Please check out the following website for a wonderful YouTube video on Living with a TBI. http://www.youtube.com/watch?v=FgtHvBF4t-E
Please check back for a more reader-friendly, basic description of the information on this page.
Over- emotional (expression) --> aggression, depression, lability, inappropriate behavior
Under-emotional (expression) --> flat affect, flat personality (no enjoyment)
Problems feeling/experiencing emotions --> problems knowing how to behave; problems with decision making; unaffected by consequences
Problems identifying their emotions --> confusion; don't know how to act
Problems expressing emotions (verbally and nonverbally) --> flat affect; trouble communicating feelings and needs
Problems identifying others' emotions --> misunderstand people; inappropriate behavior; does not respond to others's needs (unable to show empathy)
Since various areas of the brain are important for different emotional processes (generating, feeling, conceptualizing, and controlling emotions) it only makes sense that an injury to the brain could have a fairly significant impact on one or more aspects of emotional processing. It is not uncommon that people with brain injury have emotional problems. People with brain injury often experience many behavioral problems, and consequently have very poor social outcomes. It is plausible that many of the behavioral problems have to do with impairments of processing and understanding their own and others' emotions. Some people with brain injury have been found to be overly emotional and cannot seem to control their emotions. They can easily fly off the handle at anything. This is probably because the part of the brain that controls emotions (most likely the left ventromedial prefrontal cortex) is damaged. It is the area of the brain that helps us to reason through our emotions and the consequences of our actions. It helps to control the impulsive actions that are often stirred by our primitive limbic system (automatic reaction to emotional stimuli and events). Others seem to be under-emotional, and appear to be unaffected by anything (flat). Nothing excites them, nothing upsets them. This is usually the result of damage to the right hemisphere, cingulate cortex, limbic system, or areas that are involved in arousal. Other people with brain injury could have difficulty recognizing their own emotions. This could be because they aren't feeling any physiological changes in the body either because those changes didn't happen, or because the part of the brain that processes these feelings is damaged (somatosensory cortex). It could also be because the have damage to the part of the brain that helps them to understand those emotions and relate them to similar situations (ventral medial prefrontal cortex). People with brain injury may also have problems recognizing how others are feeling, usually due to an impairment in recognizing nonverbal cues of emotions (facial expressions, vocal expressions, gestures, postures) or being able to infer emotions from the context of a situation. When they can't tell how someone is feeling, they don't know how to act, or act inappropriately. They often perceive others to be uncaring, indifferent, or confused. Others will misread people and assume that person is angry when if fact they are not. Consequently, they (person with injury) begin to get defensive and start acting out. This behavior (acting out) will then cause the other person to really become angry as they don't know or understand why the person with the injury is overreacting about. This can create tremendous relationship problems.
Written by Dawn Neumann, Barry Willer, and Barbra Zupan
The ability to identify emotions in others is considered to be essential for the engagement of successful social interactions1,2. Studies have demonstrated that persons who have endured a traumatic brain injury (TBI) have more difficulty recognizing emotions in others when compared to their uninjured counterparts3-15. Although the prevalence of this deficit in TBI has not yet been tracked, it appears to be a very relevant concern. First, the aforementioned studies compared representative samples of persons with TBI to healthy persons. The fact that these studies found representative groups of persons with TBI to be impaired at determining affect, suggests that emotion recognition must be a relatively common problem for persons with TBI. Furthermore, informal reports from Milders et al., and Segalowitz et al. calculated between 50 to 66% of their participants with TBI to perform at least one standard deviation below the norm on standardized tests of facial affect recognition. These findings are not unsurprising given that the neuroanatomical structures involved in emotion recognition are considered to be very susceptible to damage when a TBI occurs16. These structures include areas within the prefrontal, parietal, and temporal lobes as well as the amygdala, anterior and posterior cingulate, ventral striatum, insula and other structures and connections to and within the limbic system17-21.
There are several different types of social cues that we could used to identify how someone is feeling. One process involves attending to nonverbal cues of affect such as facial expressions, voice (pitch, loudness, tempo and pause) and postures22. Another method involves making an inference about how someone would feel given the circumstances and social context. People with TBI are often impaired at using nonverbal cues and social inferencing to recognize emotions in others and this is a significant concern.
Studies have demonstrated that persons with TBI, as a group, have more difficulty than their healthy peers at using facial expressions to recognize emotion3-15,23. Impaired facial affect recognition is problematic since facial expression is a primary means of communicating emotion among humans5. Consequently, limitations in determining facial affect can severely limit one’s ability to interpret how others are feeling all together. It has been suggested that a decreased ability to read nonverbal cues of affect may result in inappropriate behaviors24 and have a negative impact on social relationships25. A study by Milders and colleagues found poor social outcomes for a group of participants with TBI who also had impaired affect recogntion10. They showed that persons with TBI not only had difficulty recognizing facial and vocal expressions of emotion, but also had significantly decreased social integration and negative changes in social behavior since their injury. However, they did not investigate whether these two outcomes were correlated. Other studies have frequently demonstrated that the social outcomes for many persons with TBI are often very grim26-32. While there may be many reasons why a person with TBI might have poor social behavior and outcomes, studies suggest that poor facial affect recognition may be an important contributory factor24,25.
Several studies have also indicated that persons with TBI have difficulty making social inferences to determine how others are feeling7,33. These studies demonstrated that persons with TBI were generally impaired at determining characters’ feelings, thoughts, and intentions even when they had the necessary contextual information. This impairment may also present many challenges for persons with the TBI, since there are various circumstances when nonverbal cues are limited (e.g., during a phone conversation), unavailable (e.g. person trying to hide how they feel) or incorrect (sarcasm). In these circumstances, a person must rely solely on correctly comprehending the context under which the emotion is occurring. Making inferences based on context involves a complicated set of cognitive tasks. For instance, events such as being fired from a job are typically associated with a specific emotion (anger). Nevertheless, to form correct assumptions about someone’s emotional reaction, additional information is required. Wierzbicka 34 suggests that we need to know the person’s wants and beliefs regarding the situation or event in order to correctly infer emotion. For example, if the person who was fired wanted to leave his job he might be happy rather than angry.
Despite the findings that many persons with TBI are impaired at identifying emotions, only one study has been published that looked at training to improve facial affect recognition in this population (Guerico). Unfortunately, this study was methodologically flawed in that they trained their three participants with the same faces that were used for testing. Consequently, one could not conclude that the participants in that study learned how to recognize facial affect, only that they learned to associate specific emotions to specific faces. Despite the fact that this area of research is so understudied, the need for this type of research has not gone unnoticed. Several researchers have stressed the importance of identifying techniques that are capable of enhancing affect recognition and social skills in persons with TBI6,8.
The Brain Injury Association of America has reported that annually, 1.5 million Americans sustain a TBI. It has further been approximated that 5.3 million Americans have incurred disabilities that result from a TBI. According to the Brain Injury Association of America Board of Directors, TBI is defined as “an insult to the brain, not of a degenerative or congenital nature but caused by an external physical force, that may produce a diminished or altered state of consciousness, which results in an impairment of cognitive abilities or physical functioning. It can also result in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.”35 Given this definition, a TBI is defined by how someone incurs damage to the brain. TBI’s are typically acquired via motor vehicle accidents (MVA’s), falls, and physical assaults including blunt trauma or gunshot wounds to the head. They do not include stroke, tumors, anoxia or hypoxia, toxins or meningitis. Depending on how the damage occurs, it may be classified as a “penetration” or “diffuse axonal injury” (DAI). A penetration injury occurs when an object pierces the brain, which tends to cause damage that is more localized to a particular structure, relative to diffuse axonal injuries.35 A DAI is when nerve tissues in the brain are torn due to the brain hitting against the skull. DAI injuries are often the result of a MVA and generally cause more global damage.35 Depending on the areas damaged, both penetration and diffuse axonal injuries may lead to impaired affect recognition.
TBI: Identifying Affect from Nonverbal Communication
There are numerous studies demonstrating that persons with TBI have significantly more difficulty recognizing nonverbal cues of affect than their uninjured counterparts[3-13,15,23].
Facial Affect Recognition
Green, Turner and Thompson, found that people with TBI were impaired at identifying and discriminating emotions from pictures of faces when compared to uninjured participants. These researchers first asked participants to select the emotional label that best described the facial expressions presented. Participants were then asked to determine if two faces portrayed the ‘same’ or ‘different’ emotion. The results demonstrated that participants with TBI were significantly impaired on both tasks. The subjects with brain injury not only had a problem identifying the emotion expressed, but also had difficulty perceiving the similarities and differences when comparing emotional states. Their inability to determine similar versus different emotional expressions suggest that people with TBI had trouble interpreting the emotional implication of the different facial characteristics.
Several studies have suggested that impaired facial affect recognition centers on the ability to differentiate negative emotions. These studies show that identifying negative facial expressions is a more difficult task for people with TBI than recognizing positive emotions[4,5,36]. Hopkins et al. had participants with and without TBI identify affect from faces and found that the individuals with TBI were impaired at recognizing negative emotions such as sadness, anger and fear. Both groups were equally successful at recognizing positive emotions. Similar findings in regard to negative emotions were reported by Jackson and Moffat. Jackson and Moffat5 investigated the ability of persons with and without closed head injuries (CHI) to recognize emotions from photographs depicting a variety of facial expressions. They assessed participants’ ability to identify the following emotions: happiness, disgust, pensiveness, anger, fear, sadness, surprise, self-satisfied, bored and neutral. The results demonstrated that persons with CHI were significantly impaired at recognizing the emotions of disgust, anger, and boredom compared to controls. Hopkins et al. also found that participants with TBI had decreased electrodermal activity compared to controls when viewing faces with negative emotions. This suggests that people with TBI do not process negative facial expressions in the same way that people without TBI do.
One factor that distinguishes affect recognition for people with TBI and those without is the difference in their ability to identify obvious emotional expressions. Spell and Frank demonstrated that people with TBI were not able to recognize emotions from obvious facial expressions as accurately as their uninjured counterparts. In this research individuals with TBI and matched controls were asked to determine emotions from both subtle and obvious facial expressions. The group with TBI had significantly more difficulty recognizing obvious emotions than the control group. This distinction was not noted for subtle expressions of emotion.
Vocal Affect Recognition
Studies by Marquardt et al.6, Spell and Frank8 and Milders et al.10also found that in addition to impaired facial affect, many participants with TBI also had significant difficulty recognizing emotions from vocal expressions. In these studies, persons with and without TBI were presented with vocal expressions and asked to identify the emotion being conveyed. Compared to their uninjured counterparts, persons with TBI were notably impaired at determining emotions from the vocal expressions. Furthermore, Marquardt et al. demonstrated that persons with TBI not only had difficulty identifying vocal expressions of emotion, but were also impaired at mimicking/or expressing those emotions. In order to test this, they had participants repeat a sentence with the same emotion portrayed by an instructor. The results indicated that persons with TBI were only 79% accurate at imitating a vocal emotion, compared to 100% accuracy for controls. Not all people with facial affect recognition impairments have impaired vocal affect recognition and vice versa (ref). However, there appears to be a link between the two, as demonstrated by Hornak and colleagues (ref). According to Hornak et al., common neuroanatomical structures, such as the ventral medial prefrontal cortex are utilized when determining emotion from both facial and vocal expressions. Therefore, it is worth noting both deficits and exploring any possible connections between both types of affect recognition. More detail on this matter will be discussed in the theory and neuroanatomical sections.
Affect Recognition from Facial or Vocal Expression versus Linguistic Content
Researchers have demonstrated that when contradictory multiple cues of emotion are presented, persons with TBI judged emotions based on the explicit content of a sentence, rather than inferring emotions from facial or vocal expressions6. In this study, Marquardt and colleagues6 presented participants with emotionally laden sentences that were accompanied with facial and vocal cues. The facial and vocal intonations were either congruent or incongruent with the emotional content of the sentence. In the congruent conditions, the intonation and facial expression were consistent with the content of the sentence. In contrast, the incongruent condition presented an intonation and facial expression that were not consistent with the sentence content. For each condition, participants were asked to identify the emotion. The results demonstrated that in the incongruous condition, participants with TBI more frequently identified emotion based on the content of the sentence and not the tone or facial expression, compared to controls. This suggests that persons with TBI use explicit content to determine emotion, rather than nonverbal cues of emotion. This has significant implications since people often say things they do not mean, especially when using sarcasm.
Affect Recognition and Dynamic, Multiple Nonverbal Cues
Some studies demonstrate that impaired affect recognition in people with TBI is not just limited to static photos or isolated information. Researchers have found that there is a relationship in the ability to recognize static versus dynamic expressions of emotion. Consequently, emotion recognition for people with TBI has also been found to be affected when viewing dynamic stimuli[7,9,38]. Turkstra, McDonald, and DePompei had adolescents with and without TBI identify emotions expressed by actors on videotape. The actors in the videotape used several nonverbal cues including facial expressions to portray different emotions. The authors found that relative to their uninjured peers, adolescents with TBI had significant deficits in interpreting the emotions played out by the actors. Similar to Turkstra and colleagues9, McDonald and Flanagan7 were interested in the ability of participants with TBI “to interpret the mental state of others” (p.574). This skill is often referred to as theory of mind (ToM). They used The Awareness of Social Inference Test (TASIT) to measure ToM in persons with and without TBI. One of the subtests of TASIT, the Emotional Evaluation Test (EET), tests the ability to infer what others feel (ie. judge emotions). Participants with TBI were impaired at identifying all emotions on the EET portion of the TASIT. These findings are important because the dynamic stimuli portrayed in the videos are more similar to what people observe in everyday interactions.
Affect Recognition and Behavior
Research by Milders et al. provides a link between emotion recognition and a person’s behavior. They measured the ability of persons with TBI to identify facial and vocal affect, in addition to assessing their social behavior. Although the authors did not test if there was a direct relationship, they found that many of the persons with TBI who were impaired at identifying facial and vocal expressions of emotions, also had increased behavioral problems after their injury. These behavioral problems included depression, interpreting gestures, inappropriateness and indifference.
TBI: Using Social Context to Infer Emotions
Another source of information by which emotions are inferred is through social context39. Social context can help lead a person to an accurate interpretation of the situation through the use of inferencing, particularly when facial affect cues are absent or subtle. Understanding a social situation and how that interacts with one’s beliefs is vital for determining the emotion someone would feel in a given situation40,41. This is especially so for people with TBI, who may have difficulty interpreting facial expressions and therefore would rely on other cues to determine an emotion. This idea is supported by Marquardt and colleagues6 who found that people with TBI are more likely to judge emotions based on the explicit content of a sentence rather than the facial expressions or vocal intonations that accompany them. As stated earlier, when there is inconsistency between the content of a sentence and the manner in which the sentence is delivered and/or the accompanied facial expression, individuals with TBI relied on the explicit content. In conclusion, they attributed more importance to information explicitly stated than they do to a person’s facial or vocal expression when determining emotions.
Using only explicit information to determine how someone is feeling can lead to errors, especially in the case of sarcasm. Inconsistency between explicit information and social context, facial, and vocal expressions describes exactly what happens when sarcasm is being used. When someone sarcastically says, “Thanks for your help”, the statement will probably be accompanied by a facial and vocal expression that implies that the person is not really grateful. If only explicit information (“Thanks for your help”) is used to determine meaning in this situation, one will conclude that the person is really is grateful. This interpretation would lead a person to incorrectly conclude that the person is also happy. A study by Channon et al.42 demonstrated that persons with TBI had trouble inferring a person’s intended meaning from sarcastic comments. They presented participants with scenarios depicting a social context that was followed immediately by either a sincere or sarcastic comment from one of the characters in the scenario. The authors found that participants with TBI had difficulty interpreting sarcastic comments in comparison to control participants. Since sarcasm requires the use of inference in social contexts, this study suggests that individuals with TBI have difficulty using social context to infer the indirect meaning of a comment. Instead, individuals with TBI focus on the literal meanings of the words and sentences43.
It is probable that participants’ with TBI have difficulty interpreting sarcasm because of their inability to use implicit information to determine emotions. Nonverbal cues such as facial or vocal expressions or the context of the situation are implicit pieces of information requiring a person to infer how someone is feeling. Ferstl and colleagues44 studied reading comprehension in persons with brain injury when they were presented with stories composed of implicit and explicit information about emotions. They determined that participants with brain injury had difficulty making inferences from implicit information. They compared three groups of patients according to localization of the lesion to age-matched controls. The groups included stroke patients with right hemisphere brain damage, stroke patients with left hemisphere brain damage and patients with TBI (diffuse damage). Patients with damage to the right hemisphere and those with diffuse TBI were found to have significant difficulty understanding implicit information. They had no difficulty comprehending explicit details. These results suggest that people with TBI had difficulty making inferences and therefore difficulty with everyday discourse. In a related study, Ferstl et al45 demonstrated that the ventromedial prefrontal cortex is activated while reading simple stories depicting emotional content. Given the susceptibility of this area of the prefrontal cortex during a TBI, one would expect that individuals with TBI will have significant difficulty inferring emotions based on contextual clues.
As discussed earlier, McDonald and Flanagan7 also tested the ability of persons with and without TBI to make social inferences. They used The Awareness of Social Inference Test (TASIT) to assess participants’ ability to infer the feelings, thoughts, and intentions of characters under a variety of circumstances. It was concluded that participants with TBI had difficulty interpreting contextual cues in order to infer emotions and understand people’s beliefs and intentions. Consequently, these participants were not able to apply explicit contextual information, or infer implicit information about a situation to determine peoples’ feelings and beliefs.
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