Anger after Brain Injury

National Institute on Disability Independent Living and Rehabilitation Research (Grant #90IF00-95-01-00)

Irritability and anger are common side effects of traumatic brain injury (TBI). From research, it is known that how we interpret others’ actions can lead us to feel irritated and angry toward those involved. A recent study suggests that one reason irritation and anger are more severe and common after TBI may be due to misinterpreting others’ harmless actions.

• Imagine someone steals your parking spot. How much would you assume the person did it on purpose with mean intentions? How much do you blame the person? How angry would you feel? People with TBI felt others’ actions were more intentional, hostile, and more to blame -- even when actions were harmless -- than people without brain injury. They also felt angrier.  
• The more hostile and intentional they felt others’ actions were, and the more they blamed others, the more irritated and angry they felt.
• This type of thinking style -- assuming actions are intentional, hostile, and to-blame -- is referred to as negative attributions and it appears to be associated with difficulty interpreting social cues (e.g., what are others’ thinking, doing, trying to say?)

Empathy and Emotion Perception after Brain Injury

The ability to recognize and empathize with others’ feelings is critical to human relationships. Recognizing and empathizing with others’ emotions can often be impaired after a brain injury, which may impact their relationships. Our research provides insight into these changes after brain injury and useful information about what to expect and what you can do about it. 

Read these helpful articles to gain a better understanding of empathy and emotion perception after brain injury:

• People with traumatic brain injury, who often lose empathy, can regain it with treatment Read Article >
• Emotional Mis-communication Changes Relationships after Brain Injury Read article >

Myths and Realities of Brain Injury

Outcomes from National Institute on Disability Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems data

Myths abound regarding brain injury outcomes. Data from the National Institute on Disability Independent Living and Rehabilitation Research Traumatic Brain Injury Model Systems debunk these myths and tell the real story.

Many believe outcome from severe brain injury is knowable in the hours and days after injury. However, this is not the case. There is a rush to prognosticate in the early days postinjury when outcomes are unknown and prognostication inaccurate and pessimistic. Time is needed to be able to more accurately predict and plan for the most appropriate care. Unfortunately, the pessimistic early predictions may be self-fulfilling and may lead to premature withdrawal of life-sustaining treatment and lack of access to rehabilitation services. Many with devastating brain injuries benefit from inpatient rehabilitation and regain independent function with a high proportion returning to competitive employment.

Many believe any potential functional gains will occur within the first 1-2 years with no improvements possible after that. The literature actually shows that people living with brain injury can continue to improve many years postinjury.

Brain Injury and Incarceration

Since 2014, RHI has been identifying and treating people with brain injuries in the Indiana Department of Correction (DOC). Researchers in the RHI Research, Training, and Outcomes Center (RTOC) for Brain Injury found that 95% of veterans in Marion County’s Veterans Court screened positive for TBI. Sixty-eight percent of veterans in Indiana Veterans Units at Edinburgh and Putnamville Correctional Facilities screened positive for moderate to severe TBI. In contrast, 8.5% of people in the overall population have a lifetime exposure to TBI. 

Intervention to Change Attributions that are Negative (ICAN)

(This work was supported by the NIH NICHD/NCMRR under Grant 1R21HD094232-01 and the National Institute on Disability, Independent Living, and Rehabilitation Research under Grants H133F110013; 90IF00-95-01-00)

This IU/RHI collaboration was a research study which looked at a 6-week group therapy (ICAN: Intervention to Change Attributions that are Negative) that trained individuals with TBI to think differently when someone does something that might be upsetting. This therapy taught people with brain injury to try and understand situations from other people's points of view and to give people the benefit of the doubt, instead of assuming people do things with bad intentions. We found that after participating in this therapy, participants with TBI were less likely to assume people's actions were intentional and less likely to blame others for unpleasant outcomes. Moreover, participants who went through the ICAN therapy, had lower anger and aggression after treatment than before treatment.

Societal Participation of People with Traumatic Brain Injury Before and During the COVID-19 Pandemic: A NIDILRR Traumatic Brain Injury Model Systems Study

How did the COVID-19 pandemic affect people living with TBI? These individuals may not be as cognitively or behaviorally flexible. So they probably had trouble adjusting to the pandemic, right? We studied this question using information from the model systems database and studied responses from about 5000 individuals before March 2020 and compared it to the period from April 2020 to March 2021. We published two papers with surprising findings.

First, we are concerned that the stress of 2020 would affect depression, anxiety, and suicidal ideation in people with TBI. Surprisingly, no differences in depression, anxiety, or suicidal ideation were found before and during the pandemic. Now, the results could have been skewed by not counting those who could not take the mental health questionnaires and discarding information from March 2020. Overall, we were impressed with the resilience of those living with TBI.

Second, we wondered if the COVID-19 pandemic affected productivity, community involvement, and social relations. TBI can cause disability, and disability can affect these things. What we found is that people were less frequently out and about, understandably, because of pandemic restrictions. We also found that their productivity and social media relations didn't drop. Due to research limitations, we are not sure if that means people were already well-integrated into their communities or if the pandemic overshadowed existing problems. Another limitation is that our survey tool could not capture if participation quality changed, for example, attending church virtually rather than in person. This study also excluded individuals who could not provide verbal responses.

These studies brought up important questions that will help researchers make changes to the types of information they collect so we are ready for research in a changing world.

Check out the full papers here:

• Depression, Anxiety, and Suicidality in Individuals with Chronic Traumatic Brain Injury Before and During the COVID-19 Pandemic: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic
• Societal Participation of People With Traumatic Brain Injury Before and During the COVID-19 Pandemic: A NIDILRR Traumatic Brain Injury Model Systems Study

Perceived Care Partner Burden After TBI

(This research was supported by grants from the US Department of Health and Human Services (HHS), Administration for Community Living’s (ACL) National Institute for Disability, Independent Living, and Rehabilitation Research (NIDILRR), 90DPTB0002 (Indiana University), 90DPTB0001 (The Ohio State University), 90DPTB0016 (TIRR Memorial Herman), and 90DPTB0010 (New York University Langone Health). 

People with traumatic brain injury (TBI) can lack awareness of their own emotions and often have problems with emotion dysregulation, affective disorders, and empathy deficits. These impairments are known to impact psychosocial behaviors and may contribute to the burden experienced by care partners of individuals with TBI. This study looked at the emotional awareness, emotional function, and empathy of individuals with TBI in relation to care partner burden one year after injury. The study found that 77% of care partners were female with most either being a spouse or parent. The study also found that high levels of hostility and low emotional self-awareness in individuals with TBI are highly associated with care partner burden.

Research has shown that issues such as hostility or poor emotional insight are common after TBI, but can be improved with appropriate therapies. Care-partners of individuals with TBI who have these types of problems might consider discussing treatment options with rehabilitation professionals. In the meanwhile, it can help to keep in mind that acts of hostility or lack of emotional expression from their loved is a consequence of the injury, and not necessarily something to take personally. Also, care partners of these individuals should be proactive in their own mental health - surrounding themselves with emotional support from other family, friends or support groups, as well as making arrangements for respite care when breaks are needed.

Full Study

Key Publications from Our Investigators

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