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