i) Anxiety conditions

There are many anxiety conditions that people can have but there are a few common ones that people have after a traumatic brain injury.

Phobia

Often people will have an anxiety about a particular situation, this is a phobia.  They might have what we call a car phobia. If you have had a serious accident in a motor vehicle you might get very anxious and frightened when you are in a car and we would call this a specific phobia or a car phobia.

Social Phobia/or Agoraphobia

At other times people might get anxious about being out in public, they could have a social phobia or agoraphobic, something called panic attacks.

Obsessive compulsive disorder

They may have obsessions and compulsions or have what we call obsessive compulsive disorder. There are lots of movies made by Hollywood about obsessive compulsive disorder,  so often it is an illness that is quite easily recognised by family members.

But it is important to know that many people after a brain injury because they are forgetful, tend to be very ordered and particular about how they do things. So they might have some obsessional features but they do not have an obsessive compulsive disorder. They have what is called “organic obsessiveness”. There is some evidence from research that memory problems can increase the checking symptoms of OCD.

If you are worried that the person might be more obsessional about things than they or you think that it is causing problems, this is when you go and speak to someone about it, be it the rehabilitation team member or someone within the community or your family doctor.

Posttraumatic stress disorder

Post traumatic stress disorders can develop in people when they have been in a really bad experience. People who have posttraumatic stress disorder often relive aspects of the trauma. They will avoid situations where they might get memories of the trauma. They may not want to talk about it, they can be quite jumpy and nervous.

Anxiety disorders following a traumatic brain injury can be a combination of a biochemical problem and a reaction to the situation

That gives us clues as to how we take care of people with anxiety problems.

Image: The Scream Edvard Munch

 

ii) Anxiety disorders

Anxiety disorders are common and they are often missed in people with traumatic brain injury.

The reason they are missed is that people often see anxiety as being normal in a particular situation. So for example if the person has had a car accident and they are anxious about being in a car everyone says oh look that's pretty normal and it will go away. It often does not go away. Typically people need to have treatment for these kinds of fears and anxieties.

The anxiety can be really disabling because it limits the activities the person will do and it very commonly occurs in combination with depression.

If you have both anxiety and depression then you really need to have a lot of help and you need it quickly because the combination of the two problems can cause lots and lots of difficulties.

Some of the common anxiety conditions that we talk about are

• panic disorder
• social phobia

Panic disorder

Panic disorder is when people have something called panic attacks where they suddenly feel frightened, they will breathe too fast, they will think something terrible or bad is going to happen to them.

Often they notice that their heart is pounding in their chest. If they have a panic attack in a shopping centre or a place where there are lots of people they will often try and take themselves away from that.

Sometimes people with panic attacks refuse to leave their home and they have something we call agoraphobia. It is very rare for a person to get agoraphobia and not have panic attacks.

Social phobia

One of the more common anxieties that people get after a brain injury is a condition called social phobia where they avoid meeting, mixing and talking with people. This typically occurs to people who have some kind of language problem associated with their brain injury.  People with social phobia fear scrutiny and embarrassing themselves.

Obsessive compulsive disorder

One of the least common anxiety disorders after brain injury but one of the ones that can be the most disabling, are the obsessive compulsive disorders. Obsessive compulsive disorders are where people do things repetitively and in a ritualistic way.

The commonest ritual is hand washing, where the person has some kind of belief about being easily contaminated or that there are germs everywhere.  They have to go and wash their hands. But they do not just go and wash their hands once, they often wash their hands for half an hour/ an hour at a time .

Other people might have rituals about counting, how they do things.  The obsessive compulsive symptoms can be really, really disabling because they stop people getting to places on time, doing rehabilitation or everyday activities.

Someone with obsessive compulsive symptoms can get very angry and aggressive if someone stops their rituals. They can also become very stressed and worried about their symptoms.

 

iii) Posttraumatic stress disorders

Some people would know it as Vietnam War syndrome. There is now something called Gulf War syndrome. People with posttraumatic stress disorder have very similar symptoms.

A number of years ago people thought that if you have a severe brain injury you did not get a posttraumatic stress disorder. But there have now been some studies looking at people who have had severe brain injury and found they can get a post traumatic stress disorder. We recognise that post traumatic stress disorder can happen when with all types of brain injury (mild to severe).

Typically posttraumatic stress disorders happen to people when they have been in a really bad experience. So if you have been in a really bad car accident, you might remember up until the point of the accident and it is those aspects of your memory that form part of the posttraumatic stress disorder. People who have posttraumatic stress disorder often relive aspects of the trauma, they will also avoid situations where they might get memories of the trauma. They may not want to talk about it and they can be quite jumpy and nervous.

It is a lot more common than we thought and sometimes people will only have some symptoms of posttraumatic stress.

Where it gets really difficult is that sometimes you can confuse the cognitive or thinking problems of a brain injury with the symptoms of a posttraumatic stress disorder.  It can take a very skilled psychologist to be able to work out the differences.

 

 

iv) Managing anxiety disorders

For the anxiety conditions that people get after a brain injury we typically suggest that they have psychological treatment before they have medication.

Some of the types of treatment that you might include are:

• relaxation training where you are taught how to relax and manage your anxiety - where they are taught to control their breathing
• techniques to try and challenge their thought processes that make them anxious.

For people with obsessive compulsive disorder we often try and get them to stop the ritual and manage the anxiety and learn that they do not have to do the ritual because nothing bad will happen if they do not carry out the ritual.

With people with brain injury, we often need to also use medication for people with obsessive compulsive disorders.

Medications

Anxiolytics

The commonest medication treatment for the anxiety disorders are what are called the anxiolytics. Behaviour or psychological treatments need to be given first and the main reason for this is the effects of some of the medications have.

The most readily prescribed anxiolytics are:

• Ducene,
• Valium,
• Serepax
• Xanax

These drugs work very quickly to get rid of the anxiety symptoms. So they are really effective.

You might think they should be prescribed all the time. But they have a big drawback. They are highly addictive and for that reason we do not encourage people with anxiety disorders to be started on the anxiolytics because it gets very hard to stop them.

The anxiolytics mask the symptoms of the anxiety but they do not treat the underlying problem so the person never learns how to cope with it without medication.

Modern antidepressants - SSRIs

Some of the more modern antidepressants, the ones we call the SSRIs - short for Serotonin Selective Reuptake Inhibitor - are antidepressants but they are also really effective for managing anxiety conditions.

People who have an anxiety disorder where the counselling therapy has not helped to control their symptoms might be started on one of these antidepressants. Some of the typical SSRI medications that are used for anxiety are:

• Zoloft
• Cipramil.

We tend to leave medications for the more severe problems or where following the behaviour therapy, because of their memory problems, they cannot remember to use the strategies when they are in situations that cause them to be anxious.

Often if you have an anxiety problem and you need medication you are going to need to be on it for a long time and it can take a number of weeks for the medication to work. Sometimes it takes eight to twelve weeks before it reduces the anxiety symptoms. So while you are waiting for it to work you need to remember to keep on regularly taking the medication.