Behavior & Emotion

• Agitation
• Denial
• Dependency: May not realize the severity of the injury and its effects on self or others
• Egocentrism: Inability to understand any perspective other than one’s own
• Excessive talking
• Impatience
• Inappropriate social behavior
• Irritability
• Lack of motivation
• Loss of control: May not be able to control what one says or does in social situations
• Perseveration: Thinking, saying, or doing one thing for an extended period of time
• Poor initiation: Decreased ability to independently start or plan activities
• Verbal and/or physical outbursts

Agitation is a loss of control over one’s behavior. It often occurs in response to frustration or overstimulation. In a person with brain injury, agitation may represent an overreaction to even minor frustration. There are often identifiable factors that cause the agitation. Determining what these factors are will provide clues on how to minimize or avoid agitation in the future.

Examples of agitation

Here are a couple of examples of what this kind of behavior looks like.

1. In the course of getting dressed for a family gathering, Sam noticed a large stain on his pants. He became very angry with his wife for not having his pants cleaned. He started cursing loudly and pacing around the room. Finally, he threw his pants across the room and kicked the bedpost. Sam was mumbling under his breath about how things never go his way. He would not put on other pants to go to the gathering; instead, he stayed mad all day.
2. During supper at a restaurant, Mary had trouble getting her pasta on a fork. She tried a second time, but the food slipped off the fork. She became very frustrated and yelled out to the other customers in the restaurant, “What are you looking at?” Mary then began eating with her hands.

Tips for preventing agitation

• Give simple directions to tasks.
• Offer tasks within the person’s general abilities to limit frustration.
• Follow a schedule suggested by the rehabilitation team, including rest times.
• Limit visitors to 2-3 people at a time for shorter visits (about 30 minutes) until better control of behavior is established.
• Allow the person to have some space.
• Avoid noisy places with large crowds.
• Keep household noise level to a minimum and avoid multiple noise sources at one time.

Ways to help

• Speak softly and calmly.
• Maintain a safe distance.
• Ignore the behavior if it is safe to do so.
• Change the subject to direct attention away from the cause of agitation.
• Eliminate extra noise in the surrounding area if possible (such as TVs, radios, or noisy guests).
• Direct the person away from crowds to a quieter area.
• Show support by acknowledging their frustration. Say: “I know this has really upset you.”
• Don’t challenge, confront, or scold the person.
• Remove dangerous items that may be used as weapons.
• Never leave a confused or agitated person alone. Keep them in sight but at a safe distance.
• If possible, let a physically aggressive person move freely in a safe, large space. Avoid trying to restrain or touch.
• Get help if the person is a danger to himself or others. Ask someone nearby to call, if necessary.
• If circumstances warrant, inform your healthcare provider.

Anxiety and depression are common problems that may be experienced after a brain injury.

A person may feel uneasy or apprehensive and/or sad, discouraged, or helpless. Depression and anxiety can be problems in daily life by interfering with a person’s ability to take on new challenges, learn new things, and/or participate fully in therapeutic activities.

A person may act very upset or overwhelmed when learning new tasks or when there is a change in the daily schedule. Frequent or unnecessary questions may be asked, or there may be a general resistance to trying new things. The person may be afraid to be alone or seek isolation from others. Tearfulness and irritability are also common.

Examples of anxiety and depression

Here are a couple of examples of what this kind of behavior looks like.

1. Jose is at a brain injury camp this summer. He is helping to set up for the dance this evening. He has asked the leader five times about whether he is decorating nicely. The leader encourages him and tells him he is doing a great job. While Jose is taping up balloons, he becomes very nervous. He then repeatedly asks the leader what time it is. He says that they will never be finished in time for the dance. Jose says he just can’t get all of this done and can’t help anymore. He goes back to his cabin. Jose’s anxiety has interfered with his ability to help with the dance.
2. Sarah has a brain injury. She left inpatient rehabilitation feeling sad and irritable. She did not feel like participating in outpatient rehabilitation, preferring to stay in bed and be alone. Sarah is depressed, which negatively impacts her recovery by interfering with her ability to fully participate in her outpatient rehabilitation.

Ways to help

• Encourage rest periods and quiet time.
• Tell the person what is going to happen during an activity in order to prepare them so anxiety will be minimized.
• Orient the person to the situation, such as day, place, anticipated tasks, etc.
• Maintain as much structure/routine in the daily schedule as possible.
• Introduce unanticipated changes slowly and calmly.
• When leaving usual surroundings, keep familiar items nearby, such as photographs, toys, and special clothing.
• Start with small challenges and gradually progress as tolerated.
• Inform the doctor if anxiety and/or depression are interfering with daily activities, including active therapy participation.

Some people have a lack of awareness or insight into the problems resulting from the brain injury.

Changes or limitations since the brain injury that are obvious to family members may not be obvious to the person with the injury. The person may have some awareness, but it may be limited. It may seem like the person is denying that any problems exist or underestimating the severity of these problems. This occurs mostly because the injury may have affected the brain’s frontal lobes that control self-awareness. This does not happen because the person is intentionally trying to be stubborn or difficult. It is also not a problem with psychological denial.

When lack of awareness or insight is an issue, a person may not show normal reactions when making a mistake or may not even realize that a mistake was made. The person thinks that he is fine and that anything he does is also fine. Because of this, the person may refuse help from caregivers.

A person with this problem may set unrealistic goals and expect to keep the same lifestyle or goals as before the injury. This lack of awareness can pose a threat to a person’s safety. Driving, using heavy machinery, being left alone and climbing tall ladders are all examples of activities that pose safety risks after a brain injury.

Please follow the safety guidelines and precautions explained by the treatment team.

Example of awareness and insight

Here’s an example of what this kind of behavior looks like.

Frank had a traumatic injury to the right side of his brain. He has severe left-sided weakness that affects his legs and arms. He also has some trouble with balance. Frank needs a wheelchair to get around and one person to assist him to get on and off the toilet. He cannot be left alone in the bathroom because he has fallen twice when he has tried to go alone. Frank has a new caregiver today. He tells the nurse he can get on the toilet by himself and needs no help. He says, “I can’t understand what all the fuss is about in the bathroom. I’m fine and I can do this myself.” The nurse asks him about his recent fall and Frank replies, “Oh, I didn’t fall. I just lost my balance. Everyone is overreacting. I’m fine.” Frank has a problem with awareness.

Ways to help

• Remember, safety first.
• Keep surroundings safe and free of potential hazards.
• Keep keys out of reach.
• Keep dangerous machinery locked up.
• Consider safety issues in the kitchen, such as knives, the stove, etc.
• Keep firearms out of reach and out of sight.
• Avoid confrontation. Do not argue or try to reason. Instead, offer two safe choices.
• When giving feedback, praise efforts first, then offer suggestions for improvements.
• Never leave a person with decreased awareness or insight alone until cleared by the doctor and/or rehabilitation team. Keep in mind that safety issues may reappear in new environments for an otherwise safe patient.
• Alert other caregivers and emergency personnel of the person’s limitations, and help them understand how to promote safety.
• Observe the person for improvements. The person may be ready to start practicing to be more independent. Speak with the doctor if you think it is time to reevaluate the situation.

Impulsivity is a tendency to act very quickly without taking time to plan or think about consequences. The action may be sudden or occur in response to a strong urge or idea to do or say something. Impulsive behaviors can be seen anywhere. They are common in social situations and at work, school, or home.

Impulsivity is a fairly common problem after brain injury. It is caused by an injury to the part of the brain that controls a person’s ability to plan, organize, and perceive. Injuries to the frontal areas of the brain often cause problems with impulsivity.

Examples of impulsivity

Here are a couple of examples of what this kind of behavior looks like. Please notice the lack of planning and lack of awareness of consequences.

1. Karen is at the grocery store with her mother. They are shopping without any problems until Karen sees some Popsicles that look tasty. Karen decides to open the box and have a Popsicle. She puts the rest of the box back in the freezer section at the store.
2. Mike and his brother are on their way to a baseball game. They have parked the car and are walking to the front gate. Mike suddenly begins to cross the very busy city street without stopping to check the traffic. His brother quickly grabs him and saves him from an approaching vehicle.
3. Mary and her husband Jeff are dining at an upscale restaurant. Jeff suddenly notices that the waitress is attractive. When she leans over to fill his water glass, Jeff says a suggestive remark and tries to touch her inappropriately, but Mary quickly redirects his reach. She reminds him he’s there with her for dinner and they should talk about what they’d like to order from the waitress.

Ways to help

• Remember, safety first.
• Make a detailed daily schedule.
• Plan ahead and be prepared. Remove dangerous tools, appliances and keys to cars and machinery.
• Remove weapons and household poisons from reach.
• Consider safety issues in the kitchen, such as knives, the stove, etc.
• Keep firearms out of reach and out of sight.
• Make sure that rooms are well lit.
• Stay alert when out of the home with the person in order to prevent wandering or injury. Walk close together when in large crowds and public areas where it might be possible to get lost.
• Stand close when crossing streets or using public transportation.
• Plan things together.
• Be supportive and non-confrontational.
• If sexual impulsivity happens, approach it with a matter-of-fact  attitude. Do not appear shocked or angry.
• Avoid confrontation. Do not argue or try to reason. Instead, offer two safe choices.
• When giving feedback, praise efforts first, then offer suggestions for improvements.
• Never leave a person with decreased awareness or insight alone until cleared by the doctor and/or rehabilitation team. Keep in mind that safety issues may reappear in new environments for an otherwise safe patient.
• Alert other caregivers and emergency personnel of the person’s limitations, and help them understand how to promote safety.
• Observe the person for improvements. The person may be ready to start practicing to be more independent. Speak with the doctor if you think it is time to reevaluate the situation.

Sometimes lack of initiation can be very troubling to family members of the person with a brain injury.

Even though a person may be physically able to perform a task, they may fail to do so despite a lot of help or prompting. The person may seem content just sitting and doing little to nothing during the day. This lack of initiation is usually caused by an injury to the frontal lobes of the brain. The frontal areas help a person plan, organize, and begin an activity.

Problems with initiation are not the same as laziness. It can be difficult to know if a person is having problems with initiation or motivation. If the person expresses a desire to quit or give up, it may be lack of motivation.

Example of initiation and apathy

Here’s an example of what this kind of behavior looks like.

Nick’s brain injury happened 6 months ago. He is able to perform daily activities safely without assistance from others. Since he has been home, his daughter has noticed that he does not start many activities independently. When he wakes up, he will sit in front of the TV in his pajamas for a couple of hours. When his daughter asks him to shower and get dressed, he goes upstairs and takes care of himself. After his shower, he sits at the kitchen table for about 20 minutes. Nick’s daughter suggests that he fix a sandwich for lunch, and he does so. Still, his daughter becomes frustrated about having to prompt him repeatedly to do things. Nick has a problem with initiation.

Ways to help

• Be supportive and encouraging.
• Set up a schedule with the person who has a brain injury, and encourage their participation.
• Offer two good choices when it is difficult to get the person going.
• Offer incentives for performing activities or staying on schedule.
• Be sure to make the rewards meaningful to the person with ideas that they really like to do or have.
• Provide creative rewards and be consistent in your follow through.
• If necessary, help the person get started with the activity.
• Maintain scheduled rest periods as suggested by the therapy team to avoid fatigue.

Most people with brain injury have some changes in emotional behavior. They may have emotional lability or a flat affect. A person’s affect can be thought of as the way they express their emotions with facial expressions.

• Emotional lability occurs when a person may laugh or cry in response to minor events. The response is out of proportion or opposite to what would normally be expected, and the mood may change suddenly. The person’s expression does not necessarily reflect their internal feelings.
• Flat affect is a lack of emotional response. The person may show limited or no emotion to anything. There may be a general lack of smiling, laughing, or crying in any type of interaction during the day. This can be mistaken for depression. It is important to ask your loved one about their mood rather than guessing it based on how they look.

Problems with affect can occur as a result of the brain injury. Certain parts of the brain control normal emotional expression and response. In addition, the brain controls the ability to respond appropriately in an emotional situation.

Your doctor may prescribe certain medicines to help the patient with better control over their emotions. Some of these medicines work on a chemical in the brain called serotonin. Serotonin is thought to help improve mood as well as decrease feelings of despair and hopelessness. Common brand names include Prozac, Zoloft, Paxil, Lexapro, Celexa, and Effexor. Other medications, such as Seroquel, Geodon, and Depakote affect other brain chemicals and may help reduce mood swings and irritability.

Examples of mood

Here are a couple of examples of what this behavior looks like.

1. Kate has a problem with flat affect since her brain injury. She was normally very close with her husband and two grown sons. Bill, her eldest son is in the Navy and is currently stationed overseas. She has not seen Bill in over a year. Bill came home for a surprise holiday visit. When Kate saw Bill, she hugged him, but did not smile or act happy. She said hello and then went back into the kitchen to finish baking. Bill was very puzzled by his mother’s lack of response to his visit.
2. Joe has a problem with labile emotions. When his wife, Jane, came home from church, Joe greeted her and began sobbing. Jane confirmed nothing bad had happened. Later that day, Jane tripped on the carpet and twisted her ankle, and Joe began laughing.

Ways to help

• Don’t take it personally when lability or flat affect is present.
• Be aware that these responses are part of the brain injury and are not being done on purpose.
• Encourage rest periods as suggested by the therapy team.
• Tell other friends and family members of the affect problems so they do not become upset with the person.
• Encourage a non-emotional distraction when a person becomes labile, such as bringing up a neutral topic.
• Help the person become aware of affect noting how they feel and asking how they feel.

Social skills or social competence relate to one’s ability to focus on another person and understand that person’s mood, feelings, and unspoken messages.

Problems with social skills are common after brain injury and often result in isolation for the patient and the patient’s family. This only compounds the losses associated with the brain injury. Good social skills also involve behaving according to commonly accepted social rules. This includes exercising self-control when it is necessary, being courteous, waiting for a turn, and using appropriate language.

The inability to understand another’s point of view may lead to saying or doing something inappropriate for the situation. Others who are not aware of the person’s brain injury may react negatively and even inappropriately.

Another example of good social skills is participating appropriately in a conversation. A person with a brain injury may not take turns talking or may not follow the topic of the conversation.

There are strategies that can be learned to improve social skills. For example, a person with a brain injury can be taught to listen actively through repetition, to identify facial expressions of emotions, and to avoid interrupting the person who is speaking.

Coping with social situations

• Begin socializing with familiar people such as your family or very close friends who understand about your brain injury. Socialize in small groups at first until you see improvements in your memory and
  ability to interpret other people’s emotions in conversation.
• Balance social situations with quiet time. When several people wish to visit you at the same time, encourage small, brief gatherings instead, especially at first.
• Avoid becoming fatigued by too much social activity. If you get tired, you may find that you begin to think less clearly. This is when you are more likely to do or say something that is not appropriate.
• Socialize with people you are comfortable with, people with whom you can relax. It can be stressful to be in a room full of strangers. As you recover, your social skills may also improve. Just do the best you can. Your friends will understand if you struggle at first.
• Never let your injury keep you from having a social life. It is important to get out of the house or have family and friends come to visit. Practicing social interactions will help you get better at them.