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.

Resource Facilitation for Brain Injury Dramatically Increases Return-to-Work Rates

Groundbreaking work in Indiana over the past few years has proven that the consequences of brain injury can be mitigated. Rehabilitation Hospital of Indiana (RHI) partnered with Indiana Vocational Rehabilitation (VR) in 2009 through two federal Health Resources and Services Administration grants to develop and provide Resource Facilitation (RF), which connects those with Traumatic Brain Injury (TBI) to both TBI-specific and instrumental resources to enable participants to return to work and school.

These studies demonstrated that RF dramatically improved the previously reported return-to-work rate in Indiana with rates at or above 64%.[i],[ii],[iii] In fact, Indiana Vocational Rehabilitation Services reported a return-to-work rate of 18% for TBI clients prior to engagement with RHI’s RF program. RHI completed the first randomized controlled trial of RF in 2010 and translated that into a statewide clinical service by 2015 through its Research, Training, and Outcomes Center for Brain Injury.  RF became a statewide service in 2014 and has reached return-to-work outcomes as high as 70%. Further, people who received RF used significantly fewer social services and their desire for services also significantly declined at the end of RF and they were also found to have a significantly decreased level of disability. It is also worth noting that the average RF client is roughly 10 years post-injury. 

Economic Impact of Resource Facilitation in Indiana

Researchers at the Center for Business and Economic Research, Miller College of Business at Ball State University recently completed an economic impact study of RF in Indiana. They demonstrated that if Indiana provided RF to those with moderate to severe TBI, the annual aggregate lifetime savings generated as a result of RF for Indiana would be $249.1 million a year for wages and benefits, $30.97 million a year in additional Indiana state taxes paid, $80.1 million a year for savings to SSDI/private disability, and $6.6 million a year for SNAP, resulting in a total of $366.77 million in savings a year. Their study did not, however, capture the savings associated with reduced need for services. 

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

Key Publications from Our Investigators

View list of Brain Injury publications (PDF) > 
View list of Spinal Cord Injury publications (PDF) >
View list of Stroke publications (PDF) >

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[i] Trexler, L.E. & Parrott, D.R (2018).  Models of Brain Injury Vocational Rehabilitation: The Evidence for Resource Facilitation from Efficacy to Effectiveness.  J  Vocational Rehabil 49(2), 195-203.

[ii] Trexler, L.E., Parrott, D.R., & Malec, J.F. (2016). Replication of a Prospective Randomized Controlled Trial for Resource Facilitation to Improve Return to Work after Brain Injury. Arch Physical Medicine and Rehabil, 97(2), 204-210.

[iii] Trexler, L.E., Trexler, L.C., Malec, J.F., Klyce, D., & Parrott, D. (2010).  Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury.  J Head Trauma Rehabil, 25(6), 440-446.