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After Brain Injury: The Dark Side of Personality Change, Part 2

Tips for understanding and managing anger after brain injury

When anger and agitation are ongoing problems after brain injury, life can get dangerous. Dangerous for the survivor, and for the family caregiver. In my last post, "The Dark Side of Personality Change, Part 1," I described some of the reasons my husband Alan's brain injury impacted our relationship and safety. In this post, I'll share some suggestions for understanding and changing potentially dangerous behaviors.

Step One: Understand the purpose of the anger.

There can be many injury-related reasons for a person who has a brain injury to have problems managing frustration, anxiety, and anger. There are also plenty of understandable emotional responses to all of the losses, changes, and challenges of recovering from brain injury. However, it's important for family to understand that anger and agitation serve a purpose for the person experiencing strong emotions, even if he/she can't tell you the purpose. Anger is an attempt to communicate, even though it often shuts down communication.

There are many medical reasons a person might have an angry outburst. These include pain, headache, poor sleep, medication reactions, infections, seizures, or problems with hearing or vision. If the angry outbursts are a new problem, start by looking for a medical explanation.

Substance abuse adds fuel to the fire. Alcohol or drug use increases the risk of violence. Get help early.

Anger can arise from awareness of losses, changes in family and job roles, frustration about being less independent, and not being able to process or control what's going on around him. Alan's worst outbursts were triggered by not being able to drive his car due to cognitive and physical limitations that made driving unsafe. I eventually understood that Alan's car symbolized both the intangible and concrete losses he'd suffered: his profession as a professor of physics, his family roles, his independence and freedom, and his status in society.

Over time, Alan (and I) gradually grieved his losses, then built a new identity and life based on his current abilities, interests, and passions. He exerted control over new aspects of life he could safely manage.

Step Two: Figure out the cause of the anger.

In the beginning, it's most helpful to work with a specialist in behavior problems. This might be a neuropsychologist or psychotherapist. Behavior therapists often recommend the A-B-C method.
A stands for antecedent, which means the trigger that happened right before the outburst. For example, Alan became overstimulated by all the cereal choices in a crowded grocery store.

B stands for behavior in response to the trigger. When overstimulated, Alan might shout and stomp out of the store, pushing aside anyone in his way.

C stands for the consequence of the behavior. This is what happens next that either increases or decreases the chance of the problem happening again.

Sometimes the triggers showed that Alan needed to learn a new skill to better handle a situation. At other times, I realized that my unrealistic expectations were beyond his capabilities, so I scaled back the expectations.

Step Three: Pick an approach and give it a fair try.

Here are some specific strategies we found effective.
1. Learn to recognize early signs of anger and take action. For Alan, that meant noticing muscle tension, taking a deep breath, and relaxing his shoulders and hands.

2. Put anger into words early. Alan tried to tell me as soon as he noticed feeling anxious, angry, humiliated, or frustrated so I could help him solve the problem or reality test his thoughts. Humiliation turned out to be a prime trigger, so we worked on competency skills to build self-esteem.

3. Plan a way to take a "time out" instead of arguing. Alan liked to go to his office alone and read an interesting book to distract from the thoughts making him angry. I checked on him unobtrusively, but gave him space. I took a "time out" when I got too frustrated to be reasonable.

4. Limit stimulation and choices to avoid getting overwhelmed. We only went to stores early in the day, and then I'd hold up two kinds of cereal for Alan to make his choice.

5. Use the communication strategies that work for the survivor. Allow plenty of preparation time for changes and new experiences. Get help learning better communication techniques.

6. Get plenty of physical exercise. Exercise provides tension relief, stress release, and a sense of accomplishment.

7. Write out the plan you are practicing. Alan carried an index card to remind him of the strategy he was working on.

8. Focus on what you can do, rather than on what you can't do. Offer alternatives such as going for a walk or calling a friend to blow off steam, rather than yelling.

9. Reward each step toward positive change.

Key points to remember

1. Safety is your first priority. As a caregiver, you must ensure your safety as well as the survivor's. Have an emergency plan and don't hesitate to activate it. I called the police a few times when Alan's rage reached threatening levels. Their presence and skill helped him regain control.

2. Tell a professional about the problem. They can evaluate for medical or psychiatric causes, and recommend better ways to manage. Sometimes medications can be a valuable part of the treatment plan.

3. Ask for help learning communication skills for your situation. Update skills as the situation changes.

4. Take anger seriously. As a psychiatric RN I knew that when a person yells, turns red, clenches his muscles, makes fists or suddenly gets very quiet he is capable of striking out. Stand at least a leg length away, speak clearly in short sentences, and use your emergency plan to get help.

5. Don't get trapped into unproductive arguing. Disengage, and focus on defusing the situation.

In my memoir, Professor Cromer Learns to Read: A Couple's New Life After Brain Injury, I detail many of the strategies we found helpful to communicate more effectively and help Alan manage his emotions and behavior.

Visit for more tips for caregivers.

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