It is no longer the same as before

Written by: Dra. Beatriz Castaño Monsalve
Edited by: Top Doctors®

In 1848 Phineas Gage, a railroad worker, had an accident as a result of an explosion. A metal rod 6 kg, 1 m long and more than 3 cm in diameter pierced his skull on the left cheek and exited through the top after passing through the cerebral cortex. After two months, the patient was discharged by the physician considering he was completely recovered and displayed no physical alteration or language.

Twenty years later, Dr. Harlow, who had treated the patient, described it in a medical publication:“ equilibrium or balance between his intellectual faculty and animal propensities are destroyed, they returned irreverent, blasphemous, impatient and stubborn”

Soon after the accident, Phineas lost his job and never was able to keep one for a long time, as they seized or abandoned by their rinas continuous with peers. Her marriage ended because his wife thought it was not the same before and had become an aggressive man. After working on several farms, Phineas was exhibited in the circus, which was teaching his wounded pride and the iron rod that caused. Died at 38 years due to epileptic seizures. Now preserved both his skull and the iron bar in the Museum of Harvard University, since it was one of the first cases in history of medicine where they revealed the relationship between a lesion of the brain and changes behavior.

In our days the story of Phineas keeps repeating with different names and mechanisms of injury: falls from scaffolds, assaults, car accidents or motorcycle, etc.. Although it's been 162 years and has been a great development in medicine, unfortunately, still the consequences of behavior can not be properly diagnosed or treated, leaving the individual who suffers and their families in a situation of emotional overload chronic and deteriorating quality of life.


frontal lobe

You can not talk about behavioral changes without making mention of the frontal lobe, the area of the brain located in the most anterior part of the skull, just behind the forehead, which is responsible for the major forms of mental activity such as intelligence, creativity, abstract reasoning and conceptual skills. It is, also, what makes us human, intelligent and sensitive and allows us to learn from the experiences and adjust our behavior depending on the situation.

To get an idea of its importance in human, note that the frontal lobe takes up 33 % of the brain, while the chimp represents 15 % and 3% cats.

The frontal lobes connected with deep brain structures and the temporal lobe, areas involved in, hormonal, visceral, sensory and autonomic emotional functions. The proper meshing of these systems occurs as a result the individual to regulate his behavior according to each situation taking into account the previous experiences and can be guided by objectives and engage productively in different facets of the human experience.

Thus a malfunction of this regulatory system has on the person who suffers a state of disinhibition of behavior and emotion alteration, manifested a tendency to irritability, mood swings, impulsivity, inappropriate behavior in the field social or family and, in more severe cases, verbal or physical aggression.


Causes of acquired brain injury

Not only injuries cause brain damage, also the stroke ( bleeding or cerebral artery infarcts ), tumors, encephalitis and encephalopathy anoxic (lack of oxygen to the brain ). Just keep in mind that these lesions differ from one another by factors such as the area of the brain affected and the extent thereof; some of them are localized, while others affect very large areas or even the whole brain. In this sense, manifestations, evolution and prognosis between the different types of brain injury are not comparable.

Finally, there are a patient -specific factors that may influence negatively the evolution of behavior changes. These factors include history of regular alcohol consumption and toxic, advanced age and the prior existence of psychiatric pathology, mental retardation, developmental disorders or learning or brain injury.


Phases of brain damage

Depending on the exact moment at which the patient is, we will see a series of alterations or changes in behavior. The phases described below does not have a specific duration and are always presented in the same order and manifestations can vary depending on the type of brain injury and in each particular case.

In general, during the first days or weeks the patient can not communicate, display confused and not recognize family members;is frequent disorientation in time, place and even in person;can have an incoherent speech, restlessness present a sometimes reaches agitation or hallucinations that generally are visual type ( see animals, dead people, fire).

Sometimes, since the first phase is a state of disinhibition evident, impulsivity and mood swings. Generally these alterations will fade with time and with different treatments initiated. Subsequently, there is a subacute or transitional period in which the patient recovers, gradually, the orientation, the sense of self, recognition of people and coherence in their ideas, may recover partially or completely, its operation previous mental.

In chronic stages, when it has been many months of injury, these behavioral changes are more evident and family make comments&ldquo type, is no longer the same as before”. This is known as according to doctors manuals organic disorder or personality change, defined as a sustained or persistent change in the previous features of the individual that cause a relative impairment in social, occupational, or. The rate of change of personality in severe head injury can reach 80 % of cases.


Changes in behavior and emotions

For better compression, I have grouped the different behavioral syndromes and emotional symptoms that can present the patient with acquired brain injury.


Alteration of affection

In the early stages of brain damage is very frequent emotional incontinence with minimal crying to stimuli. Also emotional lability may occur, this is difficulty to control laughter or crying usually occurs in situations of stress or nervousness.

The patient may go through a period of depression, reactive to the situation of disability, which sometimes manifests itself at an early stage and sometimes occurs when returning to their environment and cope with the changes in lifestyle.

A long run is characteristic emotional and affective instability with difficulty regulating emotional responses, presenting mood swings that can be minutes, hours or days. Patients with depressive states may alternate phases of euphoria, sometimes without an external trigger.

Are also frequent changes in the expression of emotions that family members describe as&ldquo, is more affectionate than before” or“he is indifferent”...


Loss of impulse control

It is a failure, instinctive and motor control mechanisms of behavior that may manifest in the verbal area. Are frequent inability to wait with impatience, low tolerance for frustration, irritability and demanding attitude.

In the verbal realm, the patient can make an uncontrolled expression of opinions or feelings indiscretions, loss of verg Wü;embarrassment and occasionally use foul language. Also, there may be an overly gentle, seductive and accommodating attitude, need to greet, thank or touching others. They can also express sexual disinhibition. And, in the field engine, the patient impulsive acts thoughtlessly without considering the consequences of their actions.

The result of all this may be a behavior not consistent with the patient's age and inappropriate social behavior.



Aggression is also the result of a loss in the control pulse is accompanied by a feeling of unease and anger by an external or internal stimulus. The answer may be verbal, in the form of insults or threats, or physical, against objects or persons against acts such as breaking, throwing things, pushing, biting, punches and self-harm, among others.

Unlike psychiatric illness, aggression secondary to brain damage is reactive and disproportionately so happens to minimal stimuli, is unplanned and has a purpose, is very sharp in his presentation, usually short, and once past episode, causing regret and emotional distress in the patient.



The apathy is essentially a lack of motivation manifested in behavioral, cognitive and emotional aspects. There is a decrease of behavior that can be mild, as slowing for the different tasks of daily living, or severe life, causing inability to initiate or maintain most activities.

Typically, the patient has no plans or ideas and shows a decrease in the expression of feelings, so that seems indifferent and not very reactive to environmental events, both positive and negative.

The apathy is often a matter of great concern for the family and for not so affected because the patient usually has a sense of calmness and indifference.


Other manifestations

The self-awareness also usually affected, so that the patient with brain injury may not be aware of their deficits, which greatly hinders any therapeutic intervention. Moreover, cognitive inflexibility makes the patient displays stubborn, selfish and inconsiderate to the people around them.

In some cases, paranoid symptoms that manifest with exaggerated distrust, pathological jealousy, fear that others may do harm and other unrealistic ideas are presented. These ideas are often accompanied by changes in behavior.

The changes described are a direct result of organic brain injury and are presented along with their own reactions to anyone who goes through a period of illness, such as the appearance of regressive aspects, in need of attention and care from their loved ones;so, keep in mind that not all behaviors are attributable to brain injury.



Disruptions in behavior and emotions may go unnoticed at first, especially for people who did not know the patient before brain lesion;however, altered behavior can completely change the relationship of a couple or family members and cause separation.

The impact depends, basically, on factors such as the frequency and severity of changes in the patient as well as the degree of coexistence with the patient.

In the hospital setting and rehabilitation centers, behavioral disorders can disrupt or prevent the development of activities negatively affecting the utilization of therapy and cognitive performance.

Such behavior is often altered because of work, social and family dysfunction. Long term causes rejection, stigma and increasing isolation, mainly of the person who suffers it but sometimes also of family. For those closest to him why the patient is suffering and emotional overload.


Pharmacological Treatment

The approach of behavioral and emotional disorders of patients with brain damage should be made in interdisciplinary with neuropsychology. It is essential to the treatment of cognitive problems, as well as the preparation and education of family patterns of acting and control of environmental factors that may trigger conflict situations with the patient.

From neuropsychiatry, the use of psychotropic drugs is widely justified as a tool to get a quick control symptoms in a large proportion of cases, which allows for greater participation and collaboration of the patient for rehabilitation therapy and a lower overhead caregiver.

It is important to know that psychotropic drugs have a primary indication and are approved for different pathologies of the present one, however, its use in the treatment of cognitive-behavioral sequelae of brain damage is supported by extensive scientific studies and information. Thus, for example, atypical antipsychotics and antiepileptic drugs used for psychomotor agitation, irritability, uncontrolled impulses and mood stabilizers as. To improve alertness, attention, increased motor activity and initiative we prescribe some antidepressants, dopamine and psychostimulants.


General Recommendations

During the visits is essential to talk openly with the doctor about the behavioral and emotional changes that the patient and that you hear the reason why you are prescribed a drug. The patient should be involved in this decision in order to increase the therapeutic alliance with your physician and encourage compliance. So, the doctor is responsible for monitoring and periodic valuation of treatment, while the control and proper administration of the medication is the responsibility of the family or caregiver.

Most of the psychotropic drugs can cause unwanted effects the first few days, which should not persist beyond a week; in that case, or if they are bothersome, should contact the physician to assess the continuity of treatment before stopping without consulting. You should also inform the doctor about the behaviors of the patient 's discharge of the medication, as incorrect footage decreases efficiency and cause poor control of symptoms.

Alcohol and other substances is contraindicated with the use of such drugs as carries risks as alteration of consciousness, epileptic seizures and behavioral changes.

In our hospital an interdisciplinary approach, both neurological patients and their families, integrating the physical, neuropsychological and neuropsychiatric treatment for better control of the sequelae of acquired brain injury is provided.

*Translated with Google translator. We apologize for any imperfection

By Dra. Beatriz Castaño Monsalve

Prominent psychiatrist, Dr. Brown Monsalve is a specialist in psychiatric intervention in Neurorehabilitation. He currently serves as Medical Assistant at the Institut Guttmann de Barcelona. PhD in Psychiatry at the Autonomous University of Barcelona, ​​has a postgraduate degree in marital and family therapy by the Fundació Vidal i Barraquer.

*Translated with Google translator. We apologize for any imperfection

View Profile

Overall assessment of their patients

TOPDOCTORS utiliza cookies propias y de terceros para facilitar su experiencia como usuario de nuestra web y captar datos estadísticos mediante el análisis de sus datos de navegación. Si usted continúa con la navegación, entendemos que nos ofrece su consentimiento para el uso de cookies. Puede cambiar la configuración de cookies u obtener más información here.