Mental Illness and Brain Injury - Fact Sheet

Apart from the many cognitive effects of a brain injury, individuals may find themselves struggling with mental illness as well.

The key parts for understanding peoples’ experience of mental illness include ‘distress’, ‘impairment of functioning’ and ‘increased risk’. The use of the term ‘mental illness’ may unfortunately imply that a person’s suffering is ‘all in their head’. Such uninformed views fail to appreciate the very real and genuine suffering that a person endures day after day.

It is also clear that there may be a physical basis to an individual’s psychological problems e.g. depression related to cancer treatment, or a psychological basis to physical problems e.g. a stress induced stomach ulcer. Understanding the relationship between a person’s physical health and psychological well-being becomes particularly important for people with acquired brain injury where misunderstandings about the cause of symptoms are common.

Consider the following relationships that may exist between an individual’s psychological well-being and physical health:

Therefore, an individual with an acquired brain injury who suffers from mental illness requires a high level of understanding and support. As previously discussed such individuals are often significantly distressed and at an increased risk of suffering, pain, disability and loss of freedom, or even death.

Depression

A very common type of mental illness experienced by people with acquired brain injury is depression. The symptoms of depression may include a sad mood for most of the day, loss of interest, poor sleep, negative self-concept, low energy and recurrent thoughts of death or suicide. For people who think about ending their lives, suicide may represent an answer to what they feel is an otherwise unsolvable problem. The choice may appear preferable to other circumstances such as enduring emotional distress or disability, which the person may fear more than death. It is worth noting here that the suicide rate of people with acquired brain injury is two to nearly five times higher than the general population.

Dual Diagnosis

There are several types, or combinations, of disabilities that come under the heading of ‘dual diagnosis’, one of which is acquired brain injury and mental illness. The people who fall into this group experience many difficulties.

People can be affected physically by a brain injury, but mostly, there are no obvious outward signs. Generally, it is the psychological and psychiatric problems associated with the brain injury that engender any number of complications, and ongoing distress for those in contact with the affected person.

A person’s behaviour following a brain injury may be different to what it was before, or, it can exacerbate previous behavioural traits. In fact, there is broad agreement that roughly two-thirds of people with acquired brain injury exhibit shifts in behaviour post-injury. Perhaps the most troublesome changes for the individual and those around him, or her, are depression, low frustration levels, poor impulse control and aggressive tendencies such as explosive verbal and/or physical outbursts towards others.

The Psychiatric Aspect

In regard to the psychiatric aspects of a brain injury, experts generally agree that people who have acquired a brain injury through traumatic means, such as car accidents or assaults, are at risk of developing psychiatric disorders (as well as subsequent brain injuries). Conversely, people with psychiatric conditions are at risk of incurring a subsequent brain injury.

The types of psychiatric disorders present either before or after a brain injury may include major depression, anxiety disorders, borderline and avoidant personality disorders, and bi-polar affective disorder.

It is also fairly common for people who have experienced a traumatic brain injury to experience the problem of unrealistic self-appraisal. This means that they may not be able to relate the problems they are having to their brain injury.

They may also have the associated problem of impaired social awareness so that they may not understand the intentions of others or be able to pick up on social cues in a way that the rest of us take for granted. This can cause them to become progressively suspicious and uncooperative. In time, some may become “frankly paranoid and even delusional”. In most cases, this is related to significant cognitive dysfunction related to temporal lobe damage.

In short, some personality problems of people with acquired brain injury are clearly related to cognitive impairment. However, there are also many “non-neurological variables that seem to influence the presence and severity of psychiatric disturbances following brain injury”.

Contributing Factors to Poor Service Responses

People with acquired brain injury fall into a chasm. They either do not ‘fit’ the criteria of available programmes or the programmes are inadequate or inappropriate. Lack of understanding and awareness of people with this disability severely limits their access to services. Such situations are frustrating and distressing not only for people with this disability but also for family members and those service providers who struggle to support them.

The lives of people with acquired brain injury who experience homelessness are particularly bleak. However, if they also have a dual disability, i.e., an acquired brain injury and a mental illness, a problem with alcohol and other drugs, and/or involvement with the criminal justice system, then life can get down to simply surviving each day and many are unable to do this. I might add that the inter-relationship between these three factors has been well established.

A brain injury can leave these people vulnerable to exploitation, violence and the commitment of criminal offences. Living on the streets and in other dangerous or unhealthy environments can also lead to incidents where they incur further brain injuries.

Despite the nature of a dual diagnosis, people affected by it are often refused assistance by mental health services throughout Australia. If they are accepted by a mental health service, they may receive treatment for the psychiatric aspect of the dual diagnosis, but their acquired brain injury is neglected.

There will also be many people in the mental health system with this dual diagnosis whose brain injury remains undiagnosed. It is an unfortunate thing to have to say, but mental health professionals will often deny the presence of an obvious mental health disorder on the basis that an individual has an acquired brain injury!

At the policy level, no government agency takes responsibility for this group of people. This plays out at the service level where people with a dual diagnosis are bounced back and forth between the disability, health and homelessness sectors.

Steps Needed to Plug the Gaps in Service

To stop people with dual diagnosis falling through the cracks, the following steps need to be taken:

This article has been adapted from a speech made by Jan Bishop as President of Brain Injury Australia, at the 3rd National Homelessness Conference in Brisbane, April 2003.

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