Mental health and TBI

i) The many meanings of "depression"

One of the most common mental health problems that you can get after a brain injury is a condition called depression.

"Depression" is a very tricky word because it has different meanings.

"Depression" can describe a symptom - I feel depressed.

"Depression" can also be part of an illness a person can; for example, with schizophrenia have depressive symptoms.

"Depression" is also used by psychiatrists and psychologists as a description of an illness - a depressive illness.

These many uses of the word "depression" can be confusing.

If I say - Oh I feel depressed todaythat does not necessarily mean I have a depressive illness.

It is usually the job of the psychiatrist or psychologist to make the diagnosis of a depressive illness.

Image: The Starry NightVincent van Gogh 1889

ii) Depressive illnesses

When psychiatrists talk about depression they use a number of different words to describe different types of depressive illnesses but the common ones that a psychiatrist might talk about are:

• a major depression
• a minor depressive illness.

Psychiatrists use these terms to try to communicate to other doctors or health professionals what we mean as psychiatrists. The types of treatments we might use are also often influenced by the type of diagnosis a person has.

Depression can be a reaction to a situation.

For example: our boyfriend leaves us or someone who we really care about dies, and we might develop a depressive reaction.

Depression however can also be a biochemical imbalance.

There are particular chemicals in the brain that are important for our mood. If we get a disturbance in that balance of chemicals we can develop a depressive illness.

iii) Depression and brain injury

Often depression that people get after a brain injury is a combination of chemical/biological changes and a reaction to the person’s new situation.

We know that depression is a lot more common after a brain injury. Studies estimate that up to one third of people suffer from depression following brain injury.

Depression is common in the community - about 1 in every 10 people will at some stage get a depressive illness.

If you have a brain injury your risk for depression increases by about 2 to 3 times that of the community rate. Therefore a lot of people who have had a brain injury are going to, at some time, develop a depressive illness and they are going to need treatment.

The earlier after the brain injury a person develops depression the more likely it is going to be due to a disturbance of chemicals in the brain which has happened as a result of the brain injury.

Depression is probably one of the most common types of mental health problems that someone will have after a brain injury.

i) A generic term for a group of symptoms

Psychosis is a generic term for particular group of symptoms that can include hallucinations, delusions and disorder of thought processes.

Hallucinations

People who have a psychosis may have hallucinations. That is where they see or experience things that are not happening in reality. Auditory hallucinations such as hearing voices are the commonest types of hallucinations that people get.

Delusions

Delusions are when people have an abnormal idea. They believe this idea and despite giving them evidence to show that their idea is not true or valid they still hold the idea. For example, a person might believe that they are being poisoned. Any type of food that is given to them they are not going to eat because they think that food is poisoned. No amount of reassurance is going to stop them thinking that they are being poisoned. That i s what we call a delusional idea.

Thought disorder

People who have a psychosis can have problems organising their thoughts which means that when they speak it does not make a lot of sense. Psychiatrists call this thought disorder. Thought disorder is rare in a psychosis that happens after a brain injury. However people who have a brain injury can have problems just organising their own thoughts without having a psychosis so it is always really important that if you think a person is having some of these symptoms to talk to a health professional about it.

    Image Courtesy of Peggy Cyphers, New York

ii) Psychotic illnesses

Some of the typical terms that you might hear when a person has a psychosis are:

• schizophrenia
• bipolar disorder.

The common feature between both of these illnesses is that a person can have psychotic symptoms.

When people have a brain injury their psychotic illness is very different to schizophrenia and bipolar disorder in a person who does not have traumatic brain injury. We know that over the longer term they do not have the same kind or number of episodes of illness as someone without a brain injury who has schizophrenia or bipolar disorder might have.

A lot of the people with a brain injury who also have a psychosis become very upset when someone suggests that they have schizophrenia because they themselves know that their illness is different but there are some characteristics that can be similar.

It can be sometimes very hard to distinguish between schizophrenia and a person who has a psychosis because they have had a serious brain injury.

Psychosis in the community generally is pretty rare, only about 1% to 2% of the population will ever have a psychotic illness.  (This is schizophrenia and bipolar disorder added together). But if you have a brain injury, your risk goes up by about 2 to 3 times, so about 3% of people who have a brain injury might develop a psychosis at some stage after the illness.

The closer the psychosis occurs to the time the person has had the brain injury the more likely doctors are to say that the psychosis happened because of the brain injury.

You may have a family member who got knocked on the head when they were about 11 or 12 and then when they were in their mid-20s they developed a psychosis. It is unlikely that the brain injury in this situation has caused the psychotic illness.

Psychosis is always caused by a chemical imbalance and so medication is always going to be part of the management of this illness.

iii) Difficulties in diagnosis

Psychotic illnesses can be hard to diagnose.

Mental health professionals need as much information as they can get to help them make a diagnosis.

One problem with diagnosing psychosis is that the symptoms are ones that most people know mean that you are mentally ill. For example, most people in the community knows that hearing voices means that you are mentally ill. So people are going to be very embarrassed about talking about hearing voices. If they have ideas that are delusions then they are going to stop telling people about the delusions because they are tired of hearing someone say – “Oh well that is not true, that is rubbish. Do not talk about that.” So they do not.

Th is proves to be a real challenge for the mental health professional because if they do not hear about the symptoms it is difficult to make the diagnosis.

Another problem with diagnosing psychosis is that a person can often control the symptoms or not talk about them when they are seeing the mental health professional. So if a member of your family has the type of symptoms described earlier, hallucinations, delusions, then it is important to go along and tell the mental health professional what you know about what they are doing. It might be the only clue that there is something more serious going on.

It is possible for a psychiatrist to talk to someone and think , oh I cannot find anything wrong with that person. What am I going to do? And then the family member or carer will come in and say you know they are doing this in the middle of the night, they are locking all the doors, they are talking about people breaking in and then the psychiatrist can ask more questions of the traumatically brain injured person and find out the kind of symptoms that are important for making the diagnosis.

v) Psychosis and brain injury

A psychosis can start any time after the brain injury but the usual rule is that the closer to the time of the brain injury the more likely it is to be caused by the brain injury.

Damage to the temporal areas of the brain is an important reason why people can get psychotic illnesses.

Psychosis and marijuana

Marijuana or cannabis can have a role in starting off a psychosis.

It is common to see young adult males ( because men seem to smoke more marijuana than women), who used to be able to smoke marijuana before their brain injury without any problems.  After their brain injury they tend to go back to smoking the marijuana because they are bored, it gives them something to do, it stops them from feeling restless and agitated. But now they develop a psychosis.

We do not know why this happens but we do know that it is a common problem.  If the person stops smoking the marijuana the psychosis does not go away. So it develops a life of its own and then you need to have treatment for the psychosis. If people smoke marijuana while being treated for the psychosis then the medication does not work as well.

Psychosis after a brain injury is not like schizophrenia

Most people with schizophrenia develop the illness when they are young adults between the ages of 16 and 25.  When people (with no history of schizophrenia) develop psychosis after brain injury this is a different kind of illness course to schizophrenia. So someone who is 40 can develop a psychotic illness after a brain injury. We do not really know what the risk factors are for developing a psychotic illness, apart from the fact that if you have temporal lobe epilepsy, you have had damage to your temporal regions of the brain and a family history of psychotic disorders you have a slightly higher risk of getting a psychosis. Sometimes the only sign of a person having a psychosis is that they are aggressive, very irritable and irrational in the conversations you have with them.

i) Anxiety conditions

There are many anxiety conditions that people can have but there are a few common ones that people have after a traumatic brain injury.

Phobia

Often people will have an anxiety about a particular situation, this is a phobia.  They might have what we call a car phobia. If you have had a serious accident in a motor vehicle you might get very anxious and frightened when you are in a car and we would call this a specific phobia or a car phobia.

Social Phobia/or Agoraphobia

At other times people might get anxious about being out in public, they could have a social phobia or agoraphobic, something called panic attacks.

Obsessive compulsive disorder

They may have obsessions and compulsions or have what we call obsessive compulsive disorder. There are lots of movies made by Hollywood about obsessive compulsive disorder,  so often it is an illness that is quite easily recognised by family members.

But it is important to know that many people after a brain injury because they are forgetful, tend to be very ordered and particular about how they do things. So they might have some obsessional features but they do not have an obsessive compulsive disorder. They have what is called “organic obsessiveness”. There is some evidence from research that memory problems can increase the checking symptoms of OCD.

If you are worried that the person might be more obsessional about things than they or you think that it is causing problems, this is when you go and speak to someone about it, be it the rehabilitation team member or someone within the community or your family doctor.

Posttraumatic stress disorder

Post traumatic stress disorders can develop in people when they have been in a really bad experience. People who have posttraumatic stress disorder often relive aspects of the trauma. They will avoid situations where they might get memories of the trauma. They may not want to talk about it, they can be quite jumpy and nervous.

Anxiety disorders following a traumatic brain injury can be a combination of a biochemical problem and a reaction to the situation

That gives us clues as to how we take care of people with anxiety problems.

Image: The Scream Edvard Munch

ii) Anxiety disorders

Anxiety disorders are common and they are often missed in people with traumatic brain injury.

The reason they are missed is that people often see anxiety as being normal in a particular situation. So for example if the person has had a car accident and they are anxious about being in a car everyone says oh look that's pretty normal and it will go away. It often does not go away. Typically people need to have treatment for these kinds of fears and anxieties.

The anxiety can be really disabling because it limits the activities the person will do and it very commonly occurs in combination with depression.

If you have both anxiety and depression then you really need to have a lot of help and you need it quickly because the combination of the two problems can cause lots and lots of difficulties.

Some of the common anxiety conditions that we talk about are

• panic disorder
• social phobia

Panic disorder

Panic disorder is when people have something called panic attacks where they suddenly feel frightened, they will breathe too fast, they will think something terrible or bad is going to happen to them.

Often they notice that their heart is pounding in their chest. If they have a panic attack in a shopping centre or a place where there are lots of people they will often try and take themselves away from that.

Sometimes people with panic attacks refuse to leave their home and they have something we call agoraphobia. It is very rare for a person to get agoraphobia and not have panic attacks.

Social phobia

One of the more common anxieties that people get after a brain injury is a condition called social phobia where they avoid meeting, mixing and talking with people. This typically occurs to people who have some kind of language problem associated with their brain injury.  People with social phobia fear scrutiny and embarrassing themselves.

Obsessive compulsive disorder

One of the least common anxiety disorders after brain injury but one of the ones that can be the most disabling, are the obsessive compulsive disorders. Obsessive compulsive disorders are where people do things repetitively and in a ritualistic way.

The commonest ritual is hand washing, where the person has some kind of belief about being easily contaminated or that there are germs everywhere.  They have to go and wash their hands. But they do not just go and wash their hands once, they often wash their hands for half an hour/ an hour at a time .

Other people might have rituals about counting, how they do things.  The obsessive compulsive symptoms can be really, really disabling because they stop people getting to places on time, doing rehabilitation or everyday activities.

Someone with obsessive compulsive symptoms can get very angry and aggressive if someone stops their rituals. They can also become very stressed and worried about their symptoms.

iii) Posttraumatic stress disorders

Some people would know it as Vietnam War syndrome. There is now something called Gulf War syndrome. People with posttraumatic stress disorder have very similar symptoms.

A number of years ago people thought that if you have a severe brain injury you did not get a posttraumatic stress disorder. But there have now been some studies looking at people who have had severe brain injury and found they can get a post traumatic stress disorder. We recognise that post traumatic stress disorder can happen when with all types of brain injury (mild to severe).

Typically posttraumatic stress disorders happen to people when they have been in a really bad experience. So if you have been in a really bad car accident, you might remember up until the point of the accident and it is those aspects of your memory that form part of the posttraumatic stress disorder. People who have posttraumatic stress disorder often relive aspects of the trauma, they will also avoid situations where they might get memories of the trauma. They may not want to talk about it and they can be quite jumpy and nervous.

It is a lot more common than we thought and sometimes people will only have some symptoms of posttraumatic stress.

Where it gets really difficult is that sometimes you can confuse the cognitive or thinking problems of a brain injury with the symptoms of a posttraumatic stress disorder.  It can take a very skilled psychologist to be able to work out the differences.

i) What is personality?

One of the biggest areas of difficulty after a brain injury is personality change.

Most psychiatrists find it difficult to define what we mean by personality.

It can be very hard to describe one's own personality.

However, after a brain injury we know that often people's personality, who they are, what they were like, how they react to situations, is changed by the fact that they have had a brain injury.

    Image: MARTIN O’NEILL CUT IT OUT STUDIO (used with permission)

ii) Personality change

All changes in personality do not have to be bad, they can be positive, but it is rare.

We do know that most people who have had a severe brain injury will have some change in their personality after they have had that brain injury. So it is very common.

Exaggeration of aspects of personality

Typically what happens is that people with a brain injury get an exaggeration of their personality traits. So it is not like they become someone completely new, it is not a Jekyll and Hyde situation. If they might have been a bit fussy they become very fussy. If they tended to get easily cranky before now they get cranky more easily. It is an exaggeration of how they were.

Difficulty controlling emotions

One of the biggest problems we have after a brain injury is for those people who have problems controlling their emotions or aggression. Not only do rehabilitation specialists find that a huge challenge, but also psychologists, family members and people within the community.

Low Motivation/Apathy

Some of the personality changes that often do not get talked about but can be really frustrating particularly for carers are the changes in personality where a person is less motivated.

The brain injured person is very flat, they do not do anything. They do not seem to have any kind of motivation to get up and do things. They talk about I am going to do this, I am going to do that, but they never get to do it. They have a problem with drive or initiative. This is a very difficult change in personality because it can be very hard to treat and often people do not understand what it is about and think that the person is lazy.

Lack of awareness of changes in personality

The biggest problem in changes in personality is usually that the person who has the change in personality is that they are not aware that they are different. Everyone will say – “Oh now you do this - or - You weren't like that before”. The person who has the brain injury is completely unaware of it. This causes a lot of frustration and also can cause a lot of misunderstanding.

Why does this happen?

We know that the front part of the brain, particularly the right front part of the brain or the right frontal cortex is really important for recognising or being aware of things. So if you damage that area could have a big problem being aware of what is going on. It is the people who have damage to the right frontal area that often do not recognise that their personality has changed.