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PTSD Questions & Answers
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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Anger & Brain Injury

Q: Dear Frank, A survivor wrote to me and asked "Can you speak to the issue of anger and head injury? What possible treatment options are there? I can be the nicest guy but occasionally someone or something can push a button in me and even if I’m conscious of what’s going on in me I still blow up. Thank you."

A: Dear Joyce, It takes considerable courage to admit to an anger management problem, so I salute this “nicest guy” who asks for help with his easily triggered rage. Brain injury, particularly injury to the frontal lobes of the brain, can weaken our social reflexes. When that happens, our instincts take over and we are easily threatened or insulted or offended. Before we know it, we shout or we threaten or we sulk. Once we recover our full awareness of our exaggerated emotion, we are often embarrassed and self-critical. Here is an excellent link explaining why these episodes occur, with good advice for preventing and managing outbursts: https://www.brainline.org/article/anger-following-brain-injury. Here are some excerpts from this site:


(Advice to caregivers, family and friends)

Prevention

  • Make the environment safe
  • Remove potential weapons
  • Keep alcohol and drugs inaccessible
  • Keep vehicles and dangerous tools inaccessible
  • Regulate Level of Stimulation
  • Some need to avoid over stimulation
  • Some need to be kept busy and distracted
  • Provide Appropriate Level of Supervision
  • Provide the least restrictive environment possible
  • Provide Reorientation as Needed
  • Much of the anger in an agitated confused and disoriented person can come from misperceiving and misunderstanding the situation
  • Staff and families should frequently remind the person of where they are, what is happening and why

Management

  • Withdraw

  • Leave the person alone for a short period of time if this can be done safely. As you leave, tell them briefly what you are doing and why. “You are beginning to get upset. We are going to leave you alone for a few minutes so you can calm down.”
  • Distract
  • Change the subject, the focus of activity or the location
  • Use a concrete object as a focus when possible
  • Reorient and Reassure
  • Remind the person of where they are, what is going on and why
  • Try to clear up misunderstandings when this can be done without renewing argument
  • Direct the person in activities that may reduce agitation, such as guided relaxation

Self-Control Strategies

These strategies are to be phased in when the brain injured person has recovered enough learning abilities and awareness to begin to cooperate in learning to control anger.

“Back Off, Calm Down, Try Again”

Because the impulsive anger resulting from brain injury often comes and goes suddenly, an effective way to deal with it is for the angry person to back off, calm down and try again. This strategy can be phrased in the individual’s own words or whatever expression is comfortable such as “retreat, relax, return” or “take a break” or “time out”.

Back Off

When warning signs appear, the person should leave the situation and go to a safe place. Others will have to cue him or her to leave. If the person will not leave, the other people present should leave instead, if possible. Practicing backing off when not angry (like a fire drill) will help this go more smoothly when it is really needed.

Calm Down

When the person has backed off to a safe place, he or she should work on claming down. Many techniques can be used to calm down including:

  • deep breathing
  • soft music
  • meditation
  • prayer
  • closed eyes
  • physical exercise

Preparing to Return

Once calm, the person may need to rethink the situation and prepare to return.

Reviewing a list of questions is a possible preparation;

  • Do I need to apologize?
  • Do I need to explain why I left?
  • Do I need to tell anyone my feelings?
  • What can I do to avoid this next time?

Here are some statements to encourage rethinking the situation;

  • “I don’t hate my mother; I’m just angry with her”
  • “Maybe she had a point I should listen to”
  • “He’s not wrong, we just disagree”

Try Again

When the person returns from backing off and calming down he or she may need to

  • apologize,
  • talk through the issue,
  • explain the backing off and feelings
  • resume what he or she was doing.

Once a person has learned to back off, calm down and try again successfully, he or she can work on calming down in the situation without leaving.

Anger Cue Cards

Anger cue cards can be used to remind the brain injured person of their warning signs such as Loud Voice, Tense Muscles, Confusion, or Thoughts of Hitting. These cards should be carried by the brain injured person and optional copies can be placed where anger incidents often happen or where backing off takes place.

A Back Off card might say:

  • “I’m feeling angry, I need to back off”
  • Leave the room
  • Breathe deeply
  • Relax muscles.

Note especially the need to restrict access to weapons, to alcohol and to those who may be physically or emotionally harmed. But also note the many simple, practical ways to build resilience and to learn self-soothing techniques. Most important, honor the person that you are.

I’d sum it up this way: brain injury does not remove your essential self. Your values, your faith, your inner core are still there. You are still “the nicest guy.” But a brain circuit has been affected and there will be episodes of inappropriate, exaggerated anger. Your closest friends and family can help by reading about the condition. They can be understanding, supportive and kind. Together, you and they can agree to avoid words and behaviors that trigger your “melt downs” and take actions that reduce the intensity of rage reactions once they begin.

Medications may help. A condition called Intermittent Explosive Disorder often responds to drugs used for epilepsy. The same drugs that help with anxiety, depression and PTSD often help with TBI. By the way, many of us have concluded that PTSD should now be called PTSI. It is an injury, not a disorder. Whether the injury comes from a blow to the head or a horrifying event, the fear and anger centers of the brain are unleashed. They are easily triggered and no longer automatically suppressed once the conscious mind returns.

We, the folks who deal effectively with trauma, are now doing all we can to improve public understanding and to replace stigma with honor. You are a survivor. Do what you can to honor yourself and to educate others so that they can be resourceful, not resentful, when these inevitable episodes occur.

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