Personality change

Personality change after head injury results in more suffering than any other single sequel. (3,33) In general, the personality change goes hand in hand with cognitive impairment. However, a severe personality change is occasionally found in somebody with almost no impairment of cognitive function. Normal test scores for memory and intellect do not rule out brain injury as a cause of personality change after head injury.

Aetiology

It is not easy to predict who will develop a change in personality after head injury. Sometimes a personality trait present before the injury becomes much more troublesome, but often there is no obvious predisposition. The site of the brain injury may play a role. Convexity lesions, on the lateral surface of the brain, can produce impairments of drive. Orbitofrontal lesions may cause a more troublesome personality change with impairments in social behaviour.

Post-traumatic factors also need to be considered. Some patients seem to learn maladaptive patterns of behaviour; for example the response of the carers may unwittingly reinforce unwanted behaviours. Chronic mental illness may be manifest as personality change, which may be aggravated by chronic psychosocial stressors. Dependence on drugs, particularly alcohol, frequently confounds the picture.

Characteristics of the personality change

Changes in personality(34) include apathy and impairment of motivation and ambition. Patients are often described as childish; this covers a range of traits including impulsivity, poor tolerance of frustration, being demanding and self-centred, and generally lacking the ability to take on the adult role in terms of independent decision-making. Patients may be fatuous and facetious. Antisocial behaviours (see below) and disinhibition are severe handicaps that make integration back into the community very difficult. Sexual disinhibition of any type is particularly worrisome. A spectrum of severity is seen, ranging from being inappropriately flirtatious through to indiscriminate sexual assaults. Head injury is a risk factor for borderline personality disorder. (,35>

In acquired antisocial personality disorder(36) the person is often self-centred and relatively oblivious to the needs of others. They are likely to be tactless and, on occasion, offensively rude. Irritability and aggression and impulsive behaviour are seen. They may show a lack of remorse for the violent behaviour. These personality traits often are accompanied by the dysexecutive syndrome. Thus not only does the person show disturbed social decision-making, resulting in antisocial behaviours, but also disruption of the planning and organizational skills needed for cognitive tasks. For example, helpful and supportive friends may be alienated in favour of disreputable acquaintances, at the same time as money is impulsively spent, and lost, on risky projects without any attempt to weigh up the options.

Effects on family and carers

Families find personality change particularly difficult to cope with. (37) Children may be ignored and the partner's needs, particularly emotional needs, forgotten. The healthy balance of the relationship with the partner may be destroyed, with the head-injured person now unable to take an effective part in the household. The partner becomes a carer and the change in roles may have a serious impact on the sexual relationship. Divorce frequently follows. However, parents may find the childish personality of the brain-injured person easier to cope with; they revert to taking on the parental role.

Personality change may deteriorate. Supportive social networks are lost and social isolation and financial problems may contribute to depression or alcohol abuse, which then cause a deterioration in the behavioural problems associated with the personality change. Follow-up studies lend some support to this argument. Some behavioural problems are found to have deteriorated at 5 years after head injury(38), and family burden increases over this period.

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