Anger / Irritability
Behavioral changes such as agitation and aggression occur in 10 to 40% of people with acquired brain injury.
Agitation is 'non-intentional' behavior, in which the inner restlessness leads to ineffective behavior, with a highly repetitive character.
Non-intentional means that someone does not do this consciously.
A distinction is made:
- motor agitation: constantly walking around, unable to sit or lie still, rattling doors, tapping on the table, turning everything upside down;
- verbal agitation: continuous talking, mumbling;
- vocal agitation: whining, screaming, shouting, singing, making (stereotypical) sounds.
Aggression, on the other hand, is 'intentional' in nature. Intentional means that someone does this consciously.
A distinction is made:
- verbal aggression: swearing, cursing, accusing, threatening;
- acting aggression: hitting, pushing, kicking, destroying, throwing objects, making threatening gestures, harming oneself (self-mutilation).
The question is whether someone with brain damage is consciously and intentionally aggressive.
Aggressive behavior after brain injury is often a result of damage to brain areas responsible for emotion and behavior, for example the frontal lobe. The frontal lobe has an important role in problem solving, reasoning, and impulse control.
The frontal lobe inhibits the amygdala, one of the brain's most important emotion centers.
All of these functions of the frontal lobe are necessary to regulate a person's behavior. When the frontal lobe becomes damaged, it can affect behavioral skills. This can lead to aggressive behavior. There is great difficulty in controlling inappropriate behavior. This is often seen in combination with risky behavior and poor decision-making after brain injury. There are more brain areas associated with aggression after brain injury. See our special page about aggression and brain injury.
Although aggressive behavior seems unpredictable, it is often caused by emotional or physical discomfort.
The frustrations of the changes caused by the brain injury can put so much pressure on someone that an 'explosion' can follow.
Someone can feel so unworthy, dependent and no longer in control of life, that he or she is more likely to be insulted or perceive a blame that it can be enough for an aggressive outburst.
Examples of physical discomfort:
- the intense fatigue (neurofague or organic fatigue/brain fatigue), the physical effort it takes to wash or dress yourself, pain in the body due to the brain injury, a full bladder or hunger, low blood sugar, sensory stimuli such as light, noise, too busy an environment, an environment that is too hot or too cold, etc.
- Examples of emotional discomfort:
depressed mood as a result of the brain injury, too high, unattainable, unrealistic goals for rehabilitation, the expectations that do not come true, difficulty asking for help, etc.
Anyone who can recognize and prevent these triggers will go a long way in helping you learn to control aggression.
The above text is a brief summary of our special page about aggression and brain injury.
Becoming irritated/angry more quickly
A frequently heard comment about people with brain damage is that these people become 'irritable' / angry more quickly.
This should not be confused with the concept of 'overstimulation'.
For some people it can be a result of overstimulation, but it can also arise from being overloaded, from frustration or from a reduced inhibition with regard to the emotions. Furthermore, it can also arise from an enhanced character trait that made someone react more agitated, also before the injury.
The definition of irritability can be divided into three parts:
1) Literally it means reacting to stimuli from the environment, in the sense of increasing irritation, anger to aggression.
When neuropsychologists, cognitive therapists, or occupational therapists use this term, they are referring to the behavior of the person who reacting with anger.
2) Medically it is the ability to generate energy in nerve cells, the irritation and irritability of the skin, the intestines, the respiratory tract, the muscles that can cause muscle contractions.
Some neurologists refer to 'increased excitability of the brain', by which they refer to overreaction of the brain to ordinary stimuli or signals by becoming ill. Such as epilepsy, migraine, concussion in the acute phase, etc. Often accompanied by neurovegetative dysfunction (such as vomiting, light aversion, headache, etc.).
3) It can also mean emotional lability, for example:
- morning moodiness,
- menstruation, PMS (Pre menstrual syndrome),
- during menopause, after giving birth,
- during a period of mourning,
- in case of depression,
- burnout, anxiety,
- post traumatic stress disorder (PTSD),
- in psychiatric disorders,
- when the thyroid gland is functioning too quickly (Hyperthyroidism),
- in Prader-Willi Syndrome (a genetic abnormality),
- in babies with hydrocephalus,
- in babies and toddlers with a middle ear infection or another condition,
- with excessive caffeine use,
- in dementia,
- pituitary abnormality causing someone to drink excessively and urinate a lot (diabetes insipidus) etc. etc.
Brain injury and behavior
Irritability is often associated with short-tempered behavior in brain injured people.
This can have several causes:
- acute brain injury that has not yet been diagnosed, for example in
encephalitis meningitis / brain abscess / metabolic diseases / brain tumor
- frontal lobe damage
- frontotemporal degeneration
- cerebellar affective syndrome cerebellum
- neurodegenerative disorders
- environmental factors/external factors (crowding, sensory stimuli such as light noise, ambient sounds)
- personality factors that were already present before the injury
- reduced self-management
- having difficulty expressing her- / himself in language, aphasia, dysarthria and apraxia of speech
- apraxia, no longer knowing how to perform an action
- reduced ability to sense and indicate boundaries
- overexertion, people with brain damage are less resilient,
- being overwhelmed by cognitive problems:
- delayed information processing
- impaired memory function
- reduced concentration
- reduced perception
- reduced language skills
- pragmatic language disorder
- word-finding problems
- take language literally
- reduced empathy
- reduced decision-making skills
- reduced sense of reality
- reduced stress resistance
- changed emotions
- reduced emotion regulation
- being able to assess the reduced behavior of others
- executive dysfunctioning
- shame about performance
- auditory processing disorder
- hyperacusis (hearing too much) and tinnitus (ringing in the ears)
- sensory or cognitive overstimulation
Irritable or overstimulated?
Unfortunately, the term irritability is too often confused with
overstimulation, a neurological complaint that arises because the brain can no longer filter the multitude of information or inhibit stimuli.
Multiple brain structures are involved in transmitting, decoding and filtering stimuli from the environment and from the body itself. In addition, the large brain cells and intermediate cells (interneurons) and nerve pathways are involved, as well as signaling substances (neurotransmitters) that must transmit stimuli and neurotransmitters that must inhibit stimuli.
If this fine-tuning of the brain and neurotransmitters does not work sufficiently due to brain damage, it can lead to irritability in situations, but this does not happen to everyone with overstimulation complaints*. [*source the surveys conducted by us and personal information provided to us] Irritability is one of the possible consequences of overstimulation. The concept of 'irritability' is therefore not a synonym of the concept of 'overstimulation'.
People often talk about 'the short fuse' in people with brain injury. It seems as if this is synonymous with having a brain injury. That is not the case. There are many people with brain damage who do not have a 'short fuse'. We therefore regard this term as a stigmatizing label that we would rather not use.
The term 'short fuse' refers to emotional irritability that builds up quickly and can even become explosive during outbursts of anger. Usually as a result of overload at that moment.
Frustration can add up quickly. If someone cannot take time out or cannot sense that a time out is necessary, non-drug intervention is an important first step.
In addition, creating an adequate (low-stimulus) environment for the patient is necessary to prevent aggression. Possibly with medicinal influence on neurotransmitter systems. Aggression is difficult to treat but easy to prevent.
Take a step back and look at it from a distance at rest. Time-out.
Psychomotor therapy may be advisable
Psychomotor therapy is a non-verbal form of therapy that focuses on experiencing, practicing and experimenting. A common belief among people is that an impulse breakthrough comes from nowhere. The therapy is based on the belief that increasing tension and emotions precedes an impulse breakthrough. By becoming aware of this, people with brain damage can learn to respond differently before their impulse breakthrough.