Aggressive and violent behaviors are common with brain injuries.  This type of behavior is extremely difficult to deal with especially when the survivor is young, healthy, and physically strong.  Behavior changes are related to brain changes.  Do not take behaviors personally but keep yourself and anyone around safe, especially any children and others vulnerable.  Increased stimuli does increase agitation.  Is this stimuli external or internal?

Behavior changes can be related to increased stimuli.  Most often we look for external stimuli, but we forget that the survivor ‘s body has changed and they are not familiar with the signals or lack of signals of their body. Their brain is not sending the same signals as it used too.  It’s a devastating position to be in as a survivor as one does not know how to respond to what others perceive as “normal” stimuli.

Ask yourself these questions

• Is this a new change after a brain injury? When did it start?
• Was the survivor doing well then suddenly developed agitation? Aggressive behaviors?
• Describe exactly what you believe triggers the behaviors.
• Write down or voice record day and time behaviors start and what if anything stops behaviors.
• How long (duration) do the behaviors continue?

The following are a few common and serious problems with brain injury survivors.  Identify when the problem started, and what makes it better or worse.  If this is a new symptom only you know that.  Get help ASAP.  The sooner a problem is identified the quicker it can be treated.

If you try to get help, and no one listens … keep going back until they listen.  Otherwise find someone to listen.  Don’t assume it’s you.  That’s a dangerous position.  Don’t take the blame.  It’s up to healthcare professionals to help problem solve.

Here is one example: Many people do not know that a urinary tract infection in those who are chronically ill, elderly, or injured can cause many problems including extreme confusion.  Once the UTI is treated, the patient returns to “baseline”.

Common & easily treatable conditions that increase agitation … Contact your Healthcare Professional to help treat & resolve problems

• Urinary tract infection (UTI)
• Respiratory infection (URI)
• Blood pressure changes
• Headache
• Pain
• Fever
• Cold
• Flu
• Poor Sleep
• Poor Rest
• High Ammonia Levels

Many other conditions cause behavioral changes and aggression often not just those with TBI.

If you suspect any problems and especially Serious problems … Contact Healthcare professional immediately

• Increased intracranial pressure (ICP)
• Meningitis
• Encephalitis
• Infections
• Anoxia (Lack of oxygen to the brain)
• Blood clots
• Strokes (CVA-Cerebral Vascular Accident)
• Heart Attacks (MI-Myocardial Infarction)

In brain trauma, brain surgeries, and brain dysfunction of all sorts the neurological system is damaged. Messages received from the brain have gone haywire.  With each brain surgery, it’s another type of brain trauma and can lead to additional complications but it also can correct the problem at hand.  It’s a risk-benefit situation.  What are the risks?  What are the benefits?

Brain injury is far more then cognitive changes as most focus on. Our brains control every aspect of the bodies functioning.  The messages are not consistent with what they knew before their injuries.  This is not delusions as some professionals might think. If the survivor is smiling and it seems out of sorts for a situation, it can easily be perceived as delusions when in fact it’s new responses and new behaviors.

It might also be that the survivor understands far more then others believe and they may believe what they hear and see is ridiculous.  This is often the situation.   It’s a fact but unless you’ve been there you simply can’t understand.

Your body doesn’t function as it once did; your thinking is scrambled; you struggle to process information; yet often you are aware of your surroundings and can’t change anything.  Your verbal responses are not spontaneous and accurate.  Often, it seems like no one listens because they believe “you don’t know what you are talking about”.

You just can’t express what you are thinking and feeling.  Your life and needs are in another’s hands.  Now all your needs are based on what others believe is wrong, and it’s all about interpretation. Unfortunately, all too often the people who healthcare providers are counting on are giving inaccurate information which can destroy the process of proper or any health care for that individual.

Another example: A young male patient was able to walk and appeared “normal”.  When he expressed himself he was serious but spoke only in terms of tools.  Such as “My nails were left and the hammer didn’t work.  The circular saw left lots of saw dust.  A wrench was left but it was rusty.”  This was an explanation of a patient’s pain.  He pointed to different areas of his body.  Once realized he was explaining his pain, he was treated and improved. Until that time, he’s verbal communication was considered “delusional”, but his nonverbal communication pointed to problems.

That feeling of “helplessness” is unbelievable.  It’s a different type of “helplessness” because it’s based upon lack of control.  Unable to control very little of your internal environment (within your body) and because others don’t understand your needs and control is limited in the external environment.   All while you want everything to be better.  This is a struggle to find balance.

Since survivors struggle so much, they feel they are a total burden.  You don’t want to put your loved one through this, and the feelings of “suicide” are very real.  Here I will cite an example to help clarify how we understand how survivors feel as they recover from the most severe injuries.

Example:  A patient who lost a leg in her accident  ripped apart a 12 inch incision in her other leg.  She was unable to verbally express herself, but is alive and doing well but remembers it clearly and that was 23 years ago.  Professionals thought she was confused.  She was not confused, and “hoped to die”.  No one ever thought she was trying to die. She was agitated, suffered severe pain, but wast given anything for pain.  She was finally given something for pain and that changed her behavior.  She was never on pain medications (except Tylenol) for months following her accident even though she broke nearly every bone in her body (while being run over by a car while stopping to help another motorists on a highway).

Pain is under treated

Altered Pain syndromes are common with brain injury

And the wheels keep spinning.

How do you measure pain in someone who doesn’t understand what is happening to them, can’t think clearly, and can’t express what’s happening?  Anyway, I’ve seen this happen to patients and I’ve experienced this pain personally and I couldn’t fix it myself either.

If one has a high tolerance to pain, it’s the least likely problem others would think of … and rarely the survivor will think of pain when  thinking is already clouded.

With the patients I’ve seen, once the pain was treated the agitation decreased significantly or ceased.  There is so much focus on giving a number for pain on a scale of 1 to 10, but that scale wouldn’t even apply when the level of confusion is far beyond comprehension.

I’m also incorporating my own personal experience here.  My body felt like it was on fire all the time.  I mean, as though someone lit a match and it kept burning.  It lasted 10 years, until accidentally I was given Neurotin to relieve constant muscle jerks.  Neurotin resolved the muscle jerks but also eliminated the burning pain.  What a pleasant surprise!

I’m taking the maximum dose 1200 mg three times a day but pain control is frequently overlooked.    Now, that brings up another situation.  Brain injured survivors also have a sensitive brain and chemicals need to be monitored closely.  Often a small dosage helps, but usually needs to be increased slowly.

Is the medications your loved one, or you sufficient to treat the problem?  

How have you or your loved one improved? 

Our bodies are all chemicals and they are produced in the brain.  PAIN IS IN THE BRAIN. if the brain is damaged all the chemicals and hormones in the body can be off, and it takes a long time to regulate the brains chemistry.  I suggest seeing a neuro-endocrinologist, neurologist, or physical medicine and rehabilitation (PM&R) physician as they deal primarily with brain dysfunction and brain injuries.  Ask to see someone who SPECIALIZES and treats brain injuries

Expressing oneself is even harder.  How do you tell anyone you are in pain, when you can’t figure out basic functioning of the body, brain or mind?  If you can’t understand how your body is functioning.  If you can’t understand why the clarity of thought is so cloudy, and yet you see everything around you appears “like it use to” it’s extremely hard to figure anything out.

I’ve had several patients all between the ages of 25-40 and in the process of being transferred to skilled nursing facilities because their behaviors were “out of control” and “dangerous” to others.  They were all given different types of medications, but combined with something for pain and 100% of these patients improved drastically ultimately being released to home without significant violent behavior problems.  These patients could not even care for their basic needs, but everything changed once balanced with proper chemicals.

I’m not a huge fan of medications, but brain injury often needs different medications.  Unfortunately, because the brain is so sensitive, less is better … but not always!  If you are a caregiver keep a journal because it’s detective work to problem solve.  If you are a survivor you will need to do the same.  It’s up to both the caregiver or the survivor to solve these problems.

Chemical and physical restraints of all sorts increase agitation, but it’s necessary if the patient may harm oneself or another.  Sometimes the only way to help combative patients is with one-on-one care to sit quietly with the survivor by releasing restraints.  NEVER do this if it jeopardizes anyone’s safety. Unfortunately, volunteers are not around after the initial injury and the immediate family must deal with problems alone.

This type of intervention is best when performed by healthcare professionals in a controlled environment as behaviors are so unpredictable and can easily lead to injury.  Always prevent injury.  Safety should always be number one.

Cranial sacral therapy is helpful to adjust the spinal fluid balance.

Here is something to think about:  Rating scales are measured usually by a number between 1-10.  Are we talking about this past week? Past month? Are we comparing before injury and after injury?  Just give a number 1-10.  These numbers are different for every patient as they are perceptual experiences.

For example sleep.  Sleep may be good for a week or 7 days out of a month.  If that 7 days happens to have been an entire week, any brain survivor will be pleased to give a score of 10.  But that 10 may only represent the current situation.  Survivors focus on the positives.  There should be comparisons of the same person, at the same time giving numbers of the past week and the past month.  There are too many other variables and even with best research cannot control or eliminate all variables.

Finally, if there is a CHANGE or new behavior something else may be going on.  It could be something as simple as a urinary tract infection that can easily be treated with antibiotics, but it could be a complication of brain injury such as another infection somewhere in the body.  It may not even be related to brain injury, but passed off as though “It’s all part of brain injury.”  Your child, sibling, parent, spouse, friend, all relying on you to figure out their body and responses and that’s a huge burden to bear!

***What have you found works?  What has been your personal experiences that trigger behavioral changes?

**********All material presented on Brain Injury Self Rehabilitation (BISR) is copyright and cannot be, copied, reproduced, or distributed in any way without the express, written consent of Edith E. Flickinger, BSN RN.