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Emotional changes following brain injury: psychological and neurological components of depression, denial and anxiety

Journal of Rehabilitation, April-June, 1991 by Carol Armstrong

Neurological components of depression, denial, and other affective changes are reviewed. Rehabilitation is particularly important to improve long-term psychological outcome of patients. Behavior modification can be used effectively to reduce problematic behavior and to support the patient's motivation. Finally, emotional changes in family members, which occur as well, are reviewed, particularly increased depression and anxiety.

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Emotional difficulties, personality changes, and neurotic reactions may be the most prominent consequences of head injury, especially in the case of mild head injuries. These reactions may be indistinguishable from psychoneurosis to those who are not intimately involved with the head injured individual. In fact, it is more typical for emotional disturbances to be interrelated components of neurologic or cognitive deficits, which can create difficulties in evaluating individual cases. Changes in coping ability caused by the injury are likely to result in reactive, adaptive, psysiologically-generated denial and depression. Changes in coping will often not be seen as multifactorial, and prominent emotional dynamics are likely to cloud underlying issues when problems occur in relationships. Altered coping also occurs in family members in response to the disabled person. A symmetrical process of frustration and helplessness is likely to develop when family members are unware of the organic causes of altered perceptions, coping, and poor judgment of the injured person.

An example of thee processes is the case of a 35-year-old woman who sustained a mild head injury and spinal whisplash in an auto accident. She received medical treatment and some rehabilitation for her back and pain problems. Eventually she began to see a psychologist, whom she sought out on her own, because of an increasing depression. The psychologist treated her for a few months, but soon suspected another level to her difficulties and requested an neuropsychological evaluation. This evaluation uncovered significant cerebral dysfunctions which were not only affecting he reasoning and judgment, but also her personal relationships and outlook in major ways. Prior to the accident she had been a well adjusted person, outgoing, and happily employed. After the accident, among other problems, she was alienating her family and husband by being unable to read their emotional reactions as well as the underlying meanings of what they said to her. She perceived their comments in a restricted way-- only as an assault on her control and independence, and not as their attempts to help her see alternative solutions. Thus, attempts to talk through problems with her were unsuccessful because she was relating in a superficial and overly egocentric way. These decificts also meant that she would have great difficulty becoming aware of these or other problems because of the brain injury's affects on her self-awareness. When the family gave feedback to her, it became an exercise in frustration and rejection for her family, and an exercise in frustration and anger for her. Eventually she became more and more depressed in reaction to her neurological condition of denial. Almost three years after her injury, she admitted herself to a psychiatric hospital for triage of her depression. Lezak (1896) considers these types of individuals to be most at risk for serious depression because of the insidious process of alienation which they create as a result of their brain injuries.

The neuropsychological evaluation of this case revealed bilateral anterior brain dysfunction, with greater right hemisphere than left hemisphere dysfunction at the time of the testing. This bilateral presence of injury was likely having significant effects on her ability to integrate her perceptions and feelings, to organize her thoughts and feelings, and on system-wide processes such as speed of perception and response. Some research indicates that when the brain is insulted in the right, or nondominant, hemisphere with preservation of the dominant hemisphere, denial, or lack of awareness, is a resulting syndrome. Thi denial (Babinski's Syndrome) was first thought to pertain only to denial of physical movement or visual sensation (Babinski, 1918, Nathanson, Bergman & Gordon, 1952), but the concept of anosognosia was later extended to neglect of left-sided complex sensorimotor praxia (Hecaen, Penfield, Bertland, & Malmo, 1956) and to unawareness of disabilities and of other stressful experiences (Weinstein & Kahn, 1955). This brain area plays an important role in awareness of context and gestault, in self-evaluation, attention, and synthesis of subparts to make meaningful wholes. It helps us to evaluate ourselves and the world around us by synthesizing information and assessing whether things seem right or not, and thus has an important role in judgment and the development of appropriate behavior. Injuries in the left, or dominant, hemisphere with preservation of the nondominant hemisphere, tend to correlate with hypersensitivity, poor attention to detail, inability to generate pleasurable feelings (anhedonia), and uninhibited negative emotions which result in an immediate depression. Lezak (1986) reports that the prognosis of individuals with left hemisphere injury is probably better, because they have intact awareness of their disabilities, are reacting in an overly sensitive way, but are more likely to ovecome their depression. The case example demonstrates that even when such injuries are mild, organic dysfunction of awareness and emotion account partially for altered coping. This patient was helped by her psychotherapist to improve her awareness, decrease impulsive responding, and become more functional in relationships with family members. When retested two years after the first evaluation and almost three years after her injury, her right hemisphere functions had improved most significantly, with lesser improvement in left hemisphere functions. She also developed more serious depression over time, resulting in her self-admission to a psychiatric hospital.

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Emotional changes following brain injury: psychological and neurological components of depression, denial and anxiety

Journal of Rehabilitation, April-June, 1991 by Carol Armstrong

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