Traumatic Brain Injury: Not Just a Problem for Athletes

Traumatic Brain Injury: Not Just a Problem for Athletes

By Mark Herceg, Ph.D, Special to Everyday Health
Each year in the United States, traumatic brain injuries (TBI) contribute to a substantial number of deaths and cases of permanent disability.
According to the U.S. Centers for Disease Control, in 2010 approximately 2.5 million TBIs occurred either as isolated injuries or along with other injuries. The CDC data included concussion-related injuries, which have become an increasingly popular topic of conversation among sports and media professionals. TBI is a contributing factor in one-third of all injury-related deaths in the United States — and approximately 75  percent of those injuries are classified as concussions or other forms of mild TBI.

Children up to age 4, adolescents ages 15 to 19, and adults over 65 are most likely to sustain a TBI. Children up to age 14 account for almost half a million emergency department visits for TBI annually, including visits for concussions, also referred to as Mild TBI.

Currently, we have no way of knowing how many people with brain injuries are seen in emergency departments or how many receive no care for their injuries.

What Is Traumatic Brain Injury?

A TBI can be caused by a bump, blow, jolt to the head, or a penetrating head injury that disrupts the normal function of the brain. Not all blows or jolts to the head result in a TBI. The severity of a TBI can range from mild (that is, a brief change in mental status or consciousness) to severe (an extended period of unconsciousness or amnesia after the injury).

TBI can result in a variety of neuropsychological disturbances ranging from subtle deficits to severe intellectual and emotional disturbances. Typical changes attributed to TBI include cognitive impairments, mood disorders, anxiety disorder, psychosis, and behavioral problems.

How TBI Can Affect Your Mood

A brain injury can change the way people feel or express emotions. A person with TBI can have several types of emotional problems. Some people may experience emotions very quickly and intensely, or they may seem as if they’re on an emotional roller coaster — we call this emotional lability.

Mood swings and emotional lability are often caused by damage to the part of the brain that controls emotions and behavior. These sudden emotional responses are often unprovoked, which can be confusing for family members who might think they accidentally did something to upset the injured person. There are medications that may help improve or stabilize this emotional response.

Major depression occurs in approximately 25 percent of patients with TBI. These individuals experience feelings of loss, demoralization, and despair quite soon after injury. Fatigue, irritability, suicidal thoughts, anhedonia (the inability to feel pleasure in actitives that you used to enjoy), disinterest, and sleep disturbance are seen in a substantial number of patients 6 to 24 months (or longer) after TBI. Long-lasting psychological impairments and poor cooperation with rehabilitation are strong indicators of a persistent depressive disorder in someone with TBI.

Apathy, Anxiety and Depression From TBI

Clinical and research studies have also shown that poor pre-injury level of functioning and past history of psychiatric illness are major risk factors for depression. It is important to note that depression after TBI is not that same as regular, daily depression. The mood change is attributed to an actual organic change in the brain due to injury. The treatment of depression secondary to TBI  however, is very similar to the treatment of major depressive disorder. It includes rehabilitation psychotherapy, antidepressants, and if warranted, psychostimulants based on the presentation of the mood disorder.

Anxiety disorders are also common in patients with TBI. Individuals with TBI often experience persistent worry, tension, and fearfulness. Some anxiety can be attributed to cognitive deficits, such as reduced processing speed. Antidepressants such as SSRIs can be used in the treatment of anxiety disorders after TBI. Benzodiazepines and antipsychotics should always be avoided because they cause cognitive impairment. Behavioral therapy and psychotherapy are as important as medication.

Ten percent of patients tend to have apathy without depression, and 60 percent have some degree of apathy and depression following TBI. Apathy refers to a syndrome of disinterest, disengagement, inertia, lack of motivation. Apathy may be secondary to damage of the mesial frontal lobe, and it often responds well to either stimulant or antidepressant treatment.

Complex, Comprehensive Treatment

Treatment of mood and personality changes due to TBI is complicated, but not impossible. In order for treatment to be effective, it has to be comprehensive. This includes drug therapy and rehabilitative interventions, both of which are equally important.

Intense, acute rehabilitation should begin on the day of the injury and continue until the patient is stable. Rehabilitation needs to be multifaceted. A comprehensive neuropsychological evaluation should be conducted in order to properly assess cognitive and emotional changes.  Such an evaluation will determine deficits and strengths, and serve as a baseline after TBI. Finally, additional therapy, including: cognitive rehabilitation, behavioral treatment, social skills training, vocational training, individual therapy, group therapy, and family therapy can help patients work toward optimal outcomes.

Dr. Mark Herceg is the Director of Neuropsychology at Burke Rehabilitation Hospital in White Plains, N.Y. He holds a faculty appointment at Weill-Cornell Medical College as Assistant Professor of Psychology in Clinical Neurology and is a member of the Weill Cornell Concussion Clinic.  He is in charge of neuropsychological assessment and services for brain injured individuals,  and he consults with high school, collegiate and professional athletes who have sustained concussion, including the neuropsychology staff of the New York Giants.