Category: TBI

Behavioral Changes After a Traumatic Brain Injury

In a previous blog post, I discussed the emotional changes that may result from traumatic brain injury (TBI). Another consequence of TBI that patients may not recognize themselves are behavioral changes. It is crucial that loved ones pay attention to shifts in behavior in order to provide support and connect patients with the care they need. It is important to note that behavioral changes resulting from brain injury can vary significantly, given that no two brain injuries are identical. In this post, I outline several changes that survivors and their loved ones or caregivers may benefit from understanding.

Changes in Personality After a TBI

Brain injury survivors may display the same personality traits as prior to their injury; however, these traits may be amplified. For instance, an individual who was calm and not easily excitable prior to their brain injury may come across as apathetic or aloof post-injury. There may even be instances where the individual displays traits that are conflicting with their pre-injury temperament, as in the case of someone who was demure but becomes highly outspoken and outgoing. Regardless of the type of personality change, it can be challenging for the individual to accept or even acknowledge. Increased understanding and acceptance from loved ones and friends is imperative to adapting to changes in personality. Making negative comments or judgments about how different the individual’s personality is can be detrimental to their emotional and mental well-being.

Executive Functions & Memory Changes Impacting Behavior

In a blog post about the importance of routines and TBI, I described executive functions as higher-order cognitive tasks, which include planning, attention, problem-solving, working memory, emotional self-regulation, initiation and inhibition of behavior. Below I have outlined the ways in which impaired cognitive functions, in particular, the executive functions, may impact behavior.

  • Impulsivity: Reduced control over the initiation and inhibition of behaviors can lead to impulsivity. Brain injury survivors, particularly those who have experienced frontal lobe injuries, may engage in more risky activities without considering the consequences. Such activities may include impulsive spending or reckless driving to name some examples. The individual may also be more willing to speak out on things that others might choose to filter and make crude, hurtful, or inappropriate remarks. Inappropriate remarks or behaviors may even be sexual in nature. Angry outbursts can also be a hallmark of impulsivity, even if this was not at all part of the individual’s temperament prior to the injury. It is important to understand that brain injury survivors do not have control over these behaviors but can be provided with tools to manage them. These tools may include thoughtful feedback, practicing appropriate social skills, as well as implementing cues that indicate the individual should reflect on their actions in the moment.
  • Mental Flexibility: Mental flexibility can be compromised as a result of brain injury. TBI survivors may be more rigid in their thinking. In other words, they may have difficulty adapting to changes that arise from situations or their environment. Generally, people can modify their thoughts and/or actions to adapt to unforeseen changes; however, this can be particularly taxing on those dealing with TBI. Survivors may also have diminished ability to see more than one solution to a problem. It is crucial to acknowledge that these reactions to a lack of structure and predictability are not a desire to be “difficult” or “stubborn” on the part of the injured person. Sometimes perseveration, which can be described as the repetition of thoughts, behaviors, or statements, may also be prevalent. Although individuals with TBI may become aware of perseverative behaviors, they may not be able to cease them on demand. Patience, the use of cues, and encouraging task switching is essential when dealing with this particular symptom.
  • Memory and Concentration: It is common for TBI survivors to experience memory deficits. In some instances, they will not be able to remember periods of time, particularly those that occur post-injury. It is common for short-term memory to be adversely affected, making learning new concepts a major challenge. Compensatory strategies, such a writing things down, repetition, experiential learning, and maintaining routine/structure, can address memory deficits. Individuals who have suffered a brain injury may be more prone to distractibility, which may manifest as having difficulty focusing on more than one task or maintaining focus during a conversation. This may also impact ability to learn new concepts or remember details. Loved ones should be patient and understanding, creating an environment that seeks to reduce distractions, prevent overstimulation, and enhance memory cues.

This list is not exhaustive by any means. It is essential for those with TBI and their loved ones to be open to ongoing learning in order to maximize potential for rehabilitation and to manage adapting to changes. A lack of insight or self-awareness can be an effect of TBI and can very well cause impediments to addressing such behavioral changes. Clinicians at PNBC are equipped with the skills and training to promote insight, improve optimism and self-esteem, as well as provide a sense of control over what can feel like dramatic changes for patients and family members alike. We aim to foster growth and self-empowerment by educating patients and their families, while keeping in mind the barriers that require empathy and understanding.

Written by: Beverly Sharifian, MA, APCC

Ms. Sharifian is an associate professional clinical counselor at Pacific Neurobehavioral Clinic, PC.

Emotional Effects of Traumatic Brain Injury

Survivors of traumatic brain injury are often left to deal with unforeseen changes and symptoms. Impact to various regions of the brain, such as the area responsible for regulating emotions, can cause survivors of TBI to sense a lack of control over their feelings. Adjusting to life after brain injury may also trigger stress and lead to adverse emotional states. Below are some of the emotional symptoms that may manifest following traumatic brain injury:

  • Mood Fluctuations: Depending on the area of impact, TBI can cause sudden shifts in mood, such as fluctuating from content to irritable without any triggering event. In some instances, survivors of TBI may find themselves laughing for extended periods or experiencing sudden bursts of crying. This can be particularly challenging to manage because the emotional expression is often incongruent with the individual’s internal feelings. In other words, the individual is unable to control or cease laughter, when in actuality, they are feeling down or depressed. These exaggerated shifts in mood are referred to as emotional lability. This symptom can be concerning to both survivors and their loved ones due to its unpredictable nature and the individual’s lack of control over the expression of emotion.

  • Anger: Irritability is another common emotional change following TBI. Impact to brain regions that control emotional expression, in addition to difficulty adjusting to changes in recovery and experiencing intense pain, may all contribute to increased irritability and anger. Some survivors have diminished patience and find it difficult to control their temper. Regardless of the individual’s temperament prior to injury, angry outbursts may include yelling or screaming, using profanity, threatening others, and throwing or slamming things. These feelings can be unfamiliar to some survivors of TBI who had rarely experienced or expressed them in this manner prior to the onset of injury.

  • Depression: It can be particularly difficult to distinguish symptoms of depression from the symptoms of brain injury. Sudden onset of symptoms may be attributed to the injury, whereas gradual onset tends to point to depression. General feelings of sadness can be expected throughout the recovery process, given the experience of significant life changes. However, when feelings become overwhelming or impair functioning, they may be indicative of depression. Depressive symptoms may include low mood, loss of pleasure in activities, lack of motivation, changes in appetite, sleep disturbances, isolation, fatigue, hopelessness, and thoughts of dying. Feelings of guilt may complicate this experience, as survivors may feel that they are to blame for their injury or that they should have gratitude for surviving the event.

  • Anxiety: Survivors of brain injury may become more sensitive to stimuli and find that daily tasks, such as making decisions about what to wear, are stressful. The pressure of not being able to return to work or modifications in daily routines due to sensory overload can trigger anxiety. Feelings of anxiety may be physiological (increased heart rate, difficulty breathing) or cognitive (excessive worry, difficulty concentrating). Survivors of TBI may even suffer from panic attacks, which occur suddenly and unexpectedly without any particular trigger, causing behavioral changes (avoidance). Given the significant life adjustments following injury and throughout the recovery process, anxiety may be a temporary response. However, it is wise to consult with a professional in order to determine the cause of anxiety, as well as the appropriate interventions.

Managing Emotional Symptoms


Communicating feelings can seem unfeasible when individuals cannot quite understand what it is that they are feeling or experiencing. It is nevertheless important to express needs and feelings to loved ones/caregivers who may also observe these emotional changes but are uncertain about what they can do to help. Isolating from others can compound problems and make the symptoms feel increasingly unmanageable. It is crucial to ask for support when needed. Survivors of TBI may find peer support, either in the form of mentoring or TBI support groups, more effective than leaning on loved ones. Consulting with medical providers about symptoms can provide clarity regarding treatment options, which may include medication management or counseling services. It is important to note that each individual’s experience with TBI is unique, resulting in distinct needs that require tailored interventions.

Clinicians at PNBC use empirically-based interventions and psychoeducation to help TBI survivors distinguish the symptoms of injury from symptoms that may be indicative of a mood disorder. The clinicians’ diverse backgrounds and specializations enable clients to receive care attuned to their needs. Examples of interventions include cognitive behavioral therapy to address negative thought processes and manage pain, relaxation strategies such as grounding techniques or progressive muscle relaxation to reduce anxiety, and trauma-informed approaches that may relieve post-traumatic stress. Therapy can increase insight into symptoms, reducing the unknowns and making the recovery process feel more manageable.

Written by Beverly Sharifian, MA, APCC.

The Importance of Routines for TBI Neurorehabilitation

Daily routines can be essential to maintaining physical and mental health, as they increase productivity, help manage stress, and enable us to make progress towards our short-term and long-term goals. Disruptions in daily routines and activities can be upsetting, particularly for those navigating the recovery process. It is natural to want to return to our baseline level of functioning after suffering injury; however, successful recovery is centered on a gradual return to previous activity levels. For survivors of traumatic brain injury (TBI), a flexible routine is an essential component of treatment, as it seeks to address impairments and promote normative functions.

Cognitive Processes and TBI

Cognitive symptoms and deficits are common following traumatic brain injury. The APA Dictionary of Psychology defines cognition as, “all forms of knowing and awareness, such as perceiving, conceiving, remembering, reasoning, judging, imagining, and problem-solving.” Executive functions, including planning, attention, problem-solving, working memory, emotional self-regulation, initiation and inhibition of behavior, decision-making, motivation, and flexible thinking are more complex cognitive tasks. These cognitive abilities are often compromised following traumatic brain injury, highlighting the importance of a consistent routine that seeks to re-establish these functions. It can be especially challenging when tasks that used to be second-nature feel strenuous or unmanageable. A predictable daily routine can help survivors of TBI regain their cognitive skills and enhance executive functions.

How Routines Can Improve Quality of Life

Sleep Hygiene

All individuals can benefit from a consistent bedtime routine in order to ensure that they are getting adequate, quality sleep and maintaining a healthy circadian rhythm. However, for individuals who have suffered a TBI, rest is even more crucial, as it promotes recovery and healing of the brain. Waking up and going to bed at the same time every day, in addition to establishing both a bedtime routine and morning ritual, can improve quality of sleep and reduce fatigue. Given that sleep disturbances and fatigue are common symptoms of TBI, treatment may involve psychoeducation on sleep hygiene and promoting the practice of activities that optimize energy levels, such as mild physical exercise.

Routines with ADLs

Activities of daily living (ADLs) are life skills that foster independence. They include hygiene practices, eating, getting dressed, mobility, and continence. Due to cognitive deficits, ability to perform ADLs may be significantly impacted following TBI. For instance, memory impairments and attention deficits may impede the ability to shower and get dressed in a reasonable time frame. Practicing these skills at a set time each day and in a specific order can create automatic habits, as well as increase awareness surrounding particular areas of need that should be addressed in treatment.

Instrumental activities of daily living (IADLs) involve higher-order cognitive abilities and include medication management, finances and budgeting, shopping and preparing meals, as well as housekeeping. An unfamiliar aspect of one’s daily routine following TBI may include remembering to take medications or engaging in rehabilitation exercises, such as those learned in physical, occupational, or speech therapy. Daily structure can increase the likelihood that these tasks will be completed and allows survivors to focus on one task at a time without distractions.

Self-Care Activities

Engaging in self-care via physical activity, relaxation techniques, engagement in hobbies or special interests, and social interaction is part of a well-rounded routine. Self-care practices can promote emotion regulation, stress management, a positive outlook, as well as improve overall well-being. Daily routines should involve some form of self-care based on the unique needs and preferences of the individual. For some, self-care may involve journaling or spending time alone while others might find that spending time with loved ones is what they need to recharge.


Focus of Treatment and Rehabilitation

A routine that is adapted to meet our current needs and abilities will promote the most growth in recovery. It is imperative that survivors of TBI understand and acknowledge limitations in order to prevent overexerting themselves early on in the recovery process. It is normal to feel disappointed about diminished independence and difficulty managing life skills. For instance, an individual who worked a full-time job, drove independently, and multi-tasked throughout the day may have trouble adjusting to a less strenuous routine.

Clinicians at PNBC can foster acceptance in regards to current impairments, encouraging and empowering clients to execute a rehabilitative routine that will eventually lead to a more familiar lifestyle. Psychotherapeutic treatment at PNBC can assist clients with improving insight into their symptoms and recovery, practicing compensatory strategies to manage deficits, and processing emotions related to impairments. TBI survivors require both predictability and flexibility in their routines, keeping in mind that sensory overload can have adverse impacts on their well-being. Taking a slow and steady approach while remaining motivated and committed to making gradual improvements day-to-day will create long-lasting improvements.


Written by Beverly Sharifian, MS, APCC. Ms. Sharifian is an associate professional clinical counselor working under the supervision of Dr. Delia Silva at PNBC.