Behavioural effects

Brain injury can have a profound impact on how you feel (emotions) and act (behaviour). It helps to understand how your behaviours may have changed and how to manage those changes.

Topics in this section include:

Aggression, anger & frustration

Aggression
In the acute stage of recovery after a brain injury, a person may display uncharacteristic aggressive behaviour if they are scared, frustrated, or confused. This usually happens when the injured person is not yet consistently aware of their situation (the injury and its consequences) and surroundings (where they are, what day or month it is, etc.). Aggression can show itself in a variety of ways, including:

  • Damaging or destroying objects
  • Excessive swearing
  • Threatening harm to others
  • Inability to self-monitor
  • Verbal, physical attacks

Episodes of aggression often come on very quickly and tend to pass within minutes. Aggression is upsetting for both the person exhibiting it and the caregivers or family members who witness it. Some aggressive behaviours can be risky to a person’s safety. That’s why it’s important to take steps to manage it.

  • Ask caregivers or healthcare workers to explain what they are doing before they do it
  • Identify and eliminate/reduce aggression triggers (when possible)
  • Keep the amount of stimulation in the room (e.g., light and noise) low
  • Redirect to calming activities or go to a quiet place if you are feeling confused, angry or scared
  • Use calming tactics such as deep breathing or meditation

If you are the person experiencing the aggression, you may have a limited ability to calm down, so help from others is necessary to prevent and de-escalate aggression. If your episodes of aggression continue or cause others to feel unsafe, you should consult a behavioural therapist.

Anger
It is common for people living with brain injury to get frustrated, angry or irritated more often or more quickly. This can lead to yelling, cursing, threats, destruction of property and physical outbursts.

These episodes of anger or an increase in irritability can be triggered by:

  • Confusion
  • Frustration with a task that is harder than it used to be
  • Fatigue
  • Misunderstanding another person’s intentions
  • People telling you what to do or pointing out mistakes
  • Too much stimulation (e.g., light, noise, and movement)

If you’re experiencing periods of anger or irritability, try some of the following coping methods.

  • Engage in calming activities – listening to music or reading are some examples
  • Practice deep breathing
  • Remove yourself from the situation and go to a more calming location
  • Work with a doctor who is familiar with acquired brain injury and emotions on some self-calming methods and communication strategies – being able to communicate what you’re feeling to others can be extremely helpful when it comes to emotional situations. Cognitive behaviour therapy can provide support and tools to help manage anger/aggression and understand why you have these reactions.
Frustration
It’s normal to feel frustration after a brain injury, and that frustration will come and go throughout recovery. Frustration will be caused by different things for different people. For example, it can come from not being able to complete a task or being annoyed with other people or self-criticizing. When someone is frustrated, they may give up on tasks, avoid things because they are too hard, or have emotional outbursts.

If you experience frustration, ways you can cope with it include:

  • Celebrate your success, especially if you complete a task that used to frustrate you
  • Do challenging tasks for only short periods at a time or with scheduled breaks.
  • Have a quiet place to go when you’re feeling frustrated.
  • Identifying what makes you frustrated. While you may not be able to entirely avoid being frustrated, understanding what causes you to feel that way is the first step in learning to cope with it
  • Take slow, deep breaths to help calm yourself

Anxiety

Anxiety stems from feelings of worry and fear. After a brain injury, people commonly worry about recovery being too slow, getting back to school or work, not having enough money, and relationship difficulties. Anxiety may lead to unhelpful behaviours, such as avoiding places or situations, re-checking things excessively, and asking the same questions over and over. Anxiety can also lead to panic attacks. Panic attacks (sudden, intense fear and physical sensations like rapid heart rate, shallow breathing, and sweating) – can be brought on by overwhelming situations or emotions, a person’s thought process, or by upcoming events/appointments. Some ways to cope with anxiety include:

  • Developing routines that are clear and able to be used repeatedly
  • Medications
  • Participate in counselling geared toward anxiety (e.g. cognitive behavioural therapy and mindfulness)
  • Practice slow, mindful breathing
  • Redirect yourself to a familiar place or activity that makes you feel safe and calm
  • Schedule “worry appointments” so that you can contain your worry to a time and place of your choice (e.g., after breakfast) rather than having worries pop into your mind when you are trying to do other things

It’s important to be patient and kind to yourself. Anxiety is deeply personal and emotional.

Some worry after brain injury is normal. When it becomes difficult to control and interferes with your sleep and daily activities or relationships, mental health treatment (e.g., cognitive-behavioural therapy) may be necessary.

Denial

Brain injury comes with a wide variety of changes and people often can’t do the things they would normally do. This can be incredibly difficult to cope with: as a result, people begin experiencing denial. They don’t recognize how serious their injury was and how it continues to impact them. A brain injury can also impair a person’s ability to monitor and judge their own performance. They may become angry or frustrated, place their blame for their challenges on someone else, or engage in risky actions to ‘prove’ that they haven’t been affected.

You probably won’t recognize denial in yourself – at least right away. It may be helpful for you to speak with a caregiver or therapist about your current feelings and concerns. They can offer emotional support and practical advice on coping with the changes you are experiencing and how to move past denial into acceptance.

Depression

Depression is a complex health condition involving a person’s thinking, emotions, and behaviour. Depression is linked to grief. Many people with depression may feel sad much of the time, lose interest in usual activities, withdraw from others, have a negative outlook on life, and experience changes in energy, sleep, and appetite. It’s important to understand the impact of depression, and how to cope with it. Depression may not only be psychological – brain injury can alter the brain’s structure, so depression can also be biological. The challenge of dealing with emotional and behavioural changes like depression require as much commitment in recovery as working on cognitive and motor skills.

When symptoms of depression continue for weeks or longer, mental health treatment may be necessary.

Disinhibition/impulsivity

Impulse control/inhibition is the ability to think through actions and speech. When someone is experiencing disinhibition or impulsivity after a brain injury, they may:

  • Be easily irritated
  • Buy things they don’t need or can’t afford
  • Do risky, dangerous things
  • Have mood swings
  • Ignore social and safety rules
  • Make inappropriate remarks
  • Not be able to think things through
  • Speak impulsively

If you’re struggling with impulse control and disinhibition, there are ways to cope with these challenges.

Ask someone for assistance
Impulse control includes elements of decision-making, and you don’t have to make every decision on your own. You can ask someone to listen to your thought process out loud. You can also ask for recommendations about how to act or respond to a situation.
Develop a process for decision-making
Having a decision-making process can help prevent impulsive, risky behaviour and ensure that you consider all factors that go into the decision. This includes:

  • Your decision options
  • How your decision could affect others
  • How your decision could affect yourself
  • Write out the pros and cons of each option
  • Ask for advice
  • Share your decision with someone you trust before you act on it
Practice before social interactions
If you have plans with other people and are worried about social interactions, practicing with a caregiver or family member beforehand is a great way to build your confidence, identify possible areas to make improvements, and revisit your decision-making process.
Use verbal and visual cues
Caregivers, friends, or family members can help you identify when you need to check in with yourself and self-moderate your behaviour using verbal and visual cues.

Grief

Grief is an emotion that has a direct impact on how a person behaves. Someone experiencing grief after a brain injury may engage in risky behaviours or have angry/aggressive/emotional outbursts either alone or directed at others.

It’s normal to experience grief after a brain injury, but it’s important to understand how grief works and how to manage it so that your behaviours don’t put you or your loved ones at risk.

Obsessiveness

Obsessiveness is when someone becomes ultra-focused on an object, a task, or even something someone said. They can’t think about anything else, may become incredibly stubborn, or do something over and over again. This can be made worse by anxiety or by injury to the parts of the brain that enables a person to shift the focus of attention. It can make it harder to solve problems and maintain relationships.

Obsessiveness can be caused by a variety of things and can be managed with the right supports.

  • Identify what causes the obsessive behaviour, and eliminate the cause if possible
  • Ask for help in identifying when you’re being obsessive
  • Give yourself a break – it’s normal to experience these challenges
  • Speak with a therapist

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a mental health disorder that occurs in people who have suffered a traumatic event. It’s common in individuals that have experienced assault, accident survivors, and people in the military. Behavioural symptoms of post-traumatic stress disorder include:

  • Anxiety
  • Increase in negative thoughts, feelings, and beliefs stemming from the trauma
  • Disassociation – losing touch with the present and feeling like you are experiencing the trauma again
  • Avoidance of certain situations that may recall (trigger) the trauma
  • Feeling on guard all the time
  • Sleep problems

Not every person who suffers a traumatic brain injury will have post-traumatic stress disorder. Additionally, not everyone with post-traumatic stress disorder will have had a brain injury. Only a licensed professional like a psychologist or psychiatrist can diagnose post-traumatic stress disorder.

Self-image loss

Brain injuries not only change a person’s abilities; they affect identity (e.g., “Who am I now?”) and self-image because of the physical, cognitive, emotional and mental impacts. Someone with a brain injury may only focus on their limitations and fail to see their positive qualities. The emotions related to these changes can lead to behaviours such as withdrawal, avoidance or choosing not to take actions, and a lack of motivation to do anything – including work on rehabilitation and recovery.

It can be difficult to recognize that you’re experiencing self-image loss. You may recognize it but find it difficult to break the cycle of focusing on what you have lost. But it’s important to work towards acceptance of your new  normal. It can be helpful to ask a caregiver to work with you to provide positive reinforcement. You can also:

  • Celebrate your successes
  • Figure out how you can get back to doing activities that were important to you, in a different way if necessary
  • Give yourself a break. It’s normal to feel loss, and it’s important to let yourself process it
  • Identify the ways that you have NOT changed
  • Keep a positivity journal: at the end of the day (or as they happen), write down the good things that happened to you

Sexually inappropriate behaviour

An uncommon behavioural effect of brain injury can be sexually inappropriate behaviour. This includes making inappropriate comments about themselves or someone else, inappropriate actions (such as touching), and exhibitionism, which is the act of displaying genitals in public places or to people without their consent. This behaviour can also include masturbation at inappropriate times or in inappropriate places.

It’s difficult for people with a brain injury to recognize that they are being sexually inappropriate. They may think their behaviour is normal. It’s important to work with a healthcare professional or a caregiver to identify what is appropriate. Examples include:

  • Writing down what’s appropriate to say or do in social situations
  • Setting clear boundaries of where masturbation is acceptable (in the bedroom, with the door closed)

If you have questions about sexual behaviour or sexual health, these should be shared with a caregiver or healthcare professional. It’s important to share your questions and have open, honest discussions about what you’re feeling/experiencing.

Social dysfunction

Socializing after a brain injury can be difficult due to several factors, including how the person with a brain injury behaves. It’s common for people living with acquired brain injury to:

  • Have trouble keeping up in group conversations
  • Lack awareness regarding how others feel emotionally
  • Make inappropriate comments
  • Misinterpret social cues such as facial expressions
  • Mistake sarcasm for literal statements
  • Show aggression and frustration

Trouble socializing can lead to social isolation, anxiety and depression. Socialization is incredibly important for mental health, so it’s important to understand what is involved in being social after a brain injury.

See sources
Information for this section sourced in part from the Ontario Brain Injury Association (Brain Basics), Headway, and Synapse