Cognitive consequences

What is a high EQ? How does brain injury affect it?

EQ stands for emotional intelligence: the ability to consciously manage your own feelings and those of others. How do you communicate? Can you show empathy, solve problems together, and build lasting relationships?
A brain injury can affect these skills. While empathy may not change internally, the need to maintain one's own boundaries can create an inner conflict in someone with a brain injury.
People with brain injuries and a damaged, underpowered inner battery pay the price when they try, at their own expense, to give others the same space they could once effortlessly offer. It has been proven that listening requires more effort for people with brain injuries than speaking.
However, some have changed in their empathy or in their ability to communicate effectively. We have written other pages about this.

Difficulty controlling impulses

People may find it harder to control their impulses. The brakes are off.

For example, someone might swear more quickly if something doesn't work out.

But someone might also eat and snack without inhibition.
People may be uninhibited when it comes to sex. Read about changed relationships, intimacy, and sexuality.
Injury to the frontal lobe, in particular, causes problems with impulse control. Teenagers with brain injuries where the frontal lobe hasn't yet fully developed can also have difficulty with this.

Lack of initiative/apathy

After a brain injury, a person may lack initiative. They may experience decreased activity and a lack of engagement. They may appear listless, indifferent, lack emotional expression (emotionally flat), and be difficult to motivate. There appears to be no correlation between the severity of the injury and apathy, nor between the duration of the brain injury and apathy.

Apathy is described as "a persistent decrease in motivation, responsiveness, and goal-directed behavior. It meets specific diagnostic criteria that distinguish it from depression."
The word apathy comes from the Greek word apatheia (ἀπάθεια). A = without or none. Pathos = suffering or passion.

Apathy is a syndrome of primary loss of motivation that cannot be attributed to impaired consciousness, cognitive impairment, or emotional problems.
Apathy can manifest as, among other things, a lack of goal-directed behavior, a decrease in goal-directed thinking, and emotional indifference with a flat affect (feeling). (Marin 1991)

In whom and how often does apathy occur?

Apathy is seen in neurological disorders such as Alzheimer's disease (63-90%), Frontotemporal dementia/FTD (92%), Vascular dementia/VD (72%), Lewy body dementia (57%), Progressive Supranuclear Palsy/PSP, CADASIL, Parkinson's disease, and Huntington's disease.
It also occurs in brain injuries such as stroke (36%), traumatic brain injury (20-70% with an average of 49%), brain infections, and brain tumors.
Furthermore, apathy occurs in several mental health conditions (including depression, PTSD, and schizophrenia).

Furthermore, apathy is a warning sign of dehydration, exhaustion, liver failure, poisoning and substance use (e.g., cannabis or alcohol), shock, underactive thyroid (hypothyroidism), and other conditions.

Rule out illness, depression, and medication side effects

Apathy can be a direct consequence of the brain damage itself.

Sometimes apathy is a symptom of another condition or of depression, as mentioned in the paragraph above. Therefore, it is important to rule out illness or possible depression. If depression is diagnosed, the depression should be treated first. It is also important to distinguish apathy as a side effect of medication. Discuss this with your doctor.

Recognize, acknowledge, and treat where possible

Apathy after a brain injury can be a barrier to rehabilitation and recovery. Therefore, it is important to recognize, acknowledge, and treat apathy where possible.

Where in the brain?

Apathy has been linked to damage to several brain areas, including the frontal lobe, basal ganglia, and cingulate gyrus. A blockage of dopamine pathways also appears to play a role.

How to approach?

It is important to approach a person exhibiting apathetic behavior with clear and repeated "gentle encouragement." Establishing a consistent structure and automatisms is recommended. The goal is for the person to perform as many routine tasks as possible, such as bathing, dressing, and other personal care tasks (if possible), independently.

Certain medications may have beneficial effects in reducing apathy. However, their effectiveness is not always clearly proven. Setting very specific goals can also help.

Continue to offer sufficient water, tea, or other drinks to prevent the person from becoming apathetic due to a lack of fluids.

Caregivers

It is often difficult for those around them when someone completely loses initiative and seems disinterested in anything. That's why it's important for the partner or caregiver to monitor their own resilience and health and to seek support if needed. See, for example, the CaregiverStrain Index on this page.

Limited flexibility

After a stroke or traumatic brain injury, people often struggle to cope with change or adapt to new situations. If something doesn't go as expected they may become completely disoriented.

This can lead to difficulty switching between tasks or finding solutions to unexpected problems. This is often because the brain processes and coordinates signals less effectively after an injury.

Unexpected visitors or a setback, for example, are difficult situations.
People with brain injury experience difficulties switching from one task to another.
This also applies to switching from one thinking task to another, such as working on a computer and then switching to an unexpected phone call.

The brain itself is no longer flexible enough to handle such a switch to a completely different task.
If the conversation partner switches to a different topic this may also cause difficulty for the person with a brain injury.

This is not a matter of unwillingness, but of inability.

Stress tolerance may also decrease. During times of acute stress or major problems, all areas of the brain are activated simultaneously, creating a kind of short circuit.
Read our dedicated page on reduced stress tolerance.

Quotes from people who have become less flexible 

• Sometimes, after a conversation ends, I have to come back to something because I can't interpret in time what I heard. It took me a little longer to find the right word, and then the conversation continued because I was lost in thought, or I got distracted again, or something was said (by me or someone else) that wasn't right, and it takes me a while to realize it...

• I am simply not as flexible anymore. I also generally perform my tasks a bit more slowly than before.

• If I am busy with something and a phone call comes in, I can't switch gears. I can't even think at that moment. Apparently, when you have brain injury, you try to focus on a task with all your might, so much so that you lose track if it has to stop abruptly and unexpectedly.

• During a conversation, I often can't adjust because I'm so busy trying to stay focused that I don't even think to ask for a moment's pause or to repeat something. Having a conversation can be very difficult, and even if the problem is identified beforehand, it's not always taken into account.

• I live a structured life, get up at set times, and do my activities. Even on vacation, I try to maintain my morning routine. That way, it doesn't take as much energy to get back on track after the holiday.

• People often underestimate how difficult it can be to learn new "tasks" and adapt to a different work environment or situation. It takes time to establish new routines, and you often quickly forget exactly how to do something. This happens, for example, when you start at a new job or stay in a different house or vacation home. Even small (learned) tasks, such as a morning routine at home (making the bed, getting dressed), or how to start at work (turning on the computer, preparing folders), can suddenly become a challenge. Getting used to a new situation or environment again is always a difficult adjustment.

More dependent

Some people become increasingly dependent on their partner or other loved ones. They let them have conversations, make arrangements, and do physical tasks. Their partner gradually takes over more and more, so the dependency worsens.
Our advice is to try to continue arranging things together and in case that exceeds the capacity of te person with brain injury, assign smaller tasks.

Cognitive pyramid

Cognitive functions have a certain hierarchical relationship with each other.
The functioning of a particular lower cognitive function in the pyramid will influence the functioning of a higher function.

Someone who struggles with memory may experience this due to problems with attention and concentration, and not simply because memory is impaired. 

The reverse is also possible. Impairments in executive functions may impair the functioning of other cognitive functions.

Executive functions represent the higher level of control over basic abilities, which involves whether and how someone uses their knowledge, skills, and intellectual talent (Fasotti & Spikman, 2001).

Someone who is tired or overstimulated is no longer able to function because sensory perception is the foundation.

Pyramids are often used in literature to illustrate cognitive functioning. Several exist worldwide, each with a slightly different structure.
Our general pyramid model for overstimulation in brain injury is based on a framework that encompasses the neural networks of the autonomic nervous system and sensory systems.
Mental capacity fluctuates daily, and so does functioning.

We emphasize that you perceive with your senses and during perception you may become overstimulated due to poor filtering. The other layers of the pyramid lie above perception.

In case the base isn't functioning properly, the functions above it will not function properly either.

(Copyright J.van Haastrecht en A.van Schaaijk, team Hersenletsel-uitleg 2018)

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