Traumatic Brain Injury - Essay Example

www.academia-research.com Sumanta Sanyal d: 08/04/07 An Investigation: Do Personality Changes Occur in Adults Following Traumatic Brain Injury Introduction: The main purpose of this paper is to establish whether personality changes occur in adults following traumatic brain injury (TBI). To do this the paper adopts a strategy of reviewing a set of 5-6 research studies that themselves seek to establish the same. The strategy has been to select the set of research studies in such a manner that one part of the set has found that personality changes do occur in adults following TBI while the other part of the set has found the opposite – that personality changes do not occur in adults following TBI. It is believed that scrutinising these opposing views will reveal the true fact about TBI and personality changes in adult humans. The studies are reviewed according to their objectives, particular analytical design, nature of participants, the measured outcomes, the variables, if predictable or not, taken into account and, finally, the results. In essence, the scope of the review is to determine how TBI injuries affect survivors and, thus, by considering how exactly they are affected, how they can be better enabled to rehabilitate back to their personal and workplace settings. Assessment Criteria: The assessment criteria for interviewing an adult TBI survivor may be broken down into three elements. These are 1) the population on which the personality model is based; 2) the source of information for generating the model; and 3) the procedure used for generating the model (Obonwasin et al, 2007). Other research groups may have used more complex criteria standards but, for the purpose at hand, the paper finds that this is sufficient. The Population Base: It is notable, in the context of this review, that most studies test personality post-TBI using scales with underlying personality models that have been specifically developed for populations groups other than those with TBI. Such scales, such as the NPRS[2] and the NBAP[3}, may not be effective in the sense that when they are deployed on TBI populations they are standardised for this purpose though they had been initially developed for other population groups (Obonwasin et al, 2007). Scales like the NEO-PI,[4] have been developed for the general population and when it is standardised for use on TBI populations the net effect is probably that of imposing a framework developed on personality relevant to the general population on personality changes usually deemed to be associated with TBI (Obonwasin et al, 2007). In contrast to these non-TBI specific scales NRS[5], the CPP[6] and the HIBS[7] were all developed based on information gathered from TBI survivors (Obonwasin et al, 2007). It is noted that though the CPP scale is very useful it has not led to any significant changes in the theoretical structure for TBI personality change enquiry. The HIBS is considered too recent to be judged on usefulness yet and the NRS is more of a scale that is useful and popular for assessing neurobehavioural functionalities. Its factor structure is such that a framework is provided for assessing general neurobehavioural changes rather than personality ones (Obonwasin et al, 2007). The review thus feels, as per Obonwasin et al, 2007, the NRS[5] seems most suitable for use in assessing personality changes in adults post-TBI but it will certainly include and consider those studies that do not use it for the purpose of determining its objective. The Information Source: It has often been found that the TBI survivor is not very well aware of his/her cognitive and behavioural problems. In such a context a significant other (SO), someone who knows the survivor well, is interviewed alongside the TBI survivor and both interviews are compared for true value and accuracy of responses (Obonwasin et al, 2007). The discrepancies between the two accounts is meant to be taken as the survivor’s ‘lack of insight’ (Obonwasin et al, 2007). It is notable here that this is not an exact means of determining the TBI survivor’s personality change post-TBI. This is because there is no direct evidence that the survivor’s account is less accurate that the SO’s. There is evidence, though, that the survivor’s lack of insight is not fully responsible for the discrepancy and there are factors associated with the SO that contribute significantly to it (Obonwasin et al, 2007). Thus, though this manner of comparative assessment is conducted universally to assess personality and behavioural change post-TBI there is no consensus on the accuracy of the method. Nevertheless, in absence of any other recommendable alternative, the paper shall review some papers that have conducted their studies based on this form of information gathering. The Procedure: The procedure involves identifying the items that shall constitute the elements of enquiry. Such elements may be selected on the basis of two types of analyses – psychometric and non-psychometric. The Non-psychometric group items intuitively to reduce complexity of information in their approach to personality in TBI while psychometric analysts use clinical judgement to select items in addition to items already existing for scales designed for non-TBI populations. Both types of analysts use factor analyses on the responses to generate TBI and SO statistics (Obonwasin et al, 2007). It is notable that items selected for TBI-specific personality may be inclusive with a comprehensive approach where all significant items, whether they are frequently or infrequently related to TBI personality, are selected. Otherwise, they may be more specific with only frequently related items and only those that can be easily assessable (Obonwasin et al, 2007). The paper shall keep this in mind when it starts the review of the research studies. The Negative Viewpoint As stated earlier in the introduction, the paper shall posit two viewpoints – the positive and the negative ones. The negative viewpoint is placed earlier and is of the opinion that post-TBI survivors do not develop personality changes. A study of clinical literature reveals that there is some evidence of personality changes in adults post-TBI. It is clear that varying degrees of behavioural changes are evident in patients with direct injury to the brain and it is also clear that such changes may be due to the consequences of adjustments made to compensate that injury (Rush et al, 2006). Nevertheless, Rush et al, 2006, admit that there is little direct evidence that personality structure changes with such injuries to the brain or, evenly less evidently, whether specific personality traits are also affected (Rush et al, 2006). Nevertheless, the Rush et al, 2006, study contains significant information on what Tate (2003) had predicted on personality change post-TBI. Tate (2003) investigated specifically such change with the aid of SO ratings on pre-morbid and post-TBI personality function at 6 and 12 months post injury. She used the Eysenck Personality Questionnaire-Revised (EPQ-R) and the Current Behaviour Scale (CBS) (Rush et al, 2006). She predicted that high pre-morbid extraversion, psychoticism, addiction and criminality derived from the EPQ-R would lead to increased loss of emotional control post injury, as derived from the CBS. In contrast, individuals with low pre-morbid extraversion would experience high rate of loss of motivation post injury (Rush et al, 2006). The actual assessment proved that pre-morbid personality ratings were similar to general, non-injured populations matched by age and gender. There was some marginal but significant changes observed between the pre-morbid and post injury ratings in neuroticism, addiction and criminality. Tate construed this as not being sufficient basis for supporting hypotheses that specific pre-morbid personality traits generate specific post-injury ones (Rush et al, 2006). This is important to the paper. In effect, Rush et al, 2006, investigated posttraumatic amnesia from both patients and SO at 1-2 months post injury. They found that, up to 2 years after injury, there was evidence of depression and neuroticism that affected behaviour but they could not construe this as significant personality change. The outcomes of the enquiry were affected by the neuroticism and depression but this was construed as slight behaviour change rather than change of personality (Rush et al, 2006). Thus, Rush et al, 2006, together with Tate (2003), conclude that there are signs of behaviour change in post-TBI survivors but there is no significant change in personality, especially specific personality traits. Rush et al, 2006, used the NEO-Pl-R scale with five major domains of personality functioning – neuroticism, extraversion, openness, consciousness and agreeableness. These five domains were spanned by 240 items and 30 facets (subscales). Participants rated each item on a 5-point Likert scale with 1 (strongly agree) and 5 (strongly disagree). The raw scores were converted to a T score with M - 50 and SD – 10. The strategy was to ask the TBI survivors and SOs were asked to respond to items at a few months after injury and again at 1-2 years after injury. No significant changes in both types of respondents at both times were noticeable, as mentioned earlier (Rush et al, 2006). Rush et al notes that the NEO-Pl-R scale has been frequently used to assess TBI patients and it has proven reliability and validity. The next scale used was the Independent Living Scale (ILS) which has been used effectively in assessing rehabilitation capabilities of TBI survivors in the past (Rush et al, 2006). Post-clinical staff judge patients for self-care capabilities and hours of supervision required on a 5-point scale where 5 means capability for total independence while 1 means total lack of independence (Rush et al, 2006). The scale was deployed at 1-2 years post injury and it was found that better outcomes on the ILS was associated with less neuroticism and depression and more extraversion (Rush et al, 2006). No other significant effect was noticed. The other two assessment tools used were the Vocational Independence Scale (VIS), which assesses independence in the workplace post injury, and the Mayo-Portland Adaptability Inventory (MPAI), which assesses adaptability to outside life post hospital discharge. Since both tools demonstrated no significant results they are not described here in details. The Positive Viewpoint A slightly old research study by Parker (1995) showed that patients with minor traumatic brain injury demonstrated various disorders including personality changes. The affectations were observed on both the physiological and psychological levels. Aside from physiological discomfort and dysfunction in certain sectors like sexuality emotional distress, often acute is reported in the study. There is report of patients who, post injury, demonstrated significant personality changes such as progressing pre-morbid to post injury from introversions to extroversion, non-gambling to gambling, friendliness to hostility, etc. (Parker, 1995). The Parker (1995) study is more of a discussion than a real study. Parker (1995) notes that certain personality dimensions in TBI survivors are affected by certain outside factors. These are posited below. The social context: Socially, survivors are often subjected to exclusion when friends and relatives and others move away from the survivor because of the pain, lack of communication, lack of money for aid, embarrassment, etc. (Parker, 1995). Information processing: Consequent to the brain injury, often information processing from outside stimulation is affected and adaptive behaviour, as a result is impaired. This results in social non-acceptance and behavioural ineffectiveness in the presence of others (Parker, 1995). Lack of identity: The survivor experiences lack of identity from loss of social initiative and feeling impairedness (Parker, 1995). Unconscious psychodynamic processes: These can affect the manner in which the survivor conceives of the trauma experienced (Parker, 1995). Subclinical seizures: These can cause hallucinatory effects and sensations that change the manner in which the survivor perceives reality and affects his/her control of reality and self-confidence (Parker, 1995). Affective changes: These influence the survivor to regard events at disproportionate emotional levels and affect his/her peace of mind and social acceptability (Parker, 1995). Reduced motivation: This hampers rehabilitation, causes lack of social interest and loss of social desirability (Parker, 1995). Conclusion The Parker (1995) study is highly significant as it goes to the crux of the problem in assessing whether patients post-TBI really experience what may be truly called personality changes. Rush et al, 2004, state that mild traumatic brain injury survivors are frequently found with emotional disorders that persist well after the injury period. They state that these disorders cannot be significantly attributed as personality changes as true elements of personality are still not distinguishable in the changes. True empirical evidence is lacking to positively demonstrate this. This reiterated in the Rush et al, 2006, study. Max et al, 2001, observed varying levels of personality changes in children and adolescents that diminished with degree of injury. They used the Neuropsychiatric Rating Schedule (NPRS) consisting of personality change (PC) subtypes – labile, aggressive, disinhibited, apathetic and paranoid (Max et al, 2001). 57% of the survivors proved with PC. The paper now notes three significant findings As per Parker (1995), survivors are often subjected to socio-emotional changes in their social environment post-trauma. As per Rush et al (2006), survivors are often noticed with emotional/behavioural changes post-TBI. Socio-emotional changes in the social environment may be due either as an ignorant reaction to the survivor’s own changed emotional/behavioural status (Rush et al, 2006) or by misconceived perceptions of the survivor in others in that environment. This last fact is noted by Weddell & Leggett (2006) in their study wherein they note that others socio-emotional status is often changed post-trauma leading to misconceived notions of the survivor. This often leads to wrong assessment during PC studies when the SO is thus influenced. Based on these findings that paper recommends, also as per Weddell & Leggett (2006), that socio-emotional changes around the survivor be studied to ensure that the survivor is not subjected to a socio-emotional context that is not inducible to rehabilitation both in personal settings and in the workplace. References Max, J.E., et al, The Phenomenology of Personality Change Due to Traumatic Brain Injury in Children and Adolescents, J Neuropsychiatry Clin Neurosci, 13:2, Spring 2001. Obonwasin, M.C., et al, A model of personality change after traumatic brain injury and the development of brain injury personality scales (BIPS), J. Neurol. Neurosurg., Published Online – 26th Jan, 2007. Parker, Roland S., The spectrum of emotional distress and personality changes after minor head injury incurred in a motor vehicle accident, Brain Injury, 1996, Vol. 10, No. 4, 287-302. Rush, Beth K., et al, Personality and Functional Outcome Following Traumatic Brain Injury, Rehabilitation Psychology, 2006, Vol. 51, No. 3, 257-264. Schretlen, D.J., Do Neurocognitive Ability and Personality Traits Account for Different Aspects of Psychosocial Outcome after Traumatic Brain Injury, Rehabilitation Psychology, 2002, Vol. 45, No. 3, 260-273. Weddell, R.A., and Leggett, J.A., Factors triggering relatives’ judgements of personality change after traumatic brain injury, Brain Injury, November 2006; 20(12); 1221-1234. Bibliography Malec, J.F., et al, Personality Factors and Injury Severity in the Prediction of early and Late Traumatic Brain Injury Outcomes, Rehabilitation Psychology, 2004, Vol. 49,k No. 1, 55-61. Read More