View
215
Download
2
Category
Preview:
Citation preview
NICOLEJOANNE WOOD, MA, LCPCPSYCHOLOGY INTERN
LAKEVIEW SPECIALTY HOSPITAL AND REHABNIKI.WOOD1@GMAIL.COM
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
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
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), 255-262.
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
Recommended