Living with Brain-Behavior Challenges

Monday, September 6, 2004 | 0

By Tina M. Trudel, PhD

For many individuals who sustain brain injury, personality change and behavioral challenges are a persisting problem. In fact, in many long-term outcome studies, these behavioral factors are often described as the greatest obstacles to success for the individual, and the greatest sources of distress for the family members surveyed. Approaches to ameliorate neurobehavioral difficulties typically involve both medication and behavioral approaches. Understanding common patterns of brain - behavior relationships and day-to-day application of behavioral principles can be helpful in easing stress and increasing the joy in life for everyone involved.

Injury to certain regions of the brain often results in characteristic behavior clusters highlighted below. Bear in mind that individuals with more severe brain injuries may have multiple brain regions affected. Also, an individual may demonstrate only one or many of the symptoms typically associated with injury to a particular brain region. Understanding the brain - behavior relationship helps all of us to avoid blaming, making inaccurate attribution or developing false assumptions regarding the 'why' of problem behaviors post brain injury. This understanding also empowers the individual to make better choices, avoid likely problem areas and learn to play to their strengths.

Patterns of Brain-Behavior Relationships The frontal region of the brain controls executive functions. Executive functions refer to the cognitive abilities involved in the initiation, planning, sequencing, organization and control of behavior. They incorporate basic abilities, such as working memory and inhibitory control, as well as complex overarching abilities, such as generating novel solutions and self-monitoring. Even within the frontal lobe, there are different patterns of brain-behavior functions.

Injury to the frontal convexities (the out convex surfaces of the frontal lobe) often contributes to a person feeling very apathetic and indifferent. Problems with discrepant behavior may occur, where the person may say they will do or have done something, while actually never mobilizing themselves to get things done. S/he may mistakenly be viewed as lazy or dishonest, when in fact, this is a brain-based syndrome that can be worsened by the fatigue that often accompanies TBI, especially in the earlier stages of recovery. Individuals with frontal convexity damage are also prone to perseveration (saying/doing the same thing over and over) and being stimulus bound (hyper-focused on something while missing out on the main point). Problems with abstract reasoning, and therefore problem solving and decision making, are also common.

Orbital frontal injuries often prove to be the most behaviorally disruptive. These types of injuries, involving the 'rolled under' frontal region behind our sinuses, are very common in acceleration-deceleration scenarios such as motor vehicle crashes. The most prominent behavioral challenge common to individuals with orbital frontal injuries is disinhibition - the lack of effective 'brakes' to check or modify underlying drives such as aggression, appetite and sexual arousal. Unfortunately, in some situations, individuals with significant behavioral dis-inhibition have ended up arrested, assaulted and injured. The individual with orbital frontal injury may be very difficult to assist, as impaired awareness of disability (anosagnosia), self-centeredness, poor judgment, diminished insight, and difficulty with perspectives are also quite common. Those offering support may find it is unwelcome and can easily fall into a pattern of nagging, argument and power struggles. Further, distractibility and emotional lability may also complicate matters.

Medial frontal injuries involve the central area of the frontal lobe and may occur with hydrocephalus. While injury in this region is less common, it is noteworthy for creating an amotivational state, wherein a person presents a paucity of output, not really doing much of anything. Shuffling gait and incontinence may also be observed.

The temporal lobes are also often injured in acceleration-deceleration injuries. Aside from language and auditory processing functions, the temporal lobes play an important role in memory and are closely intertwined with our limbic system, home to our emotions, and also an area commonly affected by injury and disease. Individuals with temporal lobe damage may present with paranoid and anxious features. Sleep disturbance is common, and explosive episodes or pathological rage may also be present. Researchers also note interpersonal viscosity (stickiness) as another behavioral symptom, one that makes relationships and disengagement far more difficult. Epilepsy may also develop as a result of injury, and those with identified temporal seizure foci have higher rates of mental health problems.

Injuries to the left hemisphere of the brain are associated with depressive reactions as well as impairment of expressive and/or receptive communication. Problems in communication may be subtle, and it can be easy to forget or not notice that a person does not fully understand or is infrequently commenting. Right hemisphere damage is noted for a greater sense of indifference and unawareness. Communication can be affected in terms of both the ability to produce and distinguish the prosodic elements of speech - those subtle changes in inflection, pitch and rhythm that fills words with meaning and emotion.

The next article in this series will review what certain behaviors are.

Tina M. Trudel, PhD, 1-800-473-4221 Vice-President of Clinical Services, Lakeview NeuroRehabilitation and Adjunct Asst. Professor of Psychiatry, Dartmouth Medical School. Dr. Trudel can be e-mailed at ttrudel@lakeview.ws.

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