Module 8: Mood, behaviour and mental health

A mental health crisis, when someone may hurt themselves or others, is an emergency. If you, or someone you care for is in crisis and needs support call Lifeline on 13 11 14.

Now that it’s been a few months since your injury, you have probably begun to make sense of what happened to you. As you start to understand the road ahead, you might find yourself experiencing a mix of emotions.

So far, your doctors and healthcare team have mostly focused on the changes to your body, physical health and physical abilities. You might have noticed changes to your mood and mental health too. These feelings may come and go, and they may be confusing and unrelated to what you are doing at the time. This is very common. More than 50% of people with TBI are diagnosed with a mental health disorder at some point (39).

This module will help you to recognise the signs of some common mental health disorders that can occur after TBI, and help you get help and support.

What causes changes in mood, behaviour and mental health after TBI?

TBI is a major event that causes many life changes. The sudden and unexpected nature of the accident or injury event may have unsettled you. This may cause you to feel shocked or uncertain of your future. There are several factors that may contribute to changes in your mood, behaviour and emotions after your TBI.

Physical changes to the brain due to your injury

Mood and behaviour changes may result from injury to the specific areas of the brain that control emotions and behaviour. There may also be changes to some of the natural chemicals in the brain, called neurotransmitters, that can make it hard to control your emotions (40).

Adjustment and emotional responses to injury You may find that your mood changes some time after your initial injury. This could be because of challenges adjusting to temporary or lasting disability, role changes within your family or workplace, the shock of the events surrounding your injury, or awareness of the changes in your abilities (41).

Genetics and personal factors

Some people have a higher risk of depression, anxiety, or other mental health challenges because of inherited genes, previous experiences or other factors. If you experienced mood disturbances before your injury, be mindful that they may reoccur or worsen after your injury.

Behavioural and personality changes

Following TBI, behaviour and personality changes are common. These changes often occur soon after the injury, and may change over time. This can be difficult for people to understand, as friends and family may be confused about these changes and treat you differently.

These changes can be varied, but some common ones are impulsive behaviour, irritability and anger, anxiety, emotional lability (rapid mood swings), apathy and difficulty considering the feelings of others.

These changes can come from three sources after an injury (41):

• Physical changes to the brain that impact the way you see the world,
• Emotional reactions to the changes in your life after your injury,
• Side effects of the medications you may be taking.

Some of these changes may be permanent, and some may not. There is some evidence to suggest that individualised behaviour support plans and behavioural management techniques can help people with TBI and their families to manage some of these difficult behaviours (42, 43).

Depression and low mood

“You have to try to stay positive as you go through the dark moments. And there are lots of dark moments. What helped me get through the dark moments was believing that you can somehow – you know there is no perfect ending. Somehow you can grow and live with your TBI”
- Person with TBI

Depression is a feeling of sadness that can last for a long time (weeks or longer). You may feel you have lost your “zest for life”, and you may feel sadness or despair. You may feel a loss of hope. These feelings are quite common after a TBI, as your life has changed drastically. You may also find that you are angry or irritable, feel guilty or worthless, and you no longer enjoy the activities you would usually enjoy.

Depression is common for people in Australia, with one in 6 people experiencing depression in their lifetime (45). It is estimated that 43% of people with TBI will be impacted by depression at some stage after their injury, and almost 1 in 5 in the first year (39).

Feelings of depression may also develop as you progress through rehabilitation and begin to understand the full impact of your injury and the changes you may be facing.

It is normal to feel depressed after a TBI and feeling depressed is nothing to be ashamed about. If the depression becomes too much and affects the way you live your life, then it is important to seek help.

Anxiety

Following an event like a TBI, life can be incredibly stressful. Sometimes the stress can build up and lead to anxiety. Anxiety means that you are worried about something or feeling fearful. You may notice racing thoughts, or sensations in your body like you have just been exercising, such as a fast heartbeat.

Anxiety is very common, with 1 in 4 people experiencing anxiety at some stage in their life (45). After brain injury, it is estimated that up to 36% of people will experience an anxiety disorder, and 1 in 5 within the first year after injury (39). The most common types of anxiety disorders experienced by people with a brain injury are post-traumatic stress disorder or generalised anxiety disorder (46).

Generalised anxiety

Generalised anxiety involves feeling afraid or worried most of the time. These feelings may be persistent, intense and involve worry about everyday things, like catching public transport, meeting new people, or having enough money. You may find it hard to stop worrying.

Post traumatic stress disorder (PTSD)

PTSD is an anxiety disorder that can develop after extremely traumatic events, like life-threatening accidents or natural disasters. When faced with such an experience, you may feel intense fear, panic and helplessness. In the time after the traumatic event a range of triggers, symptoms and reactions can contribute to ongoing emotional distress which may have an impact on your day-to-day functioning. These experiences may include nightmares, intrusive memories, avoidance of thoughts and feelings associated with the trauma, and hypervigilance for danger.

Anxiety and brain injury

A brain injury may make someone more likely to experience an anxiety disorder due to the impact the injury has on the brain and the changes in thinking, behaviour and emotions that can occur. But these feelings do not have to last forever. There are many treatments that may help you if you are experiencing anxiety, and your medical team will be able to help you access these treatments: just ask.

Substance Use

Substance use refers to the consumption of mood or perception altering substances, such as alcohol, cannabis or methamphetamine. Some of these substances are legal for adults to consume, like alcohol, and some are illegal to even have in your possession, like methamphetamine. It is important to find out whether the substances you may be using are legal as it may impact your eligibility for certain rehabilitation programs.

For some people, the consumption of these substances interferes with their daily life and is classified as a Substance Use Disorder. Up to 75% of people presenting to hospital with Substance Use Disorder have experienced a traumatic brain injury (47).

People use substances for a lot of different reasons (48):

• To relax or for enjoyment,
• To avoid physical or psychological pain,
• To overcome boredom,
• To cope with problems.

Some people feel guilty about their substance use and try to hide it from their families or medical team. Try to remember, using substances is nothing to be ashamed of, but it is important to discuss your use with your medical team. Substance use may interfere with your medical treatment and impact your recovery, as drugs and alcohol can have both short- and long-lasting negative impacts on the brain (44, 45)(49, 50). For example, alcohol is known to reduce coordination or balance. Should you be attempting to improve your coordination following your brain injury, this substance may interfere with your rehabilitation progress.

Anger and aggression

Anger and aggression are common feelings after TBI, and can include irritability, short temper (getting angry quickly), verbal or physical outbursts (yelling, hitting), abusive language (swearing) or threatening behaviour (51). People with TBI tend to report more frequent feelings of anger as well as greater difficulty controlling feelings of anger relative to the general population (52). There may be many causes of anger after brain injury (52), including:

• Feeling tired or fatigued,
• Having trouble remembering things,
• Feeling depressed,
• Frustration at the changes in your abilities,
• Difficulties understanding what people are asking of you,
• Lower tolerance for frustration.

It may be helpful to work with the people around you to identify some of the triggers of your anger so they can help you avoid situations in which your anger may be difficult to control (e.g. feeling tired). It may be helpful to arrange a predictable schedule for your day to help reduce stress and irritability. Don’t be ashamed to ask for help when you need it and speak to your doctors about medications or psychological treatments that may help you learn to better manage your feelings.

Impulsive behaviour and impulse control disorders

Impulsive behaviour is when a person does or says things without thinking them through. Impulsive behaviour common after TBI, as parts of the brain involved in planning or resisting urges may be damaged (53). Some examples of impulsive behaviour are:

• Having trouble waiting or taking turns in activities or conversation,
• Rushing into things without thinking them through,
• Saying things that may be rude or hurtful to others,
• Having physical or verbal outbursts,
• Regretting things you have said or done or regretting decisions later.

In some cases, impulsive behaviour may cause harm to yourself or others, or lead to illegal behaviour like stealing or setting fires. This is when it becomes an impulse control disorder.

It can be hard to manage impulsive behaviours, but there are some strategies you can use to cope (54). Try to ask yourself whether you really want to do something before acting, and consider the consequences of your actions. In social situations, make sure you aren’t talking over other people and watch for signs from others that you are interrupting. Ask your family and friends for information before making decisions, and apologise if you are unintentionally hurtful or rude. Some medications have been shown to be helpful in the management of serious impulsive behaviour (55).

Suicidal Ideation

Suicidal ideation refers to thoughts that life isn’t worth living. This can include fleeting thoughts of dying, through to plans for taking your own life. These thoughts are not uncommon among people who have experienced a traumatic or life-changing event, like a TBI (56, 57). These thoughts may be associated with other mental health conditions, like depression, but this is not always the case. These thoughts can be distressing and isolating, but it is important to note that they can pass. While it is OK to have these thoughts, it is important to let someone know how you are feeling. Help is available:

• Talk to a friend or family member about how you are feeling,
• Talk to someone on your medical team,
• Call Lifeline on 13 11 14 or go to www.lifeline.org.au for confidential support.

If you are feeling this way often, speak to your medical team about creating a safety plan. A safety plan will include steps you can take to stay safe when you are having suicidal thoughts. It will help equip you with skills to manage how you are feeling in those moments.

Coping with changes in mood and mental health

At this stage after your injury, you may be experiencing many different emotions. The way you feel or express your feelings may have changed since your TBI. This may be distressing for you, your family or your friends, but this is a normal part of recovery. There are many things you can do to manage your mental health and emotions:

• Talk to a family member or friend about how you are feeling,
• Talk to your GP, who can write a Mental Health Plan and refer you to a psychologist,
• Speak to your doctor about whether medication may be appropriate,
• Contact available helplines and resources below.

Remember, emotional distress is not a sign of weakness and it is not a matter of “toughing it out”. It is important to get support to manage your mental health. Research suggests that poor mental health can result in worse outcomes from rehabilitation (58), and good emotional adjustment can explain approximately 30% of the improvement in cognitive and motor rehabilitation after brain injury (14).