I I . PATIENT BEHAVIORS TABLE OF CONTENTS A. Agitation B. Irritability C. Verbal Outbursts D. Temper Tantrums E. Family Abuse F. Egocentrism G. Impulsivity H. Liability I. Denial J. Paranoia K. Obsessional Disorder L. Depression M. Lack or Motivation N. Social Immaturity 0. Social Dependency P. Change in Sexual Interest Q. Insatiable Drive for Nourishment Excessive Talking. 28 I I. PATIENT BEHAVIORS II. PATIENT BEHAVIORS In the initial stages of a severe head injury, the only behavior that you are concerned with is "living" — day by day your major concern is for the life of your loved one. This time might be labeled the "sitting at bedside stage." As the days have passed the loved one has moved toward the "medically stable" stage and you have thought that you are out of the woods. You have interpreted the thrashing and agitated behavior as a very positive sign ... He is alive and moving. The reality is that this is the Beginning of a long and hard road that will probably lead you into a woods that is very unfamiliar. We are all somewhat familiar with death and there are universal methods of dealing with it; but your loved one did not die. We are even more familiar with the concept of dealing with broken bodies — in time all will heal and it will be life as usual. On the contrary, we are not at ail familiar with the "Broken brain" and there is little data to tell you how long it will take and if it will ever work like it did before. Thus, families are ill equipped to understand and handle the impending actions of the head injured patient. In working with families we have experienced a similar expression over and over. This is best displayed by the following thoughts: Those who have felt comfortable with us have actually verbalized that if they had known what lay ahead they would not have been so anxious for the patient to live. Their ability to express themselves in this manner is often followed by the realization that this is not the same person they knew and loved before the accident. They know they would have wanted the other person to return to them, but they experience doubts regarding this stranger who is going through either the "looking good — acting bad" or "looking good — thinking bad" stage. Many families deny the relevance or the patient's inappropriate behavior by relating it to the physical trauma the patient has just experienced. There is some validity in this thinking. Patients frequently respond to the question, "Why are you here in the hospital?" by saying things like "Because I did something bad" or "I've been captured by the Germans" or "I am being murdered." It is not difficult to conceive of why they might feel they have been imprisoned. They have spent days where nurses have pushed, poked, and pulled them and where doctors have possibly cut openings in their throat. They may have been tied down for extended periods of time so that they could not pull out tubes that were feeding them or helping them breathe. Many family members say that they would probably act the same way if they have been through a similar ordeal. Although there is truth to this interpretation, the major factor involved with the patients' behavior is altered brain functioning. The brain has been jostled around or injured in some respect so that insight and judgment are significantly impaired. The attention and arousal center has been affected so that the patient no longer has the social control over his behavior that previously was maintained with little to no effort. The outer covering of your loved one may look familiar but he may have become what some have termed a "completely different person." In order to best deal with these changes, we hope that we can provide you with a comprehensive explanation of all the possibilities you may face. Following is a list of the various behaviors. They are arranged somewhat chronologically. The initial topics are behaviors that occur shortly after injury and are the result of damage to the brain cells. The latter deal with longer range social and emotional complications that are a consequence of the patient's attempt to adjust to his altered world. Your family member may experience all eighteen (18) of these or only three or four of them due to the fact that the results of the head injuries are extremely variable. However, we feel that we should briefly expose you to the varying possibilities. A. AGITATION Agitation encompasses a multitude of observable behaviors including: (1) Constant movement; (2) Inability to focus one’s attention; (3) Pacing; (4) Getting up and down from one’s seat; (5) Repetitive purposeless activity; and (6) Self-destructive actions. These behaviors are usually unprovoked and unrelated to the patient’s family or environment. Thus, there is nothing that you have done to bring on the restlessness. The patient’s world has been turned inside out and upside down leaving him generally confused and disoriented. Engaging in these agitated behaviors is a coping mechanism. One patient described this by saying, “I used to walk up and down the halls. I felt like if I stopped I would go crazy.” This period of time is often just as hard on the family as it is the patient — remember, it is only a stage that the patient passes through and not a permanent behavior change. Examples 1. Patient continually pulls out IV tube while hospitalized. 2. Patient becomes very upset and restless when his therapist does not come to get him on time. 3. Patient becomes agitated that his family member did not visit when he expected. 4. Patient continually attempts to get up and down out of chair during his staff meeting. 5. Patient talks incessantly about driving his new truck again and continually searches for the keys in an agitated state. Resolutions for Agitation they need the security or 1. Be available as much as possible during the agitation state - - they need the security of someone they know. 2. Move the patient gently into new activities — do not make sudden or quick changes. 3. Redirect the patient’s attention away from the focus of agitation. 4. Allow excessive talking — this may be an effective way to work through the agitation. 5. Model calm behavior. Appear calm even if you are not calm. 6. Structure the patient’s time so that there are not long periods where he can ruminate. 7. Restructure the environment so that excessive distracters (both visual and auditory) are removed. 8. Monitor your own behavior carefully. Eliminate all nonverbal cues that could possibly be misinterpreted by the patient (e.g., frowning, eye rolling, head shaking, tongue-clicking. throat clearing, tone of voice). If you are unaware of your own nonverbal methods of communicating frustration or anger, ask another family member who is experienced at reading you. B. IRRITABILITY We are all aware of what is meant by irritable behavior. In a sense it is a mild case of agitation that characterizes the patient as constantly in a bad mood or generally a "grouch." From an organic standpoint the injury has altered the patient's ability to: (1) interpret situations accurately; (2) perform simple tasks effectively; (3) attend to important cues and ignore useless information. Thus, the individual is much more inclined to display irritable behavior. Like agitation, excessive irritability is a stage, but the individual may always remain generally more easily annoyed by trivial matters than he was prior to the accident. Examples 1. The patient responds negatively to environmental noises such as vacuum cleaner running, children playing, television "blasting," etc. 2. The patient may be irritable because he cannot hear correctly due to the injury resulting in a true hearing loss and/or auditory discrimination problems. 3. The patient may become very irritable if he has to wait in a doctor's office. 4. The patient may be resistant and irritable to any true change in plans or any misconstrued change in plans. 5. The patient may show irritability to mild physical discomforts such as too hot, too cold, or a 6. minor injury such as stubbing his toe. Resolutions for Irritability 1. Do not challenge or confront the patient about his apparent "bad mood." 2. Compromise whenever possible. Do things he does not like somewhere else. 3. Negotiate: A. The vacuum cleaner is bothering you now. Tell me when it would be a better time to run it. 4. Would it be acceptable for the children to play inside if they go in the room and close the door? 5. Structure the day so that unexpected happenings are at a minimum. 6. Whenever possible, allow the patient to be a part of the decision making and activity planning. He should have a say so not only in outings but also in what time he will bathe or eat.. meals. If he has been a part of the decision it will 'be more difficult to criticize. 7. Do not consider irritability a manipulation and do not take it personally. It is a result of the brain injury. C. VERBAL OUTBURSTS If the head injury of your loved one was severe, you may have been or you may now be panicked that they will never talk again. That concern quickly diminishes when verbal behavior reinitiates; however, it is often replaced by extreme concern over what they are saying. Head injured patients fairly consistently go through a stage whereby they blurt out the first thought that emerges from their confused and disoriented thinking. The verbage during this stage is often automatic as opposed to volitional and is no different than the inability to control urine or any other physical response. The filtering system is at best dysfunctional and initially nonexistent. The little voice that previously said, 'I better not tell Aunt Mary I think she's a jerk because my mother will be mad at me’ is no longer operating. If Aunt Mary visits she will probably learn that she is considered a jerk. Excessive cursing is often a characteristic of the verbal outbursts. No one is immune — even the person who never spoke a foul word in his life. You must be prepared to hear thoughts and language you may never have thought existed in the patient's head. If the patient tended to utilize excessive profanity prior to the accident, it is very likely that every word out of his mouth will be foul for a period of time. Verbal outbursts are a stage, but again, the patient may throughout the rest of his life be more open and honest with his true feelings. As the patient becomes re-socialized these outbursts will diminish in intensity and frequency. As language skills increase, the need to rely upon this type or communication decreases. Examples of Verbal Outbursts 1. Patient: "Where's the G— D— nurse now?" 2. Patient: "You don't care about me. If you really loved me you'd be here every day to see that I get good care." 3. Patient: 'They don't know what they're doing here. Take me home now." 4. Patient: "You're probably just as glad I'm not at home to bug you." 5. Patient: "Why did Aunt May come with you today? You have never liked her." Resolutions for Verbal Outbursts 1. Whenever possible, ignore the verbage. 2. Do not take it personally. 3. When appropriate, redirect the patient's attention to something else. 4. Warn friends and family that the patient has had an injury to the head which has altered his ability to think clearly. 5. If possible, discourage visitors with whom the patient has not had positive communication prior to the accident. 6. When you feel that the patient has some capability for control, be direct about your feelings — but not critical. a) My feelings are hurt when you talk to me this way. b) I am offended by the words you use c) It embarrasses me when you tell other people things I have said to you about them. D. TEMPER TANTRUMS Brain injured individuals often resort to physical expression of their anger and frustration because they are experiencing: (1) difficulty verbalizing their feelings: (2) difficulty controlling their impulses; and (3) inability to cope effectively with their environment. They can become combative with little or no provocation. At one moment they may be lunging toward their wife screaming, "I'm going to strangle you," and the next moment they may be innocently asking, "What's for dinner, dear?" If you are the type of person who holds a grudge, you will need to change. Destructive behavior may be the patient's method of showing other people how helpless and out of control he feels. The same techniques apply that are utilized with small children who have temper tantrums. It is best to remember that these are spontaneous acts with little to no forethought or purpose and that their duration is usually shortlived. Examples 1. The patient throws his cup of coffee when he discovers that he has problems drinking it without spilling. 2. The patient throws the puzzle on the floor and tells the Therapist to pick it up indicating he does not want to do baby tasks. 3. The patient pushes the wife on the floor in an attempt to go outside and drive away in his car. 4. The patient throws the vacuum cleaner in the yard because he is bothered by the noise. Resolutions for Temper Tantrums 1. Protect yourself and others by removal if necessary. 2. Ignore, ignore, ignore. 3. Do not remind the patient of the incident. 4. Verbalize for them what you think they may be feeling, but do so without condemnation. 5. Remember that the person usually is not truly angry at the person they have struck, so do not take the action personally. 6. Redirect the patient's focus to a more positive goal or task. 7. Do not display fear. 8. If you are a grudge holder, see someone who can help you change this behavior (pattern possibly utilizing — relaxation 'or other techniques. 9. Allow time for the individual to make amends and recognize the consequences of his behavior, e.g.. -.spaghetti on the floor, broken glass on the floor, etc. E. FAMILY ABUSE There is obvious overlap in this area with both verbal outbursts and temper tantrums; however due to the extreme emotional stress that family members experience as a result of verbal and physical abuse, we feel that this deserves to be addressed separately. This is the age old story of "you only hurt the one you love" in that family members often receive the major portion the abuse the patient has to offer. At first, the patient may have had no control whatsoever and he will be abusive with anyone and/or everyone. As he begins to develop some behavioral control, he becomes more socialized with staff, friends, and strangers but often remains difficult with family. A similar type of phenomenon occurs in the care of an elderly person whereby the primary caretaker gets all the abuse, but other family members or friends are treated with respect. Families often say, "If he can be nice when the nurse is here, I know he can be nice with us too if he really wants to." At this point, they misinterpret and conclude that the patient is being nasty with them on purpose. This is not initially the case. From a neurological standpoint, the patient has now developed some self-control and he has learned to use it with people outside the family because he has begun to reintegrate his socialization skills. On the other hand, he may never have learned to utilize socialization with his own family prior to the accident. In fact, the person may never have considered the need to control his thoughts or actions at home. He is really not thinking any differently than before. He is not any meaner than he was before. He is really thinking the same, but responding more spontaneously due to the head injury. He does not know how to use the controls at home — he must learn something that he has never had to do before. This must be approached gradually and in a nonthreatening and nonconfrontive manner. The issue of family abuse can become extremely complex as behavior patterns are set up in the home. Families often find themselves compromising and avoiding anything that may "set off' the patient. In essence, they change many things to please the patient. As the patient becomes more aware of his actions, there is always the danger that he will learn to manipulate family members as he realizes the control he has over their life. This transition is often gradual so that no one realizes the change from the patient being completely out of control to the patient controlling everyone's behavior. Awareness that this transition can take place is the first step in preventing or at least deterring these results. Another issue that is important in the area of family abuse is knowledge and recognition of those points of family disagreement that existed prior to the accident. Injury to the head tends to lead to an exaggeration of thinking and personality patterns. If the patient was involved with a long standing feud with a son-in-law, you can pretty well assume that the feud will be increased to the point that the son-in-law may no longer be allowed to come to the house or even call on the telephone. Thus, there exists the potential for increased family conflict on top of all the strain related to the accident. You, as a primary caretaker, may find yourself functioning as a family referee as well as a counselor to those with hurt and angry feelings toward the patient. Examples 1. A head injured grandfather pushes his grandson off his lap. 2. A head injured stepfather does not allow his stepdaughter to come to the house or telephone due to previous dislike for the stepdaughter's husband. 3. A head injured husband accuses his wife of infidelity. 4. 4.. A head injured woman insists that her husband go everywhere with her or she begins to scream hysterically. Resolutions for Family Abuse 1. Don't take it personally. 2. Treat each occurrence as an isolated incident. The patient probably does not remember he acted this way before. 3. Maintain some type of outside support (counselor, friend, etc.) to express your feelings. At this point in time the patient himself will not appreciate discussing your feelings. 4. If young children are involved, help them to recognize and avoid behavior that could be potentially harmful. 5. Educate all family members in order to provide consistent responses to the abusive behavior. If the patient learns that he can obtain a desired response from one person and not the other, he will quickly learn to move into the "manipulative stage" with the individual who is giving in. 6. Do not allow issues to become "win-lose" struggles. Eventually both patient and family lose with this tactic. 7. Remember that most threats are expressions of fear (fear of dependence, fear of abandonment, etc.) or anger at a situation rather than at an individual. 8. Do not allow yourself to live in a reign of terror. Succumbing to the patient's threats may set up a pattern that could take years to break. 9. If you find that you are already trapped into living your life exactly as the patient demands, you may need to seek assistance to preserve your right to choose your own activities and friends. F. EGOCENTRISM After a severe head injury, the patient often becomes completely self-centered displaying behavior similar to that of a three- or four-year-old. The person's capacity to be empathetic to other's needs is diminished. He possesses a significant decrease in insight and is not aware of the effect his actions have on other people. The world revolves around him and his concerns. He interprets all actions in relation to himself. Due to his difficulty perceiving social situations adequately he may misinterpret another person's response either by assigning to it a hostile interpretation or by thinking a response is specifically directed toward him when, in fact, the issue at hand is completely unrelated to him. This trait, along with the previously addressed issue of family abuse, can be the "crowning blow" to efforts by family members to reintegrate the patient back into the home environment. We are all very willing to go the extra mile for someone who realizes and appreciates our efforts. However, we are trained to be unresponsive to selfish individuals, and this is often a very appropriate descriptor of the head injured patient. As a result, families either unknowingly or even knowingly pull away from this self-centered person, and this in turn often results in the patient becoming even more egocentric. This is another behavioral problem that does not cure itself with time and, in fact, can worsen if appropriate steps are not taken. Examples 1. A grandfather becomes jealous of the attention paid to his grandson by his wife. 2. A grandfather hides candy saying that the grandchildren will eat it when they come over. 3. A Vocational Rehabilitation client feels that his counselor is delaying services to hinder his progress. 4. A wife does not want her husband to go out without her. 5. A husband wants to cut off the hot water to save money, and is not concerned that his wife must bathe and wash dishes in cold water. Resolutions for Egocentrism 1. Do not relinquish everything to the patient's needs. 2. Do not allow the patient to get to the point of expecting that all his demands will be met. 3. Be aware that his egocentricism may interfere with your desire to continue to assist his rehabilitation. 4. Do not expect the patient to respect your rights — you may have to do some demanding of your own. 5. If possible, get the patient involved with a head injury support group. Often the best way to get someone to realize his own fault is to see it in another patient and, thus, criticize the results of selfishness. G. IMPULSIV1TY Impulsivity is the lack of behavioral control over either action, verbalizations, or both. The part of the brain that deals with attention is damaged to the point that the patient acts before he thinks or acts upon inappropriate or confused thoughts. The patient responds to anything and everything equally. He does not have in operation any effective filtering system. This characteristic is not only frustrating but also very embarrassing for the family. Impulsivity leads to excessive "demanding behavior" which can be both tiring and irritating. It is also characterized by a propensity to blurt out the first thought that enters his mind regardless of who is present. While the family may be mortified, the patient does not appear to comprehend the significance of the breach of etiquette. Examples 1. The patient grabs the newspaper from his wife while she is reading it. 2. The patient tries to put together a bookshelf in a quick manner so that his rushing leads to difficulty with a simple task which, in turn, leads to increased frustration. 3. Upon answering the door, the patient says to the neighbor, "Why do you always come over when we are about to eat?"'' 4. The patient turns off the TV even though others are watching because he thinks the program "is stupid." 5. The patient walks out of therapy when the receptionist says the therapist will be five minutes late. 6. The patient chain smokes with little realization that he just finished a cigarette. Resolutions 1. Behavior management systems can be utilized to bring the patient behavior under control. You will need assistance from a knowledgeable therapist, counselor, or social worker to effectively implement a system. 2. You yourself can set short term rewards for brief periods of self-control (e.g., not telling every stranger about his accident, spacing cigarettes in order to decrease smoking, eliminating impulsive between-meal snacks, etc.). 3. Re-direct the patient's attention to appropriate behavior. If they act or speak impulsively because the TV is too loud, direct them into another room and attempt to refocus their actions to something constructive. H. LABILITY Lability is nothing more than a loss of control over emotions. The fact that the emotions are more quickly displayed does not mean the emotion is stronger than it ever was. Instead, the patient does not have the ability to discriminate about how and when to express his feelings. While a "normal" person may be able to control joy or sadness or anger and express appropriately at the right time and place, the brain injured individual cannot. This excessive display of emotions can be very unsettling to families who are attempting to bring their own emotions under control. This stage is due to damage to the brain, especially the areas dealing with impulses and emotional responses. These quick and frequent mood swings can be extremely tiring to family members who are attempting to keep things on an even keel. Due to the patient's misperception of the environment, mood changes are difficult and at times impossible to avoid. This lack of control can lead the family members to view the situation as so unpredictable that they entertain thoughts of "escape" or at least respite care. Examples 1. The husband (patient) starts talking to the therapist about his wife and immediately begins to sob. 2. The therapist may be discussing activities that were favorites in the past such as painting and the patient may begin to cry. 3. The nurse may remark that the picture of his children shows they are very "good looking" and the patient will begin to cry. 4. The mention of anything about which the patient feels sentimental can bring tears. 5. The patient may laugh and giggle before every comment he makes regardless of its content. Resolutions for Lability 1. Do not criticize. Brain injured patients are very sensitive to criticism which can thus lead to excessive overreaction. 2. Praise him and point out those times when he does control his emotions. At those times, attempt to get him to explain how he is managing to maintain self-control. If he knows how he does it, he can use it again. 3. Reassurance and confrontation regarding lability are unnecessary. In fact, addressing the issue may embarrass the patient. 4. Address the behavior rather than the feelings. Say such things as ""calm down," "get ahold of yourself," etc. 5. Model calm behavior yourself. 6. Realize that the brain injured have great difficulty coping with even mild stress. Attempt to structure his environment so that unnecessary stress factors are removed. I. DENIAL The deficit that works at complete odds with rehabilitation efforts is that of denial. If the patient cannot recognize the weak cognitive areas, he can see no reason for therapy and will eventually sabotage all therapeutic efforts. Once the patient is released from the hospital and once he is able to physically move into the community, he thinks that he is "cured." He may admit to some slight physical deficiencies such as a slight limp, difficulty seeing, speech misarticulations or slowed reaction times; however, it is rare for a head injured patient to admit to faulty thinking, reduced problem solving skills, or perceptual difficulties. If the patient possesses some mild inkling of his difficulties, he may become a master at avoiding confronting the problem by manipulating others into acting in his behalf. He may make excuses about not completing tasks by describing them as "baby activities" that are unnecessary. What he fears is putting out the effort and then not being able to perform this infantile task. Thus, denial becomes even stronger and interferes with the minimal recognition that may have existed. Denial is a method of preserving the patient's self-image. He wants to see himself again as the person he was before the accident. He truly believes that he is ready to drive, go back to work, and get on with his original goals. Over the years, he will gradually gain a more realistic viewpoint; however, it is possible that he will never completely accept the effect of his injury and see himself as those close to him do. Examples 1. The patient says he will not ride a bus to his job because he is tired of busses while, in fact, he is afraid of getting lost. 2. A patient verbalizes that he is no longer having difficulties, goes home from the hospital and does not remember how to turn on the shower, find his bedroom, or something else that was second nature to him in the past. 3. A patient for months has walked with his parents around the block in his neighborhood. He insists that he can go on his own and finds himself lost after 30 minutes, six blocks from his house. 4. The patient looks at a puzzle task in cognitive therapy and refuses to do it because it is too childish. 5. The patient looks at the activity and insists that it cannot be done. 6. The patient says, "I got all A's in cognitive therapy." Resolutions for Denial 1. If it is not dangerous, allow him or even encourage him to try an activity that he is sure he can do. 2. When the patient displays the deficit, calmly or nonchallenging draw his attention to it — do not badger or gloat. 3. In order to reorient a person in the denial stage, place signs around the house: Front door — "No" "Do Not Open" Hallway — "Kitchen this way" "This way to the bathroom" 4. Do not be fooled by threats of discontinuing O.T. or cognitive therapy due to childish tasks. In all likelihood he is experiencing grave difficulty with these very simple activities making it all the more important that he stick with the activity. 5. Remember that uncooperative behavior may actually be a ""smokescreen" to cover up denial.. 6. Involve the patient in head injury support groups. There will be people at various stages and those that have worked through some of this denial may be able to help him recognize and accept his deficit areas. 7. Be patient — remember that the denial is a result of neurological damage and not an effort on the part of the patient to be obstinate. Neither is it due to a severe emotional problem involving loss of contact with reality. Instead, it is a result of the head injury. 8. Once you feel that patient can handle confrontation, it may be necessary to challenge him and show him that the task he says nobody can do is actually very easy for you. This may be needed to obtain or maintain his compliance in therapies or other activities that are therapeutic for him. J. PARANOIA This is a psychological term indicating that the patient thinks that other people are doing things to him or talking about him behind his back. This phenomena in a head injured patient does not mean that he is crazy. Instead, the behavior is a result of the inability to pick up appropriate cues, the loss of the ability to use logic, and the ultimate drawing of inaccurate conclusions. The patient picks up clues that others are reacting to him differently and this feeling often gets blown out of proportion. Moreover, people are constantly not allowing the patient to do what "he wants." Rather than interpreting this as concern for his well being, he often misinterprets and thinks that other people spend all their time figuring out ways to keep him from going back to his former lifestyle. Examples of Paranoia 1. A patient decides that he is being poisoned in the hospital. 2. A patient says that his roommate is taking all his clothes. 3. A patient insists that his Vocational Rehabilitation counselor is holding him back from working. 4. A patient insists that his wife is having an affair with the male night nurse. 5. A patient insists that the police officer at the scene of the accident is blaming him for the accident rather than being the person responsible for saving his life. Resolutions for Paranoia 1. You cannot argue with irrationality — so don't try. This is a no win situation. 2. Do not challenge the patient. Ignore the accusations. 3. Control your anger. Go do something else to get your mind off any unfair accusations. 4. Attempts to verbally defend yourself will probably result in increased delusional behavior because the patient will interpret your defenses as "covering up." K. OBSESSIONAL DISORDER This type of behavior is somewhat like tunnel vision. The patient will obsess on a particular idea or thought and then beat it into the ground. This is partially due to the memory difficulties whereby the patient does not realize he has brought the subject up fifty times that day. From a neurological standpoint it is also due to damage to the brain that results in an inability to switch to another thought pattern. The patient can literally stay on one topic for hours. Needless to say, this type of behavior is at best irritating for family members and friends. It is often one of the major factors that leads to social isolation in that friends begin to characterize the patient as being too eccentric. Examples of OBSESSIONAL DISORDER 1. The patient talks constantly about getting back to work. 2. The patient talks constantly about the difficulties of obtaining social security disability payments. 3. The patient obsesses on getting a car and blames his lack of social contacts on his lack of transportation. 4. The young patient begins to hoard his toys and will not go to therapy without all of them. 5. The patient puts on all of his shirts at one time. Resolutions for Obsessional Disorder 1. If possible, ignore. 2. Do not confront or belittle the behavior — this will only lead to further obsession or an emotional 3. outburst. 4. Redirect the patient's attention to a new and/or more constructive idea or behavior. 5. Reassure the patient. This type of behavior is often a reflection of anxiety so alleviating the 6. fear may help him move on to another thought. 7. Praise the patient regarding the progress he has made. This is another method of reducing anxiety. L. DEPRESSION Depression is a very common emotional consequence that usually comes later in the rehabilitation stage. Take heart — it actually is a sign of progress. The patient has now developed some awareness of his cognitive and motor deficits and is reacting to them by feeling frustrated and depressed. You will recognize depression in your loved one by the following symptoms: (1) lack of interest in life in general; (2) excessive sleeping; (3) loss of ability to feel pleasure; (4) lack of motivation; (5) withdrawal from social contacts; (6) passivity; (7} excessive TV. watching. These effects of depression are often difficult to deal with emotionally and even more difficult to modify. Examples 1. The patient makes the statement, "Why should I go to therapy, my life's over anyway." 2. The patient says, "I should have died in the accident — it would have been better." 3. The patient sleeps until 1:00 or 2:00 p.m. every day. 4. The patient watches TV. from the time he gets up until the time he goes to bed at night. 5. The patient shows little emotion — either positive or negative. Resolutions to Depression 1. If suicidal thoughts are expressed — take them seriously and seek professional help. 2. Utilize diversionary tactics to get their minds off depressive thoughts. 3. Do not take responsibility for the depression — it is not your fault. 4. Watch carefully for signs that the patient may be turning to drugs or alcohol as a method of coping with depression. 5. Do not remind the patient of his progress by reiterating how bad he used to be — he will feel worse with this approach. M. LACK OF MOTIVATION Initially or early in the recovery process, apathy or lack of motivation is a result of injury to the brain. The patient is confused and unable to conceptualize and plan activities. All projects or goals, however small, are overwhelming so it is less threatening and anxiety provoking to sit and ruminate. As time passes, the inertia often represents a symptom of a previously described reaction — depression. This lack of initiative is extremely frustrating to families who are aware of the precious time that is taken away from rehabilitation efforts when the patient says, "I don't want to do anything." As time passes, patients themselves often verbalize the fact that they have lost all interest in hobbies that were once very pleasurable to them. Examples 1. The patient spends the entire day. watching television. 2. The patient shows no spark of interest in his coin collection. 3. When the patient is asked to do a cognitive task he responds, "Why?" 4. The patient verbally expresses interest in various activities, but is never willing to follow through when the time comes. Resolutions for Lack of Motivation 1. Do not feel relieved that agitation has been replaced by inertia — this is not a good sign, even though it may be an emotional relief. 2. Make decisions for the patient. Do not ask, "Do you want to ... ?" The answer will usually be no. 3. Break down the activity into smaller steps to avoid overwhelming the patient. Eg. "Go wash your face" Then "Go get into the car" Then "Come with me to the mall" 4. Obtain assistance from a professional in setting up a contingency management system to break the cycle of inactivity. 5. Speak in a definitive manner that portrays the necessity of compliance. 6. For the higher level patient, give him a choice between two desirable activities. 7. Get the patient involved in a support group. This can lead to involvement with other patients and their activities. N. SOCIAL IMMATURITY After head injury, social graces are at an all time low. The adult patient assumes a childlike role and displays an inability to interact on an adult level. All the social amenities must be relearned. As you are attempting to re-educate your loved one, you will at times be very frustrated and even embarrassed. You may be putting a lot of energy in getting the patient to go out in public, but he/she is so inappropriate that everyone is discouraged from continuing the socialization efforts. If the head in|ury is severe, this behavior may always exist in some degree. This does not mean, however, that the patient cannot learn to act with maturity in most social interactions. Examples 1. The patient walks up to a stranger in the mall and begins to talk about his accident. 2. The patient sees the therapist as a social peer and asks the individual personal questions. 3. The patient feels that the whole world revolves around him and, thus, gets upset when the family cannot go to a favorite uncle's house because he has called and is ill. 4. The patient stomps his feet because he wants to go get pizza and the car will not start. Resolutions for Social Immaturity 1. Before you go out in public, coach the patient just like you might a child. For example, "Don't talk about your injury," "Be polite," and "Thank you, Mrs. Jones, for a nice dinner." 2. Never reinforce the inappropriate behavior by responding to it or trying to cover it up. 3. Ignore the action. 4. Indicate your dissatisfaction in a non-threatening manner such as, "This is not the place for that," "Do not talk about that here," or "We will discuss this issue later at a better time." O. SOCIAL DEPENDENCY Social dependency reflects a decrease in the patient's ability to take responsibility for social or interpersonal contacts of any sort. He/she may be unable to keep up old friendships or to approach and meet new people. There may be difficulty contacting other people far any reason, such as making a dentist's appointment, making a purchase from a salesperson in a store, or meeting people in a professional setting. Instead of increasing his/her social contacts, the loved one may depend more heavily on you or other family members to provide him/her with a social life as well as to do the personal interacting for him/her. This is a behavioral area that can frequently show a regression as opposed to an improvement. Examples 1. The patient will not allow the wife to go anywhere without him. 2. The patient interacts only with his roommates and goes into his bedroom when visitors come to the house. 3. The 25-year-old injured son demands that his mother make all the calls to his vocational rehabilitation counselor. 4. The teenager asks her mother to buy her makeup when she always wanted to pick it out herself before. Solution for Social Dependency 1. Do not let yourself become the patient’s only friends. 2. Add new people one at a time. Don’t push the patient into a situation where several strange people are around. 3. Take the patient to places where people familiar to them congregate. 4. Stay away from setting where something will be expected of them. Let the patient be a passive observer in any group activities. 5. Have the patient become involved in a head injured support group so that they can begin to develop a new group of friends with whom to relate. P. INCREASED OR DECREASED SEXUAL INTEREST This phenomenon could be the result of actual injury to the center in the brain that regulates hormonal activity, or to depression or other psychological response to injury. Many patients feel they no longer look appealing or that anyone could respond to them sexually. Other patients think of little else besides sexual functioning and behave inappropriately, making passes at people of the opposite sex, talking about sexual activity, etc. The sexually inhibited patient needs to be helped to dress nicely, to keep his body clean, and to groom his/her hair attractively. Feeling attractive will help him/her reassert his/her sexuality. This is something they will have to handle at their own pace. They should not be pressured to increase their sexual activity nor should an issue be made of this. It will only increase their anxiety and magnify the problem. Sexually hyperactive patients are another problem. It is embarrassing to most people to have someone around who is always making sexual remarks or overtures, masturbating, or doing some other socially unacceptable behavior. These actions definitely lead to problems such as social isolation. You as a family member will not want to take the patient in public and continually be embarrassed by his inappropriate responses. Former friends will sever contacts because they will quickly tire of the off-color jokes or even physical advances. Often the patient will not comprehend the relationships between a loss of friendship and his obsessional interest in sexual remarks or activity. He will blame other people for deserting him in this time of need. It may take a group setting whereby other head injured patients are able to point out the offensive nature of this type of social response before the patient is willing or capable of changing. Examples of Decreased Interest 1. The patient comes to bed without bathing or brushing his teeth. 2. The patient avoids sexual advances by accusing the spouse of cheating on him. 3. The patient continues to sleep in the "extra bedroom" even after he has stabilized his health issues. The excuse he uses is that he wakes up frequently in the night and is afraid he will disturb his partner. 4. Resolutions for Decreased Sexual Interest 5. Do not take your spouse's disinterest personally. 6. Do not pressure or attempt to embarrass the patient into a sexual relationship prematurely. 7. Remember that the disinterest PAGE 25 Examples of Increased Interest 1. The patient pinches the nurse. 2. The patient makes off-color remarks to most female staff members. 3. The patient manipulates the necessity for physical contact with staff members of the opposite sex. 4. The patient makes sexual threats to his wife when she indicates that she does not wish to be involved sexually at this point in time. 5. The female patient offers sexual innuendoes toward either her husband or someone else's husband while in a social gathering of friends. Resolutions for Increased Interest 1. The patient should be told as often as necessary that such behavior is not acceptable. 2. If he/she does not curtail the behavior he/she could be removed from other's company if at all possible. 3. Do not feel obligated to respond to sexual demands every time. You have a right to say when and how often you want to engage in sexual activity. 4. Sexual aggressiveness toward other people should be handled the same as any other aggressiveness: isolation, restraint, call for help if needed. 5. Get the patient involved in a support group which can make him aware of the consequences of this behavior. Q. INSATIABLE DRIVE FOR NOURISHMENT Initially after injury it is very important for the patient to increase the calorie intake in order to assist with the healing process; thus. concern is focused on the patient eating enough food. Families often equate the act eating with "getting well" since they may have watched for months as their loved one was fed through a tube. Seeing the patient eating "real food" is a pleasurable experience. However, there may come a point when the patient will eat constantly and will gain an unhealthy amount of weight. This insatiable appetite is often due to organic or brain related damage. The hypothalamus which lies within and below the central portion of the brain regulates appetite control as well as drinking, sleeping, waking, body temperature, heart rate, hormones and sexual emotions. This area can be damaged with an insult to the brain and, thus, the patient becomes unable to feel and perceive that his stomach is full. The brain continuously registers "hungry." There can also be an emotional component to the overeating, especially if the individual was one who had weight problems prior to the accident. Overeating indicates unsatisfied dependency needs, and we have already discussed the fact that head injured patients become more dependent on family members. Examples 1. The patient goes home and her husband cannot keep food in the house to feed the three children as his wire devours everything on a daily basis. 2. The patient sneaks off to the hospital snack bar after the physician has ordered a weight loss diet. 3. The family daily brings their daughter her favorite M&M's as a form of showing their love and affection. 4. The patient outgrows his wheelchair within four weeks after it was delivered. Resolutions for Insatiable Drive for Nourishment 1. If the problem is organic (physical) there is no way to change the hunger except to see a physician for possible medical management. 2. Change the environment — remove extra food. 3. Provide alternative behaviors. The patient cannot eat while exercising, sewing, wood working, etc. 4. If the problem appears emotionally based, then the family or therapist should address the self-concept and dependency issues.

I I . PATIENT BEHAVIORS

TABLE OF CONTENTS

A. Agitation

B. Irritability

C. Verbal Outbursts

D. Temper Tantrums

E. Family Abuse

F. Egocentrism

G. Impulsivity

H. Liability

I. Denial

J. Paranoia

K. Obsessional Disorder

L. Depression

M. Lack or Motivation

N. Social Immaturity

0. Social Dependency

P. Change in Sexual Interest

Q. Insatiable Drive for Nourishment

Excessive Talking. 28

I I. PATIENT BEHAVIORS

II. PATIENT BEHAVIORS

In the initial stages of a severe head injury, the only behavior that you are concerned with is "living" — day by day your major concern is for the life of your loved one. This time might be labeled the "sitting at bedside stage." As the days have passed the loved one has moved toward the "medically stable" stage and you have thought that you are out of the woods. You have interpreted the thrashing and agitated behavior as a very positive sign ... He is alive and moving.

The reality is that this is the Beginning of a long and hard road that will probably lead you into a woods that is very unfamiliar. We are all somewhat familiar with death and there are universal methods of dealing with it; but your loved one did not die. We are even more familiar with the concept of dealing with broken bodies — in time all will heal and it will be life as usual. On the contrary, we are not at ail familiar with the "Broken brain" and there is little data to tell you how long it will take and if it will ever work like it did before. Thus, families are ill equipped to understand and handle the impending actions of the head injured patient.

In working with families we have experienced a similar expression over and over. This is best displayed by the following thoughts:

Those who have felt comfortable with us have actually verbalized that if they had known what lay ahead they would not have been so anxious for the patient to live. Their ability to express themselves in this manner is often followed by the realization that this is not the same person they knew and loved before the accident. They know they would have wanted the other person to return to them, but they experience doubts regarding this stranger who is going through either the "looking good — acting bad" or "looking good — thinking bad" stage.

Many families deny the relevance or the patient's inappropriate behavior by relating it to the physical trauma the patient has just experienced. There is some validity in this thinking. Patients frequently respond to the question, "Why are you here in the hospital?" by saying things like "Because I did something bad" or "I've been captured by the Germans" or "I am being murdered." It is not difficult to conceive of why they might feel they have been imprisoned. They have spent days where nurses have pushed, poked, and pulled them and where doctors have possibly cut openings in their throat. They may have been tied down for extended periods of time so that they could not pull out tubes that were feeding them or helping them breathe. Many family members say that they would probably act the same way if they have been through a similar ordeal.

Although there is truth to this interpretation, the major factor involved with the patients' behavior is altered brain functioning. The brain has been jostled around or injured in some respect so that insight and judgment are significantly impaired. The attention and arousal center has been affected so that the patient no longer has the social control over his behavior that previously was maintained with little to no effort. The outer covering of your loved one may look familiar but he may have become what some have termed a "completely different person."

In order to best deal with these changes, we hope that we can provide you with a comprehensive explanation of all the possibilities you may face. Following is a list of the various behaviors. They are arranged somewhat chronologically. The initial topics are behaviors that occur shortly after injury and are the result of damage to the brain cells. The latter deal with longer range social and emotional complications that are a consequence of the patient's attempt to adjust to his altered world. Your family member may experience all eighteen (18) of these or only three or four of them due to the fact that the results of the head injuries are extremely variable. However, we feel that we should briefly expose you to the varying possibilities.

A. AGITATION

Agitation encompasses a multitude of observable behaviors including:

(1) Constant movement;

(2) Inability to focus one’s attention;

(3) Pacing;

(4) Getting up and down from one’s seat;

(5) Repetitive purposeless activity; and

(6) Self-destructive actions.

These behaviors are usually unprovoked and unrelated to the patient’s family or environment. Thus, there is nothing that you have done to bring on the restlessness. The patient’s world has been turned inside out and upside down leaving him generally confused and disoriented. Engaging in these agitated behaviors is a coping mechanism. One patient described this by saying, “I used to walk up and down the halls. I felt like if I stopped I would go crazy.” This period of time is often just as hard on the family as it is the patient — remember, it is only a stage that the patient passes through and not a permanent behavior change.

Examples

1. Patient continually pulls out IV tube while hospitalized.

2. Patient becomes very upset and restless when his therapist does not come to get him on time.

3. Patient becomes agitated that his family member did not visit when he expected.

4. Patient continually attempts to get up and down out of chair during his staff meeting.

5. Patient talks incessantly about driving his new truck again and continually searches for the keys in an agitated state.

Resolutions for Agitation they need the security or

1. Be available as much as possible during the agitation state - - they need the security of someone they know.

2. Move the patient gently into new activities — do not make sudden or quick changes.

3. Redirect the patient’s attention away from the focus of agitation.

4. Allow excessive talking — this may be an effective way to work through the agitation.

5. Model calm behavior. Appear calm even if you are not calm.

6. Structure the patient’s time so that there are not long periods where he can ruminate.

7. Restructure the environment so that excessive distracters (both visual and auditory) are removed.

8. Monitor your own behavior carefully. Eliminate all nonverbal cues that could possibly be misinterpreted by the patient (e.g., frowning, eye rolling, head shaking, tongue-clicking. throat clearing, tone of voice). If you are unaware of your own nonverbal methods of communicating frustration or anger, ask another family member who is experienced at reading you.

B. IRRITABILITY

We are all aware of what is meant by irritable behavior. In a sense it is a mild case of agitation that characterizes the patient as constantly in a bad mood or generally a "grouch." From an organic standpoint the injury has altered the patient's ability to:

(1) interpret situations accurately;

(2) perform simple tasks effectively;

(3) attend to important cues and ignore useless information.

Thus, the individual is much more inclined to display irritable behavior. Like agitation, excessive irritability is a stage, but the individual may always remain generally more easily annoyed by trivial matters than he was prior to the accident.

Examples

1. The patient responds negatively to environmental noises such as vacuum cleaner running, children playing, television "blasting," etc.

2. The patient may be irritable because he cannot hear correctly due to the injury resulting in a true hearing loss and/or auditory discrimination problems.

3. The patient may become very irritable if he has to wait in a doctor's office.

4. The patient may be resistant and irritable to any true change in plans or any misconstrued change in plans.

5. The patient may show irritability to mild physical discomforts such as too hot, too cold, or a

6. minor injury such as stubbing his toe.

Resolutions for Irritability

1. Do not challenge or confront the patient about his apparent "bad mood."

2. Compromise whenever possible. Do things he does not like somewhere else.

3. Negotiate: A. The vacuum cleaner is bothering you now. Tell me when it would be a better time to run it.

4. Would it be acceptable for the children to play inside if they go in the room and close the door?

5. Structure the day so that unexpected happenings are at a minimum.

6. Whenever possible, allow the patient to be a part of the decision making and activity planning. He should have a say so not only in outings but also in what time he will bathe or eat.. meals. If he has been a part of the decision it will 'be more difficult to criticize.

7. Do not consider irritability a manipulation and do not take it personally. It is a result of the brain injury.

C. VERBAL OUTBURSTS

If the head injury of your loved one was severe, you may have been or you may now be panicked that they will never talk again. That concern quickly diminishes when verbal behavior reinitiates; however, it is often replaced by extreme concern over what they are saying. Head injured patients fairly consistently go through a stage whereby they blurt out the first thought that emerges from their confused and disoriented thinking. The verbage during this stage is often automatic as opposed to volitional and is no different than the inability to control urine or any other physical response. The filtering system is at best dysfunctional and initially nonexistent. The little voice that previously said, 'I better not tell Aunt Mary I think she's a jerk because my mother will be mad at me’ is no longer operating. If Aunt Mary visits she will probably learn that she is considered a jerk.

Excessive cursing is often a characteristic of the verbal outbursts. No one is immune — even the person who never spoke a foul word in his life. You must be prepared to hear thoughts and language you may never have thought existed in the patient's head. If the patient tended to utilize excessive profanity prior to the accident, it is very likely that every word out of his mouth will be foul for a period of time. Verbal outbursts are a stage, but again, the patient may throughout the rest of his life be more open and honest with his true feelings.

As the patient becomes re-socialized these outbursts will diminish in intensity and frequency. As language skills increase, the need to rely upon this type or communication decreases.

Examples of Verbal Outbursts

1. Patient: "Where's the G— D— nurse now?"

2. Patient: "You don't care about me. If you really loved me you'd be here every day to see that I get good care."

3. Patient: 'They don't know what they're doing here. Take me home now."

4. Patient: "You're probably just as glad I'm not at home to bug you."

5. Patient: "Why did Aunt May come with you today? You have never liked her."

Resolutions for Verbal Outbursts

1. Whenever possible, ignore the verbage.

2. Do not take it personally.

3. When appropriate, redirect the patient's attention to something else.

4. Warn friends and family that the patient has had an injury to the head which has altered his ability to think clearly.

5. If possible, discourage visitors with whom the patient has not had positive communication prior to the accident.

6. When you feel that the patient has some capability for control, be direct about your feelings — but not critical.

a) My feelings are hurt when you talk to me this way.

b) I am offended by the words you use

c) It embarrasses me when you tell other people things I have said to you about them.

D. TEMPER TANTRUMS

Brain injured individuals often resort to physical expression of their anger and frustration because they are experiencing: (1) difficulty verbalizing their feelings: (2) difficulty controlling their impulses; and (3) inability to cope effectively with their environment. They can become combative with little or no provocation. At one moment they may be lunging toward their wife screaming, "I'm going to strangle you," and the next moment they may be innocently asking, "What's for dinner, dear?" If you are the type of person who holds a grudge, you will need to change. Destructive behavior may be the patient's method of showing other people how helpless and out of control he feels. The same techniques apply that are utilized with small children who have temper tantrums. It is best to remember that these are spontaneous acts with little to no forethought or purpose and that their duration is usually shortlived.

Examples

1. The patient throws his cup of coffee when he discovers that he has problems drinking it without spilling.

2. The patient throws the puzzle on the floor and tells the Therapist to pick it up indicating he does not want to do baby tasks.

3. The patient pushes the wife on the floor in an attempt to go outside and drive away in his car.

4. The patient throws the vacuum cleaner in the yard because he is bothered by the noise.

Resolutions for Temper Tantrums

1. Protect yourself and others by removal if necessary.

2. Ignore, ignore, ignore.

3. Do not remind the patient of the incident.

4. Verbalize for them what you think they may be feeling, but do so without condemnation.

5. Remember that the person usually is not truly angry at the person they have struck, so do not take the action personally.

6. Redirect the patient's focus to a more positive goal or task.

7. Do not display fear.

8. If you are a grudge holder, see someone who can help you change this behavior (pattern possibly utilizing — relaxation 'or other techniques.

9. Allow time for the individual to make amends and recognize the consequences of his behavior, e.g.. -.spaghetti on the floor, broken glass on the floor, etc.

E. FAMILY ABUSE

There is obvious overlap in this area with both verbal outbursts and temper tantrums; however due to the extreme emotional stress that family members experience as a result of verbal and physical abuse, we feel that this deserves to be addressed separately. This is the age old story of "you only hurt the one you love" in that family members often receive the major portion the abuse the patient has to offer. At first, the patient may have had no control whatsoever and he will be abusive with anyone and/or everyone. As he begins to develop some behavioral control, he becomes more socialized with staff, friends, and strangers but often remains difficult with family. A similar type of phenomenon occurs in the care of an elderly person whereby the primary caretaker gets all the abuse, but other family members or friends are treated with respect.

Families often say, "If he can be nice when the nurse is here, I know he can be nice with us too if he really wants to." At this point, they misinterpret and conclude that the patient is being nasty with them on purpose. This is not initially the case. From a neurological standpoint, the patient has now developed some self-control and he has learned to use it with people outside the family because he has begun to reintegrate his socialization skills. On the other hand, he may never have learned to utilize socialization with his own family prior to the accident. In fact, the person may never have considered the need to control his thoughts or actions at home. He is really not thinking any differently than before. He is not any meaner than he was before. He is really thinking the same, but responding more spontaneously due to the head injury. He does not know how to use the controls at home — he must learn something that he has never had to do before. This must be approached gradually and in a nonthreatening and nonconfrontive manner.

The issue of family abuse can become extremely complex as behavior patterns are set up in the home. Families often find themselves compromising and avoiding anything that may "set off' the patient. In essence, they change many things to please the patient. As the patient becomes more aware of his actions, there is always the danger that he will learn to manipulate family members as he realizes the control he has over their life. This transition is often gradual so that no one realizes the change from the patient being completely out of control to the patient controlling everyone's behavior. Awareness that this transition can take place is the first step in preventing or at least deterring these results.

Another issue that is important in the area of family abuse is knowledge and recognition of those points of family disagreement that existed prior to the accident. Injury to the head tends to lead to an exaggeration of thinking and personality patterns. If the patient was involved with a long standing feud with a son-in-law, you can pretty well assume that the feud will be increased to the point that the son-in-law may no longer be allowed to come to the house or even call on the telephone. Thus, there exists the potential for increased family conflict on top of all the strain related to the accident. You, as a primary caretaker, may find yourself functioning as a family referee as well as a counselor to those with hurt and angry feelings toward the patient.

Examples

1. A head injured grandfather pushes his grandson off his lap.

2. A head injured stepfather does not allow his stepdaughter to come to the house or telephone due to previous dislike for the stepdaughter's husband.

3. A head injured husband accuses his wife of infidelity.

4. 4.. A head injured woman insists that her husband go everywhere with her or she begins to scream hysterically.

Resolutions for Family Abuse

1. Don't take it personally.

2. Treat each occurrence as an isolated incident. The patient probably does not remember he acted this way before.

3. Maintain some type of outside support (counselor, friend, etc.) to express your feelings. At this point in time the patient himself will not appreciate discussing your feelings.

4. If young children are involved, help them to recognize and avoid behavior that could be potentially harmful.

5. Educate all family members in order to provide consistent responses to the abusive behavior. If the patient learns that he can obtain a desired response from one person and not the other, he will quickly learn to move into the "manipulative stage" with the individual who is giving in.

6. Do not allow issues to become "win-lose" struggles. Eventually both patient and family lose with this tactic.

7. Remember that most threats are expressions of fear (fear of dependence, fear of abandonment, etc.) or anger at a situation rather than at an individual.

8. Do not allow yourself to live in a reign of terror. Succumbing to the patient's threats may set up a pattern that could take years to break.

9. If you find that you are already trapped into living your life exactly as the patient demands, you may need to seek assistance to preserve your right to choose your own activities and friends.

F. EGOCENTRISM

After a severe head injury, the patient often becomes completely self-centered displaying behavior similar to that of a three- or four-year-old. The person's capacity to be empathetic to other's needs is diminished. He possesses a significant decrease in insight and is not aware of the effect his actions have on other people. The world revolves around him and his concerns. He interprets all actions in relation to himself. Due to his difficulty perceiving social situations adequately he may misinterpret another person's response either by assigning to it a hostile interpretation or by thinking a response is specifically directed toward him when, in fact, the issue at hand is completely unrelated to him.

This trait, along with the previously addressed issue of family abuse, can be the "crowning blow" to efforts by family members to reintegrate the patient back into the home environment. We are all very willing to go the extra mile for someone who realizes and appreciates our efforts. However, we are trained to be unresponsive to selfish individuals, and this is often a very appropriate descriptor of the head injured patient. As a result, families either unknowingly or even knowingly pull away from this self-centered person, and this in turn often results in the patient becoming even more egocentric. This is another behavioral problem that does not cure itself with time and, in fact, can worsen if appropriate steps are not taken.

Examples

1. A grandfather becomes jealous of the attention paid to his grandson by his wife.

2. A grandfather hides candy saying that the grandchildren will eat it when they come over.

3. A Vocational Rehabilitation client feels that his counselor is delaying services to hinder his progress.

4. A wife does not want her husband to go out without her.

5. A husband wants to cut off the hot water to save money, and is not concerned that his wife must bathe and wash dishes in cold water.

Resolutions for Egocentrism

1. Do not relinquish everything to the patient's needs.

2. Do not allow the patient to get to the point of expecting that all his demands will be met.

3. Be aware that his egocentricism may interfere with your desire to continue to assist his rehabilitation.

4. Do not expect the patient to respect your rights — you may have to do some demanding of your own.

5. If possible, get the patient involved with a head injury support group. Often the best way to get someone to realize his own fault is to see it in another patient and, thus, criticize the results of selfishness.

G. IMPULSIV1TY

Impulsivity is the lack of behavioral control over either action, verbalizations, or both. The part of the brain that deals with attention is damaged to the point that the patient acts before he thinks or acts upon inappropriate or confused thoughts. The patient responds to anything and everything equally. He does not have in operation any effective filtering system. This characteristic is not only frustrating but also very embarrassing for the family. Impulsivity leads to excessive "demanding behavior" which can be both tiring and irritating. It is also characterized by a propensity to blurt out the first thought that enters his mind regardless of who is present. While the family may be mortified, the patient does not appear to comprehend the significance of the breach of etiquette.

Examples

1. The patient grabs the newspaper from his wife while she is reading it.

2. The patient tries to put together a bookshelf in a quick manner so that his rushing leads to difficulty with a simple task which, in turn, leads to increased frustration.

3. Upon answering the door, the patient says to the neighbor, "Why do you always come over when we are about to eat?"''

4. The patient turns off the TV even though others are watching because he thinks the program "is stupid."

5. The patient walks out of therapy when the receptionist says the therapist will be five minutes late.

6. The patient chain smokes with little realization that he just finished a cigarette.

Resolutions

1. Behavior management systems can be utilized to bring the patient behavior under control. You will need assistance from a knowledgeable therapist, counselor, or social worker to effectively implement a system.

2. You yourself can set short term rewards for brief periods of self-control (e.g., not telling every stranger about his accident, spacing cigarettes in order to decrease smoking, eliminating impulsive between-meal snacks, etc.).

3. Re-direct the patient's attention to appropriate behavior. If they act or speak impulsively because the TV is too loud, direct them into another room and attempt to refocus their actions to something constructive.

H. LABILITY

Lability is nothing more than a loss of control over emotions. The fact that the emotions are more quickly displayed does not mean the emotion is stronger than it ever was. Instead, the patient does not have the ability to discriminate about how and when to express his feelings. While a "normal" person may be able to control joy or sadness or anger and express appropriately at the right time and place, the brain injured individual cannot. This excessive display of emotions can be very unsettling to families who are attempting to bring their own emotions under control. This stage is due to damage to the brain, especially the areas dealing with impulses and emotional responses. These quick and frequent mood swings can be extremely tiring to family members who are attempting to keep things on an even keel. Due to the patient's misperception of the environment, mood changes are difficult and at times impossible to avoid. This lack of control can lead the family members to view the situation as so unpredictable that they entertain thoughts of "escape" or at least respite care.

Examples

1. The husband (patient) starts talking to the therapist about his wife and immediately begins to sob.

2. The therapist may be discussing activities that were favorites in the past such as painting and the patient may begin to cry.

3. The nurse may remark that the picture of his children shows they are very "good looking" and the patient will begin to cry.

4. The mention of anything about which the patient feels sentimental can bring tears.

5. The patient may laugh and giggle before every comment he makes regardless of its content.

Resolutions for Lability

1. Do not criticize. Brain injured patients are very sensitive to criticism which can thus lead to excessive overreaction.

2. Praise him and point out those times when he does control his emotions. At those times, attempt to get him to explain how he is managing to maintain self-control. If he knows how he does it, he can use it again.

3. Reassurance and confrontation regarding lability are unnecessary. In fact, addressing the issue may embarrass the patient.

4. Address the behavior rather than the feelings. Say such things as ""calm down," "get ahold of yourself," etc.

5. Model calm behavior yourself.

6. Realize that the brain injured have great difficulty coping with even mild stress. Attempt to structure his environment so that unnecessary stress factors are removed.

I. DENIAL

The deficit that works at complete odds with rehabilitation efforts is that of denial. If the patient cannot recognize the weak cognitive areas, he can see no reason for therapy and will eventually sabotage all therapeutic efforts. Once the patient is released from the hospital and once he is able to physically move into the community, he thinks that he is "cured." He may admit to some slight physical deficiencies such as a slight limp, difficulty seeing, speech misarticulations or slowed reaction times; however, it is rare for a head injured patient to admit to faulty thinking, reduced problem solving skills, or perceptual difficulties. If the patient possesses some mild inkling of his difficulties, he may become a master at avoiding confronting the problem by manipulating others into acting in his behalf. He may make excuses about not completing tasks by describing them as "baby activities" that are unnecessary. What he fears is putting out the effort and then not being able to perform this infantile task. Thus, denial becomes even stronger and interferes with the minimal recognition that may have existed. Denial is a method of preserving the patient's self-image. He wants to see himself again as the person he was before the accident. He truly believes that he is ready to drive, go back to work, and get on with his original goals. Over the years, he will gradually gain a more realistic viewpoint; however, it is possible that he will never completely accept the effect of his injury and see himself as those close to him do.

Examples

1. The patient says he will not ride a bus to his job because he is tired of busses while, in fact, he is afraid of getting lost.

2. A patient verbalizes that he is no longer having difficulties, goes home from the hospital and does not remember how to turn on the shower, find his bedroom, or something else that was second nature to him in the past.

3. A patient for months has walked with his parents around the block in his neighborhood. He insists that he can go on his own and finds himself lost after 30 minutes, six blocks from his house.

4. The patient looks at a puzzle task in cognitive therapy and refuses to do it because it is too childish.

5. The patient looks at the activity and insists that it cannot be done.

6. The patient says, "I got all A's in cognitive therapy."

Resolutions for Denial

1. If it is not dangerous, allow him or even encourage him to try an activity that he is sure he can do.

2. When the patient displays the deficit, calmly or nonchallenging draw his attention to it — do not badger or gloat.

3. In order to reorient a person in the denial stage, place signs around the house: Front door — "No" "Do Not Open" Hallway — "Kitchen this way" "This way to the bathroom"

4. Do not be fooled by threats of discontinuing O.T. or cognitive therapy due to childish tasks. In all likelihood he is experiencing grave difficulty with these very simple activities making it all the more important that he stick with the activity.

5. Remember that uncooperative behavior may actually be a ""smokescreen" to cover up denial..

6. Involve the patient in head injury support groups. There will be people at various stages and those that have worked through some of this denial may be able to help him recognize and accept his deficit areas.

7. Be patient — remember that the denial is a result of neurological damage and not an effort on the part of the patient to be obstinate. Neither is it due to a severe emotional problem involving loss of contact with reality. Instead, it is a result of the head injury.

8. Once you feel that patient can handle confrontation, it may be necessary to challenge him and show him that the task he says nobody can do is actually very easy for you. This may be needed to obtain or maintain his compliance in therapies or other activities that are therapeutic for him.

J. PARANOIA

This is a psychological term indicating that the patient thinks that other people are doing things to him or talking about him behind his back. This phenomena in a head injured patient does not mean that he is crazy. Instead, the behavior is a result of the inability to pick up appropriate cues, the loss of the ability to use logic, and the ultimate drawing of inaccurate conclusions. The patient picks up clues that others are reacting to him differently and this feeling often gets blown out of proportion. Moreover, people are constantly not allowing the patient to do what "he wants." Rather than interpreting this as concern for his well being, he often misinterprets and thinks that other people spend all their time figuring out ways to keep him from going back to his former lifestyle.

Examples of Paranoia

1. A patient decides that he is being poisoned in the hospital.

2. A patient says that his roommate is taking all his clothes.

3. A patient insists that his Vocational Rehabilitation counselor is holding him back from working.

4. A patient insists that his wife is having an affair with the male night nurse.

5. A patient insists that the police officer at the scene of the accident is blaming him for the accident rather than being the person responsible for saving his life.

Resolutions for Paranoia

1. You cannot argue with irrationality — so don't try. This is a no win situation.

2. Do not challenge the patient. Ignore the accusations.

3. Control your anger. Go do something else to get your mind off any unfair accusations.

4. Attempts to verbally defend yourself will probably result in increased delusional behavior because the patient will interpret your defenses as "covering up."

K. OBSESSIONAL DISORDER

This type of behavior is somewhat like tunnel vision. The patient will obsess on a particular

idea or thought and then beat it into the ground. This is partially due to the memory difficulties

whereby the patient does not realize he has brought the subject up fifty times that day. From

a neurological standpoint it is also due to damage to the brain that results in an inability to switch

to another thought pattern. The patient can literally stay on one topic for hours. Needless to

say, this type of behavior is at best irritating for family members and friends. It is often one of

the major factors that leads to social isolation in that friends begin to characterize the patient

as being too eccentric.

Examples of OBSESSIONAL DISORDER

1. The patient talks constantly about getting back to work.

2. The patient talks constantly about the difficulties of obtaining social security disability payments.

3. The patient obsesses on getting a car and blames his lack of social contacts on his lack of transportation.

4. The young patient begins to hoard his toys and will not go to therapy without all of them.

5. The patient puts on all of his shirts at one time.

Resolutions for Obsessional Disorder

1. If possible, ignore.

2. Do not confront or belittle the behavior — this will only lead to further obsession or an emotional

3. outburst.

4. Redirect the patient's attention to a new and/or more constructive idea or behavior.

5. Reassure the patient. This type of behavior is often a reflection of anxiety so alleviating the

6. fear may help him move on to another thought.

7. Praise the patient regarding the progress he has made. This is another method of reducing anxiety.

L. DEPRESSION

Depression is a very common emotional consequence that usually comes later in the rehabilitation stage. Take heart — it actually is a sign of progress. The patient has now developed some awareness of his cognitive and motor deficits and is reacting to them by feeling frustrated and depressed. You will recognize depression in your loved one by the following symptoms: (1) lack of interest in life in general; (2) excessive sleeping; (3) loss of ability to feel pleasure; (4) lack of motivation; (5) withdrawal from social contacts; (6) passivity; (7} excessive TV. watching. These effects of depression are often difficult to deal with emotionally and even more difficult to modify.

Examples

1. The patient makes the statement, "Why should I go to therapy, my life's over anyway."

2. The patient says, "I should have died in the accident — it would have been better."

3. The patient sleeps until 1:00 or 2:00 p.m. every day.

4. The patient watches TV. from the time he gets up until the time he goes to bed at night.

5. The patient shows little emotion — either positive or negative.

Resolutions to Depression

1. If suicidal thoughts are expressed — take them seriously and seek professional help.

2. Utilize diversionary tactics to get their minds off depressive thoughts.

3. Do not take responsibility for the depression — it is not your fault.

4. Watch carefully for signs that the patient may be turning to drugs or alcohol as a method of coping with depression.

5. Do not remind the patient of his progress by reiterating how bad he used to be — he will feel worse with this approach.

M. LACK OF MOTIVATION

Initially or early in the recovery process, apathy or lack of motivation is a result of injury to the brain. The patient is confused and unable to conceptualize and plan activities. All projects or goals, however small, are overwhelming so it is less threatening and anxiety provoking to sit and ruminate. As time passes, the inertia often represents a symptom of a previously described reaction — depression. This lack of initiative is extremely frustrating to families who are aware of the precious time that is taken away from rehabilitation efforts when the patient says, "I don't want to do anything." As time passes, patients themselves often verbalize the fact that they have lost all interest in hobbies that were once very pleasurable to them.

Examples

1. The patient spends the entire day. watching television.

2. The patient shows no spark of interest in his coin collection.

3. When the patient is asked to do a cognitive task he responds, "Why?"

4. The patient verbally expresses interest in various activities, but is never willing to follow through when the time comes.

Resolutions for Lack of Motivation

1. Do not feel relieved that agitation has been replaced by inertia — this is not a good sign, even though it may be an emotional relief.

2. Make decisions for the patient. Do not ask, "Do you want to ... ?" The answer will usually be no.

3. Break down the activity into smaller steps to avoid overwhelming the patient. Eg. "Go wash your face" Then "Go get into the car" Then "Come with me to the mall"

4. Obtain assistance from a professional in setting up a contingency management system to break the cycle of inactivity.

5. Speak in a definitive manner that portrays the necessity of compliance.

6. For the higher level patient, give him a choice between two desirable activities.

7. Get the patient involved in a support group. This can lead to involvement with other patients and their activities.

N. SOCIAL IMMATURITY

After head injury, social graces are at an all time low. The adult patient assumes a childlike role and displays an inability to interact on an adult level. All the social amenities must be relearned. As you are attempting to re-educate your loved one, you will at times be very frustrated and even embarrassed. You may be putting a lot of energy in getting the patient to go out in public, but he/she is so inappropriate that everyone is discouraged from continuing the socialization efforts. If the head in|ury is severe, this behavior may always exist in some degree. This does not mean, however, that the patient cannot learn to act with maturity in most social interactions.

Examples

1. The patient walks up to a stranger in the mall and begins to talk about his accident.

2. The patient sees the therapist as a social peer and asks the individual personal questions.

3. The patient feels that the whole world revolves around him and, thus, gets upset when the family cannot go to a favorite uncle's house because he has called and is ill.

4. The patient stomps his feet because he wants to go get pizza and the car will not start.

Resolutions for Social Immaturity

1. Before you go out in public, coach the patient just like you might a child. For example, "Don't talk about your injury," "Be polite," and "Thank you, Mrs. Jones, for a nice dinner."

2. Never reinforce the inappropriate behavior by responding to it or trying to cover it up.

3. Ignore the action.

4. Indicate your dissatisfaction in a non-threatening manner such as, "This is not the place for that," "Do not talk about that here," or "We will discuss this issue later at a better time."

O. SOCIAL DEPENDENCY

Social dependency reflects a decrease in the patient's ability to take responsibility for social or interpersonal contacts of any sort. He/she may be unable to keep up old friendships or to approach and meet new people. There may be difficulty contacting other people far any reason, such as making a dentist's appointment, making a purchase from a salesperson in a store, or meeting people in a professional setting. Instead of increasing his/her social contacts, the loved one may depend more heavily on you or other family members to provide him/her with a social life as well as to do the personal interacting for him/her. This is a behavioral area that can frequently show a regression as opposed to an improvement.

Examples

1. The patient will not allow the wife to go anywhere without him.

2. The patient interacts only with his roommates and goes into his bedroom when visitors come to the house.

3. The 25-year-old injured son demands that his mother make all the calls to his vocational rehabilitation counselor.

4. The teenager asks her mother to buy her makeup when she always wanted to pick it out herself before.

Solution for Social Dependency

1. Do not let yourself become the patient’s only friends.

2. Add new people one at a time. Don’t push the patient into a situation where several strange people are around.

3. Take the patient to places where people familiar to them congregate.

4. Stay away from setting where something will be expected of them. Let the patient be a passive observer in any group activities.

5. Have the patient become involved in a head injured support group so that they can begin to develop a new group of friends with whom to relate.

P. INCREASED OR DECREASED SEXUAL INTEREST

This phenomenon could be the result of actual injury to the center in the brain that regulates hormonal activity, or to depression or other psychological response to injury. Many patients feel they no longer look appealing or that anyone could respond to them sexually. Other patients think of little else besides sexual functioning and behave inappropriately, making passes at people of the opposite sex, talking about sexual activity, etc.

The sexually inhibited patient needs to be helped to dress nicely, to keep his body clean, and to groom his/her hair attractively. Feeling attractive will help him/her reassert his/her sexuality. This is something they will have to handle at their own pace. They should not be pressured to increase their sexual activity nor should an issue be made of this. It will only increase their anxiety and magnify the problem.

Sexually hyperactive patients are another problem. It is embarrassing to most people to have someone around who is always making sexual remarks or overtures, masturbating, or doing some other socially unacceptable behavior. These actions definitely lead to problems such as social isolation. You as a family member will not want to take the patient in public and continually be embarrassed by his inappropriate responses. Former friends will sever contacts because they will quickly tire of the off-color jokes or even physical advances. Often the patient will not comprehend the relationships between a loss of friendship and his obsessional interest in sexual remarks or activity. He will blame other people for deserting him in this time of need. It may take a group setting whereby other head injured patients are able to point out the offensive nature of this type of social response before the patient is willing or capable of changing.

Examples of Decreased Interest

1. The patient comes to bed without bathing or brushing his teeth.

2. The patient avoids sexual advances by accusing the spouse of cheating on him.

3. The patient continues to sleep in the "extra bedroom" even after he has stabilized his health issues. The excuse he uses is that he wakes up frequently in the night and is afraid he will disturb his partner.

4. Resolutions for Decreased Sexual Interest

5. Do not take your spouse's disinterest personally.

6. Do not pressure or attempt to embarrass the patient into a sexual relationship prematurely.

7. Remember that the disinterest

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Examples of Increased Interest

1. The patient pinches the nurse.

2. The patient makes off-color remarks to most female staff members.

3. The patient manipulates the necessity for physical contact with staff members of the opposite sex.

4. The patient makes sexual threats to his wife when she indicates that she does not wish to be involved sexually at this point in time.

5. The female patient offers sexual innuendoes toward either her husband or someone else's husband while in a social gathering of friends.

Resolutions for Increased Interest

1. The patient should be told as often as necessary that such behavior is not acceptable.

2. If he/she does not curtail the behavior he/she could be removed from other's company if at all possible.

3. Do not feel obligated to respond to sexual demands every time. You have a right to say when and how often you want to engage in sexual activity.

4. Sexual aggressiveness toward other people should be handled the same as any other aggressiveness: isolation, restraint, call for help if needed.

5. Get the patient involved in a support group which can make him aware of the consequences of this behavior.

Q. INSATIABLE DRIVE FOR NOURISHMENT

Initially after injury it is very important for the patient to increase the calorie intake in order to assist with the healing process; thus. concern is focused on the patient eating enough food. Families often equate the act eating with "getting well" since they may have watched for months as their loved one was fed through a tube. Seeing the patient eating "real food" is a pleasurable experience. However, there may come a point when the patient will eat constantly and will gain an unhealthy amount of weight.

This insatiable appetite is often due to organic or brain related damage. The hypothalamus which lies within and below the central portion of the brain regulates appetite control as well as drinking, sleeping, waking, body temperature, heart rate, hormones and sexual emotions. This area can be damaged with an insult to the brain and, thus, the patient becomes unable to feel and perceive that his stomach is full. The brain continuously registers "hungry."

There can also be an emotional component to the overeating, especially if the individual was one who had weight problems prior to the accident. Overeating indicates unsatisfied dependency needs, and we have already discussed the fact that head injured patients become more dependent on family members. Examples

1. The patient goes home and her husband cannot keep food in the house to feed the three children as his wire devours everything on a daily basis.

2. The patient sneaks off to the hospital snack bar after the physician has ordered a weight loss diet.

3. The family daily brings their daughter her favorite M&M's as a form of showing their love and affection.

4. The patient outgrows his wheelchair within four weeks after it was delivered.

Resolutions for Insatiable Drive for Nourishment

1. If the problem is organic (physical) there is no way to change the hunger except to see a physician for possible medical management.

2. Change the environment — remove extra food.

3. Provide alternative behaviors. The patient cannot eat while exercising, sewing, wood working, etc.

4. If the problem appears emotionally based, then the family or therapist should address the self-concept and dependency issues.