NICOLEJOANNE WOOD, MA, LCPC PSYCHOLOGY INTERN LAKEVIEW SPECIALTY HOSPITAL AND REHAB [email protected] Personality Changes Following Brain Injury “The.

NICOLEJOANNE WOOD, MA, LCPCPSYCHOLOGY INTERN

LAKEVIEW SPECIALTY HOSPITAL AND [email protected]

Personality Changes Following Brain Injury

“The response to head injury depends on the kind of head that was injured.” ~Symonds (1937)

Personality Changes Following Brain Injury:

Outline

Review influential case- Phineas Gage

IntroductionPrevalenceTypes of personality and

behavioral changesComorbid or other

associated new-onset disorders

Outcome and treatmentReferences

“NO LONGER GAGE”

A Classic Example:Phineas P. 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 mins-1 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 aggression or rage that are grossly out of proportion to any precipitating stressors

38%

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); 2-3% (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

Taken from a study by Max, Robertson, & Lansing (2001)

Example of disinhibited behavior and impaired social judgment 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, problem-

solving 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

Comorbid or Other Associated New Onset Disorders

Personality change after TBI is significantly associated with new onset disorders in children

Outcome and Treatment:

Outcome- males versus females

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

Recommendations influenced by Bezeau, Bogod, & Mateer (2004)

Intervention strategy recommendations Elementary-

Supervision Behavioral strategies Clearly differentiate appropriate and

inappropriate boundaries and behaviors

Pharmacological interventions Intermediate-

Psychoeducation Practice social skills Discuss emotions and thoughts

Advanced- Establish behavior relapse plan Challenge cognitive distortions

Brain Injury Family Intervention (BIFI) (Kreutzer et al., 2009)

Brain Injury Family Intervention-Adolescent (BIFI-A) (Gan et al., 2010)

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

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