In the wake of a traumatic brain injury (TBI), friends and family may find it easy to understand that physical recovery will take time. Fewer people are aware that TBI can take a significant toll on the emotional well-being of the injured person. Yet studies have shown that up to a third of all people with a TBI, whether mild or severe, experience irritability and anger. And patients who wrestled with anger prior to injury may find that a TBI intensifies the problem.
According to Tessa Hart, PhD, director of the MossRehab Traumatic Brain Injury Clinical Research Laboratory and director of the Moss Traumatic Brain Injury Model System, patients with TBI have legitimate reasons to feel angry.
“The brain is the organ that controls emotions,” says Dr. Hart, “and injury to the brain can affect how you express emotions, including anger and irritation. Patients with brain injury also experience drastic changes in their lives, such as the loss of independence, and cognitive problems that interfere with simple things like following a conversation. All of these changes can be very frustrating and can contribute to outbursts of anger. Patients who are angry after a brain injury should know that they are not alone—these are common problems.”
Problems with irritability and anger also can adversely affect those who interact with patients.
“Many people with TBI are at risk for losing their social support networks,” says Dr. Hart, “because people who display anger tend to drive others away. Irritability is also something that can be very difficult for professionals to handle—even those with experience treating brain-injured patients. Compared with other emotional disorders, such as depression and anxiety, anger doesn’t tend to garner much sympathy from others.”
Outside of a few small trials, the management of anger and irritability after brain injury is an area that is only beginning to be explored.
In 2011, Dr. Hart and colleagues from MRRI and Craig Hospital in Englewood, Colorado launched the first multicenter, randomized controlled trial of a psycho-educational treatment for anger following TBI. Funded by an NIH grant, the trial is designed to test and refine a unique protocol that teaches patients how to manage their anger more effectively.
Combining their brain injury expertise with the anger management expertise of collaborator Roland Maiuro, PhD, who directs a domestic violence center in Seattle, Dr. Hart and her colleagues have adapted anger management principles and techniques so that they can be used by patients who have difficulty with reasoning and memory.
“During eight highly structured one-on-one sessions, therapists and patients are guided by a manual that is almost scripted,” says Dr. Hart. “There’s a lot of repetition, which helps to compensate for memory deficits. For example, sessions always begin with a review of the previous session and then end with a recap of the current session. Each session has a particular theme or topic, and topics are organized so that they begin with introductory educational material, and gradually incorporate more sophisticated techniques for self-managing anger.”
The sessions are designed to help patients recognize their feelings and why they have them. Patients learn that anger is a protective emotion that occurs when they feel threatened. They discover that after brain injury, they are more susceptible to feeling belittled, confused, or frightened, and they learn that it’s easy to react to these threats in a knee-jerk way, with anger.
“We teach people to express the underlying emotions instead of reacting in anger. Patients might learn to say ‘I’m confused, can you explain that?’ which works better than a frustrated outburst. We show them how to express themselves in more effective ways to get what they need.”
One patient, who had automatically responded to her mother’s complaints with anger, gradually learned to change their interactions.
“When my mother started complaining to me,” she said, ‘I learned to say: ‘Mom, I really need a time out right now. I know you’re just venting, but can we talk about it later? You can finish venting in about 20 minutes. Right now I’m feeling overwhelmed.’”
The patient’s mother understood and apologized, and communication between the two became more productive.
Recently Dr. Hart and colleagues added a special type of follow-up, a “treatment enactment” phase, to their trial.
“This part of our research is unique,” says Dr. Hart. “The treatment enactment phase allows us to find out how a person has changed his or her everyday behavior in response to this therapy. We hear about the changes in patients’ daily lives, and so far we are getting promising feedback that will help us make the therapy even better.”
At MRRI, Dr. Hart also directs other research involving emotional regulation, including a randomized controlled trial examining the use of the everyday technology of text messaging to help individuals with TBI manage anxiety and depression.