Anger and Traumatic Brain Injury: Common Companions

"I have to walk on eggshells around her." "He blows up at the slightest thing." "I used to be pretty mellow, but now I have no patience with anyone." "He has zero frustration tolerance." As a neuropsychologist involved in TBI rehabilitation for more than 30 years, I've heard about anger and irritability more times than I can count. The research bears out that anger is a very common problem after TBI, affecting one-third to one-half of TBI survivors at some point in their recovery.

Granted, some people have problems with anger before their TBI-in a minority of cases, the TBI is caused by being assaulted in an angry altercation. And everyone, with or without a TBI, gets angry and irritated sometimes-more on this below. But for many people with TBI, anger is a new problem, one that threatens jobs, relationships, and self-esteem. Why should this be, and what can be done about it?

There are many reasons why anger becomes a problem, or more of a problem, after TBI. If the frontal lobes have been injured, it may be more difficult to apply the "brakes" on emotional responses, or to think through the best ways to approach a conflict. Anger and irritability may also arise from the frustration caused by being less able to follow conversations, multi-task, or deal with crowds, noise, and other everyday life stressors. Frustration can be piled on by the major life changes that are often associated with TBI-loss of independence, unemployment and financial strain, and changes in significant relationships. Irritability can even be a side effect of certain medications. It's very hard to disentangle all these potential factors and figure out exactly "why" a given person has anger difficulties after TBI. Instead, let's consider what may help people with TBI to re-gain emotional control.

In my experience, it's helpful for everyone involved to remember that anger is a normal, essential reaction to threat. Anger is what prepares us to "fight back" when we're under attack; without it, we'd be defenseless. The goal should never be to get rid of anger (this would be impossible as well as unhealthy), but to manage it differently. Often, a good first step is to learn how to identify the threat. Does the person with TBI feel belittled, disrespected, inferior, stupid, confused? Many people with TBI have told me that they have these kinds of "threat" feelings every day, and that they do indeed contribute to blow-ups. Recognizing the situations that have become threatening can help the injured person and family prevent or work around them. For example, negotiating a certain way of offering help can result in less threat to the person's sense of independence and self-esteem if help is needed. Asking the people crowded around the dinner table to try to speak one by one, rather than all over each other, can reduce the threats caused by misunderstandings. And we should all realize that negative expectations and negative language contribute to negative feelings like anger. People with TBI tell me that they start to feel overwhelmed by "Can'ts" and "Don'ts." "You can't drive... you can't go back to work... don't go out alone... don't forget your medication." Even if some of these reminders are necessary, anger and irritability will lessen in an atmosphere that also recognizes and celebrates "Cans" and Dos"-- strengths, skills and accomplishments.

But none of us can avoid all threats or angry feelings; they are part of everyday life. The person with TBI can learn how to handle threats differently when they do occur. The simple "count to 10" strategy is a cliché, but variations on this time-out method can be quite effective in breaking up the impulse to snap back. Even a few moments of cooling down can clear the path to better thinking about how to handle a threatening situation. We can also try expressing the "threat" feeling instead of the anger that goes with it. "Wait, I'm confused!" will usually lead to a better resolution than "You make me so mad!" Depending on the situation, the best decision may be not to handle it overtly at all, but to engage in "self-talk" to remind oneself that's it not personal, and not worth the trouble. And everyone has at least one "calming strategy" that can be put to good use when anger rises. For some of us it's listening to music, for others taking a walk, retreating to a favorite chair, or texting a friend. With permission from the person with TBI, family members can remind him or her to use these go-to strategies in a tense moment.

Do you or a family member affected by TBI have any anger management strategies to share? We'd love to hear about them and to revisit this topic in future blogs.