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Industry: Email Alert RSS FeedEmotional changes following brain injury: psychological and neurological components of depression, denial and anxiety
Journal of Rehabilitation, April-June, 1991 by Carol Armstrong
The main characteristic of the frontal lobe personality are so well known that they are considered excellent indicators of frontal lobe pathology. Frontal lobe pathology falls along a continuum between two types of disorder resulting from disturbance of two major behavior control centers of the frontal lobe. Patients tend to exhibit mixed characteristics from these two types, although a predominance of one may be helpful in diagnosing the location of the more major lesions.
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One type of disorder is the "pseudo-retarded" or "pseudo-depressed", characterized by lethargy, little spontaneity in behavior, unconcern, reduced sexual interest, little overt emotion, and inability to plan ahead. These behaviors result from injury to the dorsolateral areas of the frontal lobe (Stuss & Benson, 1983, Valenstein & Heilman, 1979). In addition to the highly inhibited, unexpressie behaviors listed above, one cannot eliminate the possibility of impulsive decision-making or sudden expression of feelings. An example of the injury-related pseudo-depressed personality type is the patient who had been aggressive before his head injury, but afterwards became very cooperative and passive. He capable of expressing emotion in his face, but simply did not do so. He received therapy for production of appropriate affect, and came occasionally to express feeling visibly and spontaneously. However, he was experiencing strong emotional reactions despite his difficulty in expressing them. In fact, when particularly frustrated, he might suddenly show a fist or bang on the table. Though he appeared flat, even depressed on the surface, he was having unseen feelings which he lacked the thought fluency or organization to understand.
The second type is the "pseudo-psychopathic" subtype, characterized by a childish, jocular attitude, sexual disinhibition, increased motor activity, inappropriate social irritability and anger, and little concern for others. These problems result from injury to the orbitofrontal areas of frontal lobe (Stuss & Benson, 1983; Valenstein & Heilman, 1979). Despite the apparent euphoria and hyperexpressiveness, one cannot eliminate the possibility of depression or reduced endurance or stamina in these patients. An excellent example of the pseudo-psychopathic disorder is the young male head injury patient who could not stop attracting attentin by telling inappropriate jokes to staff, despite their feedback not to do so. He was lonely and had a strong need for affectin. He wanted to repress his compulsion to tell jokes because he would receive social and material reward if he succeeded, but he could not inhibit his socially negative behavior.
Depression and anxiety post-injury are very problematic to clinicians because they represent a three-way diagnostic question: is the depression or anxiety an adaptive response to the catastrophe, representing bereavement or self-criticalness, is it a sign of decompensation and impaired coping, or it is a direct result of organic injury? The explanation of narcissitic injury is less prominent in the treatment of brain injury than it is in the treatment of other cases of catastrophic injury such as spinal cord injury or amputation. However, the psychodynamic issues related to narcissistic injury are more accessible and ingrained in the training of psychologist, than are the issues related to the brain's regulation of emotion. These psychodynamic ideas are critical in the therapy and management of brain-injured persons, but if used alone, can lead to misinterpretation of behavior and less effective case management. In each issue where ego defenses are clearly involved, the patient is also demonstrating efforts to compensate for cognitive disturbance with only partial success. The partial success at compensation, with emotional controls out of balance, becomes part of the ego dystonia.
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