We are all different. We all have different family situations, different jobs, different strengths, and different weaknesses. Despite all these differences, there are a number of very common emotional stages that people with a head injury go through. This is based upon my own experience treating patients, but many investigators note similar findings.
Confusion and Agitation
The first phase that I see people going through is a confusion/agitation phase. This can last minutes or it can last for months. I've had people get in a car accident and be somewhat dazed for a few minutes, but then direct traffic around their car. Others had been brought into the hospital in a coma requiring intensive medical efforts. When they wake up, they may go through the confusion/agitation phase. In the hospital setting, this is very difficult for family members. Someone who is very meek and mild, for example, can be physically aggressive. They may punch the nurses, or swear and curse at family members. It's very frightening for family members, and it feels like it is going to last forever. For 99% of the patients that I've worked with, this confusion/agitation phase goes away. It may take a while, but people eventually come out of it.
The next emotional phase that I see people typically go through is denial. The patient says, "There's nothing wrong with me." For example, they're in a motor vehicle accident, they're briefly seen in an emergency room, and they go home. Suddenly, they're having difficulties. They're forgetting things or burning food. Family members may say, "you seem different." But the head-injured person says "No, there's nothing wrong with me." Often the medical system unknowingly supports denial. Many doctors will say, "Go home, relax for two weeks, and everything will be better." For some people, things don't get better. They wonder why they're doing some silly things. For example, why did they put their shoes in the refrigerator? Or why did they put the milk in the closet? They have these odd events and they keep rationalizing them away. Denial can be very difficult for both family members and medical staff. For example, the head-injured person may say, "Yes, I can drive," but family members who have been with the person know that it would be dangerous. This can stir up huge arguments. The person in denial says there's nothing wrong, even when directly confronted by family members. When someone is in denial, you must give consistent feedback that everything is not "okay." Generally, very direct feedback is necessary. However, some people get really angry when they're constantly being told "NO". I often find that distraction, such as changing the topic of conversation, is better than getting into long-winded or violent arguments. For example, the head-injured person may want to drive when it's not safe to do so. Instead of arguing, it might be better to say, "Your doctor has not cleared you to drive" and move on with the conversation.
There are two types of denial. The first type of denial is an emotional one. Something has happened that is so terrible, or so frightening that they just don't want to deal with it. The second type of denial comes from changes to the brain. The brain literally refuses to process certain types of information. For example, there is one type of injury to the brain where the patient cannot receive visual information on the left side. Their vision is gone on the entire left sidebut they don't know it. They may bump into walls, or, if driving a car, they may run into things. If drawing a picture, they may leave out half the drawing. The brain doesn't like missing information, so it tends to fill in that information. You may be thinking that you dont know anyone who has part of their vision missing. Think again! Did you know that part of your vision has a hole in it? Where the optic nerve comes through on the eyeball, there are no visual receptors. The brain doesnt like missing information and "fills in" that little hole. If you close your left eye, hold a pencil about one foot from the eye (down and to the right), the eraser will just disappear when you find this small hole. So, now you see how the brain can contribute to "denial."
Anger and Depression
Denial is a very common problem, but eventually it breaks down. Head injury problems just don't go away. The same problems happen over and over and over again. This leads to the next phase, in which the person has a limited awareness of the head injury, beginning what I call the depression/anger phase. When you realize you are different and can't do things like you used to, you may become angry or depressed. In many ways, anger and depression share a lot in common. Some people think of depression as anger at oneself, a kind of anger turned inward. A lot of people who are depressed will say to themselves, "I'm a failure. I can't do this. I'm no good." On the other hand, people who are struggling to deal with the vast changes produced by a head injury may get angry at people around them. They may see people as not being supportive of them or not understanding their head injury. Some of this anger may also be due to the head injury. They'll notice that this anger comes on extremely quickly and also goes away just as quickly. That's due to the head injury. The sections of the brain that control those emotions have been injured.
Not all of this anger or depression is due to physical changes in the brain. Instead, we're talking about an emotional way of coping with things. Virtually all people who go through a serious illness or injury will have some anger and depression. If it is a car accident, they may be angry at the person who ran into them. They may be angry at themselves for getting into an accident. Sometimes it is justified, such as in a case where a person has been drinking and driving, resulting in a head injury. Sometimes they unreasonably blame themselves--"If I had only left my house five minutes later or five minutes earlier, I wouldn't be in this mess." There was no way of knowing that an accident would happen. When we have difficulty dealing with overwhelming situations, we often go back and blame ourselves. That's a very common reaction. Many religious people become angry at God--Why would God want me to suffer? They may question their faith, or wonder why God is so vindictive. Just about everybody goes through this cycling pattern, becoming depressed or angry. This can go back and forth; some people never move on to the next phase.
The next phase almost always follows after a period of recovery and improvement in thinking abilities. When people eventually realize they are improving, they go through the testing phase. Basically, they test themselves to see their limits. To some degree, there's a little bit of denial in this. The person feels, "I'm really close to the way I was, so I'll just act the way I was. I'll do things as I always did." For example, many people with a head injury have a fatigue disorder. They know they get tired easily. But during this testing phase, they "forget" they have a head injury and say, "Well, I've got a lot of friends visiting this weekend. I'm just going to stay up really late. I'm going to see if I just can't be the way I used to be." When you overdo and go beyond your abilities, you may spend the next several days paying for it. Sometimes, people will test themselves and fail. For example, they previously may have been an A or B student. They take a class and come out with a C or D, even though they put in twice the effort for that C. For many people, getting a C is a failure. There's a period of time when the head-injured person says, "Why can't I be the way I used to?" This a very painful stage.
The next phase is what I call uneasy acceptance. This is when head-injured people learn where they stand and what their limits are. They've learned after many failings and many times of paying for it, that they can only handle a limited number of hours of work or play. They've learned to keep a consistent schedule and will stick to that schedule. For example, they can work six hours a day, but realize that 8 hours is too much. They've learned to say, "I have to deal with this head injury." Does this mean they like it? NO. They're not happy about it, but they've learned to accept it. Often individuals in this phase begin to use words like the "old" me and the "new" me. Many of their old friends are no longer with them, but they've found new friends. They've moved on to new relationships, maybe even new work, and they've basically said, "People have to like me for what I am." That's "uneasy acceptance".
Now you will notice that I haven't talked about the level of injury (or how bad off the person is). I have many patients who have no scars, no physical problems, and have largely returned to their own job, yet they're different. Sometimes those people have the greatest difficulty with acceptance. Often people who "seem fine" have greater emotional problems than those who have obvious disabilities. These emotional phases really don't correlate with how physically impaired they are, or whether they return to their own job or not. It varies with the person.
Factors in Emotional Adjustment
Some people tend to handle the stress of a head injury better than others. In general, people who do well emotionally tend to have a very strong work ethic. They tend to believe that it's important to contribute to society and to people around them. It's important to help others. They look outside of themselves to see what they can do to make the world around them better. In my experience, these people tend to do better. On the other hand, people who are extremely self-centered and who have poor social relationships before their injury tend not to do well. One important predictor of how well people do is a sense of humor. I believe that humor is an essential component to getting better. I like to joke with the people that I work with, but not in a hostile way or to make fun of them. Sometimes people can make jokes about themselves; that's a very positive sign. One of my patients told me, "Sometimes laughing keeps me from crying." Another factor is people's avoidance of drug and alcohol problems. Some people cope with their personal failures or personal problems through alcohol or drugs. If you return to alcohol or drugs and don't see the destruction it causes, you will have a hard time coping with this injury. That doesn't mean that people who abuse alcohol or drugs are always going to have negative outcomes. The question is, have those people learned that using alcohol or drugs will make their brain worse?
Another factor in head injury is whether or not people freely admit to others that they have a head injury. Many of my patients at first didn't want anybody to know about their injury. People are afraid that others might think they are "dumb" or "retarded." But after a while, these same patients realize that there are a lot of people in this world who have had head injuries. People who have dealt with a head injury over a long period tend to "reach out" to those who are just starting the process of recovery. Some of my patients have gone beyond just talking with someone on a one-to-one basis. Some have even lectured, have gone to schools and talked about wearing helmets; or talked about drinking and driving. People who have suffered a head injury somehow move beyond their suffering to help others.
People who go to support groups often get a lot of positive feeling from being with other head-injured people. They want to openly talk about their frustrations or fatigue or forgetting things. Those people do better. On the other hand, people who avoid talking about their accident, avoid telling people they have a head injury, and avoid being with other head-injured patients tend to have a poorer adjustment. In every state in the United States, there is a brain injury association with some type of support group. Dont be afraid to check one out.
By Dr. Glen Johnson, Clinical Neuropsychologist
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