Emotional changes after traumatic brain injury: understanding and managing the impact 

By Georgia Stevenson, former Assistant Psychologist at Kerwin Court, the Brainkind Neurological Centre in Horsham 

 

Traumatic Brain Injury (TBI) is a life-altering event that can lead to a wide range of emotional changes [1]. These changes can be just as challenging as the physical and cognitive impairments that often follow the injury [2]. This month on Research Digest we revisit Georgia Stevenson’s (former Assistant Psychologist at Brainkind) exploration of relevant research on the emotional changes that may occur after TBI, and her discussion of the strategies available for managing these emotional challenges as part of a comprehensive rehabilitation approach. 

Common emotional changes after TBI 

Emotional changes after TBI can vary widely depending on the severity of the injury, the location of the brain damage, and individual factors such as personality and pre-injury mental health [3]. Some of the most common emotional changes include: 

1. Depression
   Depression is one of the most prevalent emotional changes following a TBI [4]. People may experience persistent sadness, loss of interest in activities, feelings of hopelessness, and changes in appetite or sleep patterns. Research shows that the prevalence of depression after TBI ranges from 20% to 50%, depending on the study population and time since injury​ [5]. The risk of developing depression is particularly high in the first-year post-injury, but it can persist or even emerge years later [6]. 
2. Anxiety
   Anxiety disorders, including generalized anxiety, panic attacks, and post-traumatic stress disorder (PTSD), are also common after TBI [7]. People may experience excessive worry, fear, and physical symptoms, such as increased heart rate or shortness of breath. Anxiety can be triggered by the stress of coping with the injury, changes in life circumstances, or the trauma associated with the injury event itself [8]. 
3. Irritability and anger
   Increased irritability, frustration, and difficulty controlling anger are frequently reported by TBI survivors [4]. These emotional changes can strain relationships and make social interactions challenging. Research suggests that irritability and anger are often linked to damage in the frontal lobes, which are responsible for impulse control and emotional regulation​ [9]. 
4. Emotional lability
   Emotional lability, or rapid and exaggerated mood swings, is another common outcome of TBI [7]. People may find themselves crying or laughing uncontrollably, often in situations where such reactions are inappropriate or unrelated to their actual feelings. This condition, known as ‘pseudobulbar affect’, is believed to be caused by disruptions in the neural pathways that control emotional expression​ [10].  
5. Apathy
   Apathy, or a lack of motivation and emotional responsiveness, can also occur after TBI [7]. People with brain injury may seem indifferent or uninterested in activities they previously enjoyed. Apathy is particularly challenging as it can hinder engagement in rehabilitation and delay recovery. It is often associated with damage to the frontal lobes and basal ganglia, areas of the brain involved in motivation and reward processing​ [11].  

 Causes of emotional changes 

The emotional changes experienced after TBI are multifaceted and can be attributed to several factors: 

• Direct result of brain damage: the injury itself can damage areas of the brain responsible for emotion regulation, such as the frontal lobes, limbic system, and brainstem [12]. This damage can disrupt the normal functioning of neurotransmitters, leading to mood disorders and emotional dysregulation. 

• Psychological response to the injury: the trauma of the injury, along with the resulting changes in cognition, physical abilities, and life circumstances, can lead to significant psychological stress [13]. This stress may manifest as depression, anxiety, or other emotional disorders. 

• Social and environmental factors: the changes in relationships, loss of independence, and challenges in returning to work or social roles can exacerbate emotional difficulties [14]. Social isolation, financial stress, and the loss of self-identity can all contribute to emotional changes following a TBI​. 

Strategies for managing emotional changes 

Addressing emotional changes after TBI requires a comprehensive approach that may include medical, psychological, and social support. Here are some strategies that can help: 

1. Psychotherapy
   Cognitive Behavioural Therapy (CBT) and other forms of psychotherapy can be effective in treating depression, anxiety, and emotional lability after TBI [15]. Therapy can help people develop coping strategies, challenge negative thought patterns, and build emotional resilience. For some, counselling that includes family members can be beneficial in improving communication and understanding within the household. 
2. Medication
   Antidepressants, anti-anxiety medications, and mood stabilizers may be prescribed to help manage emotional symptoms [16]. It is essential that healthcare providers work closely with people with TBI to find the right medication, as this population may be more sensitive to side effects and drug interactions. 
3. Support groups
   Joining a support group for TBI survivors can provide emotional support, reduce feelings of isolation, and offer practical advice from others who have had similar experiences. Peer support has been found to be a valuable resource for coping with the emotional impact of TBI [17]. 
4. Lifestyle modifications
   Regular physical activity, a balanced diet, and good sleep hygiene can have a positive impact on emotional wellbeing. Exercise, in particular, has been shown to reduce symptoms of depression and anxiety by releasing endorphins and improving brain health [18]. 
5. Mindfulness and relaxation techniques
   Mindfulness meditation, deep breathing exercises, and other relaxation techniques can help people with a brain injury manage stress, reduce anxiety, and improve emotional regulation [19]. These practices can be particularly useful in managing irritability and emotional lability. 
6. Education and awareness
   Educating both the patient and their family about the potential emotional changes after TBI is crucial. Understanding that these changes are a result of the injury can help reduce stigma and promote compassion and empathy in those providing care and support. 

Conclusion 

Emotional changes are a common and challenging aspect of life after traumatic brain injury. Understanding the underlying causes of these changes and implementing effective management strategies can significantly improve the quality of life for TBI survivors. By addressing emotional health as a key component of rehabilitation, health and social care providers can help people with TBI navigate the complexities of recovery and achieve better long-term outcomes. This evidence-based approach continues to enhance our understanding of the emotional impact of TBI and drive best practices for supporting those affected by this life-changing condition​.  

 

References 

[1] Gouick, J., & Gentleman, D. (2004). The emotional and behavioural consequences of traumatic brain injury. Trauma, 6(4), 285-292. 

[2] Shulman, L. M. (2020). Emotional traumatic brain injury. Cognitive and Behavioral Neurology, 33(4), 301-303. 

[3] Schachar, R. J., Park, L. S., & Dennis, M. (2015). Mental health implications of traumatic brain injury (TBI) in children and youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie Canadienne de Psychiatrie de L’enfant et de l’Adolescent, 24(2), 100–108. 

[4] Anson, K., & Ponsford, J. (2006). Coping and emotional adjustment following traumatic brain injury. The Journal of Head Trauma Rehabilitation, 21(3), 248-259. 

[5] Juengst, S. B., Kumar, R. G., & Wagner, A. K. (2017). A narrative literature review of depression following traumatic brain injury: prevalence, impact, and management challenges. Psychology Research and Behavior Management, 10, 175–186. https://doi.org/10.2147/PRBM.S113264 

[6] Choi, Y., Kim, E. Y., Sun, J., Kim, H. K., Lee, Y. S., Oh, B. M., Park, H. Y., & Leigh, J. H. (2022). Incidence of depression after traumatic brain injury: a nationwide longitudinal study of 2.2 million adults. Journal of neurotrauma, 39(5-6), 390–397. https://doi.org/10.1089/neu.2021.0111 

[7] Howlett, J. R., Nelson, L. D., & Stein, M. B. (2022). Mental health consequences of traumatic brain injury. Biological Psychiatry, 91(5), 413–420. https://doi.org/10.1016/j.biopsych.2021.09.024 

[8] Headway (n.d.). Anxiety after brain injury. Retrieved September 9, 2024, from https://www.headway.org.uk/media/12016/anxiety-after-brain-injury-publication.pdf 

[9] Neumann, D., Miles, S. R., Sander, A., & Greenwald, B. in collaboration with the Model Systems Knowledge Translation Center (2021). Understanding and coping with irritability, anger, and aggression after TBI. Retrieved June 6, 2025, from https://msktc.org/tbi/factsheets/understanding-and-coping-irritability-anger-and-aggression-after-tbi 

[10] Engelman, W., Hammond, F. M., & Malec, J. F. (2014). Diagnosing pseudobulbar affect in traumatic brain injury. Neuropsychiatric Disease and Treatment, 10, 1903–1910. https://doi.org/10.2147/NDT.S63304  

[11] Worthington, A., & Wood, R. L. (2018). Apathy following traumatic brain injury: A review. Neuropsychologia, 118(Pt B), 40–47. https://doi.org/10.1016/j.neuropsychologia.2018.04.012 

[12] Schwarzbold, M., Diaz, A., Martins, E. T., Rufino, A., Amante, L. N., Thais, M. E., Quevedo, J., Hohl, A., Linhares, M. N., & Walz, R. (2008). Psychiatric disorders and traumatic brain injury. Neuropsychiatric Disease and Treatment, 4(4), 797–816. https://doi.org/10.2147/ndt.s2653  

[13] Weil, Z. M., White, B., Whitehead, B., & Karelina, K. (2022). The role of the stress system in recovery after traumatic brain injury: A tribute to Bruce S. McEwen. Neurobiology of Stress, 19, 100467. https://doi.org/10.1016/j.ynstr.2022.100467 

[14] Berwick, D., Bowman, K., & Matney, C. (Editors), National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Sciences Policy, Board on Health Care Services, Committee on Accelerating Progress in Traumatic Brain Injury Research and Care, (2022). Traumatic brain injury: A roadmap for accelerating progress. The National Academies Press. https://nap.nationalacademies.org/read/25394/chapter/1  

[15] Gómez-de-Regil, L., Estrella-Castillo, D. F., & Vega-Cauich, J. (2019). Psychological intervention in traumatic brain injury patients. Behavioural Neurology, 6937832. https://doi.org/10.1155/2019/6937832  

[16] Robert, S. (2020). Traumatic brain injury and mood disorders. The Mental Health Clinician, 10(6), 335–345. https://doi.org/10.9740/mhc.2020.11.335 

[17] Levy, B. B., Luong, D., Perrier, L., Bayley, M. T., & Munce, S. E. P. (2019). Peer support interventions for individuals with acquired brain injury, cerebral palsy, and spina bifida: a systematic review. BMC Health Services Research, 19(1), 288. https://doi.org/10.1186/s12913-019-4110-5 

[18] Perry, S. A., Coetzer, R., & Saville, C. W. N. (2020). The effectiveness of physical exercise as an intervention to reduce depressive symptoms following traumatic brain injury: A meta-analysis and systematic review. Neuropsychological Rehabilitation, 30 (3), 564–578. https://doi.org/10.1080/09602011.2018.1469417 

[19] Higgins, L. (2019) The efficacy of mindfulness-based interventions and cognitive rehabilitation on emotional and executive functioning problems after acquired brain injury. [Doctoral thesis, University of East Anglia]. https://ueaeprints.uea.ac.uk/id/eprint/72923/