Personality Changes Following
Brain Injury
NICOLEJOANNE WOOD, MA, LCPC
PSYCHOLOGY INTERN
LAKEVIEW SPECIALTY HOSPITAL AND
REHAB
NIKI.WOOD1@GMAIL.COM
“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
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http://www.cdc.gov/injury/wisqars/LeadingCauses.html
http://www.cdc.gov/ncipc/pub-res/tbi_in_us_04/tbi_ed.htm