIN, MD : Yeah, so as you said, there are not many of these programs. NYU has one of four in the country, and this is a six-year combined residency in psychiatry and neurology. So residents are trained to be board certified in both psychiatry and neurology. We shorten the training period—instead of doing two four-year residencies back to back, you do it all in six. You're qualified to practice as a psychiatrist or neurologist, but we train our residents to practice as combined neuropsychiatrists to see, as you said, these very complex patients who have symptoms of the overlap.

[00:02:01] CHARLES MARMAR, MD: So what I was used to from my training at the University of Toronto—I'm originally Canadian—was that we have psychiatry courses for neurologists, we have neurology courses for psychiatrists, and we try to do our best. But this is a much deeper solution, which is actually to have one person have all of the deep knowledge of both disciplines and at the interface of psychiatry and neurology. Which of the very challenging patients that we care for in our psychiatric practice do you think are most relevant for the double-boarded neurologist-psychiatrist to care for?

[00:02:41] LINDSEY GURIN, MD : So there are, of course, a lot of patients who fall into that category, and we think about people with neurological problems—many of them have psychiatric issues that come with that, and neurologists are not frequently comfortable with managing those problems. Patients come to see psychiatrists who are not necessarily familiar with the neurological problems, so it gets complicated. The way I got interested in this area was in medical school I worked at a traumatic brain injury clinic at the Veterans Administration hospital and saw patients who had overlapping symptoms of traumatic brain injury and post-traumatic stress disorder—this is a clinic for people who were coming back from Iraq and Afghanistan at that time—and it was difficult to distinguish them. And the clinic basically took the position of: these are not distinguishable, these symptoms overlap, and you need a combined approach to treat them.

[00:03:28] CHARLES MARMAR, MD: You and I have a deep shared interest in the care of veterans with PTSD and TBI, and it's wonderful that was what inspired you. In a previous lifetime, I was chief at a big VA hospital in San Francisco before I was recruited to be chair here, and got very deeply interested in the problem. One of the things I was interested in as I was writing about the history of this in military psychiatry was the idea of "shell shock," and how shell shock was described in World War I. Is shell shock a psychologically shocking traumatic experience in that sense? Or is it actually the product of the physical wave of an exploding shell causing actual direct neural injury? What are your thoughts about that ambiguous term "shell shock"?

[00:04:24] LINDSEY GURIN, MD : Yeah, it's a great question, and I think what you're talking about is a particular type of traumatic brain injury—blast injury—which is particular to military populations. We can see this sometimes in other populations as well, civilians who have different kinds of injuries. But this idea of, yeah, being in that kind of dissociative state, essentially, that probably is both psychological and neurological—and the severity of that initial experience. And it does seem that blast injury probably produces that somewhat more, but that that dissociative sort of experience can carry through, of course, the rest of the disorder for some people and make it challenging to treat other problems.

[00:05:06] CHARLES MARMAR, MD: One of the challenges we have in the care of complex patients at the interface of neurology and psychiatry is—when we do the initial assessment of someone who has experienced both psychological trauma and neurotrauma of some form, how can we differentiate TBI alone from PTSD without TBI from some kind of complex mixture of PTSD and TBI when PTSD and TBI share some symptoms in common that don't allow us to say which one it might be? Are there ways to separate that so you can say, "This person is predominantly suffering from PTSD" and "This person is suffering more from TBI"?

[00:06:00] LINDSEY GURIN, MD : I think it's very hard to separate them, and that's where the combined approach really comes in. And I think as I've done this longer—I specialize in people with traumatic brain injury, and I started out seeing more severely injured patients in rehab, but my practice has shifted more to people with mild traumatic brain injury or concussion, especially people with persistent symptoms—there is this combination of both that it's hard to distinguish them. And as I've worked with these patients, I've started to see that the psychological trauma of a brain injury—there's a neurological impact, but then there's this idea of this thing that happened to me, and your identity changes, and how you make sense of the problems you're having now as opposed to before. And is there continuity of you as a person from before and after? These dynamic situations, these sort of dynamic factors are very important and often are overlooked in people with neurological injury, but the psychiatric aspects are very relevant.

[00:06:54] CHARLES MARMAR, MD: I've had the privilege of helping care for many people with these combined problems. Sometimes when the TBI component is more severe, especially, the patients refer to themselves as "V1" and "V2"—who they were before the brain injury and who they are now—and how they try to navigate that change and deal with the change in their not just capacities, which may be altered, but their identity, which may be altered in some way.

[00:07:25] LINDSEY GURIN, MD : Yeah, it's very difficult. It's interesting that "V1" and "V2"—I have not heard that terminology, but people do express that a lot, that feeling of "This is who I was, I was doing these things, I was this kind of person, and now I'm this person with a brain injury." And what's hard with concussion or mild TBI is that there's this idea you should be better in three months, right? And so if you're not better after three months, you have these problems that maybe this is a "you problem," maybe this is something going on for you that is not really neurological anymore. And these patients often see a lot of different doctors who can't make sense of the real problems that they're having, and they start to feel like, "Maybe I am this damaged person." And so that dynamic kind of begets more symptoms. And so a lot of the work I do with these patients is helping them understand the symptoms, get granular about what's really happening, and then find continuity with the person that they were before. And one interesting thing that I've started to see—and that is borne out in the literature—there's a lot of ADHD-type symptoms in these patients, but also ADHD is a risk factor for traumatic brain injury. And so sometimes people are having symptoms that are probably related to something they had before. And if you can make that continuity and help to frame the symptoms in a way that is not, "Oh, I'm brain damaged now," but is more about, "Oh, I had these problems and I had this stressor on top of it," you can start to put the sort of identity back together and move forward.

[00:08:46] CHARLES MARMAR, MD: That's extremely interesting, and I failed to mention that one of the great contributions you make to NYU Langone Health is that you're a professor in three departments: psychiatry, neurology, and rehab medicine. So you can really work across those boundaries. I think one of the problems in our field—we have so much specialization and even subspecialization within, say, neurology and psychiatry. We have Parkinson's doctors, we have depression specialists in psychiatry. As someone who started my medical career as a family doctor, I could never fathom the level of complexity and siloing of doctors from each other in these subspecialties, and the person is suffering across all of them and needs an integrated model for care. A perfect example you've raised is someone who starts with ADHD, maybe in school, and was diagnosed with ADHD. ADHD is a risk factor for persistent post-concussive symptoms after mild TBI. ADHD is also a risk factor for PTSD, and ADHD is probably a risk factor for depression. So if we're dealing with an extraordinarily complex situation where someone has a long-time history dating back to childhood or early adolescence of ADHD and has experienced psychological and neurological trauma, how do we approach the treatment to deal with the profound effects on executive functioning?

[00:10:28] LINDSEY GURIN, MD : Yeah, I think it's hard, and I would say it's even a little bit harder than you described, because often—and I think of this because a lot of my patients, I see a lot of women in my practice with these problems—and as you know, ADHD is historically underdiagnosed in women, and so often there is not a formal diagnosis. These are women who were very high-functioning and maybe had these traits but worked around them, did very well in school, and now are for the first time having these clear executive function and attention problems that when you go back, historically they were there, and you can find the features of ADHD. But I think this is a situation where making that diagnosis can be very helpful and just framing the symptoms and understanding, "This is why you're having these problems." And again, this puts you in a category of many people who are very talented and have neurodivergent ways of thinking, as opposed to thinking of yourself as irreversibly damaged, and these difficulties you're having are evidence of brain damage. In terms of treatment, I prescribe a lot of stimulants for patients with traumatic brain injuries, especially with concussion. Often with mild traumatic brain injury in particular, people have—it can have a lot of autonomic, subtle autonomic dysfunction and other features that make them sensitive to the side effects of medication. We have to be careful with those. But often stimulants can be very helpful. And I say to the rehab residents who I do teaching with, I say, "Using stimulants for someone with a traumatic brain injury is a power move," because it seems scary, but actually it's very helpful for these patients a lot of the time. It can really help both with the attention and concentration and also maybe impulsivity and emotional lability that comes with that as well.

[00:12:13] CHARLES MARMAR, MD: That's a wonderful case example and a treatment—the stimulant treatment—which is probably trans-diagnostically helpful in some way, that if the stimulants are addressing underlying executive dysfunction that would be useful in ADHD, they would be useful for some of the chronic post-concussive symptoms and maybe even for some of the chronic stress-related symptoms as well.

[00:12:40] LINDSEY GURIN, MD : Exactly. Yeah. And I think one thing that gets confusing in the literature and in clinical practice is we talk about this idea of a post-concussive "syndrome"—it's this blanket term for a lot of different symptoms that are going on or disorders, each of which might be individually treatable, but together it becomes this overwhelming sort of cloud of problems this person is having. And so what we try to do with these patients is, again, get granular about what's going on. If you're having attention problems, we can think about that. If you're having migraines—those can be treated. If you're having vertigo—maybe that's with your migraines, or maybe it's related to inner ear problems you're having since the accident. And just thinking about what are the different problems—and things become much more manageable when you break them down in that way.

[00:13:27] CHARLES MARMAR, MD: We aren't at a point in the fields of both neurology and psychiatry in which traditional treatments—let's say in the case of psychiatry, psychotherapies and pharmacotherapies—are being complemented by the new field of interventional and neuromodulation psychiatry, and of course that's very true of neurology also. What are your thoughts about the future of interventional psychiatry for the kinds of complex patients you care for?

[00:13:58] LINDSEY GURIN, MD : Yeah, I think that there is a lot of potential there. I'm very excited about a lot of the things that are coming down the pike. I think both transcranial magnetic stimulation and transcranial direct current stimulation—this is actually something that we've been using. We've used it recently in the acute rehab to help people get motor function back after injuries. And I think in the outpatient setting it can be helpful with cognitive functions. This is all still experimental. But these sort of—the idea is that these treatments can improve neuroplasticity and help with redeveloping those pathways in conjunction with therapy and meds.

[00:14:35] CHARLES MARMAR, MD: How useful do you think transcranial direct stimulation might be in the aftermath of stroke?

[00:14:42] LINDSEY GURIN, MD : So actually useful, surprisingly. And I'll say, without giving specific patient information, we had a patient recently in rehab where we were using this for somebody who had a subcortical stroke. Transcranial direct current stimulation really affects the cortex, but this person had a deeper injury that we were able to—our amazing tDCS team here was able to address. And what we did there, what they did, was pair stimulation of motor cortex and the dorsolateral prefrontal cortex to improve initiation behavior and paired that with physical therapy. And we saw improvements after that was added. And so, I think that was a more severe case and I think shows that there's potential for this, and especially in milder cases.

[00:15:37] CHARLES MARMAR, MD: And would you say that the underlying mechanism of change is in part creating greater neuroplasticity for new learning?

[00:15:46] LINDSEY GURIN, MD : Yes, I think so. And I think that the rationale for how this was done was creating more plasticity at the cortical level that then drove neural repair and regeneration further downstream.

[00:16:01] CHARLES MARMAR, MD: And it seems to me, Lindsey, as psychiatry, as neuropsychiatry, as molecular neuropharmacology and neurocircuit psychiatry matures, and our understanding of genomic influences on brain circuitry and so on develops, that the fields of neurology and psychiatry, which were once much closer together and then became siloed, should in general come together more, and that your double board program becomes even more relevant. What are your thoughts about that?

[00:16:34] LINDSEY GURIN, MD : I couldn't agree more. I think this is so true, and we work on the same organ and yet have different words for talking about things and different perspectives on the disorders. I think that as we move forward, we're getting more knowledge of the brain bases of these disorders. I think we will be able to have a closer connection with neurology. At the same time, I think the psychiatrist is always going to be extremely important in these cases, because I think, as we said at the beginning, the importance of maintaining the person at the center, and having a psychiatrist who sees the person who has the disorder and not just the disorder itself is really, I think, the most important thing to helping these people recover.

[00:17:12] CHARLES MARMAR, MD: Thank you, and thank you for the wonderful work you're doing every day. And one thing that we're particularly proud of at NYU is we have a very deep bench in neuropsychiatry. We have a large—I think the largest—number of double-board psychiatrist-neurologists on our faculty of any major medical school in the country, which positions us very well to care for the patients that present enormous challenges, not just in psychiatric practice, but I think in neurological practice also—a kind of a sweet spot to fill that gap. And you've been a wonderful leader in that, both as a fantastic clinician but also in your training role. So thank you so much for all these tremendous contributions.

[00:18:02] LINDSEY GURIN, MD : Thank you so much for having me. And yes, I feel fortunate to be here at NYU.