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Dr. Kant
The NeuroPsychiatry CenterBRAYDEN BROSKY, DNP, PMHNP-BC 13 Feb 2025, 12:49 am
Brayden Brosky, DNP, PMHNP-BC is a board-certified Psychiatric Mental Health Nurse Practitioner who joined Neuropsychiatry Center in 2024. He earned his Doctor of Nursing Practice (DNP) from Robert Morris University in 2024, building upon his foundational education from the University of Pittsburgh and Duquesne University.
With a diverse background in health care, Brayden has developed a comprehensive skill set in diagnosing and treating a wide range of psychiatric conditions. He is committed to employing evidence-based treatment strategies, while always maintaining a compassionate, empathetic approach. His focus is on creating a therapeutic environment where patients feel genuinely heard, understood, and supported throughout their mental health journey.
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LAUREN NEDZELSKI, PA-C 11 Dec 2023, 1:40 pm
Lauren Nedzelski, PA-C is a certified Physician Assistant who joined NeuroPsychiatry Center in 2023. She is a graduate of Duquesne University and earned her Master of Physician Assistant Studies from Chatham University in 2020.
She has had training in multiple specialties, including psychiatry in both the outpatient and adolescent inpatient settings, in addition to providing healthcare for underserved communities. Lauren is a native to the area and is dedicated to serving individuals in her community. Her passion lies in empowering patients with knowledge of their diagnosis and treatment options in order to create a plan together that maximizes their quality of life.
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SAMANTHA GIMIGLIANO, LPC 3 Mar 2023, 6:58 pm
Samantha Gimigliano is a Licensed Professional Counselor. She received her bachelor’s degree in social work and her master’s degree in Community and Agency Counseling from California University of Pennsylvania. Samantha has worked in a variety of clinical settings including a residential treatment facility, drug and alcohol rehabilitation and halfway house, adventure-based, in-home, school-based and private practice therapy. Samantha’s approach to counseling is both holistic and client centered. Samantha believes in creating healthy and realistic habits, coping, and communication skills to incorporate into everyday life to build a client’s self-esteem and focus on self-care. Samantha works alongside her 9 month old Newfypoo Homer, a therapy dog in training.
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RACHEL SHUBA, LPC 10 Feb 2016, 8:46 pm
Rachel Shuba is a Licensed Professional Counselor and Nationally Certified Counselor. She received her bachelor’s degree in psychology and her master’s degree in Community and Agency Counseling from California University of Pennsylvania. She has worked in a variety of clinical settings since 2006.
Rachel’s approach to therapy is both holistic and client centered. She is dedicated to continued education and research in cutting edge treatments such as EMDR which enables her to provide best practices for her clients. The treatment methods that she uses assist in resolving relational issues, ADHD, depression, anxiety, and trauma related issues (PTSD) in the clients she works with at NeuroPsychiatry Center.
Eye Movement Desensitization Reprocessing (EMDR)
Rachel was formally trained by the EMDR Institute and has been utilizing EMDR in therapy since 2018.
EMDR is a psychotherapy that enables individuals to heal from the symptoms of emotional distress that are the result of disturbing life experiences. The goal of EMDR, as a trauma therapy, is to form new connections between the unprocessed memory (trauma) and the more adaptive information that are contained in other memory networks. EMDR focuses directly on all the perceptual components of disturbing memories such as imagery, cognition, affect and body sensations and maintains these in a dynamic state while the patient simultaneously engages in bilateral stimulation (eye movements). Research has shown the eye movements decrease the vividness and intensity of these disturbing memories.
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Apathy Syndrome 18 Nov 2014, 4:33 pm
Apathy syndrome after head injury and treatment outcomes
Ravi Kant, M.D.
Emotional and personality changes are common after head injury. Aggression and irritability are frequently reported but apathy is also noted to cause significant disability. Apathy is at times mistaken for depression. We conducted a study to estimate the prevalence of apathy after head injury in a clinical population and response to treatments. Apathy Evaluation Scale-Self (AES-S) and Beck Depression Inventory (BDI) were used at initial evaluation and follow up visits in 83 patients with CHI- 73.5% male; mean age 38+12.27; 74.7% mild CHI. Family members completed the informant version – AES-I. Ten patients were treated for apathy syndrome with methylphenidate. Of the 83 patients, 9 (10.84%) were apathetic without depression and same number were depressed without apathy. 50 (60.24%) were both depressed and apathetic while 15 (18.07%) had neither. Family members rated patients significantly higher on AES (p.000001). Younger age (p.04) and higher severity of injury (.01) correlated with apathy.
AES scores improved after treatment for twelve weeks with methylphenidate in ten patients (p.004). Similar change in AES – I scores was noted (p.01). BDI scores did not change (p.227). These gains were maintained on long term treatment (Ave. 11 months). We believe apathy is a frequent symptom after CHI and it responds well to dopaminergic agents. It appears to be an independent entity, but may co-exist with depression.
(Submitted for publication)
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Apathy Secondary to Neurologic Disease 18 Nov 2014, 4:31 pm
Apathy secondary to neurologic disease
James D Duffy and Ravi Kant
The phenomenology and treatment response of secondary psychiatric disorders provides a valuable model for exploring the pathophysiology of primary psychiatric disorders. This article provides a broad overview of (1) case reports that have applied a “lesion analysis” approach in studying apathy and related disorders of diminished motivation (ADDM) and (2) studies that have used standardized assessments of apathy in well-defined populations of patients with neurologic disorders. This rapidly expanding clinical database provides a valuable resource for defining the neural substrates of motivation and its clinical disorders. Psychiatric Annals 27:1/January 1997
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Prevalence of Apathy – Head Injury 18 Nov 2014, 4:30 pm
Although several studies have examined the demographics of mood disorders and personality changes following closed head injury (CHI), there are no studies that address the prevalence of apathy after CHI. Utilizing standardized evaluation tools, this study examines the prevalence of apathy in 83 consecutive patients seen in a neuropsychiatric clinic. A total of 10.84% had apathy without depression while an equal number were depressed without apathy: another 60% of patients exhibited both apathy and depression. Younger patients were more likely to be depressed and apathetic. Patients with severe injury were more likely to exhibit apathy alone. Family members rated the patients higher on apathy scale. These findings suggest that apathy is a frequent symptom after head injury and may occur either alone or in association with depression.
Brain Injury, 1998, vol. 12, No. 1, 87-92.
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Post Concussion Syndrome 18 Nov 2014, 4:27 pm
More than two million closed head injuries (CHI) occur in this country in a year.Earlier studies had estimated the incidence rate of about 220/100,000 persons (1). Recent study by Sosin et al. (1996) estimates the incidence of mild to moderate head injury to be about 610/100,000 persons per year in a non-institutionalized population (2).This is almost three times what the earlier studieshave indicated. The earlier studies were based on retrospective reviews of hospital records. The highest rate ofCHI is for males at all ages (except 75 years and older) and peak rates are noted for males aged 15 – 24,rate for males being twice as high as that for females. The ratio of males to females decreases to nearly 1:1 after age 75 because mostof head injuries occur due to falls. The most common causes of CHI are motor vehicle accidents (MVA) (42%) and falls (20%).In almost 50% of head injury cases, intoxication is a contributing factor (1). About 85% ofCHIs are classified as mild. The rate of injury is inversely correlated with family income, the highest rates being in the lowest income group and were more often caused by MVA or assaults (3).
Mechanism of injury and pathophysiology CHI causes trauma to the muscles, bones, ligaments, blood vessels, nerves in the neck and head in addition to an injury to the brain. All CHIs do not necessarily involve trauma to the brain. There are multiple physical forces involved, in addition to the neuro-chemical changes in the brain, which determine the severity of injury. The physical forces impacting on the brain include direct trauma to brain, coup-counter coup injury, rotational forces, pressure gradients, stretching of brain stem and spinal cord, changes in intra-cranial pressure, cerebral edema, contusions, and hemorrhages.CHI causes shear strain and diffuse axonal injury to the brain and hence, producing “multi-system” neurobehavioral symptoms. Frontal lobes are the most common site of injury (4) and temporal lobes are the next common site. Cerebral contusions and hematomas can be seen even after mild head injury. Severity of head injury is usually determined by Glasgow Coma Scalescore (GCS) (5) (Mild – GCS score of 13 – 15; Moderate – GCS score of 9 – 12, and Severe – GCS score of8). Clinical Features
Common post concussion syndrome symptoms are physical, emotional, and cognitive(see table 1). Headache, sleep disturbance, dizziness, irritability, anxiety, cognitive slowing, difficulty in handling information, and short term memory problems (manifesting as forgetfulness, misplacing things, difficulty in learning new materials etc.) are commonly seen. Most of these symptoms abate in a few weeks to three months. In about 50% of patients, a few symptoms may persist beyond six months and about 10 -20% patients may go on having Persistent Post-Concussion Syndrome ( PPCS) i.e. two or more symptoms persisting beyond one year (6). These patients need comprehensive neuro-psychiatric evaluation and treatment focussed on head injury and its associated symptoms for proper rehabilitation and return to work.
Following are some of the common neuropsychiatricconditions seen after closed head injury.
Headache
Headache is the most common complaint after CHI. It is reported to have a greater frequency and duration after mild CHI compared to moderate or severe head injury. Cause for post- traumatic headaches is multi-factorial. These factors include soft tissue injury, neuroma formations, tissue scarring, entrapment of nerves in bony or fibro-muscular tissues, direct injury to nerves such as greater occipital nerves, vascular, and myofacial injuries. Post-traumatic headachesare of multiple types, and patients usually have more than one type. Essentially all types of headaches could be seen after CHI.Following types of headaches are commonly seen after CHI-migraine, tension-type, occipital neuralgia, cervicogenic, basilar artery migraine, and dysesthesia due to posterior cervical sympathetic nerve injury. Detailed history should be taken to evaluate the headaches and look for psychological and social factors, including legal issues. Treatments should be based on the type of headache and also eliminating or minimizing the exacerbating factors.Psychological and legal issues should be addressed as needed. Avoid use of narcotics and other medications with addicting potentials.
Depression
Depression is reported in 25 to 50% of patients after head injury (7).It is one of the most disabling conditions after head injury that the patients experience. Depression negatively affectsthe family and social relationships. It also have impact on cognitive functioning and ultimately delays return to premorbid level of funtioning. Depressed patients cannot effectively participate in rehabilitation services. There is some controversy about the underlying cause- whether it is psychogenic, biological, or both. The frontal lobes are the most common site of injury to the brain after a CHI (4) and frontal lobe dysfunction is commonly seen in patients with endogenous depression. Other factors contributing to depression may be physical, social, and cognitive changes following injury which include headaches, insomnia, inability to work, dependency, social withdrawal, discouragement, and demoralization along with cognitive difficulties described above. Because of all of these changes going on concurrently, it is difficult to separate biological from psychogenic factors. There may be a difference in the degree of contribution of these factors in each patient and at different stages of recovery.
Anti-depressants and other treatment modalities can be used for treatment of depression including electroconvulsive therapy (ECT). ECT has been effective in treating depression after head injury. We have successfully treated 13 such patients with ECT (8,9). In some cases, depression becomes chronic, refractory, and is difficult to treat. Careful attention should be paid in selecting an anti-depressant because of their cognitive side effects. Anti-cholinergic side effects of the tricyclic anti-depressants (cause dry mouth, constipation etc.)can impair memory, concentration, and attention span.
Anxiety
Anxiety is another common condition seen after head injury.There are no prospective studies to estimate the incidence of anxiety syndromes, but it has been reported to occur in 10 to 50% of patients.Generalized anxiety manifests as fearfulness, worry, persistent tension, and intense feeling of anxiety.Obsessive-compulsive behaviors have been seen, at times manifesting as a full-blown syndrome of an obsessive-compulsive disorder (10). At times, a person may have a catastrophic reaction to an acute situation. Post traumatic stress disorder (PTSD) is also seen in some patients, especially those who did not lose consciousness.PTSD in itself can lead to symptoms of depression, cognitive deficits, behavior changes such as anger and irritability, and somatic symptoms of sleep and appetite disturbance. Treatment usually involves educating the patient and the family, providing a supportive environment, and at times medication.Anti-anxiety medications should be selected very carefullybecause of their potential of dependance and worsening of cognitive deficits.
Personality Change Personality changes are one of the most significant problems seen after head injury. Family members frequently complain that the patient is a totally changed person after the injury. Sometimes this is an exacerbation of a person’s pre-morbid personality traits. Some patients become aggressive and disinhibited on one extreme while others may become apathetic and lack initiative on the other extreme. Apathetic patients look depressed and hence mistakenly treated with antidepressants. We conducted a study to estimate the incidence of apathy after CHI. We found that apathy occurs in about 11% of patients seeking treatment for neuro-psychiatric problems after head injury (11). At times patients become very labile and paranoid, and some patients develop childish behavior. These extreme changes are seen after moderate to sever CHI. Personality changes can also be secondary to temporal or frontal lobe seizures. Some of these symptoms can be treated by behavior modification and medications, while for others, patient and family education and environmental changes are needed.
Cognitive Deficits
Cognitive changes involve problems with short-term memory, attention, concentration, information processing, difficulty making decisions, and executive functioning. Long term memory usually remains intact after mild to moderate CHI. Patients are forgetful about simple things such as telephone numbers, names, faces, and daily tasks. They get confused in over stimulating environments such as malls, large grocery stores, and large crowds. Patients have difficulty learning new materials. This in itself causes a lot of frustration, anger, and other emotional difficulties. At times, it is difficult to carry out simple tasks because of executive dysfunction. This leads to despondency, self-doubt, and frustration.Treatment of underlying conditions such as depression, anxiety, insomnia, chronic pain etc. improves the cognitive status. Some patients may need cognitive retraining and/or medication interventions for improving their cognitive status.
Psychosis
Perceptual changes are commonly seen in the early phase of brain injury, especially in the subacute phase.However, psychotic symptoms can also happen a few months to many years after the injury. It can manifest as hallucinations, delusions, paranoia, or any other perceptual disturbances.Sometimes psychotic symptoms are secondary to temporal lobe seizures. Overall, incidence of perceptual disturbances is very low, except for in the acute and sub-acute phase.
Other Some unusual or late sequelae ofclosed head injury include anosmia, chronic pain syndrome, seizures, endocrine disorders due to injury to hypothalamic – pituitary axis,dystonia,hydrocephalus, cortical atrophy, aneurysms, sleep-wake cycle alteration(12), movement disorders including hemiballismus (13),and somatization disorders. Clinicians should be aware of these conditions and should not label the patient as malingering or having conversion reaction without proper evaluation.
Treatment
Wait and see approach should be employed in the first few weeks after injury except for conservative symptomatic treatments for pain and insomnia. Patients with continued disabling symptoms of cognitive, behavioral, or emotional changes four weeks or so after injury or if symptoms are getting worse, should be referred for comprehensive neuro-psychiatric evaluation. It is very important to establish the baseline severity of symptoms early and follow the progression of symptoms. It is especially important in patients with mild head injury because their primary disability usually arises from neuro-psychiatric symptoms.
Evaluation should be done by someone who is familiar with and have experience in evaluating and treating patients with head injuries. Comprehensive evaluations may include neuro-psychiatric evaluation, neuro-psychological testing, neuro-imaging such as MRI and/or SPECT scan of brain, EEG, and neuro-rehabilitation evaluation. Also, assess for individual and/or familytherapy, cognitive retraining, chronic pain program, and vocational retraining.
Treatment process involves educating the patient and his/her family members, on-going evaluations, and comprehensive treatment strategies which may involve identifying and treatingphysical, emotional, cognitive, and neurological symptoms. Appropriate referrals to neuro-psychology, rehabilitation, and neurology should be considered. Careful selection of medications is very important as some of the commonly used medications can have significant negative effects on the motor and/or cognitive recovery process. Outcome measures should be utilized to measure the baseline severity of symptoms, progression, and response to treatments.
Prognosis
Following factors favor good outcome – young age, no past CHIs, no history of substance abuse, good family support, married, no past history of disabilities, stable and high skill job, and above average intellectual functioning.
References 1.Krause JF, Sorenson SB. Epidemiology. In: Silver JM, Yudofsky SC, Hales RE, eds. Neuropsychiatry of Traumatic Brain Injury. Washington, DC: American Psychiatric Press Inc. 1994:3‑41.
2.Sosin DM, Sniezek J, Thurman DJ. Incidence of mild to moderate brain injury in the United States, 1991. Brain Injury. 1996;10:47‑54.
3.Cooper JD, Tabaddor K, Hauser WA. The epidemiology of head injury in the Bronx. Neuroepidemiology. 1983;70‑88.
4.Mattson AJ, Levin HS. Frontal Lobe dysfunction following closed head injury. Journal of Nervous and Mental Disease. 1990;178:282‑91.
5.Teasdale G, Jennett B. Assessment of coma and impairment of consciousness: a practical scale. Lancet. 1974;81‑4.
6.Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995;45:1253‑60.
7.Jorge RE, Robinson RG, Starkstein SE, et. al. Comparison between acute and delayed onset depression following traumatic brain injury. J Neuropsychiatry Clin Neurosci. 1993;5:43‑9.
8.Kant R, Bogyi A, Carosella N, Fishman E, Coffey CE. ECT as a therapeutic option in severe head injury. Convulsive Therapy. 1995;11:45‑50.
9.Kant R, Bogyi A, Coffey CE. ECT after traumatic brain injury. Convulsive Therapy. 1995;11:[Abstract]
10.Kant R, Seemiller L, Duffy J.D. Obsessive compulsive disorder after closed head injury: Review of literature and report of four cases. Brain Injury. 1996;10:55‑63.
11.Kant R, Duffy J, Pivovarnik A. Prevalence of apathy following closed head injury. Unpublished data. 1996.
12.Bachman D. L. The diagnosis and management of common neurologic sequelae of closed head injury. J Head Trauma Rehabil.. 1992;7(2):50-59.
13.Kant R, Zeiler D. Hemiballismus following closed head injury ‑ case report. Brain Injury. 1996;10:155‑8. Table 1Common Post-Concussion Syndrome Symptoms
Physical
1. Headache
2. Dizziness
3. Sleep disturbance
4. Diplopia and blurring of vision
5. Light and sound sensitivity
6. Neck pain
7. Tinnitus (ringing in ears)
8. Fatigue
Emotional
9.Anxiety
10. Irritability
11. Depression
12. Mood lability
Cognitive
13. Slowed thinking
14. Short-term memory problems
15. Impaired concentration and attention span
16. Periods of confusion
17. Difficulty learning new material
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Head Injuries in Children 18 Nov 2014, 4:23 pm
Head Injuries in Children
(Letter published in Post Gazette, Pittsburgh, PA)
This letter is regarding the May 25th article on traumatic injuries in children. One case of a severe head injury due to a skating accident was described. Most of the information was focussed on physical injuries. We would like to address the serious issues that arise after a head injury, especially in children.
Traumatic brain injury primarily affects cognitive abilities, such as short-term memory, attention, concentration, and learning new materials. Children have difficulty returning to their previous level of functioning at school. They may become hyperactive, irritable, aggressive and show other changes in their personality. They may show signs of ADHD with lack of concentration, easy distractibility, and difficulty to grasp new concepts. Their grades could start to decline. They may show significant mood swings ranging from rage outbursts to depression. These changes in a young child’s life lead to frustrations for parents, teachers, and the child himself. The children start to withdraw and develop problems with self-esteem and self-confidence. They may even become apathetic.
Other symptoms of head injury may include physical, emotional, behavioral, and neurological changes. These may include – headache, sleep problems, chronic pain, seizures, anxiety, depression, nightmares, disruptive behaviors, etc. Anxiety syndromes manifest as fearfulness, worry, and persistent tension. Depression is not easy to recognize in children and it can be very disabling. Unlike most injuries, such as a broken leg or a third-degree burn, the evidence of the trauma is often intangible, and the symptoms can be puzzling and unclear. Such an experience oftentimes is very stressful for the patient, his family, and his doctor.
Children are especially at high risk for head injury because of involvement in sports, bike riding, skating, swimming, vacation travel etc., more so in summer months. The use of a helmet, which for the state of Pennsylvania is a law for all children under the age of 12, is essential when riding a bike. Making sure the children are wearing a seatbelt and preferably ride in the back seat of an automobile. The effects of a head injury can be life long.
Most children show good recovery from a mild head injury over one to three months while the symptoms of severe head injuries usually persist. Anyone with symptoms beyond three months should seek further evaluation and treatments from specialists such as neurologists, child psychiatrists, or neuro- psychiatrists. Educating the family, teachers, and the patient is very important. Depression, anxiety, irritability, and problems with self-esteem and self-confidence can be treated with education, counseling, and medications. There are many organizations that provide support and information for patients and their families about brain injury. (Brain Injury Association at 703-236-6000; www.biausa.org)
Sincerely,
Ravi Kant, MD
Michele Bellini
Head Injury Clinic
Pittsburgh, PA 15017
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Impact of Clozapine on Clinical Outcomes – Severely Ill 18 Nov 2014, 4:02 pm
Objectives: To evaluate the impact of clozapine on aggressive behavior and clinical outcomes in children and adolescents with schizophrenia or schizoaffective disorder.
Methods: Charts of six children and adolscents who were consecutively admitted to a long-term care facility were reviewed for clinical outcomes including seclusion and restraints incidents prior to and during clozapine treatment, and a representative case-history is presented.
Results: Clinically significant improvements were noted in social interactions, decreases were noted in the number of violent episodes, homicidal and suicidal thoughts. The global assessment of functioning scores improved significantly. There was significant weight gain.
Conclusions: These cases illustrate the benefits of clozapine in refractory childhood onset schizophrenia, similar to outcomes described in adults. Even though open data llimts conclusions from this study, it is pertinent that there was a clinically significant improvement with aggressive behaviors. This may be particularly important from the point of view of improved morale for patients, their families, and treating staff.
(submitted for publication]
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