Not the same as before

In 1848 Phineas Gage, a railroad worker, suffered an accident as a result of an explosion. A metal rod weighing 6 kg, 1 m long and more than 3 cm in diameter pierced his skull through the left cheek and exited through the upper part after passing through the cerebral cortex. After two months, the patient was discharged by the doctor considering that he was fully recovered since he did not show any physical or speech impairment.

Twenty years later, Dr. Harlow, who had treated the patient, described in a medical publication: “The equilibrium or balance between his intellectual faculty and his animal propensities was destroyed, he became irreverent, blasphemous, impatient and obstinate”.

As a result of the accident, Phineas lost his job and was never able to hold one for long, as he would quit them or be fired for his continuous quarrels with co-workers. His marriage ended, as his wife felt he was not his old self and had become aggressive. After working on several farms, Phineas was exhibited in the circus, where he proudly showed his wound and the iron bar that caused it. He died around the age of 38 due to epileptic seizures. Both his skull and the iron bar are now preserved in the Harvard University Museum, as it was one of the first cases described in the history of medicine where the relationship between brain injury and behavioral changes was demonstrated.

In our days the story of Phineas keeps repeating itself with different names and mechanisms of injury: falls from scaffolding, run over, car or motorcycle accidents, among others. Although 162 years have passed and there has been a great development in medicine, unfortunately, behavioral sequelae may still not be adequately diagnosed or treated, leaving the sufferer and his or her family members in a situation of chronic emotional overload and deterioration in quality of life.

Frontal lobe

Behavioral disorders cannot be discussed without mentioning the frontal lobe, the area of the brain located in the most anterior part of the skull, just behind the forehead, which is responsible for the main forms of mental activity such as intelligence, creativity, abstract reasoning and conceptual abilities. It is also what makes us human, intelligent and sensitive and allows us to learn from experiences and regulate our behavior depending on each situation.

To get an idea of its importance in humans, it is worth mentioning that the frontal lobe occupies 33% of the brain, while in chimpanzees it represents 15% and in cats 3%.

The frontal lobes connect with deep brain structures and with the temporal lobe, areas involved in emotional, hormonal, visceral, sensory and autonomic functions. The correct meshing of these systems results in the individual being able to regulate his or her behavior according to each situation, taking into account previous experiences, and to be goal-directed and productively involved in different facets of the human experience.

Thus, a malfunction of this regulatory system causes a state of disinhibition of behavior and alteration of emotions in the sufferer, which manifests itself with a tendency to irritability, sudden mood swings, impulsivity, inappropriate behavior in the social or family environment and, in more severe cases, verbal or physical aggression.

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Causes of acquired brain damage

Brain injury is not only caused by trauma, but also by stroke (hemorrhage or infarction of cerebral arteries), tumors, encephalitis and anoxic encephalopathy (lack of oxygen to the brain). We must bear in mind that these lesions differ from each other in factors such as the area of the brain affected or the extent of the lesion; some of them are localized, while others affect very large areas or even the whole brain. In this sense, the manifestations, evolution and prognosis between the different types of brain damage are not comparable.

Finally, there are patient-specific factors that can negatively condition the evolution of behavioral alterations. These factors are a history of habitual consumption of alcohol and toxic substances, advanced age and the previous existence of psychiatric pathology, mental retardation, developmental or learning disorders or brain injury.

Stages of brain damage

Depending on the patient’s stage of development, a series of alterations or changes in behavior can be observed. The phases described below do not have a specific duration nor do they always occur in the same order and the manifestations may vary depending on the type of brain injury and in each particular case.

In general, during the first days or weeks the patient may not communicate, be confused and not recognize family members; disorientation in place, time and even in person is frequent; he may have an incoherent speech, present a great motor restlessness that sometimes reaches agitation or have hallucinations that, generally, are of visual type (see animals, dead people, fire).

Sometimes, from the first phase, a state of disinhibition, impulsivity and mood swings is evident. Generally, these alterations are attenuated with time and with the different treatments implemented. Subsequently, there is a subacute or transition period in which the patient progressively recovers orientation, sense of self, recognition of people and coherence in his ideas, being able to recover, partially or completely, his previous mental functioning.

In chronic phases, when many months have passed since the injury, these changes in behavior are more evident and family members make comments such as “he is not the same as before”. This is known in medical manuals as an organic personality disorder or change, which is defined as a sustained or persistent change in the individual’s previous traits causing social, occupational or family impairment. The frequency of personality change in severe traumatic brain injury can reach 80% of cases.

Behavioral and emotional changes

For a better understanding, I have grouped into syndromes the different behavioral and emotional symptoms that the patient with acquired brain injury may present.

Alteration of affect

In the early stages of brain injury, emotional incontinence is very frequent, with crying in the face of minimal stimuli. Emotional lability may also occur, consisting of a difficulty in controlling laughter or crying, which generally occurs in situations of stress or nervousness.

The patient may go through a period of depression, reactive to the situation of disability, which sometimes manifests itself from the initial phase and sometimes occurs when returning to their environment and facing changes in lifestyle.

In the long term, emotional and affective instability is characteristic, with difficulty in regulating emotional responses, presenting abrupt mood changes that can last minutes, hours or days. Patients may alternate depressive states with phases of euphoria, sometimes without an external triggering factor.

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Changes in the expression of emotions are also frequent, described by relatives as “he is more affectionate than before” or “he is indifferent”….

Loss of impulse control

It is a failure in the behavioral control mechanisms that can be manifested in the verbal, instinctive and motor areas. Impatience with inability to wait, low frustration tolerance, irritability and demanding attitude are frequent.

In the verbal area, the patient may make an uncontrolled expression of opinions or feelings with indiscretions, loss of shame and, sometimes, use of foul language. Likewise, an excessively affectionate, seductive and complacent attitude may appear, with the need to greet, thank or touch others. They may also show sexual disinhibition. And, in the motor area, the impulsive patient acts thoughtlessly without considering the consequences of their actions.

The result of all of the above may be behavior not in keeping with the patient’s age and inappropriate social behavior.

Aggressiveness

Aggressiveness is also the result of a loss of impulse control that is accompanied by a feeling of discomfort and anger at an external or internal stimulus. The response can be verbal, in the form of insults or threats, or physical, against objects or people with acts such as breaking, throwing things, pushing, biting, punching, and self-injury, among others.

Unlike psychiatric diseases, aggression secondary to brain damage is reactive and disproportionate, so that it occurs in response to minimal stimuli, is not planned or purposeful, is very acute in its presentation, usually lasts a short time and, once the episode is over, causes regret and emotional discomfort in the patient.

Apathy

Apathy is essentially a lack of motivation that manifests itself in behavioral, cognitive and emotional aspects. There is a decrease in behavior that can be mild, in the form of slowing down for the different tasks of daily life, or severe, causing inability to initiate or maintain most activities.

Typically, the patient has no plans or ideas and shows decreased expression of feelings, so that he or she appears indifferent and unresponsive to environmental events, both positive and negative.

Apathy is usually of great concern to family members but not to the affected person, as the patient usually has a sense of placidity and indifference.

Other manifestations

Self-awareness is also often affected, so that the brain-damaged patient may not be aware of his or her deficits, which makes any therapeutic intervention extremely difficult. On the other hand, cognitive inflexibility causes the patient to be stubborn, selfish and inconsiderate of the people around him.

In some cases, there are paranoid symptoms manifested by exaggerated distrust, pathological jealousy, fear that others may do harm and other unrealistic ideas. These ideas are often accompanied by behavioral changes.

The described alterations are a direct consequence of the organic lesion of the brain and are presented together with the reactions typical of any person going through a period of illness, such as the appearance of regressive aspects, with the need for attention and care from loved ones; thus, we must bear in mind that not all behaviors are attributable to the brain lesion.

Consequences

Disorders in behavior and emotions may go unnoticed at first, especially for people who did not know the patient before the brain injury; however, altered behavior can completely change the relationship of a couple or family members and cause separation.

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The repercussions depend basically on factors such as the frequency and severity of the changes presented by the patient, as well as the degree of cohabitation with the patient.

In hospitals and rehabilitation centers, behavioral disorders can alter or impede the development of activities, negatively affecting the use of therapy and cognitive performance.

An altered behavior is often the cause of work, social and family dysfunction. In the long term, it causes rejection, stigma and progressive isolation, mainly of the person who suffers from it, but sometimes also of family members. For those closest to the patient, it is a cause of overload and emotional suffering.

Pharmacological treatment

The approach to behavioral and emotional alterations in patients with brain damage should be carried out in an interdisciplinary manner with neuropsychology. The treatment of cognitive problems is essential, as well as the preparation and education of the family in the guidelines for action and in the control of environmental factors that may trigger conflictive situations with the patient.

From the point of view of neuropsychiatry, the use of psychotropic drugs is widely justified as a tool that allows rapid symptom control in a large proportion of cases, which enables greater patient participation and collaboration in rehabilitation treatment and less caregiver overload.

It is important to know that psychotropic drugs have a primary indication and are approved for pathologies different from the one we are dealing with; however, their use in the treatment of cognitive-behavioral sequelae of brain damage is supported by studies and extensive scientific information. Thus, for example, we use antiepileptics and atypical antipsychotics for psychomotor agitation, irritability, impulse dyscontrol and as mood stabilizers. To improve alertness, attention, increase initiative and motor activity we prescribe some antidepressants, dopaminergics and psychostimulants.

General recommendations

During the visits it is essential to talk openly with the physician about the behavioral and emotional alterations presented by the patient and that he/she listens to the reason for prescribing medication. The patient should be involved in this decision in order to increase the therapeutic alliance with the physician and encourage compliance. Thus, the physician is responsible for the control and periodic assessment of the treatment, while the control and correct administration of the medication is the responsibility of the family members or caregiver.

Most psychotropic drugs may cause undesirable effects in the first few days, which should not persist for more than a week; in this case, or if they are very bothersome, they should be reported to the physician to assess the continuity of treatment before discontinuing it without consultation. The physician should also be informed about the patient’s behaviors that make it difficult to comply with the medication, since incorrect intake reduces efficacy and leads to poor symptom control.

The consumption of alcohol and other substances is contraindicated with the use of this type of drugs, since it entails risks such as altered state of consciousness, behavioral changes and epileptic seizures.

Our hospital offers an interdisciplinary approach, both to neurological patients and their families, integrating physical, neuropsychological and neuropsychiatric treatment for better control of the sequelae of acquired brain damage.