The not so hidden impact of a head injury
By Professor Gus A. Baker
Most people will have an understanding that a head injury can often have psychological and neuropsychological complications. Depending on the severity of the head injury these can vary between being quite subtle to life-changing. In the case of a mild head injury there can be reported difficulties with attention and concentration and memory alongside changes in personality and behaviour characterised by irritability and low mood. This is perhaps not surprising, particularly when there are also associated physical injuries. Fortunately, most people with a mild head injury will recover within a matter of weeks or months with no long-term consequences. However, there will be a small group whose problems may persist for a much longer period.
The situation is different when the head injury is considered as moderately severe to very severe. Such a severity will be associated with an increased risk of permanent psychological and neuropsychological changes. There will often be evidence of brain damage as seen on a CT or MRI scan. There will also be quite significant changes in functioning. From my own clinical experience there are often physical difficulties [e.g. pain, sleep problems and fatigue] neuropsychological changes [e.g. problems with attention and concentration, memory, multitasking and organisation and planning] and psychological changes [e.g. mood, disinhibition, apathy, lack of motivation]. Least understood are the changes in personality and behaviour.
The changes in personality and behaviour I believe represent the most significant challenge to family and friends. These changes are often described by family as “it’s like living with a complete stranger” or “they are not the same person.” According to research, some individuals following a head injury may show a lack of insight or may be unwilling to admit to changes in personality, or they may underestimate the significance or consequences of such changes. In a seminal paper by Brooks and McKinley [Journal of Neurology, Neurosurgery, and Psychiatry 1983;46:336-344], the authors identified, from interviewing a close relative of a brain injured individual, a range of changes observed that were present for at least 12 months post-accident.
These are reported in the following table:
|Even-temper - quick-temper||Down to earth - out of touch|
|Unhappy - happy||Likes company - dislikes company|
|Relies on others - self-reliant||Rash - cautious|
|Excitable - calm||Irritable - easy-going|
|Talkative - quiet||Listless – enthusiastic|
|Energetic - lifeless||Mature - childish|
|Affectionate - cold||Sensitive - insensitive|
|Cruel - kind||Generous - mean|
It is impossible to predict how any individual will be affected in terms of their personality and behaviour. It will depend on the nature and extent of the head injury and how they were before their accident. It is unlikely that any of the individuals involved with the immediate medical care of the affected individual will be able to predict with any accuracy how that individual will be in the longer term. Some of the changes will be apparent quite early in the recovery and some difficulties will emerge with time. There is no real preparation for families or friends in dealing with the changes that occur.
As part of the rehabilitation it will be important that there is a multidisciplinary team involved, to identify problems, as early as possible and look at what strategies can be put into place in an attempt to ameliorate their effects. However, this alone will not necessarily help prepare the family come to terms with the changes that have occurred. That is why such charities as The Brain Charity have an important role in providing a source of support and help for not only the affected individuals but their families as well. Families need to understand what has happened to their relatives. They need to understand the effects of the brain injury and more importantly they need to know what the future will look like. It may not be possible to provide an accurate picture for any one individual but charities will have experience of working with families who have experienced similar events.
In summary, it is important to recognise and understand that head injuries can and do affect the individual in terms of their personality and behaviour and that these effects can range from “mild” to severe and permanent effects. Affected individuals and families will be need some support and advice in making adjustments to these hidden impacts.