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. 2022 May 22;16(4):331–337. doi: 10.1002/pmh.1550

Personality disorder and mild traumatic brain injury

James P Moley 1,✉, Joshua L Norman 1, Emil F Coccaro 1
PMCID: PMC9675684  NIHMSID: NIHMS1805010  PMID: 35598165

Abstract

Mild traumatic brain injury (mTBI) poses risk to the neurocognitive, emotional, and financial well‐being of affected individuals. While aggression and impulsivity have been examined in relation to mTBI, little work has been done to evaluate the relationship between history of mTBI and personality disorder (PD). The authors examined the associations between history of mTBI and PD in a control group without history of mTBI (N = 1189) and individuals with history of mTBI (N = 267). Results demonstrated that any PD diagnosis is a significant risk factor for mTBI (p < 0.001). Cluster B diagnoses, particularly borderline and antisocial PD, were independently significant risk factors for mTBI. These data suggest a role for screening for a history of mTBI in patients with PDs and associated traits.

INTRODUCTION

Diagnosis and care of mild traumatic brain injuries (mTBI) place a significant physical, emotional, and economic burden on affected individuals and health‐care systems (Humphreys et al., 2013; Rockhill et al., 2010). The World Health Organization Collaborating Center Task Force and the Centers for Disease Control and Prevention (CDC) define mTBI as “an acute brain injury resulting from mechanical energy to the head from external physical forces” (Carroll et al., 2004). mTBI affects over 42 million people worldwide each year (Gardner & Yaffe, 2015), a number that is likely an underestimate given the notion that many individuals who suffer from mTBI choose not to be clinically evaluated (Voss et al., 2015) or have symptoms that resolve quickly and do not require intervention. Diagnosis of mTBI is frequently associated with cognitive dysfunction and specific deficits in attention, processing speed, executive function, and/or memory (Kay et al., 1992; Prince & Bruhns, 2017; Williams, Potter, & Ryland, 2010). Although most patients who sustain mTBI return to cognitive baseline within 90 days following mTBI (Karr et al., 2014), many will experience persistent post‐mTBI symptoms including lingering physical symptoms and mood disturbances (Dean et al., 2012; Spinos et al., 2010). mTBI and associated care have also been shown to result in substantial healthcare resource utilization (HRU) costs within the first 90 days as well within a 12‐month follow‐up period of care in the United States (Pavlov et al., 2019). There are likely a variety of contributing factors to the length and cost of treatment including injury beliefs, stressors, and medical comorbidities (Snell et al., 2013; Yue et al., 2019).

mTBIs have been shown to be more prevalent in specific populations including athletes, veterans, and criminal offenders. Up to 3.8 million sports‐related head injuries and concussions occur annually in the United States, a number that is likely a significant underestimate given the unique pressure felt by athletes to minimize symptoms of mTBI in order to prevent removal from competition (Harmon et al., 2013). These injuries have been linked to short‐ and long‐term psychiatric sequelae in athletes including mood symptoms, sleep disturbances, and emotional lability (Brent & Max, 2017; Hutchison et al., 2018). Hoge et al. showed that up to 20% of veterans deployed in Iraq and Afghanistan had evidence of mTBI upon return from combat (Hoge et al., 2008). Veterans who had blast‐associated mTBI have also displayed evidence of multifocal white matter abnormalities associated with severity of the mTBI (Vasterling et al., 2009), as well as increased chronic posttraumatic stress disorder symptoms hypothesized to represent a post‐concussive syndrome following mTBI (Trudeau et al., 1998). Forensic research has also shown that prisoners have a high rate of mTBI exposure. Williams et al. (2010) found that, in a sample of male offenders, nearly 50% had experienced mTBI, which was associated with high rates of repeat offending. Further, 60% of mTBIs were found to be repeat injuries in patients who had sustained previous mTBI, giving consideration to the impact of recurrent mTBI. Slaughter et al. (2003) reported that up to 58% of prisoners reported having previously suffered mTBI, including 29% within 1 year prior.

Further research has focused on identifying traits, behaviors, and/or neuroimaging findings common among those with head injuries and mTBI. Much of this work has focused on both verbal and physical aggression, which have been shown to increase after mTBI and may be secondary to neuropsychological and emotional deficits including decreased inhibition and increased frustration (Alderman, 2003; Roy et al., 2017). Substance use, mood disorders, and aggression prior to mTBI have also been shown to be predictive factors of post‐mTBI associated aggression (Tateno et al., 2003). With growing interest in identifying aggression as a possible risk factor for mTBI, Mosti et al. (2018) showed that individuals with intermittent explosive disorder (IED) are more likely than those without to have a history of mTBI and that other‐ and self‐directed aggression increased as a function of mTBI history in a community sample. These findings are supported by growing neuroimaging findings of those affected by mTBI. Work by Epstein et al. (2016) showed that those with a history of mTBI showed cortical thinning of the right orbito‐frontal cortex compared with those without history of mTBI, and Kraus et al. (2007) added evidence of fractional anisotropy with limited white matter functioning in the fronto‐temporal‐occipital brain regions as a finding common in those with history of mTBI.

While recent work has focused on aggression and impulsivity in relation to mTBI, relatively little work has been done to investigate the relationship between personality disorders (PD) and associated personality traits with mTBI. It is estimated that the prevalence of PD in a community sample may range from 4% to 15% (Coid et al., 2006; Samuels et al., 2002), but this is likely an underestimate given that a majority of individuals with PD do not access care for their PD traits (Bender et al., 2001). It is clear, however, that having any PD diagnosis carries an increased risk of negative outcomes including suicide, mood disorders, and psychotic disorders (Björkenstam et al., 2016; Keown et al., 2002; Skodol et al., 1999). The link between PD and violence and aggression has also been investigated, with particularly strong evidence for antisocial PD (ASPD), borderline PD (BPD), and narcissistic PD (NPD) showing increased rates of violent behavior in the general population (Kolla et al., 2017; Lambe et al., 2018). Any PD diagnosis, particularly ASPD and BPD, has also been found to have higher prevalence rates in groups previously shown to have higher rates of aggression and violence such as prisoners and domestic violence offenders (Green & Browne, 2020; Player, 2017). Despite existing evidence showing a relationship between aggression and mTBI, as well as aggression and PD, there remains a gap in understanding of the direct relationship between PD and mTBI.

The goal of this study was to examine the relationship between history of mTBI and PD in a large community research sample. We hypothesized that (a) participants with any PD diagnosis would be more likely to have a history of mTBI and (b) participants with any cluster B personality diagnosis, specifically ASPD and BPD, would be more likely to have a history of mTBI than those with other PD diagnoses and traits.

METHODS

Participants

This study enrolled and evaluated 1456 adult participants as part of a larger program designed to examine correlates of personality‐related, aggressive, and impulsive behavior. Participants were recruited via advertisements in the media, newspaper, and through public service announcements. Recruitment specifically targeted individuals who struggle with psychosocial difficulty related to one or more psychiatric conditions, as well as those who do not suffer from any psychiatric conditions. Each individual subject provided informed consent to participate in the study, which was reviewed and approved by the Institutional Review Board.

Assessment for PD

Study design and assessment was completed using similar criteria to Mosti et al. (2018) with modification to include additional analyses of PD diagnoses in relation to mTBI. PD diagnoses were made according to DSM‐5 criteria. This process utilized information gathered from a clinical psychiatric interview according to the Structured Interview for DSM Diagnoses (SCID, First & Gibbon, 2004) for syndromal (formerly Axis I) disorders and the Structured Interview for DSM‐IV Personality (formerly Axis II) Disorder (Pfohl et al., 1997). Other available clinical data were also used, with final diagnoses determined via best‐estimate consensus procedures utilizing expertise from research and clinical psychiatrists and psychologists as described by Coccaro et al. (2012). Populations of participants who were excluded from this study based on information obtained during the structured clinical interview include individuals with the following: intellectual disability, history of substance use disorder, history of any bipolar disorder, and history of any psychotic disorder.

Assessment for history of mTBI

For the sake of this assessment and in line with guidelines from the American Congress of Rehabiliation Medicine, mTBI was defined as an acute brain injury associated with mild and brief neurological symptoms including but not limited to disorientation, dizziness, loss of consciousness lasting no longer than 30 min, and post traumatic amnesia (PTA) lasting no more than 24 h following injury (American Congress of Rehabilitation Medicine [ACRM], 1993). Individuals with loss of consciousness following mTBI of greater than 30 min were excluded from this study. History of mTBI was collected using self‐reported data throughout the course of the diagnostic assessment interview described previously. This structured interview contained a majority of elements listed in the Ohio State University TBI‐ID (Corrigan & Bogner, 2007), although not all given that the timing of its release occurred during data collection for this study.

Group assignment and demographics

Following the structured interview and exclusionary criteria assessment, 1189 individuals were determined to have no history of mTBI and were subsequently grouped as “no mTBI”; 267 individuals were found to have history of mTBI with about half (135) having loss of consciousness lasting less than 30 min.

Statistical analysis and data reduction

Chi‐square, t test, and logistic regression were performed as appropriate. All reported analyses were adjusted for age, sex, ethnicity, and socioeconomic status. A two‐tailed alpha value of 0.05 was used to denote statistical significance.

RESULTS

Demographic characteristics of study participants

The most notable demographic difference between the three groups was in biological sex, with the mTBI group having a greater proportion of males compared with the No mTBI group. Otherwise, the groups displayed a marginal difference in age, with the mTBI group being modestly older than the No mTBI group. The groups did not differ in terms of ethnicity or in SES scores (Table 1).

TABLE 1.

Demographic characteristics of study participants

No mTBI (N = 1189) mTBI (N = 267) p
Age a 34.2 ± 11.0 36.2 ± 10.8 =0.030
Gender (% male) b 41.3% 58.1% <0.001
Race (% White) b 53.8% 62.2% =0.173
SES score a 43.5 ± 12.8 43.2 ± 12.6 =0.733
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Abbreviations: mTBI, mild traumatic brain injury; SES, socioeconomic status.

a

p from ANOVA.

b

p from Chi‐square test.

Relationship between any PD and history of mTBI

Study participants with PDs represented a higher proportion of those with history of mTBI. The adjusted odds ratio for this comparison with the control group was 1.92 (95% CI: 1.44–2.55, p < 0.001) (Table 2).

TABLE 2.

Relationship between personality disorder and history of mTBI

No mTBI (N = 1189) All mTBI (N = 267)
Any PD (N = 689) 532 (77.2%) 157 (22.8%)
No PD (N = 767) 657 (85.7%) 110 (14.3%)
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Note: Chi‐square = 17.29, df = 1, p < 0.001.

Abbreviations: mTBI, mild traumatic brain injury; PD, personality disorder.

Relationship between PD diagnoses and history of mTBI

Only study participants with a Cluster B PD diagnosis demonstrated a significant association with history of mTBI (odds ratio: 1.95 [95% CI: 1.38–2.75], p < 0.001). Subsequent analyses of the four Cluster B PD diagnoses revealed that only ASPD (2.75 [95% CI: 1.64–4.61], p < 0.001) and BPD (1.82 [95% CI: 1.26–2.71], p < 0.01) demonstrated a significant association with history of mTBI. Given the relation of Cluster B traits to mTBI, post hoc analysis examined specific PD‐associated traits. Within ASPD, “rule‐breaking” (ASPD Criterion 1: 1.82 [95% CI: 1.43–2.32], p < 0.001) and “aggression and irritability” (ASPD Criterion 4: 1.27 [95% CI: 1.06–1.52], p < 0.01) were uniquely related to history of mTBI. Within BPD, only “anger dysregulation” (BPD Criterion 8: 1.23 [95% CI: 1.04–1.45], p < 0.001) was uniquely related to history of mTBI. Between these three ASPD/BPD traits “rule‐breaking” (ASPD Criterion 1: 1.58 [95% CI: 1.29–1.94], p < 0.001) and “anger dysregulation” (BPD Criterion 8: 1.23 [95% CI: 1.05–1.43], p < 0.012) were uniquely associated with history of mTBI (Table 3).

TABLE 3.

Relationship between personality disorder and history of mTBI

No mTBI (N = 1189) mTBI (N = 267) p Odds ratio CI
PD (N = 689) 532 (44.7%) 157 (58.8%) <0.001 1.76 [1.35, 2.31]
No PD (N = 767) 657 (55.3%) 110 (41.2%)
Cluster A Dx (N = 95) 70 (5.9%) 25 (9.4%) 0.054 1.65 [1.03, 2.66]
No Cluster A Dx (N = 1367) 1119 (94.1%) 242 (90.6%)
Cluster B Dx (N = 296) 216 (18.2%) 80 (30%) <0.001 1.93 [1.43, 2.60]
No Cluster B Dx (N = 1160) 973 (81.8%) 187 (70%)
Cluster C Dx (N = 170) 117 (14.9%) 53 (19.9%) 0.051 1.42 [1.01, 2.00]
No Cluster C Dx (N = 1226) 1012 (85.1%) 214 (80.1%)
ASPD (N = 94) 56 (4.7%) 38 (14.2%) <0.001 3.36 [2.17, 5.19]
No ASPD (N = 1362) 1133 (95.3%) 229 (85.8%)
BPD (N = 223) 163 (13.7%) 60 (22.5%) 0.001 1.82 [1.31, 2.54]
No BPD (N = 1233) 1026 (86.3%) 207 (77.5%)
NPD (N = 90) 69 (5.8%) 21 (7.9%) 0.207 1.39 [0.834, 2.30]
No NPD (N = 1366) 1120 (94.2%) 246 (92.1%)
Histrionic PD (N = 24) 18 (1.5%) 6 (2.2%) 0.423 1.50 [0.588, 3.80]
No histrionic PD (N = 1432) 1171 (98.5%) 261 (97.8%)
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Abbreviations: ASPD, antisocial personality disorder; BPD, borderline personality disorder; Dx, diagnosis; mTBI, mild traumatic brain injury; NPD, narcissistic personality disorder; PD, personality disorder.

DISCUSSION

The most important finding from this study is that any PD diagnosis is a significant risk factor for history of a mTBI. When considering diagnoses by cluster, only Cluster B PD diagnoses are significantly associated with a history of mTBI with only AsPD and BPD diagnoses significantly associated with a history of mTBI. These findings support our hypothesis that individuals with PD, specifically AsPD and BPD, are at greatest risk for mTBI compared with those without these diagnoses.

Based solely on these data, we cannot ascertain that the presence of PDs and their associated traits led participants to situations in which they were more likely to sustain an mTBI. However, traits common to many PDs including impulsivity and aggression have been shown to manifest early in life (Tremblay, 2014), which may lead to individuals placing themselves in situations in which sustaining mTBI is more likely. These findings also support prior evidence that individuals with AsPD and/or BPD traits are more likely to exhibit disregard for rules and for anger dysregulation (ACRM, 1993; Coccaro et al., 2012; First & Gibbon, 2004; Pfohl et al., 1997), which then leads to higher rates of mTBI. Neuroimaging evidence may also provide supporting evidence for a link between PD and mTBI. A reduction in grey matter found in the dorsolateral prefrontal cortex (DLPFC) has been shown in subjects with BPD compared with healthy controls, and this region has also been shown to have less activation during cognitive control of aggression in subjects with BPD (New et al., 2009; Sala et al., 2011). A broad range in DLPFC deficits have also been seen in individuals diagnosed with ASPD compared with individuals without this diagnosis (Dolan & Park, 2002). Chen et al. (2008) showed that in a sample of athletes with history of mTBI, functional MRI studies revealed reduced activation in the DLPFC relative to a group of controls without history of mTBI. Data from our study, while not providing direct evidence of this link, support the notion that certain neurobiological deficits may play a role in both PDs and mTBI.

This study has several strengths, including the large participant sample that allowed for a powerful analysis through validated clinical research interviews. The sample also provided an opportunity to study large groups of individuals both with and without self‐reported history of mTBI, thus creating substantial experimental and control groups for statistical analysis. The makeup of the population was also significant in that it likely represents a true community sample, as recruitment and advertising for the study were completed in diverse environments not limited to clinical settings. Future work studying specific populations, such as athletes, would be beneficial in determining differences in associations within population subgroups. One limitation of the study is that the context of each injury was not recorded, although most participants reported that their injury occurred during a motor vehicle accident or athletic activity. Despite the lack of timing, context of injury, and information about recurrent mTBI, it was known that none of the participants experienced more than a mild TBI or LOC greater than 30 min. Additionally, this study investigated mTBI only and did not include data about moderate and severe TBI, both of which would be interesting areas of further investigation.

CONCLUSION

Individuals with any PD diagnosis are significantly more likely to have a history of mTBI compared with individuals who do not have a PD diagnosis. Presence of any Cluster B PD diagnosis, particularly AsPD and BPD, was independently associated with increased rates of history of mTBI. These findings support the hypothesis that individuals with PDs are at greater risk for mTBI compared with those without PDs. It is likely that traits associated with certain PDs, such as “disregard for rules” and “anger dysregulation,” place affected individuals in circumstances in which mTBI is more common. Evaluation for the presence of PD, and of specific associated traits, should include screening questions about history of mTBI. Such expanded clinical assessments would allow for a more complete evaluation of patients who may fall within the subgroups presented in this study and more focused clinical care.

CONFLICT OF INTEREST

Dr. Coccaro reports being a consultant to and being on the Scientific Advisory Boards of Azevan Pharmaceuticals, Inc. and of Avanir Pharmaceuticals, Inc., and being a current recipient of a grant award from the NIMH. Dr. Moley and Dr. Norman report no conflicts of interest regarding this work.

ETHICS STATEMENT

This study had ethical approval granted by the Institutional Review Board (IRB) of the Biological Sciences Division of the University of Chicago (Protocol #10375). Each subject signed the informed consent document reviewed and approved by this IRB, before taking part in this study.

ACKNOWLEDGEMENTS

This research was supported in part by grants from the National Institute of Mental Health: RO1 MH60836, RO1 MH66984, and RO1 MH104673 (Dr. Coccaro); and the Pritzker‐Pucker Family Foundation (Dr. Coccaro). Open access funding enabled and organized by Projekt DEAL.

Moley, J. P. , Norman, J. L. , & Coccaro, E. F. (2022). Personality disorder and mild traumatic brain injury. Personality and Mental Health, 16(4), 331–337. 10.1002/pmh.1550

Funding information National Institute of Mental Health, Grant/Award Numbers: RO1 MH104673, RO1 MH60836, RO1 MH66984; Pritzker‐Pucker Family Foundation

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