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 breathes 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

Emotional effects

When the brain is injured, a person’s emotional processing and responses can change. Major life changes and stressors associated with brain injury can add to emotional difficulties. You may experience less emotion or more intense emotions. You may feel and act in ways that are out of character for you. For example, a person who was mostly calm and cheerful before an injury may get angry more easily after the injury.

Like with all parts of brain injury recovery, it takes time to learn how your emotions are affected and what you can do to manage them.

Topics in this section include:


 Changes in emotions

Anger/irritability
It is common for people living with brain injury to get frustrated, angry or irritated more often or more quickly. They may even become aggressive. This can lead to yelling, cursing, and physical outbursts. This is often distressing both for the survivor and their loved ones.

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.
Anxiety
Anxiety is a common emotion related to your mental health. It 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.

Depression
Depression is common after a brain injury. Adjusting to your new self and your experiences is difficult and can result in decreased motivation and feelings of sadness, loneliness, and even despair. When these feelings last for weeks or longer, a person may be diagnosed as having Major Depressive disorder, a health condition that requires treatment.

Emotional control
A lack of emotional control means you speak or do something before thinking it through, reacting solely based on your emotions. You don’t consider the outcome/consequences of what you say or do. You may also do risky or dangerous things. Emotional control and behavioural (or impulse) control are closely linked because they are both managed by the same brain systems.

If you have a decision to make, even a simple one, give yourself a reminder to stop, think, and ask if you really want to do or say something. You can also ask someone to be your safety net – ask them about what you want to do and listen to their advice.

Mood swings
Mood swings – also called emotional lability – are when you go from one emotion to another quickly, often for short periods of time. It can also mean you experience emotional outbursts – for example, laughing or crying a lot even if you don’t feel very happy or sad.

Mood swings are common when the parts of the brain that control emotion are injured. Sometimes there is an obvious reason why your emotions suddenly change. At other times there is no specific event that causes a change in mood: it appears random to other people. Mood swings can also be unrelated to a situation or the way you feel. This can be confusing.

In general, these mood swings are outside a person’s control. It’s important not to be hard on yourself. Mood swings happen. Instead, celebrate the times you feel calm and in control. Other ways to cope with mood swings include:

  • Calming activities
  • Deep breathing
  • Distract yourself from the thing that is making you laugh or cry more than you want to
  • Speaking with your doctor – they may be able to help with mood stabilizing medications and tools. If you do take medication, remember that it may not work right away and you will need to work closely with your doctor to find the right medication and dosage

You can ask a caregiver or family member to help you with calming strategies like deep breathing, exercises or calming activities. Over time, many people find that their mood swings happen less and less as their emotions balance out and they use coping methods to help.

Personality changes
Personality changes can come from both emotional and behavioural changes. Personality traits may become exaggerated or more intense after a brain injury. For example, a quiet person may become even quieter; an assertive, active person may become aggressive and outspoken. The opposite can happen too, where a normally quiet person becomes very outgoing or outspoken.

These changes can happen with all brain injuries. While some people find that their emotions and personality changes fade as they recover, some changes may be permanent.

I’m feeling upset over my brain injury – how do I cope with my new reality?

It’s normal to feel upset, angry, and sad about your brain injury. It’s also easy to get swept up in your grief over what has changed. It’s important to let yourself feel grief – but don’t dwell on it. Instead, do your best to focus on the improvements you’re making, things you’re looking forward to, and things that make you happy. Try breaking your goals down into smaller pieces – you’ll more easily be able to see your progress.

It’s going to take a long time, and some days will be better than others. If you are having difficulties, make sure to share them with your family, caregivers, and doctors.

Identifying and managing emotional changes

Working with a cognitive behavioural therapist (CBT)
One of the most effective ways to manage the emotional effects of brain injury is to work with your healthcare team. Cognitive behavioural therapists develop a personalized program that will address your areas of need. This includes coping with emotional challenges. Cognitive behavioural therapy is goal-oriented, meaning you have specific things you want to achieve, and you actively participate to reach those goals. These plans can adapt over time as new goals are set, but in general cognitive behavioural therapy is meant to be a short-term treatment that teaches you the skills you need to cope with cognitive, emotional, and behavioural changes.

If not available at your local rehabilitation hospital or mental health clinic, this kind of service may have a fee. While cognitive behavioural therapy may be covered under some insurance plans, this can be an out-of-pocket expense.

Psychiatrists and psychologists specialize in talk therapy and mental health, which can have a huge impact on emotions. The main difference between them is that psychiatrists have medical degrees rather than primarily academic degrees and can prescribe medication. Working with either a psychiatrist or a psychologist can help you share your feelings, access feedback, and understand the relationship between mental state and emotions.

Deep breathing
If you’re feeling overwhelmed, pausing and taking deep breaths is a good tool to help you focus. This is something your caregiver or family member can help you with by talking you through it. Deep breathing sounds relatively simple but there’s a lot more to it than just “in and out.” There are additional steps you can take to bring more mindfulness to the exercise.

Take a rest break
When we’re tired, we tend to get more emotional. After a brain injury, many people experience fatigue. Make sure you take all the time you need to rest or have some alone time.
Remove stressors
Are there things in your house or in your life that are stressing you out? If so, try to find ways to remove them. Depending on what your stressors are, you’ll need to come up with different ways to handle it. One example: if you get stressed because you can’t remember what house cleaning needs to be done, a checklist can help manage that stress.
Visit support groups
Many communities have local brain injury associations or support groups with activities and resources. Participating in support groups is a great way to build up your community; it also gives you a place where you can feel safe and welcome, which will have a huge impact on your mental health. Support groups are also a great place to hear about other experiences and learn new tips/strategies that have helped others in recovery.

Disclaimer: There is no shortage of web-based online medical diagnostic tools, self-help or support groups, or sites that make unsubstantiated claims around diagnosis, treatment and recovery. Please note these sources may not be evidence-based, regulated or moderated properly and it is encouraged individuals seek advice and recommendations regarding diagnosis, treatment and symptom management from a regulated healthcare professional such as a physician or nurse practitioner. Individuals should be cautioned about sites that make any of the following statements or claims that:

  • The product or service promises a quick fix
  • Sound too good to be true
  • Are dramatic or sweeping and are not supported by reputable medical and scientific organizations.
  • Use of terminology such as “research is currently underway” or “preliminary research results” which indicate there is no current research.
  • The results or recommendations of product or treatment are based on a single or small number of case studies and has not been peer-reviewed by external experts
  • Use of testimonials from celebrities or previous clients/patients that are anecdotal and not evidence-based 

Always proceed with caution and with the advice of your medical team. 

Create a routine
Since you’ve experienced a lot of changes, creating a schedule for each day or each activity you have to do can take a lot of stress away. When you know exactly what’s happening and what to expect, you can mentally and emotionally prepare yourself.
Exercise
Exercise can have a positive effect on both the body and the mind. Even if it’s just a few arm circles, a walk, or leg stretches. It’s a great way to occupy yourself and focus your energy.

Please note: You should only do exercises that have been doctor-recommended.

Spend time outside (if possible)
Fresh air is a great way to boost your mood. Even if you’re only outside for a few minutes at a time, this change of venue and activity can be incredibly stimulating.
Medication
In some cases, it might make sense to take medication to help with depression or anxiety. Please note: only your doctor can recommend and prescribe you with medication.

See sources