Recovery-Specific Outcomes- Anger Management

Understanding and managing anger after Viral- Encephalitis

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