An elementary school student displays uncooperative behavior, emotional outbursts, social difficulties and learning challenges, and is placed in special education. A young veteran, recently home from active duty, attempts to return to pre-deployment functioning, but is hampered by feelings of despondency and hopelessness that fuel an emerging drinking problem. A recent college graduate and former star quarterback for his university’s football team has been fired from his first two jobs out of college because his low mood and lack of motivation in pursuing his vocational goals have led to excessive absenteeism.
As mental health professionals, we might easily suspect clinical depression as an underlying factor of these psychosocial difficulties. But what if we also knew that the elementary school student was in a coma for three weeks following a recent, serious car accident, that the veteran survived a blast from a roadside bomb in Iraq prior to returning home to civilian life and that the college football player received multiple concussions during his athletic career? Greater sensitivity to the sequelae of traumatic brain injury could dramatically change the course of treatment.
As clinicians and social service providers, we may be familiar with the physical and/or cognitive impairments that can result from traumatic brain injury. However, we may not realize the degree to which traumatic brain injuries are also associated with a variety of behavioral health symptoms. These include increases in depressed or irritable mood, anxiety, outbursts of anger, poor judgment and decreased impulse control. If we are not aware of the mental and emotional risks traumatic brain injuries pose, these symptoms can be attributed to psychiatric illness alone, with the unfortunate consequences of inaccurate diagnosis and less than optimal treatments.
What is traumatic brain injury? Traumatic brain injury (TBI) is an umbrella term that refers to damage to the brain due to a specific event, rather than the result of a degenerative neurological condition or other disease process. Events can include physical force, such as blows to the head, or medical emergencies such as strokes or high fevers. TBI may also result from brain damage due to consuming poisonous substances or from malnutrition. While no one has a life that is totally free of potential TBI risk, certain populations are at increased risk, including children from 0 to 4 years of age, youth aged 15-19 and older adults aged 65 or older.1 Military personnel and athletes take on increased risk, as both face the increased possibility of receiving blows to the head from combat or competition.
Often, traumatic brain injuries are not detected by standard medical tests, such as MRIs, CT scans or other tests, as the events that cause TBI may not leave an easily detectable wound or other physiological signs of injury. Individuals who have sustained a traumatic brain injury will likely require very extensive evaluation to pinpoint difficulties in processing information, memory, distractibility and other aspects of cognitive functioning, and to receive an accurate diagnosis. Without a thorough assessment, including an evaluation by a neuropsychologist, individuals who have TBI will not obtain a comprehensive plan for recovery. Treatment for TBI typically includes cognitive rehabilitation, occupational therapy, physical therapy, speech therapy, learning how to use assistive technologies and to modify the environment in order to build on retained capabilities and skills.
Much of the available information about traumatic brain injuries stresses that only a small proportion of people who sustain these types of injuries will go on to have significant and long-lasting challenges in their physical or psychosocial functioning. In contrast, however, a study of people with mild or unidentified brain injuries indicates as many as two-thirds reported having poor emotional health.2 Additionally, even mild traumatic brain injuries are associated with an increased risk of mental illness within 6 months of sustaining the injury. For example, another study found that traumatic brain injury increases the risk of depression over the course of a lifetime to 54%.3 The effective diagnosis and treatment of these symptoms remain challenging for a variety of reasons, including the delayed onset, changes in brain anatomy and chemistry due to the brain injury and other complicating psychosocial factors. Yet there is no doubt that earlier identification of the behavioral signs of TBI is essential for those of us working with populations at high risk of TBI to be aware of its emotional, cognitive and behavioral manifestations in order to intervene by providing timely and appropriate referrals for neuropsychological evaluations and other necessary rehabilitative services.
We can start by asking individuals with this constellation of symptoms whether or not they have sustained a head injury or lost consciousness. Even this simple screening question could be helpful in identifying individuals who may need a more extensive assessment. At the same time, medical and other professionals working with people who have sustained TBI can also become more aware of the potential of depression and other emotional symptoms, so that if these arise, they can make the appropriate referrals to behavioral health services.
This year, the Mental Health Association of New York City has added raising awareness of the mental health impact of TBI to its policy and public education agendas. Working in partnership with other stakeholders, MHA-NYC strives to highlight the importance of protecting one of the human body’s most valuable organs, the brain, while at the same time promoting the ability of individuals, families, and the myriad professionals who treat TBI, to identify and better understand the warning signs of emotional distress that may be caused by this condition. Please join us in learning more about how to effectively prevent and treat traumatic brain injury.
- Faul, M., Xu, L. Wald, M.M., Coronado, V.G. (2010). Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002-2006. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
- Gordon, W., Brown, M. (2008). Mild traumatic brain injury: identification, the key to preventing social failure. Brain Injury Professional. 5(2): 8-11.
3. Aravich, P., McDonnell, A. (2005). Successful aging of individuals with brain injury. Brain Injury Professional. 2(2): 10-14.