Psychosocial Considerations for Traumatic Brain Injury

Introduction

There are many cognitive impairments which occur following traumatic brain injury. More than 60% of people with moderate or severe traumatic brain injury report cognitive and behavioural changes lasting more than 10 years post-traumatic brain injury. One longitudinal study[1] over 10 years reported that more than 50% are unable to return to their previous work, the author also states that "there were few changes in work status once 18 months to 2 years had elapsed since the injury, and the pattern of employment, once established, tended to remain stable". A large 2019 study[2] examined the relationship of cognitive status to employment status at one year post moderate-severe traumatic brain injury in 320 patients, the authors reported that fewer than 40% of participants were employed at 1-year follow-up, plus resumption of driving and injury severity were also related to return to work.

Effects on Intellect

Attention Span & Concentration

Following severe traumatic brain injury there is a noticeable reduction in:

  • information-processing speed
  • attention span;
  • focused/selective attention;
  • sustained attention;
  • and supervisory attentional control.[3]

Memory & Learning

Working memory deficits are common following moderate and severe traumatic brain injury, and can also occur in cases of mild traumatic brain injury.[4][5] It is well documented that traumatic brain injury causes memory and cognitive dysfunction, but it is very difficult to establish which memory phase, (encoding, maintenance, or retrieval) is specifically altered by traumatic brain injury.[6]

Reasoning and Judgement Difficulties

These commonly include:

  • difficulty recognising when there is a problem, which is the first, and essential, step in problem solving
  • decisions may be made quickly without pausing to consider the matters involved
  • when solving problems, a person with traumatic brain injury may have difficulty in evaluating the best solution
  • reduced analysis skills
  • inflexible thinking

Emotional Effects

Emotional Lability/Mood Swings

This is a common sequelae of brain injury. The individual feels strong emotions for a short period of time. They may experience sudden anger, happiness or sadness, but the feeling does not last very long. They may cry for a few minutes, but then quickly laugh as their mood changes. This can baffle their family members who may worry when they make a small remark and the patient bursts into tears. Education of family members is important, reassuring them that this is not unusual following traumatic brain injury, and sometimes the emotional expression (laughing, crying, etc.) does not seem to bear any relationship to the social situation. In most cases, the person is not able to control their emotional outburst. In some cases, emotional lability improves over the first few months following traumatic brain injury. Family members/carers can be advised to remain calm when an emotional outburst occurs ie.do not become emotionally excited themselves, and if possible take the person to a quiet private area to give them ca hance to recover their composure.

Reduced Empathy, Increased Egocentricity

It is becoming apparent that people with traumatic brain injury may show reduced empathy due to a reduced ability to interpret the social cues provided by other people, in particular interpretation of facial expression. [7] A 2010 study [8] examined the degree of emotional empathy in 64 patients with traumatic brain injury, comparing their scores on the Balanced Emotional Empathy Scale to matched controls; the traumatic brain injury group exhibited significantly lower emotional empathy scores than the control group.

Anxiety

A person with traumatic brain injury may suffer from increased anxiety - a feeling of nervousness or fear, which is out of proportion to the situation. This can manifest in any situation, but is particularly common when the person is in a situation which causesa eneral increase in arousal and require an increase in information processing, eg. being in a noisy environment; being in a busy/crowded place. Again, family members should be offered support to help manage anxiety, encouraging them to provide reassurance to their relativses In severe cases, anti-anxiety medication may be helpful.

Depression

This is not uncommon following traumatic brain injury, and is exacerbated by the individual struggling to come to terms with their new disability as well as their altered role within the family and wider society. All strategies which can be employed for depression in the population without brain injury may be employed, usually with much success. Physiotherapists can play a useful role in this by structuring the physical rehabilitation which the person is undergoing in such a way as to increase aerobic activity which helps people with depression. One 2012 study[9] evaluated the effects of exercise in a population of 40 people with traumatic brain injury with specific reference to depression, using the Beck Depression Inventory [BDI] score, and reported "Participants reduced their scores on the BDI from baseline to 10 weeks and maintained improvement over time. Many participants (48%) demonstrated increased physical activity at 6 months compared with baseline. Those who exercised more than 90 minutes had lower scores on the BDI at the 10-week and 6-month assessments and reported higher perceived quality of life and mental health."

Irritability & Temper Outbursts

These are a frequent consequence of traumatic brain injury, with the person becoming irritable and/or angry when they experience frustration. They occur more frequently when the person is tired, feeling depressed, experiencing social isolation or in pain. Psychological treatment including self-calming strategies, relaxation and better methods of communication can be very helpful. In severe cases, there are medications which can help. Family members benefit from advice from a psychologist on the best way to manage temper outbursts, including refraining from arguing/challenging the person during an outburst; not giving into the person's demands; letting the individual with traumatic brain injury know that it is not socially acceptable to shout loudly, strike out at others or verbally threaten others.

Personality Changes

Personality changes are frequent sequelae to traumatic brain injury.[10] These changes have a large effect on the other members of the family,[11] as well as on the wider social circle. A 3 fold increase in the prevalence of personality disorders following traumatic brain injury has been reported.[12]

Effects on Family Relationships

The result of these emotional and cognitive changes has an enormous impact on the patient's family unit. Frequently roles of family members will alter significantly, [11] and the family unit has to reorganise in order to compensate for the changes in which the person with traumatic brain injury shows in behaviour and cognitive ability. This can lead to a family breakdown in some cases.

Effects on Wider Social Context

It is not uncommon for the emotional and intellectual sequelae of traumatic brain injury to have huge impact on the place of the person within society.

  1. They may be unable to resume their usual work, leisure and study activities.[11]
  2. There is evidence that alcohol misuse is higher in the traumatic brain injury population than in the general population.[13] One study identified 4 psychosocial factors which contribute to alcohol misuse following traumatic brain injury:[14] uncertainty over the ability to return to work/perform adequately at in the workplace; physical limitations and mood changes following injury; increased leisure time and boredom; increased enabling from family and friends.

Resources

The Model Systems Knowledge Translation Center (MSKTC), an American institution, has a website with a large number of very useful resources for people with traumatic brain injury and their families. These are all available in English and in Spanish. Here are just a few of their resources:

References

  1. Johnson R. How do People get back to work after severe Head Injury? A 10 year Follow-up Study. Neuropsychological Rehabilitation. 1998; 8(1):61-79
  2. Hart T, Ketchum JM, O'Neil-Pirozzi TM, Novack TA, Johnson-Greene D, Dams-O'Connor K. Neurocognitive status and return to work after moderate to severe traumatic brain injury. Rehabilitation Psychology. 2019; 64(4):435–444
  3. Mathias JL, Wheaton P. Changes in attention and information-processing speed following severe traumatic brain injury: a meta-analytic review. Neuropsychology. 2007;21(2):212-23.
  4. McAllister TW, Flashman LA, Sparling MB, Saykin AJ. Working memory deficits after traumatic brain injury: catecholaminergic mechanisms and prospects for treatment -- a review. Brain Inj. 2004;18(4):331-50.
  5. Wolf JA, Koch PF. Disruption of Network Synchrony and Cognitive Dysfunction After Traumatic Brain Injury. Front Syst Neurosci. 2016; 10():43. doi: 10.3389/fnsys.2016.00043
  6. Paterno R, Folweiler KA, Cohen AS. Pathophysiology and Treatment of Memory Dysfunction After Traumatic Brain Injury. Curr Neurol Neurosci Rep. 2017;17(7):52. doi: 10.1007/s11910-017-0762-x.
  7. Bogart E, Togher L, Power E, Docking K. Casual conversations between individuals with traumatic brain injury and their friends. Brain Inj. 2012; 26(3):221-33.
  8. Williams C, Wood RL. Alexithymia and emotional empathy following traumatic brain injury. Journal of Clinical and Experimental Neuropsychology. 2010; 32(3): 259-67, DOI: 10.1080/13803390902976940
  9. Wise EK, Hoffman JM, Powell JM, Bombardier CH, Bell KR. Benefits of Exercise Maintenance after Traumatic Brain Injury. Archives of Physical Medicine & Rehab. 2012; 93(8):1319–23.
  10. Garcia PG, Mielke MM, Rosenberg P, Bergey A,  Rao V. Personality Changes in Brain Injury. J Neuropsychiatry Clin Neurosci. 2011; 23(2): E14. doi: 10.1176/appi.neuropsych.23.2.E14
  11. 11.0 11.1 11.2 Kersel DA, Marsh NV, Havill JH, Sleigh JW. Psychosocial functioning during the year following severe traumatic brain injury.Brain Inj. 2001;15(8):683-96.
  12. Hibbard MR, Bogdany J, Uysal S, Kepler K, Silver JM, Gordon WA, et al. Axis II psychopathology in individuals with traumatic brain injury.Brain Inj. 2000; 14(1):45-61.
  13. Koponen S, Taiminen T, Portin R, Himanen L, Isoniemi H, Heinonen H, et al. Axis I and II psychiatric disorders after traumatic brain injury: a 30 year follow-up study. Am J Psychiatry. 2002; 159:1315–21 10.1176
  14. Reilly EL, Kelly JT, Faillace LA. Role of alcohol use and abuse in trauma. Adv Psychosom Med. 1986; 16:17–30
  15. MUSHPWeb1. Cognitive and Psychological Consequences of Traumatic Brain Injury. Available from: https://youtu.be/jFPPJd8Qsxg[last accessed 30/08/19]
  16. Attitude. Life After a Head Injury. Available from: https://youtu.be/q6AbN5IfPU4[last accessed 30/09/19]