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Neurological Rehabilitation

Management of Agitation during Acute Inpatient Rehabilitation in a Chronic TBI Patient with Premorbid Psychiatric Disorders: A Case Report

Thursday, October 23, 2025
5:00 PM - 6:30 PM MT
Location: Open Kiosks

    Primary Author(s)

  • Lance Reccoppa, MD

    Resident Physician
    University of Miami/Jackson Health System PM&R Program
    Miami, Florida

    • Poster Presenter(s)

  • Reid McCullough, DO

    Resident Physician
    University of Miami/Jackson Health System PM&R Program
    Miami, Florida

    • Co-Author(s)

  • ZH

    Zeeshan Haque, MD

    Brain Injury Medicine Fellow (PGY-5)
    University of Miami/Jackson Health System PM&R Program
    Miami, Florida

  • GA

    Gemayaret Alvarez, MD

    Associate Professor
    University of Miami Health System
    Miami, Florida

Disclosure(s):
Reid McCullough, DO: No financial relationships to disclose
Zeeshan Haque, MD: No financial relationships to disclose
Case Diagnosis: Agitation in a chronic TBI patient with a premorbid diagnosis of dissociative identity disorder and bipolar disorder.

Case Description or Program Description: A 39-year-old woman with a history of dissociative identity disorder, bipolar disorder, and a motor vehicle accident about 18 months prior was admitted to an acute inpatient rehabilitation center after the removal of an infected baclofen pump. Upon arrival, the patient exhibited an intensely paranoid expression, excessive yelling, self-harming behaviors by hitting herself in the chest, and noncompliance with therapies.

Setting: Acute Inpatient Rehabilitation

Assessment/Results: The patient was admitted on propranolol, sertraline, and amantadine. Throughout the rehab stay her propranolol and sertraline were increased, while amantadine was discontinued due to her mental status. However, her agitation persisted. Therefore, with psychiatry’s input, the additional agents of valproic acid and quetiapine were added and given in conjunction with one another. Following this medication adjustment, the patient's agitation significantly improved, allowing for enhanced participation in rehabilitation.

Discussion (relevance): Management of agitation in TBI patients with pre-existing psychiatric disorders requires a multi-modal approach, combining pharmacological interventions with a strong interdisciplinary team effort. The medications used for mood and agitation in TBI lack overwhelming evidence, so different medications were trialed, and her symptoms were monitored closely. The patient had a prolonged inpatient rehabilitation stay, which allowed for a stable regimen to be established under close monitoring. The timely co-administration of quetiapine and valproic acid remarkably affected the patient’s clinical presentation and participation towards the end of her rehabilitation stay

Conclusions: This case highlights a challenging case of agitation in the acute inpatient rehabilitation setting. Valproic Acid, sertraline, quetiapine, and propranolol proved beneficial in this case and warrant further consideration for management in the setting of premorbid psychiatric disorders.