Challenging & complex behaviours - anger
Anger is a common
emotional response after a brain injury and can be directly related
to impairments caused by the injury.
A brain injury can damage areas of the brain involved in control
and regulation of emotions, particularly the frontal lobe and
limbic system. Other effects of a brain injury can lead to
irritability, agitation, lowered tolerance and impulsivity, which
also increase the likelihood of angry outbursts. Anger issues are
commonly associated with a traumatic brain injury but occur
with other types of brain injury as well.
There is usually an 'on-off' quality to the anger - an explosive
angry outburst one minute but calm again shortly after. This can be
very difficult for family members and partners to cope with. In
some cases, a brain injury can impact self-awareness. The person
may not acknowledge they have trouble with anger, and may blame
others for provoking them. It may take carefully phrased feedback
and plenty of time for the person to gradually realize that anger
management is an issue.
Triggers for anger
When there is sufficient self-awareness for the person to
realize they need to manage their anger, the first step is
recognizing the triggers for their anger.
Common triggers for anger include:
- Lack of structure or unexpected events
- Perceived lack of control
- Being confronted with task the person is no longer capable of
- Fatigue or confusion
- Confusion & overstimulation e.g. crowds, lots of noise and
- Other people's behaviour e.g. insensitive comments.
- Unrealistic self-expectations
- Barriers to goals or routines e.g. queues
- Buildup of stress or frustration.
Recognizing these triggers is an important step, as the person
can either avoid those situations, or prepare for them mentally and
use various strategies to manage their anger.
Recognize the signs of anger
It is important to become aware of personal thoughts, behaviours
and physical states associated with anger, such as increased
heart-rate, sweating, muscles tightness or raised voice. After a
brain injury it can be difficult to recognize these signs and avoid
unpleasant situations or prepare for them.
Coping strategies for managing anger are a skill learned over
many years as we grow up. A brain injury can mean needing to
relearn these skills. Depending on an individual's level of
self-awareness, learning ability and cognitive skill, assistance
from family members or a carer may be needed.
Keep a record of events, triggers and associated levels of
anger. This can assist with finding coping strategies that
The back off, calm down and try again
technique is a technique from the Brain Injury
Association of Washington. It involves:
- leave the situation when early warning signs of anger
- move to a safe place and calm down
- review the situation and prepare for return
- If needed, talk through the situation with others upon your
The Stop - Think technique is similar.
When you feel anger rising, Stop and think before reacting to the
situation, this may require someone to assist you with creating a
cue to signal when you are becoming frustrated. Consider the
options for how to respond to your frustration; do you need to walk
away, find a better way to communicate or take some time out.
Extra trips that many people find useful after
a brain injury include:
- Distracted yourself from a stressful situations e.g. carry
- Explain to another person how they can be of help to solve the
- Leave the situation if possible if you feel you are losing your
- Phone a friend or a crisis centre to talk about the
- Make changes to routines e.g. avoid peak hour
- Speak with a doctor, psychologist or rehab specialists for
Recommended strategies for family and
It is important family and carers do not take anger personally
and recognize the individual has an impaired ability to control
anger. Below are some tips for coping with anger.
Validation and understanding - try and
understand why the individual is angry, listen to them and
validate/acknowledge their feelings and try and find a way to
assist the person with finding a solution to the problem.
Maintain structure - changes in
structure or surprises in routine can result in agitation and
frustration. Make sure the person had advance notice on changes to
routines, is clear on what is happening and why the changes are
Distraction involves changing the discussion topic, activity
or setting. Once the person has been distracted it can help to
change the activity to one that is calming and
Self-removal & safety
If anger has escalated you may need to remove yourself from the
situation if it safe to do so. Tell the person what you are doing
e.g. "You're getting upset, we are leaving for a few minutes so you
can calm down". Tell them you will return when their anger under
control. If the person is being verbally abusive ignore the
behaviour by reducing eye contact and verbal interaction.
Maintain a safe environment e.g. remove potential weapons
or dangerous objects that could be thrown or used to damage