Dr Huw Williams, Clinical Psychologist, Oliver Zangwill Centre for Neuropsychological
Rehabilitation
“I just can’t tolerate the kids’ noise, and all the rest of it
at home..”
“I used deal with all kinds of hassle, it didn’t touch me. Now I fly
off the handle.”
“it’s like there’s little warning, a short fuse, and then
an explosion. Over trivial things.”
Overview:
Emotional and behavioural changes are very common following any form of brain injury.
The brain is the seat of all our emotions. It is also the control centre. There
are a number of factors that come together to lead to particular types of emotional
reactions following brain injury.
Brain injury, through encephalitis, may lead to direct emotional and behavioural
changes, or lead to in-direct changes. These reflect a combination of primary brain
damage and secondary psychological reactions to the injury and its consequences.
Primary changes, which may lead to irritability and impulsivity, interact with secondary
reactions, such as frustration, loss of confidence and depression, to lead to chronic
problems in anger control.
Neurological damage:
There may be injuries to parts of the brain directly related to controlling emotions.
Tolerance of frustration and controlling emotion is often affected after brain injury.
The injury itself might affect the parts of the brain that are to do with tolerance
and control (limbic system in the brain stem, and the frontal areas). The frontal
lobes are particularly involved in controlling emotions. As we develop we learn
to over-ride instincts and impulses to do with what we “want” and learn
ways of coping with not having something happen, or happen later. Also we learn
to initiate behaviour, to plan and organise and carry out actions so that we meet
our needs. Such as to have something pleasant happen. For some people following
brain injury, when these complex neuro-mechanisms are damaged, as there may well
be with encephalitis, the survivor may well have difficulties in inhibiting
behaviour. They may be particularly prone to saying and doing things which may appear
insensitive or irritable. Often there may be difficulties in initiating an planning
behaviour.
Previous personality:
The survivor of brain injury may become a more exaggerated type of person she/he
was before the trauma. If, as in frontal damage, the kinds of controls (brakes)
that held aspects of the person’s tendencies in check are affected, then the
person may be more exaggerated in her/his behaviour. A person who was prone to acting
impulsively and without thinking, may become more exaggerated in this tendency.
Conversely, a person may suffer a change of personality. Someone who was calm and
“laid back” may become the opposite.
Stress of adjustment:
The general stress of managing one’s life, particularly after so much change,
may be very influential on a person’s mood, and in particular, on their ability
to handle their feelings of anger. Experiencing memory problems, having difficulties
holding down a job and general changes in social roles may each contribute to frustration.
Indeed, there are a myriad of possible frustration and sources of upheaval and stress.
Often its the “little” things that trigger major reactions. This is usually
because those little things are major reminders of what one used to be able to do
without a problem (forget an appointment, mislay a key) and hence the loss.
In some forms encephalitis, the person may have such extensive memory impairments
they may not to be able to recall what is happening around them or why. They may
be perplexed by the world, and others, being so incoherent.
Environment:
The types of social environment (family, friends, neighbours and professional staff)
and physical environments can affect a survivor’s mood. Being away from
loved ones and affection, being with people who do not understand their needs,
or, equally, being with people who might not be able to hold back from doing things
for them. There is often a difficult balance to keep between enabling the person
to feel supported or over-protected. The person may react negatively as a result
of needs not being met, and therefore the behaviour, of being angry, may be seen
as a way of communicating this frustration, or un-met need. This may be particularly
important to consider when the person’s ability to communicate through other
means (due to language, attention or memory problems) is compromised.
Managing anger and irritability
A number of approaches may be taken to support people with anger control difficulties.
It is important to assess what the main factors are that affect a person’s
anger reactions. It is very important for the person’s behaviour to be assessed
from an understanding of their cognitive difficulties. A systematic assessment
of a person’s anger issues would best be undertaken through a referral to
a Neuropsychologist at the person’s local Clinical Psychology department and/or
their Neurological rehabilitation or physical disability teams. If medication
is an issue to be addressed, referral would need to be made to a Neuropsychiatrist
or Psychiatrist.
It may be that with management of attention and memory problems (such as through
environmental cues to ensure they have prompts to orientate them) that frustration
could be lessened. Often the behaviour has a “message value”, and
it will be possible to predict when it may happen. If this is the case then it could
be possible to enable the person to communicate their need in another way.
The person may be helped to develop such appropriate behaviours by developing
routines to manage the anger. The following ANGER control routine may be used.
- A Anticipate situations that trigger anger.
Record where, when, why, with whom it happens.
- N Notice signs of anger building - early tell-tale
signs (irritation, muscle tightening, breathing more heavily....and try to stop
it there)
- G Go through a temper routine. Deep breaths,
calming statements, drop shoulders and relax muscles etc.
- E Extract yourself from the situation. Have
places to go to or something to do that will distract and relax (burn off the adrenaline,
the anger fuel).
- R
Record how you coped, note how changing.
The person may be encouraged to develop such skills as relaxation thorough modelling
of these skills and prompting by another. Cue cards may be helpful or reinforce
what is needed. A chart to show change in behaviour may help reinforce change.
If there are immediate concerns over the safety of the person or any other person
contact should be made with the person’s General Practitioner for advice.
For more information on Charterered Clinical Psychologists in your area visit the
British Psychological Society web site at:
www.bps.org.uk
Or telephone the BPS on 0116 254 9568 and ask for information on your nearest library
which contains a directory of Clinical Psychologists
Last modified: January 2005