Can TBI affect emotions and behavior?

Keywords: TBI and anger, TBI and behavior, TBI and emotion, TBI and aggression, TBI and disability

Focus keyword: emotions and behavior

Can TBI affect emotions and behavior?

Traumatic brain injury (TBI) leads to different types of disability with consequences affecting the individual (physical, cognitive, executive, and emotional). One of the core functions of the human being is the development and maintenance of interpersonal relationships. Emotions represent the fundamental pillars of interindividual interaction and significantly contribute to our psychological welfare. Besides the disability types mentioned above, TBI can lead to impairment of emotions and behavior through emotional dysregulation that can manifest with anger, ranging in intensity from irritability to aggressiveness. Some studies have underlined that up to one-third of TBI patients might experience these emotional experiences, either exacerbated or newly appeared. These can significantly impact social activity and correlated with:

• familial problems
• unemployment
• social isolation
• legal problems 
• medical problems [1, 2].

How can TBI change behavior? The curious case of Phineas Gage

Phineas Gage was a healthy 25-year-old railroad worker from New Hampshire (Picture 1). He was bright, energetic, friendly, responsible, and diligent. One day, while at work, during an explosion, an iron bar was steered upward, entering his head through the lower and upper jaw, behind his left eye and left part of his brain, exiting the head through the frontal bone. After the accident, Phineas was able to walk and talk. A difficult period followed the accident, followed by physical recovery within 4 years after the TBI. However, Gage sustained changes affecting his emotions and behavior. He became disrespectful, capricious, profane, and vulgar, with an intellectual ability of a child.

His friends stated that “he was no longer Gage“. 

From a medical point of view, this represented the first case that suggested the role of the frontal part of the brain in determining and influencing a person’s personality and behavior. Furthermore, it is asserted that this case might have also contributed to the later development of psychosurgery, namely lobotomy [3, 4].  

What regulates emotions, and what related disabilities can appear after a TBI?

When discussing emotions, it is worth mentioning the processes that regulate them:

• The expression of an emotion
• The reaction to different emotions
• The emotions felt or expressed [1].

Disabilities concerning emotions and behavior are well known to appear after TBI, with major consequences for the patient and his surroundings. Some of these are:

• Depression 
• Anger 
• Anxiety
• Irritability
• Aggressiveness [1, 2].

These have an increased incidence in TBI patients, with studies showing that over half of them encounter irritability and anger because of a prior lower threshold for emotional triggers. secondary to a lower threshold for triggers before TBI. These emotions can manifest over various responses, ranging from aggressive language or physical reactions aimed at things or, more rarely, other human beings [5].

What leads to emotional dysregulation (irritability, anger, or aggression) after TBI?

The complexity of the brain resides not only in its structure but also in its function. Thus, a brain lesion on one or more parts of the brain can lead to emotional dysregulation. 

• • Region of Injury. The frontal part of the brain is known to have a critical significance and influence on emotions, behavior, and rational reasoning. Consequently, lesions to this brain region may impair anger management and the ability to avoid impulsiveness and aggressiveness.  
  • Cognitive changes. TBI can lead to several cognitive impairments, ranging from attention deficit to problem-solving and memory loss. These significantly impact the appearance of irritability, anger, or even aggression.
  • Emotional changes. Depression is a significant disability that TBI patients often encounter. Post-TBI disability frequently leads to negative emotional responses like anxiety, sadness, depressive reaction, or depression disorder. Another essential component of these changes is the patient’s inability to identify and realize their emotional responses, thus increasing the chance of exaggerated emotional responses, like aggressiveness. Moreover, some patients might lose the capacity to recognize emotions and interpret actions, leading to emotional reactions toward other people.

• Adaptive capacity post-TBI. As mentioned before, post-TBI disability has a significant impact on society. Nevertheless, the patient is the most affected. The quality of life of TBI patients is significantly impacted, leading to significant changes in their daily life, including relationships, the ability to socialize, maintaining roles in the family and society, or employment.

• The personal impact of disability. The trouble with sleep, pain, headache, photo- or noise sensitivity, or weariness can often lead to irritability [5].

Can we predict the onset of anger, irritability, and aggressiveness?

Several factors are considered to have predictive value for post-TBI anger, irritability, and aggressiveness:  

• Demographic characteristics: male gender, lower level of education, lower age, lower socioeconomic level
• Brain injury characteristics: frontal or temporal region of the brain lesion 
• Prolonged need for rehabilitation
• Disability regarding communication, memory, cognitive and attention, vision
• Psychological impairments (past or current):  depression, anxiety, substance abuse, post-traumatic stress disorder (PTSD)

These factors represent an essential step in preventing and rehabilitating patients after TBI. Even though the characteristics of the head injury and factors regarding the rehabilitation are not changeable, in some cases, they can have predictive value (e.g., frontal lobe lesions frequently lead to agitation or other emotions and behavioral changes). Moreover, knowledge about the possibility of their appearance in patients and the fact that the situation can improve alleviates stress for all people affected directly and indirectly by TBI. By educating patients, their relatives, and carers about post-TBI mental disabilities, these can be understood, addressed, and modified, thus enabling patients and people around them to have a better quality of life post-TBI [5–7].

How should these emotional disabilities be addressed?

Patient:

• Exercise (regular everyday walks)
• Healthy lifestyle (having a balanced diet)
• Compliance with indicated medication (regular intake of medication)
• Regular sleep (minimum of 7 hours a night)
• Relaxation techniques (meditation, breathing techniques)

Caregiver:

• Identification of emotional triggers (memories, fatigue, overloaded sensation)
• Comprehension and adaptation to the situation (emphasis on patient’s situation, realistic expectations, highlight on respectfulness)
• Use of adaptative techniques (calmness in the face of anger, aggressiveness, or irritability)
• Positive and detached thinking (understanding the mirroring of the brain injury in the emotional responses, not necessarily the person’s feelings towards other individuals, highlighting positive aspects in comparison to negative ones)
• Safety evaluations of individuals (considering the safety of everyone involved and affected by the brain injury (from patient to surrounding family, friends and acquaintances, etc.)

Healthcare professionals:

• Early identification of emotional disability (warning signs)
• Pharmacological influence (acknowledgment of secondary effects of the medication that can influence emotional aspects)
• Behavioral, anger management, or psychotherapy (depression, anxiety) [5].

How can education, prevention, and care for TBI be improved?

The significant impact on the quality of life of the directly or indirectly affected individuals by the emotional TBI consequences (anger, irritability, and aggressiveness) highlights the need for education regarding TBI impact. Proper information and sensitization of the patients, families, and caregivers to the possible occurrence of these manifestations can alleviate the impact and help them prepare, adapt, and manage said consequences. Additionally, healthcare professionals can use screening methods to predict these changes’ development and offer rehabilitation treatment and adequate, individualized referrals for therapy. By expanding knowledge of anger, irritability, and aggressiveness in the context of TBI, the identification, management, and overall increase in the quality of life of the affected individuals can be improved [1–7].

Explore other articles related to TBI:

• Fatigue frequency after TBI
• Concussions recovery after TBI – what is the process?
• Can TBI affect balance?

Bibliography

1. Winter L, Moriarty HJ, Short TH. Beyond anger: emotion regulation and social connectedness in veterans with traumatic brain injury. Brain Inj. 2018;32(5):593-599. doi:10.1080/02699052.2018.1432895
2. Hart T, Brockway JA, Fann JR, Maiuro RD et al. Anger self-management in chronic traumatic brain injury: protocol for a psycho-educational treatment with a structurally equivalent control and an evaluation of treatment enactment. Contemp Clin Trials. 2015; 40:180-192. doi:10.1016/j.cct.2014.12.005
3. Twomey S. “Finding Phineas.” Smithsonian [image]. Jan 2010; In:Wikipedia.com; c2022; Available from: https://en.wikipedia.org/wiki/Phineas_Gage#T
4. Wikipedia contributors. Wikipedia, The Free Encyclopedia; c:2022. Phineas Gage;2022,; Available from https://en.wikipedia.org/w/index.php?title=Phineas_Gage&oldid=1104307890
5. Neumann D, Miles SR, Sander A, Greenwald B. Model Systems Knowledge Translation Center MSKTC,c:2022. Understanding and Coping With Irritability, Anger, and aggression after TBI, 2021; Available from: www.msktc.org/tbi/factsheets
6. Miles SR, Brenner LA, Neumann D, et al. Posttraumatic Stress Disorder Symptoms Contribute to Staff Perceived Irritability, Anger, and Aggression After TBI in a Longitudinal Veteran Cohort: A VA TBI Model Systems Study. Arch Phys Med Rehabil. 2020;101(1):81-88. doi:10.1016/j.apmr.2019.07.018 
7. Miles SR, Hammond FM, Neumann D, et al. Evolution of Irritability, Anger, and Aggression after Traumatic Brain Injury: Identifying and Predicting Subgroups. J Neurotrauma. 2021;38(13):1827-1833. doi:10.1089/neu.2020.7451