Depression, Anxiety and Bipolar After Brain Damage

Brain damage mood disorders are common after trauma, and include depression, anxiety and complex personality changes that hard to categorize and treat. Organic injury to the cells of the brain will change how the brain feels and acts.

By Rebecca Martin

It is a widely held belief that brain damage mood disorders involve three factors and their interactions with each other. First, we must look at those factors which preceded the brain damage. Second, we must examine the brain injury itself and third; we must consider those factors which are present during the recovery process. In order to understand the interaction of these factors, we have to break down each of those timelines to understand the likelihood and impact of long term brain damage mood disorders.

brain damage mood disorders

Brain damage mood disorders are inherent after traumatic brain damage as an organic injury to the cells of the brain, will implicate how the brain feels, thinks and networks everything that a human being does.

Mood disorders are defined as mental health disorders which involve emotional disturbances. The most common of these is depression. Depression itself occurs across a spectrum from the occasional sadness or irritation we all feel from time to time to major depressive disturbances (MDD) which impact a person’s ability to enjoy life and function in a normal manner. We generally think of a major depressive disturbance as occurring over a lengthy period of time.

Phases of Brain Damage Mood Disorders

When we look at major depression in the general population, in the absence of a traumatic brain injury, it often occurs without a specific trigger and the onset differs for each particular patient. It may develop over time or come on rapidly. In the initial stages, it is described similarly to the stages of grief with the first phase being denial and isolation with a refusal to accept that there is an issue. In this early phase, the sufferer may feel that it can be overcome with effort on their part. The sufferer may draw back from former contacts and activities.

The next stage can be anger, often undirected but all encompassing. Towards oneself, towards life, towards the world, generally due to the helplessness felt when self-help has failed. This leads inevitably to the next phase which involves negotiations with one’s self in an attempt to fend off the depression which has now gained a life of its own. Again, this self-help is rarely successful and leads to the next phase in which the entire situation seems hopeless and overwhelming, becoming a spiral of negative thoughts and negative self-worth. And finally, the realization that this depression is more than a temporary phase, that it is an illness. It is often at this final phase that the sufferer seeks help.

Major Depressive Disorder – Something out of the Ordinary

The Stanford School of Medicine estimates that 10 percent of Americans will suffer from a depressive episode at some point in their lives. These can be brought on through life experiences or situations, predispositions from early life, genetic factors; or traumatic brain injury. The result can be temporary or lifelong. Major depression, however, is considered a serious medical condition that can impact one’s life in a very dramatic way.

There are many health issues associated with major depression. Overeating or binging can lead to diabetes. Older adults may experience geriatric anorexia or a loss of interest in eating. Depression and stress impact the cardiovascular system. Increased heart rates and constricted blood vessels may increase the risk of heart attack. The immune system can also be compromised as there is a clinical relationship between inflammation and depression.

Major depression also increases the risk of suicidal ideation and increases the risk for suicide. For more on suicide risk after brain injury, click here. 

Preexisting Problems Worsen Brain Damage Mood Disorder

I spoke at the beginning about the three distinct phases of depression as related to traumatic brain injury. In the pre-injury phase we must take into account predispositions or existing depressive tendencies which are present in the population in general. Someone may never have experienced a major depressive episode prior to an injury, but factors related to the injury may trigger chemical changes in the brain which were not previously triggered. One may have a predisposition due to childhood trauma, PTSD, or other environmental factors. Or one might have a combination of genetic factors which could contribute to the likelihood that an event such as a traumatic brain injury can become a catalyst.

We must recognize that a certain number of people might already suffer from major depression before an event. In this case it is highly likely that either coping skills or treatment have kept a balance which can be thrown off by brain injuring event. In this scenario a conservative diagnostic approach must be used to determine if the depression is the result of the TBI. This is particularly important as these patients often become symptomatic after a longer period of time.

However many people have no predisposition or evidence of major depressive disorders prior to a traumatic brain injury and because of the interactions of the different phases, they find themselves in the same spiral as those considered predisposed to a major depressive disorder.  According to an article by Ricardo E. Jorge and David B. Arciniegas published by the National Institutes of Health https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985339/

Depressive disorders develop commonly among persons with TBI, with estimated frequencies ranging from 6-77%. Within this range, most experts on this subject accept an estimated first-year post-TBI depression frequency in the range of 25-50%, and lifetime rates of 26-64%.

 Studies have found no definitive link between genetic predisposition and the severity of depression following a traumatic brain injury. Age and gender shows that some statistics may lean a bit towards the young, female or the elderly, but this has not been well defined in existing studies.

Preexisting Mental Health Issues Lengthens Recovery

What has been seen is that those with no previous history of psychosocial adversity were more likely to suffer most in the early stages following a traumatic brain injury, while those with a previous history of major depression were more likely to suffer later on.

There is also a definitive connection between alcohol use and depression following a traumatic brain injury. Jorge, et. al., also found: “three quarters of patients who abused alcohol in the year after their TBI had a coexistent mood disorder.”

As already mentioned, the onset of depression often is left to self-help methods with self-medication being a very real risk for someone striving to overcome depression without the intervention of professional help. This is very understandable when we look at the different aspects of depression itself.

One of the most pressing issues is the development of negative thought patterns regarding one’s self. This can encompass appearance, vocation and/or social contacts or lack thereof. These thoughts can extend to a world view in which social/economic or environmental issues contribute to a feeling of “what is the use?”  Helplessness on a personal level can evolve into helplessness and hopelessness on a global level.

Social Media Worsens Brain Damage Mood Disorders

This is exacerbated by an increase in social media over the last decades. In the documentary, The Social Problem, a dramatic increase of depression and anxiety is discussed as it pertains to young people with up to an 82% increase in depression in teenagers. Skewed perceptions of the world around us have flourished and our online connections have become primary social connections. Often these social connections are based on division.  Suicide rates have increased dramatically.

Because social networking has developed algorithms targeted specifically to each individual, more division and isolation have resulted.  These algorithms determine personality traits such as introversion, isolation, depression and anxiety and tend to direct us to media designed to appeal to those thought processes. We are just now beginning to understand the impact this may be having on our mental wellbeing in the technological age.

When we imagine a person experiencing the isolation that comes after a traumatic brain injury, amidst negative thought processes and an interruption in the social network after the event, we can understand why social media may become a factor. Often those who have suffered a disruption in thought processes due to a traumatic brain injury do not have a self-awareness of deficits as keenly as those family members, friends, and employers might have looking in from the outside; and therefore the change in social interactions are incomprehensible. The person is not aware that they have changed but may be aware that others’ reactions have changed which inevitably leads to further self-isolation.

We are rapidly becoming an entire population familiar and comfortable with social media and sadly, less personal face to face interaction. Even traditional social activities such as applying for drivers licenses and dating have decreased as a result.  We will continue to see social media making an impact on society and undoubtedly those with mood disorders will be impacted in ways we cannot yet determine.

Appetite Impacted by Brain Damage Mood Disorders

Another facet of depression is a change in appetite. Although not every TBI survivor will experience this, depression can lead to either a complete loss of appetite or development of an eating disorder or food addiction. Food is a well-known coping mechanism which is prone to increase negative thinking.

Hormone levels change when under depression and stress and can severely affect sleep patterns. This can lead to insomnia or overwhelming fatigue. The brain is seeking respite from stress and the results can lead to a general lethargy.

This is understandable in the constant battle to overcome depression on one’s own and failing again and again. This is a no-win scenario that leads to increased feelings of worthlessness and helplessness. In the extreme, this can lead to thoughts of suicide.

Professional Help Can Make a Difference

Seeking professional help in the early stages of depression is the best case scenario. Through therapy and even medication, the spiral can be stopped before everything spirals out of control. One of the factors mentioned in regard to brain damage mood disorders is the extent of the actual brain damage. Those who suffer a severe damage are most likely to be hospitalized for a period of time and receive early and ongoing care for depression. But those with a milder case are less likely to be hospitalized and less likely to be inducted into an early treatment program unless they prevail in seeking ongoing medical care. And while most TBI survivors will experience depression within a year of the injury, there are those who will not present with depression until more time has passed. It often falls on the families to be the vehicles of intervention in these cases, especially when self-awareness is lacking.

A familiarity with traumatic brain injury in general is paramount for families and it is advisable for medical follow ups to be done after any traumatic brain injury event. Changes in habits and behavior should be taken seriously. Changes in schoolwork, changes in employment and productivity, changes in social interaction are all notable, not only in identifying deficits (diagnosed or undiagnosed) but in the mood disorders which can result.

Only conscientious professional care can determine which deficits stem directly from brain damage or changes, and which are caused by the predisposition for mood disturbances following such an injury. Ultimately changes in the brain and its functions may play a greater role in the propensity for mood disturbances. When we take into account that depression can affect cognitive function and contribute to dementia, the interconnectedness of physical injury to the brain and depression is of urgent interest.

Early studies show that chronic neuroinflammation is often the result of traumatic brain injury. The link between inflammation and an increased risk of depression is understudied according to an article on the National Institutes of Healthcare’s website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128046/

Increases in cytokines similar to those seen in depression in the general population are also increased following a TBI.

This is not limited to those who have suffered a severe traumatic brain injury.

Even with the resolution of symptoms in the vast majority of people following a mild TBI, there is compelling evidence that progressive brain atrophy, as well as cognitive dysfunction, continue after a mild TBI (Gardner and Yaffe, 2015; Rabinowitz et al., 2015; Theadom et al., 2018).

For those who have experienced a concussion with symptoms lasting longer than three months and thus diagnosed with post-concussive syndrome, this means that they may experience long term symptoms including sleep disturbances, memory impairments, headaches and mood disorders. Traditionally, a medication based approach has not always proven effective in treating mood disorders following a traumatic brain injury. And with up to 56% of TBI sufferers experiencing depression within 10 weeks of the injury, new studies are leaning towards the link between inflammation and post-TBI depression.

Much of this is due to our growing knowledge of how the human body works. We once thought neurotransmitters acted in the nervous system and cytokines acted in the immune system. We now know that our nervous and immune systems use both neurotransmitters and cytokines. Cytokines have been measured post-TBI, and even more specifically, following mild TBI, especially those in military personnel. There has been some progress in utilizing cytokine blockers in the treatment for depression in post-TBI cases.

Much of this was based on the observation that cytokines affect our behavior when we are sick with the flu, for example. We display many of the behaviors that a person suffering from depression suffers. The cytokines affect our behavior in order to fight infection and influence behaviors like our desire to self-isolate, for example. As scientists collect more data on the elevated levels of cytokines and their connection to post-concussive depression we will undoubtedly see more effective treatments involving cytokine blockers and anti-inflammatories utilized in the treatment of traumatic brain injury.

Depression and Anxiety Correlate

There is also a definitive correlation between depression and anxiety. You might think they are different sides of the spectrum but in actuality they often exist in a cycle. Anxiety can trigger depression and depression can trigger anxiety. Cognitive difficulties such as concentration and memory problems can contribute to feelings of anxiety. One common cause of anxiety is returning to work or the classroom too soon after a TBI. The added pressure to meet previous demands can lead to anxiety and failure to meet those standards can result in depression.  Of course we all experience anxiety but many people find themselves in the emergency room seeking help when anxiety escalates to panic attacks.

It is not uncommon for a person who has suffered a brain injury to experience mood swings or emotional lability. This can present as outbursts of anger, or any type of emotional response which is inappropriate to the situation. This is normally an issue which resolves more quickly after a TBI and is normally attributed to more severe cases.

There has been some discussion as to whether bipolar disorders have a connection to prior TBI. But some studies did not show a significant link to mania/depression due to a prior TBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162005/

We have much to learn about how our brains function and many questions to be answered. But an understanding of what happens to the individual following even a mild brain injury is an enormous step on the path to providing intervention and help to all survivors.

 

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  1. […] Survivor’s Guilt and other Anxiety related symptoms interact with brain damage deficits to significantly complicate recovery after carbon monoxide poisoning. This blog is a followup to last weeks blog on brain damage and mood disorders. […]

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