Behavior & Emotions

• Agitation
• Denial
• Dependency, as they may not realize the severity of the injury and its effects on themselves or others
• Egocentrism, as they may have an inability to understand any perspective other than one’s own
• Excessive talking
• Impatience
• Inappropriate social behavior
• Irritability
• Lack of motivation
• Loss of control, as they may not be able to control what they say or do in social situations
• Perseveration, or thinking, saying, or doing one thing for an extended period of time
• Poor initiation, or a decreased ability to independently start or plan activities
• Verbal and/or physical outbursts

Behavior problems can be a temporary part of recovery. How long the behaviors will last depends on the person’s injury. Some problems may go away, while others may stay the same or lessen in frequency and/or severity.

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

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 a stroke. 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 (knives, 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.

Most people with a stroke 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.

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

• 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.
• 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 a stroke and often result in isolation for the patient and the patient’s family. This only compounds the losses associated with the 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 injury may react negatively and even inappropriately.

Another example of good social skills is participating appropriately in a conversation. A person with a stroke 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 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/friends come to visit. Practicing social interactions will help you get better at them.