Changes in behaviour are common after traumatic brain injury (TBI) due to the involvement of the frontal aspects of the brain. Early after brain injury, confusion, delirium and restlessness are common and improve as post traumatic amnesia state improves. These changes result in disrupted relationships, unemployment, decreased quality of life and increased caregiver burden. Behavioural rehabilitation is one of the highest priority topics that clinicians identified in surveys. Furthermore, it is believed that the brain injury causes changes in the neurotransmitters that predispose individuals for increased mental health issues such as anxiety, depression, mood disorders and possibly even psychosis. It is essential that clinicians be aware of the proper assessment of behaviour including understanding precipitating factors [antecedents] and the consequences of the behaviour that affect the chance of future problematic behaviour. Once a behavioural assessment has been completed, a detailed behavioural plan incorporating the goals and perspectives of the patient is necessary. A holistic approach is needed incorporating the behavioural assessment with both cognitive and behavioural as well pharmacological treatments, if required.

Note: Please refer to the Principles of Medication Management in section T.

Staff and clinicians should be trained in behavioural assessment and treatment techniques and understand the benefits and limitations. It is important that ethics of consent and capacity be respected and that the behavioural plan be explained to the individuals with brain injury, their family and caregivers. Specialized clinicians should be provided with specific training and should be accessible to brain injury rehabilitation teams on a timely basis to ensure patient and staff safety. In an emergency situation, staff should be trained in nonviolent crisis intervention and it may be necessary to use stronger sedative medications, however these should be limited. The use of screening tools for depression and anxiety may increase recognition of these important complications. There should be a robust program of patient and family education with regards to how to manage behavior.

Indicators exemples

• Proportion of individuals with TBI who are screened for depression using a standardized tool monthly.

• Proportion of individuals with TBI and depressive symptoms undergoing mindfulness-based cognitive therapy.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

• Medication Algorithm (to be used by physicians making decisions regarding Pharmacological Management of Agitation and Aggression following TBI)
• Rancho Levels of Cognitive Functioning Scale
• Galveston Orientation and Amnesia test (GOAT)
• Overt Behaviour Scale (OBS)
• Agitated Behaviour Scale
• Mini-Mental State Examination (MMSE)
• BECK Depression Inventory (BDI)
• Canadian Network for Mood and Anxiety Treatments (CANMAT)
• Guide des meilleures pratiques en réadaptation cognitive. Paquette, C. (2009). Presses de l'Université du Québec : Québec (in French only)
• Cognitive behaviour therapy for TBI manual – Guidebook for Psychologists: Working with Clients with Traumatic Brain Injury
• A therapist’s guide to Brief Cognitive Behavioral Therapy. Cully JA & Teten AL (2008)
• The BC Guidelines – Major Depressive Disorder in Adults: Diagnosis & Management
• Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. Katzman, M. A., P. Bleau, et al. BMC Psychiatry (2014) 14(1): S1
• Medication use for physicians: UpToDate or DynaMed resources
• Indications of use (Health Canada) and insurance coverage (for Quebec only) for the Pharmacological Management of TBI related Impairments
• Medication Adverse Side Effects: CANMAT Guidelines document table

Patient and Family Resources:

• Brochure intended for victims and family members – SAAQ
• Interventions for Behavioral Problems After Brain Injury – BrainLine
• Positive Coping with Health Conditions, A Self-Care Workbook (Dan Bilsker, Joti Samra, Elliot Goldner)

Other Resources:

• Programme pour les personnes présentant un trouble grave du comportement (Program for Persons with Severe Behavior Disorder) – CR Lucie-Bruneau, CIUSSS Centre-Sud-de-l’Île de Montréal (in French only)
• Neurological exam example (video)
• Mindfulness-Based Cognitive Therapy for Acquired Brain Injury – ONF ABI Webinar

A detailed neurobehavioural assessment includes the understanding of the antecedents to the behaviour, collection of detailed behavioural data and understanding the consequence or function of the behaviour for that individual. Factors that should be considered in the assessment of neurobehavioral issues include a patient’s medical and metabolic status, patient’s level of self-awareness (Heinicke & Carr, 2014; Prigatano & Leathern, 1993; Spikman & van der Naalt, 2010; Ylvisaker, Turkstra, & Coelho, 2005), history of substance abuse or psychological issues (MacMillan et al., 2002; Taylor et al., 2003)and the presence of sleep disturbances (Bloomfield, Espie, & Evans, 2010), both prior to and after the TBI.

Bogner et al. (2015) studied 555 patients admitted for inpatient rehabilitation after index TBI between 2008 and 2011, who exhibited agitation during their stay to identify predictors of the severity of agitated behavior. Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. It may be that the medications associated with severe agitation were being used for treatment and not causal of the agitation. They concluded that these associations support the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose. (Bhatnagar et al., 2016; Plantier & Luauté, 2016; Waldron-Perrine et al., 2008) provide overviews of current state of knowledge of medications used after brain injury. A detailed review can also be found in ERABI Neuropharmacology Chapter (Evidence-Based Review of Moderate To Severe Acquired Brain Injury (ERABI), 2016).

Aggression is the most dangerous neurobehavioural issue, as it can pose serious threats to the patient, caregivers and rehabilitation staff. For managing aggression, beta-blockers can be an effective medication. The results of RCTs have supported that pindolol (Greendyke & Kanter, 1986) and propranolol (Greendyke, Kanter, Schuster, Verstreate, & Wootton, 1986) treatment significantly reduced incidence of assaults by patients. Studies have found that carbamazepine, valproic acid and divalproex decrease irritability disinhibition and aggressiveness (Azouvi et al., 1999; Showalter & Kimmel, 2000; Wroblewski, Joseph, Kupfer, & Kalliel, 1997).

A recent RCT found that amantadine improves patients’ self-perception of their irritability compared to placebo treatments (Hammond et al., 2015). Similarly, methylphenidate can be a safe option to control agitation (Maryniak, Manchanda, & Velani, 2001). Antidepressants can also reduce irritability and aggression, as evidenced by a study on SSRIs (Kant et al., 1998) and TCA usage (Mysiw, Jackson, & Corrigan, 1988). Lastly antipsychotics may also be prescribed. A case series found quetiapine to reduce aggressive behaviour (E. Kim & Bijlani, 2006),  Ziprasidone in the PTA stage can control agitation (Noé, Ferri, Trénor, & Chirivella, 2007), and Lithium carbonate can decrease self-destructive behaviour but usage is prone to a high risk of neurotoxicity (Glenn et al., 1989). Depression screening is imperative as it is the most common diagnosed mood disorder following a TBI (Jorge & Starkstein, 2005; Seel, Macciocchi, & Kreutzer, 2010). When diagnosing depression, TBI specialists should be observant of symptoms of irritability, frustration, anger and aggression as these are more common than conventional apathy, sadness or tearfulness (Seel et al., 2010). In terms of treatment and management of depression, several non-pharmacological options are available. Exercise is a common intervention as it is both beneficial and cost-effective. Studies have found that exercise can increase mood (Blake & Batson, 2009; Driver & Ede, 2009; Gemmell & Leathem, 2006; Gordon et al., 1998), however these mood improvements are not always better than control treatments (Gemmell & Leathem, 2006).The amount of exercise can result in additional benefits to the individual. Music therapy is another positive mood regulator. Listening and playing music also improves mood (Guetin, Soua, Voiriot, Picot, & Herisson, 2009; Thaut et al., 2009).

The use of mindfulness based therapies in improving mood and stress reduction is another viable option for managing depression. Mindfulness training, which emphasizes new ways of positively thinking about life, was found to be effective in reducing stress and maintaining happiness (Bedard et al., 2003; Bedard et al., 2014; Behn et al., 2012). Coping skills should also be taught to patients (Anson & Ponsford, 2006a, 2006b). Although the improvement was not significantly greater than control treatments, two RCTs did not show improvements in mood with groups receiving cognitive behavioural therapy (D'Antonio, Tsaousides, Spielman, & Gordon, 2013; Ruff & Niemann, 1990).

Medications employed for depression treatment included selective serotonin reuptake inhibitors (SSRI), methyphendiate, and tricyclic antidepressants (TCAs), however their usefulness in a TBI population remains inconclusive. SSRIs including sertraline and citalopram have been studied. Two RCTs found that sertraline improved depressive symptoms but it was found to be no more effective than control treatments (Ashman et al., 2009; Lee et al., 2005). Similar results were found citalopram usage (Rapoport et al., 2008; Rapoport et al., 2010). Citalopram in combination with carbamazepine also can improve depressive symptoms (Perino, Rago, Cicolin, Torta, & Monaco, 2001). Desipramine, a TCA was found in a small RCT to be effective for treating long-standing depression (Wroblewski et al., 1996).

Anxiety is another common neurobehavioural problem following TBI that negatively affects a patient’s quality of life and their interactions with others. Cognitive behavioral therapy (CBT) is a promising option for treating anxiety after TBI. Three RCTs found that CBT improved social phobia, general anxiety, mood and community reintegration (Arundine et al., 2012a; Hodgson, McDonald, Tate, & Gertler, 2005; Hsieh, Ponsford, Wong, & McKay, 2012).

When dealing with hypersexual behaviours from individuals with TBI, the use of Depo-provera, an anti-androgen, may aid in minimizing inappropriate behaviour when taken continuously (Emory, Cole, & Meyer, 1995).

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