Personality Changes Following
Brain Injury
NICOLEJOANNE WOOD, MA, LCPC
PSYCHOLOGY INTERN
LAKEVIEW SPECIALTY HOSPITAL AND
REHAB
[email protected]
“The response to head injury depends on the kind of head that was
injured.” ~Symonds (1937)
 Review influential case- Phineas
Personality
Changes
Following
Brain
Injury:






Outline
Gage
Introduction
Prevalence
Types of personality and
behavioral changes
Comorbid or other associated
new-onset disorders
Outcome and treatment
References
A Classic Example:
Phineas P. Gage
“NO LONGER GAGE”
Phineas P. Gage
 September 1848: 25-year-old Gage was struck with a
tamping iron


13 pounds, 3 feet 7 inches in length, and 1 ¼ inch in diameter
Passed mostly through the left frontal lobe
 April 1849: Almost complete physical recovery
 However, it seems that Gage’s personality changed
dramatically.
Fitful, irreverent, engages in profanity
 Little respect for others
 Impatient when conflicts with his desires
 Very stubborn
 Abandons plans

Introduction:
‘The walking wounded’
 Traumatic Brain Injury (TBI):
 Insult to the brain caused by external
physical force
 May produce a diminished state of
consciousness
 Usually results in impairment of
cognitive abilities or physical
functioning, as well as:
Mood
 Personality
 Impulsive aggression
 Impaired self-regulatory behavior

 TBIs often considered a risk
factor for psychiatric disorders
Severity of TBI Classification Criteria using the Glascow Coma
Scale (GCS), Loss of Consciousness (LOC), and Posttraumatic
Amnesia (PTA)
Classification
GCS
LOC
PTA
Mild
≥13
<20
mins1 hour
<24 hours
Moderate
9-12
1-24
hours
>24 hours to <7 days
Severe
≤8 (in a
coma)
>24
hours
>7 days
 High risk groups
 Males 15-24 years old
 Substance abusers
 Infants (64% due to child abuse)
 Elderly
 Individuals who have had a prior brain injury
Prevalence:
Note: All prevalence
rates are
approximations.
 Prevalence rates for TBI are high
 5.3 million Americans disabled
secondary to TBI
 TBIs common cause of childhood
acquired disability


475,000 TBIs occur among children ages
0-14 years (1 year; United States only)
1.4 million people sustain a TBI; about
50,000 die, 235,000 are hospitalized,
and 1.1 million are treated and released
(1 year; United States only)
 Behavioral changes after TBI:
 10-21% (mild); 62-67% (severe)
 Personality changes after TBI:
 Approximately 60-80%
Types of
behavioral and
personality
changes:
Taken from a study by
Max, Robertson, &
Lansing (2001)
Symptom
Percentage
Personality change
57%
Affective instability
49%
Marked shifts from normal
mood to
•Depression
•Irritability
•Anxiety
•8%
•41%
•5%
Laughs inappropriately and/or
excessively
24%
Pathological crying
19%
Recurrent outbursts of
38%
aggression or rage that are
grossly out of proportion
to any precipitating
stressors
Markedly impaired social
judgment
38%
Symptom
Percentage
Uninhibited/disinhibited
•Acts
•Verbalization
•32%
•41%
Lack of tact or concern for
others; not sensitive to
other’s feelings/reactions
22%
Inability to plan ahead
27%
Sexually inappropriate
16%
Marked apathy or indifference
14%
Suspiciousness or paranoid
ideation
5%
Explosive
32%
Perseveration
35%
Immaturity
24%
 5 major subtypes of personality
change:





Affective liability
Aggression
Disinhibition
Apathetic
Paranoid
 Facial affect recognition
difficulties

Especially negative emotions: Anger,
disgust, sadness, and fear
 Aggressive behavior
 Higher incidence of pre-morbid
aggressive behavior
 Sexually intrusive behavior
 70%
 Personality functioning
 Decreases in
Extraversion
 Openness
 Agreeableness
 Conscientiousness


Increase in

Neuroticism
 Elevations in personality disorder
traits (Axis II)







Histrionic
Narcissistic
Compulsive
Dependent
Avoidant
Paranoid
Schizoid
Psychiatric disorders (Axis I)
Disorder
TBI Population
General
Population
Major Depression
44.3%
5-9% (females); 23% (males) point
prevalence
Generalized Anxiety Disorder
9.1%
5%
Bipolar Disorder
4.2%
0.4-1.6%
Obsessive-Compulsive
Disorder
6.4%
0.5-2.1%
Panic Disorder
9.2%
1-2%
Posttraumatic Stress Disorder
14.1%
8%
Schizophrenia
0.7%
0.5-1.5%
Substance Abuse
13%
 Other neuropsychiatric sequelae
after TBI

Psychosis- 0.7-9.8%
 Psychosocial problems
 Increasing unemployment rates
 Effects on family members
 73% of spouses have at least mild
depression
 42-64% of couples eventually divorce
 Disruptions in family functioning- less
effective coping, problem-solving and
communication
 Judgment of personality change
 Example of disinhibited behavior
and impaired social judgment

Taken from a study by
Max, Robertson, &
Lansing (2001)



12-year-old female (1 year post): “At
least I don’t bite anymore”
7-year-old male (6 months post): “He
is more outspoken and blunt”
7-year-old female (1 year post): “Get
back at other people”
6-year-old male (3 years post): “Boy,
you’re fat”
 Several additional characteristics
that affect personality change
after TBI





Anosognosia
Executive dysfunction
Apathy
Hope
Optimism
 Anosognosia (Awareness/Insight)
 Observed when patient does not report,
denies or minimizes difficulties
 Possibly used as a defense mechanism
against the reality of life post-injury
 Over time, impaired awareness may
lead to increased distress
 Less insight = more behavioral
problems and familial stress
 3 possible types of deficits in awareness
Intellectual awareness of deficits
 Emergent awareness deficits
 Anticipatory awareness

 Executive dysfunction
 Purposeful, goal-directed, problemsolving behaviors
 Sub-components may include
Attentional control
 Strategic planning and problem-solving
 Cognitive flexibility of thought and
action
 Concept formation and abstraction
 Information processing

 Apathy
 Occurs in about 66-71% of TBI
population
 May be treated pharmacologically
 Hope and optimism
 Hope
An inner feeling that a problem will
ultimately be solved
 Negatively related to general
maladjustment and suicidal ideation
 More dominant in predicting depression
severity


Optimism

Future orientation with a general
expectancy that good rather than bad
will happen
 Personality change after TBI is
Comorbid or
Other
Associated
New Onset
Disorders
significantly associated with new
onset disorders in children
 Outcome- males versus females
Outcome and
Treatment:
 Multifaceted rehabilitation
 Cognitive rehabilitation
 Behavioral treatment
 Social skills training
 Vocational training
 Individual therapy
 Group therapy
 Family therapy
 Parenting skills programs
 Social-emotional factors
 Parental warmth and responsiveness
 Intervention strategy
recommendations

ElementarySupervision
 Behavioral strategies
 Clearly differentiate appropriate and
inappropriate boundaries and behaviors
 Pharmacological interventions
Recommendations
influenced by Bezeau,
Bogod, & Mateer
(2004)


IntermediatePsychoeducation
 Practice social skills
 Discuss emotions and thoughts


AdvancedEstablish behavior relapse plan
 Challenge cognitive distortions

Brain Injury
Family
Intervention
(BIFI) (Kreutzer et
al., 2009)
 BIFI/BIFI-A
 Structured treatment for TBI patients
and their families
 5-6 sessions; 90-120 minutes each
 BIFI topics
Effects of brain injury on the survivor
and family
 Understanding recovery
 Solving problems and setting goals
 Managing stress and intense emotions
 Strategies for optimal recovery

Brain Injury
Family
InterventionAdolescent
(BIFI-A) (Gan et
al., 2010)
 Rehabilitation approaches
 Direct approach





Restorative interventions
Behavioral compensation
Environmental modification
Problem-solving
Example
5-step flow chart with feedback loops
 1. STOP: What am I doing?
 2. DEFINE: The main task
 3. LIST: The steps
 4. LEARN: The steps and do it
 5. CHECK: Am I doing what I
planned to do?
Conclusions
 Traumatic Brain Injury (TBI)
 Insult to brain that may cause
impairments in behavioral, emotional,
cognitive, and physical functioning
 5.3 million Americans disabled
secondary to TBI
 Changes affecting personality
include:



Mood (depression, anxiety, etc.)
Behavior (disinhibition, aggression,
etc.)
Executive functioning (anosognoia,
planning, apathy, etc.)
 Numerous neuropschological
aspects affect personality
functioning
 Co-morbid disorders




ADHD
Oppositional Defiant Disorder
Anxiety
Depression
 Treatment considerations
 Multifaceted
 Include families
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of
mental disorders (Revised 4th ed.). Washington, DC: Author.
Anderson, V., Brown, S., Newitt, H., & Hoile, H. (2011). Long-term outcome from
childhood traumatic brain injury: intellectual ability, personality, and quality of life.
Neuropsychology, 25(2), 176-184.
Andersson, S., Gundersen, P.M. & Finset, A. (1999). Emotional activation during
therapeutic interaction in traumatic brain injury: effect of apathy, self-awareness
and implications for rehabilitation. Brain Injury, 13(6), 393-404.
Armstrong, C. (1991). Emotional changes following brain injury: Psychological
and neurological components of depression, denial and anxiety. Journal of
Rehabilitation, 15-22.
Babbage, D., Yim, J., Zupan, B., Neumann, D., Tomita, M.R., & Willer, B. (2011).
Meta-analysis of facial affect recognition difficulties after traumatic brain injury.
Neuropsychology, 25(3), 277-285.
Bezeau, S.C., Bogod, N.M., & Mateer, C.A. (2004). Sexually intrusive
behaviour following brain injury: approaches to assessment and rehabilitation.
Brain Injury, 18(3), 299-313.
Catroppa, C., & Anderson, V. (2006). Planning, problem-solving and
organizational abilities in children following traumatic brain injury: Intervention
techniques. Pediatric Rehabilitation, 9(2), 89-97.
Gan, C., Gargaro, J., Kreutzer, J.S., Boschen, K.A., & Wright, F.V. (2010).
Development and preliminary evaluation of a structured family system
intervention for adolescents with brain injury and their families. Brain Injury,
24(4), 651-663.
Ganesalingam, K., Yeates, K.O., Taylor, H.G., Walz, N.C., Stancin, T., & Wade,
S. (2011). Executive functions and social competence in young children 6
months following traumatic brain injury. Neuropsychology, 25(4), 466-476.
Golden, Z., & Golden, C.J. (2003). Impact of brain injury severity on
personality dysfunction. International Journal of Neuroscience, 113, 733-745.
Golden, Z., & Golden, C.J. (2003). The differential impacts of alzheimer’s
dementia, head injury, and stroke on personality dysfunction. International
Journal of Neuroscience, 113, 869-878.
Greve, K.W., Sherwin, E., Stanford, M.S., Mathias, C., Love, J., & Ramzinski, P.
(2001). Personality and neurocognitive correlates of impulse aggression in
long-term survovors of severe traumatic rain injury. Brain Injury, 15(3), 255262.
Grieve, A.W. (2010). Phineas P Gage- ‘The man with the Iron bar.’ Trauma,
12, 171-174.
Heberlein, A.S., Adolphs, R., Pennebaker, J.W., & Tranel, D. (2003). Effects of
damage to right-hemisphere brain structures on spontaneous emotional and
social judgments. Political Psychology, 24(4), 705-726.
Jennekens, N., Dierckx de Casterle, B., & Dobbels, F. (2010). A systematic
review of care needs of people with traumatic brain injury (TBI) on a cognitive,
emotional and behavioural level. Journal of Clinical Nursing, 19, 1198-1206.
Kant, R., Duffy, J.D., & Pivovarnik, A. (1998). Prevalence of apathy following head
injury. Brain Injury, 12(1), 87-92.
Kreutzer, J.S., Stejskal, T.M., Ketchum, J.M., Marwitz, J.H., Taylor, L.A., & Menzel,
J.C. (2009). A preliminary investigation of the brain injury family intervention:
Impact on family members. Brain Injury, 23(6), 535-547.
Maillard-Wermelinger, A., Yeates, K.Ow., Taylor, H.G., Rusin, J., Bangert, B.,
Dietrich, A., Nuss, K., & Wright, M. (2009). Mild traumatic brain injury and
executive functions in school-aged children. Developmental Neurorehabilitation,
12(5), 330-341.
Max, J.E., Levin, H.S., Schachar, R.J., Landis, J., Saunders, A.E., Ewing-Cobbs,
L., Chapman, S.B., & Dennis, M. (2006). Predictors of personality change due to
traumatic brain injury in children and adolescents six to twenty-four months after
injury. The Journal of Neuropsychiatry and Clinical Neurosciences, 18, 21-32.
Max, J.E., Robertson, B.A.M.; & Lansing, A.E. (2001). The phenomenology of
personality change due to traumatic brain injury in children and adolescents. The
Journal of Neuropsychiatry and Clinical Neurosciences, 13, 161-170.
McBrinn, J., Wilson, F.C., Caldwell, S., Carton, S., Delargy, M., McCann, J.,
Walsh, J., & McGuire, B. (2008). Emotional distress and awareness following
acquired brain injury: An exploratory analysis. Brain Injury, 22(10), 765-772.
Miller, L.J., & Donders, J. (2001). Subjective symptomatology after traumatic
head injury. Brain Injury, 15(4), 297-304.
Murrey, G.J., Hale, F.M., & Williams, J.D. (2005). Assessment of anosognosia in
persons with frontal lobe damage: Clinical utility of the Mayo-Portland
adaptability inventory (MPAI). Brain Injury, 19(8), 599-603.
Park, E., Bell, J.D., & Baker, A.J. (2008). Traumatic brain injury: Can the
consequences by stopped? Canadian Medical Association Journal, 178(9),
1163-1170.
Peleg, G., Barak, O., Harel, Y., Rochberg, J., & Hoofien, D. (2009). Hope,
dispositional optimism and severity of depression following traumatic brain injury.
Brain Injury, 23(10), 800-808.
Port, A., Willmott, C., & Charlton, J. (2002). Self-awareness following traumatic
brain injury and implications for rehabilitation. Brain Injury, 16(4), 277-289.
Rao, V., & Lyketsos, C. (2000). Neuropsychiatric sequelae of traumatic brain
injury. Psychosomatics, 41(2), 95-103.
Ruocco, A.C. Swirsky-Sacchetti, T., & Choca, J.P. (2007). Assessing
personality and psychopathology after traumatic brain injury with the Millon
Clinical Multiaxial Inventory-III. Brain Injury, 21(12), 1233-1244.
Sbordone, R.J., Seyranian, G.D., & Ruff, R.M. (1998). Are the subjective
complaints of traumatically brain injured patients reliable? Brain Injury, 12(6),
505-515.
Slewa-Younan, S., Baguley, I.J., Heriseanu, R., Cameron, I.D., Pitsiavas, V.,
Mudaiar, Y., & Nayyar, V. (2008). Do men and women differ in their course
following traumatic brain injury? A preliminary prospective investigation of early
outcome. Brain Injury, 22(2), 183-191.
Symonds, C.P. (1937). Mental disorder following head injury. Proceedings of
the Royal Society of Medicine, 30, 1081-1092.
Tellier, A., Marshall, S.C., Wilson, K.G., Smith, A., Perugini, M., & Stiell, I.G.
(2009). The heterogeneity of mild traumatic brain injury: Where do we stand?
Brain Injury, 23(11), 879-887.
van Reekum, R., Cohen, T., & Wong, J. (2000). Can traumatic brain injury cause
psychiatric disorders? The Journal of Neuropsychiatry and Clinical
Neurosciences, 12, 316-327.
Wade, S.L., Cassedy, A., Walz, N.C., Taylor, H.G., Stancin, T., & Yeates, K.O.
(2011). The relationship of parental warm responsiveness and negativity to
emerging behavior problems following traumatic brain injury in young children.
Developmental Psychology, 47(1), 119-133.
Weddell, R.A., & Leggett, J.A. (2006). Factors triggering relatives’ judgments of
personality change after traumatic brain injury. Brain Injury, 20(12), 1221-1234.
http://www.cdc.gov/injury/wisqars/LeadingCauses.html
http://www.cdc.gov/ncipc/pub-res/tbi_in_us_04/tbi_ed.htm
Download

Personality Changes Following Brain Injury: Outline