Behavioral and Emotional Effects After TBI

You may notice changes in the way your family member acts. People with a TBI may have many emotional and behavioral effects.

That’s because our brain controls the way we act and feel. An injury to the brain — usually an injury to the frontal lobe — causes changes in emotion
and behavior. The life changes that happen after a TBI also affect how people act and feel.

Changes in behavior may include:

• frustration, increased anger/aggressiveness
• impulsivity or difficulties in self-control
• faulty or poor judgment
• decreased ability to initiate conversation or activity
• repetitive behaviors (perseveration)
• less effective social skills
• changes in sexual behaviors
• impaired self awareness about how TBI impacts him/herself and others.

Emotional effects may include:

• depression
• increased anxiety
• mood swings (emotional lability)
• changes in self-esteem.

Pay attention to changes in how your family member acts and feels. Ask the health care team for advice. They can help your family member manage these changes through counseling, medication, and healthy coping behaviors.

What Are Common Behavioral Effects?

Frustration, Increased Anger/Aggressiveness

After a TBI, many people become frustrated more easily than before. Your family member may not be able to do things as easily as he or she once did. Sometimes, he or she may not know what others expect. This can be frustrating.

You may notice a quicker temper or a tendency to fly off the handle more easily.

Loss of independence, fatigue, overstimulation, or cognitive problems can also lead to feelings of frustration and anger.

What you might see:

• Strong reaction to minor annoyances or sources of frustration
• General lack of patience (e.g., when others don’t understand the changes resulting from the injury)
• Low tolerance for change
• Unexpected outbursts of anger
• Increased irritability
• Verbal or physical demonstrations of anger
• Increased tendency towards anger when tired, in new situations, and during high levels of stress.

How you can help:

• Develop a plan to manage frustration or anger. This might mean taking a walk or going to another room and turning on the television.

This can be a good signal to others in the family that your family member needs to be alone for awhile.

• Remain calm. Encourage your family member to recognize when he or she is becoming angry or frustrated. Help him or her learn to ask for a break or some space to calm down.
• Reinforce all efforts to use effective anger management strategies.
• Prepare your service member/veteran for challenging situations when possible.
• Simplify tasks and provide a consistent, structured environment.
• Try to avoid surprises. People with TBI do better when they are prepared and can anticipate a change in plans.
• Try to consistently react to certain behaviors in a certain way. Often, a consistent approach helps to manage difficult behaviors.
• Rehearse and role play specific situations to boost confidence in managing life outside the home.
• Approach challenges calmly and allow yourself to take a break when necessary.
• If your family member is often angry, ask the health care team to develop a plan to manage this behavior. The rehabilitation psychologist or neuropsychologist is the team member who will work on this plan.

Impulsivity or Difficulties in Self-Control

Many individuals with TBI react before thinking. “Stop and think” is a good way to help a person make up for various cognitive problems. It allows the person to stop, slow down, pause, and take the needed time to think about something before doing it. This allows time to develop a reasonable plan or response.

What you might see:

• Saying whatever comes to mind without thinking about how it might affect the person him/herself or someone else
• Acting without thinking about potential consequences (e.g., crossing the street without checking traffic)
• Inappropriate comments to or about others.

How you can help:

• Use redirection (e.g., suggest a different activity or topic of conversation).
• Develop a special “stop and think” signal that you can use to alert your family member when he/she is doing or saying something inappropriate (e.g., raising your finger, saying a special word).
• Suggest that your family member stop and think, slow down, and consider options.
• Praise and reward desired behaviors; discuss consequences in private, after the fact.
• Avoid comparing past and present behaviors.

Poor Judgment

Sometimes it’s hard for a person with TBI to analyze a situation and understand what could happen.

What you might see:

• Inappropriate decisions; potentially harmful decisions
• Difficulty reasoning
• Ineffective problem solving.

How you can help:

• Help your service member to use effective problem-solving skills:
  • Identify the problem. If the problem has many parts, break it down into one problem at a time.
  • Brainstorm possible solutions together. Think of as many possibilities as you can.
  • Evaluate the alternatives. Consider the pros and cons of each possibility.
  • Choose a solution, the one that seems to fit best.
  • Role play with your service member/veteran to prepare him or her for various situations.
  • Have him or her try the solution out.
  • Evaluate the solution. If it didn’t work, try another solution until he or she finds the one that works.

Reduced or Lack of Initiation

Your family member may seem to have lost interest in activities he or she used to enjoy. You may find yourself offering frequent reminders to do simple tasks, like brushing teeth or taking a bath.

Your service member/veteran may not begin activities on his or her own. This is not laziness. Injury to the brain is the reason.

What you might see:

• Remaining in bed until encouraged to get up
• Spending much of the day sitting around, not actively engaged in activities
• Not speaking unless spoken to
• Problems completing tasks without a lot of supervision
• Agreeing to do something, but then not following through.

How you can help:

• Set up a regular schedule for your service member/veteran to follow. The goal is to learn a routine so well that it becomes automatic.
• Post the schedule. Make sure it is in the person’s calendar or memory notebook.
• Work with your service member/veteran to develop a list of goals or tasks to be completed. Help your family member check off completed tasks so he or she can see progress.
• Encourage your service member/veteran to become involved. Having purpose along with structure can help.

Repetitive Behaviors (Perseveration)

Perseveration means getting stuck on one idea or one behavior and repeating it again and again. Injury to the frontal lobe of the brain is the cause.

What you might see:

• Writing the same letters or words or repeating the same word or phrase over and over
• Repeating physical movements or tasks
• Getting “stuck” on one topic or theme (e.g., “when can I drive?”, “when can I go home?”, “I need a cigarette.”).

How you can help:

• Use redirection (i.e., try to change the topic or focus of interest to something else).
• Try engaging the person in a physical task if he or she is verbally "stuck” on a topic.
• Try engaging the person in a conversation or thinking task if he or she is physically “stuck” on a task.

Less Effective Social Skills

Social skills are all of the things we do and say in order to fit in, get along with others, and read and understand the people and situations around us.

Social skills form the foundation for relationships with others. They include:

• Thinking of topics for a conversation
• Listening to the other person without interruption
• Keeping the conversation going
• Reading the facial and verbal cues that the other person sends and responding to them
• Knowing when and how to end a conversation.

What you might see:

• Lack of awareness of personal space and boundaries (e.g., talking about private family matters, asking questions that are too personal, flirting with a married person)
• Reduced sensitivity for the feelings of others
• Possible disregard for acceptable standards of conduct at home or out in public
• Use of vulgar language or behavior.

How you can help:

• React calmly.
• Role play or rehearse responses to social situations.
• Use an agreed-upon signal to let your service member/veteran know that he/she may be saying something inappropriate.
• Use redirection (i.e., try to change the topic or focus of interest to something else).
• Praise and reinforce appropriate behavior.

Changes in Sexual Behaviors

Many people with TBI change how they act during intimate moments.

Those with moderate to severe TBI may sometimes act in sexually inappropriate ways. These behaviors can often be managed over time. It takes patience, feedback, and a consistent approach.
What you might see:

• Hypersexuality (thinking about or wanting frequent sexual activity, e.g., masturbation)
• Hyposexuality, or a lack of interest in sex
• Discomfort with intimacy
• Trying to kiss or touch strangers
• Making suggestive or flirtatious comments to or about others
• Disrobing or engaging in masturbation in front of others.

How you can help:
• Develop a “stop and think” signal to let your family member know that he/she is saying something inappropriate.
• Use redirection (i.e., try to change the topic or focus of interest to something else).
• Talk to your family member about what are and are not acceptable ways to act in public.
• Tell your family member that having sexual feelings is normal. Sexual behavior, however, is a private matter.
• Find a way for your family member to express his or her sexual needs (i.e., in the privacy of his or her room).
• Emotional changes and physical symptoms can affect desire for intimacy and sex. Ask your family member to discuss concerns with the doctor or counselor. (See Module 3.)

Lack of Self-Awareness

Your family member may not be aware of how the TBI has affected him or her. He or she may also not understand how it affects others.

Self-awareness means understanding our own strengths and weaknesses. Our sense of self-awareness is housed in the frontal lobe of the brain.

A reduced sense of self-awareness is a hallmark effect of TBI. Your family member may say very little has changed. He or she is not deliberately denying there is a problem. People with TBI simply do not understand that they are having problems.

Self-awareness usually improves with time and feedback from others. People with TBI learn from their successes and failures, just as we all do.

What you might see:

• Underestimating the problem areas related to TBI
• Not understanding why rehabilitation therapies are needed
• Not following the recommendations of the health care team (i.e., driving restrictions, no alcohol)
• Unrealistic expectations about future plans or abilities
• Inaccurate self-perception or self-image.

How you can help:

• Learn how to use safe, “supported risk taking” techniques from the health care team. This method allows the person to try to do something that he thinks he can do but that may be beyond his capabilities. The goal is to raise the person’s awareness through real trial and error situations.
• Work with your service member/veteran to use effective problemsolving techniques.
• Give realistic and supportive feedback.
• Help to set realistic goals. Develop plans to take steps towards larger goals.
• Use a memory notebook to track progress and setbacks.

What Are Common Emotional Effects?

Emotions start in the brain. Emotional self-control may be more difficult following a TBI. TBI can affect the complex neurochemistry system in the brain. This can lead to changes in emotional functioning.

Depression

Many people with TBI become depressed. This depression comes from both the physical changes in the brain due to the injury and the emotional reactions to it.

It is sometimes hard to tell the difference between symptoms of depression and effects of the TBI. For example, depressed people and people with TBI may have:

• low activity level
• sleep problems
• difficulty controlling emotions
• lack of initiation.

Men and women often have different symptoms of depression. They also have different ways of coping with the symptoms.

Men often report symptoms of:

• fatigue
• irritability/anger
• loss of interest in pleasurable activities
• sleep disturbances.

Men are more likely than women to use alcohol or drugs when they are depressed. They may engage in reckless, risky behavior. Men also tend to avoid talking about their feelings of depression with family or friends.

Women are more likely to talk about depressive symptoms to others. They often report feelings of:

• persistent sadness
• anxiety
• excessive crying
• feelings of guilt/worthlessness
• decreased energy
• increased appetite
• sleep problems
• weight gain.

In severe cases, both men and women may experience thoughts of suicide.

If you suspect that your family member is depressed, ask your health care team to evaluate his or her mental health. This is very important.

Depression can be treated with counseling and medication. If the depression is affecting the family, marriage and/or family therapy can help.

What you might see:

• Persistent sad, anxious, or “empty” feelings
• Feelings of hopelessness and/or pessimism
• Feelings of guilt, worthlessness, and/or helplessness
• Irritability, anger, restlessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Problems concentrating, remembering details, and making decisions
• Insomnia, early morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Persistent aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
• Less attention paid to grooming and personal appearance
• Thoughts of suicide, suicide attempts.

How you can help:

• Offer emotional support, understanding, patience, and encouragement. Remind your family member that depression usually fades with time and treatment.
• Talk to your family member and listen carefully.
• Acknowledge feelings, point out realities, and offer hope.
• Get your family member involved in activities outside the house (e.g., walks, shopping, movies, church services, volunteering). If he or she declines, keep making gentle suggestions but don’t insist.

Module 4, Chapter 5 provides information on suicide prevention resources.

Remember, depression is common as a person struggles to adjust to the temporary or lasting effects of TBI. Being depressed is not a sign of weakness. It is not anyone’s fault. Help is available…do not wait to call someone if you think your family member needs help.

Increased Anxiety

People with TBI often become anxious. Anxiety sometimes goes hand in hand with depression.

What you might see:

• Constant physical tension
• Excessive worry, racing thoughts
• Feeling jumpy, irritable, restless
• Racing heart, dry mouth, excess sweating, shakiness, or feeling short of breath
• Feeling panic or having a sense that something bad is going to happen.

How you can help:

• Work with your family member to recognize problems that he or she may be worried about. Use problem-solving techniques (page 48) to address them. This can help put the issue into perspective.
• Suggest that your service member/veteran write things down or keep a journal. Sometimes this alone can be calming and can slow down racing and nervous thoughts.
• Use redirection (i.e., try to change the topic or focus of interest to something else).
• Ask your family member to talk with the doctor about medications for anxiety. Counseling may also help.
• The health care team may suggest other ways to reduce anxiety. These could include relaxation training, controlled breathing, and other coping strategies. If they do, practice these strategies with your family member.

Mood Swings (Emotional Lability)

It can be frustrating and embarrassing when you can’t control your emotions. It can make it hard to participate in social situations.

What you might see:

• Laughing one minute, and feeling sad or crying the next
• An emotional response that does not “fit” the situation (i.e., crying when others are laughing, laughing when receiving news about the death of a loved one)
• Frequent, unexpected shows of emotion.

How you can help:

• Reassure your family member that you understand that his or her display of emotion may not match the situation. Be nonjudgmental.
• Help family and friends understand sudden shifts in your family member’s mood.
• Distract your family member. Use redirection (i.e., try to change the topic or focus of interest to something else).
• If the mood swings are interfering with your family member’s everyday life, ask him/her to talk with the doctor. Medications may be helpful in
• managing mood swings.

Changes in Self-Esteem

A person’s view of him or herself can be negatively affected by TBI. Feelings of low self-esteem go hand in hand with depression.

What you might see:

• Negative self statements: “I am worthless,” “I’ll never be normal again,” “How can you love me like this?”
• Less interest in personal appearance
• Social withdrawal.

How you can help:

• Encourage your family member to express his or her feelings. Try to redirect the person to more positive thoughts.
• Encourage your family member to spend time with others. Encourage him or her to take part in independent activities.
• Help your family member to set realistic, attainable goals. Help him or her to choose activities that he or she can successfully complete.

Should I Stay in Touch with the Health Care Team?

Your health care team is your best resource for support and education. It is important that you tell the health care team about the emotional and behavioral effects that you observe. This is particularly true as these effects change over time.

Remember, many TBI effects improve over time. Until they do, the health care team can help manage the challenges that your family member is facing. Rehabilitation, counseling, and medication are tools that the team can use.

See more information included in Module 2: Understanding the Effects of Traumatic Brain Injury and What You Can Do to Help.