Loss of Self After TBI

The consequences of suffering a traumatic brain injury (or TBI) are serious and may be long-lasting. TBIs are categorized into three groups: mild, moderate, and severe. These categories are based upon changes in one’s mental state or consciousness at the time of injury. A mild traumatic brain injury (mTBI or commonly called concussion) is characterized by a brief change in mental status or consciousness or no loss of consciousness at the time of injury. Most TBIs that occur each year are mTBIs or concussions. The term “mild” in mTBI does not mean a concussion is an unimportant or minor injury; regardless of category, it is a diagnosis of a sudden neurophysiological event resulting from blunt impact to the head, neck, or body with transmitting forces to the brain. The consequences of TBI can include deficits in cognition, and in physical, emotional, and social functioning. Patients with mTBI often experience headaches, fatigue, dizziness, balance issues, difficulties with focus, attention, concentration, and memory, sleep disturbances, anxiety, depression, changes in mood and temperament, and many more symptoms. An incredibly important but largely overlooked consequence of TBI is the loss of sense of self or one’s identity. The inward process of negative self-evaluation after TBI is often missed or marginalized. However, studies have long found loss of self a commonly experienced consequence of TBI.(1) One study notes that loss of sense of self after TBI is so common it has been described in scientific literature as “almost the sine qua non of brain injury.”(2) Sine qua non translated literally means, “without which, not.”          

The Process of Loss of Self Explained

Family members are often eyewitnesses to the changes in a loved one who has suffered a TBI. They are often an important resource in describing the shifts in personality, temperament, memory, mood, and cognitive functioning of a loved one after injury. Family members may also provide insight into how often or the degree to which a loved one post-TBI is experiencing physical symptoms like headaches, dizziness, balance issues, and sleep disturbances. These outwardly displayed symptoms are typically obvious to a close family member or companion. But much like the injury itself, there is frequently a process occurring inside the person that is not visible to the outside world. The process is a loss of self which is a conscious awareness the person is not the same person pre-injury and subsequently attaching negative self-images or self-evaluations which cause emotional distress. 

Loss of self is a complex and multi-faceted process that varies among individuals. Loss of self is as unique to the individual as the initial injury itself. Just as outcomes vary widely after TBI, based upon factors such as age, gender, history of concussion, overall health, etc., loss of self varies among individuals. The intensity and number of symptoms a person is suffering and the length of time the symptoms have persisted will factor into loss of self. Notably, certain personality types (like Type A) and a high pre-injury self-image has been found to increase the incidence of loss of self experienced after TBI.

Four Parts of Loss of Self

Brain injury research has loosely identified four parts to loss of self: 1) a conscious awareness of being different post-injury; 2) assigning negative self-evaluations to post-injury functioning; 3) emotional distress; and 4) using denial as a protective mechanism. A conscious awareness that a person is not the same person pre-injury can vary in intensity from feelings of differentness to complete dissociation from a person’s prior identity. The person recognizes inconsistencies in his or her current functioning with his or her pre-injury self. For example, a person may no longer be able to or struggle with driving, working, or hobbies. Additionally, a person can recognize changes in his or her behavior - acting aggressively and/or impulsively and becoming easily irritated which is at odds with his or her pre-injury personality. An awareness of functional differences and personality changes from a pre-injured self is the precursor to a loss of self. Typically, people have developed a narrative over time about who and what role they play in life. For example, a person who identifies him or herself as a good spouse will internalize and attach words to describe what that role means to them - caring, compassionate, loving, supporting, dependable, attentive, a provider, etc. If the person is acting inconsistently or at odds with their definition of a good spouse, for example the person is irritated, frustrated, and lashing out at his or her spouse and/or not as dependable or capable as he or she once was, the role of “good spouse” and all the positive feelings associated with it becomes threatened. 

Assigning Negative Self-Evaluations Post-Injury is Not Uncommon

Many negative self-evaluations are in regard to functioning. This is especially true if someone was a hard worker or successful at his or her vocation. Just as someone identifying as a good spouse attaches words to describe what that entails, so is true with work. A worker may attach words such as smart, competent, energetic, professional, adept, successful, skilled, talented, etc. Facing a functional limitation, a person may now assign negative evaluations to him or herself when it comes to work. They may think of and describe themselves as marginal, ineffective, incompetent, irrelevant, slow, or stupid. (Often echoing the unfortunate stigma society has placed upon them.) The degree to which negative self-evaluation of functioning one harbors seems to be correlated with personality type pre-injury. High achievers and those with Type A personality, who had a more robust sense of functional self-pre-injury, are more critical of themselves after injury. This can hit an individual hard in the area of occupational self. An occupational identify is broader than a work identity. Work identity typically refers to a job or career or work to earn money. Occupational identity encompasses what people do to occupy their time and includes social and leisure pursuits as well as employment. Developing an occupational identity and participating in one’s daily occupations have been described by researchers as “essential to our health and well-being.”(3) Adjusting to new limitations in one’s occupations can be difficult and lead to avoidance or withdrawal of work, social interactions, and hobbies once enjoyed. 

Loss of Self Can Be Emotionally Distressing

A conscious awareness of differences post-injury and attaching negative feelings to those differences are emotionally distressing. Left untreated, emotional distress can manifest itself as anxiety and depression. Emotional distress can also be taxing physically causing headaches, lower immune function, sleep disturbances, and fatigue. The greater the negative self-evaluations, the greater the emotional distress one experiences.  

As a way to cope with newly acquired limitations, negative self-evaluations, and emotional distress, sometimes people will resort to denial. Denial is an avoidance mechanism. In an attempt to avoid the awareness of functional limitations and the corresponding negative emotions, the person may avoid situations which have the opportunity to reveal them. For example, a person may retreat from family or social situations where there is a likelihood of becoming agitated and act inconsistently with his or her pre-injury self. Likewise, a person who has returned to work can shy away from tasks that may reveal his or her new limitations or “incompetencies.” While the person may evade situations for a short time, denial is not a long-term solution. Not only is withdrawing from social, family, and work situations creating isolation and loneliness, denial makes the situation worse. Psychology research has long held that an avoidance of thoughts and emotions inevitably leads to an increase and intensity of the undesired thoughts and emotions. It is as simple as telling someone, “don’t think about a car” and the person immediately thinks of a car. Not being able to avoid or deny negative thoughts and emotions can lead to someone losing a sense of control. This loss of control simply compounds emotional distress making denial a vicious cycle. Stopping short of denial, patient may diminish or underreport their symptoms in an effort to evade criticism, stigma, negative feelings, or emotional distress.  

Loss of self after TBI can significantly impact one’s life. Often, the negative emotions and feelings a person is experiencing after suffering a TBI are difficult to acknowledge or articulate. Identifying a loss of self is often the result of a qualified healthcare provider, like a neuropsychologist, recognizing its prevalence and complexity. Rehabilitative therapy may be helpful to those who are experiencing a loss of self after TBI.

If you hear of anyone in Florida who has suffered an injury or suspects a TBI, please connect with me directly here. If you’re a fellow attorney, please reach out here. I’m happy to help.

References

(1) A Scoping Review on Occupational and Self Identify After a Brain Injury/M. Bryson-Campbell et al.

(2) Understanding and Treating Loss of Sense of Self Following Brain Injury/Stephen Myles

(3) Reflections on Doing, Being and Becoming/Wilcock