Understanding and Coping With Irritability, Anger, and Aggression After TBI

What are irritability, anger, and aggression and how can you recognize them?

• Irritability is an emotional state in which a person has a short temper and is easily annoyed or angered. As a result, small things can lead to harsh reactions (for example, snapping at family or friends). This is most likely to happen if the person does not know how to manage their feelings or if the person is stressed. People may feel tense, uptight, touchy, or on edge when they are irritable.
• Anger is an emotion. It’s a strong feeling of annoyance or displeasure. Sometimes angry emotions can get intense and feel out of one’s control. Anger can lead to aggressive acts. When angry, people may feel tension in their forehead, jaw, shoulders, or fists. They may feel their heart beat faster and their bodies may feel hot.
• Aggression is a type of behavior. It is often an expression of anger. Actions can range from mildly aggressive to extremely aggressive. Aggression can be hurtful comments—what you say and how you say it. It may include insults, cursing, or yelling. On the more extreme and less common end, it can include acts of violence, such as throwing things or hitting someone or something. Aggression may include other threatening actions meant to cause fear or displeasure, such as following a driver on the highway to intimidate them or refusing to do something your loved one wants to do.
• As shown below, irritability, anger, and aggression are not the same, but they can overlap or occur together. However, each can also happen on their own. For instance, someone could feel angry but not act aggressively, or someone could get angry without being irritable. Tips for managing these emotions and behaviors are presented below.

What changes can be expected after a TBI?

Feeling irritable or angry from time to time is common for most people, but a TBI may cause changes that make these feelings more of a problem.

• Irritability and anger are more common in people with TBI than they are in people without TBI. Some research shows that up to three-fourths of people with TBI have irritability. In addition, up to 50% of people with TBI have problems with anger. A person who was not prone to irritability or anger before their TBI may now be easily irritated or angered after their TBI.
• Irritability and anger after TBI can be sudden and unpredictable. After a TBI, feelings of irritability and anger can occur suddenly and ramp up quickly. These feelings may be triggered more easily than before the TBI. They may also be hard to predict.
• Anger and aggression can lead to behaviors that are difficult to control after a TBI. A TBI can make it hard for a person to talk in a respectful way about things that make him/her angry or frustrated. The person may also find it hard to stop an aggressive response, such as shouting, saying mean things, or cursing. Sometimes, they may express anger through physical acts, such as throwing things, punching a wall, or slamming doors. In more extreme and rare cases, anger can lead to physical fights, such as hitting others.

Why do people with TBI have problems with irritability, anger, and aggression?

• Injury to parts of the brain that control how we feel and manage our emotions. TBI often causes injury to one or more of the many parts of the brain that control how we feel and manage our emotions. An example is the orbitofrontal region (pictured to the right). This front part of the brain helps us to monitor and evaluate our feelings, and to think rationally about situations. This helps keep our anger in check and stops us from being impulsive and aggressive. It helps us figure out appropriate ways to deal with our anger and the situation. People who have injured this part of their brain often have trouble controlling their anger and aggression.
• Changes in how the person thinks. After a TBI, changes such as slowed thinking, trouble focusing, poor memory, or difficulty solving problems can occur. These issues can be frustrating and may increase irritability and anger.
• Emotional struggles. Irritability is often a sign that a person is dealing with other emotional struggles, such as feeling sad, depressed, and/or anxious.
• Not fully recognizing emotions. People with TBI may find it hard to know when they are getting upset or irritated. As a result, feelings of anger can easily grow and get out of control.
• Adjusting to the injury. Many people with TBI have a hard time coping with changes after their injury. Limitations in activities and responsibilities (e.g., driving, managing bills, household chores) may make them feel irritable or angry.
• Misunderstanding others. TBI can affect a person’s ability to interpret other people’s actions and emotions. They may think that other people are angry or have bad intentions when they don’t. This can lead to anger.
• Feeling unwell. Pain, fatigue, and poor sleep are common after TBI. These can lead to irritability and aggression.
• Sensitivities to surroundings. People with TBI may be more sensitive to light and/or noise. This can lead to irritability.

What are the consequences of irritability, anger, and aggression after TBI?

Below are some common areas that can be impacted by these emotional and behavioral changes:

• Negative health effects. Anger may cause a faster heart rate and the person may be in a constant state of alert. In the long term, this can have negative physical health effects and mental health effects, such as heart disease and anxiety.
• Intimate relationships. It may be difficult for others to relate to a person who is easily irritated, angry, or aggressive. Unpredictable reactions may make partners feel as if they have to “walk on eggshells” around the person with TBI. This can lead to stress, conflict, and/or fear, and the quality of the relationship may suffer.
• Friendships. Friends of persons with TBI may have similar reactions as spouses or partners do. If not addressed, friendships are likely to dwindle and it may be harder to make new friends.
• Return to work. Trouble controlling emotions and behaviors can lead to friction or arguments with peers and employers. Irritability can make learning new skills and receiving critical feedback from others more difficult. Aggressive or defensive behaviors may lead to disciplinary action or job loss.
• Legal troubles. Due to the injury, a person with TBI may have difficulty controlling impulsive and inappropriate reactions when they are irritable or angry. Some acts may even be illegal (e.g. property damage, assault) and can result in fines, arrests, or even incarceration. Reasons for these actions after TBI can often be misunderstood. If someone with a TBI is accused of an illegal act, law enforcement and the legal system should consider recommending rehabilitation services that can treat the person’s needs, as opposed to criminal punishment.

How can health care providers help reduce irritability, anger, and aggression?

Find a licensed health care provider who is trained in treating emotional problems after TBI. Examples include psychologists, rehabilitation counselors, physiatrists (physicians who specialize in rehabilitation), social workers, occupational therapists, or speech pathologists. The following methods are often used by providers with good results.

• Psychotherapy or counseling. Healthcare providers, such as psychologists or licensed professional counselors, can help people with TBI learn to cope with anger and related emotions (e.g., posttraumatic stress disorder, anxiety, and depression) in healthy ways. They may do this in different ways, such as helping people to notice their thoughts and feelings without judging them, helping them to evaluate how their thougts or feelings may be leading them to act in unhealthy ways, and/or assisting them to evaluate the accuracy of their thinking.
• Problem solving. Some health care providers can help people with TBI learn problem-solving skills, which is known to reduce anger and aggression.
• Early detection. Some health care providers can teach people with TBI how to spot early warning signs of irritability and anger so that they can try to lessen the chance that they will become aggressive. Meditation and mindfulness can help people notice how they feel and calm themselves.
• Social skill training. Some providers can help persons with TBI re-learn key social skills that are often impacted by the brain injury. This may help the person with the TBI to better understand others’ thoughts, intentions, and feelings (e.g., to see things from others’ perspective). This can prevent misunderstandings and reduce anger and aggression.
• Medications. Doctors can use medicines to treat irritability, anger, and aggression. However, no medicines have been approved by the Food and Drug Administration for behavioral problems related to TBI. After TBI, people may be more sensitive to medicines. Talk to your doctor about what changes you notice in yourself with the medicine and side effects for all the prescription medications you are taking.

What can a person with TBI do to help reduce irritability, anger, and aggression?

• Rest. Try to get at least 7 hours of sleep every night. If you are having trouble sleeping, consult a physician or other health care provider.
• Move your body. Make sure to exercise, such as walking or doing yoga, every day.
• Relax. Practice relaxation exercises, like mindfulness, meditation, and/or deep breathing every day.
• Practice a healthy diet. Drink eight glasses of water every day, eat healthy foods, and don’t use recreational drugs or alcohol.
• Remember your medications. Make sure to take the medications your doctor has prescribed for you (see above).

How can caregivers help people with TBI reduce their irritability, anger, and aggression?

Caregivers often find their loved one’s irritability, anger, and aggression to be some of the most difficult changes to deal with after the injury. Here are some helpful hints for caregivers.

• Notice patterns. Be aware of things that cause irritability or anger. Being tired, overstimulated, or too hot may be triggers. Some topics, like being reminded of things that he or she has difficulty with, may be very upsetting for the person with TBI. Try to be sensitive about triggers such as these. It’s not your job to avoid every situation that may trigger these emotions, but noticing patterns can be helpful.
• Empathize and try to understand the problem. Do your best to understand where the person with TBI is coming from and what is causing your loved one to be upset. Realize that something you are doing or saying may be interpreted in a way that triggers their anger. Try to help resolve the situation that is upsetting the person.
• Manage your own expectations and emotions. Make sure your expectations of the person are realistic. Try to remain calm in response to anger and aggression. Suggest a break until everyone has calmed down. Go to another room or leave the house if needed. Come back later to talk calmly. Consider attending caregiver support groups for support, and/or make sure to get help and care from other family and friends.
• Agree on ground rules for communication. Everyone should agree to be respectful toward one another. For instance, speak calmly, without yelling or any other aggressive behavior.
• Focus on positive behavior. Pay attention to and reward positive behaviors, such as when the person calmly expresses his/her feelings. Try not to respond to negative behaviors, which can sometimes increase them.
• Try not to take things personally. Understand the injury to the brain often makes it harder for the person to manage anger and other emotions. Knowing that it is not personal or not the person’s fault may help you stay calm.
• Note any safety concerns. Your safety and the safety of other family members is important. If you have safety concerns about yourself or your loved one, talk to your doctor or another health professional. In some cases, you may need to consider living apart from the person with TBI.

Recommended Readings

• You Did That on Purpose! Misinterpretations and Anger after Brain Injury
• Anger and Frustration After Brain Injury (Brainline.org)
• MSKTC TBI resources at https://msktc.org/tbi on:
  • Emotional Problems After TBI
  • Understanding TBI
  • Depression After TBI
  • Fatigue and TBI
  • Sleep and TBI
  • Headaches After TBI
  • Cognitive Problems After TBI

Authorship

Irritability, Anger, and Aggression After TBI was developed by Dawn Neumann, PhD, Shannon R. Miles, PhD, Angelle Sander, PhD, and Brian Greenwald, MD in collaboration with the Model Systems Knowledge Translation Center. Special thanks to Sagar Parikh, MD, for creating the picture of the brain used in this factsheet.

Source:The content in this factsheet is based on research and/or professional consensus. This content has been reviewed and approved by experts from the Traumatic Brain Injury Model Systems (TBIMS) program, funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), as well as experts from the Polytrauma Rehabilitation Centers (PRCs), with funding from the U.S. Department of Veterans Affairs.

Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider regarding specific medical concerns or treatment. The contents of this factsheet were developed under grants from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90DP0082, 90DPTB0016, 90DRTB0002, and 90DPTB0014). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The contents of this factsheet do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the federal government.

Copyright © 2021 Model Systems Knowledge Translation Center (MSKTC). May be reproduced and distributed freely with appropriate attribution. Prior permission must be obtained for inclusion in fee-based materials.