Behavioral/Emotional Consequences of TBI

Emotional and behavioral changes experienced by persons with TBI are often one of the more significant sources of difficulties and stress for the individual and his/her family. They also can have a substantial impact on performance in work and school settings.

Personality changes

• Families often report that the injured person's personality has changed.
• The individual may be seen as more or less outgoing, irritable, active, etc.
• The individual may demonstrate changes in interests (e.g., loss of interest in previously enjoyed activities).

Anger/ Frustration

• Following a TBI, the injured person may be seen as "short tempered" and quick to get angry/frustrated.
• The injured person may seem less patient in general.
• A low tolerance for change can be noted.
• The person may have anger outbursts, and may be more likely to become verbally or physically aggressive.
• Problems with frustration tolerance may be particularly notable in new situations and/or when the person is tired or stressed.

Emotional distress

• Symptoms of depression and/or anxiety are not uncommon following TBI.
• They may directly result from changes to the brain.
• They may reflect problems adjusting to cognitive, physical, behavioral difficulties since the TBI.
• Symptoms experienced may be influenced by circumstances surrounding the injury.

• Anxiety may manifest in general nervousness or restlessness, or in panic attacks.
• Individuals may also experience fear/anxiety in situations related to the TBI (e.g., while riding in the car following a motor vehicle accident).
• Adaptation to change in the person's sense of self, or self-identity, can be a source of distress.

Difficulties with Social Relationships

• Problems with skills associated with effective interpersonal communication may occur, including:
• Reciprocal interactions (e.g., taking turns in conversations, truly listening to other participants).
• Use of appropriate eye contact.
• Awareness of and respect for interpersonal space.
• Awareness and appropriate use of non-verbal communication skills (e.g., gestures, facial expressions, body language).

• Persons with TBI may have difficulties understanding nuances in social relationships.
• They may need to be told directly when a behavior is not appropriate rather than be expected to pick up on social cues designed to convey this.

• Following a TBI, individuals may be less sensitive to social norms and have less sensitivity to the feelings of others.
• They may use inappropriate language or behave in a socially unaccepted way at home and in public.

Executive function difficulties

• Reduced self-control and increased impulsivity may be seen.
• This can manifest in problems inhibiting automatic (sometime inappropriate) responses (e.g., non-tactful statements to others).
• Increased impulsivity in behaviors (e.g., increased tendency to engage in risk-taking) and decision-making (e.g., impulsive spending).

• Persons with TBI may have problems with judgment and reasoning.
• This may lead to increased suggestibility (ability to be led or influenced by others).
• Poor decision-making (e.g., related to managing finances) may occur.

• Decreased motivation and/or interest (apathy) may occur due to TBI.
• The injured person may not seem to be motivated to engage in activities.

• He/she may report plans to do things but then not follow through.
• He/she may be less likely to speak unless spoken to.
• He/she may spend much of the day not engaged in activities (e.g., staying in bed late).

Professional Treatment for Behavioral/Emotional Issues

Behavioral/emotional difficulties following a TBI may be best addressed by combining interventions by healthcare professionals with strategies used by the person with TBI and those interacting with him/her.

Physicians and Rehabilitation Psychologists/Neuropsychologists are two types of healthcare professional who can offer valuable interventions.

Physicians

• Significant behavioral/emotional difficulties may respond to medications in combination with behavior-based interventions and strategies.

• Physiatrists and/or psychiatrists experienced in treatment of TBI may recommend medications for reducing agitation/anger, depression, emotional lability.

Rehabilitation Psychologists/Neuropsychologists

• In addition to assessment of cognitive and behavioral functioning, these providers offer therapy services to persons with TBI and other affected individuals (e.g., family members).
• Goals of therapy can include:
• Identification of specific strategies to manage behavioral changes from TBI.
• Anger management, impulse control strategies
• Emotional lability
• Reduced motivation/apathy
• Help with psychological adjustment to changes in functioning caused by the TBI.
• Address lowered self-esteem secondary to TBI-related difficulties.
• Provide specific strategies for managing depressed mood, anxiety.
• Assist with adjustment to changes in family roles that can occur after a TBI (e.g., if parent with TBI now requires help from the child in doing daily activities).

Management Strategies for Behavioral/Emotional Issues

Treatment from healthcare professionals plays an important role in helping address behavioral/emotional issues in persons with TBI, whether they are having a modest or significant impact on the person's functioning.

Importantly, if the affected person's emotional distress is high (e.g., there are concerns about potential for self-harm), professional help should be sought immediately.

In addition, there are many strategies that can be used by the person with TBI and those interacting with him/her that can have positive effects on behavioral/emotional functioning. Below are some specific strategies that can be used to address common behavioral/emotional difficulties following TBI. As with all strategies for changing human behavior, patience, consistency, and repetition in the use of these strategies are needed to obtain the best results.

Anger/ Frustration

Strategies for Others

• When the person is angry, talk in a soothing manner.
• Acknowledge the person's frustrations and help with problem-solving if possible.
• Try to distract the person and help turn his/her attention to something else if he/she is too upset to problem-solve effectively.
• Serve as a model by using effective anger management strategies.
• Be patient in the moment and persistent over time in helping the person manage his/her anger.
• DON'T try to reason with the person when he/she is at peak anger levels.
• DON'T criticize the individual if his/her strategies for managing anger don't work at first.

Strategies for the Person with TBI

• Practice anger-management strategies before anger occurs.
• Learn to identify early signs of anger.
• Learn to identify situations ("triggers") that can lead to anger.
• Avoid triggers if possible, or learn and use anger-management strategies in those situations.

• Get help from family, friends, and others in efforts to learn and use anger-management strategies.
• Seek to include regular activity, hobbies, and other sources of enjoyment in one's life.

Emotional Distress

Strategies for Others

• If the person appears down, ask about his/her mood in an accepting, non-judgmental manner (acknowledging that it is OK to feel distressed).
• Try to help the person identify source of distress (e.g., is it related to transient issue, or does it reflect ongoing distress about situation, etc.).
• If the distress is related to specific issue, encourage and help the person to problem-solve regarding how to address the issue.
• Alternatively, try to distract the person if the issue is not one that can be readily addressed.

• If distress is related to general sense of loss since the TBI, consider the following strategies:
• Acknowledge the person's sense of loss as a result of changes following the TBI.
• Provide honest but supportive feedback regarding changes observed (e.g., don't deny difficulties, but also be sure to highlight ongoing strengths).
• Support the person's efforts to develop new ideas about him/herself and what he/she may be able to do.
• Help to identify new goals (both short-term and long-term) and think of ways to achieve these goals.

• Ensure that the person has opportunities for positive experiences. This may include:
• Spending time in settings the person enjoys (e.g., outside, in nature).
• Gathering with supportive friends/family.
• Engaging in activities the person enjoys (e.g., movies, etc.).
• DON'T criticize the person by making statements about differences in his/her behaviors/skills/etc. prior to the TBI.
• DON'T attempt to minimize or make light of the person's distress about perceived changes in self since the TBI.
• DON'T assume that the person is not aware of, and possibly distressed by, changes that others observe.

Strategies for the Person with TBI

• Acknowledge and allow self to grieve changes/losses that occurred since the TBI.
• Accept support/encouragement offered by others.
• Work to move from focusing on TBI-related difficulties to instead recognizing current strengths and abilities.
• Enlist the help of trusted family and friends in identifying strengths.
• Identify new, reasonable goals given strengths and weaknesses.
• Work with family members, friends, and healthcare providers (rehabilitation psychologist/neuropsychologist ) to develop strategies to achieve these goals.
• In addition to striving for accomplishment, pursue hobbies and/or other sources of enjoyment.

Emotional Lability

Strategies for Others

• Work with the person with TBI to identify situations that are associated with emotional lability (e.g., frustration, fatigue).
• Use some basic strategies to de-escalate potentially problematic situations:
• Recognize early signs of increased emotionality.
• Use distraction to decrease focus on cause of emotional reaction.
• Encourage/help the person take a break from the situation associated with the emotional reaction (e.g., leaving the room and going to a safe, quiet place).
• When the person is emotionally labile, maintain an interactional style that is non-confrontational and soothing (e.g., speaking in a calm voice, with non-threatening body language).
• Acknowledge the person's distress and help with problem-solving if possible.
• During non-emotional times, help the person identify words that can be used to communicate with others about his/her emotions.
• DON'T engage in discussions/arguments with the person when he/she is experiencing high levels of emotionality.
• DON'T further escalate the person's emotions by responding with intense emotions.
• DON'T try to reason with the individual during periods of high emotionality.

Strategies for the Person with TBI

• Attend to early signs of emotionality.
• Be aware of factors that contribute to increased emotionality (e.g., fatigue, pain).
• Try to minimize exposure to situations that are associated with increased emotionality, particularly when at risk for increased emotionality (e.g., due to fatigue, pain, etc.).
• Use strategies to cope with high emotionality, including:
• Using words to express emotions.
• Removing self from the stress-inducing situation.
• Using relaxation techniques (can be developed with the aid of psychologist).
• Enlist the help of trusted family member, friends, healthcare providers in developing strategies to manage emotional responses.

Self-control/Impulsivity/Poor Judgment

Strategies for Others

• Be aware of the relationship between TBI-related changes in brain functioning and increased impulsivity.
• Work with the person to identify triggers to impulsive behaviors (e.g., increased emotionality, influence of peers).
• Try to identify environmental changes that may help avoid triggers (e.g., minimize contact with peers having a negative influence).
• Develop a subtle signal (e.g., a hand gesture) to help the person remember to stop and think before acting when questionable behaviors are occurring in social contexts.
• Use redirection as needed.
• When not in social situations, provide the person with non-judgmental feedback regarding the appropriateness of his/her behaviors/decisions.
• This may initially be tried while the behaviors are occurring. If the person responds poorly at that time, follow-up at a later time after his/her behaviors and emotions have stabilized.
• Balance encouraging independence with helping the person with TBI recognize his/her limits in decision-making.
• Talk with the person about "pros" and "cons" for decisions/behaviors. Help him/her to weigh the positive and negative aspects.
• Serve as a model by making important decisions in a thoughtful manner and including the person with TBI in the reasoning process.
• DON'T criticize the person for impulsive behaviors without providing constructive ideas about other ways to behave.
• DON'T compare past and current abilities.
• DON'T try to convince the person to change behaviors when his/her level of emotionality is high (use distraction and wait until the person is calm before addressing the issue).

Strategies for the Person with TBI

• Identify triggers to impulsive behaviors with help of trusted others (e.g., family, friends, healthcare providers).
• Develop strategies to reduce the likelihood of acting before considering consequences.
• Have family members/friends give a signal to help with stopping and considering behaviors before acting further.
• Accept feedback from trusted others (e.g., family, good friends) regarding when it is important to stop and consider behaviors even if it is difficult to recognize the need for this.

Apathy

Strategies for Others

• Recognize that apathy may result from changes to the brain associated with TBI.
• Recognize that apathy can also be a sign of depression.
• Look for other symptoms of depression (e.g., sadness, appetite/sleep difficulties, feelings of worthlessness).
• If other signs of depression are present, consider using strategies for coping with Depression (see above) in addition to seeking help from healthcare providers .

• Use techniques to enhance initiation, including:
• Work with the person to develop a set of agreed-upon goals.
• Develop a schedule of daily activities and check off each activity as it has been completed.
• Develop a schedule that involves slowly increasing activities and responsibilities over time.
• Add 1-2 new responsibilities each week, and reward the person for successfully adding new tasks.
• Choose activities or other rewards that the person will receive after completing less interesting tasks.

Strategies for the Person with TBI

• Accept help from trusted others (e.g., family, friends) in identifying plans/schedules for activities.
• Use a timer to provide prompts when a task needs to be done (e.g., a watch alarm can sound when medications need to be taken).
• Set appropriate goals for activities each day, with the help of trusted others.