Anxiety is a subjective sensation of apprehension of danger and dread that may be accompanied by signs of restlessness, tension, tachycardia and shortness of breath that are part of the fight or flight response. Anxiety can be quite disabling whether it is generalized or includes a specific phobia to a certain stimulus. Anxiety disorders (e.g., Generalized Anxiety Disorder, PTSD, etc.) are common following ABI. Anxiety can be related to confusion and cognitive impairment or may be specifically related to the psychological trauma of the injury itself. It may also be a common symptom post ABI (e.g., associated with depression, related to stress, etc.). In the non-brain injured population, a cognitive-behavioural program directed at managing and reducing the disabling symptoms that cause avoidance of the stimulus may effectively treat anxiety. However treatment of anxiety post ABI may not be as effective because of cognitive impairments in this population.
Incidence and Prevalence post ABI
Post ABI, anxiety or anxiety disorders have been reported to occur in 4 to 28% of those who have been injured (Deb et al. 1999; Fann et al. 1995; O'Donnell et al. 2008; Osborn et al. 2015; van Reekum et al. 1996). A meta-analysis including 32 studies discovered that self-reported rates of anxiety in the TBI population is 37% (Osborn et al. 2015). In a study conducted by Hibbard et al. (1998) looking at various anxiety disorders post ABI, 19% of the study population was diagnosed with PTSD, 15% with OCD, and 14% with panic disorder. These findings were confirmed in a study where the most frequently reported disorders post TBI were anxiety disorders otherwise not specified, followed by PTSD (Gould et al. 2014). These results also reported that patients with TBI who experienced post injury anxiety were generally older than patients without post injury anxiety (Gould et al. 2014).
Non-Pharmacological Interventions for the treatment of anXIETY
Although anxiety disorders appear to be well recognized post ABI there is little in the literature regarding use of non-pharmacological Interventions.
Several studies have investigated the benefits of CBT to reduce anxiety levels in those who sustained a TBI (Arundine et al. 2012; Hodgson et al. 2005; Hsieh et al. 2012). Hodgson et al. (2005) found that anxiety scores on the Hospital Anxiety and Depression Scale (HADS) and the Social Phobia and Anxiety Inventory decreased significantly more following 9 to 12 weeks of CBT treatment than for the wait list control group, indicating that CBT training can reduce anxiety and depression in a TBI sample. Hsieh and colleagues (2012) examined CBT in combination with other therapies; specifically, motivational interviewing and CBT (group 1), the non-directive counselling group and CBT (group 2), or the treatment as usual (TAU) group (group 3). Those in groups 1 and 2 showed a significant reduction in anxiety following treatment as compared to group 3. Those in group 1 showed a greater response to the CBT compared to group 2 (Hsieh et al. 2012). In terms of the way in which CBT is delivered, Arundine et al. (2012) found that both face-to-face group CBT and one-to-one telephone CBT were effective in improving community integration and mood, with no significant differences between groups. Study authors suggest teletherapy may be just as beneficial to patients post TBI as group therapy (Arundine et al. 2012).
There is Level 1b evidence that Cognitive Behavioural Therapy does reduce anxiety post-acquired brain injury.
Cognitive Behavioural Therapy does reduce anxiety and depression post-acquired brain injury.
Obsessive Compulsive Disorder (OCD)
Following a TBI, anxiety disorders such as OCD, panic attacks and stress disorders are common both within the adult and paediatric populations. OCD is believed to be present in less than 10% of the brain injury population (Berthier et al. 2001), it is rarely reported in the literature (Drummond & Gravestock 1988). Studies conducted by McKeon et al. (1984) and Kant et al. (1996) have found OCD symptoms appearing shortly after injury, within the first few hours to the first week. Some patients were found to develop symptoms within the first 6 months of sustaining their injury. Several authors have suggested the location of the brain lesion may predict OCD in patients (Bilgic et al. 2004; Donovan & Barry 1994; Jenike & Brandon 1988). To date, although several theories have been put forth (lesion location, age of the individual) there is still no conclusive evidence. Grados (2003) noted that OCD has been treated successfully with serotonin selective re-uptake inhibitors such as fluoxetine, paroxetine, fluvoxamine or sertraline. Other supportive therapies have also been reported to be successful although there were no clinical trials found in the literature.
In each of these case studies, individuals were treated with a variety of medications to reduce or extinguish the frequency of OCD post ABI. In each case the individualized drug treatment therapy chosen was shown to be effective. No conclusions can be drawn from this study.
Although Obsessive Compulsive Disorder has been identified post-acquired brain injury there does not appear to be one method of intervention that works for all, but rather interventions remain individualized.
Little research has been conducted looking at the effects of various interventions on Obsessive Compulsive Disorder post-acquired brain injury.
POST-traumatic stress disorder
Earlier literature of PTSD following TBI focussed on patients with mild brain injury. This was based on the belief that PTSD could not develop in the presence of amnesia for the traumatic event (Bryant et al. 2001; Mayou et al. 1993; Warden et al. 1997). Since then, research has found the PTSD can occur with mild, moderate and severe TBI (Al-Ozairi et al. 2014; Bryant et al. 2001). A recent population-based TBI sample reported nearly 18% of patients met criteria for PTSD, a sample which included patients with moderate and severe TBI (Barker-Collo et al. 2013). However, research within the severe TBI population is needed, as PTSD in this group is less studied than many other psychological disorders post TBI.
A growing body of literature suggests that PTSD symptoms can develop after mild, moderate, and severe TBI. However, it has frequently been suggested that severe brain injury may be associated with a diminished risk of PTSD and research with a TBI sample compared to a control sample has also supported this claim (Zatzick et al. 2010). Additional research is necessary to confirm factors that may correlate with PTSD in moderate to severe TBI, and to implement accompanying treatment programs involving interventions to target PTSD symptoms.
Little research has been conducted regarding Post-Traumatic Stress Disorder in patients with moderate-severe traumatic brain injury, additional research is needed.
Suicidal ideations are the thoughts or considerations of suicide that when left unattended can lead to distress and attempted suicide. Risk factors for suicide overlap with characteristics present after a TBI; therefore, it is not surprising that there is an increased risk of suicide following a TBI (Bahraini et al. 2013; Simpson & Tate 2007). Unfortunately, the risk for suicidal ideation and attempt remains high at 20 years after ABI (Fisher et al. 2016).
Incidence and Prevalence Post ABI
Within the TBI population, 23-28% of individuals report suicidal ideation after sustaining a TBI (Mackelprang et al. 2014; Simpson & Tate 2002; Tsaousides et al. 2011). Male veterans are more likely to have suicidal ideation compared to females (Wisco et al. 2014); however, no such relationship was found for age at time of injury (Mackelprang et al. 2014; Simpson & Tate 2002). Risk of suicidal ideation can be further augmented with co-morbid diagnosis of depression, anxiety or PTSD (Tsaousides et al. 2011) and the number of sustained TBIs (Wisco et al. 2014). Furthermore, elevated suicidal ideation at 1 year post-TBI is associated with continual elevation of ideation at 5 years (Fisher et al. 2016), demonstrating the necessity for therapies targeting such ideations.
If suicide ideation is not minimized, the risk of suicide attempts is prevalent (Simpson & Tate 2007); this risk is further increased when emotional distress, a common TBI characteristic, is present (Gutierrez et al. 2008; Simpson & Tate 2002). Within their lifetime, 26% of individuals post TBI attempt suicide, with half making more than one attempt (Simpson & Tate 2002, 2005). Men are at a higher risk of attempting suicide post TBI compared to the general population, where women are more likely (Simpson & Tate 2002). Furthermore, emotional disturbance and substance abuse history increase the risk for attempted suicide by a factor of 21, compared to individuals with no history (Simpson & Tate 2005).
Hopelessness is a precursor to suicidal ideation, which in turn increases the risk of suicide. One RCT found that feelings of hopelessness after severe TBI may be reduced through group-based therapy that targets associated psychological problems. Hopelessness decreased in the treatment group, but suicidal ideation increased in the control group who did not receive treatment, underlining the risk of leaving suicidal distress untreated (Simpson et al. 2011). It is important to continue therapy after the primary intervention, as only half of the individuals were able to maintain the reduction in hopelessness by study end (Simpson et al. 2011). Simpson et al. (2011) argue that hopelessness and depression can manifest independently; hopelessness decreased in the treatment group whereas depression levels remained the same. It is therefore important to develop therapies focused on the precursors of suicidal ideation, such as hopelessness, and not solely depression (Simpson et al. 2011). Therapies may target the prevention/alleviation of psychological symptoms of suicide to improve outcomes post-TBI, but further research is warranted, as only one high quality low powered study is presented.
There is Level 1b evidence that reducing hopelessness post-traumatic brain injury may be effective at decreasing suicidal ideation.
Little research has been conducted regarding treatments for suicide in individuals with moderate or severe traumatic brain injury; further research is warranted.