Traumatic Brain Injuries: Why Survivors Face an Increased Risk of Developing Depression and Anxiety

Alleviating the Aftermath of a TBI

Each year, approximately 2.5 million individuals suffer from a traumatic brain injury (TBI) in the United States.[1] As a result of suffering a TBI, individuals can experience a multitude of physical effects, including: mood changes, memory or concentration problems, difficulty sleeping, headaches and fatigue.[2] In addition, individuals who experience a TBI are also more susceptible to developing a mental health disorder. A study conducted by Fann and colleagues in 2004 found that 49% of individuals who suffered a moderate to severe TBI and 36% of those with mild TBI also received a psychiatric diagnosis within a year following their injury. The prevalent comorbidity of traumatic brain injuries and mental health disorders is one that must not be overlooked by physicians and mental health care providers.[3] 

Depression after a TBI: a distinct disease

Depression is one of the most common mental health disorders that TBI survivors face. The heightened risk for depression is largely due to the stress that occurs on the brain following a traumatic injury, such as a TBI. The brain’s neural pathways can become altered with a TBI, causing formally strong and functional pathways within the brain to no longer work properly.[4] How this relates to depression is we rely heavily on these pathways to understand and communicate our own emotions. With damage to these pathways, it becomes difficult to carry out these crucial functions, subsequently leading to an inability to process emotions.[5]

Common symptoms of depression that an individual may face following a traumatic brain injury include:[6]

• Feelings of sadness, emptiness, or hopelessness

• Angry outbursts, irritability or frustration 

• Sleep disturbances

• Tiredness and lack of energy, with small tasks taking extra effort

• Feelings of worthlessness or guilt

• Trouble thinking, concentrating, or decision-making

Anxiety after a TBI

In addition to depression, anxiety is a common problem individuals face after experiencing a traumatic brain injury. Due to the changes that can occur to an individual following their accident, they may feel overwhelmed more easily in situations that previously did not bother them. This can be due to the fact that individuals may struggle to focus, think fast, or process information quickly - so in situations where these tools must be used, they can become easily anxious.[7] It's also important to note that individuals who suffered from anxiety prior to their TBI may find their symptoms have worsened following their accident and more difficult to manage.[8] Common symptoms of anxiety that an individual may experience after a TBI include:[9]

• Feeling nervous, restless, or tense

• Having a sense of impending danger or doom

• Having an increased heart rate

• Breathing rapidly 

• Having trouble sleeping

• Having difficulty controlling worry

Targeted treatments

In order to effectively help treat the depression and anxiety that can occur following a TBI, combination therapy should be used. However, these therapies must be targeted directly to an individual’s TBI. The first treatment course that is often considered when attempting to alleviate the symptoms of depression and anxiety are SSRIs. This class of antidepressants are often used in the treatment of anxiety and depression, and work to increase the amount of serotonin in the brain.[10] The reason why they work so well in the treatment of depression and anxiety after a traumatic brain injury is their dopaminergic effects can help improve cognition in individuals who have suffered a TBI, while also improving their mental state.[11]

In addition to pharmacological interventions, cognitive behavioral therapy (CBT) is extremely effective at helping depression and anxiety in TBI survivors. Cognitive behavioral therapy may be tailored to utilize two things: cognitive restructuring and behavioral activation. Cognitive restructuring helps survivors address and redirect irrational thoughts following their accident, which allows an individual to shift to a more positive mental space.[12] Behavioral activation is a tool used when treating TBI survivors to encourage them to plan activities to improve their mood. This could be as simple as planning a daily walk or as extravagant as a trip away; using this technique allows survivors to look forward to their life again.[13]

Another extremely important treatment in addressing depression and anxiety following a TBI is positive psychology. Positive psychology helps to rewire a survivor's brain and encourage them to use forward, optimistic thinking. This could include simply writing in a journal a gratitude list for the day, or expressing positive thoughts out loud to another individual, daily. This practice has been extremely helpful with survivors' neuroplasticity - the ability of the brain to reform and strengthen neural pathways in the brain. Following a TBI, these pathways can be lost, which is why rewiring these pathways with positive thinking can help alleviate feelings of anxiety and depression.

Overall, it is essential that TBI survivors understand the risk factors for and key signs of anxiety and depression. If you or someone you know would like to learn more about how to seek help alleviating the symptoms of anxiety and depression following a TBI, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support. 

Contributed by: Daphne Lasher

Editor: Jennifer (Ghahari) Smith, Ph.D.

references

1 Brain Trauma Foundation. (n.d.). Frequently asked questions (FAQ). Brain Trauma Foundation. https://braintrauma.org/info/faq#:~:text=Each%20year%20about%202.5%20million,Falls%20(28%25)

2 The Mayo Clinic. (2021, February 4). Traumatic brain injury. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

3 Fann, J. R., Burington, B., Leonetti, A., Jaffe, K., Katon, W. J., & Thompson, R. S. (2004). Psychiatric illness following traumatic brain injury in an adult HealthMaintenance organization population. Archives of General Psychiatry, 61(1), 53. https://doi.org/10.1001/archpsyc.61.1.53

4 Cooney, E. (2023, July 6). Why depression after traumatic brain injury is distinct - and less likely to respond to standard treatment. STAT. https://www.statnews.com/2023/07/06/depression-after-traumatic-brain-injury/

5 Ibid. 

6 The Mayo Clinic. (2022, October 14). Depression (major depressive disorder). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

7 Model System Knowledge Translation Center

8 Ibid.

9 The Mayo Clinic. (2018, May 4). Anxiety disorders. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961

10 The Mayo Clinic. (2019, September 17). The most commonly prescribed type of antidepressant. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825

11 Fann, J. R., Hart, T., & Schomer, K. G. (2009). Treatment for depression after Traumatic Brain Injury: A systematic review. Journal of Neurotrauma, 26(12), 2383–2402. https://doi.org/10.1089/neu.2009.1091

12 Flint Rehab. (2023, January 6). Brain injury and depression: Causes, symptoms, & treatments. Flint Rehab. https://www.flintrehab.com/brain-injury-and-depression/ 

13 Ibid.

Understanding Anxious Depression

Double Trouble

Illnesses are considered “comorbid” when a person experiences two or more conditions simultaneously.[1] One of the most common comorbid conditions is anxious depression (i.e., anxiety and depression) where roughly 45-67% of patients with major depressive disorder (MDD) meet criteria for at least one comorbid anxiety disorder and 30-63% of patients with anxiety disorder meet criteria for comorbid MDD.[2] The American Psychiatric Association defines someone as having MDD with anxious distress if they meet the criteria of major depressive disorder plus at least two of five anxiety symptoms (e.g., feeling keyed up or tense, being unusually restless, having trouble concentrating because of worry, having fear that something awful may happen, or feeling that one might lose control of oneself).[3]

How Is Anxious Depression Different?

Anxious depression has a few distinguishing factors from non-anxious depression. A study by Rajkumar R.P. (2022) found that people with comorbid depression and anxiety tend to have an earlier age at the onset of either illness, higher rates of childhood trauma, higher levels of neuroticism, more severe functional impairment, and poorer treatment response.[4] Additionally, people with anxious depression were found to have more frequent episodes of major depression, a higher risk of suicide ideation and previous suicide attempts.[5] Demographically, patients with anxious depression are significantly more likely to be in a primary care setting, female gender, non-single, unemployed, and less educated, according to the NIMH-funded “Sequenced Treatment Alternatives to Relieve Depression” project (STAR*D).[6] Physiologically, a study by Inkster et al. (2011) found that patients with anxious depression had more gray matter in their temporal gyrus compared to those with non-anxious depression.[7]

Reasons For Comorbidity 

Multiple theories explain why the two illnesses co-occur so frequently. One view holds that the two conditions have similar biological mechanisms in the brain, making them more likely to appear together.[8] Another theory states that dysregulation of biological mechanisms (e.g., immune-inflammatory pathways, amygdala, hypothalamic-pituitary-adrenal axis) is the cause.[9] A developmental approach finds that insecure attachment in childhood creates a predisposition to the development of anxious depression.[10] Regarding the environment, theory states that the conditions often present simultaneously when an external stressor or stressors trigger a person.[11] Lastly, there is a diagnostic theory that states since anxiety and depression have many overlapping symptoms (e.g., problems with sleep), people frequently meet the criteria for both diagnoses.[12]

Treatment for Anxious Depression 

The National Alliance on Mental Illness (NAMI) notes that anxious depression is often more challenging to treat due to the illnesses “working together” to cause more intense and persistent symptoms.[13] Thus, individuals may need more specialized treatments to combat their symptoms.[14] For example, if antidepressants prescribed by a psychiatrist improve a person’s mood but not their anxiety, the next step would be to seek a therapist for cognitive behavioral therapy (CBT).[15] 

Various drug therapies are available to help treat anxious depression. An analysis by Choi et al. (2020) revealed that SSRIs were effective in treating anxious depression, benzodiazepines can be used to augment SSRI and treat baseline anxiety, and atypical antipsychotics can be used as augmentation agents for treating major depressive disorder.[16]

If you think you or someone you know may have Anxious Depression, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.

Contributed by: Maria Karla Bermudez

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Salcedo, B. (2018, January 19). The comorbidity of anxiety and depression. NAMI. https://www.nami.org/Blogs/NAMI-Blog/January-2018/The-Comorbidity-of-Anxiety-and-Depression  

2 Choi, K. W., Kim, Y. K., & Jeon, H. J. (2020). Comorbid Anxiety and Depression: Clinical and Conceptual Consideration and Transdiagnostic Treatment. Advances in experimental medicine and biology, 1191, 219–235. https://doi.org/10.1007/978-981-32-9705-0_14

3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

4 Rajkumar R. P. (2022). Comorbid depression and anxiety: Integration of insights from attachment theory and cognitive neuroscience, and their implications for research and treatment. Frontiers in behavioral neuroscience, 16, 1104928. https://doi.org/10.3389/fnbeh.2022.1104928

5 Choi et al., (2020)

6 Fava M, Rush AJ, Alpert JE, Carmin CN, Balasubramani GK, Wisniewski SR, et al. What clinical and symptom features and comorbid disorders characterize outpatients with anxious major depressive disorder: a replication and extension. Can J Psychiatry. 2006;51(13):823–35.

7 Inkster B, Rao AW, Ridler K, Nichols TE, Saemann PG, Auer DP, et al. Structural brain changes in patients with recurrent major depressive disorder presenting with anxiety symptoms. J Neuroimaging. 2011;21(4):375–82

8 Salcedo (2018)

9 Rajkumar (2022)

10 Ibid. 

11 Salcedo (2018)

12 Ibid. 

13 Ibid. 

14 Ibid.

15 Ibid.

16 Choi et al., (2020)

TREATING BODY DYSMORPHIA: THE CASE FOR MORE RESEARCH

When Beauty Is the Beast

January 2019. My workouts get longer and my meals get smaller along with my waist. Subtract twelve pounds but the mirror still shows me a monster. Acne, dark spots, rolls of fat— I am a billboard displaying my worst nightmares. At least that’s what my brain tells me. Everything around me proceeds as normal: boys ask me out, girls ask me how, and everyone calls me beautiful. Why does my brain refuse to see me as I actually am? 

The DSM-5 characterizes body dysmorphic disorder (BDD) as a fixation on perceived imperfections in physical appearance that are insignificant or unnoticeable to others.[1] This occurs as a consequence of abnormal visual processing in the brain that results in an increased focus on minute details and an inability to see the bigger picture.[2] BDD often co-occurs with major depressive disorder (MDD) as well as with suicidal thoughts and tendencies. It is also associated with anxiety, social avoidance, neuroticism, and perfectionism.[3] About 1.7% to 2.9% of the general population is impacted by BDD, which is equivalent to about 1 in 50 people. In the US alone, approximately 5 to 10 million people have this disorder.[4] BDD impacts women more frequently than men— with women comprising roughly 60% of the impacted population.[5] However, BDD still remains quite under-diagnosed and the true prevalence may not be known at present.[6]

Photo credit: Sanjana Bakre

Current Treatments for BDD

The two most common treatments for BDD are cognitive behavioral therapy (CBT) and selective serotonin re-uptake inhibitors (SSRIs). Combining both is the most common method of treatment used today.[7] In terms of alleviating symptoms and how long effects last beyond completion of treatment, CBT appears to be the most effective and lasting treatment available. Continuous use of SSRIs is required to alleviate symptoms in the long run.[8] However, neither treatment has yet been proven to be both effective and permanent.[9]

Cognitive Behavioral Therapy (CBT) for Treating BDD

CBT techniques focus on curbing damaging behaviors and thoughts by helping individuals perceive themselves more holistically beyond small imperfections. This helps alter the abnormal visual processing caused by BDD that involves heightened focus on minute details. As it targets this key mechanism of the disorder, CBT remains the recommended treatment for BDD today.[10] Moreover, CBT encourages patients to face their fears— such as going out in public without concealing their perceived flaws— and ultimately aims to adapt patients’ belief systems to be more flexible and self-accepting.[11]  

Research suggests that CBT is moderately effective in treating BDD, both in terms of improvement and permanence: it has been found to reduce symptoms between 50-78% and last at least 2 months.[12] In a study by Wilhelm et al. (2014), after 24 weeks of CBT, the Yale-Brown Obsessive-Compulsive Scale modified for Body Dysmorphic Disorder (BDD-YBOCS) scores of all participants decreased by 30% or more; this margin that indicates that symptoms had “much improved”.[13,14] In another study by Rosen et al. (1995), after undergoing 8 weeks of CBT, participants scored significantly lower on the Body Dysmorphic Disorder Examination (BDDE); these scores remained constant even 4.5 months after treatment was stopped.[15] These results suggest that the effects of CBT are somewhat lasting, likely due to alterations to the negative belief systems and perceptions that directly reinforce BDD. 

However, there is a lack of research confirming that the positive effects of CBT last beyond 6 months.[16] Longitudinal observation in one study conducted by Krebs et al. (2017) supported the opposite notion: adolescents continued to have significant symptoms of BDD and were still at risk for related, dangerous behaviors a year after CBT was stopped.[17] Therefore, it can be reasonably concluded that CBT is, at best, moderately effective as it does not completely alleviate symptoms and appears to be rather short-term in its effects. Continuous CBT is required in order for BDD patients to remain symptom-free in the long-term.[18]

SSRIs for Treating BDD

SSRIs are antidepressant drugs that alleviate a majority of BDD symptoms by altering neurotransmission in the brain. They have been proven to be the most effective antidepressants for treating BDD.[19] SSRIs prolong the effects of the neurotransmitter serotonin by preventing its re-uptake in synapses, inducing feelings of positivity and relaxation.[20] These are generally prescribed to make BDD patients’ daily lives easier and to make them more receptive to CBT.[21]

SSRIs improve both the symptoms and the mechanisms of BDD, reducing anxiety and compulsive behaviors while also altering perceptions of flaws— as with most medication, it is an effective treatment but there is no scope for continuity of the positive effects after treatment is stopped.[22,23] According to research, SSRIs can result in reductions across all elements of the BDD-YBOCS.[24] Patients who took SSRIs also showed significant improvements in their scores on BDD modification of the Fixity of Beliefs Questionnaire for OCD, suggesting meaningful changes in their beliefs regarding physical appearance. These changes are important as they undermine the very maintenance mechanism of BDD.[25] These alterations likely occur in response to improvements in one’s overall mood as well as a reduction in obsessive thoughts.  However, there is a lack of research observing the long-term effects of SSRI treatment beyond 6 months, let alone what occurs after these medications are stopped. A study by Hollander et al. (2008) has been published on the effects of continuing treatment for 6 months and it was found that 8% relapsed and 60% did not improve further.[26] This highlights that while SSRIs may prevent relapse, it only causes improvements for a short period of time.[27] Overall, SSRIs can be considered extremely effective in alleviating symptoms of BDD; however, this effect is ephemeral so SSRIs must be taken continuously in order be considered a permanent treatment for BDD.[28] While SSRIs are considered fairly safe to take long-term, they also have adverse side effects such as weight gain, gastrointestinal issues, and sexual dysfunction. Additionally, there is a lack of empirical data identifying the impacts of taking these beyond 10 years, let alone indefinitely.[29,30]

The Future of BDD Treatment

Overall, both CBT and SSRIs alleviate symptoms— with SSRIs causing greater improvements— for a few months at least. Although SSRIs can technically continue to prevent symptoms if continuously taken, they don’t necessarily allow patients to remain non-reliant on treatment and their long-term side effects are relatively unknown. It appears as though CBT in conjunction with SSRIs, is the most effective existing treatment. 

Unfortunately, research by Rossell et al. (2017) suggests that these treatments only result in a 50-70% improvement because they do not address new findings regarding other mechanisms of BDD, such as abnormal connectivity between brain structures and correlations with GABA receptors.[31] Additionally, a lacuna in BDD-specific research has made it quite difficult to draw conclusions about the efficacy of existing treatments— there are less than 10 published studies investigating each of these treatments, and none of them explore their long-term effects beyond 6 months.[32] At present, more research into BDD treatment is needed not only to better evaluate the efficacy of current treatments, but also so that these can be further developed and optimized. Further research into the mechanisms of BDD can also potentially aid these efforts by providing more guidance in the development of new treatments. Given that BDD and its co-morbidities can severely interfere with people’s lives, future research efforts to inform and advance BDD treatments are essential. 

Contributed by: Sanjana Bakre

Editor: Jennifer (Ghahari) Smith, Ph.D.

If you think you may be suffering from BDD, please reach out to a licensed mental health professional for guidance/assistance.

REFERENCES

1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

2  Feusner, J. D., Moody, T., Hembacher, E., Townsend, J., Mckinley, M., Moller, H., & Bookheimer, S. (2010). Abnormalities of Visual Processing and Frontostriatal Systems in Body Dysmorphic Disorder. Archives of General Psychiatry, 67(2), 197. https://doi.org/10.1001/archgenpsychiatry.2009.190

3 American Psychiatric Association (2013) 

4 Phillips, K. A. (n.d.). Prevalence of BDD. International OCD Foundation. Retrieved September 28, 2022, from https://bdd.iocdf.org/professionals/prevalence/#:~:text=Body%20Dysmorphic%20Disorder%20affects%201.7,United%20States%20alone%20have%20BDD

5 Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis. 1997 Sep;185(9):570-7. doi: 10.1097/00005053-199709000-00006. PMID: 9307619.

6 Phillips, K. A. (n.d.). Who gets BDD? International OCD Foundation. Retrieved September 28, 2022, from https://bdd.iocdf.org/about-bdd/who-gets/

7 Hollander, E., Allen, A., Kwon, J., Aronowitz, B., Schmeidler, J., Wong, C., & Simeon, D. (1999). Clomipramine vs Desipramine Crossover Trial in Body Dysmorphic Disorder. Archives of General Psychiatry, 56(11), 1033. https://doi.org/10.1001/archpsyc.56.11.1033

8 Phillipou, A., Rossell, S. L., Wilding, H. E., & Castle, D. J. (2016). Randomised controlled trials of psychological & pharmacological treatments for body dysmorphic disorder: A systematic review. Psychiatry Research, 245, 179–185. https://doi.org/10.1016/j.psychres.2016.05.062

9 Beilharz, F., & Rossell, S. L. (2017). Treatment Modifications and Suggestions to Address Visual Abnormalities in Body Dysmorphic Disorder. Journal of Cognitive Psychotherapy, 31(4), 272–284. https://doi.org/10.1891/0889-8391.31.4.272

10 Phillipou et al. (2016)

11 Beilharz et al. (2017)

12 Ibid.

13 Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U., Greenberg, J. L., Fama, J. M., … Steketee, G. (2014). Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial. Behavior Therapy, 45(3), 314–327. https://doi.org/10.1016/j.beth.2013.12.007

14 Phillips, K. A., Hart, A. S., & Menard, W. (2014). Psychometric evaluation of the Yale–Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). Journal of Obsessive-Compulsive and Related Disorders, 3(3), 205–208. https://doi.org/10.1016/j.jocrd.2014.04.004

15 Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63(2), 263–269. https://doi.org/10.1037/0022-006x.63.2.263

16 Harrison, A., Cruz, L. F. D. L., Enander, J., Radua, J., & Mataix-Cols, D. (2016). Cognitive-behavioral therapy for body dysmorphic disorder: A systematic review and meta-analysis of randomized controlled trials. Clinical Psychology Review, 48, 43–51. https://doi.org/10.1016/j.cpr.2016.05.007

17 Krebs, G., Cruz, L. F. D. L., Monzani, B., Bowyer, L., Anson, M., Cadman, J., … Mataix-Cols, D. (2017). Long-Term Outcomes of Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder. Behavior Therapy, 48(4), 462–473. https://doi.org/10.1016/j.beth.2017.01.001

18 Ibid. 

19 Hollander et al. (1999)

20 National Health Service UK. (2021, December 8). Overview - Selective serotonin reuptake inhibitors (SSRIs). NHS UK. Retrieved September 22, 2022, from https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/medicines-and-psychiatry/ssri-antidepressants/overview/#:~:text=It's%20thought%20to%20have%20a,messages%20between%20nearby%20nerve%20cells

21 Greenberg, J. L., Wilhelm, S., Feusner, J., Phillips, K. A., & Szymanski, J. (2019, January 23). How is BDD Treated? International OCD Foundation. https://bdd.iocdf.org/about-bdd/how-is-bdd-treated

22 Phillips, K. A. (2005). The broken mirror: understanding and treating body dysmorphic disorder. Oxford University Press.

23 Phillips, K. A., & Hollander, E. (2008). Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach. Body Image, 5(1), 13–27. https://doi.org/10.1016/j.bodyim.2007.12.003

24 Ibid. 

25 Hollander et al. (1999)

26 Phillips et al. (2008)

27 Jain S, Grant JE, Menard W, Cerasoli S, Phillips KA. A chart-review study of SRI continuation treatment versus discontinuation in body dysmorphic disorder. Abstracts, National Institute of Mental Health NCDEU 44th Annual Meeting; Phoenix, AZ. 2004. p. 231.

28 Phillipou et al. (2016)

29 National Collaborating Centre for Mental Health (UK). Depression in Adults with a Chronic Physical Health Problem: Treatment and Management. Leicester (UK): British Psychological Society (UK); 2010. NICE Clinical Guidelines, No. 91.

30 Peterson A. (2019) New Concerns Emerge About LongTerm Antidepressant Use. Anxiety and Depression Association of America. Retrieved September 28, 2022, from https://adaa.org/sites/default/files/New%20Concerns%20Emerge%20About%20Long-Term%20Antidepressant%20Use.pdf

31 Beilharz et al. (2017)

32 Phillipou et al. (2016)