The presentation of behavioral health difficulties resulting from a traumatic brain injury (TBI) are often seen immediately after the injury and may linger for an indefinite period of time. Psychiatric symptoms and behaviors present challenges to the patient, family and treating clinicians. Psychological trauma resulting from the event that led to the TBI, such as combat associated explosions, motor vehicle accidents and serious falls, can cause post-traumatic stress disorder (PTSD) which may complicate recovery.
According to Brian Bronson, MD, Clinical Associate Professor and Director of Consultation and Liaison Psychiatry at Stony Brook University’s School of Medicine, neuropsychiatric manifestations of a TBI generally appear early after the injury.
“Persons with a severe TBI with a prolonged loss of consciousness often awaken with an initial period of delirium,” he notes. “This generally includes impairments in multiple domains of cognition, such as attention, orientation, memory and executive function, and may also include behavioral disinhibition and affective instability among other psychiatric symptoms.”
According to Bronson, medical and surgical providers working with patients in intensive or acute inpatient medical and surgical settings often describe the behavior as agitated. Disorganization of behavior, including pulling out of intravenous lines is also common, making the immediate care of the patients challenging for nursing staff when trying to ensure patient safety and proper care. Families may express concern and ask questions about potential long-term personality change. Educating families early on about the potential short and long term effects helps to mitigate frustration with the injured person and sets realistic expectations of long-term outcomes.
With TBI, the brain can suffer direct and indirect injury, resulting in different types of residual effects. More specific neuropsychiatric changes often reflect the particular location of injury to the brain. Frederick Gutman, MD, Assistant Professor of Clinical Neurological Surgery and Orthopedics at Stony Brook University’s School of Medicine, noted that the brain can be left with areas that are irreversibly damaged, as well as areas that are partially damaged, which have the capacity to recover some of their functions. It is this information and detail that patients and families seek in an effort to hold onto the hope that a full recovery is possible.
According to Bronson, the severity of the initial cognitive and behavioral disturbances will often fluctuate throughout a given day and may be marked by periods of relative lucidity. Over the days and weeks following an injury, the initial delirium will generally improve, leaving behind more stable behavioral and cognitive deficits which are themselves expected to show some further improvement over the ensuing weeks to months.
Gutman also says, “The recovery period can be prolonged, with patients continuing to improve their function 2 years or longer following their injuries. The long-term behavioral effects of brain injury depend on which areas of brain were injured and the extent of recovery.”
Patients with TBI can be left with a variety of problems related to comprehension, language, memory, judgment, weakness, coordination, mood and others. They can develop seizures. Rehabilitation focused on speech, psychological, physical and occupational therapies can improve the extent and speed of recovery.
Medication can help with seizure control, wakefulness, mood, pain and other symptoms. Some functions may recover to normal but with limited capacity. Stress from fever, illness, fatigue and emotional distress can make seemingly recovered functions worse. As noted earlier, TBI is often accompanied by PTSD. Military veterans with a TBI suffered in combat, or an individual with a brain injury as a result of an episode of domestic violence, offer clear examples of how PTSD symptoms can impact recovery due to these added psychological stressors.
Post-injury substance abuse
It is not unusual for the effects of a TBI to be frustrating for the patients, families and caregivers and cause difficulty in these relationships upon the patient’s discharge from the acute care setting. According to Gutman, “Many patients need help adjusting to their inability to perform and function as well as they are accustomed to, even though they may feel relatively normal.”
Andrea Kabacinski, MS, RN, Interim Associate Director of Nursing for Neurosciences at Stony Brook says, “There is often a disconnect between thinking, action and behavior, resulting in a difficult transition to post-injury living.”
There is also a high incidence of substance abuse among those with TBI. Regardless of whether the substance use was directly associated with the injury or developed as a maladaptive coping mechanism post injury, it is something that cannot be overlooked as it pertains to the patient’s overall health, wellness and continued recovery.
Follow-up with brain injury professionals such as neuropsychologists, neurologists, psychiatrists and diverse rehabilitation specialists will assess the patient's progress and adjust treatment to maximize recovery. Depending on the patient’s prognosis, a treatment plan should be implemented to address not only the physical aspects of recovery, but also community reintegration, social and educational rehabilitation, needed housing adaptations, family supports and vocational services.
Community agencies who serve individuals with mental health and substance abuse difficulties, particularly returning veterans, must prepare their staff to understand the nuances of TBI and the crossover with behavioral and psychiatric manifestations, especially those resulting from combat situations. When individuals with TBI are referred to these settings as part of a plan for psychosocial and vocational rehabilitation, families are sometimes concerned due to the stigma associated with behavioral health.
The importance of patient and family education cannot be emphasized enough to ensure that this type of fear does not prevent the injured person from accessing what may be a necessary and positive contributor to long-term recovery. The key to a successful rehabilitation includes the input of an interdisciplinary team and participation from the patient and everyone involved in his or her life. A patient, supportive and consistent approach is ideal.Kristie Golden is Associate Director of Operations for Neurosciences, Stony Brook Medicine and Vice President of the Board of Directors, Association for Mental Health and Wellness
Centers for Disease Control and Prevention
Veterans Administration practice guidelines relating to brain injury and PTSD
Defense and Veterans Brain Injury Center