A model of personality change after traumatic brain injury and the development of the Brain Injury Personality Scales

"We can all relate": patient experience of an emotion-oriented group intervention after Acquired Brain Injury

Introduction

Group interventions are carried out routinely across neuropsychological rehabilitation services, to improve understanding of brain injury and aspects of impairment. Treatment provided in a group modality can bring additional perceived benefits, such as co-operative learning. However, there are very few studies which explore patient perceptions and experiences of such interventions. In the present study we investigated the experience of attending a group-based educational intervention for the consequences of acquired brain injury (ABI), which had a strong focus on emotion and emotion regulation.

Methods

Using qualitative semi-structured interviews (approximately 20 minutes), the study explores the lived experience of participating in the seven-session programme, the better to identify the perceived efficacy, salience and value of individual elements. Twenty participants with ABI took part in individual interviews, after completion of the group programme (the Brain Injury Solutions and Emotions Programme, BISEP). The study adopted a descriptive phenomenological philosophy, which focuses on lived experience to explore a phenomenon (i.e. the experience of BISEP). As regards methods, the study employed thematic analysis to cluster experiences into themes of meaning.

Results

Five themes were identified: (1) 'Long term consequences and psychological needs', which related to the persistent nature of direct consequences of injury and adjustment, and how these result in a need for interventions such as BISEP. (2) 'Positive experiences of participating in the programme', referred to participants' overall experience of the programme and valued elements within it. The remaining themes referred to the programme as (3) a social milieu; (4) a place to learn; and (5) a place to promote positive emotional experiences.

Discussion

Similar to previous studies, many people reported high acceptability and perceived value of the group programme, and its role in facilitating adjustment and understanding of injury. Of particular importance was the opportunity to socialise with people who "can all relate", in line with a growing emphasis on social rehabilitation. The findings especially highlight the relevance of emotion-focused group programmes for ABI, promoting emotion regulation, and practical tools that are delivered optimistically. Further implications for practice and future research include to focus on long term rehabilitation, a social milieu, and strategies to support adjustment.

Personality traits beyond Neuroticism predict post-concussive symptomatology in the post-acute period after mild traumatic brain injury in premorbidly healthy adults

There is growing evidence that an individual's personality traits are related to post-concussion symptomatology beyond the acute period after mild traumatic brain injury (mTBI). Few studies, however, have analyzed this impact beyond the personality trait of Neuroticism. We examined the impact of personality traits on post-concussion symptoms (PCS) by measuring the Big Five personality domains and their lower-order aspects in 87 pre-morbidly healthy participants assessed 6-12 weeks post-mTBI (n = 53) or physical trauma (n = 34). As expected, Neuroticism predicted PCS endorsement in both groups. Conscientiousness and Openness/intellect were predictive of lower PCS endorsement, but only in the mTBI group. Withdrawal, one aspect within the Neuroticism domain, independently predicted PCS endorsement in the mTBI group; the remaining Neuroticism aspect, Volatility, did not predict PCS endorsement in either group. These findings suggest that individuals high in Neuroticism are more likely to report PCS following mTBI and that this relationship is driven by susceptibility to depression/anxiety symptoms (Withdrawal aspect) rather than irritability (Volatility aspect). Further, they suggest that the current focus on the relationship between Neuroticism and PCS reporting in individuals with mTBI should be broadened to include other personality domains, such as Conscientiousness and Openness/intellect.

Patients' experiences and wellbeing after injury: A focus group study

Background

Injury can have physical, psychological and social consequences. It is unclear which factors have an impact on patients’ wellbeing after injury. This study aimed to explore, using focus groups, patients’ experiences and wellbeing after injury and which factors, impede or facilitate patients’ wellbeing.

Methods

Trauma patients, treated in the shock room of the Elisabeth-TweeSteden Hospital, the Netherlands, participated in focus groups. Purposive sampling was used. Exclusion criteria were younger than 18 years old, severe traumatic brain injury, dementia, and insufficient knowledge of the Dutch language. The interviews were recorded, transcribed verbatim, and analyzed using coding technique open, axial, and selective coding, based on phenomenological approach.

Results

Six focus groups (3 to 7 participants) were held before data saturation was reached. In total, 134 patients were invited, 28 (21%) agreed to participate (Median age: 59.5; min. 18 –max. 84). Main reasons to decline were fear that the discussion would be too confronting or patients experienced no problems regarding the trauma or treatment. Participants experienced difficulties on physical (no recovery to pre-trauma level), psychological (fear of dying or for permanent limitations, symptoms of posttraumatic stress disorder, cognitive dysfunction), social (impact on relatives and social support) wellbeing. These are impeding factors for recovery. However, good communication, especially clarity about the injury and expectations concerning recovery and future perspectives could help patients in surrendering to care. Patients felt less helpless when they knew what to expect.

Conclusions

This is the first study that explored patients’ experiences and wellbeing after injury. Patients reported that their injury had an impact on their physical, psychological, and social wellbeing up to 12 months after injury. Professionals with the knowledge of consequences after injury could improve their anticipation on patients’ need.

Correlates of the personality change judgments of individuals who have MS

Objectives: This is the first study to estimate prevalence of self-reported personality change (PC) in people with multiple sclerosis (MS). Methods developed in traumatic brain injury studies explore physical, and psychosocial triggers for PC judgments.Participants: 69 MS clinic attendees living with their partner.Measures: Participants rated the degree of PC. 28 Current and pre-MS characteristics were rated. The Multiple Sclerosis Impact Scale, the MS Neuropsychological Questionnaire, the Beck Depression Inventory-FastScreen, and the Hospital Anxiety and Depression Scale quantified neuropsychological status. The Family Questionnaire, McMaster Assessment Device and the Social Provisions Scale sampled perceived social influences.Results: 54% perceived substantial PC. Current characteristics predicted PC better than perceived behavior changes. PC was associated with specific characteristics denoting stress reactions, emotional distress, perceived cognitive impairment and poorer family functioning. PC was not significantly related to severity of physical symptoms or social support. This study also suggested that the specific characteristics questionnaire probed at least 2 components of reconstructed identity: PC/Reactivity and Disability.Conclusions: This study raises methodological concerns about measures that simply sum ratings of characteristics related to self-identity. It also proposes possible ways of collaborating with individuals in their efforts to respond constructively to PC and other changes. .

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Stable psychological functioning after surgery for epilepsy: An informant-based perspective

OBJECTIVE

Psychological adjustment following surgery for epilepsy has been assessed primarily with self-report measures. In the current work, we investigated pre- to postoperative changes in various dimensions of personality and behavior from the perspective of a well-known family member or friend for 27 patients operated on for medically intractable epilepsy.

METHODS

For each patient, a close family member or friend ("informant") provided pre- and postoperative ratings on five dimensions of personality and behavior. All ratings were collected during the chronic epoch of recovery, when personality and behavior of the patients are relatively stable. Self-report measures were also used to examine the relation between self-report and informant-report assessment of psychological adjustment. Lastly, the relation between seizure outcomes and psychological adjustment was investigated.

RESULTS

Personality and behavior characteristics, as rated by an informant, remained stable and within a normal range of functioning following surgery for epilepsy. There were no significant differences between pre- and postoperative levels of executive functioning, social behavior, hypo-emotionality, irascibility, or distress. Informant-ratings on levels of current depression and overall current psychological functioning were significantly related to patient reports of current depression and global personality characteristics derived from the MMPI-2 (e.g., psychasthenia, schizophrenia, hypomania, psychopathic deviation, social introversion). There was no significant relationship between seizure outcome and psychological adjustment.

SIGNIFICANCE

Informant-based reports on psychological adjustment following surgery for epilepsy provide a unique perspective on important aspects of the success of the intervention. Assessing outcomes beyond seizure status is important for developing a comprehensive understanding of the potential consequences of surgery for epilepsy. Based on the current work, personality and behavior seem to be stable following surgery for epilepsy, and our study provides a unique informant-based perspective on this encouraging result.

'Just can't hide it': a behavioral and lesion study on emotional response modulation after right prefrontal damage

INTRODUCTION

Historically, emotion regulation problems have been reported as a common consequence of right prefrontal cortex (rPFC) damage. It has been proposed that the rPFC, particularly the rIFG, has a key role inhibiting prepotent reflexive actions, thus contributing to emotion regulation and self-regulation. This study is the first to directly explore this hypothesis, by testing whether damage to the rIFG compromises the voluntary modulation of emotional responses, and whether performance on inhibition tasks is associated with emotion regulation.

METHOD

10 individuals with unilateral right prefrontal damage and 15 matched healthy controls were compared on a well-known response modulation task. During the task participants had to amplify and suppress their facial emotional expressions, while watching film clips eliciting amusement. Measures of executive control, emotion regulation strategies usage and symptomatology were also collected.

RESULTS

As a group, individuals with rPFC damage presented a significantly reduced range of response modulation compared with controls. In addition, performance in the suppression task was associated with measures of cognitive inhibition and suppression usage. Interestingly, these effects were driven primarily by a subgroup of individuals with rPFC damage, all of whom also had damage to the right posterior insula, and who presented a marked impairment in suppressing facial emotional expressions.

Exploration of correlates of self-reported personality change after moderate-severe traumatic brain injury

OBJECTIVE

Individuals with traumatic brain injury (TBI) often express concern that their personality has changed. Factors generating that conclusion are rarely explored quantitatively. Accordingly, this study examines neurobehavioural correlates of self-reported personality change.

METHODS

Seventy-one participants and informants were interviewed M = 57.9 (SD = 46.9) months after a moderate-severe TBI. The degree of self-reported personality change was correlated with scores on measures of general cognitive functioning, executive functioning, olfaction, social-emotional behaviour, emotional distress and the Expressed Emotion close informants directed towards them.

RESULTS

As expected, self-reported personality change correlated with dysexecutive symptoms and depression. Although anosmia (a putative index of ventral frontal damage) correlated with reduced self-reported emotional recognition and empathy, against prediction, the latter measures did not correlate with self-reported personality change. Neither were the predicted positive correlations found between high Expressed Emotion (criticism and emotional over-involvement) and self-reported personality change.

DISCUSSION

These findings are discussed in the context of previous work. A need to replicate and extend the present findings is suggested. A strategy to further clarify the relationships perceived personality change have with (a) self-reported change in specific behaviours and (b) identity change is advocated. Implications for intervention are suggested.

Personality change associated with chronic diseases: pooled analysis of four prospective cohort studies

BACKGROUND

Common chronic conditions, such as heart disease and cancer, are associated with increased psychological distress, functional limitations and shortened life expectancy, but whether these diseases alter aspects of personality remains unclear.

METHOD

To examine whether the onset of heart disease, stroke, diabetes, cancer, hypertension, arthritis and respiratory disease is associated with subsequent changes in personality traits of the five-factor model, we pooled data from the Health and Retirement Study, the Midlife in the United States Survey, and the graduate and sibling samples of the Wisconsin Longitudinal Study for an individual-participant meta-analysis (total n=17,493; mean age at baseline 55.8 years).

RESULTS

After adjustment for age, we observed consistent decreases in extraversion [-0.25 T-scores per one disease; 95% confidence interval (CI) -0.40 to -0.10], emotional stability (-0.40, 95% CI -0.61 to -0.19), conscientiousness (-0.44, 95% CI -0.57 to -0.30) and openness to experience (-0.25, 95% CI -0.37 to -0.13) but not in agreeableness (-0.05, 95% CI -0.19 to 0.08) after the onset of chronic diseases. The onset of each additional chronic disease accelerated the average age-related personality change by 2.5 years in decreasing extraversion, 5.5 years in decreasing conscientiousness, and 1.6 years in decreasing openness to experience, and attenuated the increasing levels of emotional stability by 1.9 years. Co-morbid conditions were associated with larger changes than single diseases, suggesting a dose-response association between morbidity and personality change.

CONCLUSIONS

These results support the hypothesis that chronic diseases influence personality development in adulthood.

Reappraisal generation after acquired brain damage: The role of laterality and cognitive control

In the past decade, there has been growing interest in the neuroanatomical and neuropsychological bases of reappraisal. Findings suggest that reappraisal activates a set of areas in the left hemisphere (LH), which are commonly associated with language abilities and verbally mediated cognitive control. The main goal of this study was to investigate whether individuals with focal damage to the LH (n = 8) were more markedly impaired on a reappraisal generation task than individuals with right hemisphere lesions (RH, n = 8), and healthy controls (HC, n = 14). The reappraisal generation task consisted of a set of ten pictures from the IAPS, depicting negative events of different sorts. Participants were asked to quickly generate as many positive reinterpretations as possible for each picture. Two scores were derived from this task, namely difficulty and productivity. A second goal of this study was to explore which cognitive control processes were associated with performance on the reappraisal task. For this purpose, participants were assessed on several measures of cognitive control. Findings indicated that reappraisal difficulty - defined as the time taken to generate a first reappraisal - did not differ between LH and RH groups. However, differences were found between patients with brain injury (LH + RH) and HC, suggesting that brain damage in either hemisphere influences reappraisal difficulty. No differences in reappraisal productivity were found across groups, suggesting that neurological groups and HC are equally productive when time constraints are not considered. Finally, only two cognitive control processes inhibition and verbal fluency- were inversely associated with reappraisal difficulty. Implications for the neuroanatomical and neuropsychological bases of reappraisal generation are discussed, and implications for neuro-rehabilitation are considered.

Changes in personality after mild traumatic brain injury from primary blast vs. blunt forces

INTRODUCTION

Injuries from explosive devices can cause blast-force injuries, including mild traumatic brain injury (mTBI).

OBJECTIVE

This study investigated changes in personality from blast-force mTBI in comparison to blunt-force mTBI.

METHODS

Clinicians and significant others assessed US veterans who sustained pure blast-force mTBI (n = 12), as compared to those who sustained pure blunt-force mTBI (n = 12). Inclusion criteria included absence of any mixed blast-blunt trauma and absence of post-traumatic stress disorder. Measures included the Interpersonal Measure of Psychopathy (IM-P), the Big Five Inventory (BFI), the Interpersonal Adjectives Scale (IAS) and the Frontal Systems Behaviour Scale (FrSBe).

RESULTS

There were no group differences on demographic or TBI-related variables. Compared to the Blunt Group, the Blast Group had more psychopathy on the IM-P, with anger, frustration, toughness and boundary violations and tended to more neuroticism on the BFI. When pre-TBI and post-TBI assessments were compared on the IAS and FrSBe, only the patients with blast force mTBI had become more cold-hearted, aloof-introverted and apathetic.

CONCLUSION

These results suggest that blast forces alone can cause negativistic behavioural changes when evaluated with selected measures of personality. Further research on isolated blast-force mTBI should focus on these personality changes and their relationship to blast over-pressure.

Concrete behaviour and reappraisal deficits after a left frontal stroke: a case study

Concrete behaviour, the inability to disengage from immediate experience in order to manipulate ideas and thoughts, has long been understood to be a common problem after frontal lobe lesions. However, there has been little consideration of the impact that concreteness may have on emotional functioning, specifically in the use of thinking to manipulate emotional responses. One widely studied emotion regulation strategy is reappraisal, which depends on several frontal lobe related cognitive control processes. While there have been numerous neuroimaging findings on reappraisal, no study has used brain injured patients to investigate this issue. The present case study is the first to describe the capacity to generate reappraisals in a patient (Mrs M), whose behaviour became concrete after a left prefrontal stroke. Using a picture-based reappraisal paradigm, her performance was compared to non-concrete brain-lesioned patients, and neurologically healthy controls. Although Mrs M showed relatively preserved overall cognitive function, she was completely unable to spontaneously generate reappraisals. In striking contrast, once external support was offered, in the form of prompts, her capacity to reappraise dramatically improved. The results are analysed in terms of three neuropsychological capacities - all compromised in Mrs M - previously proposed as reappraisal components: response inhibition, abstraction, and verbal fluency. A number of implications for rehabilitation are discussed, including how the use of prompting may facilitate reappraisal capacity.