Behavior/Emotional
QUESTION:
My 14-year-old son sustained a serious brain injury in a car crash a little over a year ago. He was in a coma for a couple of weeks, but he made a remarkable recovery and is back in school. I am concerned about his behavior, specifically some pretty dramatic mood swings he has exhibited since the injury. Usually he seems depressed, and he used to be a basically happy, even-tempered kid. Could this be due to the brain injury? Is it possible that he is still emotionally upset by the trauma of the accident? To what degree could his erratic behavior be attributed to his age?
ANSWER #1
While moodiness is common in adolescents, dramatic mood swings are much less common. The timing of your son’s mood swings suggests they may in fact be due to his brain injury, and such alterations in mood are known to occur following a severe brain injury. I recommend that your son be seen by a neuropsychiatrist (a psychiatrist specializing in brain-related disorders). A trial period of medication may be indicated. There are medications that have been shown to stabilize the mood of persons with a brain injury. In addition to, or instead of medication, a behavior management plan put together by a neuropsychologist (a psychologist specializing in brain-related disorders) may help to reduce the extent and frequency of mood swings. Such a plan might focus on helping your son increase his awareness of when a swing may occur and train him in strategies for coming up with alternative behaviors. He must be motivated for change, of course, for this strategy to work. It is unlikely that your son is emotionally upset by the trauma of the accident. In fact, it is likely that he does not even remember the accident at all. Serious brain trauma typically wipes out all memory traces of the accident that caused it. However, his sadness could be related to his awareness of how much things have changed, or how much he has lost, since the accident. Perhaps he has had to work so hard to stay afloat in school and there has been no time for fun things. Is it possible that he might benefit from some academic support? Have his friends stuck by him? It may be helpful for him to see the school counselor in order to explore these issues and he/she will be able to make a referral to a brain injury specialist if necessary.
ANSWER #2
Youngsters who have survived severe brain injuries, like adults, can and do have delayed problems. Within the context of the excitement and thankfulness for "remarkable recovery" comes the disappointment and surprise of the delayed onset. The delayed reaction can have either a neurologic or psychological basis. About one of every four persons with a TBI experiences depression in the first few years following the injury. Some have depression early onset in their injury and frequently this is based on the brain injury (location and type of injury), while others have depression onset that emerges over the next two years. Late onset depression can be due to the emotional reaction to the changes that have taken place and more frequently have psychological factors in addition to the brain injury. The factors causing the depression are very important because your doctors and clinical specialists will choose different approaches based on the causative influences either neurologic or psychosocial. The more neurologic based the depression, the more the doctors may recommend medications to help. In contrast, the more psychosocial features, the more psychotherapeutic and social development resources may be needed in addition or by themselves.
With your youngster, the effects of his developmental age are also important. Your son’s normal adolescent development can be playing a part in the depression either because he is an adolescent or the injury interfered with his expected social development. Get a complete diagnosis that includes medical and psychosocial considerations; explore the use of both medications and psychosocial treatments. Remember the delayed onset is not unusual and your son may have recovered well enough to confront the more subtle and complex problems of social membership. In your consideration for supports, remember that the entire family is struggling and eager to succeed, so supports for all should be considered.
QUESTION:
My 19-year-old son sustained a severe brain injury when he was in elementary school. He recovered well enough to go back to school with additional help from tutors and the school counselor. Seemingly out of the blue, when he was in high school, my son began to exhibit irrational behavior, including paranoid delusions. He had never behaved this way in his life, but now he requires the care of a psychiatrist. Is it possible that the brain injury caused his psychiatric problems? If so, what specifically is the connection between brain injury and psychiatric illnesses?
ANSWER #1:
Brain injuries can result in psychiatric problems directly, particularly when areas of the brain involved in emotional functioning and/or behavior are damaged. It is difficult, however, to link your son’s brain injury and his current psychiatric problems in a causal fashion given the long gap between the injury and the onset of the irrational behaviors. Also, late adolescence or early adulthood is the time when paranoid behaviors typically show up in the general population. Many believe this is due to the fact that adolescence is a time when demands on the individual are greater than ever before (e.g., higher educational load and expectations, peer pressures and dating). A family history of similar problems would suggest that your son was at risk for these problems even without his brain injury. It is also possible, however, that your son’s brain injury increased his risk for the development of such a disorder in a variety of ways. These might include: (1) interfering with the way information is processed in the brain -- perhaps making it more difficult for him to attribute cause and effect or sift through competing stimuli in his environment, (2) altering communication skills (e.g., reducing the ability to handle the subtleties of language, read non-verbal signals) and (3) reducing problem solving ability -- thereby leaving him with fewer resources to cope with the challenges of adolescence. It is important to note that any sudden behavioral change in a young person could suggest the possibility of substance abuse, and this should be investigated. Work on keeping the communication channels open with your son.
ANSWER #2:
Psychiatric illness following TBI is being more aggressively studied, but is not well understood as of present. Especially severe psychiatric symptoms like "paranoia" and thought disorders that produce "irrational behaviors" are more under study presently. Early after injury, difficulties with thinking, reasoning, and social conduct are expected. However, the delayed onset of significant disorders is now being considered a more frequent occurrence than previously expected. Also, there are psychiatric illnesses that first emerge during the young adult years. Therefore, the relationship between your son’s condition and the brain injury is not necessarily one-to-one. First, you must have a comprehensive diagnostic, which may include psychiatric, neuropsychological, and psychosocial evaluations. A complete diagnostic is a must, given the possibility of both a brain injury related illness and a psychiatric illness.
Also, following your diagnostics, consider a wide range of treatment resources. Medications can be very useful in helping your son. However, the physician should have experience and familiarity with medications that are best for psychiatric and neurological patients, like TBI survivors. In addition, individual therapies that promote improved cognitive and reasoning skills could be very appropriate. Furthermore, the development of social skills and the ability to promote social maturity strongly support recovery and have been found to help establish the individual’s ability to prosper with others.
Therefore, consider a complete diagnostic, and explore the use of an array of treatments including medications and psychosocial therapies.
ANSWER #3:
The development of irrational behavior several years following brain injury in childhood is a situation that is described in the medical literature. This development may occur whether or not there is any family history of mental illness or paranoid disorders. There appears to be a relationship between the individual’s impaired ability to understand complex situations occurring socially and a premature judgment regarding the causes of those situations. This premature conclusion typically is reached on impulse and is based upon the individual’s perception of being slighted or excluded from a social activity. The care of a psychiatrist or neuropsychiatrist is often necessary to assist with medication adjustment as well as appropriate supportive psychotherapy to assist in reality testing and socialization.
QUESTION:
Since my brain injury a year ago, I have had many problems that will not go away: depression, memory loss, difficulty expressing myself, and an inability to keep up at my job. Since losing my job for poor performance, I have consulted a counselor, a psychiatrist, and my general practitioner. The GP and counselor both say that my problems are psychiatric, and the psychiatrist has me on Prozac. However, I am no better. How can I get the help I need? I am looking for someone who will at least believe that my problems are not imaginary.
ANSWER #1:
The symptoms that you describe are very common residuals (or persistent deficits) in persons who have suffered a mild-moderate brain injury. I am confident that your depression is real (either due to your reaction to the changes and losses you describe, or an alteration of your brain chemistry, or both) but this does not mean that your problems are solely psychiatric. Anti-depressant medication is not a bad idea particularly if your mood is depressed enough to interfere with daily activities. However, if your mood has not improved on Prozac you may want your psychiatrist to consider switching you to another medication, or you may want to cease medication altogether. Please consider individual therapy with a psychologist or rehabilitation counselor familiar with brain injury. I would definitely suggest a brain-injury support group. The individuals there will be very familiar with the difficulties and frustrations you describe and may have some good suggestions to improve things. Contact the nearest Brain Injury Association for information. A neuropsychological evaluation may help convince others (professionals and non-professionals alike) that you have deficits related to your brain injury. A good report detailing the results of such an evaluation would specify your current strengths and weaknesses, describe skill areas possibly affected by your injury, and contain specific recommendations for facilitating recovery and coping with the deficits you are experiencing. It may also be helpful to see if you qualify for assistance getting back to work through a government agency such as the Department of Rehabilitative Services. These agencies work with your employer, provide job coaches, etc. to persons with disabilities trying to return to work. A social worker may be helpful in making a referral.
ANSWER #2:
Your problems are frequently found with persons who have suffered a brain injury. Unfortunately, there are many clinicians, including physicians who are not familiar with your problems. For those clinicians you are presently working with, introducing them to written material from the Brain Injury Association can help introduce them to your problems. You do have the job of educating them if you intend to remain in their services. Written materials, names and numbers of specialists in your area familiar with brain injury can help introduce your clinicians to the type of problems you have. Seeking other help can best be done by contact with your local Brain Injury Association. The national Brain Injury Association in Washington, D.C. (202-296-6443) can direct you to local resources. Also, there are Model Systems Programs funded by the Federal Government in various locations around the country (for information on Model Systems Programs nationwide, see the Medical College of Virginia’s Model Systems homepage at: http://www.tbi.pmr.vcu.edu).
QUESTION:
I am a case manager working with a person who sustained a severe brain injury. My client is also working with a drug/alcohol counselor, a social worker, and an attorney. I have talked with these other professionals and we all agree that our client’s progress is impeded by his behavioral difficulties (e.g., lack of follow-through, emotional highs and lows, lack of insight). How can we help this person make the most of the services we have to offer?
ANSWER #1:
To ensure that a plan is in place to assist the individual to meet his goals and to become an active participant in community life, the case manager may wish to consider the development of a supportive team which is composed of the individual, family members, service providers, and members of the community. The function of the team is to build supports around the individual based on his unique capabilities, aspirations, and needs. Team members can assist the individual to express his preferences, encourage his participation in decision-making, and emphasize the importance of taking responsibility for the achievement of goals.
For individuals with challenging behavior, the team process encourages the exchange of information and ideas regarding strategies which can be used effectively by the individual at home and in the community. A team format is also an extremely effective mechanism for enhancing communication between team members, sharing information on resources, and offering a safe environment for giving and receiving feedback. The development of a cohesive team which is invested in the individual’s success avoids excessive reliance on one member of the team and increases the likelihood that support will continue to be available even if some services are discontinued.
ANSWER #2:
Your client has one of the most difficult problems in someone recovering from TBI. He is dual diagnosed and will require treatment for both conditions either in series or simultaneously. Family supports and family systems dynamics are important in both conditions. Stability of family and living environments is a must in order to establish a sound foundation for the clinical interventions. When such stability is not possible on an outpatient basis, an inpatient stay may be necessary. In addition, the integration of therapies needed for his care is as important as the individual therapies themselves. Each therapist must be integrated with the other, and the case manager serves as the coordinator and organizing influence. It is best when all services are included within one setting. Many brain injury programs can provide the combined therapies. When evaluating services for your client, this will be an important consideration. In addition, the therapists must have familiarity with both diagnostic groups. This helps with integration and coordination. However, where this is not possible, then the external case manager is the organizing influence. Services that include drug/alcohol counseling, cognitive therapies, psychosocial therapies, and possibly medication therapies are all possible positive influences. However, it is the identification of the management component that will best serve the synergy of the combined therapies. Your client will have a protracted recovery because of the dual conditions. Your resource management and allocation of funds and services must be used with this in mind. Even with knowledgeable and integrated care, long-term management will be required if relapse and recidivism is to be minimized or prevented.
QUESTION:
Since his injury, my son lacks sexual inhibition to an embarrassing degree. He makes graphic sexually-oriented remarks to anyone, and he is constantly touching females he barely knows (holding hands, grabbing at various body parts). How should we, his family, address this? Should some type of medical professional be involved?
ANSWER:
This depends on a number of factors including your son’s living situation, marital status, level of dependency on others for care, his age, history of sexual activity, family and community values.
Sexual desires are a natural part of our lives, in fact the reason that each of us is here. Following brain injury, many people do become dis-inhibited about many things, and it is not surprising when this includes basic biological urges. Damage in certain areas of the brain, such as within the limbic system, can serve to increase a person’s sexual arousal. Other neurologic damage, especially in the areas of the frontal lobes, can result in a person becoming dis-inhibited, to say what is on their mind more quickly, or to "fail to engage their brain before engaging in their behavior." Thus, increased sexual arousal combined with decreased inhibition can contribute to the challenges that your son is facing. (On the other hand, different types of neurologic damage can contribute to the opposite situation of hypo-sexuality among some people, as well.)
However, there are other factors to consider including what sexual outlets, if any, your son has access to. Remember, sex is a natural human function. Life-long abstinence is rarely a realistic solution. At the same time, many people who experience severe disability following brain injury are unable to find reasonable, safe and acceptable partners, or are prevented from doing so by others. Helping your son find satisfying and acceptable means of sexual relief may help to address some of the issues. Unfortunately, too few people with severe disability are successful finding a special someone for a full fledged intimate relationship. In the past, some people have used sexual surrogates, although this practice is less common today with AIDS and other virulent sexually transmitted diseases. For most people, masturbation may be the most frequent option. It is better to set reasonable settings and outlets for such sexual activity than to try to suppress it.
Another factor may be the level of your son’s social awareness. If he is aware of his actions and how other people respond to his behavior, social skills training may help him learn how to better interact with members of his sexual preference. This can take a lot of time and training, but such patience can pay off handsomely.
If your son relies on caregivers for daily needs it is important that they be able to handle the situation. Again, if he is responsive to social re-direction, a person of your son’s sexual preference who can handle "embarrassing" situations calmly and re-direct him in a supportive and non-shaming manner, while at the same time establishing clear boundaries for such behavior will be of great benefit. If your son is more obtuse to social cures and social re-direction, then caregivers that are not of his sexual preference may be the most appropriate to employ for his care. (This must be carefully balanced with the right of each consumer to identify who may care for him or her.) Similarly, you may want to establish specific environments and situations where your son can explore and attain sexual release that are clearly distinguishable from other situations.
There are medications such as Deprovra that have been used with some success in cases of extreme sexual acting out to reduce sexual urges in males. However these are not panaceas by themselves and do not always guarantee results. Too often they can offer false hope and promise.
Ultimately, this challenge may require all who are involved with your son to take on a new perspective, just like many of the other challenges that you have come across. Removing shame from the situation, supporting his overall value, and finding ways to establish effective boundaries are the best first approaches to the situation. Remember, biological evolution is a much stronger force than social mores.
QUESTION:
Is a person more likely to develop psychiatric dysfunction after a traumatic brain injury? Are there certain psychiatric illnesses that show up more often than others in the population of brain injury survivors?
ANSWER:
Psychiatric conditions seem to be more prevalent in patients after brain injury compared with the general population. There are few-to-no good studies that have addressed this issue, but depression and anxiety problems seem to be the most common. Depending on the studies, depression and anxiety problems occur in 50-60% of patients with brain injuries, compared to up to 20-25% of the general population.
If cognitive problems are considered to be psychiatric dysfunction, then this is also not uncommon. Most commonly, the cognitive deficits are manifested by slowing of calculations and problem solving and altered memory and concentration. If the deficits are significant they may constitute a diagnosis of delirium and/or post-traumatic amnesia. Many of these deficits resolve or improve by three to six months. Post-traumatic dementia appears to be quite rare.
The best treatment for major depression is a combination of counseling and medications. The counseling and medications vary some with the psychiatrist. The most commonly used antidepressants for patients with major depression after brain injury are the same used in patients with major depression without brain injury, and they include: fluoxetine hydrochloride (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), nefazadone (Serzone), venlafaxine, (Effexor), desipramine (Norpramin), nortriptyline (Pamelor), bupropion, (Wellbutrin), imipramine (Tofranil) and amitriptyline (Elavil). I do not feel that Ritalin is an adequate medication for major depression.
QUESTION:
What is emotional lability? Are there prescription drugs to treat it?
ANSWER:
Emotional lability refers to sudden, often frequent, and unexpected mood changes that can occur after brain injury but is not solely related to brain injury. It has probably been most formally studied in post-stroke patients and is also referred to as "emotional incontinence." In its milder forms, it can be seen as more irritability but in its more severe forms can require formal treatment. Rarely, it is part of a seizure disorder. When the main emotional manifestation is crying, the patient needs to be further evaluated for a clinical depression. Other psychiatric conditions that involve emotional ability are manic depression (Bipolar illness), delirium, and dementia. The most commonly used medications are antidepressants, but other medications include buspirone (Buspar), carbamazepine (Tegretol), valproate (Depakote or Depakene), as well as benzodiazapines and antipsychotics. There is no good consensus about length of treatment, but once the lability is under control, a trial at weaning the patient off the medication is not unreasonable to see if the symptoms return. Additionally, behavioral treatments can also be quite effective.
QUESTION:
I have heard that an injury to the frontal lobe of the brain can result in significant personality changes. Why does this happen? Does the injured person ever return to normal?
ANSWER:
If by normal you mean exactly the way things were before the injury, then the answer is usually not, although some mild and very focal injuries may diminish completely in terms of their behavioral effects. The frontal lobe is very involved with how we behave. Think of the frontal lobe as the conductor of an orchestra. Without the conductor leading all of the orchestra members, the music probably will not sound too great even though all of the instruments are well-tuned and the musicians are skilled (an over-simplified view but very accurate). So, when the frontal lobe is injured we may exhibit changes in our ability to start activities (i.e., initiation), stop activities (i.e., perseveration), switch from one activity to another, withhold responses that are overly angry, etc. Sometimes medication can be helpful, and many times behavioral therapies can also promote changes. It's always important to separate issues of a personality nature -- there are personality factors which existed before an injury, those which are adjustment concerns, and organic factors relating to the brain injury. This is not an easy task and often requires professional help (i.e., from a neuropsychologist and/or neuropsychiatrist).
QUESTION:
A friend of mine exhibits behavior problems since his brain injury, and I would like to help. I understand that there may be "behavior management programs" that could address his specific problems. If so, how would I go about finding such a program, and what should I expect from the program?
ANSWER:
Your friend is lucky to have you; all too often friends fade away from someone with a brain injury. The type of program you would want is called a "post-acute neurorehabilitation program." You are already ahead of the game by the fact that you are using the Internet to find information! Check with your state Brain Injury Association (BIA) and get a listing of the post-acute neurorehabilitation programs in your region; you may need to travel to find a good program.
The key element you are looking for is behavioral services. Ask who is in charge of the service and what are their credentials? The best answer is someone who has a graduate degree in Applied Behavior Analysis, as this person would specialize in behavior and learning. However, qualified behavior analysts working in brain injury rehabilitation are hard to find. You may call the Association for Behavior Analysis International at (616) 387-8341 and ask for help in locating a behavior analyst in your region or one who is working in brain injury rehabilitation. Neuropsychologists can also be effective if they have sufficient experience in applied behavior analysis.
Another service to look for is cognitive rehabilitation to go along with the behavioral aspect. The credentialing for cognitive rehabilitation is less clear. Most cognitive programs are experimental and work off a neural networking model based on computer simulation. This research is very interesting; however, the translation to applied cognitive rehabilitation is lagging far behind. But don't give up! There are many very talented and creative speech and occupational therapists out there who conduct cognitive therapy. Look for those trained in assessing and prescribing compensatory tools and strategies for functional skills, i.e., memory, problem solving, planning, organizing, etc.
Also, there are some neuropsychologists who are very talented and also provide cognitive therapy. You will have to see who carries out the cognitive therapy, as neuropsychologists are frequently called upon to conduct neuropsychological assessments and may not have time to consistently treat clients. You can start by reviewing the literature and seeing who's who and where they are located. You can also contact CARF (an accreditation organization for rehabilitation facilities) for a listing of accredited brain injury community integrated programs: (520) 324-1044. Finally, the Brain Injury Association has begun a credentialing program for brain injury rehabilitation professionals; you may contact the association at (703) 761-0750.