Understanding Behavioural Impairment
The symptoms of Dysexecutive Syndrome (DES) are usually considered in three broad categories – cognitive, behavioural and emotional.
*Causes of behavioural changes
*Viewing the body as a whole system
*Other impairments that affect behaviour
*Behavioural effects, such as impulsivity, apathy, and disinhibition
The signs of behavioural and emotional outcomes often overlap in understanding, but the signs of cognitive outcomes are generally easier to spot. However, it can be difficult for people to understand what is causing a certain behaviour or action because often, many things are happening all at once.
For example, someone glued to the sofa could be struggling with apathy. There can also be problems with someone knowing where to start, with flooding, depression, or difficulty breaking things down, and so on. It could also be all of these things happening together. The best thing to do, as an observer, is to resist making any judgements. People often base their assumptions on what we would typically assume about the everyday world, rather than being based in clear and objective understanding about brain injury.
By learning more about the outcomes, and what causes them, we can all start to be better objective observers; even those who are learning all over again to be self-objective.
It is important to bear in mind that some changes may be an exaggeration of previous personality traits.
It is also really important to be both patient and sensitive towards people as it is possible that dealing with a huge array of changes and problems could cause mental health issues.
New science tells us that the gut can also affect behaviour, and, given that the chemical reactions of the brain to injury can cause adrenal fatigue, hormonal imbalance, changes to gut flora, stomach acids, and the workings of other vital organs, we need to view the body as a whole system and look beyond just the cellular brain.
Changes to the way executive functions work can also directly affect behaviour. It is important to remember that changes can be overcome and very often, people aren’t aware that what you see is different from what they intended.
Many behaviours ‘just happen’ to a person following a brain injury with no conscious awareness and often without preceding contemplation or thought. Just as PTSD can ‘fire’ without control, so too can behaviour.
There are a lot of things to take into account, such as possible pre-injury factors, upsets caused by the trauma itself, and even psychological issues that may need addressing and may exacerbate certain behaviours.
Some changes may seem completely out-of-character and often these are attributed to the effects of the trauma, which sometimes means the real cause may be missed or misunderstood. Misunderstandings can very easily and quickly lead to frustration and anger as people struggle to express themselves clearly and to fully understand.
Differences in behaviour do not automatically mean that the core personality has changed and that someone will never be the same again. Recovering the sense of self can take time, and very often, the confusion and fear caused by outbursts are significantly distressing.
Behavioural changes can be extremely difficult to understand, and for families and loved ones to adapt to.
Because the brain is constantly rewiring following injury, there is a good chance that control will be regained. In cases of very severe injury, it may be necessary to use medications to control behaviour, especially aggression and sexual changes. With the guidance of a functional neurological specialist, it may be possible to gradually replace prescription drugs with natural substances.
For those receiving intensive treatments, it is always imperative to follow the guidelines of the specialist.
Behavioural changes can also occur after mild or moderate brain injuries.
It is important to treat the behavioural outcomes as individual events as letting them amass can lead to assumptions about the cause.
People can also find it really difficult to be aware of or notice their own behavioural changes, which will impact their ability to both understand the changes and describe them.
Those living with outcomes may appear to be less flexible, obsessive or seem to have a complete change in attitude. Someone who was previously self-responsible may now seem to be more prone to a victim mentality, and someone who was conscientious may now seem less motivated or willing to help themselves. There will be very real structural and chemical reasons for these changes, which are the preferred understanding, rather than the label that is generally given – change in personality. The personality has not changed – the behaviour has.
Believing that it is a change in personality can distance some people from dealing with their own levels of understanding and expectations. It is often seen as an unhelpful way to think because it enables people to dismiss what is going on around them and to avoid taking responsibility.
All of these behaviours can cause worry, and very often it is those on the ‘outside’ who are most concerned.
It is possible for the person living with the outcomes of brain injury to be oblivious to the changes others see. They may only become aware of behaviour if it is pointed out to them, or after a period of reflection about their confusion. Insights gained may quickly be forgotten and in this respect, recovery can be very stop-and-start.
Knowing what to expect and understanding why things are happening can really help in our approaches to dealing with outcomes. It may be that everyone needs to adjust and be more aware of their expectations.
Examples of impulsivity are: spending more money than can be afforded, saying things or making remarks without thinking about how this could upset someone, or, as commonly happens, agreeing to or offering to carry out a task without considering if they will be able to either do it or complete it. The willing attitude is still there – it just hasn’t been updated to understand the range of deficits that make many things much harder.
It is really difficult for people to be able to see a bigger picture, which is why consequences fail to be considered. It can be that there simply isn’t enough space in conscious thinking abilities to stretch further than a moment. See Processing
Perseverance is a common outcome and may stem from a deep desire to be understood, meaning that a person tries to cover every angle possible and shares it all ‘out loud’ instead of being able to summarise.
People may also become obsessed with safety issues, so they will regularly check their money or that the house is locked. Most of the time, these behaviours are driven by the fear that something will be missed, lost or forgotten, and people are constantly rechecking things to make sure they have carried out responsible duties.
Many people also insist on certain routines and doing things a certain way. This is mostly driven by the fear of forgetting how to do something after they have learned it again. When relearning strategies and coping mechanisms, people will be obsessive about repetition because they understand this is important to regaining lost skills. This can make people appear far less flexible but in reality, they need support and the room to stick to these learned routines until such time as the new neural pathways are strong enough that they will have formed habits.
The more people recover the less obsessive they are.
Irritability and aggression
They can appear to be impatient and this is generally caused when they are struggling to keep focused, rather than attitude. People can also be intolerant of others’ mistakes, and again, this isn’t down to them having made judgements or assumptions about someone but is usually caused by a fear of their attention capacity being overloaded which, usually causes them to forget other important things they are trying to keep in mind and remember.
Irritation can also occur as the result of disruptions or interference, and noise can be a big problem as it also makes it much more difficult for people to maintain their attention and concentration.
Observers can tend to wonder why people keep repeating the same ‘mistakes,’ but this isn’t about putting your foot in it occasionally: it is about having to live with an impairment that you cannot control and struggle to learn about because of memory issues and other cognitive impairments.
People can make tactless remarks, give too much personal information about themselves, or others, and can also laugh at the wrong things and times. These are awful events for people, especially when they pertain to making inappropriate sexual remarks or advances. Sometimes overwhelming feelings of frustration with being unable to control this can lead to temper outbursts or even aggression.
- Specialist services are available to help with managing behavioural issues. Speak to your doctor and ask for a referral to a neuropsychologist.
- All of these changes and more are looked at in more detail in the articles and posts section of the site. These are regularly uploaded to the Global Brain Injury Awareness page on Facebook. To receive notifications, all you need to do is like or follow the page.
- Always discuss strategies and ideas that may help with each other and with professionals.
- Keep hope and remember that neuroplasticity means this is not forever.
- Talk to other people, learn from mistakes and recognise vulnerability.
- At some level, people will be aware that their behaviour is inappropriate. It isn’t always necessary to constantly correct people, try and judge when it is okay to ignore or overlook behaviour.