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

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.

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.

The effects of brain injury on the ability to function in relationships, self-awareness, self-regulation, fluency of expression of thoughts and feelings, and on the excitation and inhibition of emotion, result in long term personality dynamics. Identit changes, usually perceived as increasingly negative even as self-awareness improves, most often lead to impaired psychological functioning (Oddy, Coughlan, Tyerman, & Jenkins, 1985, Tyerman & Humphrey, 1984, Weddell, Oddy & Jenkins, 1980), which is identified as one of the major problems in long-term rehabilitation of people with head injuries. Armstrong (1987) compared the MMPI profiles of documented cases of cerebral dysfunction who also had chronic pain, with a comparison group of chronic pain sufferers, with only apparent cerebral dysfunction (pseudoneuropsychological), and with a control group of chronic pain sufferers with neither behavioral nor neuropsychological signs of brain injury. What set the brain injured subgroup apart were response on the Minnesota Multiphasic Personality Inventory which suggested insecurity, psychological instability, and social isolation, all more so than in the other two chronic pain comparison groups who also suffered from chronic stress and disability. Those with cerebral dysfunction had significantly elevated levels of depression and anxiety, presented themselves in a negative light, tended to withdraw from social interaction, and had diminished self-esteem. We would expect the chronic pain population to also suffer from these problems, which they do more so than a healthy population who are not faced with the daily challenge of coping with chronic disability. But why do the brain injured suffer these consequences even more? Both groups have permanently altered identities, permanently changed life styles, greater dependency to deal with, frustrations, job loss, and physical pain. There are a number of answers to the question of why the brain injured have even higher levels of psychological distress, but at least two are directly related to the presence of neurological injury. Some emotional reactions, such as depression, denial, and increased anxiety, are direct results of the location of the injuries in the brain. These injuries also require the development of new ways of coping.

After brain injury we seel diminishing of some flexibility, inability to bounce back, lack of a acceptance of problems in stride, difficulty ignoring irritations and frustrations, and reduced capacity to develop new coping strategies. Thus when we see a severely injured patient who responds with humor, determination, or eve arrogant self-belief, we should prescribe the symptom, rather than try to cancel it. It represents the reemergence of the ego, and the building block of a new coping ability.

Neurological Aspects

The frontal lobe has long been thought of as the seat of reason and will, but it roles in the mediation of emotion are more recently understood. The early lobotomies, used to quell the agitated behavior of psychiatric patients, were seen as panaceas. However, because thought and emotion are inextricably linked, the destruction of brain areas which stimulate affect also caused inertia of thought, perservation, aspontaneity, and lack of concept formation and of thought planning. Healthy emotion, reasoning, and goal exploration are dependent on frontal lobe connections with the limbic system, with the basal ganglia and forebrain, with other cortical areas, and reciprocal connections within itself. Emotional reaction is a collaboration between the left and right, superior and inferior areas of the frontal lobe, each which stimulates and inhibits positive and negative emotions. In addition to its higher cognitive processing, the frontal lobe mediates the underpinnings of consciousness and emotional expression, such as arousal, anxiety (Gur, 1983) and pleasure.

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.

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.

Robinson and Szetela (1980) examined the occurrence of depression after a unilateral cerebrovascular accident in relation to the location of the injury. They related depression post injury to dysfunction of the frontal lobe in humans (Lipsey, Robinson, Pearlson, Krishna Rao, & Price, 1983, Robinson, 1987, Robinson, Lipsey & Price, 1985). The greater the degree of depression, the closer were the injuries to the left frontal lobe. (Depression was more highly correlated with left than right, anterior than posterior, and left frontal than right frontal injuries.) A study (Ahern & Schwartz, 1985) of the localization of emotion in uninjured brains provided interesting evidence of the brain's organization. The use of EEG spectral analysis revealed that in frontal zones, there was greater left hemisphere activation or positive emotional reactions (e.g., excitement and happiness) and relative right hemisphere activation for negative emotions (e.g., fear and sadness). Although there appear to be conflicting results on laterality of emotion, this disagreement seems to reflect the way emotions are measured. Many studies have found lateralized differences (Ahern & Schwartz, 1979, Schwartz, Ahern & Brown, 1979, Schwartz, Davidson & Maer, 1975, Tucker, 1981, Tucker, Stenslie, Roth & Shearer, 1981), and most studies have linked the mediation of negative and positive emotions to the right and left hemispheres respectively. However, a new thrust in the study of the laterality of emotion and psypathology is the linkage of depression with posterior right hemisphere injuries (Finset, Goffeng, Landro, & Haakonsen, 1989). Another functionally-based dynamic may be the relative left and right contributions to excitation and inhibition of emotion, and research is recommended in this area.

Studies of the lateralization of emotion in non-brain injured and brain injured subjects suggest that depression may result from injury to either hemisphere, although qualitative differences exist. Depression characterized by anxiety, fear, and sometimes agitated, hostile, or aggressive behavior can occur in right hemisphere dysfunction, while depression characterized by sadness, lethargy, and perseverative feelings can occur with left hemisphere dysfunction (Von Knorring, 1983). Injury in one hemisphere not only means that some emotion is not being stimulated, but also that the injured side is not inhibiting the uninjured side and thus is being overriden by the intact frontal hemisphere. In non-brain injured persons, left hemisphere excitation has often been correlated with positive emotions, while the right hemisphere has responded to affective stimuli most often with negative emotions (Davidson & Schaffer, 1983, Sackheim, Greenberg, Weiman, et al., 1982). A more comprehensive review of the literature on lateralization of emotion can be found in Flor-Henry & Gruzelier (1983).

Another aspect of post-injury emotional reactions to be considered is the corter's sensitivity to stimuli from the environment. Changes in the threshold at which stimuli are perceived as well as the degree of pleasantness of the stimuli can easily affect human relationships. In addition, arousal and internal reactivity are necessary for personal expression. The left anterior hemisphere, when injured, has been found to result in dysfluency of thought and word, which makes it difficult for injured persons to express thoughts and feelings in words. They are more likely to experience a catastrophic reaction and, in fact, appear to be more sensitive than those injured in the opposite hemisphere alone. Galvanic Skin Responses (GSR) increase in relation to stimulation, making the stress reaction overly sensitive (Valenstein & Heilman, 1979). In addition, injuries to language expression areas of the frontal lobe can reduce the individual's ability to regulate their orienting reflect and arousal via verbal mediation (Luria, 1964). This has implications for the limited usesfulness of traditional psychotherapy with individuals with these injuries.

On the other hand, when persons injured in the right anterior hemisphere lose the ability to express the tonal, inflective, or nonverbal aspects of emotion, they sound flat and uninterested. Defending on the exact site of injury, there may also be inability to perceive emotional signals from others, as was the problem in the example given initially. These problems are very frustrating for caretakers as it renders the injured individual insensitive, in contrast to the left hemisphere injured person. In addition, the right anterior hemisphere injured patient may appear indifferent and unemotional, unable to express emotion in tone or gesture, although they are indeed experiencing emotion. In this case, the GSR response decreases (Valenstein & Heilman, 2979), and arousal mechanisms shared with the frontal lobe may be overly inhibited.

These differences--emotional, perceptual and cognitive; receptive and expressive--between the hemispheres cannot be related to severity of deficits, and the differences exist regardless of the overall severity of the injury. However, we must also remember that the acquired injury to one hemisphere can create disruptions in the functionining of the other hemisphere due to diaschisis (dysfunction due to lack of normal afferent impulses), metabolic disturbance, or edema. In head injury, some disruption of both hemispheres is most common. These problems are usually found nearly in the more severely injured, and as very subtle changes in the more mildly injured. Positive psychological and cognitive interventions can help relink the disassociation of emotion and thought. (Grisgby, 1986).

Rehabilitation

For persons with head injuries and their families, what counts most in the long run are cognitive and personality changes, rather than physical disability (Bond, M., 1976). It was suggested by Weddell, Oddy and Jenkins (1980) that rehabilitation centers should relinquish their emphasis on physical recovery, develop more effective retraining for those with mental changes, and emphasize ways of helping patients and relatives adjust to what cannot be mended. Adjustment problems and emotional imbalance may increase when injured people get to rehabilitation units after long delay, for too short a time, or not at all. A study on early rehabilitation interventions done at Santa Clara Valley Medical Center in San Jose found better outcomes inpatients admitted earlier than in those admitted later to rehabilitation (Cope & Hall, 1982).

Few studies have been done to assess the outcome of rehabilitation (Cope & Hall, 1982, Miller, 1980, Miller, 1984, Rimmele & Hester, 1987, Tyerman & Humphrey, 1983). The cost associated with treating brain injured persons are increasingly problematic (Deutsch, 1987, Kalsbeek, McLaurin, Harris, & Miller, 1980), and studies of the effectiveness of rehabilitation are sorely needed. England has developed 25 years of experience in brain injury rehabilitation, and has recognized the importance of psychological rehabilitation. HEADWAY, a program for head injured patients in England, conducted a follow-up study of groups of ex-patients who had 12 and 24 weeks of inpatient treatment on average at two different rehabilitation centers. They (Tyerman & Humphrey, 1983) showed that while the longer course did not give more functional independence than the shorter, it did produce modest improvement in personality and behavior. However, at follow-up, 35 weeks after discharge during which time the ex-patients received no treatment, the emotional states of patients of both groups had worsened. Staff had expected 80% to become independent in self-care and capable of productive work. Most had failed this expectation. They concluded that the primary problem was failure to address the most basic underlying need, which was the continuation of structured yet flexible, individualized rehabilitation environments for these individuals.

Studies have shown that manu ex-patients stay at home doing nothing after rehabilitation has ended with much distress accompanying the social isolation and lack of productive work (Ben-Yishay, Silver, Piasetsky, & Rattok, 1987, Prigatano, et al., 1984). Disturbances of motivation, the ability to cope flexibly, slowed fluency of thought or disturbed reasoning and judgment have neurological bases in the brain. These mental changes leave individuals with great difficulty in self-structuring, planning of activities, and organization of their lives. Long-term psychological and cognitive help as well as special work training opportunities are a great need.

Behavioral Management

"I find the methods (of behavior modification) distasteful but they seem to work in head injury" (Gloag, 1985, p.913). Family members are often concerned about giving structured responses to patients which they fear will be just one more negative restriction on the patient. Correct use of behavior modification is motivating to patients, and behavior modification programming is often used with persons with head injury. The purpose of behavior modification plans is to structure the environment in a way that enhances the recovery process. Behavior modification plans are not primarily to control or punish, but to rehabilitate. They teach self-control to a disinhibited mind. They teach new skills and routines to one wit unstable motivation. They provide overlearning. They help the patients anticipate future events, an ability often impaired in patients with traumatic brain injury (Freedman, Bleiberg, & Freeland, 19876). Behavior modification plans also address the need for increased attention related to ego needs, by replacing negative attention with positive attention. The patient is shown what behavior will be rewarded. The psychologist provides structure which limits the cognitive field and thus decreases the patient's confusion while making choices.

If the structure is relevant to the impairment, then long-term change will result. Often the positive attention component is the most powerful, and plans will suffice simply if based on this factor. Patients have difficulty interpreting interactions with others because their integration of their perceptions is impaired and they cannot easily see alternative viewpoints. Their view of staff, from the vantage point of injured and overcontrolled hospital patients, is also tarnished by their frustration with their restrictions and with their many losses. They more often experience the environment as well as internal signals as negative, painful, punitive, or not worth the effort of compliance. They require a very empathetic environment which builds their ego resources. For example, a patient was recovering from a severe injury, and was not yet able to identify or express her thoughts and feelings adequately. She very much needed attention, and sought it in the only way she knew, which was to whistle, swear, and make other noises incessantly. By angering the other patients to whom her behavior was irritating, she elicited hostile reactions from them. This provided her with more negative attention which was apparently not really meeting her needs. The treating team tried several behavior modification methods with her such as withdrawing attention from her actions, isolating her so she was not reinforced by other patients, and rewarding her with favorite foods or activities. However, all these plans failed. Finally they tried "affection therapy". Affection therapy consisted of frequent and regular reminders to her that she was wanted and cared about, especially focusing on physical signs of affection. Thus, staff would give her a hug and a friendly comment before and after every interaction with her, regardless of her performance. The unconditional reward of affection very quickly caused her to cease her annoying behaviors, because she was receiving the kind of positive attention she really needed.

A number of factors determine how effective behavior modification methods will be. For example, patients with anoxia, due to varying etiologies which often accompany head injury (e.g., cardiac arrest and respiratory distress or arrest, or ischaemia from the breakage of small blood vessels in the brain) or those with longstanding psychiatric problems, may not respond well (Gloag, 1985).

In general, behavioral methods work better if: (1) they are provided soon after the problem emerges rather than later, before problems have worsened; (2) they can prevent rejection of the behaviorally disturbed from rehabilitation settings; and (3) they can be used in the patient's and family's natural environment. Delayed or absent treatment of behavioral problems is one of the most common problems learned from working with outpatient families and a family support group. An unfortunate example of the results of no behavioral therapy where it was warranted is the case of a patient who became extremely combative and destructive after a severe head injury and exhibited bizarre and dangerous behavior. Eventually he regained the ability to process the environment, and was able to talk and ambulate. He returned home but had difficulty modulating his frustration and expressing his thoughts and feelings. His need for attention and affection was great, and he sometimes competed with his sister for their parents' attention, even though the patient and his sister were both in their late 20s. Sometimes he would grab or push her, because he knew of no other way to express his feelings when he was anxious. This family needed a psychologist to work with the family as a whole, to teach each member how to set limits with him consistently. However, the had no source of payment for this service. Families need support from insurance companies and other payors of services for outpatient psychological therapy for patients' behavioral problems as well as family therapy to set up a systematic behavioral approach. Patients and families will also benefit if we stop taking behavior modification for granted. Behavior modification has multiple purposes and uses: it can not only be used to reduce problematic behavior, but can be used to support patients' involvement in rehabilitation therapies. In other words, it's a strategy for "peacetime" as well as "war".

Examples of behavioral management approaches which can be used with denial and depression can be found in a training manual for rehabilitation specialists (Armstrong, Patterson, Peterson, & Long, 1985). Issues of the patient's awareness are interrelated with adaptive responses, resulting in a broader understanding of behavior, as well as recommendations for treatment strategies.

Family Reactions

Family reactions to traumatic brain injury are likely to follow a developmental course, beginning with a response to acute stress which is reactive and crisis-oriented. This means the family can mobilize resources to meet the new challenges. This acute response will be followed by the varied patterns of response to prolonged stress, characterized by a continuum of adaptive to maladaptive responses. An inevitable cost to continuing performance of "normal" roles despite a continuing high stressor, is depression. Depression following head injury is epidemic in families perhaps due to prolonged states of fear and stress, and an underlying sense of frustration and helplessness which cannot be expressed or revealed. Families involved in supportive services have all pointed to the trauma caused by the constant changes in acute-care trauma treatment. In any case, depression has been found in relatives regardless of the severity of the injury or the duration of the patient's hospitalization. Oddy, Humphrey, and Uttley (1978) studied the emotional reactions of families, and found that the severity of the mood disturbance in relatives was found to correlate with the confusion (forgetfulness, disorientation), and verbal expansiveness (talking too long, too loud, too illogically) of the patient.

Fears about the patient's present and future preoccupy the stressed relatives. Present concerns may be about poorly controlled behavior, the possibility of seizures, and the physical and mental exertion required to care for the disabled family member. Ambiguity naturally leads to anxiety. It is no wonder that family members have difficulty trusting professionals under these conditions, or that they persevere with their own judgments.

Although families differ in their acknowledgment of the magnitude of problems, they all feel stressed when pondering the patient's future. Unanswered questions and uncertainties far outweigh known problems until long after the injury, often several years later. In the Oddy, Humphrey and Uttley study (1978), 25% of relatives reported an illness in themselves during the last six months of the first year after the injury, and these illnesses, in the majority, were psychosomatic or emotional in nature. Overall, this study found that the stress on relatives as a group showed no sign of diminishing over time.

Lezak (1978) describes the stresses upon families in a way that makes more clear the nature of the stressors, as well as the ways we can help family members.

Caretakers may feel guilty as a result of an expanding consciousness about the patient's multi-faceted problems without the knowledge or resources to provide solutions. Family members often feel guilty about not being able to protect the patient from physical and especially psychological pain. The problems endured by the family usually have the greatest effect upon the family member who has the primary responsibility for the care of the patient (Lezak, 1978).

The caretaker's personal needs, interests, and even individuality may become submerged with the needs of the patient. For example, more than one family has been known to turn the living room of their home into the bedroom of a non-ambulating patient. Also well known are family members who develop new relationships based on the suitability of the relationship to the patient's needs.

Family members may find few people or no one who can understand and communicate empathy (Lezak, 1978). This is the foremost reason why family support groups are vital, as they provide a setting where each member is understood, supported, and where information can be found. Families are dealing with injured individuals who may behave in unpredictable and embarrassing ways, who may become agitated or confused by unfamiliar places or persons.

The loneliness of family members brings to focus the dynamics of the remaining healthy family members, and tests people's loyalties and empathies. Family members may feel "abandonment by the extended family" (Lezak, 1978, p.593). More distant or even closer relatives may withdraw over time as requests for occasional help and the patient's chronicity become apparent.

Without the day to day experience of the patient's irresponsibility, impulsivity, or other problems, or of the duties, other relatives as well as we, can easily misperceive the caretaker as being too protective or restrictive, or too neglectful or uncaring. Examples of this are unending, and even those professionals who are most committed or most caring can make these mistakes. Only those who have experienced the daily vigilances of care and worry are likely to be fully grateful and emotionally supportive of the family's accomplishments in fostering the patient's improvements.

The spouse's mourning may not be legitimate in the eyes of society even though he or she has surely experienced a traumatic loss and an extended period of grieving (Lezak, 1978). Their grief is similar to the family response to bereavement described in the literature on death and loss.

The spouse also has no sharing partner nor is free to get one. The intact spouse may feel the need of a more supportive partner, but is unable to elicit this quality from the injured spouse.

"The spouse cannot divorce with dignity nor in good conscience. Gratitude, fond memories, feelings of responsibility, guilt, and fear of social condemnation contribute to the reluctance" (Lezak, 1978, p. 593) to divorce the injured mate. Moreover, brain injury not infrequently prolongs an unhappy marriage due to bonds of guilt, feelings of helplessness, and fears of disapproval. The uninjured spouse is forced into a parental role, at times. The rules for this parenting role are not clear, however, and unpredictably interact with the need to give the patient independence. Rarely does the patient provide the leadership and nurturance which helped form the relationship. Spouses almost unanimously remain "undercover" about their feelings and personal needs. They are difficult to reach by giving them "permission" to protect themselves. A better strategy is to help a spouse focus on normalizing his/her relationship with the patient as early as possible, and then deal with the resulting problems in individual and couples' therapy.

Patients tend to be much more needy than they are able to provide love and comfort. The patient's own sexual competency may be far different from their demands for sexual attention, and he or she may make incessant sexual demands regardless of feedback from the spouse. The injured person may perform in a one-sided way, without regard for the partner. Lack of sexual relations may be easier to live with than overactivity.

Finally, mention must be made of the plight of the young children of an injured parent. The crises of the injury and possibly multiple hospitalizations often absorbs the parent's attention completely, and children are inadvertently ignored. Children will predictably develop angry feelings about their radically changed parent and decreased parental nurturance. A child's assertion of a need for attention and affection may come into direct competition with the patient's own demands, and both child and parent may compete for the uninjured parent's attention. Many children will either perceive no opportunity or lack the ability to express their feelings about their catastrophically altered world. However, they also have an uncanny ability to know that their uninjured parent needs help, and will offer their aid, mixed with their desire for personal involvement and attention.

Depression in family members may be a fixed emotional burden, and for others it may come and go with the patient's ups and downs, and the amount of freedom and satisfaction which they themselves can gain. Even family members who have good understanding of their depression may at times worry about their worth and mental integrity. Among these families, depression is natural and expected. These feelings must be faced in order to turn a reactive emotional disorder into an adaptive response which leads to change, growth, and preparation for the future.

Summary

Depression, denial and anxiety have all been examined with neurological, reactive, and adaptive explanations. Rather than take a reductionistic approach, it's been recommended to knit these explanations together to understand how emotional response to brain injury is truly dynamic. Interpersonal communication and relationships are very sensitive to disruption in the patient's emotional balance and coping ability. Thus, this area deserves the closest examination when trying to understand the brain-behavior of emotional and personality change. Patients often are less capable of evaluating themselves, anticipating problems, initiating resolutions, or surmounting their own feelings. Changes are often found in sensitivity, arousal, and the ability to inhibit or stimulate emotion so that it matches a situation or the consequences of behavior.

Family reactions to emotionally changed patients are also dynamic, but are likely to result in grief, depression, and often, somatic illness in family members. However, their emotional changes may be misinterpreted and untreated.

Rehabilitation and behavioral management, though lacking empirical evidence of its global efficacy, have been found to address important psychological needs of patients. They provide structure, timely and appropriate reinforcement, motivation, and explanations of patients' functioning.

Depression, denial, and anxiety in persons with acquired brain injury have varied faces and may appear as anger, apathy, agitation, or impulsivity. There is often a separation between experience and expression due to the frequency of frontal and temporal lobe injuries. Patients are often not able to integrate perceptions with thoughts, thoughts with emotions, and emotions with words or affect. The three faces of emotional change in brain injured persons are due to neurological damage, ego injury and defensiveness, and adaptive response.

The neurological bases for a flat depression are thus far associated with dorsolateral and left frontal injuries. An agitated depression with components of inappropriate anger, anxiety, and disinhibition are associated with right hemisphere injuries. The ego reactive bases of depression include ego injury, loss of sense of self, and fears and anxieties related to lack of control. Adaptive bases of the more familiar left hemisphere depression are acknowledgement of the worst, or the breaking down of denial. This is necessary to permit the adaptive and constructive ego to emerge so that a sense of self-persistence of one's beliefs and values, as well as personality, can redevelop.

The neurological bases for denial have been known longer than those for depression. Specific syndromes are associated with areas of the right hemisphere. Right frontal injury results in the inability to understand underlying or metaphorical meanings, inappropriate affective reactions, and disinhibition of anxiety which may lead to impulsivity. Right temporal injury often affects the ability to understand intention and emotional signals in speech. Integration of emotion, memory, and sensory experiences are also the function of the temporal lobes. Right parietal injury results in slower reaction times, and altered ability to attend to sensory information and events bilaterally, though with greater affect on the left body side. Right occipital injury results in loss of the visual field on the left, but also the ability to make sense of some visual stimuli perceived, such as facial affect or facial characteristics. Denial in most patients also includes an unwillingness to give up control, social place, identity, and value in the eyes of the self and others. Fears of uncontrollable loss and unpredictability may combine chaotically with disinhibited anxiety and disintegration of affect. However, denial has adaptive bases as well, primarily, the prevention of a catastrophic reaction. The more awareness a pawtient has, the more likely depression will affect motivation and self-belief. Paradoxically, denial helps to maintain emotional stability and motivation.

In a sense, a general systems approach is needed to analyze emotional changes accurately. Rehabilitation specialists will work with patients and families during the stages when explanations of emotional redevelopment are most needed.

References

Ahern, G.L. & Schwartz, G.E. (1985). Differential lateralization for positive and negative emotion in the human brain: EEG spectral analysis. Neuropsychologia, 23, *6), 745-755.

Ahern, G. & Schwartz, G. (1979). Differential lateralization for positive versus negative emotion. Neuropsychologia, 17,693-698.

Armstrong, C., Patterson, T., Peterson, S. & Long, D. (1985). Guidelines for the behavioral management of the head injured person: A further understanding of behavior and treatment techniques. Malvern, PA: Bryn Mawr Rehabilitation Hospital.

Armstrong, C. (1987), Personality characteristics of the brain injured in the context of chronic disability: A comparison of neurologic and pseudoneurologic rehabilitation patients. Paper presented at the National Head Injury Foundation Annual Conference, San Diego, December, 1987.

Babinski, J. (1918). Anosognosie. Rev. Neurol., 2, 365-366.

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CAROL ARMSTRONG, Assistant Director of Psychology, Bryn Mawr Rehabilitation Hospital, 414, Paoli Pike, Malvern, Pennsylvania 19355.
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Author:Armstrong, Carol
Publication:The Journal of Rehabilitation
Date:Apr 1, 1991
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