Traumatic Brain Injury And Emotional Health: Impact Of Tbi On Mental Health And Emotional Well-Being

Introduction 

Traumatic brain injury (TBI) is an injury that alters the normal functioning of the brain and is categorised to be mild, moderate or severe. TBI can result in various physical, cognitive, behavioural and emotional consequences, negatively affecting the quality of life.¹ 

Furthermore, psychological issues have also been reported to significantly contribute to TBI-associated disability.⁶ The arising behavioural consequences can negatively impact patients with TBI and their families by, for instance, causing difficulties in maintaining social connections or struggles to return to work.¹⁰ This article further explores the effects of TBI on mental and emotional well-being. 

Understanding traumatic brain injury (TBI)

Overview

TBI is an acquired brain injury that causes brain function impairment and results from sudden head trauma. For instance, suddenly and forcefully hitting the head or having an object pierce the skull.² Some of the TBI causes include:

• Assaults 
• Falls 
• Sport-related concussions
• Vehicle/traffic accidents
• Work-related accidents³

TBI includes at least one of the below characteristics:

• Post-traumatic amnesia
• Loss of consciousness
• Disorientation and confusion
• Neurological signs (present in more severe cases) such as visual field cuts, new seizure onset/aggravation or a pre-existing seizure disorder, and insomnia, to name a few  ²

Against this background, TBI leads to high social and financial costs, creating a considerable financial burden.³

Symptoms and classification

The symptoms of TBI can be categorised into mild, moderate, and severe, depending on the severity of the brain damage. Some of them are summarised below: 

• Mild TBI – patients either retain consciousness or lose it for a few seconds to minutes. Some other symptoms may include dizziness, headaches, ear ringing, fatigue, altered sleep, blurred vision as well as cognitive/behavioural changes
• Moderate to severe TBI – patients may exhibit the same symptoms as the ones associated with mild TBI, but could additionally experience seizures/convulsions, vomiting/nausea, headaches that worsen/do not resolve, slurred speech and lack of ability to wake up from sleep²

TBI can cause long-term effects on behavioural, physical, social and cognitive function. Its influence on cognitive abilities can lead to issues with learning, memory and attention. ¹ Furthermore, TBI has been linked to changes in patient’s personalities and behaviour as well as mood/anxiety disorders and depression.^{4, 5} 

TBI and mental and emotional health

Psychological issues

The treatment and assessment of TBI commonly centers around physical and cognitive issues, however, psychological problems also significantly contribute to the rising disability. Major depressive disorder (MDD) and anxiety have both been observed in patients with TBI and linked to these injuries.⁶ Furthermore, there is literature exploring the TBI and post-traumatic stress disorder (PTSD) comorbidity and the underlying mechanisms, observed in military personnel who often experience both – TBI and emotional trauma.⁷ 

Below are some of the key relevant scientific findings in this area:

• A study, investigating the correlates of MDD during the first year after TBI, reported that 33% of patients with TBI involved in the study had MDD; 76.7% of them showed co-morbid anxiety and 56.7% aggressive behaviour⁵
• Important to note that patients with TBI, who were also diagnosed with MDD were more likely to have a history of mood/anxiety disorders compared to individuals without MDD⁵
• Patients with TBI, who were diagnosed with MDD also exhibited significantly higher executive function impairment (cognitive processes that help navigate everyday life, such as planning, and executing goals) compared to the non-depressed participants⁵
• Furthermore, MDD was significantly more frequent in patients with TBI compared to the control group, consisting of patients with multiple traumas (without the involvement of the central nervous system)⁵
• In another study, 29% of patients with TBI exhibited severe anxiety compared to only 2 controls without a mild head trauma history⁸
• Furthermore, around 29% of patients with mild to moderate TBI history exhibited moderate to severe depression, and merely 22.6% of them had minimal, or no depression⁸
• Patients with PTSD and TBI comorbidity have been shown to have more severe PTSD symptoms in comparison to PTSD-only patients⁹
• When controlling for the severity of PTSD, there were no significant differences between the two groups in terms of depressive symptom severity. This could suggest that the severe PTSD symptoms could be causing  the increased depressive symptoms in the comorbid group⁹

Behavioural changes

Behavioural changes after TBI are not rare, with more severe TBI cases suggested to have higher prevalence rates of these alterations. Some of the emotional/social changes include:

• Aggressive behaviour 
• Indifference 
• Impulsivity 
• Irritability 
• Poor communication/social judgement¹⁰

These behavioural consequences negatively affect both – the patients and their families. They can lead to difficulties in maintaining meaningful and close social connections including friendships, personal relationships or relationships with their work colleagues. Individuals who experienced TBI can also struggle to return to work or to reintegrate into the workplace, especially given the newly arising TBI-associated social difficulties.¹⁰

Some of the findings include the following:

• Compared to healthy participants, the TBI group was reported to perform significantly worse on all emotion recognition and intention understanding tasks as well as one response selection task¹¹
• A study assessing and comparing aggressive behaviour between patients with TBI and patients with multiple trauma without TBI reported that, throughout the first 6 post-injury months, aggressive behaviour was present in 33.7% of patients with TBI and 11.5% of patients without TBI¹²
• Furthermore, aggressive behaviour was significantly linked to alcohol/substance use history, major depression, frontal lobe lesions (lesions to the front part of the brain) and poor social functioning before sustaining TBI¹²
• With regards to impulsive behaviour, moderate to severe patients with TBI showed significant increases in lack of premeditation and perseverance as well as in current urgency, when compared to pre-injury condition¹³
• Study participants with TBI showed abnormally cautious risk-taking behaviour compared to healthy participants. Healthy individuals also exhibited increasing risk-taking throughout the Balloon Analogue Risk Task while patients with TBI did not¹⁴

The nature of this association 

While population-based studies, investigating behavioural health disorders occurring post-patient’s first TBI propose a significant link between the two, causality cannot be fully established. However, it has been suggested that, regardless of the location of the head injury impact, the frontal areas of the brain, such as the frontal lobes, are most likely to be impacted. Frontal area damage can further cause executive functioning and cognitive impairment, which would increase the probability of issues associated with behavioural health.¹⁵ 

In terms of post-TBI-associated mental health disorders, there is increasing evidence to support the hypothesis that TBI can frequently cause some, but not all of them. There is also evidence that TBI can cause anxiety disorders, bipolar affective disorder and MDD.

It is important to fully understand and establish the nature of this relationship. For instance, if TBI is shown to cause mental health disorders, this would be essential information for healthcare professionals in trying to observe and prevent the outcomes. On the other hand, it would also be helpful to understand if the patient’s post-TBI struggles are secondary to a mental health disorder rather than being caused by TBI.⁴ 

TBI management

Therapies used for TBI treatment include pharmacotherapy and psychotherapy as well as cognitive rehabilitation.¹⁶ Some of the pharmacological therapies used include the following:

• Tranexamic acid, hyperosmolar agents, anaesthetics, and antiepileptics are used in the acute phase
• Antipsychotics, zolpidem, amantadine, serotonin-reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are used in the post-acute phase for neuropsychological issue management
• Botulinum toxin and muscle relaxants are used for spasticity management¹⁷ 

Some of the other mentioned management strategies can involve:

• Physical therapy such as osteopathy or chiropractic treatment to relieve muscle contractions and spasms 
• Surgery for removal of the damaged/affected parts
• Acupuncture for pain reduction¹⁸

Psychological interventions have been reported to help patients in terms of cognitive rehabilitation and emotional impact management. This can be done by engaging in psychotherapeutic or psychoeducational programs. Cognitive-behavioural therapy (CBT) has been suggested to be the preferred therapeutic approach for patients with TBI to aid with emotional and behavioural disturbances. Some of the other proposed approaches include acceptance and commitment therapy,  dialectical behaviour therapies as well as mindfulness.¹⁶

Summary 

TBI is a form of an acquired brain injury that leads to brain function impairment, with some of its causes including falls, work-related accidents, assaults, sport-related concussions and vehicle/traffic accidents. Depending on its severity, some TBI symptoms involve loss of consciousness, dizziness, headaches, blurred vision, seizures, and slurred speech.

TBI can also lead to a variety of cognitive, behavioural, emotional and psychological consequences that can negatively impact the quality of life and contribute to TBI-associated disability. For instance, major depressive disorder, anxiety, post-traumatic stress disorder (PTSD), aggressive behaviour, impulsivity, irritability, poor social judgement and abnormally cautious risk-taking behaviour have been associated with TBI. 

Alongside pharmacological therapy, physical therapy and other suggested TBI treatment approaches (surgery or acupuncture, psychotherapy,cognitive-behavioural therapy) have been suggested to have the potential to help patients with TBI along with emotional and behavioural issues.