Although behavioral changes after traumatic brain injury (TBI) have been linked to work disability, research in the area is limited, especially in developing countries.1 In severe TBI, behavioral sequelae mainly include depression and personality changes. The latter is marked by varying levels of apathy, disinhibition, aggression, and affective lability.2 In a study published in the Brazilian Journal of Psychiatry,3 we found that a diagnosis of personality change due to severe TBI was associated with non-return to work independently from a range of sociodemographic, clinical and psychiatric variables. In the present study (Plataforma Brasil ethical approval 02832612.6.1001.0121), we expanded this investigation by examining the role of specific personality change symptoms in a new sample recruited three years later.
Forty-one survivors of severe TBI, who were working at the time of injury, were recruited from two intensive care units in the metropolitan area of Florianópolis, Brazil, and underwent psychiatric assessment during the chronic phase of the disease. Except for three cases, a close relative was available to describe the participants’ behavior. Major depressive episode and substance abuse or dependence were diagnosed using the Mini International Neuropsychiatric Interview. Personality change was diagnosed according to DSM-5 criteria. Using the Overt Aggression Scale, aggression was defined as any incident of verbal or physical aggression in the last month. Disinhibition and general neuropsychiatric symptoms were defined using the Neuropsychiatric Inventory-Questionnaire. Apathy was defined using Robert’s criteria and the Starkstein Apathy Scale. The participants had not engaged in vocational rehabilitation prior to assessment.
Table 1 compares participants who did and did not return to work. Lower education, aggression, apathy, and a diagnosis of personality change were associated with non-return to work. These behavioral variables were significant predictors of non-return to work in separate multiple logistic regressions, including education as a co-variate (personality change: adjusted odds ratio [AOR] = 4.4, p = 0.047, Nagelkerke R2 [NR2] = 0.25; aggression: AOR = 5.0, p = 0.037, NR2 = 0.24; apathy according to Robert criteria: AOR = 7.9, p = 0.021, NR2 = 0.31; Starkstein Apathy Scale score: AOR = 1.1, p = 0.024, NR2 = 0.31).
Table 1. Sociodemographic and psychiatric variables and return to work after severe traumatic brain injury.
| Return to work | ||||
|---|---|---|---|---|
| Variable | All participants n=41 | No n=21 (51.2) | Yes n=20 (48.8) | p-value |
| Sex | ||||
| Female | 7 (17.1) | 3 (14.3) | 4 (20.0) | |
| Male | 34 (82.9) | 18 (85.7) | 16 (80.0) | 0.697 |
| Age | 32.0 (25.0-43.5) | 35.0 (27.0-51.5) | 29.5 (23.3-40.8) | 0.140 |
| Education | ||||
| Lower than high school | 19 (46.3) | 13 (61.9) | 6 (30.0) | |
| High school or higher | 22 (53.7) | 8 (38.1) | 14 (70.0) | 0.041 |
| Married or live-in partner | ||||
| No | 31 (75.6) | 15 (71.4) | 16 (80.0) | |
| Yes | 10 (24.4) | 6 (28.6) | 4 (20.0) | 0.719 |
| Glasgow Coma Scale* | 6.0 (3.3-8.0) | 6.0 (4.0-8.0) | 6.0 (3.0-8.0) | 0.739 |
| Months since injury | 28.0 (26.0-31.5) | 28.0 (26.0-30.5) | 28.0 (25.3-32.8) | 0.865 |
| Major depressive episode | ||||
| No | 34 (82.9) | 16 (76.2) | 18 (90.0) | |
| Yes | 7 (17.1) | 5 (23.8) | 2 (10.0) | 0.410 |
| Substance abuse or dependence | ||||
| No | 35 (85.4) | 18 (85.7) | 17 (85.0) | |
| Yes | 6 (14.6) | 3 (14.3) | 3 (15.0) | 1.000 |
| NPI-Q total† | 5.5 (3.5-11.3) | 8.0 (4.0-13.0) | 4.5 (1.0-7.0) | 0.062 |
| Personality change | ||||
| No | 26 (63.4) | 10 (47.6) | 16 (80.0) | |
| Yes | 15 (36.6) | 11 (52.4) | 4 (20.0) | 0.031 |
| Aggression† | ||||
| No | 23 (60.5) | 9 (45.0) | 14 (77.8) | |
| Yes | 15 (39.5) | 11 (55.0) | 4 (22.2) | 0.039 |
| Disinhibition† | ||||
| No | 31 (81.6) | 16 (80.0) | 15 (83.3) | |
| Yes | 7 (18;4) | 4 (20.0) | 3 (16.7) | 1.00 |
| Apathy (Robert criteria) | ||||
| No | 29 (70.7) | 11 (52.4) | 18 (90.0) | |
| Yes | 12 (29.3) | 10 (47.6) | 2 (10.0) | 0.008 |
| Starkstein Apathy Scale† | 11.5 (8.0-19.3) | 13.5 (11.0-28.3) | 8.5 (4.0-13.5) | 0.006 |
Categorical variables are shown as frequency (percent) and were analyzed using a chi-square or Fisher’s test. Numerical variables were non-normally distributed; they are shown as median (1st to 3rd quartiles) and were analyzed using a Mann-Whitney test.
Bold type denotes significance.
NPI-Q = Neuropsychiatric Inventory-Questionnaire.
One missing in the group that returned to work.
Two missing in the group that returned to work and one missing in the group that did not return to work.
Study limitations include the relatively small sample and the fact that work was not characterized (e.g., according to complexity level). We also did not perform a neuropsychological assessment of the participants, although it has been proposed that personality changes and cognitive impairment represent two aspects of the same phenomenon.4
Our results add to the literature by linking aggression and apathy to work disability in severe TBI. Given the importance of reproducibility in psychological research, it is also noteworthy that our previous findings were replicated. Apathy and aggression could serve as timely markers of attention for vocational rehabilitation after severe TBI, since they emerge early in the course of the disease and are easily observed by relatives and clinicians.2,5 Larger longitudinal studies that comprehensively evaluate vocational and cognitive functioning and characterize distinct presentations of personality change may help identify accurate predictors of work disability, in addition to potential targets for interventions.
Disclosure
The authors report no conflicts of interest.
Acknowledgements
This study was supported by Programa de Apoio aos Núcleos de Excelência (PRONEX), Núcleo de Excelência em Neurociências Aplicadas de Santa Catarina (NENASC; project 56802/2010) and Programa de Pesquisa para o SUS (PPSUS; protocol 201302248), Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina – Conselho Nacional de Desenvolvimento Científico e Tecnológico – Ministério da Saúde (FAPESC-CNPq-MS).
The authors thank Dr. Victor Raphael Corrêa Voss and Dr. Fernando Arêas for their contributions to this study.
Footnotes
How to cite this article: Balan AB, Walz R, Diaz AP, Schwarzbold ML. Return to work after severe traumatic brain injury: further investigation of the role of personality changes. Braz J Psychiatry. 2021;43:340-342. http://dx.doi.org/10.1590/1516-4446-2020-1660
References
- 1.Manoli R, Delecroix H, Daveluy W, Moroni C. Impact of cognitive and behavioural functioning on vocational outcome following traumatic brain injury: a systematic review. Disabil Rehabil. 2019 Dec 22;:1–10. doi: 10.1080/09638288.2019.1706105. . Online ahead of print. [DOI] [PubMed] [Google Scholar]
- 2.Schwarzbold M, Diaz A, Martins ET, Rufino A, Amante LN, Thais ME, et al. Psychiatric disorders and traumatic brain injury. Neuropsychiatr Dis Treat. 2008;4:797–816. doi: 10.2147/ndt.s2653. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Diaz AP, Schwarzbold ML, Thais ME, Cavallazzi GG, Schmoeller R, Nunes JC, et al. Personality changes and return to work after severe traumatic brain injury: a prospective study. Braz J Psychiatry. 2014;36:213–9. doi: 10.1590/1516-4446-2013-1303. [DOI] [PubMed] [Google Scholar]
- 4.Tate RL. Executive dysfunction and characterological changes after traumatic brain injury: two sides of the same coin? Cortex. 1999;35:39–55. doi: 10.1016/s0010-9452(08)70784-6. [DOI] [PubMed] [Google Scholar]
- 5.DeBoussard CN, Lannsjö M, Stenberg M, Stålnacke BM, Godbold AK. Behavioural problems in the first year after Severe traumatic brain injury: a prospective multicentre study. Clin Rehabil. 2017;31:555–66. doi: 10.1177/0269215516652184. [DOI] [PubMed] [Google Scholar]