i) What is personality?

One of the biggest areas of difficulty after a brain injury is personality change.

Most psychiatrists find it difficult to define what we mean by personality.

It can be very hard to describe one's own personality.

However, after a brain injury we know that often people's personality, who they are, what they were like, how they react to situations, is changed by the fact that they have had a brain injury.

    Image: MARTIN O’NEILL CUT IT OUT STUDIO (used with permission)

 

ii) Personality change

All changes in personality do not have to be bad, they can be positive, but it is rare.

We do know that most people who have had a severe brain injury will have some change in their personality after they have had that brain injury. So it is very common.

Exaggeration of aspects of personality

Typically what happens is that people with a brain injury get an exaggeration of their personality traits. So it is not like they become someone completely new, it is not a Jekyll and Hyde situation. If they might have been a bit fussy they become very fussy. If they tended to get easily cranky before now they get cranky more easily. It is an exaggeration of how they were.

Difficulty controlling emotions

One of the biggest problems we have after a brain injury is for those people who have problems controlling their emotions or aggression. Not only do rehabilitation specialists find that a huge challenge, but also psychologists, family members and people within the community.

Low Motivation/Apathy

Some of the personality changes that often do not get talked about but can be really frustrating particularly for carers are the changes in personality where a person is less motivated.

The brain injured person is very flat, they do not do anything. They do not seem to have any kind of motivation to get up and do things. They talk about I am going to do this, I am going to do that, but they never get to do it. They have a problem with drive or initiative. This is a very difficult change in personality because it can be very hard to treat and often people do not understand what it is about and think that the person is lazy.

Lack of awareness of changes in personality

The biggest problem in changes in personality is usually that the person who has the change in personality is that they are not aware that they are different. Everyone will say – “Oh now you do this - or - You weren't like that before”. The person who has the brain injury is completely unaware of it. This causes a lot of frustration and also can cause a lot of misunderstanding.

Why does this happen?

We know that the front part of the brain, particularly the right front part of the brain or the right frontal cortex is really important for recognising or being aware of things. So if you damage that area could have a big problem being aware of what is going on. It is the people who have damage to the right frontal area that often do not recognise that their personality has changed.

 

iii) Managing personality change

One of the challenges with a personality change is how we are going to manage it.

There is no specific part of the brain that controls personality but we do know that the frontal lobes are very important for controlling how people behave and think about things.

The damage to the frontal lobe is very important for personality change. If you remember back to looking at the brain and the skull, the frontal lobes are at the front of the brain.  Often when you have a car accident or you have a fall what tends to happen is that the brain moves forward, hits the front of the skull and causes bruising in the frontal areas and possibly permanent damage. So personality change is going to be really common after a brain injury. It can be quite subtle or very obvious.

Sometimes people's personality improves after a brain injury. There are cases where people say oh they are much nicer, they are easier to get on with, they are a lot calmer. And that is nice if it happens but unfortunately the majority of cases the personality change is not a positive one.  Typically people focus on are the changes in personality where people become aggressive, paranoid and irritable.   

They can also be disinhibited and more childlike in their behaviour. In terms of treatments sometimes the combination of behaviour therapy and medication can settle down some of the problems. Sometimes the person might benefit from training in social skills. This often works best when other people such as family and carers are involved in training and can remind the person to use strategies that they have learned.

For a lot of the difficult behaviour changes that occur after a brain injury e.g. aggressive personalities, people typically use medicines that we use to treat epilepsy. Tegretol (Carbamazepine) and Epilim (sodium valproate) are the two commonest medications that might be prescribed for people who have personality change and tend to be aggressive and irritable.

In many cases the person might benefit from psychological interventions such as anger management therapy and behaviour support programs.  In learning to manage anger it is important to identify the triggers to anger and whether these can be minimised or avoided.  Where they cannot be avoided we need to become more aware of the signs of anger and use this as a signal to put in place some sort of calming down routine.