Psychosocial Considerations for Traumatic Brain Injury

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Original Editor - Wendy Walker

Top Contributors - Wendy Walker, Naomi O'Reilly, Kim Jackson, Tarina van der Stockt, Lucinda hampton, Admin, Rachael Lowe, Tony Lowe, Simisola Ajeyalemi, Uchechukwu Chukwuemeka and Stacy Schiurring  

Introduction

There are many cognitive impairments which occur following Traumatic Brain Injury [TBI]. More than 60% of people with moderate or severe TBI report cognitive and behavioural changes lasting more than 10 years post TBI, and one longitudinal study over 10 years reports that more than 50% are unable to return to their previous work. The author also states "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 examined the relationship of cognitive status to employment status at one year post moderate-severe TBI in 320 patients. The authors report 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.

The following areas can all be impacted by TBI:

Effects on Intellect

Attention span & concentration

Memory & learning

Thought processing difficulties

Emotional Effects

Emotional lability/mood swings

This is a common sequalae 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 TBI, 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 TBI. 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 chance to recover their composure.

Anxiety

A person with TBI 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 causes general 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 relative. In severe cases, anti-anxiety medication may be helpful.

Depression

This is not uncommon following TBI, 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 evaluated the effects of exercise in a population of 40 people with TBI 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 TBI, 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 TBI know that it is not socially acceptable to shout loudly, strike out at others or verbally threaten others.

Personality Changes

Personality changes are a frequent sequelae to TBI. These changes have a large effect on the other members of the family, as well as on the wider social circle.

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, and the family unit has to reorganise in order to compensate for the changes which the person with TBI shows in behaviour and cognitive ability.

Effects on Wider Social Context

It is not uncommon for the emotional and intellectual sequelae of TBI to have huge impact on the place of the person within society. They may be unable to resume their usual work, leisure and study activities.

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 TBI and their families. These are all available in English and in Spanish.

These include slideshows, infocomics and fact sheets. Here are just a few of their resources:

• TBI and Sleep Infocomic
• Memory and TBI slideshow
• Relationships after TBI factsheet
• Driving after TBI factsheet